DOI: 10.1111/jgs.

17375
Journal of the
American Geriatrics Society

Interventions for preventing falls and fall-related fractures

in community-dwelling older adults: A systematic review
and network meta-analysis

Lauren Dautzenberg MD, MSc1 | Shanthi Beglinger MD, MBiolSci2,3 |

Sofia Tsokani MSc | Stella Zevgiti PhD | Renee C. M. A. Raijmann MD, MSc1 |
4 4

Nicolas Rodondi MD, PhD2,3 | Rob J. P. M. Scholten MD, PhD5 |

Anne W. S. Rutjes PhD3,6 | Marcello Di Nisio MD, PhD7 |
Marielle Emmelot-Vonk MD, PhD1 | Andrea C. Tricco PhD8,9 |
8,9,10
Sharon E. Straus MD, MSc | Sonia Thomas MSc | Lisa Bretagne MD, MSc2,3 | 8

Wilma Knol MD, PhD1 | Dimitris Mavridis PhD4,11 | Huiberdina L. Koek MD, PhD1

1
Department of Geriatric Medicine,
University Medical Centre Utrecht, Utrecht
Abstract
University, Utrecht, The Netherlands Objective: To compare the effectiveness of single, multiple, and multifactorial
2
Department of General Internal interventions to prevent falls and fall-related fractures in community-dwelling
Medicine, Inselspital, Bern University
older persons.
Hospital, University of Bern, Bern,
Switzerland Methods: MEDLINE, Embase, and Cochrane Central Register of Controlled
3
Institute of Primary Health Care (BIHAM), Trials were systematically searched for randomized controlled trials (RCTs)
University of Bern, Bern, Switzerland evaluating the effectiveness of fall prevention interventions in community-
4
Department of Primary Education, dwelling adults aged ≥65 years, from inception until February 27, 2019. Two
School of Education, University of
Ioannina, Ioannina, Greece large RCTs (published in 2020 after the search closed) were included in post
5
Cochrane Netherlands/Julius Centre for hoc analyses. Pairwise meta-analysis and network meta-analysis (NMA) were
Health Sciences and Primary Care, conducted.
University Medical Centre Utrecht,
Utrecht University, Utrecht, The
Results: NMA including 192 studies revealed that the following single
Netherlands interventions, compared with usual care, were associated with reductions in
6
Institute of Social and Preventive number of fallers: exercise (risk ratio [RR] 0.83; 95% confidence interval
Medicine (ISPM), University of Bern, [CI] 0.77–0.89) and quality improvement strategies (e.g., patient education)
Bern, Switzerland
7 (RR 0.90; 95% CI 0.83–0.98). Exercise as a single intervention was associated
Department of Medicine and Ageing
Sciences, University G. D'Annunzio, with a reduction in falls rate (RR 0.79; 95% CI 0.73–0.86). Common compo-
Chieti, Italy nents of multiple interventions significantly associated with a reduction in
8
Li Ka Shing Knowledge Institute, St. number of fallers and falls rate were exercise, assistive technology, environ-
Michael's Hospital, Unity Health Toronto,
Toronto, Ontario, Canada
mental assessment and modifications, quality improvement strategies, and

Lauren Dautzenberg and Shanthi Beglinger contributed equally to this work.

The abstract of this paper has been presented at the European Geriatric Medicine Society (EUGMS) E-Congress 2020.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.
© 2021 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.

J Am Geriatr Soc. 2021;69:2973–2984. wileyonlinelibrary.com/journal/jgs 2973

 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2974 DAUTZENBERG ET AL.

9
Epidemiology Division and Institute for
Health Policy, Management, and basic falls risk assessment (e.g., medication review). Multifactorial interven-
Evaluation, Dalla Lana School of Public tions were associated with a reduction in falls rate (RR 0.87; 95% CI 0.80–
Health and Institute for Health,
Management, and Evaluation, University
0.95), but not with a reduction in number of fallers (RR 0.95; 95% CI 0.89–
of Toronto, Toronto, Ontario, Canada 1.01). The following single interventions, compared with usual care, were
10
Department of Geriatric Medicine, associated with reductions in number of fall-related fractures: basic falls risk
University of Toronto, Toronto, Ontario, assessment (RR 0.60; 95% CI 0.39–0.94) and exercise (RR 0.62; 95% CI
Canada
11 0.42–0.90).
Paris Descartes University, Sorbonne
Paris Cité, Faculté de Médecine, Paris, Conclusions: In keeping with Tricco et al. (2017), several single and multiple
France fall prevention interventions are associated with fewer falls. In addition to

Correspondence
Tricco, we observe a benefit at the NMA-level of some single interventions on
Lauren Dautzenberg, Heidelberglaan preventing fall-related fractures.
100, 3584 CX Utrecht, The Netherlands.
Email: l.dautzenberg@umcutrecht.nl KEYWORDS
community-dwelling, fall-related fractures, falls, older adults
Funding information
Horizon 2020 Framework Programme,
Grant/Award Number: 6342388; the Swiss
State Secretariat for Education, Research and
Innovation (SERI), Grant/Award Number:
15.0137; Tier 1 Canada Research Chair in
Knowledge Translation; Tier 2 Canada
Research Chair in Knowledge Synthesis

INTRODUCTION relative effectiveness between any pair of interventions, even

if these interventions have never been compared directly.8,9
Falls in older adults are a highly prevalent problem. Falls
occur in one-third of community-dwelling people aged
≥65 years at least once a year.1 Twenty percent of these
falls lead to a fall-related injury.2,3
Key Points
Many intrinsic and extrinsic risk factors for falling
have been identified.4 Suffering from multiple chronic • The single intervention exercise is most
conditions, for example, rheumatic disease, vertigo, may strongly associated with a reduction in
pose an even higher risk of falling; these medical condi- falls rate.
tions are prevalent in older people.4 • The single intervention basic falls risk assess-
Fall prevention interventions target risk factors that are ment is most strongly associated with a reduc-
modifiable and can be divided into three main groups: (1) tion in number of fall-related fractures.
single interventions (participants receive one type of inter- • Common components of multiple interven-
vention), (2) multiple interventions (participants receive the tions significantly associated with a reduction
same, fixed combination of two or more types of interven- in number of fallers and falls rate are exercise,
tions), and (3) multifactorial interventions (participants assistive technology, environmental assessment
receive a personalized selection out of two or more types of and modifications, quality improvement strate-
interventions, according to the results of a pre-executed, per- gies, and basic falls risk assessment.
sonal falls risk assessment).5 Until Tricco,6 previous system-
atic reviews (SRs) and meta-analyses were restricted to Why Does this Paper Matter?
looking at combinations of multifactorial/multiple interven-
tions on fall prevention as a whole, rather than being able to Previous reviews were restricted to analyzing fixed
disentangle the effect of the individual components from the combinations of interventions, rather than dis-
entire combination.5,7 It is, however, important to determine entangling the effect of the individual components
which particular components are most effective, as this can from the entire combination. Yet, this is vital in
result in a more accurate prevention strategy. Network order to offer a targeted/personalized fall preven-
meta-analysis (NMA) enables the evaluation of individual tion strategy, especially in high-risk groups.
components from multiple comparisons estimating the
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PREVENTION FALLS AND FRACTURES OLDER ADULTS 2975

Furthermore, previous reviews did not focus on interventions for preventing falls in community-dwelling
multimorbid older (age ≥ 75) adults.10 As this population persons aged ≥65 years. For details of the eligible study
have a high risk of falling, it is essential to gain more population, interventions, comparators, and outcomes, as
insight into which particular fall prevention interventions well as the exclusion criteria, see Table S11. We excluded
are most beneficial in this high risk group. studies on specific conditions (e.g., stroke, Parkinson's dis-
Therefore, the aim of this SR and NMA was to update ease), where the effects of the interventions cannot be
the Tricco et al. search on the effectiveness of single, mul- generalized to most community-dwelling older people.
tiple, and multifactorial interventions and their individ-
ual components for preventing falls and fall-related
fractures in community-dwelling older persons, with a Study selection
particular focus on multimorbidity and age > 75 years.
Two authors each reviewed half of the study titles and
abstracts that resulted from the search, and then both
METHODS independently reviewed the full text of all studies that
were retained. Any disagreement was resolved by consen-
Protocol sus with a third author. To ensure consistency of the eli-
gibility criteria applied, the authors performed a pilot-test
The protocol for this SR and NMA was registered online screening beforehand.
with PROSPERO (PROSPERO 2019 CRD42019137466)
and was developed in accordance with the preferred
reporting items for systematic review and meta-analyses Data extraction and outcome definition
(PRISMA) statement.
We created a data extraction sheet for the following vari-
ables: study characteristics; participant characteristics; and
Study identification primary and secondary outcome information. We
categorized the interventions into the same intervention
We updated Tricco et al.'s6 SR and NMA of fall prevention components as used by Tricco et al,6 and added additional
interventions in older adults. We applied the same search intervention components (Table 1). Primary outcomes were
terms as used in the original Tricco et al.'s review and number of fallers and number of fall-related fractures. Sec-
updated the search from December 1, 2015, until February ondary outcomes were number of repeated fallers, number
27, 2019. The following electronic databases were searched: of hip fractures, falls rate, and fracture rate.
MEDLINE (via PubMed), Embase (OVID), and Cochrane
Central Register of Controlled Trials. The search strategies
with limitations are included in Appendix S11. The elec- Risk of bias assessment
tronic search was supplemented with manual searches for
additional randomized controlled trials (RCTs), by To assess risk of bias, we used the Effective Practice and
reviewing the reference lists of previous reviews,5,7 a rec- Organisation of Care (EPOC) version of Cochrane's Risk
ommendations statement,11 and NMA.12 We extended of Bias tool.15 This EPOC version fully overlaps with the
Tricco et al.'s search by searching for additional interven- original tool, yet adds the following criteria: contamina-
tions (management of urinary incontinence, management tion, similar baseline values of the outcome measures,
of orthostatic hypotension, walking aids, and chiropractic and similarity of baseline characteristics. Risk of bias
care) from database inception to February 2019. As a NMA assessment was performed by two authors independently
is time-consuming, new papers might be published after and any disagreement resolved by consensus with a third
the search period. To check whether the findings of the author. The authors first performed a pilot test to ensure
current NMA are consistent with most recent literature, consistency in applying the risk of bias criteria.
the outcomes from two large RCTs published after the
search date13,14 were incorporated into a post hoc analysis.
Measures of treatment effect

Eligibility criteria For dichotomous outcomes, we calculated risk ratios

(RRs) accompanied by their 95% confidence intervals
We included (cluster) randomized and quasi-RCTs publi- (CI). For rates, whereby each participant may experience
shed in any language that evaluated the effectiveness of the event of interest more than once, we extracted the
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2976 DAUTZENBERG ET AL.

TABLE 1 Interventions to prevent falls categorized into 14 components

Intervention component
(abbreviation) Description
1. Exercise (exerc) Including gait-, balance-, and functional training, strength/resistance training, flexibility, 3D
training (e.g., Tai Chi, Qigong, dance and square stepping), general physical activity (e.g.,
walking groups), endurance training, and other
2. Medication (med) Vitamin D (cholecalciferol, alphacalcidol, sunlight, calcitriol, and ergocalciferol)
3. Surgery (surg) E.g., pacemaker implantation, hip prosthesis, or cataract removal surgery
4. Management of urinary Assisted toileting, bladder retraining, medication (e.g., tamsulosin, finasteride, botox
incontinencea (incont) injections), surgery (e.g., colposuspension surgery, sling procedures)
5. Fluid or nutrition therapy (nutr) Changes in diet, provision of supplements, nutritional therapy, protein drinks
6. Psychological interventions (psych) Cognitive behavioral therapy
7. Environmental assessment and Assessment and correction of home environment (e.g., flooring, home check, home safety
modifications (envir) devices, home visits by occupational therapist, home furnishings and adaptations)
8. Assistive technology (assist) Provision of aids for personal protection (e.g., hip protector) or personal mobility (e.g., walking
aidsa, comprehensive podiatry assessment and treatment, orthosis), aids for communication/
information/signaling (e.g., vision assessment and correction with glasses, personal alarm
systems, hearing aids)
9. Social engagement (social) Social group activities (watching films, leisure reading, singing, conversation), community
activities, peer support (from peers or caregivers), seminars on non–health-related topics of
general interest to older adults.
10. Quality improvement strategies - Patient-level quality improvement strategies:
(qualt) promotion of self-management, patient education, patient reminders, and motivational
interviewing
- Clinic-level or care team level quality improvement strategies:
case management, team changes, electronic patient registry, facilitated relay of information to
clinicians, audit and feedback, staff education, and clinician reminders
- Health system-level quality improvement strategies:
Interventions with positive or negative financial incentives directed at clinicians (e.g., linked to
adherence to some process of care or achievement of some target outcome). This strategy
also includes positive or negative financial incentives directed at patients or system-wide
changes in reimbursement systems
11. Management of orthostatic Wearing elastic stockings, rising slowly, sleeping in a bed with head raised, pharmacological
hypotensiona (hypot) interventions
12. Basic falls risk assessment (brisk) Cardiovascular assessment (vital signs, ECG, loop recorder, pacemaker interrogation),
medication review (review, modification, withdrawal/deprescribing), fracture risk screening
(bone mineral density)
13. Whole-body vibration (vibr) Transferring vibration of any frequency to the human body
a
14. Chiropractic care (chiro) Improving sensorimotor function associated with fall risk

Note: In general, we categorized interventions into similar components as used by Tricco et al. (2017) in order to assist with later merging of data extraction
results. We also categorized the multifactorial interventions into the 14 interventions components. In order to be able to carry out analyses, we had to assume
that all participants received these multifactorial intervention components.
a
Additional fall prevention interventions not previously investigated by Tricco et al.

number of events and total participant-time (e.g., number followed the standard approach whereby each distinct
of person-weeks of follow-up) and calculated rate ratios combination of intervention components is treated as
with 95% CIs, assuming that the risk of the event occur- a separate intervention, for example, assistive technol-
ring is constant across participants and over time. ogy + exercise versus usual care. We employed addi-
tional statistical models to disentangle the effect
(i.e., determine effect sizes) of each separate interven-
Synthesis of results tion component, for example, assistive technology ver-
sus usual care, and exercise versus usual care
For a detailed description of the meta-analysis (component-NMA [C-NMA]). A nontechnical review
methods see Appendix S11. The primary analysis of C-NMA is previously given.16 A basic assumption of
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PREVENTION FALLS AND FRACTURES OLDER ADULTS 2977

the C-NMA is the additivity assumption, in which the Study and participant characteristics
total effect of a multiple/multifactorial intervention is
derived from the sum of the relevant components The study and participant characteristics of the original
(Interventiona + b = Interventiona + Interventionb), 220 studies identified in our search are presented in
thus the effect size of each individual intervention Appendix S1 and summarized in Table 2.
component can be determined.17,18 We used statisti- In 128 studies (58.2%), the mean age of participants
cally significant effect estimates with the highest P- was between 75 and 84 years and in 11 studies (5.0%)
scores to rank interventions19 and estimate the aver- ≥85 years.
age probability of a treatment being superior to other
competing treatments.
Risk of bias assessment

Certainty of the evidence The risk of bias assessment was performed at the study
level (see Appendix S2). Most studies had a low risk of
We used the Confidence in Network Meta-Analysis bias for random sequence generation, similar baseline
(CINeMA) approach, a quality assessment tool, to deter- characteristics, similar baseline outcome measures,
mine the degree of confidence in NMA effect estimates incomplete outcome data, and other bias. Over half of
(see Appendix S11).20,21 CINeMA rates six domains: the studies had an unclear risk of bias for allocation con-
within-study bias, reporting bias, indirectness, impreci- cealment (i.e., concealment method not described or
sion, heterogeneity, and incoherence. Specifically impor- insufficient detail to allow judgment), contamination,
tant for NMAs, CINeMA helpfully considers the degree and selective outcome reporting. Most studies had a high
of incoherence, that is, the disagreement between direct risk of bias for blinding and one in five studies a high risk
and indirect evidence. of bias for incomplete outcome data. Given the methodo-
logical shortcomings emphasized here, one must inter-
pret the findings from these studies with caution. Post
Subgroup and sensitivity analyses hoc inclusion of two RCTs13,14 did not alter these conclu-
sions, namely a high risk of bias for blinding.
A priori subgroup NMAs were planned if sufficient avail-
able data: participants aged ≥75 years (subgroup age 75+)
and participants with ≥3 co-existent chronic conditions Number of fallers
(subgroup multimorbidity).22
A planned sensitivity NMA was to exclude studies The NMA for this primary outcome included 192 studies
with one or more domains considered high risk of bias, (98,388 participants), and 63 different interventions all
(caveat: with the exception of the domain for “blinding,” compared with usual care. These numbers also reflect the
because most studies were unable to conceal the interven- inclusion of two RCTs published after our search period
tion from participants). was closed, in order to present most up-to-date results.
Post hoc, we performed a sensitivity analysis compar- One study was not connected to the network, because the
ing multifactorial interventions with usual care to deter- combinations of components reported (exerc+nutr
mine whether multifactorial interventions as a whole +envir+brisk vs. exerc+nutr+envir) were not investi-
were associated with a lower risk of falls. Taking power gated by any of the other included RCTs. Therefore, this
into account, we performed this analysis for the two out- study (152 participants) was excluded from the primary
comes with the largest networks: number of fallers and analysis, but was included in the C-NMA (Figure S2).
falls rate. Appendix S3 reports the RRs and P-scores for every inter-
vention versus usual care, in which each existing combi-
nation of components was analyzed as a distinct
RESULTS intervention (primary analysis). The interventions with
significant associations are presented in Table 3, together
Study selection with rating confidence in the results using CINeMA.
Based on statistically significant effect estimates and
Figure 1 presents an overview of the study selection. high P-scores, the following single and multiple interven-
For a complete list of included references see Appen- tions were most strongly associated with reductions in num-
dix S12. ber of fallers: (a) combination of assistive technology
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2978 DAUTZENBERG ET AL.

2723 studies identified

through database search
2219 studies excluded based on
title and abstract

504 studies included for

full text screening

282 studies from Tricco et al.

review

786 studies included for

full text screening 581 excluded:
211 Lack of full publication
(e.g. study protocol)
90 No outcomes of interest
81 Ineligible setting
67 Duplicate
63 Violation of transitivity
assumption
35 Not a RCT
20 Comparison not of interest
8 Intervention not of interest
5 Mean age < 65 years
1 Paper retracted from
PubMed

14 studies identified from 1 study identified from

205 studies included screening companion reports
screening reference lists of
relevant systematic reviews Tricco et al.

220 studies + 3
companion reports
included in analysis

FIGURE 1 Flow diagram of study selection. RCT, randomized controlled trial

(e.g., provision of aids for mobility) and basic falls risk In the C-NMA, in which the relative effects of each
assessment (e.g., medication review), (b) combination of individual intervention component can be dis-
assistive technology and quality improvement strategies entangled, the following were associated with a
(e.g., patient education), (c) standing on a whole-body vibra- decrease in number of fallers, compared with usual
tion platform to improve muscle strength and balance, and care: (a) whole-body vibration (RR 0.61; 95% CI 0.42–
(d) combination of home modification, assistive technology, 0.90) and (b) exercise (RR 0.92; 95% CI 0.88–0.97).
quality improvement strategies, management of orthostatic Management of urinary incontinence was associated
hypotension, and basic falls risk assessment (Table 3). with an increase in number of fallers (RR 1.39; 95% CI
Post hoc inclusion of data from two RCTs13,14 had lit- 1.08–1.79) (Table S3).
tle effect on our conclusions, except in one small aspect We performed an additional analysis in which all
where the intervention “quality improvement” rose to multifactorial interventions were considered as one inter-
statistical significance.13 vention type. A multifactorial intervention was not signif-
There were no concerns about inconsistency as evalu- icantly associated with a reduction in number of fallers
ated by the node-splitting method, overall test for (RR 0.95; 95% CI 0.89–1.01, P-score 0.33; 188 studies,
inconsistency, and net-heat plot. 91,137 participants).
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PREVENTION FALLS AND FRACTURES OLDER ADULTS 2979

T A B L E 2 Summary of participant and study characteristics of TABLE 2 (Continued)

the 220 randomized controlled trials (n = 104,638) identified in our
Participant and study Number of
original search
characteristics studies (%)
Participant and study Number of Duration of intervention (weeks)
characteristics studies (%)
0–26 114 (51.8)
Mean age (years)
27–52 53 (24.1)
65–74 68 (30.9)
≥52 32 (14.5)
75–84 128 (58.2)
Not reported 21 (9.6)
≥85 11 (5.0)
Duration of follow-up (weeks)
Not reported 13 (5.9)
0–26 62 (28.2)
Female (%)
27–52 111 (50.5)
0–49 18 (8.2)
≥52 46 (20.9)
50–100 198 (90.0)
Not available/reported 1 (0.5)
Not reported 4 (1.8)
Number of components
History of falls in the last 12 months
Single intervention 99 (45.0)
Fallers only 33 (15.0) a
Multiple intervention 75 (34.1)
Mixed 103 (46.8)
Multifactorial interventionb 46 (20.9)
Non-fallers only 0
a
Participants received the same, fixed combination of two or more types of
Not reported 84 (38.2) interventions.
b
Year of publication Participants received a combination of two or more types of interventions,
which were personalized according to the results of a pre-executed falls risk
1990–2002 36 (16.4)
assessment.
2003–2007 45 (20.5)
2008–2012 54 (24.5)
2013–2017 67 (30.5) We performed a sensitivity NMA excluding studies at
2018–2019 18 (8.2) high risk of bias, for the outcome number of fallers; the
results were largely similar to the main analysis including
Continent
all studies.
Europe 87 (39.5)
Australia/New Zealand 49 (22.3)
North America 48 (21.8) Subgroup analyses number of fallers
Asia 29 (13.2)
South America 5 (2.3) The NMA for subgroup age 75+ included 19 studies
Multicontinent 2 (0.9)
(28,945 participants, mean age 79.8 years standard devia-
tion = 4.9) and 14 interventions that were all compared
Study design
with usual care (Appendix S4). Two studies were
Parallel 192 (87.3)
excluded from the primary analysis, as they were uncon-
Cluster 27 (12.3) nected to the network (Figure S4). Both studies compared
Both 1 (0.5) vitamin D with placebo and were later included as an
Site additional pairwise meta-analysis. Compared with pla-
Multicenter 91 (41.4) cebo, vitamin D was not associated with a reduction in
falls nor fractures.
Single center 129 (58.6)
The RRs and P-scores for every intervention versus
Sample size
usual care are reported in Figure S5, whereas the five inter-
<100 54 (24.5) ventions with a statistically significant association in
100–299 78 (35.5) Table 4. The interventions with a statistically significant
300–999 71 (32.3) association in the subgroups were consistent with the find-
≥1000 17 (7.7) ings from the main analysis, yet fewer were observed in
subgroups likely due to the smaller size of the subgroup
(Continues)
analysis. Based on statistically significant effect estimates
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2980 DAUTZENBERG ET AL.

T A B L E 3 Risk ratios and rate ratios with 95% confidence interval (CI), P-scores, and Confidence in Network Meta-Analysis (CINeMA)
confidence ratings for the interventions with a statistically significant association

Studies Participants Effect size CINeMA all CINeMA four

Intervention (N) (N) (95% CI) P-score domains domainsc
Number of fallersa
assist+brisk 1 96 0.52 (0.30–0.90) 0.89 Low High
assist+qualt 3 366 0.58 (0.41–0.81) 0.89 Low High
vibr 3 798 0.61 (0.42–0.89) 0.86 Low High
envir+assist+qualt+hypot+brisk 1 397 0.62 (0.43–0.88) 0.86 Low Moderated
exerc+envir+qualt 3 3646 0.74 (0.57–0.97) 0.75 Low High
exerc+assist 3 1338 0.77 (0.62–0.95) 0.73 Low High
exerc 56 14,825 0.83 (0.77–0.90) 0.65 Low High
qualt+brisk 10 9230 0.84 (0.73–0.96) 0.62 Low High
exerc+envir+assist+qualt+brisk 5 5391 0.85 (0.74–0.98) 0.60 Low High
exerc+qualt 30 8064 0.87 (0.80–0.96) 0.56 Low High
qualt 50 22,374 0.90 (0.83–0.99) 0.49 Low High
qualt 5 12,904 0.90 (0.83–0.98) 0.49 Low High
exerc+incont+envir+assist 1 552 1.58 (1.01–2.48) 0.05 Low High
+qualt+brisk
Number of repeated fallersa
vibr 1 710 0.33 (0.12–0.91) 0.94 Low High
exerc+assist 1 1107 0.48 (0.25–0.93) 0.88 Low High
exerc 19 5590 0.71 (0.53–0.95) 0.71 Low Moderatee
Falls rateb
envir+assist+qualt+hypot+brisk 1 397 0.42 (0.30–0.58) 0.99 ΝΑ ΝΑ
exerc+assist 2 1188 0.68 (0.54–0.86) 0.85 ΝΑ ΝΑ
exerc+med 2 616 0.68 (0.47–0.98) 0.81 ΝΑ ΝΑ
exerc+envir+assist+hypot+brisk 4 973 0.73 (0.59–0.92) 0.78 ΝΑ ΝΑ
exerc 27 7485 0.79 (0.73–0.87) 0.70 ΝΑ ΝΑ
exerc+qualt+hypot+brisk 1 298 2.08 (1.34–3.25) 0.01 ΝΑ ΝΑ
exerc+nutr+envir+assist+brisk 1 328 1.84 (1.14–2.97) 0.03 ΝΑ ΝΑ
Number of fall-related fracturesa
brisk 2 3046 0.60 (0.39–0.94) 0.72 Low Moderated
exerc 10 5678 0.62 (0.42–0.90) 0.71 Low High
b
Fracture rate
exerc 5 2511 0.49 (0.27–0.89) 0.80 NA ΝΑ
exerc+qualt 2 1975 0.52 (0.28–0.96) 0.70 NA ΝΑ

Note: Characterization not applicable (NA) because CINeMA cannot address rate outcomes.
Abbreviations: assist, assistive technology; brisk, basic falls risk assessment; envir, environmental assessment and modifications; exerc, exercise; hypot,
management of orthostatic hypotension; incont, management of urinary incontinence; med, medication; nutr, fluid or nutrition therapy; psych, psychological
interventions; qualt, quality improvement strategies; social, social engagement; surg, surgery; vibr, whole-body vibration.
a
Risk ratios.
b
Rate ratios.
c
For the domains “within-study bias” and “reporting bias” there were major concerns for all comparisons. In order to still maintain distinctiveness, the
evaluation of the confidence in the results of the NMA was based on the remaining four domains.
d
Reason for downgrading CINeMA confidence rating: indirectness.
e
Reason for downgrading CINeMA confidence rating: heterogeneity.
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PREVENTION FALLS AND FRACTURES OLDER ADULTS 2981

T A B L E 4 Risk ratios with 95% confidence interval (CI), P-scores, and Confidence in Network Meta-Analysis (CINeMA) confidence
ratings for the interventions with a statistically significant association versus usual care for the outcome number of fallers, subgroup age 75+

CINeMA all CINeMA four

Intervention Studies (N) Participants (N) Effect size (95% CI) P-score domainsa domainsa
exerc 3 1954 0.65 (0.50–0.85) 0.91 Low High
qualt+brisk 2 5771 0.75 (0.64–0.87) 0.80 Low High
exerc+qualt 4 1481 0.75 (0.67–0.83) 0.81 Low High
exerc+envir+qualt 1 3182 0.76 (0.64–0.89) 0.78 Low High
qualt 5 9681 0.85 (0.74–0.99) 0.59 Low High

Abbreviations: brisk, basic falls risk assessment; envir, environmental assessment and modifications; exerc, exercise; qualt, quality improvement strategies.
a
For the domains “within-study bias” and “reporting bias” there were major concerns for all comparisons. In order to still maintain distinctiveness, the
evaluation of the confidence in the results of the NMA was based on the remaining four domains.

and high P-scores, the single intervention exercise was components with usual care for the outcomes number of
most strongly associated with a reduction in number of repeated fallers, falls rate, number of hip fractures, and
fallers in subgroup analysis age 75+. In the C-NMA, none fracture rate are presented in Appendix S7 to S10. Table 3
of the intervention components was associated with a sig- reports the effect sizes and P-scores of interventions
nificant change in the number of fallers (Table S4). (including post-hoc analyses) with a statistically significant
The NMA for the subgroup multimorbidity included association and the corresponding CINeMA confidence
14 studies (7879 participants), and 11 interventions that rating.
were all compared with usual care (Appendix S5). For For falls rate, we performed an additional analysis in
this subgroup, there were no statistically significant which all multifactorial interventions were considered as
effects on number of fallers resulting from the primary one intervention type. Compared with usual care, multi-
analysis or C-NMA. For number of fall-related fractures factorial interventions were significantly associated with
and for the secondary outcomes, only a few studies a reduced fall frequency (RR 0.88; 95% CI 0.81–0.96,
reported on subgroups age 75+ and multimorbidity, thus P-score 0.54; 111 studies, 53,923 participants).
data were insufficient for further subgroup analysis.

CINeMA confidence rating

Number of fall-related fractures
Tables 3 and 4 present the CINeMA confidence ratings
The number of fall-related fractures NMA included for interventions that were statistically significant associ-
46 studies (43,811 participants) and 27 interventions com- ated with a lower risk of falls and fall-related fractures.
pared with usual care (Figure S8). In 60% of studies, frac- Appendix S11 provides detailed results from the CINeMA
tures were verified radiologically or through review of approach.
hospital records. Appendix S6 reports the RRs and
P-scores for every intervention versus usual care. Based
on statistically significant effect estimates with the DISCUSSION
highest P-scores, the single interventions basic falls risk
assessment and exercise were most strongly associated In this SR and NMA, we updated current evidence on
with a reduction in number of fall-related fractures; the prevention of falls and fall-related fractures in older per-
latter with higher CINeMA confidence rating (Table 3). sons, with a focus on high-risk subgroups of multimorbid
However, these significant reductions were lost at the older adults and aged ≥75 years. Compared with previous
C-NMA level. Strangely, the intervention component NMA by Tricco et al., we considered 57 new studies and
assistive technology was significantly associated with an added 4 interventions previously not considered.
increase in the number of fall-related fractures (RR 1.66; Several single and multiple interventions were associ-
95% CI 1.07–2.59) (Table S6). ated with a lower risk of falls (i.e., in keeping with Tricco
et al.) and also with fall-related fractures (divergent from
Tricco). Exercise (single intervention) was often investi-
Secondary outcomes gated in included studies and associated with a lower risk
of all primary and secondary outcomes in the primary
The results of the primary analysis (excluding post-hoc analysis. This was no longer evident once disentangled
analyses) and C-NMA comparing all intervention down to the C-NMA level, where no effect of exercise on
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2982 DAUTZENBERG ET AL.

fracture outcomes was observed. The same applied to This study has some limitations. (1) In contrast to
basic falls risk assessment. These findings did not alter Tricco and colleagues, we assigned a high risk of bias for
after post hoc inclusion of data from two recent major domain blinding when falls and fractures were self-
RCTs.13,14 reported in a patient-diary, as it was often not possible to
Common components seen in significant multiple blind participants to their intervention. This may explain
interventions were exercise, assistive technology, environ- our larger percentage of studies deemed at high risk of bias
mental assessment and modifications, quality improve- for blinding, but is difficult to prevent due to the nature of
ment strategies, and basic falls risk assessment. In the interventions. Furthermore, blinding participants to
agreement with a recent Cochrane review, multifactorial their assigned intervention could affect their willingness/
interventions were associated with a reduction in falls probability of engaging with the intervention and their
rate, but not in number of fallers.5 One possible explana- reporting of fall incidents. (2) Allocation concealment was
tion is that falls rate may measure falls risk more accu- unclear in half of the studies and this might affect the trust
rately than number of fallers. Although the latter counts we can place in the estimates of intervention effect sizes.
persons who fall once or fall repetitively as one outcome Although baseline characteristics and fall history were rea-
event, the outcome falls rate counts each fall as a separate sonably balanced (similar between the study arms in 85%
outcome event. Contrary to our findings above, Tricco and 77% of trials, respectively), it is possible that other
et al. found that multifactorial intervention (comprised of influencing factors (e.g., willingness/probability of engag-
exercise and quality improvement strategies) was associ- ing with the interventions) were less balanced across the
ated with a reduction in number of fallers (OR 0.68; 95% study arms. (3) Categorization of interventions into compo-
CI 0.49–0.94).6 nents allowed us to make inferences about the effect of
We performed a meta-analysis on vitamin D supple- these components as a whole (e.g., exercise), but not about
mentation versus placebo. We can corroborate previ- specific subcategories within these components (e.g.,
ously published literature, which showed no association strength training or tai chi). Where a component showed no
of vitamin D with the risk of falls or fall-related frac- significant effect, it could still be that subcategories within
tures.23,24 Although Tricco et al. found an effect on this component are effective, particularly so in cases with
fallers and injurious falls when vitamin D is combined high “within-component heterogeneity.” Many different
with calcium supplementation and other intervention interventions for fall prevention were evaluated, and work-
components.6 ing with clustered intervention components was necessary
Unexpectedly, considering that it is not widely used to maintain sufficient power for the NMA. (4) Similarly, to
in clinical practice, whole-body vibration was associated avoid insufficient power, we were unable to distinguish
with a lower risk of falls. This intervention was investi- between different intervention dosages, durations of treat-
gated in few studies (with small study populations and ment, or between different lengths of follow-up durations in
high summary risk of bias), so the clinical value is still the NMAs. However, we expect the effect of the interven-
unclear. The benefit we observed may be subject to tions to decrease with a longer follow-up duration, possibly
publication bias. reducing the overall effect estimates. Only 20% of included
This study has several strengths. (1) SR and NMA studies reported a follow-up longer than 1 year. Differences
were performed in accordance with the EPOC tool and in dosage and length of interventions may also lead to
CINeMA approach. (2) Based on statistically significant “within-component heterogeneity.” (5) CINeMA software
effect estimates combined with high P-scores, we ranked cannot address rate outcomes. However, most studies
interventions to draw conclusions. (3) By extracting infor- reporting rates also provided data on dichotomous out-
mation on the components forming the multifactorial comes, for which CINeMA assessment was possible. Due to
interventions, we could also address which combination this overlap, the overall certainty in the evidence is expected
of components is most effective. (4) We investigated to be similar across the dichotomous and rate outcomes.
community-dwelling older adults, applied few exclusion (6) Finally, most studies have similar baseline risk (e.g., falls
criteria, and included interventions that complied with rate) across interventions. When this is violated and large
the transitivity assumption; thus our results are widely discrepancies are present, this limits our ability to draw
generalizable. Moreover, although severe dementia was indirect comparisons across the (C-)NMA. With few studies
an exclusion criterion, we did allow studies with mild to per comparison arm, we cannot test with certainty whether
moderate dementia participants as this reflects real life baseline risk or other factors differ across intervention com-
and the increasing prevalence within the community- parisons. However, we attempted to mitigate this risk with
dwelling older population. (5) The large population size clinical ( compliance with transitivity assumption) and
enabled subgroup analyses (aged 75+, multimorbidity). statistical ( heterogeneity assessments) judgments.
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
PREVENTION FALLS AND FRACTURES OLDER ADULTS 2983

This NMA provides an extensive overview of current receiving a Tier 1 Canada Research Chair in Knowledge
evidence for effective fall prevention interventions in Translation grant. No other financial or personal conflicts
older persons. Yet some questions remain unanswered. were reported.
More research is needed on fall prevention interven-
tions in multimorbid older persons, because this sub- AUTHOR CONTRIBUTIONS
group analysis lacked sufficient power for the NMA. The study protocol was created by Lauren Dautzenberg,
Additional studies are needed to clarify and confirm the Shanthi Beglinger, Sofia Tsokani, Stella Zevgiti, Nicolas
effect of whole-body vibration, given the potential Rodondi, Rob J. P. M. Scholten, Anne W. S. Rutjes, Mar-
publication bias identified. cello Di Nisio, Wilma Knol, Dimitris Mavridis, and
Further research is needed to evaluate the effects of Huiberdina L. Koek. Lauren Dautzenberg executed the
specific subcategories within the intervention compo- literature search. Study selection was performed by
nents. For example, two recent studies performed by the Lauren Dautzenberg and Shanthi Beglinger under super-
research group of Tricco et al. explored the effects of vision of Rob J. P. M. Scholten, Marielle Emmelot-Vonk,
different quality improvement strategies and exercise Wilma Knol, and Huiberdina L. Koek. Data extraction
interventions on falls.25,26 was performed by Renee C. M. A. Raijmann, Shanthi
Beglinger, Lisa Bretagne, and Lauren Dautzenberg. A
part of the data included in this study was provided by
C O N C L U S IO N Andrea C. Tricco, Sharon E. Straus, and Sonia Thomas.
Data analysis was performed by Sofia Tsokani, Stella
Exercise is associated with a lower risk of falls and Zevgiti, and Dimitris Mavridis. The manuscript was dra-
fall-related fractures. Common components of significant fted by Lauren Dautzenberg, Shanthi Beglinger, Rob J. P.
multiple interventions are exercise, assistive technology, M. Scholten, Wilma Knol, and Huiberdina L. Koek. The
environmental assessment and modifications, quality manuscript was revised by Sofia Tsokani, Stella Zevgiti,
improvement strategies, and basic falls risk assessment. A Renee C. M. A. Raijmann, Nicolas Rodondi, Anne W. S.
multifactorial intervention is associated with a reduction Rutjes, Marcello Di Nisio, Marielle Emmelot-Vonk, And-
in falls rate, but not with a reduction in number of fallers. rea C. Tricco, Sharon E. Straus, Sonia Thomas, Lisa Bre-
Over half of the studies included had methodological tagne, and Dimitris Mavridis. The corresponding author
short comings (lack of allocation concealment and high attests that all listed authors meet authorship criteria and
risk of blinding). This points to a greater issue within the that no others meeting the criteria have been omitted.
evidence base and highlights the need for more robust
study procedures/reporting in which future policy can be SP ONS O R 'S RO LE
based on. Few studies have investigated the effect of fall The funding had no input on the study design, data col-
prevention interventions in multimorbid older people, lection, data analysis or interpretation, report writing,
which is highly recommended for future research. approval of the manuscript, or the decision to submit the
paper for publication.
A C K N O WL E D G M E N T S
This work is part of the project “OPERAM: OPtimising ORCID
thERapy to prevent Avoidable hospital admissions in the Lauren Dautzenberg https://orcid.org/0000-0003-2502-
Multimorbid elderly” supported by the European Union‘s 9988
Horizon 2020 research and innovation programme under
the grant agreement No 6342388, and by the Swiss State RE FER EN CES
Secretariat for Education, Research and Innovation 1. National Institute for Health and Care Excell. Falls in older
(SERI) under contract number 15.0137. The opinions people: assessing risk and prevention. NICE Clin Guidel. Man-
expressed and arguments employed herein are those of chester: National Institute for Health and Care Excellence;
the authors and do not necessarily reflect the official 2013:1-33 https://www.nice.org.uk/guidance/cg161/resources/
falls-in-older-people-assessing-risk-and-prevention-
views of the EC and the Swiss government. A. C. T. is
35109686728645. Accessed November 4, 2019.
funded by a Tier 2 Canada Research Chair in Knowledge 2. Tinetti M, Speechley M, Ginter S. Risk factors for falls among
Synthesis. S. E. S. is funded by a Tier 1 Canada Research elderly persons living in the community. N Engl J Med. 1988;
Chair in Knowledge Translation. 319:1701-1707.
3. Campbell A, Borrie M, Spears G, Jackson S, Brown J,
CONFLICT OF INTEREST Fitzgerald J. Circumstances and consequences of falls experi-
Dr Tricco reports receiving a Tier 2 Canada Research enced by a community population 70 years and over during a
prospective study. Age Ageing. 1990;19:136-141.
Chair in Knowledge Synthesis grant. Dr Straus reports
 15325415, 2021, 10, Downloaded from https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17375 by Nat Prov Indonesia, Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2984 DAUTZENBERG ET AL.

4. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, 18. Welton N, Caldwell D, Adamopoulos E, Vedhara K. Mixed
Negria E. Risk factors for falls in community-dwelling older treatment comparison meta-analysis of complex interventions:
people a systematic review and meta-analysis. Epidemiology. psychological interventions in coronary heart disease.
2010;21(5):658-668. Am J Epidemiol. 2009;169(9):1158-1165. https://doi.org/10.
5. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and 1093/aje/kwp014
multiple component interventions for preventing falls in older 19. Rücker G, Schwarzer G. Ranking treatments in frequentist net-
people living in the community (review). Cochrane Database work meta-analysis works without resampling methods. BMC
Syst Rev. 2018;7(7):1-307. https://doi.org/10.1002/14651858. Med Res Methodol. 2015;15(1):58. https://doi.org/10.1186/
CD012221.pub2 s12874-015-0060-8
6. Tricco A, Thomas S, Veroniki A, et al. Comparisons of inter- 20. Nikolakopoulou A, Higgins JPT, Papakonstantinou T, et al.
ventions for preventing falls in older adults: a systematic Cinema: an approach for assessing confidence in the results of
review and meta-analysis. JAMA. 2017;318(17):1687-1699. a network meta-analysis. PLoS Med. 2020;17(4):e1003082.
https://doi.org/10.1001/jama.2017.15006 https://doi.org/10.1371/JOURNAL.PMED.1003082
7. Gillespie L, Robertson M, Gillespie W, et al. Interventions for 21. Salanti G, del Giovane C, Chaimani A, Caldwell DM,
preventing falls in older people living in the community Higgins JPT. Evaluating the quality of evidence from a network
(review). Cochrane Database Syst Rev. 2012;9:1-416. https://doi. meta-analysis. PLoS One. 2014;9(7):e99682. https://doi.org/10.
org/10.1201/b12752-36 1371/journal.pone.0099682
8. Salanti G. Indirect and mixed-treatment comparison, network, or 22. Jadad AR, To MJ, Emara M, Jones J. Consideration of multiple
multiple-treatments meta-analysis: many names, many benefits, chronic diseases in randomized controlled trials. JAMA. 2011;
many concerns for the next generation evidence synthesis tool. Res 306(24):2670-2672.
Synth Methods. 2012;3(2):80-97. https://doi.org/10.1002/jrsm.1037 23. Yao P, Bennett D, Mafham M, et al. Vitamin D and calcium for
9. Mavridis D, Giannatsi M, Cipriani A, Salanti G. A primer on the prevention of fracture: a systematic review and meta-analy-
network meta-analysis with emphasis on mental health. Evid sis. JAMA Netw Open. 2019;2(12):e1917789. https://doi.org/10.
Based Ment Health. 2015;18(2):40-46. https://doi.org/10.1136/ 1001/jamanetworkopen.2019.17789
eb-2015-102088 24. Bolland M, Grey A, Avenell A. Effects of vitamin D supplemen-
10. Streit S, Da Costa BR, Bauer DC, et al. Multimorbidity and tation on musculoskeletal health: a systematic review, meta-
quality of preventive care in Swiss University primary care analysis, and trial sequential analysis. Lancet Diabetes
cohorts. PLoS One. 2014;9(4):e96142. https://doi.org/10.1371/ Endocrinol. 2018;6(11):847-858. https://doi.org/10.1016/S2213-
journal.pone.0096142 8587(18)30265-1
11. Grossman DC, Curry SJ, Owens DK, et al. Interventions to pre- 25. Tricco A, Thomas S, Veroniki AA, et al. Quality improvement
vent falls in community-dwelling older adults us Preventive strategies to prevent falls in older adults: a systematic review
Services Task Force recommendation statement. JAMA. 2018; and network meta-analysis. Age Ageing. 2019;48(3):337-346.
319(16):1696-1704. https://doi.org/10.1001/jama.2018.3097 https://doi.org/10.1093/ageing/afy219
12. Cheng P, Tan L, Ning P, et al. Comparative effectiveness of publi- 26. Sibley KM, Thomas SM, Veroniki AA, et al. Comparative effec-
shed interventions for elderly fall prevention: a systematic review tiveness of exercise interventions for preventing falls in older
and network meta-analysis. Int J Environ Res Public Health. 2018; adults: a secondary analysis of a systematic review with net-
15(3):498-511. https://doi.org/10.3390/ijerph15030498 work meta-analysis. Exp Gerontol. 2021;143:111151. https://doi.
13. Lamb SE, Bruce J, Hossain A, et al. Screening and intervention org/10.1016/j.exger.2020.111151
to prevent falls and fractures in older people. N Engl J Med.
2020;383(19):1848-1859. https://doi.org/10.1056/nejmoa2001500
14. Bhasin S, Gill TM, Reuben DB, et al.; STRIDE Trial Investiga- SU PP O R TI N G I N F O RMA TI O N
tors. A randomized trial of a multifactorial strategy to prevent Additional supporting information may be found online
serious fall injuries. N Engl J Med. 2020;383(2):129-140. https:// in the Supporting Information section at the end of this
doi.org/10.1056/nejmoa2002183 article.
15. Cochrane Effective Practice and Organisation of Care (EPOC).
Suggested Risk of Bias Criteria for EPOC Reviews. EPOC
Data S1. Supplementary information.
Resources Fo r Review Authors. United Kingdom: The Cochrane
Effective Practice and Organisation of Care (EPOC) group;
2017. http://Epoc.Cochrane.Org/Resources/Epoc-Resources- How to cite this article: Dautzenberg L,
Review-Authors. Accessed April 8, 2019.
Beglinger S, Tsokani S, et al. Interventions for
16. Caldwell D, Welton N. Approaches for synthesising complex
preventing falls and fall-related fractures in
mental health interventions in meta-analysis. Evid Based Ment
Health. 2016;19(1):16-21. https://doi.org/10.1136/eb-2015-102275 community-dwelling older adults: A systematic
17. Rücker G, Petropoulou M, Schwarzer G. Network meta- review and network meta-analysis. J Am Geriatr
analysis of multicomponent interventions. Biom J. 2020;62:808- Soc. 2021;69(10):2973-2984. https://doi.org/10.
821. https://doi.org/10.1002/bimj.201800167 1111/jgs.17375