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Intensive interventions were no more effective at reducing fractures than a booklet containing advice on falls prevention. A large study looked at screening strategies to reduce fractures in older people at high risk of falling. It found that none of the interventions reduced the rate of fractures. The study compared a booklet sent by post, an exercise programme, and multiple assessments by a range of professionals.
Falls and fall-related injuries, including fractures, are common and a serious health problem for older people. Falls can cause pain and injury, distress, loss of confidence and independence, or death. They are estimated to cost the NHS more than £2.3 billion per year.
People at high risk of falling currently receive multiple assesments by a range of professionals. All their risk factors are considered – everything from blood pressure to failing eyesight or medications. Suitable preventive measures are then offered. Before this study, it was not known how effective this approach is.
The Prevention of Fall Injury Trial (Pre-FIT) included more than 9,000 people over 70 years old living in the community. Over a period of 18 months, the study found that none of the three approaches (advice alone, exercises, multiple assessments) reduced fracture rates. The exercise programme was linked with small gains in health-related quality of life, and short-term prevention of falls, which made it the most cost-effective approach.
These findings are being considered by the National Institute for Health and Care Excellence (NICE), which is updating its current guidelines on how best to prevent injuries from falls.
What’s the issue?
As people get older, they are more likely to fall. One in three (30%) people aged 65 and older – and half of those over 80 – fall at least once a year. Falls can lead to injuries, including fractures. Reducing falls and fractures is important for maintaining the health, wellbeing and independence of older people.
Risk factors for having a fall and the severity of an injury include bone health, frailty and low weight. Older people with low bone mineral density (osteoporosis) are more likely to fracture a bone when they fall.
Current NICE guidelines state that people over 65 who are at an increased risk of falling should be considered for an individualised falls prevention programme. This includes components such as an eye test, a review of medications, and an assessment of their balance and of falling hazards at home.
The costs of this measure, and whether it reduces fractures and improves quality of life, were unknown. Pre-FIT set out to address the considerable uncertainty over the effectiveness of current strategies– and the value of targeting interventions to higher-risk groups.
Almost 10,000 people with an average age of 78 were recruited from 63 general practices across England. Practices were randomly assigned to one of three groups.
- Advice: 3,223 people received advice by mail only.
- Exercise: 3,279 people received advice by mail, plus screening to identify those at high risk. This group was offered an exercise programme (supervised home exercises to improve strength and balance, and recreational walking).
- Falls prevention: 3,301 people received advice by mail, plus screening. Those identified as at high risk were offered a falls prevention programme (assessments by a range of professionals, tailored interventions that could include strength and balance training, a medication review, home modifications and referrals to other medical specialists).
The three groups were compared in this study. About one in three (1,000 people in each of the exercise and falls prevention groups), were at high risk. But many people at high risk did not take up invitations to the exercise or falls prevention programmes: 350 people did not attend exercise sessions and 439 did not attend the falls prevention programme.
The study found that people in the exercise or falls prevention groups had a similar risk of a fracture in the 18 months of the study, compared with those in the group receiving advice only. This was the main outcome of the trial.
In other, secondary outcomes, neither the exercise nor falls prevention interventions reduced risk of falling compared to advice alone. Quality of life was marginally better for the exercise intervention but differences between the groups were slight.
An economic analysis of the programme looked at the NHS costs for a year of good health (cost/QALY) with each of the three approaches. The falls prevention programme (£3,941) was slightly less cost-effective than the other two approaches. Exercise was most likely to improve quality of life and was therefore slightly more cost-effective (£3,720) than advice alone (£3,737).
Why is this important?
Screening, and offering targeted programmes of exercise or falls prevention to those at high risk, were no more effective than advice by mail at reducing fractures. Quality of life was slightly improved in the exercise group but differences seen in this trial were slight. Despite the resources offered in the falls prevention group, a health economic analysis showed that reductions in NHS costs were marginal.
Many NHS service providers are currently screening older people and offering fall prevention programmes to those at increased risk of falling. These strategies may now need to be reconsidered to ensure they are cost-effective and provide benefits for older people.
It remains possible that the exercise and fall prevention programmes could provide benefits that were not measured in this study. Exercise could have improved muscle strength, for example. It is also possible that the interventions reduced minor injuries which did not include a fracture. These injuries are poorly recorded in England and were not included in the study.
The authors saw small improvements in health-related quality of life in the exercise group. These improvements might also be linked with reduced pain and improved mobility.
NICE clinical guidelines on preventing falls are currently being updated and should include the findings from this study. Further research is now needed into the development of more effective interventions that can prevent fall-related injuries fractures in older people.
This trial found that the NHS approach of screening to identify people at high risk, and then offering these interventions, was not effective. But it could be, for example, that more prolonged or intense exercise could reduce falls. In addition, many people in this study did not take up the offer of intervention. Future studies should examine how to encourage people at high risk of a serious fracture, to accept an intervention programme.
You may be interested to read
This NIHR Alert is based on: Lamb S, and others. Screening and Intervention to Prevent Falls and Fractures in Older People. The New England Journal of Medicine 2020;383:19
Age UK has produced advice on keeping active and reducing the risk of falling in Staying Steady leaflet.
National Institute for Health and Care Excellence (NICE), 2013. Guideline [CG161] on Falls in older people: assessing risk and prevention.
The National Falls Prevention Coordination Group (NFPCG) and Public Health England advice at: Falls and fracture consensus statement and resource pack plus updated NFPCG evidence briefing on multifactorial falls-prevention interventions.
A good practice guide from the British Geriatrics Society: Comprehensive Geriatric Assessment (CGA) in Primary Care Settings: Patients at risk of falls and fractures.
Funding: This study was supported by a grant from the NIHR Health Technology Assessment Programme.
Conflicts of Interest: Two authors have received fees from pharmaceutical companies unrelated to this study.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.