An individually-tailored multifactorial intervention program for older fallers in a middle-income developing country: Malaysian Falls Assessment and Intervention Trial (MyFAIT)

According to the United Nations’ worldwide statistics for the year 2009, the percentage of individuals aged 60 years and over will increase from 11% to 22% by 2050 [1]. In comparison to global numbers, Malaysia is expected to have an ageing society by 2035, where the population size of people aged 60 years and over will reach 44.11 million, 15% of the total population size [2]. Falls as a cause of death in Malaysia is ranked 150 in the world, compared to 80 in the United States of America and 4 (critical) in Thailand [3]. In developed countries, approximately 32% older people will fall within one year, where 20% of fallers will need medical attention, and less than one in ten cases result in a fracture [4‐6]. Growth of the older population is expected to be associated with an increase in number fallers presented to health care services, which will incur higher health care and social care costs, unless effective interventions can be implemented widely.

A fall has been defined by the Prevention of Falls Network Europe Consensus as, “an unexpected event in which the participants come to rest on the ground, floor, or lower level” [7]. This broad definition has been adopted for the present study from the Kellogg’s International Working Group’s report in 1987, as our study will include falls that have occurred as a result of dizziness, syncope and cardiovascular abnormalities [8, 9].

Published data on falls in older people from Malaysia is scarce. One Malaysian study suggested that injuries sustained from falls in older people are highly prevalent, constituting 40-60% of falls cases [10]. Previous studies have also identified the occurrence of ‘post-fall syndrome’ in fallers. Individuals who have a fear of falling appear to enter a debilitating spiral of loss of confidence, functional decline and social deprivation, physical frailty, falls, and loss of independence [11, 12]. Hypothermia, pressure-related injuries and infections may also result from falls [13].

Falls is not a part of the natural ageing process. They are often the result of a collective and individualized set of risk factors [9, 14]. The total count of possible risk factors contributing to falls exceeds 400, among the many are impaired sensorimotor functioning, cardiovascular complications, muscle weakness, environmental factors, osteoarthritis, visual limitations and depression [15, 16]. Falls are multifactorial, the culmination of various combinations of intrinsic and extrinsic factors [6]. Thus, assessment of fallers needs to be multifaceted, to identify potentially modifiable risk factors that could be addressed in order to reduce the overall falls risk. A recent Cochrane review has identified that multifactorial interventions are effective in reducing falls [5].

Majority of randomized controlled trials in falls prevention were focused in developed, Western nations. In developing countries like Malaysia, the concept of ‘geriatrics’ is still at its infancy. As a result, there are few structured geriatric support services. Falls research is also under developed in Malaysia. Falls risk factors have been shown to be dependent on cultural differences and living conditions of the elderly [17]. So, interventional approaches previously shown to be effective in developed countries may not be effective in a developing community setting. A recent Cochrane review concluded that “these are complex interventions, and their effectiveness may be dependent on factors yet to be determined” [5]. Therefore, this study will be among the first few multifactorial falls intervention studies in an Asian community. Our main objective is to evaluate the effectiveness of an individually-tailored multifactorial intervention in reducing falls among the at risk older population in Malaysia.

Multifaceted interventions in previous studies have demonstrated the effectiveness of this approach in reducing falls compared to single or multicomponent interventions [42]. However, a meta-analysis of multifaceted interventions by the most recent Cochrane review has found that although it reduces the number of falls, multifactorial interventions do not help reduce the risk of falling [5]. Strong positive outcomes were observed especially in studies with land-based exercise, medication withdrawal, vitamin D supplementation, footwear intervention, and home environment modification [14, 43].

There is however insufficient evidence that multifactorial interventions can be conducted outside a tightly controlled group of research trials and implemented into clinical practice and community services [42]. There is also a lack of evidence to prove the effectiveness of visual intervention, medications withdrawal and falls prevention education in reducing the number of falls [14, 39]. Most studies were primarily performed in Western countries, and very few RCT’s have been conducted in low and middle-income developing countries, which will be achieving the ‘ageing population’ status in a few decades, at a substantially faster rate than the Western nations [2, 44, 45]. Although many falls-related trials have been conducted, interventions or outcomes were rarely implemented in a large-scale clinical setting. Edwards theorized that the baton for falls prevention needs to be passed on by falls experts to medical practitioners for it to be incorporated into common clinical practice. Active participation of the government, policymakers and research funders is also vital [45, 46].

It is also important to take note of ethnicity and also where older fallers are recruited from. Fallers from the Stroke Unit or Accident and Emergency Department are characteristically more dependent, prone to recurring falls, and are more receptive to interventions [4, 46‐48]. Lee and colleagues reported 25.2% of 1-year falls incidence when recruiting fallers from medical and community health centers [4]. A systematic review of worldwide Chinese fallers reported a lower rate of 18% [49]. The frequently reported incidence rate of 30% annual falls in elderly [8], may therefore fluctuate depending on faller characteristics.

Cultural diversity may play an important role in falls interventions. Chinese older people residing in London were reluctant to talk about falls, tending to hide falls from their adult children to avoid worrying them; and have poor knowledge about the availability and content of interventions [13, 49]. The results of Western studies should not be directly extrapolated to Malaysia and other Asian countries due to demographic, lifestyle, cultural, environmental and health service system differences. Little is currently known about how falls can be appropriately managed in developing countries. In our setting where the population is ageing at a far faster rate than the Western developed countries, cost-effective solutions to age-related conditions are desperately needed. Hence it is important to evaluate the effectiveness of the falls intervention program on local fallers before developing relevant falls interventions in clinical practice.

Using a pragmatic RCT approach to falls, MyFAIT will evaluate the effectiveness of a multifactorial intervention in reducing the incidence of falls, and the rate of falling as a secondary prevention measure in older fallers seeking medical attention in primary and secondary care settings. This project will fill a vital gap in global falls prevention measures by targeting a culturally-diverse older Asian community of low-middle income. This study will also help to determine the characteristics of fallers in our setting and detect potential differences or similarities between existing falls research populations. If successful, these approaches have the potential for widespread application in geriatric healthcare services and should minimize the projected escalation of falls related health service needs in the future, and improve the quality of life of our older community.

While multifactorial falls interventions have been demonstrated to be effective in reducing frequency of falls in Western populations and used in many falls intervention program in developed countries, such an intervention has not been adequately evaluated in lower income countries in Asia. We are conducting a randomized-controlled study in a middle-income developing country in South-East Asia. The results of this study will provide much needed information about the potential benefits of multifactorial falls intervention outside the developed countries. This study will also provide valuable information on the characteristics of fallers and the response to individual interventions within the multifactorial program.

Tan, Pey June, Khoo, Ee Ming, Chinna, Karuthan, Hill, Keith D., Poi, Phillip J. H., Tan, Maw Pin are co-authors.