Our results indicate that preventive home visits can be effective in reducing falls in community-dwelling older people. The findings corroborate results from a previous randomized controlled trial that was also conducted in Germany,22
which reported 31% fewer falls after one year in an intervention group that received comprehensive geriatric assessment followed by a diagnostic home visit and home intervention compared with a control group that received comprehensive geriatric assessment with recommendations but usual care at home (incidence rate ratio 0.69). Moreover, our results are consistent with the findings of a Cochrane review reporting overall evidence for the effectiveness of multifactorial interventions in reducing the rate of falls in community-dwelling older people (incidence rate ratio 0.75, 95% confidence interval 0.65–0.86).9
However, a significant number of studies have failed to demonstrate the effectiveness of preventive home visits in reducing the risk of falls.11
As stated above, the systematic review reported by van Haastregt et al identified two trials showing a significant reduction in the number of falls in an intervention group with preventive home visits and also four trials not showing any effect of intervention.11
The main disadvantage of the preventive home visiting strategies identified by van Haastregt et al and by other researchers is the difficulty in distinguishing the effective components of such a complex and multidimensional intervention from the total set of components.11
Even though we also could not make such a distinction, we suggest that the effectiveness of preventive home visits in our study might be attributed to a combination of factors:
- multidimensional geriatric assessments in participants’ homes enabled identification of a broad range of possible internal and external risk factors for falling
- multidisciplinary case reviews enabled comprehensive evaluation of the risk factors identified and development of interventions tailored to the individual’s situation
- a combination of individualized interventions and recommendations for participants at risk (secondary prevention) and provision of general information to the participants in the intervention group independent of the risk of falling (primary prevention)
- a final preventive home visit to emphasize recommendations, remove obstacles, and provide further assistance, and thereby increase compliance.
Our study may be of particular interest because its findings confirm the effectiveness of preventive home visits in a sample of community-dwelling people who were quite elderly (aged 80 years or older, mean age 85.1 years), and so had a considerably increased risk of falling as well as institutionalization.
However, our study is not without limitations. First, the sample size was not calculated according to the outcome of falls, although it had sufficient power to detect a significant effect of preventive home visits on this outcome. Second, falls were assessed retrospectively by asking only two questions. A number of falls studies alternatively or additionally used prospective calendar self-reports to assess occurrence of falling and the number of falls.12
With regard to the findings of a validation study by Mackenzie et al, a retrospective self-report such as that used in our study was found to be less sensitive (56%) and less specific (94.7%) than the prospective calendar method for assessment of falls over a six-month period.23
Therefore, our data may be afflicted with some degree of inaccuracy. Third, participants and field researchers could not be blinded to group allocation. Fourth, only 21.3% of the participants in the intervention group completely followed the individualized recommendations for fall prevention (7.4% followed partially, 2.8% reduced their risk of falling using other strategies, and 25.9% refused to follow the individualized recommendations). Another 38.0% of participants stated that they felt well informed and intended to follow the individualized recommendations when it became necessary (ie, higher perceived risk of falling) in their own view (data on acceptance/refusal of recommendations for the remaining 4.6% of the participants could not be collected). However, fall prevention in the trial not only included individualized interventions and recommendations, but also provision of general information, eg, on causes of falls or on strategies to reduce the risk of falling and consequent injury. Even if participants did not follow the specific recommendations, the risk of falling might also have been reduced by the general information provided, eg, a change in behavior because of raised awareness about the underlying causes of falls. Finally, although the preventive home visits seemed to be effective in reducing falls, they were time-consuming and resource-consuming, so might not be cost-effective.
To improve the cost-effectiveness and outcomes of preventive home visits in reducing falls, further research should focus on identification and facilitation of the components of a preventive home visit program in the target group that could benefit most.4