title: Randomized Controlled Trial of Screening, Risk Modification, and Physical Therapy to Prevent Falls Among the Elderly Recently Discharged From the Emergency Department to the Community: The Steps to Avoid Falls in the Elderly Study.
abstract: To evaluate the effectiveness of a multifactorial, tailored program of physical therapy to reduce the occurrence of falls among a heterogeneous group of high-risk elderly Singaporeans recently discharged from the emergency department (ED).
  
  
  
  Randomized controlled trial.
  
  
  
  Communities.
  
  
  
  Adults (N=354) aged ≥65 years who were seen in the ED for a fall or fall-related injuries and discharged home.
  
  
  
  The intervention primarily consisted of a tailored program of physical therapy focused on progressive training in strength, balance, and gait for a period of 3 months. Participants in the intervention group also received screening and follow-up for vision, polypharmacy, and environmental hazards. Participants in the control group received usual care prescribed by a physician and educational materials on falls prevention.
  
  
  
  The primary outcome measure was experiencing at least 1 fall during the 9-month study period (a 3-mo active intervention phase and a 6-mo maintenance phase). Secondary outcome measures were the occurrence of at least 1 injurious fall during the study period and a change in the Short Physical Performance Battery (SPPB) score. Participants were assessed both after 3 and 9 months.
  
  
  
  During the 9-month study period, 37.8% of the control group and 30.5% of the intervention group fell at least once, which was not statistically significantly different (odds ratio [OR]=.72; 95% confidence interval [CI], .46-1.12; P=.146). The intervention group had statistically significantly fewer individuals with injurious falls (OR=.56; 95% CI, .32-.98; P=.041) and less deterioration in physical performance, reflected by a mean difference of 0.6 in SPPB scores (P=.029). Multivariate analyses indicated a strong interaction effect between the intervention and the presence of 2 or more major comorbidities; after accounting for this effect, the intervention program reduced the number of people experiencing at least 1 fall (OR=.34; 95% CI, .17-.67; P=.002).
  
  
  
  We observed that in this heterogeneous population, the proportion of participants experiencing at least 1 fall during the study period was not statistically significantly lower in the intervention group compared with the control group. Secondary analyses strongly suggest that individuals with 2 or more major comorbidities do not benefit from a tailored physical therapy program; however, individuals with less comorbidity may substantially benefit.
authors.affiliation: Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Internal Medicine (General Internal Medicine), Duke University Medical Center, Durham, NC. Electronic address: david.matchar@duke-nus.edu.sg.
authors.forename: David B
authors.initials: DB
authors.lastname: Matchar
authors.affiliation: Department of Neurology and Sticht Center on Aging Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
authors.forename: Pamela W
authors.initials: PW
authors.lastname: Duncan
authors.affiliation: Department of Geriatric Medicine, Changi General Hospital, Singapore.
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Lien
authors.affiliation: Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore.
authors.forename: Marcus Eng Hock
authors.initials: MEH
authors.lastname: Ong
authors.affiliation: Community Programs, St. Andrew's Community Hospital, Singapore.
authors.forename: Mina
authors.initials: M
authors.lastname: Lee
authors.affiliation: Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore; National Heart Centre Singapore, Singapore.
authors.forename: Fei
authors.initials: F
authors.lastname: Gao
authors.affiliation: Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.
authors.forename: Rita
authors.initials: R
authors.lastname: Sim
authors.affiliation: Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore.
authors.forename: Kirsten
authors.initials: K
authors.lastname: Eom
mesh_terms: D000058:Accidental Falls / Q000517:prevention & control*; D000061:Accidents, Home / Q000517:prevention & control*; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D004636:Emergency Service, Hospital; D004777:Environment; D005260:Female; D006801:Humans; D008297:Male; D010351:Patient Discharge; D010353:Patient Education as Topic / Q000458:organization & administration; D026741:Physical Therapy Modalities; D019338:Polypharmacy; D014787:Vision Tests; D014947:Wounds and Injuries / Q000517:prevention & control*
keywords: Accidental falls; Frail elderly; Randomized controlled trial; Rehabilitation