2. Disclosure belangen NHG spreker
(Potentiële) belangenverstrengeling
Niet van toepassing
Voor bijeenkomst mogelijk relevante relaties met bedrijven
Stichting ArtsenLaboratorium en Trombosedienst
VU medisch centrum
Sponsoring of onderzoeksgeld
Honorarium of andere (financiële) vergoeding
Aandeelhouder
Andere relatie, namelijk …
Stichting Achmea Gezondheidszorg

3. The effectiveness of a minimal intervention strategy to reduce falls in older women at high risk of falling
Karin Swart

4. Introduction (I) 1 out of 3 older persons (65+ yrs) falls yearly
10% physical injury
Internal and external risk factors
Balance and strength training
Multi-factorial interventions

5. Introduction (II) The Netherlands: 1. De Vries et al. (2010)
Recent fall and high fall risk of recurrent falling
Multi-disciplinary assessment
Treatment of multi-factorial risk factors
2. Hendriks et al. (2008)
Seen in emergency department after fall
Medical and occupational-therapy assessment
Recommendations/referals
No effect after 12 months
65+ers

6. Introduction (III) The Netherlands:
Multi-factorial interventions not effective
CBO guidelines “Preventie van valincidenten bij ouderen (2004)”:
Fall risk assessment after a fall
Case-finding
Treatment of risk factors
 Usual care extensive?
 Interventions not effective to
further decrease fall risk?
Lack of contrast

7. Research aim
To study the effectiveness of a minimal intervention, i.e. informing the GP, on falling among women with a high risk of falling?

8. Methods SALT Osteoporosis Study Pragmatic trial 10.465 women ≥65 yr
≥ 1 clinical risk factors for fractures
Individual randomization
Intervention group: Screening and treatment of high fracture risk
Control group: Usual care
Exclusie: age 91 years or older, weight ≥135 kg, actual use or usage in previous 5 years of bone-sparing drugs, use of high dose corticosteroids, suffering from terminal illness,

9. Methods Screening: Treatment advice to GP
Bone mineral density (DXA)
Vertebral fractures (IVA)
Absolute fracture risk (FRAX)
Fall risk
Treatment advice to GP
 Current study: women with high fall risk
Expert team for treatment advices

10. Methods High fall risk: Minimal intervention:
≥2 falls in past year, or
1 fall + high fear of falling/ use of walking aid
Minimal intervention:
Written notification of GP of high fall risk
No further action, therapies, recommendations, referrals

11. Methods Primary outcomes: Secondary outcome:
Falling in past 12 months
Recurrent falling: ≥2 falls in past 12 months
Secondary outcome:
Fear of falling
“How worried are you to fall?” (0-10 scale)
18 and 36 months follow-up
Questionnaire data

12. High drop out rate Randomization Intervention group N=5,302
Intervention group
N=5,302
Control group
N=5,163
Questionnaire 2
N=772
Exclusion or no clinical risk factor for fractures N=15,079
Baseline questionnaire
N=27,024
Exclusion by GP or not willing to participate
Female ≥65 years of age
N=54,093
Questionnaire 3
N=647
High fall risk
N=1,219
N=764
≥1 clinical risk factors for fractures N=10,465
No high fall risk
N=4,083
N=661
N=1,163
N=4,000
36 months
18 months
Baseline
High drop out rate

13. Baseline characteristics
Intervention group
(N=1219)
Control group
(N=1163)
P-value
Age (years)
77.1 (7.1)
77.3 (7.2)
0.39
Living independently (% yes)
89.0
89.3
0.52
Education level
% primary
% secondary
% higher
25.7
63.9
10.4
26.3
62.2
11.6
0.58
Fractures after age 50 years(% yes)
41.3
42.6
≥2 falls in past 12 months (% yes)
69.6
68.7
0.61
Fear of falling score (range 1-10)
6.0 [ ]
7.0 [ ]
0.01*
Use of walking aid (% yes)
59.1
60.5
0.49
Severe mobility limitations (% yes)
49.6
53.9
0.04*
Body Mass Index (kg/m2)
27.5 (5.3)
27.5 (5.2)
0.77
Smoking (% yes)
10.7
0.83
Alcohol use (number of glasses/day)
% 0-1
% 1-2
% ≥3
78.8
15.6
5.6
77.1
18.8
4.1
Vitamin D supplementation (% yes)
22.8
25.9
0.09
Number of medicines
4.0 [ ]
0.47
Selection of randomized groups: some baseline differences

14. Results on falling Intervention group Control group Total Fallers (%)
Total
Fallers (%)
Falling in past 12 months
18 months
36 months
764
661
414 (54%)
347 (53%)
772
647
421 (55%)
355 (55%)
Recurrent falling in past 12 months
241 (32%)
199 (30%)
266 (35%)
216 (33%)

15. Results on falling
Outcome
Intervention group
Control group
Total
Fallers (%)
Falling in past 12 months
18 months
36 months
764
661
414 (54%)
347 (53%)
772
647
421 (55%)
355 (55%)
Recurrent falling in past 12 months
241 (32%)
199 (30%)
266 (35%)
216 (33%)
OR (95% CI)
unadjusted
adjusteda
Falling in past 12 months
18 months
36 months
0.98 (0.80; 1.20)
0.87 (0.71; 1.08)
0.97 (0.78; 1.21)
0.92 (0.73; 1.16)
Recurrent falling in past 12 months
0.91 (0.73; 1.13)
0.86 (0.68; 1.08)
0.89 (0.71; 1.14)
0.86 (0.67; 1.10)
Multi-level analysis with GP practice as random effect

16. Results on fear of falling
Intervention group
Control group
Total N
Fear of falling
(mean ± SD)
18 months
36 months
745
648
5.3 (2.8)
5.8 (2.7)
766
641
5.5 (2.8)

17. Results on fear of falling
Intervention group
Control group
Total N
Fear of falling
(mean ± SD)
18 months
36 months
745
648
5.3 (2.8)
5.8 (2.7)
766
641
5.5 (2.8)
 Unstandardized beta (95% CI)
unadjusted
adjusted
18 months
36 months
-0.03 (-0.27; 0.22)
0.08 (-0.18; 0.34)
0.00 (-0.24; 0.24)
0.15 (-0.11; 0.41)
Multi-level analysis with GP practice as random effect

18. Discussion (I) Possible explanations:
Good identification high risk patients by GP
GP did not take action
GP did take action, but not effective
Interventions effective in high risk patients?
“Awareness” for falling among GP’s by trial participation, also in control group
Increased fall exposure in intervention group
Falling secondary outcome
Not clear if and which fall prevention actions were taken by GP
Busy agenda’s

19. Discussion (II) Differences between GP’s Registration falls
High rate of lost to follow-up
Falling secondary outcome
Pragmatic nature
The most frail were lost to FU

20. Discussion (III)
Black box: process analysis
Notification of GP’s about patients’ fall risk is not effective in reducing falls and fear of falling

21. Acknowledgements Thijs Morgenstern Petra Elders Thomas Merlijn
Natasja van Schoor
Coen Netelenbos
Christy Niemeijer