Falls in the elderly are far too common - 8% of people over 70 attend emergency rooms each year for fall-related injuries, and of these, over 30% are admitted to hospital. A healthy life-style (physical exercise, adequate dietary minerals and vitamins, medical, eyecare and footcare clinic checkups) and common sense about environmental hazards can help avoid falls in the first place. For patients who have experienced a fall, however, it is important to look for ways of preventing a recurrence. A randomized controlled trial to assess the benefits of a systematic approach in dealing with elderly patients who have had a fall has just been reported¹. Here are the main findings.

Participants were patients with falls aged 65 and over who went to the accident/emergency department of a British teaching hospital. Patients were contacted by phone and/or letter, to collect baseline data - details of the fall, any previous falls, medical conditions, medicine history, and so on. They were then randomly assigned to receive "intervention" - detailed medical and occupational-therapy assessment, with referral to relevant medical services if indicated - or no assessment, to act as controls. All participants were given a "falls diary" to record further falls.

In the intervention group, the medical assessment comprised a comprehensive physical examination, with emphasis on known risk factors for falls. After the medical assessment, an occupational therapist visited the patient at home. Functional independence and hazards in the home were evaluated. Advice on fall avoidance was given, and minor modifications made, if appropriate (e.g. removal of loose rugs, installation of handrails).

A postal questionnaire was sent to all participants every 4 months for 1 year, as follow-up. This inquired about further falls and fall-related injuries, with details of medical care. For evaluation, the two groups were compared with regard to the number of falls, serious injury (fracture or joint dislocation leading to hospitalization), and ability to go out alone.

After more than 1000 consecutive patients were screened for inclusion in the study, roughly 400 were divided into intervention and control groups. About 20% of these did not complete the study, leaving 141 intervention patients and 163 control patients for the 12-month follow-up analysis.

In the intervention group, the medical assessments revealed a wide variety of potentially relevant conditions: poor balance, poor vision, cataracts, poor mental functioning, decreased leg strength, leg nerve problems, depression and cardiovascular/circulatory disease. The principal causes of the falls were assessed as hazards outside or in the home, and cardiovascular/circulatory disease. All but 16% of cases were referred to a hospital service, day-care facility, eye-clinic or the family physician.

There were significantly fewer falls in the intervention group (183 falls in 141 patients) compared with the control group (510 falls in 163 patients). The risk of falling was significantly reduced in the intervention group - the odds were about 0.4 to 1 compared to controls - as was the risks of recurrent falls (odds of 0.33 to 1). There were also improvements in the intervention group with regard to the patients' ability to function in the home, and to go out and about.

While previous studies have shown the benefits of intervention in preventing repeated falls in elderly patients, this study has examined a more routine, structured approach. The variety of risk factors discovered at the medical assessment emphasizes the importance of addressing patient's individual problems, to see that falls don't happen again. Once someone has been to the emergency room after a fall, they are likely to be well motivated to avoid a repeat occurrence. This study shows a way in which each patient can best be helped, individually.