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.
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.
There is no evidence that community-based screening of asymptomatic older people results in improvements in vision.