Multidisciplinary assessment of elderly people with a history of multiple falls reduces the risk of further falls

Abstract

Question

Does assessment by a multidisciplinary team, or assessment by a community nurse with the ability to refer to other professionals, reduce further falls in recurrent fallers?

Design

Cluster-randomised, controlled trial.

Setting

18 general practices in the UK.

Participants

Adults aged at least 65 years, living in the community, who had experienced 2 or more falls in the past year, and who did not present to an emergency department for their most recent fall. Inability to participate for one year, abbreviated mental test score less than 7, and nursing home placement were exclusion criteria. Randomisation of 516 participants allotted 213 to care by the multidisciplinary team (secondary care), 141 to care by the community nurse (primary care), and 162 to usual care.

Interventions

Participants allocated to secondary care attended a multidisciplinary clinic (comprising a doctor, nurse, physiotherapist, and occupational therapist) with referral for investigations, interventions (including Homecheck), and follow-up if necessary. Participants allocated to primary care were assessed by a community nurse who identified risk factors for falls and could refer to other professionals. Participants in the usual care group were assessed by their usual primary care physicians, who provided management at their own discretion.

Outcome measures

The primary outcome was the proportion of participants in each group who had at least one fall during the follow-up period of 12 months. Other outcomes were death, move to institutional care, change in Barthel score, change in the timed Get Up and Go score, fall-related fractures, and hospitalisations. Participants lost to follow-up were assumed to have had an adverse outcome.

Results

466 participants contributed data to the primary outcome, with an adverse outcome assumed for a further 39 participants on falls and other dichotomous outcomes. At 12 months, 75% of the secondary care group, 87% of the primary care group, and 84% of the usual care group had fallen. Secondary care prevented significantly more falls than usual care (adjusted odds ratio 0.52, 95% CI 0.35 to 0.79). The secondary care group also had a significantly more positive Barthel index than the usual care group. The groups did not significantly differ on the other outcomes. The data were also analysed without imputing adverse outcomes for participants who were lost to follow-up. Compared to the usual care group, the secondary care group had significantly fewer falls, fractures, hospitalisations, and deaths.

Conclusion

Multidisciplinary assessment of elderly, recurrent fallers reduces the risk of further falls compared to usual care. Assessment of risk factors for falls by a community nurse with the potential to refer to other professionals did not have the same benefit.