Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials
http://www.100md.com
《英国医生杂志》
1 Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California at Los Angeles, CA 90095, USA, 2 Southern California Evidence-Based Practice Center, RAND Health, Santa Monica, CA 90407, USA, 3 Greater Los Angeles VA Medical Center, Sepulveda, CA 91343, USA
Correspondence to: J T Chang, Division of General Internal Medicine and Health Services Research, 911 Broxton Avenue, Los Angeles, CA 90095-1736, USA johnchang@mednet.ucla.edu
Abstract
Falls are a major health problem among older adults. In the United States one in three people aged 65 or more living in the community fall at least once a year. This proportion increases to one in two for those over 80 years.1-3 Worldwide, adults aged over 70 years, particularly females, have a significantly higher fall related mortality than younger people.4 The severity of fall related complications also increases with age.2 3
The primary sequelae of falls include fall related injuries, such as fractures and head injuries, and post-fall anxiety.5-7 These lead to loss of independence through disability and fear of falling. The reduction in mobility and independence are often serious enough to result in admission to hospital or a nursing home or even premature death.8 9 In the United States in 1994 the total cost of fall injuries for older people was around $20.2bn and is projected to reach $32.4bn (in 1994 US dollars) by 2020.10
Although the extensive literature on interventions to prevent falls provides many insights, there is no clear message about how best to prevent falls in older adults. To identify effective interventions and their relative effectiveness in preventing such falls, we conducted a meta-analysis of relevant randomised controlled trials. This approach builds on earlier work, where beneficial interventions are identified by using separate estimates of absolute effectiveness in different study strata.11 Our strategy provides additional insight by applying a global multivariate model, allowing for assessment of the relative effectiveness of each intervention component while controlling for the effect of other components in multifactorial interventions across all studies.
Methods
Ninety nine of 830 articles met the inclusion criteria for detailed data abstraction (fig 1). Sixty one were randomised controlled trials that included outcomes on falls. These were reviewed for potential inclusion in the meta-regression analyses. After excluding articles for being outside our specified follow up period, using idiosyncratic interventions that could not be pooled (for example, restraints, a bed alarm), or including duplicate study populations (see bmj.com>), 40 trials contributed data to the meta-analyses (see table A on bmj.com>). Using the Jadad tool for study quality (scores from 0 to 5), four trials scored 1, 22 scored 2, and 14 scored 3.12 As this scoring system gives up to two points for double blinding, and double blinding is not conceptually possible for falls intervention studies, the maximum possible score for these studies is effectively 3. Nine studies described concealment of intervention allocation.
Fig 1 Flowchart of articles
Data for the meta-analysis of participants who fell at least once came from 26 intervention groups in 22 studies. The combined data showed a significant reduction in the risk of falling (risk ratio 0.88, 95% confidence interval 0.82 to 0.95; P = 0.03; I2 = 31%, 95% uncertainty interval, 0% to 61%; fig 2). Data for the meta-analysis on monthly rate of falling came from 30 intervention groups in 27 studies. The combined data showed a significant reduction in the monthly rate of falling (incidence rate ratio 0.80, 0.72 to 0.88; P < 0.001; I2 = 81%, 74% to 86%; fig 3).
Fig 2 Pooled risk ratio of participants who fell at least once
Fig 3 Pooled incidence rate ratio of monthly rate of falling
None of the studies directly assessed the relative effectiveness of intervention components. To assess such effectiveness we therefore compared the magnitude of the effect of each of the components to a control group that received usual care. We entered all studies in the meta-regression model that assessed the effect of individual components while controlling for other components (table 1). A multifactorial falls risk assessment and management programme had a statistically significant beneficial effect on both risk of falling (adjusted risk ratio 0.82, 0.72 to 0.94) and monthly rate of falling (adjusted incidence rate ratio 0.63, 0.49 to 0.83). The two models fit relatively well, explaining 29% and 16% of the variance, respectively. The risks assessed in multifactorial risk assessments varied among studies. The most commonly assessed risks were drugs, vision, environmental hazards, and orthostatic blood pressure (table 2). Exercise was an intervention in the largest number of studies. This also had a statistically significant beneficial effect on the risk of falls (adjusted risk ratio 0.86, 0.75 to 0.99), but on monthly rate of falling (adjusted incidence rate ratio 0.86, 0.73 to 1.01) did not reach conventional statistical significance. Environmental modification and education were primary components of a few studies, and the pooled estimates were not statistically significant.
Table 1 Meta-regression estimates of effect of individual intervention components controlling for other intervention components
In the second meta-regression analysis, we were not able to detect statistically significant differences or consistent trends in the efficacy between different types of exercises (table 3). Colinearity between balance and both flexibility and strength was problematic.
Table 3 Meta-regression estimates of effect of individual exercise components controlling for other exercise components
We observed some trends in the relative effectiveness of the major components of a multifactorial falls risk assessment and management programme, but no component was most or least effective.
In a post hoc analysis we attempted to see if the greater effectiveness of the multifactorial falls risk assessment and management programme was due to the preferential enrolment of people at higher risk. Therefore we classified each study according to population (general, community dwelling, or higher than average risk groups for falls—for example, living in a nursing home, recent history of falls) and repeated our meta-regression analyses stratified by population. No significant differences were found in effectiveness of the interventions by population studied.
A visual inspection of the funnel plots indicated no evidence of publication bias for all studies included in the meta-analyses for the risk ratio of falling at least once and for the falls incidence rate ratio. Although the adjusted rank correlation test indicated no evidence of publication bias, the regression asymmetry test did indicate some evidence for the falling at least once outcome.
None of the sensitivity analyses significantly changed the estimates of the meta-regression models, nor did the additional meta-regression models yield contrary conclusions.
Discussion
Blake AJ, Morgan K, Bendall MJ, Dallosso H, Ebrahim SB, Arie TH, et al. Falls by elderly people at home: prevalence and associated factors. Age Ageing 1988;17: 365-72.
O'Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993;137: 342-54.
Tinetti ME, Speechley M, Ginter SP. Risk factors for falls among elderly persons living in the community. N Eng J Med 1988;319: 1701-7.
Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva: World Health Organization, 2002.
Sattin RW, Lambert Huber DA, DeVito CA, Rodriguez JG, Ros A, Bacchelli S, et al. The incidence of fall injury events among the elderly in a defined population. Am J Epidemiol 1990;131: 1028-37.
Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: a prospective study. J Gerontol 1991;46: 164-70.
Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995;43: 1214-21.
Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health 1992;82: 1020-3.
Dunn JE, Furner SE, Miles TP. Do falls predict institutionalization in older persons? An analysis of data from the Longitudinal Study of Aging. J Aging Health 1993;5: 194-207.
Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. J Forensic Sci 1996;41: 733-46.
Gillespie LD, Gillespie WJ, Cumming R, Lamb SE, Rowe BH. Interventions for preventing falls in the elderly. In: Cochrane Library. Issue 1. Oxford: Update Software, 2003.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17: 1-12.
Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias, dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273: 408-12.
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7: 177-83.
Hedges LV, Olkin I. Statistical methods for meta-analysis. San Deigo, CA: Academic Press, 1985.
Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002;21: 1539-58.
Berkey CS, Hoaglin DC, Mosteller F, Colditz GA. A random-effects regression model for meta-analysis. Stat Med 1995;14: 395-411.
Stata Statistical Software. Release 7.0. College Station TX: Stata, 2001.
Sharp SJ. Meta-analysis regression. STATA Tech Bull 1998;42: 16-22.
Rothman KJ, Greenland S. Modern epidemiology. Philadelphia: Lippincott-Raven, 1998.
Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone, 1997.
Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315: 629-34.
Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994;50: 1088-101.
Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 1995;273: 1341-7.
Fiatarone MA, O'Neill EF, Doyle N, Clements KM, Roberts SB, Kehayias JJ, et al. The Boston FICSIT study: the effects of resistance training and nutritional supplementation on physical frailty in the oldest old. J Am Geriatr Soc 1993;41: 333-7.
Wolfson L, Whipple R, Judge J, Amerman P, Derby C, King M. Training balance and strength in the elderly to improve function. J Am Geriatr Soc 1993;41: 341-3.
Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community-dwelling older persons: results from a randomized trial. Gerontologist 1994;34: 16-23.
Mulrow CD, Gerety MB, Kanten D, Cornell JE, DeNino LA, Chiodo L, et al. A randomized trial of physical rehabilitation for very frail nursing home residents. JAMA 1994;271: 519-24.
Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331: 821-7.
Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J Am Geriatr Soc 1996;44: 489-97.
Buchner DM, Cress ME, de Lateur BJ, Esselman PC, Margherita AJ, Price R, et al. The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults. J Gerontol A Biol Sci Med Sci 1997;52: M218-24.
Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc 2000;48: 1679-89.
Juni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA 1999;282: 1054-60.
Cumming RG, Kelsey JL, Nevitt MC. Methodologic issues in the study of frequent and recurrent health problems. Falls in the elderly. Ann Epidemiol 1990;1: 49-56.
Jensen J, Nyberg L, Gustafson Y, Lundin-Olsson L. Fall and injury prevention in residential care effects in residents with higher and lower levels of cognition. J Am Geriatr Soc 2003;51: 627-35.
Shaw FE, Bond J, Richardson DA, Dawson P, Steen IN, McKeith IG, et al. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ 2003;326: 73.
Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID, et al. A randomized, controlled trial of quadriceps resistance exercise and vitamin D in frail older people: the Frailty Interventions Trial in Elderly Subjects (FITNESS). J Am Geriatr Soc 2003;51: 291-9.
Becker C, Kron M, Lindemann U, Sturm E, Eichner B, Walter-Jung B, et al. Effectiveness of a multifaceted intervention on falls in nursing home residents. J Am Geriatr Soc 2003;51: 306-13.
Steadman J, Donaldson N, Kalra L. A randomized controlled trial of an enhanced balance training program to improve mobility and reduce falls in elderly patients. J Am Geriatr Soc 2003;51: 847-52.
Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team (HIT): results from the randomized falls-HIT trial. J Am Geriatr Soc 2003;51: 300-5.(John T Chang, clinical in)
Correspondence to: J T Chang, Division of General Internal Medicine and Health Services Research, 911 Broxton Avenue, Los Angeles, CA 90095-1736, USA johnchang@mednet.ucla.edu
Abstract
Falls are a major health problem among older adults. In the United States one in three people aged 65 or more living in the community fall at least once a year. This proportion increases to one in two for those over 80 years.1-3 Worldwide, adults aged over 70 years, particularly females, have a significantly higher fall related mortality than younger people.4 The severity of fall related complications also increases with age.2 3
The primary sequelae of falls include fall related injuries, such as fractures and head injuries, and post-fall anxiety.5-7 These lead to loss of independence through disability and fear of falling. The reduction in mobility and independence are often serious enough to result in admission to hospital or a nursing home or even premature death.8 9 In the United States in 1994 the total cost of fall injuries for older people was around $20.2bn and is projected to reach $32.4bn (in 1994 US dollars) by 2020.10
Although the extensive literature on interventions to prevent falls provides many insights, there is no clear message about how best to prevent falls in older adults. To identify effective interventions and their relative effectiveness in preventing such falls, we conducted a meta-analysis of relevant randomised controlled trials. This approach builds on earlier work, where beneficial interventions are identified by using separate estimates of absolute effectiveness in different study strata.11 Our strategy provides additional insight by applying a global multivariate model, allowing for assessment of the relative effectiveness of each intervention component while controlling for the effect of other components in multifactorial interventions across all studies.
Methods
Ninety nine of 830 articles met the inclusion criteria for detailed data abstraction (fig 1). Sixty one were randomised controlled trials that included outcomes on falls. These were reviewed for potential inclusion in the meta-regression analyses. After excluding articles for being outside our specified follow up period, using idiosyncratic interventions that could not be pooled (for example, restraints, a bed alarm), or including duplicate study populations (see bmj.com>), 40 trials contributed data to the meta-analyses (see table A on bmj.com>). Using the Jadad tool for study quality (scores from 0 to 5), four trials scored 1, 22 scored 2, and 14 scored 3.12 As this scoring system gives up to two points for double blinding, and double blinding is not conceptually possible for falls intervention studies, the maximum possible score for these studies is effectively 3. Nine studies described concealment of intervention allocation.
Fig 1 Flowchart of articles
Data for the meta-analysis of participants who fell at least once came from 26 intervention groups in 22 studies. The combined data showed a significant reduction in the risk of falling (risk ratio 0.88, 95% confidence interval 0.82 to 0.95; P = 0.03; I2 = 31%, 95% uncertainty interval, 0% to 61%; fig 2). Data for the meta-analysis on monthly rate of falling came from 30 intervention groups in 27 studies. The combined data showed a significant reduction in the monthly rate of falling (incidence rate ratio 0.80, 0.72 to 0.88; P < 0.001; I2 = 81%, 74% to 86%; fig 3).
Fig 2 Pooled risk ratio of participants who fell at least once
Fig 3 Pooled incidence rate ratio of monthly rate of falling
None of the studies directly assessed the relative effectiveness of intervention components. To assess such effectiveness we therefore compared the magnitude of the effect of each of the components to a control group that received usual care. We entered all studies in the meta-regression model that assessed the effect of individual components while controlling for other components (table 1). A multifactorial falls risk assessment and management programme had a statistically significant beneficial effect on both risk of falling (adjusted risk ratio 0.82, 0.72 to 0.94) and monthly rate of falling (adjusted incidence rate ratio 0.63, 0.49 to 0.83). The two models fit relatively well, explaining 29% and 16% of the variance, respectively. The risks assessed in multifactorial risk assessments varied among studies. The most commonly assessed risks were drugs, vision, environmental hazards, and orthostatic blood pressure (table 2). Exercise was an intervention in the largest number of studies. This also had a statistically significant beneficial effect on the risk of falls (adjusted risk ratio 0.86, 0.75 to 0.99), but on monthly rate of falling (adjusted incidence rate ratio 0.86, 0.73 to 1.01) did not reach conventional statistical significance. Environmental modification and education were primary components of a few studies, and the pooled estimates were not statistically significant.
Table 1 Meta-regression estimates of effect of individual intervention components controlling for other intervention components
In the second meta-regression analysis, we were not able to detect statistically significant differences or consistent trends in the efficacy between different types of exercises (table 3). Colinearity between balance and both flexibility and strength was problematic.
Table 3 Meta-regression estimates of effect of individual exercise components controlling for other exercise components
We observed some trends in the relative effectiveness of the major components of a multifactorial falls risk assessment and management programme, but no component was most or least effective.
In a post hoc analysis we attempted to see if the greater effectiveness of the multifactorial falls risk assessment and management programme was due to the preferential enrolment of people at higher risk. Therefore we classified each study according to population (general, community dwelling, or higher than average risk groups for falls—for example, living in a nursing home, recent history of falls) and repeated our meta-regression analyses stratified by population. No significant differences were found in effectiveness of the interventions by population studied.
A visual inspection of the funnel plots indicated no evidence of publication bias for all studies included in the meta-analyses for the risk ratio of falling at least once and for the falls incidence rate ratio. Although the adjusted rank correlation test indicated no evidence of publication bias, the regression asymmetry test did indicate some evidence for the falling at least once outcome.
None of the sensitivity analyses significantly changed the estimates of the meta-regression models, nor did the additional meta-regression models yield contrary conclusions.
Discussion
Blake AJ, Morgan K, Bendall MJ, Dallosso H, Ebrahim SB, Arie TH, et al. Falls by elderly people at home: prevalence and associated factors. Age Ageing 1988;17: 365-72.
O'Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993;137: 342-54.
Tinetti ME, Speechley M, Ginter SP. Risk factors for falls among elderly persons living in the community. N Eng J Med 1988;319: 1701-7.
Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva: World Health Organization, 2002.
Sattin RW, Lambert Huber DA, DeVito CA, Rodriguez JG, Ros A, Bacchelli S, et al. The incidence of fall injury events among the elderly in a defined population. Am J Epidemiol 1990;131: 1028-37.
Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: a prospective study. J Gerontol 1991;46: 164-70.
Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995;43: 1214-21.
Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health 1992;82: 1020-3.
Dunn JE, Furner SE, Miles TP. Do falls predict institutionalization in older persons? An analysis of data from the Longitudinal Study of Aging. J Aging Health 1993;5: 194-207.
Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. J Forensic Sci 1996;41: 733-46.
Gillespie LD, Gillespie WJ, Cumming R, Lamb SE, Rowe BH. Interventions for preventing falls in the elderly. In: Cochrane Library. Issue 1. Oxford: Update Software, 2003.
Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17: 1-12.
Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias, dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273: 408-12.
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986;7: 177-83.
Hedges LV, Olkin I. Statistical methods for meta-analysis. San Deigo, CA: Academic Press, 1985.
Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002;21: 1539-58.
Berkey CS, Hoaglin DC, Mosteller F, Colditz GA. A random-effects regression model for meta-analysis. Stat Med 1995;14: 395-411.
Stata Statistical Software. Release 7.0. College Station TX: Stata, 2001.
Sharp SJ. Meta-analysis regression. STATA Tech Bull 1998;42: 16-22.
Rothman KJ, Greenland S. Modern epidemiology. Philadelphia: Lippincott-Raven, 1998.
Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone, 1997.
Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315: 629-34.
Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994;50: 1088-101.
Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow CD, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 1995;273: 1341-7.
Fiatarone MA, O'Neill EF, Doyle N, Clements KM, Roberts SB, Kehayias JJ, et al. The Boston FICSIT study: the effects of resistance training and nutritional supplementation on physical frailty in the oldest old. J Am Geriatr Soc 1993;41: 333-7.
Wolfson L, Whipple R, Judge J, Amerman P, Derby C, King M. Training balance and strength in the elderly to improve function. J Am Geriatr Soc 1993;41: 341-3.
Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community-dwelling older persons: results from a randomized trial. Gerontologist 1994;34: 16-23.
Mulrow CD, Gerety MB, Kanten D, Cornell JE, DeNino LA, Chiodo L, et al. A randomized trial of physical rehabilitation for very frail nursing home residents. JAMA 1994;271: 519-24.
Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331: 821-7.
Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. Atlanta FICSIT Group. Frailty and Injuries: Cooperative Studies of Intervention Techniques. J Am Geriatr Soc 1996;44: 489-97.
Buchner DM, Cress ME, de Lateur BJ, Esselman PC, Margherita AJ, Price R, et al. The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults. J Gerontol A Biol Sci Med Sci 1997;52: M218-24.
Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc 2000;48: 1679-89.
Juni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA 1999;282: 1054-60.
Cumming RG, Kelsey JL, Nevitt MC. Methodologic issues in the study of frequent and recurrent health problems. Falls in the elderly. Ann Epidemiol 1990;1: 49-56.
Jensen J, Nyberg L, Gustafson Y, Lundin-Olsson L. Fall and injury prevention in residential care effects in residents with higher and lower levels of cognition. J Am Geriatr Soc 2003;51: 627-35.
Shaw FE, Bond J, Richardson DA, Dawson P, Steen IN, McKeith IG, et al. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ 2003;326: 73.
Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID, et al. A randomized, controlled trial of quadriceps resistance exercise and vitamin D in frail older people: the Frailty Interventions Trial in Elderly Subjects (FITNESS). J Am Geriatr Soc 2003;51: 291-9.
Becker C, Kron M, Lindemann U, Sturm E, Eichner B, Walter-Jung B, et al. Effectiveness of a multifaceted intervention on falls in nursing home residents. J Am Geriatr Soc 2003;51: 306-13.
Steadman J, Donaldson N, Kalra L. A randomized controlled trial of an enhanced balance training program to improve mobility and reduce falls in elderly patients. J Am Geriatr Soc 2003;51: 847-52.
Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team (HIT): results from the randomized falls-HIT trial. J Am Geriatr Soc 2003;51: 300-5.(John T Chang, clinical in)