New USPSTF Recommendations Address How Older Adults Can Prevent Falls and Fractures

Primary prevention is a medical term that means taking steps to prevent the onset of a disease or injury. It involves applying medical interventions before signs or symptoms of disease develop.

The United States Preventive Services Task Force (USPSTF) is an independent, volunteer panel of national experts in preventive medicine and primary care that rates the evidence for and make recommendations about the use of screening tests and preventive medical measures.[1]

It is safe to say that all primary care doctors want to help their patients avoid falls and bone fractures. To assist these doctors, the USPSTF recently updated its recommendations for primary prevention of falls and fractures among older community-dwelling adults.

Falls have consequences

Falling down is a common occurrence, especially for older people. The Centers for Disease Control and Prevention (CDC) reported that in 2014, nearly 30 percent of adults age 65 or older reported falling at least once in the preceding 12 months.[2]

Most people who fall are able to get right back up, but many falls result in serious injury. The CDC estimated that in 2014, 27,000 older adults in the U.S. died because of falls and 2.8 million were treated in emergency departments for fall-related injuries, with approximately 800,000 of these patients subsequently being hospitalized.[3]

Although only about 10 percent of falls result in fractures,[4] more than 95 percent of hip fractures in older adults are caused by falling.[5] Broken bones not only hurt, but they cause lingering disability. One year after suffering a hip fracture, many patients are unable to walk independently and need assistance with at least one important activity of daily living.[6]

Fall-prevention recommendations[7],[8]

The USPSTF examined whether there are any primary prevention approaches that are effective and safe for preventing falls in communitydwelling adults age 65 and older who have an average to high risk of falls. The task force focused on three commonly studied strategies for prevention of falls and fall-related injuries: vitamin D supplementation, exercise and a customized multifactorial approach based on individualized comprehensive falls risk assessments.

Vitamin D

The task force found seven randomized controlled trials that evaluated the effectiveness of vitamin D supplementation for preventing falls and fall-related injuries in a total of more than 7,500 post-menopausal women. The results of these trials were mixed: Some showed fewer falls in women receiving vitamin D supplements compared with those receiving a placebo, whereas others actually showed more falls in women receiving vitamin D, particularly at high doses. However, an analysis of data pooled together from all seven trials showed no benefit from vitamin D supplementation in the incidence of falls or death.

Furthermore, the USPSTF identified potential harms from vitamin D supplements, especially with high doses, including kidney stones, high blood calcium levels, high urine calcium levels and high blood sugar levels.

Given the lack of any clear benefit and the potential for significant harm, the task force recommended that seniors not take extra vitamin D in order to prevent falls.

Exercise

The USPSTF identified 21 clinical trials that evaluated the benefits and risks of exercise for prevention of falls and fall-related injuries. Combined, these trials enrolled nearly 7,300 subjects around the world and tested various exercise regimens for an average of about one year. The most common exercise regimens tested across trials included combined gait, balance and functional training (17 trials); resistance training (13 trials); flexibility exercises (eight trials); and endurance training (five trials).

An analysis of data pooled together from all 21 trials found that exercise resulted in a small but statistically significant reduction in the risk of falling. Eight of the 21 exercise trials monitored harms in the subjects assigned to the exercise groups. Only two trials measured harms in the control group subjects, and these trials reported no difference in the rates of serious injuries between the groups.

Based on this data, the USPSTF concluded with moderate certainty that exercise interventions provide a moderate net benefit in preventing falls in community-dwelling adults age 65 or older who are at increased risk of falls. The task force therefore recommended exercise programs to prevent falls in such patients.

Customized multifactorial approach

Walking and maintaining balance are the product of many body systems, including the brain, vision, inner ear, muscles, skin sensation and many more. Falling can result from a number of body system failures.[9] Thus, a multifactorial approach to individuals at risk of falling is intuitively appealing.

The USPSTF reviewed 26 trials involving more than 15,000 subjects in North America, Europe and New Zealand regarding this approach to fall prevention. The components of the multifaceted interventions included exercise, psychology, diet, education, medication management, incontinence management, environmental modification (for example, removing tripping hazards in the home), physical and occupational therapy, social services consultation and specialist consults (for example, eye doctor, neurologist and heart doctor).

An analysis of data pooled together from all 26 trials found that these programs reduced the number of falls but not the number of subjects who experienced a fall or the number of subjects who experienced a fall-related injury or a fall-related fracture.

Given these mixed results, the USPSTF concluded that there is moderate certainty from the literature that the net benefit of a customized multifactorial approach for preventing falls is small. The task force therefore recommended that primary doctors selectively offer multifactorial fall-prevention services to individual patients based on professional judgment and patient preferences.

Importantly, all of the USPSTF recommendations apply only to community-dwelling adults age 65 or older who do not have osteoporosis or vitamin D deficiency.

What You Can Do

If you are 65 or older, talk to your doctor about implementing a regular exercise program to prevent falls. This should involve a mix of aerobic conditioning, muscle strengthening, balance and flexibility training. Also, unless you are known to have osteoporosis, you should avoid taking extra vitamin D to prevent falls.

References

[1] About the USPSTF. U.S. Preventive Services Task Force Web Site. February 2018. https://www.uspreventiveservicestaskforce.org/Page/Name/about-the-uspstf. Accessed August 3, 2018.

[2] Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged 65 years—United States, 2014. Morb Mortal Wkly Rep. 2016;65(37):993-998.

[3] Ibid.

[4] Berry SD, Miller RR. Falls: Epidemiology, pathophysiology, and relationship to fracture. Curr Osteoporos Rep. 2008;6(4):149-154.

[5] Centers for Disease Control and Prevention. Home and recreational safety: Hip fractures among older adults. September 20, 2016.https://www.cdc.gov/homeandrecreationalsafety/falls/adulthipfx.html. Accessed August 3, 2018.

[6] Magaziner J, Hawkes W, Hebel JR, et al. Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci. 2000;55(9): M498-M507.

[7] Guirguis-Blake JM, Michael YL, Perdue LA, et al. Interventions to prevent falls in older adults: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018.319(16): 1705-1716.

[8] US Preventive Services Task Force. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018. 319(16):1696-1704.

[9] Cuevas-Tristan R. Balance problems and fall risks in the elderly. Phys Med Rehabil Clin N Am. 2017;28(4):727-737.