Falls in Older Adults: Prevention, Mortality, and Costs.

Abstract

In this issue of JAMA, Liu-Ambrose and colleagues report the results of a randomized clinical trial testing the ability of a home-based exercise program to prevent falls in older persons presenting for treatment after a prior fall.1 Over a mean follow-up time of 338 days (0.92 years), those randomized to the exercise group experienced a significantly lower number of self-reported falls (236 falls among 172 participants) compared with those in the usual care group (366 falls among 172 participants). The estimated incidence rates of falls per person-year were 1.4 in the exercise group vs 2.1 in the usual care group (absolute difference, 0.74; 95% CI, 0.04-1.78), suggesting that just 1.2 participants had to be treated per year to prevent 1 fall event. However, the study did not show differences in the number of participants who experienced 1 or more falls (105 participants in the exercise group vs 104 in the usual care group) or those who experienced fall-related fractures (15 in the exercise group vs 12 in the usual care group). The results of the study conducted by Liu-Ambrose et al add to growing clinical trial evidence that physical activity programs are highly effective for prevention of falls among older persons living in the community.2,3 This trial used the widely available home-based Otago program, which was individually delivered to those in the intervention group by a physical therapist and consisted of strengthening, balance, and walking exercises. Participants in the control (“usual care”) group received fall prevention care provided by a geriatrician. Other randomized clinical trials have shown that physical exercise programs reduce injurious falls and the number of older persons experiencing a fall.3 Among different types of interventions, including multifactorial interventions, vitamin D, and physical exercise, physical exercise was consistently the most efficacious in preventing falls and injurious falls.2,3 The 2018 Physical Activity Guidelines Advisory Committee Scientific Report highlights the strong evidence that physical exercise improves physical function and reduces risk of falls and fall-related injuries while also preventing disability in older persons.4,5 In the study by Liu-Ambrose et al, the home-based exercise program reduced the number of falls without improving physical performance measures, including the Short Physical Performance Battery and the Timed Up and Go Test, suggesting that the reduction in fall risk was mediated by mechanisms other than detectable improvements in muscle strength or physical function. Other factors not measured in this trial, such as improvements in self-efficacy and self-controlled coping awareness, may have played a role.6 The health benefits of physical exercise are well established4; however, the molecular mechanisms by which exercise produces health benefits are poorly understood. A multidisciplinary consortium funded by the National Institutes of Health, named Molecular Transducers of Physical Activity,7 has initiated a large discovery multicenter trial linked with animal studies to address this gap in evidence. Not all older persons benefit from physical exercise interventions, partly because of difficulty with adherence linked to inability or unwillingness to engage in regular exercise. Thus, future studies should address novel sustainable behavioral approaches to target risk factors for falls, such as obesity and prolonged sitting time, in addition to pain, fatigue, sleep, and depression.8 A cluster-randomized pragmatic effectiveness trial of a multifactorial fall injury prevention strategy named Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) was recently completed,9 and data analyses are ongoing. The intervention consists of multifactorial risk assessments and individualized care plans developed by a nurse, including surveillance, follow-up evaluation, and intervention strategies. However, no randomized clinical trials have specifically targeted obesity or sitting time for prevention of falls. Approximately 1 in 3 persons aged 65 years or older falls every year.10 Falling is a potentially catastrophic and lifethreatening event for older persons. Falls are frequent causes of disability, institutionalization, and mortality and are the primary causes of traumatic injury among older persons in the United States. Also in this issue of JAMA, Hartholt et al11 report data on fall-related mortality from the National Vital Statistics System in years 2000 to 2016 among persons aged 75 years or older. The absolute number of fall deaths almost tripled, from 8613 in 2000 to 25 189 in 2016, and the ageadjusted fall-related mortality rate virtually doubled in both men and women, from 60.7 to 116.4 per 100 000 men and from 46.3 to 105.9 per 100 000 women. In another report in this issue of JAMA, Montgomery et al12 analyzed the Medicare and Medicaid claims for acute hospitalization from 2008 through 2014 for persons aged 65 years or older using a nationally representative 20% sample. Traumatic injury was among the most frequent primary indications for hospitalization. Average annual payments for hospitalization, readmission, and postacute care within 90 days of discharge for traumatic injury in this 20% sample were estimated at $2.76 billion, which was significantly Related articles pages 2092, 2129, and 2131 Opinion