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Finding Evidence for Effective Fall Prevention Interventions David Greene, Ph. D, OTR April 13, 2007

Evidence: The Many Ways of Knowing! • Individual articles – AJOT and Physical Therapy (official journal of APTA) subscriptions and journal club discussions – Various journal articles found through database searches • Systematic reviews • Meta analyses • Critically Appraised Topics (www. otcats. com) • AOTA Evidence-Based Practice Briefs & Abstracts (www. aota. org)

Practitioner-Friendly Sites Introduction of practitioner-focused sites • www. aota. org Evidence-Based Practice Resources • www. otseeker. com Set up like traditional database • www. OTCATS. com Critically Appraised Topics

FREE Sites for Searching: • OT CATS - Critically Appraised Topics in OT: http: //www. otcats. com • Physiotherapy Evidence Database (PEDro): http: //www. pedro. fhs. usyd. edu. au/index. ht ml • OTSeeker: http: //www. otseeker. com/ • Pub Med: http: //www. ncbi. nlm. nih. gov/entrez/query. f cgi? db=Pub. Med

FREE Sites for Searching: • Ageline through AARP: http: //www. aarp. org/research/ageline/ • Psychbite - a free evidence database for cognitive and behavioral interventions in cases of acquired brain injury: http: //www. psycbite. com/ • New England Journal of Medicine: http: //content. nejm. org/search. dtl • Google Scholar: http: //scholar. google. com/

Databases Used by Practitioners Courtesy CSU Fall 2006 Research Group

Yield Courtesy CSU Fall 2006 Research Group

Evidence Index 2006 Courtesy CSU Fall 2006 Research Group

Evidence Index 2007 Courtesy CSU Spring 2007 Research Group

Yield in Full-Text Articles Courtesy CSU Spring 2007 Research Group

Variation of Experience Courtesy CSU Spring 2007 Research Group

Yield in Citations with Abstracts Courtesy CSU Spring 2007 Research Group

Variation of Experience

Strategies Shown in Randomized Clinical Trials to Be Effective in Reducing the Occurrence of Falls among Elderly Persons Living in the Community. * Strategy No. of Trials with + Results Balance and gait training and 2 of 3 strengthening exercise Reduction in home hazards after 1 of 1 hospitalization Discontinuation of psychotropic medication 1 of 1 Multifactorial risk assessment with targeted 3 of 3 management Specific balance or strength exercise 2 of 2 programs Tinetti. n engl j med 348; 1 www. nejm. org january 2, 2003

Exercise in the Prevention of Falls in Older People A Systematic Literature Review Examining the Rationale and the Evidence Nick D. Carter, Pekka Kannus and Karim M. Khan Sports Med 2001; 31 (6): 427 -438

Sports Med 2001; 31 (6): 427 -438

Impairments and disabilities as risks for falls Risk factor falling Relative Risk for Falls (range between studies) Lower limb strength Upper limb strength Lower limb range of motion Sensation Vestibular function Vision Cognition Static Balance Dynamic Balance/Gait . 5 - 10. 3 1. 5 – 4. 3 1. 9 0. 6 – 5. 0 4. 0 1. 3 – 1. 6 1. 2 – 5. 0 1. 5 – 4. 1 1. 6 – 3. 3 Sports Med 2001; 31 (6): 427 -438

Intervention studies which have used exercise to modify intrinsic risk factors for falls Risk factor falling Average improvement (%) [range between studies] Muscle strength Range of motion Balance Gait Reaction time 6 -174 0. 5 -18 – 7 -53 12 -48 0 -4 Sports Med 2001; 31 (6): 427 -438

Case Comparison with Evidence Our Client Study #1: Study #2: RCT (Int v Con) Existing Gps Pre/post Case Study Items Compared Gender Age group Condition/Dx Symptoms Type of intervention desired/studied Time after Dx initiated Length of intervention Administered by Outcomes desired/measured in study Level of evidence or type of design (circle one) Identify items of evidence in these studies useful to the client RCT* (Int v Con) Existing Gps& Pre/post# Case Study@

• *RCT=randomized control trial: a study in which participants are randomly assigned to intervention versus control groups; this is highest quality of research and can be most trusted. • &Existing groups study also known as quasi experimental runs the intervention on groups that already exists, for example, a number of people living in a specific setting or comprised of people with a history of falling versus no history. This is good quality, and more common, but not as trustworthy as RCT. • #Pre/post studies one group – they are measured (pretest=count number of falls in past year), undergo the fall-prevention intervention, and then are measured again (post test=number of falls in the group after intervention). This is good quality, and more common, but not as trustworthy as RCT. • @Case study is weak research – it simply describes an intervention and how well it worked on one person. We should use this information ONLY if it is all we have. Case studies that are supported by practitioners’ clinical observations of clients in their own practices carry more weight. • ________________________ • Adapted from: Bailey, DM, Bornstein, J, & Ryan, S. (2007). A case report of evidence-based practice: From academia to clinic. American Journal of

Small Group Work now. .

Out of 13 intervention studies, the following reported success in preventing falls: Lehtola et al. , 2000 • N= 131; Intervention (n=92) an exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months; Control (n=39) usual activities • Relative hazard for falls for the exercise group in 10 mo = 0. 60 [95% CI for (Intervention) compared with (Control) 0. 43, 0. 84] Sports Med 2001; 31 (6): 427 -438

Out of 13 intervention studies, the following reported success in preventing falls: Lehtola et al. , 2000 N = 131; (n = 92), • Intervention an exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 (n = 39) months; Control usual activities • Relative hazard for falls for the exercise group in 10 mo = 0. 60 [95% CI for (Intervention) compared with (Control) 0. 43, 0. 84] Sports Med 2001; 31 (6): 427 -438

Campbell et al. , 1997 • N = 232; Control [n = 84]; Intervention [n = 116], individually tailored program of exercise. Physiotherapist visited 4× in first 2 mo. Exercises 3× per wk, 30 min each, lower limb strength and balance plus encouraged walking outside 3× per wk • Total falls: (Intervention) = 88, (Control) = 152; Rate of falls per year: (Intervention) = 0. 87 [SD 1. 29] (Control) = 1. 34 [SD 1. 93], difference 0. 47 (p < 0. 05) Sports Med 2001; 31 (6): 427 -438

Campbell et al. , 1999 • N = 152, 2 y follow-up of the above 12 mo study. Intervention (n = 71), individually tailored program of exercise. Physiotherapist visited 4× in first 2 mo of the original study. Exercises 3× per wk, 30 min each, lower limb strength and balance plus encouraged walking outside 3× per wk; Control (n = 81), equal care and frequent social visits • Total falls over 2 y: Intervention = 138, Control = 220. Rate of falls person year: Intervention = 0. 83 [SD 1. 29], Control = 1. 19 [SD 1. 93]. Relative hazard for falls for the exercise group at 2 y = 0. 69 [95% CI for Intervention group compared with Control = 0. 49, 0. 97]. • Relative hazard for a fall resulting in moderate or severe injury = 0. 63 (95% CI, 0. 42, 0. 95) Sports Med 2001; 31 (6): 427 -438

Buchner et al. , 1997 • All individuals had at least mild deficits in strength or balance. Intervention in 3 groups: (S) strength and flexibility [n = 25]; (E) endurance and flexibility [n = 25]; (SE) strength and endurance (n = 25). Strength training: upper and lower limb; 3 sessions per wk for 60 min. Endurance training: stationary cycle 75% max. heart rate. • 3 intervention groups analyzed as 1 group and compared to control group [n=25]: Falls in the first year: (In) = 42%, (Ct) = 60%; Relative risk in the intervention group 0. 53 (p < 0. 05) Sports Med 2001; 31 (6): 427 -438

Wolf et al. , 1996 • Intervention: 2 groups: Tai Chi (TC) [n = 72] 15 min twice daily at home for 4 mo; computerized balance training (BT) [n = 64]; Control [n = 64] education sessions once per wk. • 47. 5% reduction in fall incidence (p<0. 01) comparing Tai Chi group to control group; no sig. difference considering balance group Sports Med 2001; 31 (6): 427 -438

“. . . a programme of Tai Chi resulted in a 48% reduction of falls in participants (mean age 76 years) compared with controls. Such a reduction was not seen in the individuals who followed a computerised balance-training programme. It is of interest that whilst the computerised balance-training group developed greater stability on balance platform measures there was little change in this parameter in the Tai Chi group. ” Wolf et al. , 1996

No significant findings!: • Intervention 3 groups: exercise (n = 57), exercise / cognition (n = 72), cognition/behavioral (n = 51). Exercise: 60 min, 3× per wk, 12 mo. Stand-up, step-up, stretching and movement to music. Cognition/behavioral: health and safety curriculum to prevent falls, relaxation, video games. Exercise/cognition: 2× per wk exercise, once per wk cognition • Intervention (n = 42) stand-up/step-up routine progressing to 4 sets of 10 repetitions. 60 min 3× per wk; Control (n = 38), hourly meeting each wk focusing on health promotion and safety education • Intervention (n = 97) individually tailored one-one physiotherapy sessions 3× per wk for 4 mo, including range of motion, strength, balance, transfer and mobility. Each session 30 -40 min; Control (n = 97), same frequency friendly visits

No significant findings (cont. ): • Intervention (n = 100) 60 -min exercise sessions, twice weekly in 4 terms of 10 -12 wk. 4 sections per session: warm-up, conditioning (aerobic, strength, balance and flexibility), stretching and relaxation • Intervention 45 min weight-bearing exercise to music, 3× per wk for 3× 10 wk terms for 2 y; Control calcium supplementation (1000 mg daily): Intervention = 15 falls, Control = 31 falls (NS at 2 y); Significant difference between groups from 12 to 18 mo (p = 0. 011) (Mc. Murdo et al. , 1997) • Intervention = 3 groups: gradual psychotropic withdrawal over 14 wk plus home-based program of exercises [n = 24], drug withdrawal only (n = 24), exercise only (n = 21).

No significant findings (cont. ): • 12 month follow up. Intervention = 3 groups: exercise to improve balance and strength, frequency and duration of exercises not defined (n = 69); home safety advice to modify environmental hazards (n = 61); medical assessment to optimize health (n = 59). Control (n = 63) education and awareness of fall risk factors • 12 wk follow-up. Intervention (n = 31) strength, endurance, mobility and balance training for 90 min, 3× per wk for 12 wk; Control (n = 28) usual activities for the follow-up period. Intervention 38. 7% reported falling, Control 32. 1% reported falling (NS). Falls adjusted for activity: Intervention 6/1000 hr activity; Control 16. 2 (p < 0. 05) (Rubenstein et al. , 2000)

Type of Exercise Activity: Number of Effective and Ineffective Studies

Duration of Exercise found Effective and Ineffective

Frequency (times/week) of Exercise found Effective and Ineffective

Go to: http: //www. cochrane. org/reviews/ And search “Falls in the elderly” Interventions in Preventing Falls in the Elderly (Cochrane Review) Gillespie, Robertson, Lamb, Cumming & Rowe

The Cochrane Database of Systematic Reviews 2007 Issue 1 Copyright © 2007 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd. Background: Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention. Objectives: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care). Main results: Sixty two trials involving 21, 668 people were included. Interventions likely to be beneficial: Multidisciplinary, multifactorial, health/environmental risk factor screening/intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0. 73, 95%CI 0. 63 to 0. 85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0. 86, 95%CI 0. 76 to 0. 98),

Cochrane Review Summary • 62 trials 21, 668 people included in the review • Studies judged according to whether they were “likely to be beneficial” or “of unknown effectiveness” or “unlikely to be effective”

Risk Ratios (RR) of “Beneficial Interventions” * *Incidence Rate

Studies of Unknown Effectiveness • Group-Delivered Exercise • Individual LE Strengthening • Home Hazard Mod. w/ Medication Suggestions • Home Hazard Mod. w/ education packet on exercise and reducing falls • Cognitive/Behavioral Approach Alone • Hm. Haz. Mod. when no Hx of falling

Interventions Unlikely to be Effective • Brisk walking in older women with UE Fx.

Meta Analyses: Development of a common outcome data set for fall injury prevention trials: the prevention of Falls Network Europe consensus. (includes abstract) Lamb SE; Journal of the American Geriatrics Society, 2005 Sep; 53 (9): 1618 -22. (journal article - tables/charts) PMID: 16137297 CINAHL AN: 2009084166 Fall-prevention programs for the elderly: a Bayesian secondary meta-analysis. (includes abstract) Lucke JF; Canadian Journal of Nursing Research, 2004 Sep; 36 (3): 49 -64. (journal article - equations & formulas, tables/charts) PMID: 15551662 CINAHL AN: 2005015262

Meta Analyses: Trauma library in review. [Commentary on] A meta-analysis of fall prevention programs for the elderly. Strever T; Whalen E; Journal of Trauma Nursing, 2002 Jul. Sep; 9 (3): 84. (journal article - abstract, commentary) CINAHL AN: 2003064892 A meta-analysis of fall prevention programs for the elderly: how effective are they? (includes abstract) Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1 -8. (journal article - research, tables/charts) PMID: 11822564 CINAHL AN: 2002038264 Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. (includes abstract) Carter ND; Sports Medicine, 2001; 31 (6): 427 -38. (journal article - research, systematic review, tables/charts) PMID: 11394562 CINAHL AN: 2002022846 Do hospital fall prevention programs work? A systematic review. (includes abstract) Oliver D; Journal of the American Geriatrics Society, 2000 Dec; 48 (12): 1679 -89. (journal article - research, systematic review, tables/charts) PMID: 11129762 CINAHL AN: 2001029614

• • Fall-prevention programs for the elderly: a Bayesian secondary metaanalysis. 2004 A secondary meta-analysis of programs to reduce falls in the elderly is undertaken to demonstrate a Bayesian analysis. The Bayesian statistical tradition is carefully distinguished from the standard Neyman-Pearson-Wald (NPW) statistical tradition. In the 12 studies, the logit effect size is used to compare treatment groups using a prevention program to control groups without a program. To contrast the Bayesian analysis, independent-effects and fixed-effect meta-analyses are first conducted in the NPW tradition. This is followed by Bayesian independent-effects and fixed-effect metaanalyses that numerically replicate the NPW results but have conceptually different interpretations. The final analyses comprise Bayesian randomeffects and predictive meta-analyses. These results differ numerically from all the previous meta-analyses and conceptually from the NPW metaanalyses. The random-effects analysis allows for heterogeneity in the effect sizes. The predictive analysis yields the distribution of 5 a ne%^$w, out%^^^%^^-of-sample effect size, which accommodates &*%$(*%^$#not only the heterogeneity of the effects $*(%^)%(*$%*($#$ but also the imprecision in the %^&*%($(*&%parameter estimates. This last analysis shows that the effectiveness of new fall-prevention programs is less definitive than that found in the sample. Bayesian statistical methods are particularly well-suited for #@!&%$^%&$#&$&^%%%*&$*&$ %*&%*&$$&$&$()(*&%% %)(^___%)(%)%($$&*%#$&*#($ 467437376449 $(*$(*##)$$(* $(*$ (* $$(*$$* !@#$%&^*%($%)$(%*$&^#$&#&^@#*#$$(*#$(*$$of nursing science studies. !@#$#$&*%$(*&%%

Bayesian statistical methods are particularly well-suited for #@!&%$^%&$#&$&^%%%*&$*&$ %*&%*&$$&$&$()(*&%% %)(^___%)(%)%($$&*%#$&* #($ 467437376449 $(*$(*##)$$(* $(*$ (* $$(*$$* !@#$%&^*%($%)$(%*$&^#$&#&^ @#*#$$(*#$(*$$of nursing science studies. !@#$#$&*%$(*&%%

A meta-analysis of fall prevention programs for the elderly: how effective are they? • RESULTS: The overall mean weighted effect size for the 12 studies included in the meta-analysis was. 0779 (Z = 5. 03, p <. 001). • Exercise alone had a mean weighted effect size of. 0220 (Z = . 5303, p >. 5) • Exercise and risk modification had a mean weighted effect size of. 0687 (Z = 3. 41, p <. 001) • Comprehensive risk assessment intervention studies had an effect size of. 1231 (Z = 3. 97, p <. 001) • Mean weighted effect size for community-based studies was . 0972 (Z = 5. 37, p <. 001) and for institution-based studies was. 0237 (Z =. 7822, p =. 22). • CONCLUSIONS: There was a 4% decrease in the rate of falls for individuals who were in the treatment groups receiving various fall prevention interventions. Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1 -8.

Effect Size (ES) – What is it? • In a way – a “magic number”: it is an index of what can be seen/observed clinically as an improvement – removed from numbers or “statistical findings” • There are many effect size measures; the most common are r and Cohen’s d effect sizes • Cohen compared various statistical findings to clinical observations in the behavioral sciences and came up with a chart of equivalences

Effect Size (ES) – What is it? • In general, a positive ES indicates the intervention group improved visibly/functionally; ES = 0 indicates no effect of therapy or “the intervention”; a negative ES indicates the intervention was harmful or had a negative effect on the group (and should not be repeated!) • A Cohen’s d of. 5 and an r of. 3 is considered a “medium effect”; d =. 8 or r =. 5 considered “large or larger than typical effect”

Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. • RESULTS: On the basis of 9 randomized controlled studies conducted since 1996, exercise appears to be a useful tool in fall prevention in older adults, significantly reducing the incidence of falls compared with control groups. However, current limitations such as inconsistencies in the measurement of key dependent and independent variables do not, at present, permit a meta-analysis of intervention trials. Carter ND; Sports Medicine, 2001; 31 (6): 427 -38.

Do hospital fall prevention programs work? A systematic review. • RESULTS: Individual components of interventions showed no significant benefit. The pooled effect of about 25% reduction in the fall rate may be a result of intervention but may also be biased. Studies did not analyze compliance with the intervention or opportunity costs resulting from the intervention. Research and clinical programs in hospital fall prevention should pay more attention to study design and the nature of interventions. Oliver D; Journal of the American Geriatrics Society, 2000 Dec; 48 (12): 1679 -89.

Evidence Brief Structured Abstract

EBP Structured Abstract Results: • Participants in the treatment group that received physical and occupational therapy showed significant improvement • There was significantly more improvement in function in daily living tasks in treatment group • Participants who received treatment also showed significant improvement over the control group in their ability to walk 10 meters quickly (p <. 05). • The treatment group had improved motor coordination after 4 months of therapy. Copyright 2003 American Occupational Therapy Association, Inc. All rights reserved. This material may be reproduced and distributed without prior written consent.

http: //www. pedro. fhs. usyd. edu. au/

Summaries of work done from individual article reviews

Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial • Intervention group showed 31% reduction in falls; this was a significant difference compared to control group, p =. 025. • Intervention gp sig. > in mobility efficacy and number of protective behaviors adopted • 70% participants followed 50% of recommendations • “Stepping on” program in Appendix and a reference to its full description Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487 -1494, 2004

What is “significantly different”? ? • We are all different on just about anything you measure about us – height, weight, how far we throw a ball, etc. • Randomly select 2 groups from this room and get average weight of each group. The two averages will be slightly different – based on CHANCE of a few more people with more weight being in one group compared to the other. • Now I want to try an intervention – a diet for one gp, and the other is the control – “ eat as usual” gp. - and we do this experiment for 2 months.

“significantly different”? ? cont. . . • How much different do the average weights of the two gps need to be to feel confident the diet worked? – as they were different to begin with! • Statistical tests give us an answer – the averages must be different enough that the chances of finding a difference that great would be rare (a low probability) in any two groups selected and weighed WITHOUT either getting the diet.

What is “p”? ? • p tells us how low the probability is • Magic value for p (which stands for “probability of finding a difference this large between groups”) is. 05 • Example: An intervention to prevent falls showed a significant difference between fall-prevention gp. and usual treatment gp, p =. 05

What is “p”? ? cont. . . • p =. 05 means the chances of having a difference in number of falls this great WITHOUT the fall-prevention intervention is only 5 times in 100. • So, a p of <. 001 means the amount of difference was so great, it would happen only 1 time in 1000 of making two gps, having no intervention, and counting the number of falls in each group

Impact of a Multifactorial Fall Prevention Program Upon Falls of Frail Adults Attending an Adult Health Day Care Center • Significantly greater % fallers in control gp compared to fall prevention gp, p<. 001 • Significantly fewer environmental hazards and behavioral hazards in fall prevention gp, p<. 001 • Strength NOT significantly different, p>. 05, between two groups @ 6 months Diener & Mitchell, Topics in Geriatric Rehab, 21 (3): 247 -252, 2005

Preventing Falls in Older People: Outcome Evaluation of a Randomized Controlled Trial • No significant difference between fallprevention gp and control gp even though fall-prevention group showed significant increase in safety devices and significant reduction in hazards: installed hand-rails, removed rugs, increased lighting, repaired floors • Concluded a “one-time intervention not enough” to impact falling in this population Stevens, Holman, Benet, Klerk. Journal of the American Gerontological Society, 49: 1448 -1455, 2001

The Effect of an Individualized Fall Prevention Program on Fall Risks and Falls in Older People: A Randomized, Controlled Trial • No significant difference in the number of falls comparing the fall-prevention group to the usual-care group • No difference in falls – even though there was a significant decrease in internal risk factors resulting from the program including improved visual acuity, improved sit-to-stand time and improved knee flexion strength Lord, Tiedemann, Chapman, Munro, Murray, Remed, & Sherington. Journal of the American Gerontological Society, 53: 1296 -1304, 2005

Fall Prevention in Residential Care Homes: A Randomized Controlled Trial • No significant difference in the number of falls comparing the fall-prevention group (2. 2 falls/resident/year) versus the usual-care group (4 falls/resident/year) • No difference in falls – even though gait/balance training, medicine review, optometry and podiatry visits resulted in reduced risk factors in the fall-prevention group Dyer, Taylor, Reed, Dyer, Robertson, & Harrington. Age and Aging, 33 (6): 596 -602, 2004

Fall Prevention in Residential Care Homes: A Cluster Randomized Controlled Trial • No significant difference in the number of falls comparing the fall-prevention group (2. 2 falls/resident/year) versus the usual-care group (4 falls/resident/year) • This “low impact” individually prescribed fall risk management resulted in 56% of the fall prevention participants falling compared to only 43% of the usual care group – this is a negative effect size = the intervention actually resulted in significantly more falls, p=. 018!! Kerse, Butler, Robinson, & Todd. Journal of the American Gerontological Society, 52: 524 -531, 2004

Fall Prevention in Long-Term Care: An In. House Interdisciplinary Team Approach • Pretest/Posttest design – found significantly fewer falls (3. 2 falls) after the fall prevention program compared to before (5. 52 falls; p<. 001) • Also significantly fewer injuries from falls • Study outlines the 20 most frequently given recommendations; 274 interventions given overall with range of 5 to 17 per resident Eakman et al. Topics in Geriatric Rehabilitation, 17 (3): 29 -39, 2002

CDC Resources • Publications help older adults prevent falls • CDC, in partnership with the CDC Foundation and Met. Life Foundation, has produced four posters and redesigned two of its popular brochures to help older adults— and those who care for them—prevent falls and the injuries and deaths that result. These materials are important resources to protect the health and independence of older adults.

CDC • What YOU Can Do to Prevent Falls outlines four key fall prevention strategies. Strategies include exercising regularly, having medicines reviewed to reduce side effects and interactions, having yearly eye exams, and reducing fall hazards in the home. • Check for Safety: A Home Fall Prevention Checklist for Older Adults guides readers in a room-by-room check of their home to find and fix hazards that can increase the risk of falling. • Four posters, designed for use in health care facilities, senior centers, and other community organizations, highlight the messages in the brochures.

CDC Resources • In 2003, more than 13, 700 people 65 and older died from falls; 1. 8 million older adults were treated in emergency departments for nonfatal injuries from falls, and more than 460, 000 of these patients were hospitalized. Free Resources: • www. cdc. gov/ncipc/duip/fallsmaterial. htm. • www. cdc. gov/ncipc/duip/preventadultfalls. htm.

Guidance for gathering information as we work: Development of a Common Outcome Data Set for Fall Injury Prevention Trials: The Prevention of Falls Network Europe Consensus Sarah E. Lamb, Ellen C. Jorstad-Stein, Klaus Hauer, and Clemens Becker on behalf of the Prevention of Falls Network Europe and Outcomes Consensus Group JAGS 53: 1618– 1622, 2005 © 2005 by the American Geriatrics Society

Recommendation 2: Falls 1. A fall should be defined as ‘‘an unexpected event in which the participants come to rest on the ground, floor, or lower level. ’’ 2. Ascertainment must consider the lay perspective of falls. Participants should be asked, ‘‘In the past month, have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level? ’’ 3. Falls should be recorded using prospective daily recording and a notification system with a minimum of monthly reporting. Telephone or face-to-face interview should be used to rectify missing data and to ascertain further details of falls and injuries. 4. Fall data should be summarized as number of falls, number of fallers/ non fallers/frequent fallers, fall rate person year, and time to first fall (as a safety measure). 5. Primary analysis of fall data should not be adjusted for physical activity, and reporting should include the absolute risk difference between groups.

Recommendation 4: Psychological Consequences of Falling 1. Psychological consequences of falls should be conceptualized in terms of fallrelated self-efficacy, defined as ‘‘the degree of confidence a person has in performing common activities of daily living without falling’’ and measured using the modified Falls Efficacy Scale (m. FES). 18 2. The measure should be scored per published guidance. 18 Recommendation 5: Measure Health Related Quality of Life 1. The recommended measures of quality of life are the Short Form 12 (SF 12) version 2 and European Quality of Life Instrument (Euro. Qo. L EQ-5 D). ______________ Reference: Euro. Qol Group. Euro. Qol. Fa new facility for the measurement of health related quality of life. Health Policy 1990; 16: 199– 208.