Falls can be reduced in men and women aged 80 years and older receiving an exercise programme from trained nurses based in general practices, and this is achievable in usual clinical practice.2,5
It was more difficult to gauge whether the exercise programme gave value for money. The programme cost a similar amount per person to deliver as the first pragmatic trial involving a district nurse prescribing the programme, and there were similar estimates for cost effectiveness ratios when the costs of implementing the programme only were considered. Hospital costs were not reduced, however, and therefore the programme was not as cost effective as the first trial. This may be due to the sample sizes used, which were based on falls and not on injury rates, and the fact that the data for hospital costs have a skewed distribution. The participants from the exercise centres had fewer moderate injuries as a result of a fall, but no differences were found in the numbers of serious injuries between the two groups.
For the trial of the exercise programme in a research setting, the programme was delivered by a physiotherapist.2
We conclude that trained nurses from general practices can also implement the programme successfully. The implementation of the programme worked well from a general practice setting, and because it took up only half the nurses' time it fitted in with other work. Nurses should be trained and supervised by a suitably qualified physiotherapist.
The earlier a health problem can be identified the better. In both our pragmatic trials the nurses acted as patient advocates on several occasions and were able to identify health concerns during the home visits and to deal with them before they became a major problem. It was reassuring that death rates were lower, although not significantly so, in the exercise groups than in the control groups in both trials.
As this was a trial of implementing a programme in the community, we used control and exercise centres rather than a randomised controlled design. The pragmatic design ensured that the delivery of the intervention matched as closely as possible what might occur in normal practice using practice nurses. This also avoided contamination as increased public awareness may lead to sharing of information. It is possible that the variable success of the programme in the different centres was influenced by the expertise of the instructor.
Different conditions in different centres may result in different rates of falls. Bias in the findings may have occurred as blinding was not possible except for classifying fall events. It is possible participants in the exercise centres did not want to report falls and disappoint their instructor. However the nurses all developed considerable rapport with the participants, and we believe the effect of this on outcome was minimal.
We investigated only the immediate health related costs and benefits in the economic evaluation, and this resulted in a conservative estimate of cost effectiveness. The benefits of exercising may continue longer than the one year of follow up. In a previous trial we found that reduction of falls continued for two years and involved very little extra use of resources.3
In this trial 53% (139 of 261) of participants completing the exercise programme said they intended to keep exercising, and 41% chose to keep the ankle cuff weights (from 1 to 8 kg). Healthcare costs after a fall may well continue to accrue for the remainder of an individual's life.
Exercise programmes can prevent falls in elderly people living in the community.8
We have also shown that withdrawing psychotropic drugs can prevent falls in people taking these drugs.9
Another intervention delivered at home by a health professional—assessment and modification of environmental hazards—has been shown to reduce falls in elderly people who were at increased risk of falling.10
A home based programme that was individually targeted and multifactorial also reduced falls in elderly people.11
We recommend a home based exercise programme delivered by trained nurses. Other components such as awareness of falls, home safety advice, and referral to doctors for reassessment of psychotropic drugs could be included to maximise effectiveness. A programme to prevent falls within general practice is practical, can reduce trauma and help maintain independence, and has the potential to reduce costs due to injury.