Exercise and Multifactorial Interventions

According to USPSTF Recommendation Statement: Interventions to Prevent Falls in Community-Dwelling Older Adults (JAMA, 2018), the USPSTF concluded that exercise interventions provide a moderate benefit in preventing falls among community-dwelling older adults at increased risk for falls. This evidence supports the Grade B recommendation. In contrast, multifactorial interventions provide a small benefit, which supports the Grade C recommendation.

Why Exercise Received a Grade B Recommendation

USPSTF Recommendation Statement: Interventions to Prevent Falls in Community-Dwelling Older Adults (JAMA, 2018) states that the USPSTF found adequate evidence that exercise interventions reduce falls in older adults at increased risk. The Task Force also concluded with moderate certainty that the net benefit is moderate.

• Evidence base: 5 good-quality and 16 fair-quality studies, with 7297 participants.
• Population: A little more than half of the studies recruited older adults at high risk for falls.
• Common risk features: Physical function or mobility limitation problems were common, and history of falls was the factor most consistently identifying persons at high risk.

Effective exercise interventions included:

• Supervised individual classes
• Group classes
• Physical therapy

The recommendation statement emphasizes that these interventions were heterogeneous, so it was difficult to identify which specific exercise components were most effective. Still, the overall body of evidence showed benefit.

Why Multifactorial Interventions Received a Grade C Recommendation

USPSTF Recommendation Statement: Interventions to Prevent Falls in Community-Dwelling Older Adults (JAMA, 2018) explains that multifactorial interventions begin with an assessment of modifiable fall risk factors and then provide customized interventions based on the problems identified. The USPSTF found adequate evidence that these interventions produce only a small net benefit, leading to a Grade C recommendation.

• Evidence base: Multifactorial interventions were the most commonly studied approach, with 26 trials.
• Effect pattern: Pooled analyses showed statistically significant reduction in number of falls, but not in several other fall-related outcomes, such as number of persons experiencing a fall.

Possible components of the initial assessment included:

• Balance
• Gait
• Vision
• Postural blood pressure
• Medication review
• Environmental assessment
• Cognition
• Psychological health

The assessment could be done as part of a multidisciplinary comprehensive geriatric assessment or by combining these specific components. Because the intervention is tailored to the individual, its content varies across patients and studies.

Pooled Results

In USPSTF Recommendation Statement: Interventions to Prevent Falls in Community-Dwelling Older Adults (JAMA, 2018), falls and the number of persons experiencing a fall were the most commonly reported outcomes. For exercise, the USPSTF judged the overall evidence sufficient to show a moderate benefit in preventing falls. For multifactorial interventions, pooled analyses showed a more limited effect: a significant reduction in the number of falls, but not consistently in other outcomes.

This difference in the strength and consistency of pooled results helps explain the difference between the two recommendations:

• Exercise: moderate net benefit
• Multifactorial interventions: small net benefit

Harms

USPSTF Recommendation Statement: Interventions to Prevent Falls in Community-Dwelling Older Adults (JAMA, 2018) reports that, because these interventions are generally noninvasive and studies reported few serious harms, the USPSTF judged the harms of both exercise and multifactorial interventions to be no greater than small.

• Exercise harms: overall no greater than small
• Multifactorial intervention harms: overall no greater than small
• Source of most reported harms in multifactorial programs: exercise components

Bottom Line

Based on USPSTF Recommendation Statement: Interventions to Prevent Falls in Community-Dwelling Older Adults (JAMA, 2018), exercise has the stronger evidence base and more consistent benefit, so the USPSTF recommends it with Grade B for older adults at increased risk for falls. Multifactorial interventions can still help, especially when tailored to modifiable risks, but their overall effect is smaller and less consistent across outcomes, so they received a Grade C recommendation.