Vitamin D May Reduce Falls in Elderly Nursing Home Residents

January 29, 2010 — Vitamin D supplementation and pharmacist review of medications may help reduce falls in elderly nursing home residents, according to the results of a systematic review reported online January 20 in the Cochrane Database of Systematic Reviews.

“Falls in nursing care facilities and hospitals are common events that cause considerable morbidity and mortality for older people,” write Ian D. Cameron, MBBS, PhD, from Sydney Medical School, the University of Sydney in Ryde, Australia, and colleagues.

The goal of this review was to determine the efficacy of interventions aiming to reduce falls by older people in nursing care facilities and hospitals. The reviewers searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2009); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 2); MEDLINE, EMBASE, and CINAHL (all to November 2008); trial registers; and bibliographies of retrieved articles.

Criteria for inclusion in the review were randomized controlled trials of interventions designed to reduce falls in older people in nursing care facilities or hospitals, with main study endpoints of fall rate and the risk of falling. Methodologic quality of the trials was independently evaluated by 2 reviewers, who also extracted and pooled data where appropriate.

There were 41 trials, enrolling a total of 25,422 participants, meeting selection criteria. Findings from 7 trials testing supervised exercise interventions in nursing care facilities were inconsistent. Overall, multifactorial interventions were not associated with a significantly lower rate of falls in 7 trials enrolling a total of 2997 participants or with a lower risk of falling in 8 trials enrolling a total of 3271 participants.

However, multifactorial interventions provided by a multidisciplinary team were associated with lower rate of falls in nursing home residents (rate ratio [RaR], 0.60; 95% confidence interval [CI], 0.51 – 0.72; 4 trials, n = 1651) and risk of falling (risk ratio [RR], 0.85; 95% CI, 0.77 – 0.95; 5 trials, n = 1925), based on a post hoc subgroup analysis.

Vitamin D supplementation in nursing home residents was associated with a lower rate of falls (RaR, 0.72; 95% CI, 0.55 – 0.95; 4 trials, n = 4512) but not with the risk of falling (RR, 0.98; 95% CI, 0.89 – 1.09; 5 trials, n = 5095).

Multifactorial interventions in hospitals for patients with a length of stay of 3 weeks or more were associated with a lower rate of falls (RaR, 0.69; 95% CI, 0.49 – 0.96; 4 trials, n = 6478) and the risk of falling (RR, 0.73; 95% CI, 0.56 – 0.96; 3 trials, n = 4824). In addition, supervised exercise interventions were associated with a significant decrease in the risk of falling (RR, 0.44; 95% CI, 0.20 – 0.97; 3 trials, n = 131).

“There is evidence that multifactorial interventions reduce falls and risk of falling in hospitals and may do so in nursing care facilities,” the review authors write. “Vitamin D supplementation is effective in reducing the rate of falls in nursing care facilities. Exercise in subacute hospital settings appears effective but its effectiveness in nursing care facilities remains uncertain.”

Limitations of this review include those inherent in the selected studies, such as lack of blinding, confounding because of differences in treatment and control groups at entry, differences in underlying care programs, poorly defined inclusion and exclusion criteria and falling events, and differences in ascertainment of falls.

“Falls prevention programmes that include exercises for frail nursing care facility residents should carefully assess each individual’s suitability, as there is the possibility that exercise programmes may increase their risk of falls,” the review authors conclude. “The choice of type of exercises may be important in avoiding an increase in falls. The rate of falls and number of fallers should be monitored before and after adopting an intervention because it might increase falls.”

South Eastern Sydney and Illawarra Area Health Service, Australia; Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney, Australia; University of Otago, New Zealand; National Ageing Research Institute, Australia; and Accident Compensation Corporation, New Zealand, supported this review. The review authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online January 20, 2010. Abstract

For more information on falls in the elderly is available from the Centers for Disease Control.
Clinical Context

Older persons in nursing care facilities and hospitals often fall, with possible complications including loss of independence, injury, and even mortality. Effective interventions to prevent falls are important for the health of these individuals as well as for public health and reduction of healthcare costs.

Interventions to lower fall risk should be evidence-based so that staff time and resources are allocated appropriately and so that older persons and their families are not subjected to the stress of ineffective interventions. This review aimed to inform best practice and to identify issues of importance for future research regarding strategies of fall prevention.

Study Highlights

• The objective of this Cochrane review was to examine the efficacy of interventions designed to reduce falls among older people in nursing care facilities and hospitals.
• Literature searched included the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2009); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 2); and MEDLINE, EMBASE, and CINAHL, all to November 2008.
• The reviewers also searched trial registers and references cited in identified articles.
• Selection criteria were randomized controlled trials of interventions designed to lower fall risk in elderly nursing home residents or hospital inpatients, with primary outcomes of fall rate and the risk of falling.
• 2 reviewers independently examined trial quality and extracted data, which were pooled when feasible.
• Inclusion criteria were met by 41 trials with a total of 25,422 participants.
• For supervised exercise interventions in nursing care facilities, 7 trials yielded inconsistent results.
• Overall, multifactorial interventions in nursing care facilities did not reduce fall rate in 7 trials (total n = 2997) or risk of falling in 8 trials (total n = 3271).
• A post hoc subgroup analysis showed that multifactorial interventions provided by a multidisciplinary team were associated with lower fall rate (RaR, 0.60; 95% CI, 0.51 – 0.72; 4 trials, n = 1651) and risk of falling (RR, 0.85; 95% CI, 0.77 – 0.95; 5 trials, n = 1925) in residents of nursing care facilities.
• In residents of nursing care facilities, vitamin D supplementation was associated with decreased fall rate (RaR, 0.72; 95% CI, 0.55 – 0.95; 4 trials, n = 4512).
• However, vitamin D supplementation did not reduce the risk of falling in residents of nursing care facilities (RR, 0.98; 95% CI, 0.89 – 1.09; 5 trials, n = 5095).
• In nursing care facilities, a clinical medication review by a pharmacist appeared to be effective in reducing the rate of falls.
• In hospitals, multifactorial interventions for patients with length of stay of 3 weeks or more were associated with a lower rate of falls (RaR, 0.69; 95% CI, 0.49 – 0.96; 4 trials, n = 6478) and risk of falling (RR, 0.73; 95% CI, 0.56 – 0.96; 3 trials, n = 4824).
• However, the reviewers could not make recommendations regarding any particular component of these multifactorial intervention programs.
• Supervised exercise interventions in hospitals were associated with a significant reduction in the risk of falling (RR, 0.44; 95% CI, 0.20 – 0.97; 3 trials, n = 131).
• The reviewers concluded that multifactorial interventions reduce falls and the risk of falling in hospitals and may do so in nursing care facilities.
• They also concluded that vitamin D supplementation effectively reduces the rate of falls in nursing care facilities.
• Although exercise in subacute hospital settings appears to be effective, it remains uncertain whether it is effective in nursing care facilities.
• Review limitations are those of the included studies, such as lack of blinding, confounding, and poorly defined inclusion and exclusion criteria and falling events.

Clinical Implications

• A Cochrane systematic review shows that for elderly persons in nursing care facilities, vitamin D supplementation effectively reduces the rate of falls. A clinical medication review by a pharmacist may also be effective in reducing the rate of falls. However, the value of exercise in reducing fall risk remains uncertain in this setting.
• In hospitals, multifactorial interventions reduce falls and the risk of falling in elderly persons. Exercise in subacute hospital settings also appears to be effective in reducing the risk of falling, based on this Cochrane systematic review.

Source: Medscape CME

Authors:

Laurie Barclay, MD
Freelance writer and reviewer, Medscape, LLC
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Brande Nicole Martin
CME Clinical Editor, Medscape, LLC
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

Laurie Barclay, MD
Freelance writer and reviewer, Medscape, LLC
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Laurie E. Scudder, MS, NP
Accreditation Coordinator, Continuing Professional Education Department, Medscape, LLC; Clinical Assistant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC; Nurse Practitioner, School-Based Health Centers, Baltimore City Public Schools, Baltimore, Maryland
Disclosure: Laurie E. Scudder, MS, NP, has disclosed no relevant financial relationships.