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The Effects and Costs of a Multifactorial and Interdisciplinary Team
Approach to Falls Prevention for Older Home Care Clients ‘At Risk’ for
Falling: A Randomized Controlled Trial
Maureen Markle-Reid, Gina Browne, Amiram Gafni, Jacqueline Roberts, Robin Weir, Lehana Thabane, Melody Miles, Vida
Vaitonis, Catherine Hecimovich, Pamela Baxter and Sandra Henderson
Canadian Journal on Aging / La Revue canadienne du vieillissement / Volume 29 / Special Issue 01 / March 2010, pp 139 - 161
DOI: 10.1017/S0714980809990377, Published online: 04 March 2010
Link to this article: http://journals.cambridge.org/abstract_S0714980809990377
How to cite this article:
Maureen Markle-Reid, Gina Browne, Amiram Gafni, Jacqueline Roberts, Robin Weir, Lehana Thabane, Melody Miles, Vida
Vaitonis, Catherine Hecimovich, Pamela Baxter and Sandra Henderson (2010). The Effects and Costs of a Multifactorial and
Interdisciplinary Team Approach to Falls Prevention for Older Home Care Clients ‘At Risk’ for Falling: A Randomized Controlled
Trial. Canadian Journal on Aging / La Revue canadienne du vieillissement, 29, pp 139-161 doi:10.1017/S0714980809990377
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Canadian Journal on Aging / La Revue canadienne du vieillissement 29 (1) : 139– 161 (2010)
doi:10.1017/S0714980809990377
139
The Effects and Costs of a Multifactorial and
Interdisciplinary Team Approach to Falls
Prevention for Older Home Care Clients
‘At Risk’ for Falling: A Randomized
Controlled Trial *
Maureen Markle-Reid , Gina Browne , Amiram Gafni , Jacqueline Roberts , Robin Weir ,
Lehana Thabane , Melody Miles , Vida Vaitonis , Catherine Hecimovich , Pamela Baxter , and
Sandra Henderson
McMaster University
RÉSUMÉ
Cette étude a déterminé les effets et les coûts d’une approche d’équipe multifactoriel et interdisciplinaire à la prévention
des chutes. Essai contrôlé aléatoire de 109 adultes plus âgés qui sont à risque de chutes. Ce fut une stratégie de
prévention multifactoriel fondée sur des données probantes de 6 mois, impliquant une équipe interdisciplinaire. Le
résultat principal a été le nombre des chutes suivi pendant 6 mois. À 6 mois, il n’y a aucune différence dans le nombre
moyen de chutes entre groupes. Des analyses des sous-groupes ont montrés que l’intervention réduit effi cacement les
chutes chez les hommes (75–84 ans) qui ont peur de tomber ou une histoire négative de chutes. Le nombre de glissades
et de trébuchés a été considérablement réduit, et la santé émotionnelle a montré une amélioration plus importante dans
le fonctionnement lié à la santé émotionnelle dans le groupe d’intervention. La qualité de vie a été améliorée, glissades
et trébuchés ont été réduits, comme l’étaient les chutes chez les hommes qui avaient peur de tomber ou une histoire de
chutes négative.
ABSTRACT
This study determined the effects and costs of a multifactorial, interdisciplinary team approach to falls prevention.
Randomized controlled trial of 109 older adults who are at risk for falls. This was a six-month multifactorial and evidence-
based prevention strategy involving an interdisciplinary team. The primary outcome was number of falls during the
six-month follow-up. At six months, no difference in the mean number of falls between groups. Subgroup analyses
showed that the intervention effectively reduced falls in men (75–84 years old) with a fear of falling or negative fall
history. Number of slips and trips was greatly reduced; and emotional health had a greater improvement in role
functioning related to emotional health in the intervention group. Quality of life was improved, slips and trips were
reduced, as were falls among males (75–84 years old) with a fear of falling or negative fall history.
* We are grateful to the following agencies for funding this project from 2005 to 2008: Canadian Patient Safety Institute (CPSI –
Grant Number RFAAA0506164), Community Care Access Centre of Halton, McMaster University System-Linked Research
Unit on Health and Social Services Utilization, and Ontario Ministry of Health and Long-Term Care. Maureen Markle-Reid is
a Career Scientist, Ontario Ministry of Health and Long-Term Care, Health Research Personnel Development Fund. This
research was possible through the ongoing support of the Community Care Access Centre of Halton, Hamilton Niagara
Haldimand Brant Community Care Access Centre, Mississauga Halton Community Care Access Centre, Halton Region Health
Department, Community Rehab, Ellen Williams, Brant Arts Dispensary, and Dr. Heather H. Keller, Department of Family
Relations and Applied Human Nutrition, Macdonald Institute, University of Guelph. We are also grateful to the following
individuals: Darlene Lane (project coordination), Leah Macdonald (data entry), Maria Wong (data analysis), and Rachel Har-
vey (administrative support).
Trial Registration: clinicaltrials . gov identifi er: NCT00463658.
Manuscript received: / manuscrit reçu : 25 / 08 / 08
Manuscript accepted: / manuscrit accepté : 30 / 06 / 09
Mots clés : chutes accidentelles , personnes agées communautaires , services d’aide familiale , population de soins à domicile ,
promotion de la santé , prévention , maladie chronique , effi cacité clinique , coûts , équipe de soins multidisciplinaires , procès
aléatoire
140 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
Introduction
Frail seniors are at increased risk of falls, with approx-
imately 50 per cent falling at least once per year (three
times the risk of healthy seniors) (Kenny, Rubenstein,
Martin, & Tinetti, 2001 ; Speechley & Tinetti, 1991 ).
They are also more likely to sustain serious injury and
take longer to recover after falling (SmartRisk, 1998).
Evidence suggests that most falls are predictable and
preventable. Previous intervention studies showed
that approximately 30 to 40 per cent of falls are pre-
ventable (Close, Ellis, Hooper, Glucksman, Jackson, &
Swift, 1999; Gillespie, Gillespie, Robertson, Lamb,
Cumming, & Rowe, 2003; Tinetti, Baker, McAvay,
Claus, Garrett, Gottschalk et al., 1994). Falls prevention
strategies could result in 7,500 fewer hospitalizations
per year among Canadian seniors (SmartRisk, 1998).
Home care occupies a strategic position in the preven-
tion of falls among older people (Todd & Skelton, 2004)
who represent 75 to 80 per cent of home care users
(Roos, Stranc, Peterson, Mitchell, Bogdanovic, & Shapiro,
2001). However, the number of older home care recipi-
ents in Canada who are at risk for falls is not well doc-
umented. As well, there is little or no information about
the best way to provide home care services for preven-
tion of falls among seniors with chronic needs.
The Burden of Falls in Canada
Thirty per cent of community-dwelling adults over 65
years of age fall at least once a year, and the proportion
increases to 50 per cent by age 80 (O’Loughlin, Robitaille,
Boivin, & Suisa, 1993 ). In people aged 65 years and
older, falls are the leading cause of injury-related ad-
missions to acute care hospitals and in-hospital deaths
(Canadian Institute for Health Information [CIHI],
2002) and explain 40 per cent of nursing home admis-
sions (Wilkins, 1999). Many older people who fall need
ongoing assistance at home from community services.
The costs of health care associated with fall-related in-
juries are staggering. The 1999/2000 costs of fall in-
juries to seniors in Canada were estimated to be $2.4
billion (CIHI, 2002). With an aging population and an
associated increase in the number of falls and fall-re-
lated injuries, these cost estimates are projected to rise
as high as $240 billion by the year 2040 (SmartRisk,
2006). Aside from the economic cost, the human cost
of a fall should not be underestimated. Fall injuries
often result in fear of falling (Fletcher & Hirdes, 2004 ;
Sjösten, Vaapio, & Kivelä, 2008 ), leading to self-
imposed restriction of activity and loss of confi dence
(Tinetti & Powell, 1993 ), low self-esteem, depression
(Sjösten et al.), chronic pain, and functional deteriora-
tion (Tinetti, Speechley, & Ginter, 1988 ). Falls and fall-
related injuries and complications are the leading cause
of death among seniors (CIHI, 2004). Clearly, preven-
tion of falls is an important issue if it can avert a de-
cline in function and independence and avoid the
associated increased costs of complications.
Home Care Services and Falls Prevention
An aging population, technological advances, and
budget constraints have led to major health care re-
forms worldwide. Extensive reform initiatives have
given rise to fewer acute care hospitals and increasing
pressure to continue to expand and enhance home
care services for older, more vulnerable, and frail indi-
viduals within the confi nes of economic constraint
(Bergman, Beland, Lebel, Contandriopoulos, Tousignant,
Brunelle et al., 1997). The result of these trends is
increasing competition for scarce home care resources.
Home care programs have responded to this increased
demand for their services by redirecting scarce
resources away from health promotion and preventive
functions, for individuals with chronic health needs, to
substitution functions to meet the more pressing need
for post-acute care (Canadian Home Care Association
[CHCA], 2003; CIHI, 2002; Hollander, 2003; Soder-
strom, Tousignant, & Kaufman, 1999 ).
Keywords : accidental falls , community-based seniors , homemaker services , home care population , health promotion , preven-
tion, chronic illness , clinical effectiveness , costs , multidisciplinary care team , randomized trial
Correspondence concerning this article should be addressed to / La correspondance concernant cet article doit être adressées à:
Maureen Markle-Reid, RN, Ph.D.
McMaster University, School of Nursing
1200 Main Street West, HSC 3N28H
Hamilton, Ontario L8N 3Z5
( mreid@mcmaster.ca )
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 141
These changes have resulted in a number of issues that
challenge the ability of home care programs to provide
effective falls prevention to older people. First, frail
older adults have limited access to professional ser-
vices directed towards preventing falls (Hollander,
2003). Second, there is limited collaboration and com-
munication among home care providers involved in
caring for older people at risk for falls. Third, there is
no evidence-based practice standard for falls preven-
tion in home care and a lack of expertise among service
providers in fall prevention strategies. The result is a
fragmented and ineffi cient system of health service
delivery, rather than a comprehensive and proactive
approach to care. Typically, on-demand care is less ef-
fective and more costly than providing comprehensive
care (Browne, Roberts, Byrne, Gafni, Weir, & Majumdar,
2001; Johri, Beland, & Bergman, 2003 ). Recent data
suggest that preventable and ameliorable adverse
events (such as a fall) are associated with one or more
defi ciencies in the system of care, such as ineffective
communication among providers (Forster, Murff,
Peterson, Gandhi, & Bates, 2003 ). New ways of ap-
proaching care are needed, and different solutions are
required to address these issues and enhance the
ability of home care programs to provide effective falls
prevention.
Multifactorial Falls Prevention Programs for Older
Adults
Falls generally result from an interaction of multiple,
diverse risk factors and situations, correction of just
one of which can reduce the frequency and morbidity
of falls (Kenny et al., 2001 ). The risk factors can be
broadly divided into “intrinsic” and “extrinsic” factors
(Kenny et al.; Masud & Morris, 2001 ). Demographic
and biological factors are intrinsic, whereas environ-
mental and behavioural factors are extrinsic (Speech-
ley & Tinetti, 1991 ). Among the community-dwelling
population, intrinsic risk factors for falling include his-
tory of falls, female gender, advanced age, reduced
lower-limb strength, gait and balance impairment,
previous slips or trips, diffi culty in activities of daily
living (ADLs), functional impairment, certain chronic
diseases (e.g., arthritis, Parkinson’s disease, diabetes,
or stroke) and co-morbidity, cognitive impairment,
depression, poor nutrition, underweight or uninten-
tional weight loss, visual impairment or hearing loss,
and urinary incontinence or nocturia. Extrinsic risk
factors for falling include taking four or more prescrip-
tion medications daily or taking sedative or hypnotic
medications, environmental hazards, fear of falling, in-
activity, inappropriate clothing or footwear, low in-
come and education levels, excess alcohol use, and
social isolation (Bueno-Cavanillas, Padilla-Ruiz, Jimé-
nez-Moleón, Peinado-Alonso, & Gálvez-Vargas, 2000 ;
Kenny et al.; Lord, Ward, Williams, & Anstey, 1994 ;
O’Loughlin et al., 1993 ; Steinberg, Cartwright, Peel, &
Williams, 2000 ; Tinetti et al., 1988 ).
Early prevention interventions that incorporate an in-
terdisciplinary approach combining a variety of strat-
egies, aimed at all possible factors that contribute to
causing a fall, will have the greatest effect because of
the multifactorial nature of falls (Chang, Morton,
Rubenstein, Mojica, Maglione, Suttorp et al., 2004;
Gillespie et al., 2003 ), especially among high-risk
groups (Gillespie et al., 2003 ; Tinetti et al., 1994 ) and
individuals with chronic conditions (Leatt, Pink, &
Guerriere, 2000 ). A key strategy for preventing multi-
factorial adverse events (such as falls) is the develop-
ment of partnerships among individuals, service
providers, and organizations, because no single disci-
pline alone can identify and address all risk factors
(National Steering Committee on Patient Safety, 2002).
Furthermore, there is accumulating evidence in Can-
ada that proactive, comprehensive, and coordinated
community care for people with chronic needs is more
effective and less expensive than providing reactive
and on-demand care (Browne et al., 2001 ; Markle-Reid,
Weir, Browne, Roberts, Gafni, & Henderson, 2006b).
The literature on the effectiveness of multifactorial falls
prevention programs specifi c to older, community-
dwelling adults is surprisingly limited. Few published
randomized controlled trials have assessed the effect
of interventions on secondary outcomes such as func-
tional health status and related quality of life, mental
health (e.g., depression) (Lin, Wolf, Hwang, Gong, &
Chen, 2007 ; Sjösten et al., 2008 ), and behavioural fac-
tors (Clemson, Cummings, Kendig, Swann, Heard, &
Taylor, 2004; Close et al., 1999 ; Day, Fildes, Gordon,
Fitzharris, Flamer, & Lord, 2002; Gallagher & Brunt,
1996 ; van Haastregt, Diederiks, van Rossum, de Witte,
Voorhoeve, & Crebolder, 2000; Hornbrook, Steven,
Wingfi eld, Hollis, Greenlick, & Ory, 1994; Kingston,
Jones, Lally, & Crome, 2001 ; Lightbody, Watkins, Leath-
ley, Sharma, & Lye, 2002 ; Nikolaus & Bach, 2003 ; Rizzo,
Baker, McAvay, & Tinetti, 1996 ; Robson, Edwards,
Gallagher, & Baker, 2002 ; Shaw, Bond, Richardson,
Dawson, Steen, McKeith et al., 2003; Shumway-Cook,
Silver, LeMier, York, Cummings & Koepsell, 2007;
Steinberg et al., 2000 ; Tinetti et al., 1994 ; Vetter, Lewis,
& Ford, 1992 ; Wagner, LaCroix, Grothaus, Leveille,
Hecht, Artz et al., 1994; Yates & Dunnagan, 2001 ), or
examined which sub-groups of home care recipients
benefi t most. In addition, older people with chronic
conditions were often excluded from these trials. These
omissions are important because depression, behavioural
factors (Sjösten et al.), and chronic conditions increase the
risk of falls (Kenny et al., 2001 ), functional decline, and
use of expensive health care resources (Stuck, Walthert,
Nikolaus, Bula, Hohmann, & Beck, 1999).
142 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
A limited number of the studies included persons
receiving home support services. Such individuals are
typically medically unstable, have severe mobility or
cognitive impairments, or are in need of assistance
with ADLs, the same conditions that are associated
with increased risks of falling and being injured (Scott,
Votova, & Gallagher, 2006b ). In addition, no study has
examined the costs of health services associated with a
multifactorial falls prevention program compared to
usual care. Furthermore, the interventions were staffed
by different types of providers, resulting in limited
information on how to optimize the allocation of health
services.
Based on the potentially important role of home care in
falls prevention for frail older people, the compelling
evidence for an interdisciplinary team approach, and
the increasing pressure for evidence of effi cient use of
scarce resources, we identifi ed the need for a study of
the effects and costs of a multifactorial and interdisci-
plinary team approach to falls prevention. The
rationing of home care services for clients with chronic
needs enabled a natural comparison of the effects of a
proactive service with those of on-demand use of these
services. Our primary hypothesis was that older people
receiving the multifactorial and interdisciplinary team
approach versus usual home care would show a reduc-
tion in fall risk factors and number of falls at six months.
Further, we hypothesized that the intervention would
pay for itself by reducing the use of expensive health
care resources.
Methods
The randomized controlled trial was conducted in
accordance with the Tri-Council Policy Statement,
“Ethical Conduct for Research Involving Humans”
(Canadian Institutes of Health Research, Natural Sci-
ences and Engineering Research Council of Canada,
Social Sciences and Humanities Research Council of
Canada, 1998). Ethics approval for the study was
obtained from the McMaster University Research and
Ethics Board and renewed yearly as required (# 05-
279). All participants provided written informed con-
sent for participation. The methods, results, and fl ow
of participants through the study (see Figure 1 ) are pre-
sented here according to the Consolidated Standards
of Reporting Trials (CONSORT)Statement (Moher,
Schulz, & Altman, 2001).
Research Questions
The specifi c research questions follow Among older
home care clients at risk for falling, (1) is a six-month
multifactorial, interdisciplinary team approach to falls
prevention effective in reducing the number of falls
compared with usual home care services; (2) does a six-
month multifactorial, interdisciplinary team approach
have a favourable effect on fall risk factors (number of
slips and trips, functional health status and related
quality of life, nutritional status, gait and balance, de-
pressive symptoms, cognitive function, and confi dence
in performing ADLs) compared with usual home care
services; and (3) what are the six-month costs to use
health services with a multifactorial, interdisciplinary
team approach compared with usual home care ser-
vices?
Participants and Setting
This was a collaborative project between researchers
in the McMaster University System-Linked Research
Unit (SLRU) and decision makers and practitioners in
the Hamilton Niagara Haldimand Brant and Missis-
sauga Halton Community Care Access Centres (CCAC)
and two direct care provider agencies (Halton Region
Health Department, Community Rehab) in Ontario,
Canada. The SLRU has extensive experience conduct-
ing community-based randomized trials. The CCAC
provides publicly funded home care using a contrac-
tual model of service delivery, wherein case managers
contract out home care services to agencies that pro-
vide care to clients.
Study participants were adults aged 75 years and older,
newly referred to and eligible for home support services
through the CCAC, living in the community (not in a
nursing home or other long-term care facility), mentally
competent to give informed consent, and competent in
English or with a translator available. Individuals were
eligible for home support services if they required assis-
tance with personal care, which could be provided by
either a caregiver or a home support worker contracted
by the CCAC. With oral consent, clients meeting these
criteria were screened for risk for falls. An older person
was deemed to be “at risk” for falls and thus eligible for
the study, if he/she answered “yes” to any of the fol-
lowing questions: Have you fallen in the past 12 months;
do you have a fear of falling, or are you unsteady
on your feet (Kenny et al., 2001 )? To validate their in-
formed consent to enrolling and continued participa-
tion in the study, participants needed to score 24
or higher on the Standardized Mini-Mental State
Examination (SMMSE) (Kukull, Larson, Teri, Bowen,
McCormick, & Pfanschmidt, 1994) or have a substitute
decision-maker to provide consent and complete the
questionnaires on their behalf.
Interventions
Control (Usual Home Care Services)
Participants randomly allocated to the control group
received standard home care services arranged by the
CCAC. These included (1) routine follow-up by the
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 143
CCAC case manager whose focus was on assessing
the client’s eligibility for in-home health services; (2)
arranging and coordinating professional (i.e., nursing,
occupational therapy, physiotherapy, social work,
speech-language pathology, and nutrition) and non-
professional home support services; (3) providing
information and referral to community agencies; and
(4) monitoring and evaluating the plan of care on an
ongoing basis through in-home assessments with cli-
ents (MacAdam, 2000 ). Additional services may have
included drug cards, supplies, equipment, transporta-
tion, and in-house laboratory services (CHCA, 2003).
Experimental (Multifactorial and Interdisciplinary Team
Approach)
The experimental group received the same standard
home care services as the control group, plus home visi-
tation by a dedicated team of professionals (CCAC case
manager, registered nurse, occupational therapist, phys-
iotherapist, and registered dietitian) a minimum of once
per month for six months. The CCAC case manager pro-
vided leadership and coordinated communication
among members of the interdisciplinary team, the family
physician, and other community services. A geriatrician
and community pharmacist were available on a consul-
tation basis. The professionals tailored their visits to the
individual needs of the client. Their main activities in-
cluded (1) conducting a comprehensive, systematic, and
routine assessment to identify known risk factors for
falls and other factors infl uencing health using validated
screening instruments; (2) regularly assessing and man-
aging modifi able fall risk factors; (3) providing intensive
client support; and (4) educating clients about falls pre-
vention. The aim of the interdisciplinary team was to
Assessed for eligibility
(n=525)
Excluded (n=258):
Did not meet inclusion
criteria (n=167)
Refused to participate (n=48)
Unable to contact (n=43)
Eligible clients
(n=267)
Randomized
(
n=109
)
Allocated to Intervention Group
(n=54)
Received allocated
intervention: 53
Did not receive allocated
intervention: 1
Analyzed (n=49)
Excluded from anal
y
sis
(
n=5
)
Lost to follow up (n=5):
Death: 3
Refused: 2
Discontinued intervention (n=4):
Long-term care: 4
Allocated to Control Group (n=55)
Received allocated
intervention: 55
Analyzed (n=43)
Excluded from anal
y
sis
(
n=12
)
Lost to follow up (n=12)
Death: 4
Refused: 8
Excluded (n=158):
Refused to participate
(n=141)
Unable to contact (n=13)
Non-English speaking (n=4)
Figure 1: Study fl ow diagram
144 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
reduce falls and fall-related injuries, enhance health and
quality of life, and reduce on-demand use of health care
services. All aspects of the intervention were developed
through a collaborative process with decision makers
and practitioners from the participating agencies with
the goal of integrating the intervention into normal
practice once the study ended.
A fall risk management protocol was developed to pro-
vide a systematic, standardized, and evidence-based
approach to the initial and ongoing assessments and
modifi cation of risk across disciplines. The protocol in-
cluded the use of validated screening instruments to
assess fall risk and other factors infl uencing health.
The screening instruments targeted proven intrinsic
and extrinsic causes of falls.
Each client was discussed by the interdisciplinary team
at a case conference a minimum of once per month for
six months. A team meeting booklet was developed to
guide the team systematically through a series of ques-
tions that triggered the assessment of fall risk factors,
use of motivational theory, and recommended actions
for prevention for each study participant. Motivational
interviewing is a directive and client-centered counsel-
ling style that relies upon identifying and mobilizing
the client’s intrinsic values and goals to stimulate
behaviour change (Miller & Rollnick, 2002 ), thus en-
couraging client and family involvement in all aspects
of care. During the case conference, the team devel-
oped a single accessible fall prevention plan to address
modifi able fall risk factors and other factors infl uencing
health using various evidence-based strategies (e.g.,
environmental modifi cation, routine exercise, health
assessment, and maintenance medication modifi ca-
tion) (Gillespie et al., 2003 ; Kenny et al., 2001 ) and to
identify and manage barriers to preventing falls such
as low self-effi cacy, low self-confi dence, and fear of
falling (Watter & Studensky, 1996 ). The plan included
specifi c short-term and six-month goals, a list of ac-
tions and referrals, and a record of all recommenda-
tions. The results of the initial and ongoing assessments
of risk and the client’s involvement in the care plan
were documented in the team meeting booklet and re-
viewed during each case conference.
One-day training sessions were provided for the CCAC
case managers and all members of the interdisciplinary
team, based on their differing levels of expertise and
team roles. The sessions focused on the problem scope
and proven fall prevention strategies, as well as more
general theory-based strategies for addressing barriers
to falls prevention. Specifi c training was given on the
use of motivational interviewing to address these bar-
riers and promote positive changes in behaviour to re-
duce falls risk. The sessions also stressed the importance
of working in partnership with clients, their families,
and other professionals, and the key features of an
effective collaboration. The training sessions were in-
teractive, based on experience, and supplemented by
follow-up sessions over the course of the trial. A
detailed description of the intervention can be found
elsewhere (Markle-Reid, Henderson, Anderson,
Baxter, Hecimovich, Browne et al., 2007; Markle-Reid,
Miles, Vaitonis, Henderson, Anderson, Baxter et al.,
2008a).
The frequency and timing of the home visits and case
conferences were tailored to individual client needs
and the results of ongoing risk assessment (Kenny et
al., 2001 ). Participants received a median of 19.5 home
visits and three telephone contacts by members of the
interdisciplinary team over the six-month study
period. These contacts consisted of a median of three
home visits and 1.5 telephone contacts by the CCAC
case manager, six visits by the nurse, four visits by the
occupational therapist, six visits by the physiothera-
pist, and zero visits by the registered dietitian, social
worker, and pharmacist. The average duration of home
visits was one hour. Participants were discussed a
median of six times at interdisciplinary team meetings.
To ensure continuity of care, team members followed
the same clients over the trial’s course.
Outcomes
Trained interviewers, blinded to the purpose of the
study and group assignment, assessed participants at
baseline and six months through a structured in-home
interview. Previous research suggests that six months
is an optimal time to assess the immediate effects
(Gillespie et al., 2003 ; Lightbody et al., 2002 ; Scott,
Bawa, Votova, Rajabali, Han, Swan et al., 2006a), while
minimizing attrition rates. The interviewers were ex-
perienced health professionals who underwent inten-
sive training, standardization, and inter-rater reliability
assessment in all interview and data collection proce-
dures.
The primary outcome was mean number of falls during
the six-month follow-up, measured by self-report. All
participants kept a calendar to record daily any slip,
trip, or fall and returned it at the end of each month.
Interviewers blinded to treatment assignment tele-
phoned participants monthly to obtain additional
information on any incident recorded on the previous
month’s fall calendar using the Falls Surveillance Re-
port, which was created by the research team (Markle-
Reid et al., 2008a). For the purposes of this study, a slip
or trip was defi ned as regaining balance without a fall
(Steinberg et al., 2000 ), whereas a fall was defi ned as
unintentionally coming to rest on the ground or fl oor
(Registered Nurses Association of Ontario, 2005). Self-
report is an essential source of data because many falls
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 145
among older community-dwelling adults are not wit-
nessed and do not require medical attention (Clemson
et al., 2004 ; Day et al., 2002 ; Lightbody et al., 2002 ;
Steinberg et al.).
Secondary outcomes were changes in fall risk fac-
tors from baseline to six months. These risk factors
included the following: (1) self-reported slip or trip
frequency measured by the Falls Surveillance Report;
(2) functional health status and related quality of life
measured by the SF-36 health survey (Ware, Snow,
Kosinski, & Gandek, 1993 ); (3) nutritional status mea-
sured by the Seniors in the Community: Risk Evalua-
tion for Eating and Nutrition, Version II (SCREEN II)
(Keller, Goy, & Kane, 2005 ); (4) gait and balance mea-
sured by the Performance-Oriented Mobility Assess-
ment (POMA) (Tinetti, 1986 ); (5) depressive symptoms
measured by the Centre for Epidemiological Studies in
Depression Scale (CES-D) (Radloff, 1977 ); (6) cognitive
function measured by the SMMSE (Folstein, Folstein,
& McHugh, 1975 ); and (7) confi dence in performing
ADLs without falling measured by the Modifi ed Falls
Effi cacy Scale (MFES) (Hill, Schwartz, Kalogeropoulos,
& Gibson, 1996 ). The thresholds for the SCREEN II,
POMA, CES-D, and SMMSE are identifi ed in Table 1 .
All measurement tools have established reliability and
validity. In addition to these data, we also collected
basic socio-demographic data and information on
health status.
The costs of use of all types of health services from
baseline to six months were determined using the
Health and Social Services Utilization Inventory
(HSSUI), which assesses costs from a societal perspec-
tive (Browne, Gafni, & Roberts, 2006 ). A societal per-
spective implies collecting all costs, regardless of who
bears them. The wider the perspective taken, the
more applicable the study is to social policy decisions
(Drummond, O’Brien, Stoddart, & Torrance, 1997 ). The
HSSUI consists of questions about the respondent’s
use of six categories of direct health care services: (1)
primary care; (2) emergency department and special-
ists; (3) hospital days; (4) seven types of other health
and social professionals; (5) medications; and (6) lab
services. Inquiries were restricted to the reliable dura-
tion of recall: six months for remembering a hospitali-
zation, two weeks for a visit to the physician, and two
days for use of a prescription medication (Browne et
al., 2006 ; Petrou, Murray, Cooper, & Davidson, 2002 ).
Questions to assess out-of-pocket costs (indirect costs,
cash transfer effects) are also included (Browne et al.,
2006 ). The six-month cost data were derived from
“quantity” data reported on the HSSUI and 2006
“price” data obtained by our team for the HSSUI. The
product of the number of units of service (quantity)
and unit cost (price) is total cost. Price data for both
direct and indirect costs were obtained from multiple
sources that are reported in detail elsewhere (Browne
et al., 2006 ). Each person’s cost data were analyzed in
relation to outcome. This measure has been previously
tested and assessed for reliability and validity (Browne
et al., 1999 , 2001 ), and was recently acknowledged as
one of the few published measures of ambulatory utili-
zation that is empirically validated (Guerriere, Ungar,
Corey, Croxford, Trammer, Tullis et al., 2006).
Sample Size
The sample size calculation was based on the primary
measure of effect, which was the difference between
groups in mean number of falls during the six-month
follow-up. We expected that the control group would
have a mean of 0.50 falls (Speechley & Tinetti, 1991 ).
The sample size was calculated to detect a 30 per cent
difference (0.15 falls) between groups. A 30 per cent re-
duction at six months was considered achievable on
the basis of other multifactorial studies in this popula-
tion (Gillespie et al., 2003 ; Lightbody et al., 2002 ; Rob-
son et al., 2002 ; Scott et al., 2006 a; Yates & Dunnagan,
2001 ) and of considerable economic importance. Using
a standard deviation of 0.25 as a conservative estimate
and a delta of 0.15, a sample size of 110 participants (55
per group) was estimated to be suffi cient to address
the primary question, allowing an additional 20 per
cent to offset drop-outs (2-tailed alpha = 0.05; beta =
0.20) (Fleiss, 1981 ).
Randomization
After participants provided written consent and com-
pleted baseline questionnaires, they were randomly
assigned by the project coordinator at McMaster Uni-
versity to one of two treatment strategies using a 1:1
allocation ratio. Randomization was achieved using
consecutively numbered, sealed, opaque envelopes
containing randomly generated numbers constructed
by a biostatistician who was not involved in the re-
cruitment process.
Blinding
Once randomization had taken place, the CCAC case
managers, members of the interdisciplinary team, and
participants were aware of group assignments. This
lack of blinding was unavoidable. However, the out-
come assessors and statistician/data analyst were
blinded to the purpose of the study and group assign-
ments.
Statistical Methods
All analyses were performed using SPSS version 15.0
for Windows. The baseline prevalence of falls, slips,
and trips and the characteristics of the sample were
146 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
Table 1: Comparison of demographic, clinical, and social characteristics between treatment groups at baseline (study completers,
n
= 92)
Characteristics Total Group Treatment Group Test Statistics
Interdisciplinary Usual Home Care
n
%
n
%
n
% χ
2
p
value
Gender
Male 26 28.3 16 32.7 10 23.3 0.998 0.318
Female 66 71.7 33 67.3 33 76.7
Age (years)
75–85 50 54 28 57 22 51 0.33 0.566
85 and older 42 46 21 43 21 49
Type of Accommodation
House or apartment 69 75 40 82 29 67 2.46 0.117
Seniors’ home 23 25 9 18 14 33
Income
< $40,000 57 62 33 67 24 56 1.30 0.522
> $40,000 9 10 4 9 5 11
Unknown 26 28 12 24 14 33
Living Arrangement
Live alone 40 43 18 37 22 51 1.94 0.164
Live with others 52 57 31 63 21 49
SMMSE Cognitive Status (0–30)
a
Severe impairment (0–17) 2 2.2 1 2.1 1 2.3 0.232 0.891
Mild impairment (18–25) 15 16.7 7 14.9 8 18.6
No impairment (26–30) 73 81.1 39 83 34 79.1
Falls in Past Six Months
None 26 28.3 12 24.5 14 32.6 1.754 0.416
1 41 44.6 21 42.9 20 46.5
≥ 2 25 27.2 16 32.7 9 20.9
Slip/Trip in Past Six Months
None 66 71.7 35 71.4 31 72.1 0.252 0.882
1 10 10.9 6 12.2 4 9.3
≥ 2 16 17.4 8 16.3 8 18.6
Total Number of High-Risk Medications
b
≥ 3 medications 43 46.7 26 53.1 17 39.5 1.683 0.194
< 3 medications 49 53.3 23 46.9 26 60.5
CES-D Depression Score (0–60)
Depressed ( ≥ 21) 15 16.3 8 16.3 7 16.3 0 0.995
Not depressed (< 21) 77 83.7 41 83.7 36 83.7
SCREEN II Nutritional Risk Score (0–64)
High nutritional risk (0–49) 62 67.4 36 73.5 26 60.5 1.785 0.41
Medium nutritional risk (50–53) 18 19.6 8 16.3 10 23.3
No nutritional risk ( ≥ 54) 12 13 5 10.2 7 16.3
Fear of Falling
Yes 41 44.6 20 40.8 21 48.8 0.596 0.44
No 51 55.4 29 59.2 22 51.2
Visual Impairment
No 71 77 37 75.5 34 79 0.165 0.685
Yes 21 23 12 24.5 9 21
Hospital Admission in Past Six Months Related to a Fall, Slip, or Trip
Yes 33 35.9 17 34.7 16 37.2 1.525 * 0.217
No 59 64.1 32 65.3 27 62.8
Cardiovascular Disorder
Cerebrovascular accident 28 30.4 15 30.6 13 30.2 0.002 0.969
Congestive heart failure 13 14.1 7 14.3 6 14 0.002 0.964
Coronary artery disease 14 15.2 9 18.4 5 11.6 0.806 0.369
Hypertension 49 53.3 29 59.2 20 46.5 1.477 0.224
Irregular pulse
19 20.7 10 20.4 9 20.9 0.004 0.951
Peripheral vascular disease 12 13 7 14.3 5 11.6 0.143 0.706
Continued
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 147
summarized using descriptive statistics expressed as
mean (standard deviation [ SD ]) for continuous vari-
ables and count (percent) for categorical variables. The
hypothesis of effectiveness and effi ciency was tested in
a two-group comparison of all participants who com-
pleted the six-month follow-up. We used repeated
measures of analysis of variance (ANOVA) to compare
the mean changes in scores for primary and secondary
outcomes at six months. We used normal probability
plots to assess normality and the Kruskal–Wallis test if
the normality assumption was seriously violated. We
used Poisson regression to adjust for potential residual
effects of key baseline characteristics on outcomes. All
statistical tests were performed using two-sided tests
at the 0.05 level of signifi cance. For regression analyses,
we checked the residuals and found no major viola-
tions of model assumptions.
Sub-group analysis was performed by regression tech-
niques using simple two-way interactions between
study group and characteristics thought to infl uence
fall risk (female gender, fall in the past six months, bal-
ance and gait, cognitive status, use of four or more pre-
scription medications, use of three or more prescription
medications affecting the cardiovascular or central
nervous systems, depression, visual impairment, nu-
tritional risk, fear of falling, unsteadiness on feet, four
or more co-morbid health conditions, age, living
arrangement, slips or trips in the past six months,
Characteristics Total Group Treatment Group Test Statistics
Interdisciplinary Usual Home Care
n
%
n
%
n
% χ
2
p
value
Neurological Disorder
Dementia 5 5.4 3 6.1 2 4.7 0.096 0.756
Head trauma 6 6.5 4 8.2 2 4.7 0.463 0.496
Hemiplegia/hemiparesis 4 4.3 2 4.1 2 4.7 0.018 0.894
Parkinsonism 4 4.3 1 2 3 7 1.342 0.247
Musculoskeletal Disorder
Arthritis 70 76.1 38 77.6 32 74.4 0.124 0.725
Hip fracture 25 27.2 14 28.6 11 25.6 0.103 0.748
Other fractures 38 41.3 21 42.9 17 39.5 0.104 0.747
Osteoporosis 34 37 14 28.6 20 46.5 3.164 0.075
Hearing Impairment
Yes
27 29 17 34.7 10 23.3 1.486 0.223
No 65 71 32 65.3 33 76.7
Number of Health Disorders (0–11)
0–3 disorders 40 43.5 23 46.9 17 39.5 0.511 0.475
≥ 4 disorders 52 56.5 26 53.1 26 60.5
POMA Score (0–28) c
Low fall risk (25–28) 11 12.2 6 12.5 5 11.9 3.064 0.216
Medium fall risk (19–24) 36 40 23 47.9 13 31
High fall risk (< 19) 43 47.8 19 39.6 24 57.1
Unsteady on Feet
Yes 68 73.9 33 67.3 35 81.4 2.344 0.126
No 24 26.1 15 32.7 7 18.6
Number of Risk Factors for Falls (fall in past 12 months, fear of falling, unsteady on feet)
1 32 34.8 18 36.7 14 32.6 1.791 0.408
2 38 41.3 22 44.9 16 37.2
3 22 23.9 9 18.4 13 30.2
Physical Discomfort Limiting Activities of Daily Living
Yes 85 92.4 47 95.9 38 88.3 1.856 0.173
No
7 7.6 2 4.1 5 11.7
* Wald Chi-Square
a Numbers do not add to 92 as a result of missing scores (
n
= 2)
b High-risk medications include these: antidepressant, anti-psychotic, anti-histamines, anticonvulsants, anti-Parkinson’s, benzodi-
azepines, non-steroidal anti-infl ammatories, cardiovascular medicines, opioid analgesics.
c Numbers do not add to 92 as a result of missing scores (
n
= 2)
Table 1: Continued
148 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
admission to acute care hospital in the past six months,
hearing impairment, environmental hazard, cardio-
vascular, neurological, or musculoskeletal disorder,
limitations in ADLs , and functional health status and
related quality of life). Number of falls during the six-
month follow-up was the dependent variable. We hy-
pothesized that older people with these risk factors
would benefi t most from the intervention. This sub-
group analysis was decided a priori.
Results
Recruitment/Participant Flow
Recruitment was conducted over a nine-month period
between May 2006 and February 2007. A total of 525
consecutive CCAC clients were screened for the study,
and 267 (50.9 % ) were considered eligible. The most
common reason for ineligibility (36.8 % ) was not being
at risk for falls (no fall within the previous 12 months,
fear of falling or unsteadiness on their feet). Other rea-
sons included refusal to participate (18.6 % ), inability to
contact (16.7 % ), non-English speaking with no trans-
lator available (16.3 % ), living outside the study region
(7.0 % ), and failing the SMMSE with no substitute
decision maker available (3.9 % ). In total, 109 (40.8 % ) of
the 267 eligible home care clients consented and were
randomized ( Figure 1 ).
Numbers Analyzed
The proportion of participants who completed the
study was 43/55 (78.2 % ) in the control group and
49/54 (90.7 % ) in the intervention group ( Figure 1 ).
Reasons for loss to follow-up included death (seven
participants) and refusal to participate (10 partici-
pants). Rates of attrition because of death did not differ
signifi cantly between groups. Thus, analyses were
based on a fi nal sample of 92 participants.
Study drop-outs were similar to completers in most
baseline characteristics. Compared with completers,
smaller proportions of drop-outs reported a slip or trip
in the past six months (5.9 % vs. 29.3 % ; p = 0.04) or a
fall, slip, or trip outside the home (0 % vs. 28.2 % ; p =
0.04). Drop-outs had lower mean scores in general
health perception (difference: 15.7; 95 % CI: 4.8 to 26.5)
and higher per-person costs of use of speech language
pathologists ( p = 0.02) and nurse practitioners ( p = 0.02)
in the past six months. All but one participant random-
ized to the intervention group (98 % ) received at least
one home visit by a member of the interdisciplinary
team. Nine additional clients discontinued the inter-
vention early because of admission to a long-term care
facility ( n = 4), death ( n = 3), or refusal to participate ( n
= 2) ( Figure 1 ).
Baseline Characteristics
Baseline characteristics by treatment group for the 92
study participants retained in the six-month follow-up
are shown in Table 1 . Most baseline characteristics
were similar in the two groups. Participants in the in-
terdisciplinary group, compared with the usual-care
group, reported fewer mean slips and trips (difference:
–0.7; 95 % CI: –2.5 to 1.1) but a similar mean number of
falls in the past six months. The interdisciplinary group
had a lower mean score in role functioning related to
emotional health (difference: 15.27; 95 % CI: 1.8 to 28.5),
lower per-person costs of use of ophthalmologist ( p =
0.03), and higher per-person cost to use day surgery ( p
= 0.03). Data were re-analyzed, adjusting for these var-
iables, with no differences in results (data not shown).
Of the 92 participants who completed the study, 72 per
cent reported at least one fall in the six months preceding
the study, 45 per cent reported a fear of falling, and 74
per cent indicated that they were unsteady on their feet.
Most participants (76 % ) had two or more of these risk
factors for falls that defi ned the target sample for the
study. Twenty-six participants (28.3 % ) reported at least
one slip or trip in the six months preceding the study.
Approximately 80 per cent of falls, slips, or trips resulted
in injury including hip or other fracture (40 % ); cuts,
scrapes, or abrasions (35 % ); bruising (29 % ); or other mi-
nor injuries (22 % ). One half of these incidents resulted in
hospitalization, with an average stay length of 32 days.
Primary Outcome: Number of Falls at 6 Months
Of the 92 participants who completed the study, 48
(52.2 % ) reported a total of 128 falls in the 6 months af-
ter randomization, including 93 injury falls, 26 fracture
falls, and 33 hospitalized falls (note that these fall types
are not mutually exclusive). In the two groups com-
bined, the mean number of falls in the last six-month
period decreased by 19 per cent from 1.72 at baseline to
1.39 at six months. The interdisciplinary and usual-
home-care groups did not differ in mean number of
falls at six months (1.45 vs. 1.33, p = 0.70) or change in
mean number of falls (–0.31 vs. –0.35, difference: 0.04,
95 % CI: –1.18 to 1.27) (see Table 2 ). In addition, there
was no difference between the two groups in the
number and type of fall-related injuries.
Secondary Outcomes: Risk Factors for Falls at Six
Months
Slips and Trips
Of the 92 participants who completed the study, 28
(30.4 % ) reported a total of 300 slips or trips in the six
months after randomization. The mean number of slips
or trips in the past six- month period decreased by 46
per cent in the interdisciplinary group (from 1.14 at
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 149
Table 2: Group comparisons of fall and fall-related risk factors at baseline and six-month follow-up
Fall and
Fall-Related
Risk Factors
Treatment Group Test Statistics
Interdisciplinary Usual Home Care
Repeat Measures
ANOVA
Difference in mean
change scores (T1–T2)
(95% Confi dence Interval)
n
M
SD
n
M
SD
t-test
p
value
Number of Falls in Past Six Months
Time 1
a 49 1.76 2.72 43 1.67 3.74 −0.04 (−1.27, 1.18)
Time 2
b 49 1.45 2.73 43 1.33 2.23
Time 1 – Time 2 49 0.31 2.55 43 0.35 3.34 0.147 * 0.702 *
Number of Slips or Trips in Past Six Months
Time 1 49 1.14 3.28 43 1.84 5.37 −4.97 (−0.84, 10.78)
Time 2 49 0.61 1.77 43 6.28 22.37
Time 1 – Time 2 49 0.53 3.54 43 −4.44 20.13 4.92 * 0.027 *
SF-36 Physical Function Score (0–100)
Time 1 49 26.53 19.95 43 21.16 15.62 4.76 (−4.14, 13.65)
Time 2 49 35.61 22.21 43 35.00 23.07
Time 1 – Time 2 49 –9.08 20.53 43 –13.84 22.41 1.06 0.291
SF-36 Role-Physical Score (0–100)
Time 1 49 15.56 19.23 43 23.26 26.88 −4.19 (−18.68, 10.31)
Time 2 49 60.59 31.93 43 64.10 36.42
Time 1 – Time 2 49 −45.03 33.63 43 −40.84 36.32 −0.57 0.568
SF-36 Bodily Pain Score (0–100)
Time 1 49 49.35 29.02 43 56.74 32.14 −8.20 (−21.03, 4.65)
Time 2 49 69.14 27.41 43 68.35 31.65
Time 1 – Time 2 49 −19.80 31.13 43 −11.60 30.71 −1.27 0.208
SF-36 General Health Perception Score (0–100)
Time 1 49 61.12 20.10 43 63.79 21.35 −1.99 (−8.55, 4.57)
Time 2 49 62.04 21.07 43 62.72 21.33
Time 1 – Time 2 49 −0.92
13.84 43 1.07 17.77 −0.60 0.548
SF-36 Vitality Score (0–100)
Time 1 49 40.69 21.39 43 40.70 20.11 −5.43 (−15.58, 4.74)
Time 2 49 55.99 19.76 43 50.58 22.69
Time 1 – Time 2 49 −15.31 24.84 43 −9.88 24.06 −1.06 0.292
SF-36 Social Functioning Score (0–100)
Time 1 49 48.21 29.09 43 49.13 29.17 −0.12 (−14.77, 14.55)
Time 2 49 74.49 29.53 43 75.29 26.51
Time 1 – Time 2 49 −26.28 34.16 43 −26.16 36.58 −0.02 0.988
SF-36 Role-Emotional Score (0–100)
Time 1 49 64.29 36.12 43 79.46 28.31 −14.13 (−28.54, 0.28)
Time 2 49 92.18 15.72 43 93.22
17.18
Time 1 – Time 2 49 −27.89 39.77 43 −13.76 29.54 −1.95 0.054
SF-36 Mental Health Score (0–100)
Time 1 49 71.33 17.79 43 73.60 17.87 3.72 (−5.05, 12.50)
Time 2 49 74.69 17.84 43 80.70 14.08
Time 1 – Time 2 49 −3.37 21.15 43 −7.09 21.11 0.84 0.401
SF-36 Physical Health Component Summary Score (0–100)
Time 1 49 37.81 13.05 43 39.98 16.11 −1.41 (−8.18, 5.35)
Time 2 49 54.76 17.45 43 55.51 20.43
Time 1 – Time 2 49 −16.94 15.10 43 −15.53 17.57 −0.42 0.678
SF-36 Mental Health Component Summary Score (0–100)
Time 1 49 57.76 18.07 43 61.96 14.83 −3.27 (−11.74, 5.21)
Time 2 49 73.07 15.33 43 74.00 14.50
Time 1 – Time 2 49 −15.31 22.02 43 −12.04 18.41 −0.77 0.446
Screen II Nutritional Risk Score (0–64)
Time 1 49 44.71 7.65 43 46.56 7.86 −1.19 (−4.44, 2.06)
Time 2 49 46.84 9.91 43 47.49 8.29
Time 1 – Time 2 49 −2.12 8.20 43 −0.93 7.39 −0.73 0.468
Continued
150 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
Fall and
Fall-Related
Risk Factors
Treatment Group Test Statistics
Interdisciplinary Usual Home Care
Repeat Measures
ANOVA
Difference in mean
change scores (T1–T2)
(95% Confi dence Interval)
n
M
SD
n
M
SD
t-test
p
value
CES-D Depression Score (0–60)
Time 1 49 12.82 7.54 43 10.70 7.90 1.07 (2.2, 4.35)
Time 2 49 9.33 7.66 43 8.28 6.10
Time 1 – Time 2 49 3.49 8.05 43 2.42 7.70 0.65 0.518
POMA Gait and Balance Score (0–28)
c
Time 1 46 19.24 4.65 40 17.58 5.81 0.58 (−1.43, 2.59)
Time 2 45 20.89 4.43 39 20.31 5.84
Time 1 – Time 2 44 −1.73 3.32 36 −2.31 5.23 0.58 0.567
SMMSE Cognitive Status (0–30)
d
Time 1 45 27.29 3.02 40 27.23 2.97 0.52 (−0.69, 1.72)
Time 2 45 26.80 3.36 40 27.25 3.80
Time 1 – Time 2 45 0.49 2.91 40 −0.03 2.66 0.85 0.400
Modifi ed Falls Effi cacy Scale Score (0–10)
Time 1 49 5.09 2.14 43 4.97 2.09 0.02 (−1.05, 1.08)
Time 2 49 6.30 2.72 43 6.20 2.49
Time 1 – Time 2 49 −1.21 2.60 43 −1.23 2.51 0.03 0.979
Number of Acute Hospital Days for a Fall
Time 1 49 10.84 22.70 43 12.53 20.92 −0.37 0.711 −4.14 (−13.60, 5.34)
Time 2 49 2.71 10.24 43 0.28 1.83 1.64 0.108
Time 1 – Time 2 49
8.12 24.59 43 12.26 20.59 −0.87 0.388
* Kruskal–Wallis Test
a Time 1 (T1): Baseline
b Time 2 (T2): Six-month follow-up
c Numbers do not add to 92 as a result of missing scores (
n
= 12)
d Numbers do not add to 92 as a result of missing scores (
n
= 7)
M
= mean
SD
= standard deviation
Table 2: Continued
baseline to 0.61 at six months) but increased more than
threefold in the usual-home-care group (from 1.84 to
6.28) ( p = 0.03). The change in mean number of slips or
trips was –0.53 in the interdisciplinary group, compared
with 4.44 in the usual-home-care group (difference:
–4.97, 95 % CI: –10.78 to 0.84) ( p = 0.03) (see Table 2 ).
Functional Health Status and Related Quality of Life
From baseline to the six-month follow-up, both groups
improved in most SF-36 dimensions of functional
health status and related quality of life, with no signif-
icant difference between groups. The interdisciplinary
group showed greater improvement in role functioning
related to emotional health than the usual-care group,
although this difference did not reach statistical signif-
icance ( p = 0.054; difference: 14.13, 95 % CI: –0.28 to
28.54). Participants in the interdisciplinary group also
had greater improvements in bodily pain and energy/
vitality that were clinically important, but not signifi -
cant. A difference of fi ve points between groups for a
domain of the SF-36 is considered clinically and so-
cially important (Ware et al., 1993 ).
Nutritional Status
The SCREEN II mean score improved in the two groups
combined by 3.4 per cent (from 45.58 at baseline to
47.14 at six months). This difference translated into a
20 per cent reduction in the number of clients at nutri-
tional risk (< 54 out of 64 on SCREEN II). The change in
nutritional risk mean score did not differ between the
two groups ( p = 0.47).
Depression
At six months, the depressive-symptom mean score
decreased overall by 25.3 per cent (from 11.83 to 8.84).
This translated into an 11 per cent reduction in the
number of clients with depression ( ≥ 21 out of 60 on
the CES-D). The change in depressive-symptom mean
score did not differ statistically or clinically between
the two groups ( p = 0.52).
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 151
Gait and Balance
Gait and balance mean score increased in the two
groups combined by 11.6 per cent (from 18.47 to 20.62).
This translated into a 15 per cent reduction in the
number of clients at high risk for falls (< 25 out of 28 on
POMA). The change in gait and balance mean score
did not differ statistically or clinically between the two
groups ( p = 0.57).
Cognitive Function
Cognitive function mean score decreased overall by 0.9
per cent (from 27.26 to 27.01). This translated into a 2.3
per cent increase in the number of clients with cogni-
tive impairment ( ≤ 25 out of 30 on SMMSE). The change
in cognitive function mean score did not differ between
the two groups ( p = 0.40).
Confi dence in Performing Activities of Daily Living
The level of confi dence in performing ADLs without
falling increased in the two groups combined by 24.2
per cent (from 5.04 to 6.26). The change in MFES mean
score did not differ statistically or clinically between
the two groups ( p = 0.98).
Cost of Use of Health Services
The mean six-month costs of use of all types of health
services decreased overall by 78.3 per cent (from $22,956
at baseline to $4,973 at six months). The change in total
per-person direct costs of use of health services did not
differ between the two groups ( p = 0.41). The interdisci-
plinary group had higher per-person costs of use of
registered dietitians ( p = 0.02), occupational therapists
( p < 0.001), and supplies ( p = 0.03). These increases in
costs were offset by lower costs of use of dentists ( p =
0.01), and lower costs of use of surgeons, chiropractors,
psychologists, optometrists, podiatrists, and prescrip-
tion medications compared with the usual-home-care
group; however, these differences were not statistically
signifi cant. There was no difference between groups in
use of any other type of health service, including acute
hospitalization for a fall ( p = 0.39) (see Table 3 ).
Sub-group Analysis
The a priori hypothesis for evaluating differences in
number of falls during the six-month follow-up in-
cluded examining characteristics thought to infl uence
fall risk. Variables with fewer than 10 participants per
sub-group were excluded from the sub-group analysis.
The fi ndings indicate that an interdisciplinary team
approach is more effective than usual home care in re-
ducing the number of falls in males ( p = 0.009), 75 to 84
years of age ( p < 0.001), with a fear of falling ( p < 0.001),
or a negative history of falls in the six months pre-
ceding the study ( p < 0.04) (see Table 4 ). The total per-
person direct costs of use of health services did not
differ between the participants in the sub-groups com-
pared to similar participants in the control group.
Discussion
The objective of the present study was to determine the
effects and costs of a multifactorial, interdisciplinary
team approach to falls prevention compared with usual
home care services. To our knowledge, this is the fi rst
randomized controlled trial with an economic evalua-
tion of the effects and costs of a multifactorial, interdis-
ciplinary team approach to falls prevention for frail
older home care clients at risk for falling, compared
with usual home care services. This study is important
because of the high prevalence of falls among older
adults receiving home support services. The baseline
fall rate of 72 per cent in the present sample greatly
exceeds the fall rates of 30 per cent typically reported
for representative samples of community-dwelling
older adults (Kenny et al., 2001 ; Speechley & Tinetti,
1991 ). This setting is also important because it repre-
sents the logical target for any initiatives to improve
the early identifi cation and management of falls and
fall risk factors.
We found that a multifactorial, interdisciplinary team
approach to falls prevention, proactively provided to
older people at risk for falling, 72 per cent of whom
reported at least one fall in the previous six months,
56.5 per cent of whom suffered from four or more
chronic health problems, and 82 per cent of whom were
functionally limited, produced signifi cant improve-
ments in fall risk factors (slips and trips, health-related
quality of life), and a reduction in the incidence of falls
among males ( 75–84 years), with a fear of falling and
a negative history of falls. Notably, these improvements
were achieved at no additional cost to society as a
whole, thus making the intervention highly feasible
given its clinical benefi ts. Although we did not directly
measure the acceptability of the intervention, the high
engagement rate (98 % ) and low “dropout” rate (9 % )
over the six-month study period suggests that this ap-
proach is highly acceptable to this population. This
study demonstrates that, with modest reorganization
of the delivery of existing home services, giving greater
priority to interdisciplinary care and prevention, sig-
nifi cant enhancements in patient safety and quality of
life can result. Previous studies have focused only on
the use of institutional care and home care services as
measures of cost (Close et al., 1999 ; Rizzo et al., 1996 ).
Our study is unique in that it measured use and costs
of the full range of health services.
The results of this study add to the growing evidence
for the effectiveness of multifactorial falls prevention
programs for older adults in reducing falls and fall-
related risk factors (Clemson et al., 2004 ; Close et al.,
152 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
Table 3: Group comparisons of selected six-month costs of use of health services at baseline and six-month follow-up
Health Services Interdisciplinary (
n
= 49) Usual Home Care (
n
= 43) Kruskal–Wallis Test
M
SD
M
SD
χ
2
p
value
Direct Costs
Family Physician
Time 1 $139.50 $171.88 $120.12 $72.76 1.09 0.297
Time 2 $178.01 $253.21 $135.23 $132.44 0.76 0.384
Time 1 – Time 2 −$38.50 $228.12 −$15.11 $124.52 1.72 0.190
Emergency Room Visits
Time 1 $210.76 $248.51 $182.73 $171.51 0.04 0.840
Time 2 $87.05 $176.39 $52.21 $182.23 3.78 0.052
Time 1 – Time 2 $123.70 $290.05 $130.52 $286.63 0.49 0.485
911 calls
Time 1 $18.56 $27.75 $15.19 $15.17 0.00 0.997
Time 2 $8.57 $17.62 $8.13 $26.39 1.77 0.183
Time 1 – Time 2 $9.99 $32.63 $7.05 $31.18 0.28 0.598
Ambulance Service
Time 1 $200.82
$278.63 $189.77 $199.83 0.03 0.855
Time 2 $83.27 $180.34 $78.14 $244.08 1.28 0.257
Time 1 – Time 2 $117.55 $343.36 $111.63 $302.44 0.43 0.513
Cardiologist
Time 1 $27.09 $52.34 $36.48 $67.32 0.13 0.718
Time 2 $18.47 $37.37 $11.23 $27.16 0.69 0.405
Time 1 – Time 2 $8.62 $40.85 $25.26 $59.23 2.36 0.125
Neurologist
Time 1 $3.69 $14.62 $12.63 $31.04 2.54 0.111
Time 2 $3.69 $14.62 $1.40 $9.20 0.79 0.376
Time 1 – Time 2 $0.00 $17.42 $11.23 $30.19 4.29 0.038
Ophthalmologist
Time 1 $15.59 $40.34 $30.59 $45.67 4.60 0.032
Time 2 $18.18 $38.73 $16.77
$41.55 0.31 0.578
Time 1 – Time 2 −$2.60 $27.94 $13.81 $53.77 4.09 0.043
Respirologist
Time 1 $16.01 $74.69 $2.81 $12.86 0.14 0.712
Time 2 $8.62 $38.95 $1.40 $9.20 0.83 0.364
Time 1 – Time 2 $7.39 $50.23 $1.40 $9.20 0.00 0.993
Surgeon – Specialized
Time 1 $27.75 $65.80 $30.36 $134.44 1.74 0.187
Time 2 $7.77 $29.37 $26.56 $57.38 0.75 0.387
Time 1 – Time 2 $19.98 $61.51 $3.79 $131.84 4.66 0.031
Other Physician Specialists
Time 1 $18.84 $38.93 $9.26 $33.36 2.74 0.098
Time 2 $25.23 $53.24 $24.96 $66.18 0.64 0.422
Time 1 – Time 2 −$6.39 $47.72 −$15.70 $63.46 0.01
0.919
Chiropractor
Time 1 $25.98 $119.87 $7.79 $30.00 0.01 0.920
Time 2 $6.84 $34.18 $26.49 $138.04 0.03 0.859
Time 1 – Time 2 $19.14 $98.62 −$18.70 $132.66 0.50 0.481
Psychologist
Time 1 $17.35 $121.43 $16.47 $108.02 0.01 0.938
Time 2 $28.91 $144.53 $36.24 $172.39 0.02 0.886
Time 1 – Time 2 −$11.56 $80.95 −$19.77 $153.28 0.27 0.602
Physiotherapist
Time 1 $90.67 $163.56 $249.09 $618.60 2.71 0.100
Time 2 $631.48 $895.43 $498.18 $950.56 3.21 0.073
Time 1 – Time 2 −$540.81 $900.21 −$249.09 $745.60 4.87 0.027
Occupational Therapist
Time 1 $42.18 $75.81 $60.08 $119.81 0.21 0.649
Time 2 $278.36 $478.29 $36.05 $89.87 13.16 0.000
Time 1 – Time 2 −$236.18 $480.97 $24.03 $155.96 14.30 0.000
Continued
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 153
Table 3: Continued
Health Services Interdisciplinary (
n
= 49) Usual Home Care (
n
= 43) Kruskal–Wallis Test
M
SD
M
SD
χ
2
p
value
Podiatrist/ Chiropodist
Time 1 $36.43 $105.54 $41.51 $110.32 0.26 0.614
Time 2 $43.37 $113.94 $59.30 $120.97 0.68 0.410
Time 1 – Time 2 −$6.94 $131.95 −$17.79 $137.01 0.24 0.625
Dietitian
Time 1 $0.00 $0.00 $5.44 $24.90 2.30 0.129
Time 2 $90.63 $315.82 $0.00 $0.00 5.56 0.018
Time 1 – Time 2 −$90.63 $315.82 $5.44 $24.90 7.59 0.006
Visiting Nurse
Time 1 $215.72 $571.84 $91.19 $329.08 0.96 0.328
Time 2 $549.74 $1,651.72 $547.15 $1,925.08 3.28 0.070
Time 1 – Time 2 −$334.02 $1,539.25 −$455.96 $1,963.04 0.09 0.767
Optometrist
Time 1 $29.08 $124.48 $19.88 $44.26
0.30 0.587
Time 2 $15.51 $44.84 $26.51 $47.84 2.36 0.124
Time 1 – Time 2 $13.57 $131.52 −$6.63 $66.84 0.42 0.515
Dentist
Time 1 $66.61 $119.55 $39.47 $96.76 1.32 0.250
Time 2 $10.66 $36.12 $57.69 $125.17 5.45 0.020
Time 1 – Time 2 $55.95 $125.00 −$18.22 $149.63 7.26 0.007
Social Worker
Time 1 $12.53 $57.43 $5.71 $37.47 0.77 0.382
Time 2 $15.04 $105.29 $2.86 $18.73 0.01 0.938
Time 1 – Time 2 −$2.51 $58.75 $2.86 $42.29 0.15 0.698
Home Support Worker
Time 1 $219.27 $717.97 $528.28 $1,161.52 0.91 0.342
Time 2 $1,085.23 $1,660.14 $1,034.36 $1,817.50 0.51 0.477
Time 1 – Time 2 −$865.96 $1,566.57 −$506.08 $1,315.31 1.23 0.268
Massage Therapy
Time 1 $0.00 $0.00 $13.95 $91.50 1.14 0.286
Time 2 $0.00 $0.00 $0.00 $0.00 0.00 1.000
Time 1 – Time 2 $0.00 $0.00 $13.95 $91.50 1.14 0.286
Complementary Therapy
Time 1 $2.14 $15.00 $13.02 $69.13 0.53 0.469
Time 2 $0.00 $0.00 $0.00 $0.00 0.00 1.000
Time 1 – Time 2 $2.14 $15.00 $13.02 $69.13 0.53 0.469
Meals on Wheels
Time 1 $0.94 $4.62 $1.84 $9.86 0.02 0.894
Time 2 $14.49 $92.87 $0.00 $0.00 2.69 0.101
Time 1 – Time 2 −$13.55 $93.14 $1.84 $9.86 1.32 0.251
Community Support Programs
Time 1 $3.93 $23.82 $2.24 $12.71 0.01 0.912
Time 2 $21.33 $106.40 $8.76 $41.67 0.11 0.742
Time 1 – Time 2 −$17.40 $109.81 −$6.52 $44.02 0.10 0.756
Outpatient Tests
Time 1 $240.98 $382.09 $182.43 $285.23 0.43 0.511
Time 2 $304.24 $389.44 $160.79 $174.39 3.33 0.068
Time 1 – Time 2 −$63.26 $411.22 $21.64 $259.46 1.76 0.185
a. Blood
Time 1 $137.64 $252.79 $114.82 $269.83 0.08 0.777
Time 2 $166.62 $330.36 $85.55 $128.29 0.27 0.606
Time 1 – Time 2 −$28.98 $311.01 $29.27 $253.10 0.50 0.480
b. Specimens
Time 1 $10.45 $18.31 $9.38 $13.61 0.05 0.827
Time 2 $10.14 $18.07 $12.63 $22.02 0.25 0.615
Time 1 – Time 2 $0.32 $15.68 −$3.25 $22.35 0.05 0.822
Continued
154 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
Table 3: Continued
Health Services Interdisciplinary (
n
= 49) Usual Home Care (
n
= 43) Kruskal–Wallis Test
M
SD
M
SD
χ
2
p
value
c. Scopes
Time 1 $3.17 $22.17 $7.22 $33.07 0.49 0.484
Time 2 $15.84 $65.27 $0.00 $0.00 2.69 0.101
Time 1 – Time 2 −$12.67 $69.67 $7.22 $33.07 2.65 0.104
d. X-rays
Time 1 $28.44 $47.73 $9.64 $20.29 3.89 0.049
Time 2 $34.59 $54.28 $25.41 $40.87 0.83 0.361
Time 1 – Time 2 −$6.15 $66.75 −$15.77 $44.44 0.41 0.524
e. Scans
Time 1 $33.50 $73.75 $10.60 $35.65 2.45 0.117
Time 2 $27.92 $65.03 $10.60 $29.58 1.49 0.223
Time 1 – Time 2 $5.58 $88.12 $0.00 $39.80 0.00 0.965
f. Visual Field Test
Time 1 $5.37 $13.29 $11.37 $19.30
2.68 0.101
Time 2 $12.28 $22.23 $10.49 $26.37 0.46 0.497
Time 1 – Time 2 −$6.91 $26.22 $0.87 $30.13 2.20 0.138
g. Outpatient Laboratory Tests
Time 1 $8.45 $28.30 $7.11 $23.51 0.02 0.879
Time 2 $23.32 $58.32 $7.30 $33.45 3.86 0.049
Time 1 – Time 2 −$14.86 $54.40 −$0.19 $42.17 2.99 0.084
Medications
Time 1 $1,121.42 $811.87 $1,368.78 $1,114.17 0.92 0.338
Time 2 $1,143.09 $816.35 $1,594.40 $2,062.41 1.54 0.215
Time 1 – Time 2 −$21.67 $660.00 −$225.62 $1,896.05 0.24 0.622
Supplies, Aids or Devices
Time 1 $84.97 $250.33 $127.12 $320.47 0.97 0.325
Time 2 $368.03 $1,641.34 $289.20 $1,524.42 4.81 0.028
Time 1 – Time 2 −$283.06 $1,676.94 −$162.08 $1,578.20 6.66 0.010
Direct Cost (excluding hospital and day surgery)
Time 1 $3,041.53 $1,711.45 $3,451.92 $2,212.92 0.83 0.362
Time 2 $13,085.90 $19,112.45 $9,899.98 $17,962.54 0.88 0.350
Time 1 – Time 2 −$10,044.40 $18,667.51 −$6,448.06 $16,729.39 2.25 0.134
Acute Care Hospital
Time 1 $16,897.20 $20,354.65 $22,637.05 $27,623.71 0.46 0.498
Time 2 $7,892.10 $17,742.48 $5,053.94 $17,412.56 0.68 0.410
Time 1 – Time 2 $9,005.09 $24,092.19 $17,583.11 $24,743.57 2.38 0.123
Day Surgery
Time 1 $215.51 $412.78 $61.40 $241.60 5.06 0.025
Time 2 $67.35 $201.85 $46.05 $170.13 0.30 0.586
Time 1 – Time 2 $148.16 $431.64 $15.35 $305.13 2.98 0.084
Direct Cost (including hospital and day surgery)
Time 1 $20,154.23 $21,068.16 $26,150.37 $28,132.20 0.76 0.383
Time 2 $5,126.45 $3,913.70 $4,799.99 $4,305.19 0.95 0.330
Time 1 – Time 2 $15,027.78 $20,517.73 $21,350.37 $27,358.80 0.68 0.409
Indirect Costs
Old Age Security
Time 1 $2,994.77 $1,054.61 $2,704.53 $932.51 0.24 0.624
Time 2 $3,136.88 $874.35 $2,509.67 $1,148.67 3.21 0.073
Time 1 – Time 2 −$142.11 $657.18 $194.86 $936.31 2.06 0.151
Canada Pension
Time 1 $2,472.17 $1,717.64 $2,292.30 $1,817.21 0.07 0.788
Time 2 $2,640.14 $1,760.60 $2,667.74 $1,544.88 0.11 0.744
Time 1 – Time 2 −$167.97 $1,055.29 −$375.43 $1,170.96 0.53 0.466
GAINS
Time 1 $0.00 $0.00 $11.58
$75.94 1.14 0.286
Time 2 $95.88 $602.73 $11.58 $75.94 0.23 0.629
Time 1 – Time 2 −$95.88 $602.73 $0.00 $0.00 1.77 0.183
Continued
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 155
Table 3: Continued
Health Services Interdisciplinary (
n
= 49) Usual Home Care (
n
= 43) Kruskal–Wallis Test
M
SD
M
SD
χ
2
p
value
Veteran’s Pension
Time 1 $535.55 $1,510.37 $183.07 $903.19 2.35 0.125
Time 2 $677.51 $1,576.17 $218.51 $1,092.94 3.86 0.049
Time 1 – Time 2 −$141.96 $1,259.06 −$35.44 $1,336.03 0.00 0.988
Survivor’s Benefi ts
Time 1 $110.20 $543.23 $402.56 $811.19 5.58 0.018
Time 2 $149.39 $599.14 $216.80 $620.19 0.72 0.396
Time 1 – Time 2 −$39.18 $283.17 $185.76 $752.23 2.46 0.117
Other Government Cheques
Time 1 $204.29 $1,107.04 $32.00 $184.32 1.03 0.311
Time 2 $171.34 $633.60 $190.70 $653.77 0.68 0.409
Time 1 – Time 2 $32.94 $1,269.94 −$158.70 $635.87 0.46 0.500
Cash Transfer Cost
Time 1 $6,316.99 $2,585.35 $5,726.91
$2,483.76 0.63 0.429
Time 2 $6,871.14 $2,628.28 $5,814.99 $2,413.93 3.07 0.080
Time 1 – Time 2 $–554.15 $2,381.66 $–88.09 $1,928.12 0.82 0.366
M
= mean
SD
= standard deviation
1999 ; Gillespie et al., 2003 ; Robson et al., 2002 ; Steinberg
et al., 2000 ; Tinetti et al., 1994 ; Wagner et al., 1994 ). How-
ever, the home care settings targeted in this study serve
a considerably frailer group of seniors than the general
population of community-dwelling seniors. Such people
are often excluded from community-based studies of
the effectiveness of multifactorial falls prevention pro-
grams. Thus, this study makes an important contribu-
tion by providing knowledge of the effectiveness of
multifactorial falls prevention among a much frailer
group of seniors than recruited in previous studies.
The baseline characteristics of our sample indicate that
we reached our intended target group – older adults at
risk for falling. Two thirds of our sample had two or
more of the leading risk factors for falls: fall within the
previous 12 months, fear of falling or unsteadiness on
their feet. Thus, the results also lend support for the
effectiveness of falls prevention programs targeted to
populations at risk (Gillespie et al., 2003 ; Tinetti et al.,
1994 ). Categorizing individuals into different levels of
risk is important from both clinical and economic per-
spectives because it is the seniors with the highest risk
of falling who will benefi t most from preventive efforts
and from avoiding the negative consequences of falls.
After six months, compared with the baseline, partici-
pants in the interdisciplinary group reported a greater
Table 4: Subgroup analysis
Characteristics Number of Falls (Baseline to Six Months) Test Statistics
Interdisciplinary Usual Home Care
n
M
n
M
95% CI
p
value
Age
Age (75–84) 28 0.89 22 1.82
Age (85 and older) 21 2.19 21 0.81 −3.30, –1.31 < 0.001
Number of Falls in Past Six Months
No fall in past six months 12 0.58 14 1.21
> 1 fall in past six months 37 1.73 29 1.38 0.04, 1.92 0.041
Fear of Falling
No fear of falling 29 1.86 22 0.91
Fear of falling 20 0.85 21 1.76 −2.81, –0.92 < 0.001
Gender
Male 16 1.50 10 2.70
Female 33 1.42 33 0.91 0.42, 3.01 0.009
M
= mean
156 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
improvement in role functioning related to emotional
health than the usual-home-care participants. Given
the lower level of role functioning in the interdisci-
plinary group at baseline, this is a clinically important
gain. At six months, the interdisciplinary group re-
ported 47 per cent fewer slips and trips than at base-
line, compared with a more than threefold increase in
the usual home care group ( p = 0.03). Our fi ndings are
consistent with those of previous studies, which have
reported signifi cant improvements in health-related
quality of life and function (Close et al., 1999 ; Light-
body et al., 2002 ; Lin et al., 2007 ; Wagner et al., 1994 )
and a reduction in slips and trips (Steinberg et al., 2000 )
with a multifactorial approach. These fi ndings are
noteworthy, given that slips and trips and poor quality
of life and function are two of the most common pre-
dictors of falls (Speechley & Tinetti, 1991 ).
One possible explanation for the improvement in
health-related quality of life and function is that many
of the risk factors for falls also contribute to functional
decline and reduced quality of life (Sjösten et al., 2008 ).
Consequently, a multifactorial approach targeted to re-
duce these risk factors could result in reductions in
falls as well as improvements in health.
A unique contribution of our study was its focus on
both falls and near falls (slips or trips). Although falls
among older adults have been studied extensively,
data are limited on the prevalence of slips and trips
and the prevention of such incidents in this age group
(Steinberg et al., 2000 ). Yet, the most common circum-
stances leading to falls are slips and trips. It has been
proposed that there is a continuum from slips and
trips, wherein balance is regained, through near falls,
to complete falls when balance is lost (Steinberg et al.).
Because both seniors and health care providers focus
on the consequences of falls, non-injurious falls may be
disregarded (Gallagher & Brunt, 1996 ). Our fi ndings
suggest that it would be benefi cial for the health care
system to focus attention on warning signs such as
slips or trips. However, future research is necessary to
determine whether improvements in these risk factors
for falls lead to reductions in subsequent falls. If slips
and trips have an effect on falls incidence, this would
also suggest an earlier point of intervention on the con-
tinuum of falls (Steinberg et al.).
The study fi ndings provide important information re-
garding which specifi c sub-groups of older home care
clients benefi ted most from a multifactorial, interdisci-
plinary team approach to falls prevention. Few trials
on the effectiveness of multifactorial falls prevention
programs have examined which sub-groups of older
adults benefi t most from the intervention (Clemson
et al., 2004 ; Hornbrook et al., 1994 ; Nikolaus & Bach,
2003 ; Shaw et al., 2003 ). As a result, it is diffi cult to dis-
tinguish whether the differences in effectiveness are
attributable to variations in the type of intervention or
to characteristics of the samples. The subgroup analyses
in this study suggested that the intervention was more
effective in men ( p = 0.009), 75 to 84 years of age ( p <
0.001), who had a fear of falling ( p < 0.001), or a nega-
tive history of falls in the months preceding the study
( p < 0.04). In these subgroups, the number of falls could
be reduced signifi cantly by interdisciplinary team in-
tervention at no additional cost.
The fi nding that the intervention was more effective in
men than women is consistent with those of previous
studies (Clemson et al., 2004 ), and may refl ect the fact
that it was more attractive to this population. Another
explanation is that, in general, men are less active in
health activities and seeking knowledge than women.
Therefore, they may have had a greater initial readi-
ness, resulting in a much greater uptake and recep-
tivity to the strategies affected by the interdisciplinary
team (Clemson et al.).
The fi nding that the intervention was more effective
for seniors with a fear of falling is noteworthy because
fear of falling is highly prevalent among seniors and is
considered to be one of the leading risk factors for
falling with effects on functional health status and re-
lated quality of life (Sjösten et al., 2008 ). One possible
explanation for the superiority of the multifactorial, in-
terdisciplinary approach in this subgroup is that falls,
and fear of falling, have multifactorial causes and actu-
ally share many risk factors (e.g., gait and balance
problems, depressive symptoms, and poor cognition).
Consequently, a multifactorial approach targeted to re-
duce several risk factors simultaneously may be more
benefi cial than a single-focused approach.
The fi nding that the intervention was more effective
for seniors with a negative history of falls in the six
months preceding the study is consistent with those of
previous studies (Clemson et al., 2004 ; Hornbrook
et al., 1994 ). One hypothesis is that the intervention
was more effective for seniors with a negative history
of falls because they had higher levels of physical, so-
cial, and psychological functioning compared with
fallers (Markle-Reid et al., 2008a). Individuals with
lower functional levels normally are apt to need more
support and receive it (Markle-Reid, Weir, Browne,
Roberts, Gafni, & Henderson, 2008b). This may have
reduced the differences between the two groups. It is
equally likely that the intervention was less effective
for seniors with a history of falls because the modifi ca-
tions of risk factors in this complex population may not
have been large enough or may have been focused on
the wrong type and so did not affect falls in this sub-
group. Home care services often are put into place to
compensate for and help people cope with irreparable
Falls Prevention for Frail Seniors La Revue canadienne du vieillissement 29 (1) 157
physical decline associated with advanced chronic
disease and the aging process in later life. The limited
effectiveness of the intervention in this sub-group may
as likely refl ect that reality as the possibility that ser-
vices are not achieving outcomes.
The fi nding that the intervention was more effective
for younger seniors (75–84 years) than older seniors (>
85 years) or individuals who did report a fall suggests
the need for a more upstream approach to falls preven-
tion, targeting a younger population at an earlier point
along the continuum of falls to prevent the onset of
falls. Overall, these fi ndings suggest that limited home
care resources may be used more effectively if targeted
toward males ( ≥ 75–84 years), with a fear of falling and
a negative history of falls.
Implications
Our study adds to the accumulating evidence showing
that high functioning interdisciplinary teams – those
that have the client at the centre, communicate easily
and frequently, have shared objectives and clear roles
and responsibilities, and conduct interdependent
decision making – improve the quality of care and
reduce adverse events among seniors with chronic
conditions (Barrett, Curran, Glynn, & Godwin, 2007;
Canadian Health Services Research Foundation,
2005 ; Ontario Ministry of Health and Long-Term Care,
Health Human Resources Strategy Division, 2007).
Given the multifactorial nature of falls, people with
multiple chronic conditions are best served by an inter-
disciplinary group of professionals with complemen-
tary skills to address the bio-psychosocial determinants
of falls (World Health Organization, 2005 ).
The fi ndings of this study also confi rm that early, proac-
tive, and comprehensive care for people with chronic
needs is both more effective and no more expensive in a
system of national health insurance than providing ser-
vices on a limited, reactive, and piecemeal basis (Browne,
Roberts, Gafni, Byrne, Weir, Majumdar et al., 1999;
Browne et al., 2001 ; Markle-Reid, Weir, Browne, Rob-
erts, Gafni, & Henderson, 2006a, 2006b). Given that the
annual cost of health services use was $11,500 per per-
son higher for fallers compared with non-fallers (Mar-
kle-Reid et al., 2008a), a program targeted to this at-risk
group of frail seniors has the potential for signifi cant
cost savings from a societal perspective. A falls preven-
tion intervention that achieves a reduction in falls could
result in enough costs savings to pay for the interven-
tion. It also has the potential to reduce the human cost
of a fall, which can include loss of independence and
confi dence, low self-esteem, depression, chronic pain,
functional deterioration, fractures, or death.
The study results support and extend the literature re-
garding best-practice guidelines for providing falls
prevention to older people at risk for falls. A multifac-
torial approach to falls prevention should target indi-
viduals at risk (Tinetti et al., 1994 ); use a variety of
strategies that are tailored to an individual’s risk pro-
fi le (Gillespie et al., 2003 ; Kenny et al., 2001 ); involve
substantial realignment of roles and scopes of practice;
formalize mechanisms for communication among
health care providers; improve integration between
home care and primary care (Leatt et al., 2000 ); include
regular follow-ups using validated screening instru-
ments and evidence-based practice guidelines; and in-
volve providers with formal training in falls prevention,
referral to and coordination of community services,
and continuity of care provider (Gillespie et al., 2003 ;
Markle-Reid et al., 2006a ).
Limitations of the Study
Although the randomized design and high engage-
ment and follow-up rates were major strengths of this
study, several limitations must be considered when ex-
amining our study results. Despite concerted efforts,
we were only able to recruit and randomize 41 per cent
of eligible clients. Thus, our sample might not have
been truly representative of the population at risk. Fu-
ture research is warranted to identify the most-effec-
tive strategies for recruiting at-risk seniors who are
truly in need of falls prevention interventions.
There may have been an under reporting of falls since
reluctance to report falls among older people has been
observed. They may fear loss of an independent lifestyle
and the associated stigma of aging (Gallagher & Brunt,
1996 ). Further, recall bias due to forgetfulness and
memory impairment might also have led to under-
reporting (Cummings, Nevitt, & Kidd, 1988 ). More
studies are needed to develop and test strategies to max-
imize the likelihood that seniors report all falling events.
Although the calendar and monthly telephone contacts
were designed primarily to record outcomes, it is pos-
sible that their use might also have constituted an in-
tervention in its own right. If the control participants
benefi ted from these contacts, this minor intervention
would have diluted the treatment effect and decreased
the differences between groups. Further research is
needed to confi rm the effect of this strategy on its own
as an effective preventive intervention. If confi rmed, it
has the potential to be a low-cost, sustainable approach
to decreasing falls and near falls among older people
(Steinberg et al., 2000 ).
Only the immediate effects of the intervention were
observed. Further research is needed to determine if
the effects of the intervention are sustained over longer
periods of time. The fi nding that there was no differ-
ence between groups in per-person costs of use of
health services may be because of an insuffi cient
158 Canadian Journal on Aging 29 (1) Maureen Markle-Reid et al.
sample size and limited power to detect differences.
Future trials with an economic evaluation are needed
that have suffi cient power to detect cost differences.
Lastly, the results refl ect what happened in two home
care programs, which may or may not be representa-
tive of other home care environments. The generaliz-
ability of the results to the wider population of older
people depends on the extent to which the services un-
der study are available and the criteria for service pro-
vision are comparable in different areas.
Conclusions
With the rapid increase in the number of seniors living
in the community, falls and fall-related injuries are be-
coming a serious problem that, without intervention,
will place extensive burdens on health care resources
(SmartRisk, 2006). Home care has the potential to play
a pivotal role in preventing falls and enhancing the
quality of life of older people with chronic needs. Our
study shows that a multifactorial, interdisciplinary
team approach is more effective and no more expen-
sive than usual home care in improving quality of life,
reducing the incidence of slips and trips, and reducing
falls among males ( ≥ 75–84 years), with a fear of falling
and a negative history of falls. Such an approach is
highly acceptable to this population, and can be imple-
mented in a home care setting using existing resources.
Home care policy makers, agencies, and funders
should work together to ensure that an interdisci-
plinary team approach is available to the subgroups of
seniors who could benefi t from it most to reduce future
falls, enhance quality of life, and reduce the on-demand
use of expensive health services.
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