Screening older people for impaired vision in primary care: cluster randomised trial. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial. Improving vision to prevent falls in frail older people: a randomized trial. Community-based fall assessment compared with hospital-based assessment in community-dwelling older people over 65 at high risk of falling: a randomized study. Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice. Randomised factorial trial of falls prevention among older people living in their own homes. Effectiveness of a falls-and-fracture nurse coordinator to reduce falls: a randomized, controlled trial of at-risk older adults. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomised controlled trial. A randomized trial of a screening, case finding, and referral system for older veterans in primary care. The Whitehorse NoFalls trial: effects on fall rates and injurious fall rates. A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls.
To determine the effectiveness of screening for visual impairment in people aged 75 or over as part of a multidimensional screening programme.
                Cluster randomised trial.
                General practices in the United Kingdom participating in the MRC trial of assessment and management of older people in the community.
                4340 people aged 75 years or over randomly sampled from 20 general practices, excluding people resident in hospitals or nursing homes.
                Visual acuity testing and referral to eye services for people with visual impairment. Universal screening (assessment and visual acuity testing) was compared with targeted screening, in which only participants with a range of health related problems were offered an assessment that included acuity screening.
                Proportion of people with visual acuity less than 6/18 in either eye; mean composite score of 25 item version of the National Eye Institute visual function questionnaire.
                Three to five years after screening, the relative risk of having visual acuity < 6/18 in either eye, comparing universal with targeted screening, was 1.07 (95% confidence interval 0.84 to 1.36; P = 0.58). The mean composite score of the visual function questionnaire was 85.6 in the targeted screening group and 86.0 in the universal group (difference 0.4, 95% confidence interval -1.7 to 2.5, P = 0.69).
                Including a vision screening component by a practice nurse in a pragmatic trial of multidimensional screening for older people did not lead to improved visual outcomes. To test whether Stepping On, a multifaceted community-based program using a small-group learning environment, is effective in reducing falls in at-risk people living at home.
                A randomized trial with subjects followed for 14 months.
                The interventions were conducted in community venues, with a follow-up home visit.
                Three hundred ten community residents aged 70 and older who had had a fall in the previous 12 months or were concerned about falling.
                The Stepping On program aims to improve fall self-efficacy, encourage behavioral change, and reduce falls. Key aspects of the program are improving lower-limb balance and strength, improving home and community environmental and behavioral safety, encouraging regular visual screening, making adaptations to low vision, and encouraging medication review. Two-hour sessions were conducted weekly for 7 weeks, with a follow-up occupational therapy home visit.
                The primary outcome measure was falls, ascertained using a monthly calendar mailed by each participant.
                The intervention group experienced a 31% reduction in falls (relative risk (RR)=0.69, 95% confidence interval (CI)=0.50-0.96; P=.025). This was a clinically meaningful result demonstrating that the Stepping On program was effective for community-residing elderly people. Secondary analysis of subgroups showed that it was particularly effective for men (n=80; RR=0.32, 95% CI=0.17-0.59).
                The results of this study renew attention to the idea that cognitive-behavioral learning in a small-group environment can reduce falls. Stepping On offers a successful fall-prevention option.
                Copyright 2004 American Geriatrics Society To determine the efficacy of vision and eye examinations, with subsequent treatment of vision problems, for preventing falls and fractures in frail older people.
                Randomized, controlled trial.
                Community in Sydney, Australia.
                Six hundred sixteen men and women aged 70 and older (mean age 81) recruited mainly from people attending outpatient aged care services.
                The intervention group received comprehensive vision and eye examinations conducted by a study optometrist. The optometrist arranged for new eyeglasses for 92 subjects and referred 24 for a home visit with an occupational therapist, 17 for glaucoma management, and 15 for cataract surgery. The control group received usual care.
                Falls and fractures during 12 months of follow-up were ascertained according to self-report using a monthly postcard system.
                Fifty-seven percent of subjects fell at least once during follow-up. Falls occurred more frequently in the group randomized to receive the vision intervention (65% fell at least once; 758 falls in total) than in the control group (50% fell at least once; 516 falls in total). The falls rate ratio using the negative binomial model was 1.57 (95% confidence interval (CI)=1.20-2.05, P=.001). Fractures were also more frequent in the intervention group (31 fractures) than the control group (18 fractures; relative risk from proportional hazards model 1.74, 95% CI=0.97-3.11, P=.06).
                In frail older people, comprehensive vision and eye assessment, with appropriate treatment, does not reduce, and may even increase, the risk of falls and fractures. The effectiveness of community-based fall assessment programs in older people is unclear. In this study, we examined the effectiveness of community-based fall assessment compared with hospital-based assessment.
                A randomized un-blind study was conducted in 369 older adults aged 65 years and over at high risk of falling. Participants were drawn from a larger cohort of community-dwelling older people. Eligible participants were identified by means of a simple five-item screening tool. A randomly chosen subset population of people at high risk of falling was then randomized into two arms, community-based and hospital-based fall assessments. The total number of falls in both groups was recorded by following up subjects' diaries and telephone interviews at 3, 6 and 12 months. Incidence Rate Ratios (IRR) for the rate of falls at 12 months between community- and hospital-based assessments were analysed as primary outcome, by intention-to-treat analysis.
                A total of 349 participants completed the study. Attendance to community-based assessment was significantly higher compared with hospital-based assessment in this older population (p=0.012). There were no statistically significant differences between the two groups in total number of falls at the 12 month follow-up. According to Negative Binomial regression, the adjusted IRR of falls in the community based arm was not significantly different from the hospital-based one (IRR 0.95; 95% CI 0.58-1.45, p=0.83).
                This study showed the increased risk of falling according to community-based fall assessment program with respect to a traditional hospital-based one in community-dwelling older adults at high risk of falling. there is inadequate evidence to support currently formulated NHS strategies to achieve health promotion and preventative care in older people through broad-based screening and assessment in primary care. The most extensively evaluated delivery instrument for this purpose is Health Risk Appraisal (HRA). This article describes a trial using HRA to evaluate the effect on health behaviour and preventative-care uptake in older people in NHS primary care.
                a randomised controlled trial was undertaken in three London primary care group practices. Functionally independent community-dwelling patients older than 65 years (n = 2,503) received a self-administered Health Risk Appraisal for Older Persons (HRA-O) questionnaire leading to computer-generated individualised written feedback to participants and general practitioners (GPs), integrated into practice information-technology (IT) systems. All primary care staff received training in preventative health in older people. The main outcome measures were self-reported health behaviour and preventative care uptake at 1-year follow-up.
                of 2,503 individuals randomised, 2,006 respondents (80.1%) (intervention, n = 940, control n = 1,066) were available for analysis. Intervention group respondents reported slightly higher pneumococcal vaccination uptake and equivocal improvement in physical activity levels compared with controls. No significant differences were observed for any other categories of health behaviour or preventative care measures at 1-year follow-up.
                HRA-O implemented in this way resulted in minimal improvement of health behaviour or uptake of preventative care measures in older people. Supplementary reinforcement involving contact by health professionals with patients over and above routine clinical encounters may be a prerequisite to the effectiveness of IT-based delivery systems for health promotion in older people. To test the effectiveness of, and explore interactions between, three interventions to prevent falls among older people.
                A randomised controlled trial with a full factorial design.
                Urban community in Melbourne, Australia.
                1090 aged 70 years and over and living at home. Most were Australian born and rated their health as good to excellent; just over half lived alone.
                Three interventions (group based exercise, home hazard management, and vision improvement) delivered to eight groups defined by the presence or absence of each intervention.
                Time to first fall ascertained by an 18 month falls calendar and analysed with survival analysis techniques. Changes to targeted risk factors were assessed by using measures of quadriceps strength, balance, vision, and number of hazards in the home.
                The rate ratio for exercise was 0.82 (95% confidence interval 0.70 to 0.97, P=0.02), and a significant effect (P<0.05) was observed for the combinations of interventions that involved exercise. Balance measures improved significantly among the exercise group. Neither home hazard management nor treatment of poor vision showed a significant effect. The strongest effect was observed for all three interventions combined (rate ratio 0.67 (0.51 to 0.88, P=0.004)), producing an estimated 14.0% reduction in the annual fall rate. The number of people needed to be treated to prevent one fall a year ranged from 32 for home hazard management to 7 for all three interventions combined.
                Group based exercise was the most potent single intervention tested, and the reduction in falls among this group seems to have been associated with improved balance. Falls were further reduced by the addition of home hazard management or reduced vision management, or both of these. Cost effectiveness is yet to be examined. These findings are most applicable to Australian born adults aged 70-84 years living at home who rate their health as good. To assess the effectiveness of a community-based falls-and-fracture nurse coordinator and multifactorial intervention in reducing falls in older people.
                Randomized, controlled trial.
                Screening for previous falls in family practice followed by community-based intervention.
                Three hundred twelve community-living people aged 75 and older who had fallen in the previous year.
                Home-based nurse assessment of falls-and-fracture risk factors and home hazards, referral to appropriate community interventions, and strength and balance exercise program. Control group received usual care and social visits.
                Primary outcome was rate of falls over 12 months. Secondary outcomes were muscle strength and balance, falls efficacy, activities of daily living, self-reported physical activity level, and quality of life (Medical Outcomes Study 36-item Short Form Questionnaire).
                Of the 3,434 older adults screened for falls, 312 (9%) from 19 family practices were enrolled and randomized. The average age was 81+/-5, and 69% (215/312) were women. The incidence rate ratio for falls for the intervention group compared with the control group was 0.96 (95% confidence interval=0.70-1.34). There were no significant differences in secondary outcomes between the two groups.
                This nurse-led intervention was not effective in reducing falls in older people who had fallen previously. Implementation and adherence to the fall-prevention measures was dependent on referral to other health professionals working in their usual clinical practice. This may have limited the effectiveness of the interventions. recent studies have found that moderate intensity exercise is an effective intervention strategy for preventing falls in older people. However, research is required to determine whether supervised group exercise programmes, conducted in community settings with at-risk older people referred by their health care practitioner are also effective in improving physical functioning and preventing falls in this group.
                to determine whether participation in a weekly group exercise programme with ancillary home exercises over one year improves balance, muscle strength, reaction time, physical functioning, health status and prevents falls in at-risk community-dwelling older people.
                the sample comprised 163 people aged over 65 years identified as at risk of falling using a standardised assessment screen by their general practitioner or hospital-based physiotherapist, residing in South Western Sydney, Australia. Subjects were randomised into either an exercise intervention group or a control group. Physical performance and general health measures were assessed at baseline and repeated 6-months into the trial. Falls were measured over a 12-month follow-up period using monthly postal surveys.
                at baseline both groups were well matched in their physical performance, health and activity levels. The intervention subjects attended a median of 23 exercise classes over the year, and most undertook the home exercise sessions at least weekly. At retest, the exercise group performed significantly better than the controls in three of six balance measures; postural sway on the floor with eyes open and eyes closed and coordinated stability. The groups did not differ at retest in measures of strength, reaction time and walking speed or on Short-Form 36, Physical Activity Scale for the Elderly or fear of falling scales. Within the 12-month trial period, the rate of falls in the intervention group was 40% lower than that of the control group (IRR=0.60, 95% CI 0.36-0.99).
                these findings indicate that participation in a weekly group exercise programme with ancillary home exercises can improve balance and reduce the rate of falling in at-risk community dwelling older people. To test whether a system of screening, assessment, referral, and follow-up provided within primary care for high-risk older outpatients improves recognition of geriatric conditions and healthcare outcomes.
                Controlled clinical trial with 3-year follow-up; intervention versus control group allocation based on practice group assignment.
                Department of Veterans Affairs (VA) ambulatory care center.
                Seven hundred ninety-two community-dwelling patients aged 65 and older identified by postal screening survey.
                The intervention combined a structured telephone geriatric assessment by a physician assistant, individualized referrals and recommendations, selected referral to outpatient geriatric assessment, and ongoing telephone case management.
                Main outcomes were VA medical record evidence of recognition and evaluation of target geriatric conditions (depression, cognitive impairment, urinary incontinence, falls, functional impairment), functional status (Functional Status Questionnaire, FSQ), and hospitalization (VA databases and self-reported non-VA usage).
                Intervention participants were more likely to have target conditions recognized, evaluated, and referred to specialized services within 12 months of enrollment, although there were no significant differences in FSQ scores or acute hospitalization between intervention and control groups at 1, 2, or 3 years follow-up. Subgroup analyses suggested improvements in depression symptoms and functional impairment at 1-year follow-up in intervention participants with these problems at baseline, but these findings were not evident at later follow-up.
                The intervention increased recognition and evaluation of target geriatric conditions but did not improve functional status or decrease hospitalization. Innovative screening methods can identify older people in need of geriatric services, but achieving measurable improvement in functional status or hospitalization rates will likely require a more-intensive intervention than a program involving primarily unsolicited referrals and short-term consultations. the burden of falls and fall-related injuries among older adults is well established. Contention surrounds the effectiveness, and hence value, of multi-component fall prevention interventions delivered in the community.
                using consensus-based analytic guidelines rather than time-to-first fall as the primary endpoint, the objective was to examine the effectiveness of the Whitehorse NoFalls trial on all falls, falls resulting in injury and falls requiring medical care to be sought. Design, setting and participants: the study was a community-based randomised controlled trial, with 1,090 participants assigned to one of eight groups, these being a combination of one or more of exercise, vision and or home hazard reduction or alternatively assignment to the control group.
                using negative binomial regression, the incidence of all falls, falls resulting in injury and those requiring medical care in the intervention groups were examined. Falls were reported using a monthly return calendar.
                exercise alone and in combination with vision and/or home hazard reduction was associated with fewer falls. For falls resulting in injury and the subset requiring medical care, the vision plus exercise intervention was associated with fewer falls.
                the findings confirm the effectiveness of exercise in preventing falls among community-dwelling older adults and supports contention that multi-component interventions do not prevent more falls than a single intervention. The results highlight the effectiveness of vision plus exercise in preventing more serious falls, a finding which warrants further consideration. to determine the clinical effectiveness of a day hospital-delivered multifactorial falls prevention programme, for community-dwelling older people at high risk of future falls identified through a screening process.
                multicentre randomised controlled trial.
                eight general practices and three day hospitals based in the East Midlands, UK. Participants: three hundred and sixty-four participants, mean age 79 years, with a median of three falls risk factors per person at baseline. Interventions: a day hospital-delivered multifactorial falls prevention programme, consisting of strength and balance training, a medical review and a home hazards assessment. Main outcome measure: rate of falls over 12 months of follow-up, recorded using self-completed monthly diaries.
                one hundred and seventy-two participants in each arm contributed to the primary outcome analysis. The overall falls rate during follow-up was 1.7 falls per person-year in the intervention arm compared with 2.0 falls per person-year in the control arm. The stratum-adjusted incidence rate ratio was 0.86 (95% CI 0.73-1.01), P = 0.08, and 0.73 (95% CI 0.51-1.03), P = 0.07 when adjusted for baseline characteristics. There were no significant differences between the intervention and control arms in any secondary outcomes.
                this trial did not conclusively demonstrate the benefit of a day hospital-delivered multifactorial falls prevention programme, in a population of older people identified as being at high risk of a future fall.
There is no evidence that community-based screening of asymptomatic older people results in improvements in vision.