Guide Evidence-Based Interventions for Community Dwelling Older Adults

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See the Clinical Considerations section for information on risk assessment for falls. D recommendation. These recommendations apply to community-dwelling adults not known to have osteoporosis or vitamin D deficiency. Falls are the leading cause of injury-related morbidity and mortality among older adults in the United States.

Effective primary care interventions to prevent falls use various approaches to identify persons at increased risk. However, no instrument has been clearly identified as accurate and feasible for identifying older adults at increased risk for falls. Although many studies used a variety of risk factors, functional tests, or both involving gait, balance, or mobility to identify study participants, history of falls was the most commonly used factor that consistently identified persons at high risk for falls.

The USPSTF found adequate evidence that exercise interventions have a moderate benefit in preventing falls in older adults at increased risk for falls. The USPSTF found adequate evidence that multifactorial interventions have a small benefit in preventing falls in older adults at increased risk for falls. Based on the noninvasive nature of most of the interventions, the low likelihood of serious harms, and the available information from studies reporting few serious harms, the USPSTF found adequate evidence to bound the harms of exercise and multifactorial interventions as no greater than small.

The USPSTF found adequate evidence that the overall harms of vitamin D supplementation are small to moderate; evidence suggests that the harms of vitamin D supplementation at very high dosages may be moderate. The USPSTF concludes with moderate certainty that multifactorial interventions provide a small net benefit in preventing falls in older adults at increased risk for falls.

Quiz Ref ID This recommendation applies to community-dwelling adults 65 years or older who are not known to have osteoporosis or vitamin D deficiency Figure 2. When determining to whom these recommendations apply, primary care clinicians can reasonably consider a small number of risk factors to identify older adults who are at increased risk for falls.

Age is strongly related to risk for falls. Studies most commonly used a history of falls to identify increased risk for future falls; history of falls is generally considered together or sequentially with other key risk factors, particularly impairments in mobility, gait, and balance. A pragmatic approach to identifying persons at high risk for falls, consistent with the enrollment criteria for intervention trials, would be to assess for a history of falls or for problems in physical functioning and limited mobility.

Clinicians could also use assessments of gait and mobility, such as the Timed Up and Go test. Given the heterogeneity of interventions reviewed by the USPSTF, it is difficult to identify specific components of exercise that are particularly efficacious. The most common exercise component was gait, balance, and functional training 17 trials , followed by resistance training 13 trials , flexibility 8 trials , and endurance training 5 trials. Three studies included tai chi, and 5 studies included general physical activity.

The most common frequency and duration for exercise interventions was 3 sessions per week for 12 months, although duration of exercise interventions ranged from 2 to 42 months. Multifactorial interventions include an initial assessment of modifiable risk factors for falls and subsequent customized interventions for each patient based on issues identified in the initial assessment. The initial assessment could include a multidisciplinary comprehensive geriatric assessment or an assessment using a combination of various components, such as balance, gait, vision, postural blood pressure, medication, environment, cognition, and psychological health.

In studies, nursing staff usually performed the assessment, and a number of different professionals performed subsequent interventions, including nurses, clinicians, physical therapists, exercise instructors, occupational therapists, dieticians, or nutritionists. Intervention components vary based on the initial assessment and could include group or individual exercise, psychological interventions cognitive behavioral therapy , nutrition therapy, education, medication management, urinary incontinence management, environmental modification, physical or occupational therapy, social or community services, and referral to specialists eg, ophthalmologist, neurologist, or cardiologist.

Evidence-Based Resource Summary

The following single interventions lack sufficient evidence for or against their use to prevent falls in community-dwelling older adults when offered alone and not in the context of a multifactorial intervention: environmental modification, medication management, psychological interventions, and combination interventions not customized to an individual risk profile. Fractures are an important injury associated with falls, and the USPSTF has issued 2 related recommendation statements on the prevention of fractures.

The USPSTF recommends screening for osteoporosis in all women 65 years or older and in younger women at increased risk. The Centers for Disease Control and Prevention has published guidance on implementing community-based interventions to prevent falls. Although the evidence does not support routinely performing an in-depth multifactorial risk assessment with comprehensive risk management in all older adults, there may be reasons for providing this service to certain patients. Important items in the patient's medical history could include the circumstances of prior falls and the presence of comorbid medical conditions.

The American Geriatric Society AGS recommends multifactorial risk assessment with multicomponent interventions in older adults who have had 2 falls in the past year 1 fall if combined with gait or balance problems , have gait or balance problems, or present with an acute fall. The burden of falls on patients and the health care system is large. Reducing the incidence of falls would also improve the socialization and functioning of older adults who have previously fallen and fear falling again.

Many other interventions could potentially be useful to prevent falls, but because of the heterogeneity in the target patient population, heterogeneity ie, multiplicity of predisposing factors, and their additive or synergistic nature, the effectiveness of other interventions is not known.

However, many interventions with insufficient evidence to support their use to prevent falls have other arguments that support their use. Studies are needed on the clinical validation of primary care tools to identify older adults at increased risk for falls. More efficacy trials are needed on how the following interventions may help prevent falls if offered alone and not as part of multifactorial interventions: environmental modification, medication management, and psychological interventions. Additional research is needed on the effectiveness of interventions in different age groups, in particular adults older than 85 years.

Additional research to identify effective components of exercise interventions would also be useful. In , approximately 2. The USPSTF commissioned a systematic evidence review on the effectiveness and harms of primary care—relevant interventions to prevent falls and fall-related morbidity and mortality in community-dwelling older adults 65 years or older. Studies conducted solely in populations with specific medical diagnoses that could affect fall-related outcomes or for which interventions could be considered disease management eg, osteoporosis, vitamin D deficiency, visual impairment, and neurocognitive disorders were excluded.

This systematic evidence review updates the review and varies from the previous review in a few ways: additional falls outcomes, such as number of falls and injurious falls, were included, and studies of vitamin D supplementation conducted in populations known to be vitamin D deficient were excluded. Most commonly, studies used history of prior falls to identify persons at high risk for future falls 16 studies. Studies that evaluated exercise interventions most commonly used physical function or mobility limitation problems to identify high-risk populations.

Therefore, history of prior falls or physical function or mobility limitation problems may be adequate and appropriate factors for determining high risk. The USPSTF reviewed the evidence from 62 trials on the use of multifactorial interventions, exercise, vitamin D supplementation, environmental modifications, psychological interventions, and multiple interventions to prevent falls and fall-related morbidity and mortality. Although many studies reported on mortality, they were generally underpowered to detect changes in mortality, and results were not statistically significant.

The most commonly reported interventions included multifactorial interventions 26 trials , exercise 21 trials , and vitamin D supplementation 7 trials. The number of study participants ranged from 55 to , and the mean age ranged from 68 to 88 years. Three studies were conducted in the United States, 1 study in the United Kingdom, 8 studies in other parts of Europe, 7 studies in Australia or New Zealand, and 2 studies in Asia.

Studies found that exercise improved several fall-related outcomes. However, given that these findings were only exploratory analyses to evaluate causes of heterogeneity, they should be interpreted with caution. Although studies used various assessment approaches, history of falls was the most common risk factor used to identify persons at high risk. The number of participants ranged from to , and the mean age ranged from The percentage of women ranged from While studies found that multifactorial interventions reduced the number of falls, these interventions did not appear to improve other fall-related outcomes.

Pooled analyses found reductions in the number of falls among participants who received multifactorial interventions IRR, 0. The initial assessment to screen for modifiable falls risk factors used either a multidisciplinary comprehensive geriatric assessment or a specific falls risk assessment that evaluated any of the following: balance, gait, vision, cardiovascular health, medication, environment, cognition, and psychological health.

Treatment interventions varied substantially across studies and included targeted combinations of any of the following components: exercise, psychological interventions, nutrition therapy, knowledge, medication management, urinary incontinence management, environmental modification, and referrals to physical or occupational therapy, social or community services, or specialists eg, ophthalmologist, neurologist, or cardiologist.

Most studies referred participants to or offered an exercise or physical therapy intervention. The majority of studies included home visits for the initial assessment, environmental modification, or physical therapy or exercise interventions; other services were conducted in outpatient settings. Total contact time was rarely reported, precluding quantification of intervention intensity. Baseline mean serum hydroxyvitamin D levels ranged from Five studies were conducted exclusively in women; women comprised approximately half of the study population in the other 2 studies.

Studies of these other interventions were too few, too small, and too heterogeneous for the USPSTF to draw any definitive conclusions. The effect of interventions to prevent falls on functional status or quality of life remains uncertain. The few trials reporting quality of life, activities of daily living, or independent activities of daily living showed no benefit, but these studies used different scales, and few were adequately powered to detect differences in these outcomes.

Quiz Ref ID Evidence on harms was reported in a subset of trials reporting on the effectiveness of interventions. One study reported 1 wrist fracture in the intervention group 21 and another study reported a rate of 2. Adequate evidence indicates that the harms of physical therapy or exercise, such as a paradoxical increase in falls and an increase in physician visits, are small. The USPSTF concluded with high certainty that exercise or physical therapy confers a moderate benefit in the reduction of falls.

Convincing evidence indicates that the harms of vitamin D supplementation are no greater than small. The USPSTF found that multifactorial clinical assessment with comprehensive management of identified risk factors reduces the risk for falls by a small amount. Among the 15 multifactorial clinical assessment interventions with less-than-comprehensive management, the risk for falling was not reduced 1. The USPSTF found that there were no serious harms associated with multifactorial clinical assessment with comprehensive management.

Therefore, the USPSTF concluded with moderate certainty that the overall net benefit of multifactorial clinical assessment with comprehensive management of identified risk factors is small. Muscle weakness, gait disturbances, and imbalance are important factors that contribute to increased risk for falls in older persons. Vitamin D receptors have been identified in various cell types, including skeletal muscle, and stimulation of these receptors promotes protein synthesis. Vitamin D receptors decline with age. Several studies have demonstrated a beneficial effect of vitamin D or its metabolites on muscle strength and balance 25— Exercise and physical therapy probably improve strength and balance and therefore result in fewer falls.

The health status of older adults is affected by many interrelated variables, some of which probably have additive effects and may explain why multifactorial risk assessment with comprehensive management is effective in preventing falls. Many comments pointed out a lack of clarity about how to identify adults at increased risk for falls who would qualify for the recommended interventions.

Although the evidence is limited on tools to assess risk for falls, the USPSTF provided a pragmatic approach to assessing risk in the Clinical Considerations section. More information on the AGS guideline was provided in several sections of the statement to clarify the similarities. The Centers for Disease Control and Prevention recommends 3 categories of interventions: exercise-based, home modification for hazard reduction, and multifaceted including medical screening for visual impairment and medication review 8.

The National Institute on Aging outlines similar interventions for the prevention of falls: exercise for strength and balance, monitoring for environmental hazards, and regular medical care to ensure optimized hearing and vision, as well as medication management According to the AGS, detecting a history of falls is fundamental to a falls reduction program. It recommends that all older Americans be asked once a year about falls It further recommends that older persons who have fallen should have their gait and balance assessed by using one of the available evaluations, and that those who cannot perform or perform poorly on a standardized gait and balance test should be given a multifactorial fall risk assessment.

The multifactorial fall risk assessment should include a focused medical history, physical examination, functional assessments, and an environmental assessment. The AGS recommends the following interventions for falls prevention: adaptation or modification of home environment; withdrawal or minimization of psychoactive or other medications; management of postural hypotension; management of foot problems and footwear; exercise particularly balance , strength, and gait training; and vitamin D supplementation of at least IU per day for persons who have vitamin D deficiency or are at increased risk for falls.

The AGS found insufficient evidence to recommend vision screening as a single intervention for reducing falls. Evidence Synthesis no. AHRQ Publication no. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U. Preventive Services Task Force. Reference values for the timed up and go test: a descriptive meta-analysis. Washington, DC: U. Department of Health and Human Services; Accessed at www. Preventing Falls: What Works. Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings.

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Vitamin D supplementation improves neuromuscular function in older people who fall. National Institute on Aging. AgePage: Falls and Fractures. Bethesda, MD: U. New York: American Geriatrics Society; Members of the U. This article was published at www. This retraction concerns the article:. Preventive Services Task Force Recommendation. CME August 07, Start Activity for Practice.

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Table of Contents

View More View Less. Related Articles. Annals of Internal Medicine; 3 : Journal Club. Related Point of Care. Related Topics. PubMed Articles. View More. Sign in below to access your subscription for full content. Create Your Free Account Why? To receive access to the full text of freely available articles, alerts, and more. All Rights Reserved. Thus, such activities are strongly reflected in the practice and policy recommendations we have put forward from this review see Table 4. Participation, through volunteering, or in skills-based or social activities, that are accessible and affordable is fundamental to personal and community resilience in community-dwelling older adults.

Table 4. Practice, policy implications and areas for future research based on identified themes. Adversity such as a natural disaster can provide an opportunity for growth by adapting or transforming the context in which the event took place However, this is only likely to occur if there is already a high level of resilience within the community before the event 10 , 25 , 30 , 43 , 46 Refer to the positive feedback loop in Figure 1. Fois and Forino 40 outline an example of transformation within an Italian village after a massive earthquake in Older adults worked with younger adults to develop an eco-village for temporary accommodation which led to the revitalization of other community facilities and assets.

Yet, as Cinderby et al. While the availability of economic and support services are important, it appears that the culture of the local community plays a significant role in how a community will respond to a crisis. Lyon and Parkins 41 compared two rural Canadian communities in the wake of mill closures and found that local culture was the key to how the community will transform. Here again, older adults can play an active role, particularly in First Nations Peoples communities where the elders are revered as keepers of cultural knowledge and ways 29 , This is where social narratives and the recalling of history, particularly in how the community has responded to difficulties in the past—stories that are held by older members of our communities—can contribute to community resilience 1.

In effect, they can help reframe the disaster experience. Counter-narratives to mainstream perceptions can also be useful in supporting resilience. Wood et al. Likewise, Seaman et al. Attention should, therefore, be paid to the narratives surrounding older adults and their contributions to personal and community resilience, and consider these narratives in policy and research endeavors see Table 4.

While the types of activities outlined above have been shown to increase resilience at a local level, it is important to emphasize this may not be sufficient to overcome structural inequities evident within the context. However, as argued by Ledwith 45 , increased community activity that enhances participation and shared decision making can contribute by empowering local communities who may go on to advocate at broader political and social levels to eventually bring about structural change.

Such action takes a long time but is at the heart of the settings approach within health promotion and community development 45 , Older adults can, and do, play important roles in such advocacy. Instigating the initial co-operative activity may occur organically through one or two people identifying an issue that is able to generate local support and eventually lead to broader action Outside facilitation may also be necessary.

For example, Steiner 14 outlines a project in Scotland whereby external facilitators worked with rural communities who were not taking advantage of funding to provide community facilities. There are a number of limitations associated with this rapid review. Due to time restraints, it was necessary to restrict the study parameters, and as such it is possible there are relevant studies that have not been included that are in languages other than English, published prior to or located in databases outside those searched. Furthermore, it was not always possible to identify the ages of participants in studies leading to the exclusion of potentially relevant studies.

As such, it is within the context of these limitations that we outline a number of potential practice and policy implications, and potential areas for future research See Table 4. These primarily relate to: 1 encouraging community-dwelling adults to participate in community activities in order to collaborate with others; 2 promoting positive and healthy aging narratives by older adults, and about older adults; and 3 developing the evidence-base associated with such activities and resilience.

This rapid review evaluated the current literature related to individual and community resilience in community-dwelling older adults to understand the status of resilience in this population, identify gaps, and make recommendations about effective interventions that promote improved individual and community level capacity.

The review found personal resilience was based on positive reframing and agency, personal meaning and purpose, and acceptance and belonging. While at a community level, resilience was nourished by social empowerment, shared decision-making, agency, and collective leadership and engagement. The review highlighted the need to reframe how communities view older adults and shift the narrative away from focusing on age-related deficits toward acknowledging the economic and social contribution older adults make to the community through activities such as volunteering and the sharing of knowledge of history, culture, and skills.

At a community level, activities that draw on these personal-level capacities to promote collective action and participation are important for increasing community resilience. The review also established that resilience is generally developed in everyday circumstances, therefore active involvement within communities needs to be encouraged within community-dwelling older adults. Developing active involvement will not only contribute to both personal and community level resilience, but will enable communities to prosper and flourish through adversity.

In addition, MO undertook the searches and MA undertook the thematic analysis. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. We wish to acknowledge funding received from UnitingCare Queensland that enabled this review to be undertaken. Glasgow Centre for Population Health Magis K. Community resilience: an indicatory of social sustainability.

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