Screening and exercise interventions did not reduce fractures in the elderly

1. In this pragmatic, randomized clinical trial, exercise or a multifactorial fall prevention strategy did not significantly affect fracture rates in the elderly

2. Exercise was cost effective at improving strength and top-level balance

Evidence Rating Level: 2 (Good)

Study Rundown: The elderly are at high risk of falls. Prevention of falls would lead to substantial improvements in quality of life and health resource utilization. In this randomized, pragmatic clinical trial, persons ≥ age 70 listed under general practices in England were assigned to mail advice only, screening for risk of falls and exercise only or screening and multifactorial fall prevention program. The multifactorial fall prevention program consisted of a medication review, exercise, home modifications, along with a referral to specialties for footwear, visual, postural hypotension and arrhythmia management. Exercise alone and the multifactorial fall prevention program did not statistically affect fracture rates. Exercise alone was found to be marginally more cost-effective driven by the quality of life improvements and reduced health care costs. The trial was limited in the method of measuring falls, as they were found through retrospective records using surveys as opposed to patient diaries. Osteoporosis was not considered which likely would have affected fracture rates. In general, this trial demonstrated that targeted use of exercise or a multifactorial fall prevention program may not result in fewer fractures.

Click here to read the study in NEJM

Relevant Reading: Multifactorial interventions for preventing falls in older people living in the community: a systematic review and meta-analysis of 41 trials and almost 20 000 participants

In-Depth [randomized controlled trial]: In this pragmatic, open-label, randomized trial of 9803 persons of age 70 and over, 3223 were assigned to mail advice only, 3279 were assigned to screening and exercise (Otago Exercise Program), and 3301 were assigned to screening and multifactorial intervention. 37% of those who completed the falls risk assessment were deemed at elevated falls risk. Fracture rates were measured in the rate of fractures per 100 person-years over 18 months. Exercise only was associated with a fracture rate ratio of 1.20 (95% confidence interval (CI), 0.91 to 1.59) and multifactorial fall intervention was associated with a rate ratio of 1.30 (95% CI 0.99 to 1.71) when compared to mail advice only. Exercise only was more cost-effective with a higher quality-adjusted life-year at the US $25,800 threshold at a probability of 70%. In those that received exercise (exercise only and multifactorial group). 86% demonstrated improved strength and 72% had improved top-level balance. There were three adverse events: one episode of angina, one fall during a multifactorial fall prevention assessment, and one hip fracture during the trial.

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