【翻譯】醫(yī)院與照護(hù)機(jī)構(gòu)預(yù)防老年人跌倒的干預(yù)措施

Cochrane

Library

OCochraneDatabaseofSystematicReviews

Interventionsforpreventingfallsinolderpeopleincare

facilitiesandhospitals(Review)

CameronID,DyerSM,PanagodaCE,MurrayGR,HillKD,CummingRG,KerseN

翻譯文獻(xiàn)：CameronID,DyerSM,PanagodaCE,MurrayGR,HillKD,

CummingRG,KerseN.Interventionsforpreventingfallsinolderpeople

incarefacilitiesandhospitals.CochraneDatabaseofSystematicReviews

2018,Issue9.Art.No.:CD005465.DOI:10.1002/14651858.

CD005465.pub4.

摘要：

1.無(wú)法確定運(yùn)動(dòng)對(duì)照護(hù)中心老年人跌倒發(fā)生率的影響（證據(jù)質(zhì)量：非常低）；

對(duì)跌倒發(fā)生的風(fēng)險(xiǎn)幾乎沒(méi)有影響（證據(jù)質(zhì)量：低）；

2.總體藥物治療的評(píng)估對(duì)照護(hù)中心老年人跌倒發(fā)生率的影響很小或沒(méi)有差異

（證據(jù)質(zhì)量：低）；對(duì)跌倒風(fēng)險(xiǎn)的影響也很小或沒(méi)有（證據(jù)質(zhì)量：低）；

3.補(bǔ)充維生素D可能會(huì)降低老年人跌倒發(fā)生率（證據(jù)質(zhì)量：中等）；但可能對(duì)

跌倒風(fēng)險(xiǎn)幾乎沒(méi)有影響（證據(jù)質(zhì)量：中等）；

4.無(wú)法確定綜合干預(yù)措施對(duì)照護(hù)中心老年人跌倒發(fā)生率的影響（證據(jù)質(zhì)量：非

常低）；對(duì)照護(hù)中心老年人跌倒風(fēng)險(xiǎn)幾乎沒(méi)有影響（證據(jù)質(zhì)量：低）;

5.無(wú)法確定監(jiān)督下運(yùn)動(dòng)鍛煉對(duì)老年人跌倒發(fā)生率的影響（證據(jù)質(zhì)量：非常

低）；亦不確定其能降低跌倒風(fēng)險(xiǎn)；

6.無(wú)法確定在床和椅子上安裝報(bào)警器的對(duì)老年人跌倒發(fā)生率和發(fā)生風(fēng)險(xiǎn)（證據(jù)

質(zhì)量：非常低）；

7.綜合干預(yù)措施可以降低醫(yī)院老年人跌倒發(fā)生率；

8.在亞急性醫(yī)療環(huán)境中綜合干預(yù)措施降低老年人跌倒發(fā)生率更明顯（證據(jù)質(zhì)

量：低）；

9.不確定綜合干預(yù)措施對(duì)老年人跌倒風(fēng)險(xiǎn)的影響（證據(jù)質(zhì)量：非常低）；

背景

在醫(yī)院與照護(hù)機(jī)構(gòu)中，老年人跌倒很常見(jiàn)，這會(huì)增加老年人的殘疾率與死

亡率。預(yù)防老年人跌倒的干預(yù)措施非常多，包括：運(yùn)動(dòng)、藥物干預(yù)、藥物治療

的評(píng)估、維生素D、環(huán)境干預(yù)和輔助技術(shù)（在床和椅子上安裝報(bào)警器）以及綜

合干預(yù)措施。本系統(tǒng)評(píng)價(jià)在2010年首次發(fā)布,并于2012年更新。

目的

本系統(tǒng)評(píng)價(jià)旨在評(píng)估減少醫(yī)院與照護(hù)機(jī)構(gòu)老年人摔倒發(fā)生的干預(yù)措施的效

果。

檢索策略

我們檢索了CochraneBone,JointandMuscleTraumaGroup

SpecialisedRegister（2017年8月），CochraneCentralRegister（2017,

Issue8）,MEDUNE,Embase和QNAHL數(shù)據(jù)庫(kù)中的相關(guān)文獻(xiàn)以及注冊(cè)試驗(yàn)

(2017年8月I

納入標(biāo)準(zhǔn)

有關(guān)預(yù)防照護(hù)機(jī)構(gòu)與醫(yī)院老年人摔倒的隨機(jī)對(duì)照試驗(yàn)。

資料收集與分析

1位作者評(píng)估了搪要，2位作者評(píng)估了全文來(lái)納入文獻(xiàn)。2位作者獨(dú)立完成

了文獻(xiàn)篩選、“偏倚風(fēng)險(xiǎn)"評(píng)價(jià)和資料提取。我們計(jì)算了跌倒發(fā)生率的相對(duì)危險(xiǎn)

度（的Q95%置信區(qū)間（CI）和跌倒風(fēng)險(xiǎn)（跌倒例數(shù)）的風(fēng)險(xiǎn)比（A/?s）和

95%置信區(qū)間（CI\若數(shù)據(jù)可以定量合并,我們則定量匯總結(jié)果，采用

GRADE評(píng)估證據(jù)質(zhì)量。

主要結(jié)果

本系統(tǒng)評(píng)價(jià)此次更新重新納入35項(xiàng)研究（77869例患者）,故共納入了

95項(xiàng)RCT（138164例患者），，71項(xiàng)研究在照護(hù)中心（40374例患者；平均

年齡84歲;75%女性）;24項(xiàng)研究在醫(yī)院（97790例參與者；平均年齡78歲;

52%女性X大部分RCT在一個(gè)或多個(gè)文獻(xiàn)質(zhì)量評(píng)價(jià)要素中表現(xiàn)為高風(fēng)險(xiǎn)偏倚,

主要是由于缺少盲法。除少數(shù)例外情況外，個(gè)體干預(yù)在任何情況下質(zhì)量評(píng)價(jià)等級(jí)

都表現(xiàn)為低或常低。骨折和不良時(shí)間的報(bào)告率^常低，即使研究有報(bào)道，證據(jù)

質(zhì)量等級(jí)也非常低，這意味著我們無(wú)法確定效應(yīng)量估計(jì)值。此次系統(tǒng)評(píng)價(jià)主要比

較跌倒的結(jié)果。

圖1文獻(xiàn)篩選流程圖

Randomsequencegeneration(selectionbias)

Allocationconcealment(selectionbias)

Blindingofparticipantsandpersonnel(performancebias)

Blindingofoutcomeassessment(detectionbias)

Incompleteoutcomedata(attritionbias)

Seledvereporting(reportingbias)

Methodofascertainingfalls

Baselineimbalance

Otherbias

0%25%50%75%100%

|Lowriskofbias||Unclearrisko(bias■Highriskofbias

圖2納入文獻(xiàn)總體質(zhì)量評(píng)價(jià)

照護(hù)中心

①運(yùn)動(dòng)

17項(xiàng)RCT比較了運(yùn)動(dòng)與常規(guī)護(hù)理，我們無(wú)法確定運(yùn)動(dòng)對(duì)照護(hù)中心老年人跌倒發(fā)

生率的影響(RaR=0.93,95%67(0.72,1.20);2002例患者,10項(xiàng)RCT;12=76%;

證據(jù)質(zhì)量：非常低)；運(yùn)動(dòng)對(duì)跌倒發(fā)生的風(fēng)險(xiǎn)幾乎沒(méi)有影響(RR=1.02,95%CI

(0.88,1.18);2090例患者,10項(xiàng)RCT研?究;代23%;證據(jù)質(zhì)量：低\見(jiàn)表lo

Comparison1.Carefacilities:Exercisevsusualcare

No.ofNo.of

OutcomeorsubgrouptitlestudiesparticipantsStatisticalmethodEffectsize

1Raceoffalls102002Raceratio(Random,95%CI)0.93@72,1.20]

2RateoffallsandnumberofOcherdataNonumericdata

fallers:trialswithincomplete

data

3Numberoffallers102090RiskRatio(Random,95%Cl)1.0210.88.1.18)

4Numberofpeoplesustaininga1RiskRatio(Fixed.95%Cl)Subtotalsonly

fracture

4.1Hipfractures1183RiskRatio(Fixed,95%Cl)0.1610.01,2.81)

4.2Allfractures1183RiskRatio(Fixed,95%CI)0.88[0.25,3.141

5Rateoffalls,excludingstudies81959Rateratio(Random,95%Cl)0.9110.72,1.15)

with<20participantsineach

arm

6Numberoffallers,excluding9RiskRatio(Random.95%CI)1.0410.89,1.21]

studieswith<20parcicipanrs

ineacharm

7Adverseevents:achesandpains1582RiskRatio(M-H,Fixed,95%CI)1.23[0.61,2.48]

7.1Severesoreness1194RiskRatio(M-H,Fixed,95%CI)0.91(0.40.2.04]

7.2Severebruises1194RiskRatio(M-H,Fixed,95%CI)2.010.18,21.69)

7.3SevereFatigue1194RiskRatio(M-H.Fixed.95%CI)4.0[0.46.35.14)

表I運(yùn)動(dòng)vs.常規(guī)護(hù)理

②總體藥物治療評(píng)估

總體藥物治療的評(píng)估對(duì)照護(hù)中心老年人跌倒發(fā)生率的影響很小或沒(méi)有差異(RaR

=0.93,95%CI(0.64,1.35);2409例患者，6項(xiàng)RCT;/2=93%,證據(jù)質(zhì)量：低);

對(duì)跌倒風(fēng)險(xiǎn)的影響也很小或沒(méi)有(RR=0.93,95%(CI0.80,1.09);5139例患者，

6項(xiàng)RCT4=48%，證據(jù)質(zhì)量：低力見(jiàn)表2。

Comparison5?Carefacilities:Medicationreviewvsusualcare

No.ofNo.of

OutcomeorsubgrouptitlestudiesparticipantsStatisticalmethodEffectsize

1Raceoffalls7Rateratio(Random.95%CI)Subtotalsonly

1.1Generalmedication62409Rateratio(Random95%CI)0.93[0.64,1.351

reviewsvsusualcare

1.2Medicationreviewfor19Rateratio(Random.95%CI)0.63(0.16,2.49]

hyponatraemia

2Numberoffallers7RiskRatio(Random.95%CI)Subtotalsonly

2.1Generalmedicationreview65139RiskRatio(Randorr.,95%Cl)0.93(0.80,1.09]

vtmiialerr

2.2Medicationreviewfor19RiskRatio(Random,95%CI)0.42(0.07,2.591

hyponatraemia

3Numberofpeoplesustaininga1RiskRatio(Fixed.95%Cl)Totalsnorselected

fracture

3.1Generalmedicationreview1RiskRatio(Fixed.95%Cl)0.0[0.0.0.0)

vsusualcare

4Raceoffallspost-hocsensitivity5Rateratio(Random.95%Cl)Subtotalsonly

2ndysis(excludingPotter

2016)

4.1Generalmedication5Rateratio(Random95%CI)0.82[0.60,1.11]

reviewsvsusualcare

5Seriousadverseevents1RiskRatio(M-H,Fxed.95%Cl)Totalsnotselected

InterventiomforpreventingfallsinNderpeopleincarefacilitiesandhospitals(Review)273

Copyright?2018TheAuthors.CochraneDatabaseofSystematicReviewspublishedbyJohnWiley&Sons,Ltd.onbehalfofThe

CochraneCollaboration.

表2總體藥物治療VS.常規(guī)護(hù)理

③補(bǔ)充維生素D可能會(huì)降低老年人跌倒發(fā)生率

補(bǔ)充維生素D可能會(huì)降低老年人跌倒發(fā)生率（RaR=0.72,95%CI（0.55,0.95）;

4512例患者，4項(xiàng)RCT,P=62%,證據(jù)質(zhì)量：中等）；但可能對(duì)跌倒風(fēng)險(xiǎn)幾乎

沒(méi)有影響（RR=0.92,95%（。0.76,1.12;4項(xiàng)RCTJ2=42%,證據(jù)質(zhì)量:中等\

這些納入研究中的人恭維生素D處于偏低水平。見(jiàn)表3.

Comparison6.Carefacilitia:VitaminDsupplementationvsnovitaminDsupplementation

No.ofNo.of

OutcomeorsubgrouptitleMudiesparticipantsStatisticalmethodEffectsize

1Rateoffalls6Rateratio(Random,95%Cl)Subtotabonly

l.lAdditionalVitaminD44512Raceratio(Kindom.95%Cl)0.72(0.55.0.95]

supplementation

1.2Mukivicamins(including191Raceratio(Random.95%CI)0.38(0.20.0.71)

vitaminD3?calcium)vs

placebo

1.3EducationonVitamin14017Rateratio(Random.95%CI)1.0310.85.1.25)

D?calcium?ostcopor<Mi?.

medicationsvsusualcare

2Numberoffallers7RiskRatio(Random,95%Cl)Subtotalsonly

2.1VitaminD44512RiskRatio(Random,95%CI)0.9210.76,1.12]

supplementation

2.2VitaminD?cakium1583RiskRatio(Random.95%Cl)1.03[0.90.1.181

supplementationvsplacebo

2.3Multivitamins(including191RiskRatio(Random,95%Cl)0.8210.40.1.66)

vitaminD3?calcium)v$usual

careorplacebo

2.4EducationonVitamin14017RiskR^(io(Random,95%Cl)1.05(0.90,1.23]

I)?calcium?osteoporosis

medicationsvsusualcare

3Numberofpeopleswuininga4RiskRatio(Random,95%CI)Subtotalsonly

fracture

3.1VicminD34464RiskR^(io(Random,95%CI)1.09[0.58.2.03)

supplementation

3.2VitaminD3?calciumvs1583RiskR^tio(Random,95%Cl)0.62[0.36,1.07]

placebo

4Adverseevents4RiskRatio(M-H,Fixed、95%Cl),lotalsnotselected

4.1Multivitamins(including1RiskRatio(M-H,Fixed,95%CI)0.0[0.0,o.ol

vitaminD3+cakium)vsusual

careorplacebo

4.2VitaminD.calcium1RiskR-i(io(M-U,95%CI)0.0[0.0.0.0)

supplementation

4.3VitaminD2RiskRatio(M-H,Fued.95%Cl)0.0[0.0,0.0|

supplementation

表3補(bǔ)充維生素DVS.不補(bǔ)充維生素D

④綜合干預(yù)措施

13項(xiàng)研究測(cè)試了綜合干預(yù)措施的預(yù)防效果，我們無(wú)法確定綜合干預(yù)措施對(duì)老年

人跌倒發(fā)生率的影響(RaR=0.88,95%Q(0.66,1.18);3439例患者，10項(xiàng)

RCT4=84%;證據(jù)質(zhì)量：非常低)；對(duì)老年人跌倒風(fēng)險(xiǎn)幾乎沒(méi)有影響(RR二

0.92,95%。(0.81,1.05);3153例患者，9項(xiàng)RCT;/2=42%;證據(jù)質(zhì)量：低I見(jiàn)

表4.

Comparison12.Carefacilities:Multifactorialinterventionsvsusualcare

No.ofNo.of

OutcomeorsubgrouptitlestudiespanicipanuStatisticalmethodEffectsize

1Rateoffalls103439Rateratio(Random.95%Cl)0.88[0.66,1.18]

2Numberoffallers93153RiskRatio(Random,95%Cl)0.92|0.81,1.05]

3Numberofpeoplesustaininga52160RiskRatio(Random,95%CI)0.79[0.30,2.07]

fracture

表4綜合干預(yù)措施VS.常規(guī)護(hù)理

醫(yī)院環(huán)境

①監(jiān)督下的運(yùn)動(dòng)

3項(xiàng)研究在康復(fù)病房(亞急性醫(yī)療環(huán)境)測(cè)試了附加物理治療(監(jiān)督下的運(yùn)動(dòng)鍛

煉)的干預(yù)效果，我們無(wú)法確定監(jiān)督下運(yùn)動(dòng)鍛煉對(duì)老年人跌倒發(fā)生率的影響

(RaR=0.59,95%CI(0.26,1.34);215例患者，2項(xiàng)RCT;I2=0%,證據(jù)質(zhì)量:

非常低)亦不確定其能降低跌倒風(fēng)險(xiǎn):RR=0.36,95%Q(0.14,0.93);83例患者，

2項(xiàng)RCT1=0%\見(jiàn)表5.

Comparison15.Hospitals:Additionalexercisesvsusualphysiotherapy

No.ofNo.of

OutcomeorsubgrouptitlestudiesparticipantsStatisticalmethodEffectsize

1Rateoffalls2215RateRatio(Fixed,95%CI)0.59(0.26.1.34]

2Numberoffallers283RiskRatio(Fixed,95%Cl)0.36[0,14,0.93]

表5監(jiān)督下的運(yùn)動(dòng)VS.常規(guī)康復(fù)

②報(bào)警器

我們無(wú)法確定在床和椅子上安裝報(bào)警器的對(duì)老年人跌倒發(fā)生率(RaR=0.60,95%

(CI0.27,1.34);2項(xiàng)RCTJ2=0%;證據(jù)質(zhì)量非常低用發(fā)生風(fēng)除RR=0.93,95%

CI(0.38,2.24);2項(xiàng)RCT,12=0%;證據(jù)質(zhì)量：非常低)的影響。見(jiàn)表6.

No.ofNo.of

OutcomeorsubgrouptitlestudiesparticipantsStatisticalmethodEffectsize

1Rareoffalls5RareRatio(Random,95%Cl)Subtotalsonly

1.1Carpetflooringvsvinyl154RateRatio(Random,95%CI)14.7311.88.115.35J

flooring

1.2Low-lowbedsvsusualcare111099RareRatio(Random,95%CI)1.39[0.22,8.78)

1.3Blueidentificationbracelet1134RateRatio(Randcm?95%CI)1.1510.72,1.84]

vsusualcare(nobracelet)

1.4Bedalarmsvsusualcare228649RateRatio(Randem,95%CI)0.60[0.27,1.34]

2Numberoffallers4RiskRatio(Fixed,95%CI)Subtotalsonly

2.1CarpetflooringvsvinylI54RiskRatio(Fixed,95%CI)8.3310.95.7337)

flooring

2.2BlueidentificationbraceletI134RiskRatio(Fixed,95%CI)1.34[0.76,2.36]

vsusualcare(nobracelet)

2.3Bedalarmsvsusualcare228649RiskRatio(Fixed,95%Cl)0.93[0.38,2.24)

③綜合干預(yù)措施可以降低老年人跌倒發(fā)生率

在醫(yī)院環(huán)境下，綜合干預(yù)措施可以降低老年人跌倒發(fā)生率(RaR=0.80,95%CI

(0.64,1.01);44664例患者，5項(xiàng)研究;12=52%)，根據(jù)亞組分析，在亞急性醫(yī)

療環(huán)境中綜合干預(yù)措施降低老年人跌倒發(fā)生率更明顯(RaR=0.67,95%

0(0.54,0.83);3747例患者,2項(xiàng)研究;F=0%;證據(jù)質(zhì)量：低)；我們不確定綜合

干預(yù)措施對(duì)老年人跌倒風(fēng)險(xiǎn)的影響(RR=0.82,95%CI(0.62,1.09);39889例患

者;項(xiàng)證據(jù)質(zhì)量：非常低見(jiàn)表

3RCT;P=0%;17e

Comparison21.Hospitals:Multifactorialinterventionsvsusualcare

No.ofNo.of

OutcomeorsubgrouptitlestudiesparticipantsStathticalmethodEffectsize

1Rateoffalls544664Rateratio(Random,95%CI)0.80[0.64,1.01]

2Numberoffallers339889RiskRatio(Random.95%CI)0.82(0.62,1.09]

3Numberofpeoplesustaininga2RiskRatio(Fixed,95%Cl)0.76(0.14,4.10]

fracture

A)總體

Comparison22.Hospitals:Multifactorialinterventionsvsusualcare(groupedbytypeofcare)

No.ofNo.of

OutcomeorsubgrouptitleStatisticalmethodEffectsize

studiesparticipants

1Rareoffalls544664RareRatio(Random,95%Cl)0.80[0.64,1.01]

1.1Acmelevelofcare135264RateRatio(Random,95%Cl)1.04[0.79,137]

1.2Subacuteoracute(mixed)25653RateRatio(Random,95%CI)0.88[0.61,127]

levelsofcart

1.3Subacutelevelofcar