- Email: [email protected]
Educational intervention to reduce falls and fear of falling in patients after fragility fracture: Results of a controlled pilot study
Preventive Medicine 42 (2006) 316 – 319 www.elsevier.com/locate/ypmed
Educational intervention to reduce falls and fear of falling in patients after fragility fracture: Results of a controlled pilot study Diana Rucker a , Brian H. Rowe b,c , Jeffrey A. Johnson c , Ivan P. Steiner b,d , Anthony S. Russell a , David A. Hanley e , Walter P. Maksymowych a , Brian R. Holroyd b , Charles H. Harley a , Donald W. Morrish a , Brian J. Wirzba a , Sumit R. Majumdar a,c,⁎ a Department of Medicine, University of Alberta, Edmonton, Alberta, Canada Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada d Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada e Department of Medicine, University of Calgary, Calgary, Alberta, Canada
b c
Available online 20 February 2006
Abstract Objectives. Falls and fear of falling are a major health problem. We sought to determine the effectiveness of an educational intervention in reducing fear of falling and preventing recurrent falls in community-dwelling patients after a fragility fracture. Methods. One hundred two community-dwelling patients aged 50 years or older who fell and sustained a wrist fracture and were treated at Emergency Departments in Edmonton, Alberta, Canada (2001–2002) were allocated to either standardized educational leaflets and post-discharge telephone counseling regarding fall prevention strategies (“intervention”) or attention-controls (“controls”). Main outcomes were fear of falling and recurrent falls 3 months after fracture. Results. Mean age was 67 years and most patients were female (80%). The majority of falls (76%) leading to fracture occurred outdoors. Three months post-fracture, almost half of patients (48%) reported increased fear of falling and 11 of 102 (11%) reported falling again. The intervention did not reduce the fear of falling (43% had increased fear vs. 53% of controls, adjusted P value = 0.55) or decrease recurrent falls (17% fell vs. 5% of controls, adjusted P value = 0.059) within 3 months of fracture. Conclusions. An educational intervention undertaken in the Emergency Department was no more effective than usual care in reducing fear of falling or recurrent falls in community-dwelling patients. Future strategies must address a number of dimensions beyond simple education. © 2006 Elsevier Inc. All rights reserved. Keywords: Falls; Fear of falling; Fall prevention; Patient education; Wrist fractures; Community-dwelling patients
Introduction Falls and fear of falling are associated with considerable morbidity and mortality among the elderly. Wrist fractures are the most common symptomatic fracture related to osteoporosis and are also a predictor of recurrent falls and future fractures (Mallmin et al., 1993). Several fall intervention programs have been tested, including patient education, medication reviews, ⁎ Corresponding author. Department of Medicine, University of Alberta, 2E3.07 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440-112th Street, Edmonton, Alberta, Canada T6G 2B7. Fax: +1 780 407 2680. E-mail address: [email protected] (S.R. Majumdar). 0091-7435/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2006.01.008
exercise programs, and environmental modifications. Multifaceted fall prevention programs that include some or all of these components have shown clinically important reductions in falls (Chang et al., 2004; Gillespie et al., 2003); however, it is often unclear which components of the interventions are most effective or even necessary. Conversely, few studies have looked at the effects of simple and feasible interventions such as printed educational leaflets. Therefore, we conducted a two-part intervention, consisting of printed educational leaflets on fall prevention followed by a brief telephone counseling session, in older people presenting to the Emergency Department after a fall-related fracture of the wrist. We hypothesized that the intervention, compared with an
D. Rucker et al. / Preventive Medicine 42 (2006) 316–319
“attention-control,” would reduce self-reported fear of falling and decrease recurrent falls. Methods
Table 1 Characteristics of 102 patients with a fracture of the wrist, stratified by allocation to falls intervention or attention-control (Emergency Departments, Edmonton, Alberta, Canada [2001–2002]) Characteristics
Setting and population Our study took place in the 2 largest Emergency Departments in Capital Health (Edmonton, Alberta, Canada [2001–2002]). Patients with a closed fracture of the distal forearm were eligible if they were aged N50 years and discharged home. Exclusion criteria were: hospital admission, living outside Capital Health or in a long-term facility, or inability to provide consent or converse in English. Patients taking prescription medications for osteoporosis were also excluded because of a concurrent intervention to improve osteoporosis management (Majumdar et al., 2004). Written informed consent was obtained from each patient and the study was approved by the University of Alberta Health Ethics Research Board.
Study design and protocol We used a previously validated nonrandomized “on–off” time series scheme to allocate patients to either intervention or control (Weingarten et al., 1994). Each Emergency Department would, 1 month at a time, be either “on” or “off ” with respect to the intervention. This continued for the 20-month study duration. Patients were enrolled by trained orthopedic cast technicians or research nurses 24 h a day, seven days a week. The primary care physician for every subject received notification of the fallrelated fragility fracture. Intervention patients received brief printed educational material with evidence-based recommendations on fall prevention (American Academy of Family Physicians, 2001) in the Emergency Department. These easy-to-read leaflets emphasized reducing environmental hazards (e.g., poor lighting, loose rugs, proper footwear) and optimizing physical health (e.g., poor vision, foot problems, seeing the doctor for medication review). In addition, every patient was called at home within 1 week of discharge to reinforce the information and answer questions. Telephone calls lasted, on average, 10 min. To control for the amount of attention intervention patients received (“Hawthorne effect”), subjects in the control group received educational leaflets and telephone counseling sessions of similar length—although this information was entirely related to osteoporosis. All patients in both groups were encouraged to follow-up with their primary care physician.
Outcomes and measurements Primary outcomes were fear of falling (using a validated four-point fear scale (Lydick et al., 1997); for ease of interpretation, differences between self-reported fear scores at baseline and 3 months were grouped as any increased fear of falling vs. no increase [i.e., same or less]) and falls. A fall was defined as unintentionally coming to rest on the ground, not as a result of a sudden illness or major hazard (e.g., traffic accident). Outcomes were ascertained by research nurses blinded to allocation status.
317
Falls intervention, n = 47
Sociodemographic characteristics Mean age in years (SD) 66 (11) Female, n (%) 38 (81) White, n (%) 32 (68) ⁎⁎ Less than high school education, 19 (40) n (%) Lives alone, n (%) 16 (34) Falls risk factors ≥2 alcoholic drinks per day, n (%) 3 (6) Need assistance walking, rising 11 (23) from chair, n (%) Wear eyeglasses or contacts, n (%) 42 (89) Patient-reported measures at baseline Health status (SF-12) a Mean mental component score 52.4 (10.6) (SD) Mean physical component score 33.1 (6.0) (SD) Fear of falling No fear 37 (79) Little fear 8 (17) Moderate or a lot of fear 2 (4) Satisfied or very satisfied with care, 37 (79) n (%) Comorbid conditions Median number of total 2 (0–7) comorbidities (range) Heart disease, n (%) 9 (19) Osteoarthritis, n (%) 16 (34) Depression, n (%) 5 (11) Medications Median prescription medications 2 (0–8) (range) ≥4 prescription medications, n (%) 9 (19) ≥2 orthostatic hypotensive 6 (13) agents, b n (%) Previous fragility fracture 37 (79) ⁎ History of falls previous to fracture Within the last month 5 (9) Within the last year 12 (25) Mechanism of fall leading to fracture Tripped 16 (34) Slipped (ice, wet floor, physical 20 (43) activity) Outside of home 39 (83)
Attention-control, n = 55 67 (12) 42 (76) 49 (89) 22 (40) 24 (44) 4 (7) 18 (33) 52 (95)
50.8 (12.0) 33.3 (7.2)
43 (78) 10 (18) 2 (4) 47 (85)
2 (0–8) 8 (15) 23 (42) 8 (15) 2 (0–8) 11 (20) 11 (20) 34 (62) 3 (5) 13 (23) 18 (33) 27 (49) 39 (71)
a
Statistical analysis The study had 80% power to detect a 30% reduction in fear of falling with the enrollment of 90 subjects (45 per arm). We assessed differences between groups by a chi-squared test. Multivariate logistic regression models were used for our primary outcome variables, adjusted for baseline characteristics that differed at a P value b 0.10. Analyses were performed on an intention-to-treat basis, using Stata software, version 8.2 (StataCorp Inc., College Station, TX).
Results Of 572 eligible patients, 102 (18%) met inclusion and exclusion criteria: 47 were allocated to falls intervention and 55
Medical Outcomes Study 12-item short form. Orthostatic hypotension agents include any antihypertensive, diuretics, antidepressants, antipsychotics, sedatives, nitrates, or antiparkinsonian medications. ⁎ P = 0.064 (all P values are between-group differences). ⁎⁎ P = 0.033 (all P values are between-group differences). b
to the attention-control group. Reasons for exclusion (n = 470) were: hospital admission (n = 132), taking osteoporosis medications (n = 125), out-of-region (n = 113), refused consent (n = 42), and other miscellaneous reasons (n = 58). Baseline characteristics are shown in Table 1. Intervention and control patients were generally comparable, although more controls were white (89% vs. 68% of intervention patients, P = 0.033) and fewer controls reported a previous fracture (62%
318
D. Rucker et al. / Preventive Medicine 42 (2006) 316–319
Table 2 Recurrent falls and fear of falling in 102 patients 3 months after a fracture of the wrist, stratified according to intervention status (Emergency Departments, Edmonton, Alberta, Canada [2001–2002]) Outcomes
Falls Attention- Unadjusted intervention control odds ratio (n = 47) (n = 55) (95% CI)
Number of patients 8 (17) (%) falling at 3 months Number of patients 20 (43) (%) with increased fear of falling at 3 months a
3 (5)
29 (53)
Adjusted odds ratio (95% CI)
3.5 (0.9–14.3) 4.3 (0.9–19.8) a
0.7 (0.3–1.5)
0.8 (0.3–1.8) a
Adjusted for study site, white race and previous fracture (see Methods).
vs. 79% of intervention patients, P = 0.064). There was no difference between groups in primary care follow-up visits (34% of intervention vs. 24% of controls, P = 0.226), and no single patient was enrolled into the available fall prevention programs within the community throughout the study. Almost half (49 of 102 [48%]) of all study patients reported an increase in fear of falling at 3 months (P b 0.001). Intervention patients were less likely to report increased fear of falling after fracture than controls (20 of 47 [43%] vs. 29 of 55 [53%]), although this difference was not statistically significant (adjusted odds ratio 0.8, 95%CI 0.3 to 1.8, P = 0.55, Table 2). Eleven of the 102 study patients (11%) reported falling again within 3 months of fracture (Table 2). There was a trend towards an increase in recurrent falls among intervention patients compared with controls (8 of 47 [17%] vs. 3 of 55 [5%]; adjusted odds ratio 4.3), but this was not statistically significant (95%CI 0.9 to 20.0, P = 0.059). Discussion We found, in relatively healthy community-dwelling patients with a recent fall-related wrist fracture, that an educational intervention consisting of printed materials and telephone counseling sessions was no more effective than nonfall-related educational materials with respect to either reducing fear of falling or falls. Although the intervention was associated with a 10% reduction in self-reported fear of falling (adjusted P = 0.55), this was offset by a 12% increase in the rate of falls (adjusted P = 0.059). Our findings are in concordance with the conclusions of Chang et al.'s (2004) recent systematic review, which estimated that “educational interventions” for fall prevention were associated with a 28% relative increase in recurrent falls (95% CI − 5% to +72%). The annual incidence of recurrent falling is 20–30% (Tinetti et al., 1988). In only 3 months, 11% of our relatively nonfrail patients had fallen again, indicating that we had selected a highrisk population. Consistent with previous reports (Arfken et al., 1994), fear of falling was present in 22% of our patients before their wrist fracture, and was increased post-fracture in almost half of our population.
Our study was limited by a relatively small sample size. Nevertheless, it is unlikely that a larger study would have led to different conclusions, particularly since our intervention led to an increased rate of falling that reached borderline statistical significance (adjusted P = 0.059) in a direction consistent with previous systematic reviews of this topic—and in which onethird of the 40 studies reviewed were smaller than our study (Chang et al., 2004). Our study population was also relatively younger and more robust than the patients usually enrolled in fall prevention studies (Tinetti et al., 1988), although our results highlight that even the nonfrail elderly are at a high risk of falling. With these limitations in mind, we conclude that a simple and pragmatic educational intervention undertaken in the Emergency Department is unlikely to be sufficient to either reduce fear of falling or falls. Our study also demonstrates that even simple, inexpensive, and well-intended interventions need to be studied in controlled trials before widespread implementation (Rowe and Majumdar, 2005). Acknowledgments The authors dedicate this work to the memory of Deb Folk (in memoriam, 2004), our project coordinator, who was not able to see the final results published. Without her dedication and tireless efforts, this work would not have been possible. The authors would also like to thank the Orthopedic Plaster Room Technicians at the University of Alberta Hospital and the Royal Alexandra Hospital for their time and effort and the Epidemiology Coordinating and Research (EPICORE) Centre of the University of Alberta for providing services related to trial coordination and data management. All of the authors contributed to the conception and design of the study, acquisition of study subjects, interpretation of the data, critical revisions of the manuscript for important intellectual contributions, and have seen and approved the final manuscript. DR was also responsible for analyses of the data and drafting of the initial manuscript. SRM was also responsible for obtaining funding, supervising the study, and will act as guarantor for the data presented. References American Academy of Family Physicians. Falls: How to lower your risk. July 2001. Available from: http://familydoctor.org/x1885.xml [Accessed December 7, 2005]. Arfken, C.L., Lach, H.W., Birge, S.J., Miller, J.P., 1994. The prevalence and correlates of fear of falling in elderly persons living in the community. Am. J. Public Health 84, 565–570. Chang, J.T., Morton, S.C., Rubenstein, L.Z, Mojica, W.A., Maglione, M., Suttorp, M.J., et al., 2004. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 328, 680–683. Gillespie, L.D., Gillespie, W.J., Robertson, M.C., Lamb, S.E., Cumming, R.G., Rowe, B.H., 2003. Interventions for preventing falls in elderly people. Cochrane Database Syst. (4), 1–117 (Rev.:CD000340). Lydick, E., Zimmerman, S.I., Yawn, B., Love, B., Kleerekoper, M., Ross, P., et al., 1997. Development and validation of a discriminative quality of life questionnaire for osteoporosis (the OPTQoL). J. Bone Miner. Res. 12, 456–463.
D. Rucker et al. / Preventive Medicine 42 (2006) 316–319 Majumdar, S.R., Rowe, B.H., Folk, D., Johnson, J.A., Holroyd, B.H., Morrish, D.W., et al., 2004. A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture. Ann. Intern. Med. 141, 366–373. Mallmin, H., Ljunghall, S., Persson, I., Naessen, T., Krusemo, U.B., Bergstrom, R., 1993. Fracture of the distal forearm as a forecaster of subsequent hip fracture: a population-based cohort study with 24 years of follow-up. Calcif. Tissue Int. 52, 269–272. Rowe, B.H., Majumdar, S.R., 2005. Improving quality of asthma care after
319
Emergency Department discharge: evidence before action. Ann. Emerg. Med. 45, 299–301. Tinetti, M.E., Speechley, M., Ginter, S.F., 1988. Risk factors for falls among elderly persons living in the community. N. Engl. J. Med. 319, 1701–1707. Weingarten, S.R., Riedinger, M.S, Conner, L., Lee, T.H., Hoffman, I., Johnson, B., et al., 1994. Practice guidelines and reminders to reduce duration of hospital stay for patients with chest pain. An interventional trial. Ann. Intern. Med. 120, 257–263.
Educational intervention to reduce falls and fear of falling in patients after fragility fracture: Results of a controlled pilot study Diana Rucker a , Brian H. Rowe b,c , Jeffrey A. Johnson c , Ivan P. Steiner b,d , Anthony S. Russell a , David A. Hanley e , Walter P. Maksymowych a , Brian R. Holroyd b , Charles H. Harley a , Donald W. Morrish a , Brian J. Wirzba a , Sumit R. Majumdar a,c,⁎ a Department of Medicine, University of Alberta, Edmonton, Alberta, Canada Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada d Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada e Department of Medicine, University of Calgary, Calgary, Alberta, Canada
b c
Available online 20 February 2006
Abstract Objectives. Falls and fear of falling are a major health problem. We sought to determine the effectiveness of an educational intervention in reducing fear of falling and preventing recurrent falls in community-dwelling patients after a fragility fracture. Methods. One hundred two community-dwelling patients aged 50 years or older who fell and sustained a wrist fracture and were treated at Emergency Departments in Edmonton, Alberta, Canada (2001–2002) were allocated to either standardized educational leaflets and post-discharge telephone counseling regarding fall prevention strategies (“intervention”) or attention-controls (“controls”). Main outcomes were fear of falling and recurrent falls 3 months after fracture. Results. Mean age was 67 years and most patients were female (80%). The majority of falls (76%) leading to fracture occurred outdoors. Three months post-fracture, almost half of patients (48%) reported increased fear of falling and 11 of 102 (11%) reported falling again. The intervention did not reduce the fear of falling (43% had increased fear vs. 53% of controls, adjusted P value = 0.55) or decrease recurrent falls (17% fell vs. 5% of controls, adjusted P value = 0.059) within 3 months of fracture. Conclusions. An educational intervention undertaken in the Emergency Department was no more effective than usual care in reducing fear of falling or recurrent falls in community-dwelling patients. Future strategies must address a number of dimensions beyond simple education. © 2006 Elsevier Inc. All rights reserved. Keywords: Falls; Fear of falling; Fall prevention; Patient education; Wrist fractures; Community-dwelling patients
Introduction Falls and fear of falling are associated with considerable morbidity and mortality among the elderly. Wrist fractures are the most common symptomatic fracture related to osteoporosis and are also a predictor of recurrent falls and future fractures (Mallmin et al., 1993). Several fall intervention programs have been tested, including patient education, medication reviews, ⁎ Corresponding author. Department of Medicine, University of Alberta, 2E3.07 Walter Mackenzie Health Sciences Centre, University of Alberta Hospital, 8440-112th Street, Edmonton, Alberta, Canada T6G 2B7. Fax: +1 780 407 2680. E-mail address: [email protected] (S.R. Majumdar). 0091-7435/$ - see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.ypmed.2006.01.008
exercise programs, and environmental modifications. Multifaceted fall prevention programs that include some or all of these components have shown clinically important reductions in falls (Chang et al., 2004; Gillespie et al., 2003); however, it is often unclear which components of the interventions are most effective or even necessary. Conversely, few studies have looked at the effects of simple and feasible interventions such as printed educational leaflets. Therefore, we conducted a two-part intervention, consisting of printed educational leaflets on fall prevention followed by a brief telephone counseling session, in older people presenting to the Emergency Department after a fall-related fracture of the wrist. We hypothesized that the intervention, compared with an
D. Rucker et al. / Preventive Medicine 42 (2006) 316–319
“attention-control,” would reduce self-reported fear of falling and decrease recurrent falls. Methods
Table 1 Characteristics of 102 patients with a fracture of the wrist, stratified by allocation to falls intervention or attention-control (Emergency Departments, Edmonton, Alberta, Canada [2001–2002]) Characteristics
Setting and population Our study took place in the 2 largest Emergency Departments in Capital Health (Edmonton, Alberta, Canada [2001–2002]). Patients with a closed fracture of the distal forearm were eligible if they were aged N50 years and discharged home. Exclusion criteria were: hospital admission, living outside Capital Health or in a long-term facility, or inability to provide consent or converse in English. Patients taking prescription medications for osteoporosis were also excluded because of a concurrent intervention to improve osteoporosis management (Majumdar et al., 2004). Written informed consent was obtained from each patient and the study was approved by the University of Alberta Health Ethics Research Board.
Study design and protocol We used a previously validated nonrandomized “on–off” time series scheme to allocate patients to either intervention or control (Weingarten et al., 1994). Each Emergency Department would, 1 month at a time, be either “on” or “off ” with respect to the intervention. This continued for the 20-month study duration. Patients were enrolled by trained orthopedic cast technicians or research nurses 24 h a day, seven days a week. The primary care physician for every subject received notification of the fallrelated fragility fracture. Intervention patients received brief printed educational material with evidence-based recommendations on fall prevention (American Academy of Family Physicians, 2001) in the Emergency Department. These easy-to-read leaflets emphasized reducing environmental hazards (e.g., poor lighting, loose rugs, proper footwear) and optimizing physical health (e.g., poor vision, foot problems, seeing the doctor for medication review). In addition, every patient was called at home within 1 week of discharge to reinforce the information and answer questions. Telephone calls lasted, on average, 10 min. To control for the amount of attention intervention patients received (“Hawthorne effect”), subjects in the control group received educational leaflets and telephone counseling sessions of similar length—although this information was entirely related to osteoporosis. All patients in both groups were encouraged to follow-up with their primary care physician.
Outcomes and measurements Primary outcomes were fear of falling (using a validated four-point fear scale (Lydick et al., 1997); for ease of interpretation, differences between self-reported fear scores at baseline and 3 months were grouped as any increased fear of falling vs. no increase [i.e., same or less]) and falls. A fall was defined as unintentionally coming to rest on the ground, not as a result of a sudden illness or major hazard (e.g., traffic accident). Outcomes were ascertained by research nurses blinded to allocation status.
317
Falls intervention, n = 47
Sociodemographic characteristics Mean age in years (SD) 66 (11) Female, n (%) 38 (81) White, n (%) 32 (68) ⁎⁎ Less than high school education, 19 (40) n (%) Lives alone, n (%) 16 (34) Falls risk factors ≥2 alcoholic drinks per day, n (%) 3 (6) Need assistance walking, rising 11 (23) from chair, n (%) Wear eyeglasses or contacts, n (%) 42 (89) Patient-reported measures at baseline Health status (SF-12) a Mean mental component score 52.4 (10.6) (SD) Mean physical component score 33.1 (6.0) (SD) Fear of falling No fear 37 (79) Little fear 8 (17) Moderate or a lot of fear 2 (4) Satisfied or very satisfied with care, 37 (79) n (%) Comorbid conditions Median number of total 2 (0–7) comorbidities (range) Heart disease, n (%) 9 (19) Osteoarthritis, n (%) 16 (34) Depression, n (%) 5 (11) Medications Median prescription medications 2 (0–8) (range) ≥4 prescription medications, n (%) 9 (19) ≥2 orthostatic hypotensive 6 (13) agents, b n (%) Previous fragility fracture 37 (79) ⁎ History of falls previous to fracture Within the last month 5 (9) Within the last year 12 (25) Mechanism of fall leading to fracture Tripped 16 (34) Slipped (ice, wet floor, physical 20 (43) activity) Outside of home 39 (83)
Attention-control, n = 55 67 (12) 42 (76) 49 (89) 22 (40) 24 (44) 4 (7) 18 (33) 52 (95)
50.8 (12.0) 33.3 (7.2)
43 (78) 10 (18) 2 (4) 47 (85)
2 (0–8) 8 (15) 23 (42) 8 (15) 2 (0–8) 11 (20) 11 (20) 34 (62) 3 (5) 13 (23) 18 (33) 27 (49) 39 (71)
a
Statistical analysis The study had 80% power to detect a 30% reduction in fear of falling with the enrollment of 90 subjects (45 per arm). We assessed differences between groups by a chi-squared test. Multivariate logistic regression models were used for our primary outcome variables, adjusted for baseline characteristics that differed at a P value b 0.10. Analyses were performed on an intention-to-treat basis, using Stata software, version 8.2 (StataCorp Inc., College Station, TX).
Results Of 572 eligible patients, 102 (18%) met inclusion and exclusion criteria: 47 were allocated to falls intervention and 55
Medical Outcomes Study 12-item short form. Orthostatic hypotension agents include any antihypertensive, diuretics, antidepressants, antipsychotics, sedatives, nitrates, or antiparkinsonian medications. ⁎ P = 0.064 (all P values are between-group differences). ⁎⁎ P = 0.033 (all P values are between-group differences). b
to the attention-control group. Reasons for exclusion (n = 470) were: hospital admission (n = 132), taking osteoporosis medications (n = 125), out-of-region (n = 113), refused consent (n = 42), and other miscellaneous reasons (n = 58). Baseline characteristics are shown in Table 1. Intervention and control patients were generally comparable, although more controls were white (89% vs. 68% of intervention patients, P = 0.033) and fewer controls reported a previous fracture (62%
318
D. Rucker et al. / Preventive Medicine 42 (2006) 316–319
Table 2 Recurrent falls and fear of falling in 102 patients 3 months after a fracture of the wrist, stratified according to intervention status (Emergency Departments, Edmonton, Alberta, Canada [2001–2002]) Outcomes
Falls Attention- Unadjusted intervention control odds ratio (n = 47) (n = 55) (95% CI)
Number of patients 8 (17) (%) falling at 3 months Number of patients 20 (43) (%) with increased fear of falling at 3 months a
3 (5)
29 (53)
Adjusted odds ratio (95% CI)
3.5 (0.9–14.3) 4.3 (0.9–19.8) a
0.7 (0.3–1.5)
0.8 (0.3–1.8) a
Adjusted for study site, white race and previous fracture (see Methods).
vs. 79% of intervention patients, P = 0.064). There was no difference between groups in primary care follow-up visits (34% of intervention vs. 24% of controls, P = 0.226), and no single patient was enrolled into the available fall prevention programs within the community throughout the study. Almost half (49 of 102 [48%]) of all study patients reported an increase in fear of falling at 3 months (P b 0.001). Intervention patients were less likely to report increased fear of falling after fracture than controls (20 of 47 [43%] vs. 29 of 55 [53%]), although this difference was not statistically significant (adjusted odds ratio 0.8, 95%CI 0.3 to 1.8, P = 0.55, Table 2). Eleven of the 102 study patients (11%) reported falling again within 3 months of fracture (Table 2). There was a trend towards an increase in recurrent falls among intervention patients compared with controls (8 of 47 [17%] vs. 3 of 55 [5%]; adjusted odds ratio 4.3), but this was not statistically significant (95%CI 0.9 to 20.0, P = 0.059). Discussion We found, in relatively healthy community-dwelling patients with a recent fall-related wrist fracture, that an educational intervention consisting of printed materials and telephone counseling sessions was no more effective than nonfall-related educational materials with respect to either reducing fear of falling or falls. Although the intervention was associated with a 10% reduction in self-reported fear of falling (adjusted P = 0.55), this was offset by a 12% increase in the rate of falls (adjusted P = 0.059). Our findings are in concordance with the conclusions of Chang et al.'s (2004) recent systematic review, which estimated that “educational interventions” for fall prevention were associated with a 28% relative increase in recurrent falls (95% CI − 5% to +72%). The annual incidence of recurrent falling is 20–30% (Tinetti et al., 1988). In only 3 months, 11% of our relatively nonfrail patients had fallen again, indicating that we had selected a highrisk population. Consistent with previous reports (Arfken et al., 1994), fear of falling was present in 22% of our patients before their wrist fracture, and was increased post-fracture in almost half of our population.
Our study was limited by a relatively small sample size. Nevertheless, it is unlikely that a larger study would have led to different conclusions, particularly since our intervention led to an increased rate of falling that reached borderline statistical significance (adjusted P = 0.059) in a direction consistent with previous systematic reviews of this topic—and in which onethird of the 40 studies reviewed were smaller than our study (Chang et al., 2004). Our study population was also relatively younger and more robust than the patients usually enrolled in fall prevention studies (Tinetti et al., 1988), although our results highlight that even the nonfrail elderly are at a high risk of falling. With these limitations in mind, we conclude that a simple and pragmatic educational intervention undertaken in the Emergency Department is unlikely to be sufficient to either reduce fear of falling or falls. Our study also demonstrates that even simple, inexpensive, and well-intended interventions need to be studied in controlled trials before widespread implementation (Rowe and Majumdar, 2005). Acknowledgments The authors dedicate this work to the memory of Deb Folk (in memoriam, 2004), our project coordinator, who was not able to see the final results published. Without her dedication and tireless efforts, this work would not have been possible. The authors would also like to thank the Orthopedic Plaster Room Technicians at the University of Alberta Hospital and the Royal Alexandra Hospital for their time and effort and the Epidemiology Coordinating and Research (EPICORE) Centre of the University of Alberta for providing services related to trial coordination and data management. All of the authors contributed to the conception and design of the study, acquisition of study subjects, interpretation of the data, critical revisions of the manuscript for important intellectual contributions, and have seen and approved the final manuscript. DR was also responsible for analyses of the data and drafting of the initial manuscript. SRM was also responsible for obtaining funding, supervising the study, and will act as guarantor for the data presented. References American Academy of Family Physicians. Falls: How to lower your risk. July 2001. Available from: http://familydoctor.org/x1885.xml [Accessed December 7, 2005]. Arfken, C.L., Lach, H.W., Birge, S.J., Miller, J.P., 1994. The prevalence and correlates of fear of falling in elderly persons living in the community. Am. J. Public Health 84, 565–570. Chang, J.T., Morton, S.C., Rubenstein, L.Z, Mojica, W.A., Maglione, M., Suttorp, M.J., et al., 2004. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 328, 680–683. Gillespie, L.D., Gillespie, W.J., Robertson, M.C., Lamb, S.E., Cumming, R.G., Rowe, B.H., 2003. Interventions for preventing falls in elderly people. Cochrane Database Syst. (4), 1–117 (Rev.:CD000340). Lydick, E., Zimmerman, S.I., Yawn, B., Love, B., Kleerekoper, M., Ross, P., et al., 1997. Development and validation of a discriminative quality of life questionnaire for osteoporosis (the OPTQoL). J. Bone Miner. Res. 12, 456–463.
D. Rucker et al. / Preventive Medicine 42 (2006) 316–319 Majumdar, S.R., Rowe, B.H., Folk, D., Johnson, J.A., Holroyd, B.H., Morrish, D.W., et al., 2004. A controlled trial to increase detection and treatment of osteoporosis in older patients with a wrist fracture. Ann. Intern. Med. 141, 366–373. Mallmin, H., Ljunghall, S., Persson, I., Naessen, T., Krusemo, U.B., Bergstrom, R., 1993. Fracture of the distal forearm as a forecaster of subsequent hip fracture: a population-based cohort study with 24 years of follow-up. Calcif. Tissue Int. 52, 269–272. Rowe, B.H., Majumdar, S.R., 2005. Improving quality of asthma care after
319
Emergency Department discharge: evidence before action. Ann. Emerg. Med. 45, 299–301. Tinetti, M.E., Speechley, M., Ginter, S.F., 1988. Risk factors for falls among elderly persons living in the community. N. Engl. J. Med. 319, 1701–1707. Weingarten, S.R., Riedinger, M.S, Conner, L., Lee, T.H., Hoffman, I., Johnson, B., et al., 1994. Practice guidelines and reminders to reduce duration of hospital stay for patients with chest pain. An interventional trial. Ann. Intern. Med. 120, 257–263.