The European Journal of Public Health Advance Access originally published online on October 29, 2008
The European Journal of Public Health 2009 19(1):7-15; doi:10.1093/eurpub/ckn099
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Systematic Reviews |
Quality of life as an outcome of fall prevention interventions among the aged: a systematic review
Sari Sinikka Vaapio1,2, Marika Johanna Salminen1,3, Ansa Ojanlatva4,5,6 and Sirkka-Liisa Kivelä1,2,3
1 Institute of Clinical Medicine, Family Medicine, University of Turku, Turku, Finland
2 Satakunta Central Hospital, Pori, Finland
3 Unit of Family Medicine, Turku University Hospital, Turku, Finland
4 Department of Teacher Education, University of Turku, Turku, Finland
5 Institute of Biomedicine, Centre for Reproductive and Developmental Medicine, University of Turku, Turku, Finland
6 Turku City Hospital, Turku, Finland
Correspondence: Sari Vaapio, MSc, Department of Family Medicine, Lemminkäisenkatu 1, FI-20014 University of Turku, tel: +358 2 333 8423, fax: +358 2 333 8439, e-mail: sasiva{at}utu.fi
Received July 10, 2008, accepted September 25, 2008
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Abstract |
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Background: Measuring quality of life (QOL) is an important part in assessing the effects of treatments and health services on patients’ well-being. This kind of an assessment should be included when assessing the effects of preventive programmes. The aim was to explore whether QOL has been used as an outcome measure in fall prevention trials and to provide a systematic review of randomized controlled trials (RCTs) that involve fall prevention interventions with an assessment of the effects on QOL among the aged. No previous systematic review about this topic among the aged was found. Methods: A search covering various medical databases was conducted to identify RCTs about the effects of fall prevention programmes on QOL. The 12 included studies were classified according to an appraisal of the population, the method of randomization, the intervention and control programmes, the QOL measures and the results. Methodological quality was assessed in relation to blinding at outcome assessment, length of follow-up and using intention to treat analysis. Results: Six studies out of 12 showed a positive effect on some dimensions of QOL (physical function, social function, vitality, mental health, environmental domain). The methods of interventions showing a positive effect varied. Conclusion: Only a few fall prevention studies reported a positive effect on QOL. Studies with larger sample sizes, longer follow-ups and multiple outcome measures are needed. QOL should be taken into account as an secondary outcome measure.
Keywords: quality of life, fall prevention, randomized controlled trial, aged
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Introduction |
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Measurement of the quality of life (QOL) is an important part in assessing the effects of treatment and health care services on patients’ well-being. The importance of understanding the kinds of impact that health care interventions have on the lives of patients is one reason why health-related quality of life (HRQOL) measures have been developed.1 The other reason is cost-utility analysis that help to determine the relative cost-effectiveness of these interventions compared with other health care interventions. The development of appropriate instruments is complicated, because there is currently no consensus as to the definition of QOL or HRQOL. The concepts are characterized by subjectivity and multidimensionality and the dimensions of QOL include, by general consensus, the universally relevant aspects of life: physical, mental–emotional and social functioning, family wellbeing, life satisfaction, intimacy/sexuality and environmental, religious and cultural factors.2–4 HRQOL consists of the same dimensions as QOL with an additional dimension about the individual's perception of his/her own health status. According to WHO, HRQOL is conceptually defined as being part of the overall QOL.5
Falls are the most common reason for accidental deaths among the aged.6–8 Due to the acute consequences of falls, such as fractures and fear of falling, fallers’ physical, psycho-social and functional abilities deteriorate longer term, and this may have a considerable impact on their perceived health and QOL. Randomized controlled trials (RCTs) have shown that every third fall or fall-related injury could be prevented.9–11 The risk of falling can be reduced either with multifactorial, individual prevention programmes targeted on risk populations12–14 or with narrow programmes targeted on risk groups with only one specific risk factor. However, more recent reviews suggest that benefits from multifactorial interventions might be smaller than those shown by previous reviews.15,16 Most fall prevention trials have aimed to reduce the physical risk factors of falling, such as poor balance, impaired muscle strength or the harmful side effects of medication. Fall-related psychosocial factors, such as depressive symptoms and fear of falling have gained less attention as risk factors of falls. The consequences of falls usually consist of physical factors, such as injuries, fractures and deaths, and less attention has been paid on social functioning and QOL.17–20
Fall prevention may affect QOL by different mechanisms. The group activities included in the programme may directly improve the participants’ QOL. The decreased number of falls and fall injuries may contribute to the improvement of QOL. The maintenance of functional abilities and social activities by decreasing fall injuries may have a positive effect on QOL. Some qualitative findings of older people's views about fall prevention indicate that the participation in different fall prevention programmes may be promoted by not only emphasizing benefits for preventing falls, but also emphasizing benefits for health, managing in activities of daily living, independence and QOL.7,21 However, if the participants consider that the prevention programme is too demanding and requires significant changes in health habits and lifestyle, the effects on QOL may even be negative.20
The purpose of this review was to explore whether QOL has been used as an outcome measure in fall prevention trials, and to provide a systematic review of RCTs that involve fall prevention interventions with an assessment of their effects on QOL or HRQOL among the aged. The main focus was to report QOL outcomes in different kinds of fall prevention interventions and to discuss outcomes of falls only briefly. The review process involved a systematic selection of articles and a qualitative assessment and synthesis of the results.
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Methods |
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Search strategy
Titles and abstracts of articles that addressed fall prevention among individuals 60 years or older were retrieved from the electronic databases of MEDLINE (1966 to March 2006) and CINAHL (1982 to March 2006). The Cochrane Controlled Trials Register (CCTR), Cochrane Database of Systematic Reviews (CDSR), Cochrane Database of Abstracts and Reviews of Effects (DARE) and ACP Journal Club were used to focus the search on evidence-based clinical trials and reviews. The search was made by using the Ovid Technologies search program allowing a simultaneous search and duplicate removal from MEDLINE, Cochrane and CINAHL. In addition to original reports, the abstracts of two reviews obtained in the search (Gillespie et al. 2003 and Chang et al. 2004) were assessed in terms of QOL.10,14 The first author and an information specialist accomplished the search by using both QOL or HRQOL indices (or at least a subindex) and the following other key words: falls, accidental falls, prevention, intervention, aged, RCTs, QOL and health-related QOL with their synonyms and equivalent MeSH terms. No restriction was applied to language or publication year. The reference lists of the retrieved articles were also used to complete the search. A later search at the time of the submission was also performed, and it produced four additional references. Two of these studies were included20,22 in this review because the results of the other two relevant studies 23,24 were not available as yet. The authors of the papers found in the completed research were not contacted for more information regarding ongoing studies or missing findings. The reviewer (S.V.) was not blinded to the names of the authors, institutions or journals.
Selection criteria
Altogether 1411 citations were retrieved via electronic, bibliographical and manual searches. The abstracts of these 1411 articles were read by the reviewer (S.V.). Of these, 1137 titles and abstracts were not relevant and were excluded. Based on the abstracts, only RCTs on fall prevention implemented among individuals aged 60 or older in which QOL or HRQOL was defined as a primary or secondary outcome measure were accepted for the second phase. A trial was defined as RCT if the allocation of participants to the treatment or control groups was described as randomized. All articles that were potentially relevant based on the information in their abstracts were included. RCT articles with no mention of QOL or HRQOL in the abstracts were initially excluded. The articles without a primary focus on fall prevention (e.g. the use of hip protector or vitamin D as parameters) were excluded. The total articles were first checked by one reviewer (S.V.), then by two reviewers (S.V. and M.S.) and finally by three reviewers (S.V., M.S. and S.-L.K.). The review process is presented in figure 1.
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Quality assessment
The reports for all eligible studies were evaluated for relevance without prior consideration of the results. Methodological quality was assessed based on the guidelines (slightly modified) recommended by Glasziou.25 Data were assessed for blinding at outcome assessors and group assignment, length of follow-up and whether intention to treat analysis was used. A trial was defined as having used intention to treat analysis if that was mentioned in the article.
Data synthesis
A qualitative analysis was undertaken due to the heterogeneity of populations, randomization, intervention methods, outcome measures and paucity of studies. Trials were first grouped according to the subjects’ baseline characteristics (community dwelling/hospitalized) and the intervention programmes (single-/multi-factorial). The classification into single- or multi-factorial interventions was based on the number of subinterventions in the programmes. Singlefactorial interventions were classified into exercise-, information- or comprehensive geriatric assessment (CGA)-oriented. The effect of an intervention was classified as positive if there was a significant difference in changes between intervention and control groups in at least one dimension of QOL or HRQOL in favour of the intervention group. If no difference in changes between the groups was found, the intervention was classified as having no effect. The rate of falls was presented if it was used as an outcome measure. Because this study focused on the QOL outcome, no other primary or secondary outcomes are presented here.
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Results |
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Search results
A total of 277 articles turned out to be potentially relevant based on the information available in their abstracts. Articles with no mention of QOL or HRQOL and RCT (n = 240) in their abstracts were excluded. Based on this first selection, the potentially eligible articles were retrieved and reconsidered for inclusion. Altogether, 37 articles were read carefully and 24 of these did not report a fall prevention intervention or its results on QOL. After a thorough selection process, 12 original studies were accepted for inclusion in this review.
General features of the studies
The studies included were published in 1996–2007.20,22,26–35 A total of 2357 persons had participated in these studies, and sample sizes varied from 50 to 513 in the studies conducted among community dwellers and from 42 to 243 in the studies on the institutional aged. The mean age varied from 69 to 82 years. The proportion of women varied from 51% to 100% (mean 76%). The inclusion criteria in these studies are presented in table 1. The exclusion criteria included e.g. materials consisting of bedridden persons, amputees, persons unable to walk 10 m or those with physical and cognitive disorders and impairments, neurological dysfunction, Parkinson's disease or Meniere's disease.
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Participants were community dwellers in seven trials, hospitalized persons in four trials and nursing home residents in one trial. Exercise-oriented interventions included one or more of the following exercises: vibration, water based, agility, stretching/weight shifting, muscle strengthening, functional, aerobic, quadriceps, balance or coordination exercises conducted by a physiotherapist. Discharge planning, home visits, assessment and modification of home hazards and safety, interviews, comprehensive risk assessment, individualized feedback, telephone contacts, written information (brochures, booklets), lectures and videos were some of the key components in information-oriented interventions. CGA-oriented interventions consisted of individual screening for medical, environmental and behavioural factors increasing the risk of falls, impairments in mobility, consultations and recommendations. Control programmes included standard care, routine daily activities, single-session counselling and guidance about falling, physical and conventional therapy, routine hospital discharge planning, written information, social seminars, telephone calls, interviews and/or home visits. The durations of the interventions ranged from 0.5 to 12 months (table 1).
Quality assessment
All the eligible studies had an RCT design, though randomization was not described in two studies,26,35 and block randomization in groups of six was used in one study.22 In nine studies, randomization had been performed using concealed randomization, computer-generated programs, consecutively numbered opaque envelopes and computerized central randomization schemes.20,29–35 Blinding of the outcome assessor was reported in three studies,27,29,30 and both blinding of the outcome assessor and group assignment were used in four studies.28,30,31,34 Blinding was not mentioned in five studies.20,22,26,33,35 Statistical analyses were conducted according to the intention to treat principle in eight studies.20,26,27,29–31,33,35 Follow-up information was published for all studies ranging from 0.5 to 18 months in duration. The follow-up periods lasted for over 6 months in three studies.20,33,34 SF-36 was used for the measurement of QOL in seven studies.26–28,34,35 RAND-36,33 EuroQol,31 WHOQOL-BREF,22 15D20 and QUALEFFO32 were used in one study each.
Six interventions were classified as exercise oriented,26,27,29–32 two as information oriented28,35 and two as CGA oriented.33,34 Lin et al.22 compared information- and exercise-oriented programmes, and the multifactorial programme reported by Vaapio et al.20 included information-, exercise- and CGA-oriented subprogrammes. The participants were community dwellers in seven trials,20,27,29,32–35 nursing home residents in one trial26 and hospitalized persons in four trials.22,28,30,31 In five studies,20,29,30,32,35 the control groups received optional care in addition to routine care.
Effects on QOL
Six studies showed significant improvements in QOL. Two of these studies26,27 were exercise oriented, one28 was information oriented and one34 was CGA oriented. One study22 reported improvement in an exercise-oriented programme compared with an information-oriented programme, and one study20 was multifactorial. All of the six studies reported significant improvements in the physical function or physical health, social function, environmental domain, vitality and mental health domains of QOL. In addition, improvements were also reported in the role physical,26,28 role emotional,28 pain26,28 and general health dimensions28 of QOL. No significant differences between the intervention and control groups were found in six studies.29–33,35 In two of these studies29,30 only a part of the SF-36 measurement was used.
The rate of falls information was published in eight studies, and the rate was significantly lower (40%) in the intervention group compared with the control group in only one study.29 The number of falls was lower in both groups in the study by Steadman et al.31 and in the study by Gallagher and Brunt 35 after the data of the intervention and control groups were combined. The rate of falls did not change in the other five studies.22,28,30,33,35 The results of one study20 were not yet published, and falls were not used as an outcome measure in three studies.26,27,34 In one study32 the number of falls was only shortly mentioned.
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Discussion |
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The purpose of this review was to explore whether the QOL has been used as an outcome measure in fall prevention trials, and to assess the effects of these trials on QOL or HRQOL. The literature searches were made by using a recommended scientific methodology.36 The strengths of the present review are the library searches made by the author in cooperation with an information specialist and the final checking of the articles included in this review by three reviewers. The electronic searches were made with care, and repeated three times between the years 2005 and 2007. The manual searches of the reference lists of the retrieved articles for titles concerning QOL or HRQOL and fall prevention were performed twice. The variability of study designs was an obvious limitation. Some studies may also have been missed because of bias or because QOL measures or results were not mentioned in the abstracts. QOL or HRQOL have often been classified as secondary outcomes, and abstracts may only report the primary outcome. However, since abstracts are usually written by taking into account the principal results, we probably have missed only very few original reports.
Only a few studies used QOL as a measure of an effect in the prevention of falls among the aged. Positive results were obtained in 5 out of 11 singlefactorial interventions and in one multifactorial intervention. The concept of QOL or HRQOL had been defined only in two studies.20,22 In five studies, the control groups received care options in addition to routine care, and the quite intensive care of the control groups may be one reason for the non-significant results between intervention and control groups. The differences in effects may be related to differences between health care settings and the components of the programmes.33
The Hawthorne effect is another possible explanation for non-differences. Participants in interventions have a tendency to change their habits regardless of the specific nature of the intervention. The intervention may also activate the control group. Therefore, significant differences in changes between intervention and control groups may be left undetected.37
Blinding was used in 7 trials out of 12, and two of these studies reported positive results. Blinding was reported inadequately in several studies. The method of blinding was not mentioned in five studies, and the success of blinding was not evaluated in three studies. Therefore, we could not assess whether omitting the use of blinding methods caused some bias in the results about QOL.38
The use of the intention to treat principle may have influenced the results. The results were analysed by using the intention to treat principle in eight studies. An advantage of the intention to treat principle is that the maximum number of subjects is included in the analyses. The disadvantage of this principle is that the subjects who were assigned to the intervention group but did not actually receive the intervention may have lead to an underestimation of the actual effect. However, in real life situations, all participants do not participate in all components of the interventions which are offered to them.37 The use of the intention to treat principle is a significant advantage in comparing the results of intervention studies with real life situations although it may lead to more critical results than the use of other methods. This fact may be one reason why four of these eight studies had no effect on QOL.
We cannot evaluate whether a person's intrinsic risk factor of falling is associated with positive results or with no effect of QOL, because nearly all participants included in the studies (11/12) had an increased risk of falling. The participants were community dwellers in three and institutionalized persons in three of six intervention studies with positive results. In four interventions with negative results the participants were community dwellers and in two trials they had a history of recent falls. Positive effects may be easier to obtain by intensive prevention programmes among institutionalized participants due to their poorer physical condition and their history of falls. The majority of participants were women. The analyses were not performed separately for men and women. Therefore, it may be important to ask whether we can generalize the outcomes to both genders, or whether we should limit our conclusions to apply to older women's QOL. The mean ages were relatively high, and there were no differences in age between the studies with positive or no effects on QOL. Nor were the sample sizes of the studies associated with the results. The durations of the interventions were about 10 weeks longer in the studies with no effects on QOL. Are the positive effects only temporary or short-term, or have the shorter interventions been more intensive? Only three studies had follow-up periods longer than 6 months, and the long-term effects of the interventions on QOL therefore cannot be critically assessed.
Eight studies reported results related to the falls, and four studies did not. No separate articles have been published about the results on falls or other outcome variables of these four studies. Fall prevention was effective in reducing the rate of falls in only one study. The number of fall injuries was an outcome measure only in three studies, which probably is due to the fact that the materials of the studies were too small to have a statistical power for these analyses. According to recent meta-analyses,15,16 most fall prevention studies are underpowered to detect significant differences between intervention and control groups in the incidence of falls and especially in the incidence of injurious falls.
Only one study included a multifactorial intervention. Thus, it was difficult to compare the results of multi- and single-factorial interventions. For example, the CGA may be a multifactorial approach in itself, but we did not consider it to be a multifactorial intervention programme, because CGA itself is actually only one measure. The contents of the programmes differed so much between the studies that they are not comparable in relation to their effects on QOL. No meta-analysis could be conducted, because the data were too sparse and heterogeneous to allow statistical aggregation.36,39 Means and standard deviations at baseline and at follow-up were presented almost in all studies, but means and standard deviations for the differences in changes were shown only in 4 studies out of 12.40 Thus, we could not calculate effect sizes (ES = Mean change in intervention group-mean change in control group/pooled standard deviation for mean change).
We could not assess the effect of the instrument on the results about QOL because a certain measure (SF-36) was used in eight studies. Many valid QOL instruments have been designed for studies in working-aged populations or for patients with a certain disease. Hence, they may not measure all dimensions of QOL or HRQOL.5,41–47 The social dimension is currently highlighted in QOL particularly among the aged, but it is almost totally lacking in assessment measures or is measured too narrowly48–50 (table 2). The challenge of measuring QOL lies in its individual uniqueness, and it is possible to measure QOL in a patient-centred way by using individualized measures.51–54 More attention should be paid to the types of instruments used to measure QOL or HRQOL in RCTs and other clinical trials. Valid and reliable instruments that measure all dimensions of HRQOL and are designed for the aged should be used.22 In addition to quantitative measures, qualitative methods such as thematic or in-depth interviews need to be used. A random sample of the total population involved in the study needs to be established and interviewed despite the shortage of resources.
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QOL was analysed in several fall prevention trials, and it was often used as a secondary outcome. Only a few studies reported a positive effect on QOL in fall prevention interventions among the aged. The differences in participants’ age ranges may be one explanation for the differences in the results. Young–old people have good functional abilities, and disabled subjects most likely to benefit from the intervention may not be reached. To increase the strengths of an RCT, blinding and intention to treat analysis should be used. Additional interventions need to be carried out to determine which kinds of prevention programmes improve QOL or HRQOL among older people, and in which way this effect is produced.
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Funding |
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Finnish Ministry of Social Affairs and Health; Hospital District of Southwest Finland; Hospital District of Satakunta;Päivikki and Sakari Sohlberg Foundation; Academy of Finland.
Conflicts of interest: None declared.
Key points
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The present review is part of the activities of the Prevention of Falls Network Europe (ProFaNe) project, which is a collaborative effort to reduce the burden of fall injuries among older people through excellence in research and promotion of best practices (Lamb et al. Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe Consensus. JAGS 2005;53:618-22) (www.profane.eu.org). We thank information specialist Helena Tähtinen for her services.
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1 Addington-Hall J, Kalra L. Measuring quality of life: Who should measure quality of life? Br Med J (2001) 322:1417–20.
2 Hendry F, McVittie C. Is quality of life a healthy concept? Measuring and understanding life experiences of older people. Qual Health Res (2004) 14:961–75.
3 Peterman A, Cella D. Evaluation of quality of life. [accessed 10 June 2006]. UpToDate 11. 2003. Available at, from http://www.uptodate.com.
4 Carr A, Gibson B, Robinson P. Measuring quality of life: Is quality of life determined by expectations or experience? Br Med J (2001) 322:240–3.
5 WHOQOL Group. Development of the World Health Organization WHOQOL-BREF quality of life assessment. Psychol Med (1998) 28:551–8.[CrossRef][Web of Science][Medline]
6 Ory MG, Schechtman KB, Miller P, et al. Frailty and injuries in later life: the FICSIT trials. J Am Geriatr Soc (1993) 41:283–96.[Web of Science][Medline]
7 Yardley L, Donovan-Hall M, Francis K, Todd C. Older people's views of advice about falls prevention: a qualitative study. Health Educ Res (2006) 4:508–17.
8 Kivelä S-L, Honkanen R. Mortality from violent causes among the elderly population in Finland in 1951-1979. Scand J Soc Med (1986) 14:31–8.[Web of Science][Medline]
9 Tinetti M, Speechley M. Prevention of falls among the elderly. N Engl J Med (1989) 320:1055–9.[Web of Science][Medline]
10 Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev (2003) 4. CD000340.
11 Campbell J, Robertson C, Gardner M, et al. Falls prevention over 2 years: a randomized controlled trial in women 80 years and older. Age Ageing (1999) 28:513–8.
12 Clemson L, Cumming RG, Kendig H, et al. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial. J Am Geriatr Soc (2004) 52:1487–94.[CrossRef][Web of Science][Medline]
13 Davison J, Bond J, Dawson P, et al. Patients with recurrent falls attending accident & emergency benefit from multifactorial intervention—a randomised controlled trial. Age Ageing (2005) 34:162–8.
14 Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. Br Med J (2004) 328:680.
15 Gates S, Lamb SE, Fisher JD, et al. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: systematic review and meta-analysis. Br Med J (2008) 336:130–7.
16 Beswick AD, Rees K, Dieppe P, et al. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet (2008) 371:725–35.[CrossRef][Medline]
17 Sjösten NM, Salonoja M, Piirtola M, et al. A multifactorial fall prevention program in the home-dwelling aged: a randomized controlled trial (Trial Design). Public Health (2007) 121:308–18.[CrossRef][Web of Science][Medline]
18 Close J, Ellis M, Hooper R, et al. Prevention of falls in the elderly trial (PROFET): a randomised controlled trial. Lancet (1999) 353:93–7.[CrossRef][Web of Science][Medline]
19 Lord SR, Tiedemann A, Chapman K. The effect of an individualized fall prevention program on fall risk and falls in older people: a randomized controlled trial. J Am Geriatr Soc (2005) 53:1296–304.[CrossRef][Web of Science][Medline]
20 Vaapio S, Salminen M, Vahlberg T, et al. Effect of risk-based multifactorial fall prevention on health-related quality of life among the community-dwelling aged: a randomized controlled trial. Health Qual Life Outcomes (2007) 5(20). Available at http//www.hqlo.com/content/5/1/20.
21 Hughes K, van Beurden E, Eakin EG, et al. Older person's perception of risk of falling: implications for fall-prevention campaigns. Am J Public Health (2008) 98:351–7.
22 Lin M-R, Wolf SL, Hwang H-F, et al. A randomized controlled trial of fall prevention programs and quality of life in older fallers. J Am Geriatr Soc (2007) 55:499–506.[CrossRef][Web of Science][Medline]
23 Masud T, Coupland C, Drummond A, et al. Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomized controlled trial. Trials (2006) 7:5.[CrossRef][Medline]
24 Zeeuwe PEM, Verhagen AP, Bierma-Zeinstra SM, et al. The effect of Tai Chi Chuan in reducing falls among elderly people: design of a randomized clinical trial in the Netherlands. BMC Geriatr (2006) 6:6.[CrossRef][Medline]
25 Glasziou P. Systematic reviews in health care: A practical guide (2001) Port Chester, NY: University Press.
26 Bruyere O, Wuidart M-A, Di Palma E, et al. Controlled whole body vibration to decrease fall risk and improve health-related quality of life of nursing home residents. Arch Phys Med Rehabil (2005) 86:303–7.[CrossRef][Web of Science][Medline]
27 Devereux K, Robertson D, Briffa NK. Effects of a water-based program on women 65 years and over: a randomized controlled trial. Aust J Physiother (2005) 5:102–8.
28 Huang TT, Liang SH. A randomized clinical trial of the effectiveness of a discharge planning intervention on hospitalized elders with hip fracture due to falling. J Clin Nurs (2005) 14:1193–201.[CrossRef][Web of Science][Medline]
29 Barnett A, Smith B, Lord S, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomized controlled trial. Age Ageing (2003) 32:407–14.
30 Latham NK, Anderson GS, Lee A, et al. A randomized controlled trial of quadriceps resistance exercise and vitamin D in frail older people: the frailty interventions trial in elderly subjects (FITNESS). J Am Geriatr Soc (2003) 51:291–9.[CrossRef][Web of Science][Medline]
31 Steadman J, Donaldson N, Kalra L. A randomized controlled trial of an enhanced balance training program to improve mobility and reduce falls in elderly patients. J Am Geriatr Soc (2003) 51:847–52.[CrossRef][Web of Science][Medline]
32 Carter ND, Khan KM, McKay HA, et al. Community-based exercise program reduces risk factors for falls in 65- to 75-year-old women with osteoporosis: randomized controlled trial. CMAJ (2002) 167:997–1004.
33 Van Haastregt JCM, Diederiks JPM, van Rossum E, et al. Effect of a programme of multifactorial home visits on falls and mobility impairments in elderly people at risk: randomized controlled trial. Br Med J (2000) 321:994–8.
34 Reuben DB, Frank JC, Hirsch S, et al. A randomized controlled trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations. J Am Geriatr Soc (1999) 47:269–76.[Web of Science][Medline]
35 Gallagher EM, Brunt H. Head over heels: impact of a health promotion program to reduce falls in the elderly. Can J Aging (1996) 15:84–96.[Web of Science]
36 Khan KS, Kunz R, Kleijnen J, Antes G. Systematic reviews to support evidence-based medicine (2003) London: Royal Society of Medicine Press Ltd. 53.
37 Fletcher R, Fletcher S, Wagner E. Clinical epidemiology. The essentials (1996) 3rd edn. Baltimore: Williams & Wilkins. 136–37. 142–3.
38 Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel group ramdomized trials. In: BMC Med Res Methodol (2001) [accessed 7 June 2008]. 1(2). Available at http://www.annals.org/cgi/content/full/134/8/657.
39 Cook DJ, Sackett DL, Spitzer WO. Methodologic guidelines for systematic reviews of randomized control trials in health care from the potsdam consultation on meta-analysis. J Clin Epidemiol (1995) 48:167–71.[CrossRef][Web of Science][Medline]
40 Cohen J. Statistical power analysis for the behavioral sciences (1998) 2nd edn. New York: Lawrence Erlbaum Associates.
41 Sintonen H. The 15D instrument of health-related quality of life: properties and applications. Ann Med (2001) 33:328–36.[Web of Science][Medline]
42 Ware E, Sherbourne CD. The MOS 36-Item Short Form Health Survey (SF-36):1. Conseptual framework and item selection. Med Care (1992) 30:473–83.[Web of Science][Medline]
43 Hays RD, Sherbourne CD, Mazel R. The RAND 36-item Health Survey 1.0. Health Econ (1993) 2:217–77.[Medline]
44 EuroQol Group. EuroQol – a new facility for the measurement of health – related quality of life. Health Policy (1990) 16:199–208.[CrossRef][Web of Science][Medline]
45 Lips P, Cooper C, Agnusdei D, et al. Quality of life in patients with vertebral fractures: validation of the quality of life questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Osteoporos Int (1999) 10:150–60.[CrossRef][Web of Science][Medline]
46 Hunt SM, McKenna SP, MCEwen J, et al. The Nottingham Health Profile: subjective health status and medical consultations. Soc Sci Med (1981) 15:221–9.
47 Bergner M, Bobbit RA, Carter WB, Gilson BS. The sickness impact profile: development and final revision of a health status measure. Med Care (1981) 19:787–805.[Web of Science][Medline]
48 Beaumont J, Kenealy P. Quality of life perceptions and social comparisons in healthy old age. Ageing Soc (2004) 24:755–69.[CrossRef][Web of Science]
49 Farquhar M. Elderly people's definitions of quality of life. Soc Sci Med (1995b) 41:1439–44.[CrossRef][Web of Science][Medline]
50 Lamb SE, Jørstad-Stein EC, Hauer K, Becker C. Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe Consensus. J Am Geriatr Soc (2005) 53:1618–22.[CrossRef][Web of Science][Medline]
51 Smith K, Avis N, Assman S. Distinguishing between quality of life and health status in quality of life research: a meta-analysis. Qual Life Res (1999) 8:447–59.[CrossRef][Web of Science][Medline]
52 Grewal I, Lewis J, Flynn T, et al. Developing attributes for a generic quality of life measure for older people: preferences or capabilities? Soc Sci Med (2006) 62:1891–901.[CrossRef][Web of Science][Medline]
53 Gabriel Z, Bowling A. Quality of life from the perspectives of older people. Ageing Soc (2004) 24:675–91.[CrossRef][Web of Science]
54 Higginson I, Carr A. Measuring quality of life: using quality of life measures in the clinical setting. Br Med J (2001) 322:1297–300.
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