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Guideline

General bone health maintenance and fracture prevention

Reducing falls

Reducing falls

Recommendation 15

Grade

Opportunistic case finding should be undertaken as per the recommended algorithm (Figure 1) to identify older people at risk of falls and fall-related injury.1

A

Recommendation 16

Grade

Offer further assessment and/or interventions to prevent falls based on the level of risk identified.

A

Most people who sustain peripheral fractures do so after a fall. There is strong evidence that a range of interventions significantly reduce falls when targeted at the right populations,1–8 and that fall prevention exercise programs significantly reduce fall-related injuries, including fractures.2–8 A systematic approach identifying people at risk of falling, assessing for modifiable risk factors and implementing strategies to reduce this risk is likely to reduce the risk of fractures.9
 

The world falls guidelines provide a simple algorithm (Figure 1) to guide clinicians in identifying and assessing the risk of falls in an older population.1

Figure 1. World falls guidelines algorithm for the identification and assessment of falls risk.

Figure 1. World falls guidelines algorithm for the identification and assessment of falls risk.

Figure 1.1
Reproduced from Montero-Odasso M, van der Velde N, Martin F, Petrovic M, et al. World guidelines for falls prevention and management for older adults: a global initiative. Age and ageing 2022; 51(9):1-36, with permission from Oxford Academic.

Using the information derived from the algorithm, people are classified as at ‘low’, ‘intermediate’ or ‘high’ risk of falls and fall-related injury. Strategies to reduce the risk of falls are then tailored to the level of risk as outlined below:

  • Older adults at low risk for falls, who should be offered education about falls prevention and exercise for general health and/or fall prevention.
  • Older adults at intermediate risk for falls, who, in addition to the above, should be offered targeted exercise or a physiotherapist referral to improve balance and muscle strength, and reduce fall risk.
  • Older adults at high risk for falls, who should be offered a multifactorial falls risk assessment to inform individualised tailored interventions.1

Gait speed or the timed up and go test are recommended as screening tools for gait and balance problems.1 Gait speed is a simple measure of distance over time, but requires sufficient space (the usual distance covered is six metres) to undertake the test. The timed up and go test measures the time taken for an older person to get up from a chair without using their arms, walk three metres, turn, return to the seat and sit down. A time of >15 seconds may indicate an increased fall risk, but it is important to assess gait quality and transfers in addition to time taken to complete the task.10

Those identified as at high risk of falls require a multifactorial assessment and tailored intervention based on the risk factors identified. This assessment may include tests of vision (including types of glasses worn), strength, balance and postural hypotension, as well as a review of medications and the identification of neurological and cognitive deficits. Attention should be paid to foot care and footwear. The information derived from this multidomain assessment should be used to formulate an intervention and management plan in partnership with the older person.

Evidence Statement

A Cochrane review found multifactorial interventions, which include individual risk assessment, reduced the rate of falls in community-living older people by 23% (rate ratio [RaR] 0.77; 95% CI: 0.67–0.87; 19 trials; 5853 participants).4 A companion Cochrane review found exercise (all types) reduced the rate of falls by 23% (RaR 0.77; 95% CI 0.71–0.83; 59 trials; 12,981 participants).2 In terms of optimal exercise modalities, balance and functional exercise programs reduced the rate of falls by 24% (RaR 0.76; 95% CI 0.70–0.81; 39 trials; 7920 participants) and multiple type exercise programs (most commonly balance and functional exercises plus resistance exercises) reduced the rate of falls by 34% (RaR 0.66; 95% CI 0.50–0.88; 11 trials; 1374 participants).2 Exercise may also reduce the number of people experiencing one or more fall‐related fractures (RR 0.73; 95% CI 0.56–0.95; 10 trials; 4047 participants).2 An RCT of home-based interventions teaching principles of balance and strength training and integrated selected activities into everyday routines (Lifestyle-integrated Functional Exercise [LiFE] program) reduced the rate of falls by 31% (RaR 0.69; 95% CI: 0.48–0.99).11

Home-safety assessment and modification interventions have been shown to reduce the rate of falls (RR 0.81; 95% CI: 0.68–0.97; six trials; 40,208 participants).5 These interventions have been most effective in people at higher risk of falling, including those with a recent fall-related hospital admission, and when implemented by an occupational therapist. When regular wearers of multifocal glasses (597 participants) were given single-lens glasses, both inside and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely, there was a significant increase in outside falls in intervention group participants who took part in little outside activity. Pacemakers reduced the rate of falls in people with carotid sinus hypersensitivity (RR 0.73; 95% CI: 0.57–0.93; three trials; 349 participants). First eye cataract surgery in women reduced the rate of falls (RR 0.66; 95% CI: 0.45–0.95; one trial; 306 participants), but second eye cataract surgery did not.5 A systematic review found that strategies to deprescribe ‘fall risk-increasing drugs’ (primarily psychotropic drugs) did not significantly reduce the rate of falls (RaR 0.98; 95% CI 0.63–1.51; five trials; 1309 participants).6 One trial (305 participants) in people with disabling foot pain found that multifaceted podiatry, including foot and ankle exercises, significantly reduced the rate of falls compared with standard podiatry (RR 0.64; 95% CI: 0.45–0.91).4

In a Cochrane review of fall prevention interventions for people residing in residential aged care facilities that included 95 trials (138,164 participants),6 the primary findings were that the following interventions probably make no, or little, difference to the rate of falls: exercise (RR 0.93; 95% CI: 0.72–1.20; 10 trials; 2002 participants); general medication reviews (RR 0.93; 95% CI 0.64–1.35; six trials; 2409 participants); and multifactorial interventions (RR 0.88; 95% CI 0.66–1.18; 10 trials; 3439 participants). Vitamin D supplementation probably reduces the rate of falls in residents of aged care facilities (RR 0.72; 95% CI 0.55–0.95; four trials; 4512 participants).12

Finally, one Australian trial,13 published since the Cochrane systematic review,6 found strength and balance exercise reduced falls by 55% (incidence rate ratio 0.45; 95% CI: 0.17–0.74) in residents of aged care facilities.

  • Develop a plan to reduce fall and fracture risk in partnership with the older person to maximise uptake and adherence to recommendations.
  • Exercise is the most evidence-based intervention and has been shown to prevent falls in both older people at increased risk and the general population of older people. Except for those with specific contraindications, exercise should be recommended for all older people. Both home- and community-based exercise programs are effective in preventing falls, but in both cases the exercises need to include medium- to high-intensity balance training (ie exercises must be undertaken while standing and challenge balance) and be of long duration, preferably ongoing2,3 (see Section 2.3).
  • Ensure medications are reviewed on a regular basis and that medications known to increase falls are avoided or prescribed at the lowest dose and for the shortest possible time.
  • Refer people with painful feet or foot deformities that increase falls risk to podiatry for intervention.
  • Provide advice on the dangers of bifocal and multifocal glasses when walking outdoors (blurring of ground-level obstacles) and recommend the wearing of single-lens glasses when outdoors.
  • Identify cataracts and refer for cataract extraction.
  • Refer people with a history of recent falls for an occupational therapy home assessment.
  • Assess for and treat postural hypotension and cardiovascular disorders.
  1. Montero-Odasso M, van der Velde N, Martin FC, et al. World guidelines for falls prevention and management for older adults: A global initiative. Age Ageing 2022;51(9):afac205.
  2. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 2019;1(1):CD012424.
  3. Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: An updated systematic review and meta-analysis. Br J Sports Med 2017;51(24):1750–58.
  4. Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2018;7(7):CD012221.
  5. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;2012(9):CD007146.
  6. Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev 2018;9(9):CD005465.
  7. Lee J, Negm A, Peters R, Wong EKC, Holbrook A. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: A systematic review and meta-analysis. BMJ Open 2021;11(2):e035978.
  8. El-Khoury F, Cassou B, Charles MA, Dargent-Molina P. The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: Systematic review and meta-analysis of randomised controlled trials. BMJ 2013;347:f6234.
  9. Benichou O, Lord SR. Rationale for strengthening muscle to prevent falls and fractures: A review of the evidence. Calcif Tissue Int 2016;98(6):531–45.
  10. Podsiadlo D, Richardson S. The timed ‘Up & Go’: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39(2):142–48.
  11. Clemson L, Fiatarone Singh MA, Bundy A, et al. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): Randomised parallel trial. BMJ 2012;345:e4547.
  12. Nowson CA, McGrath JJ, Ebeling PR, et al. Vitamin D and health in adults in Australia and New Zealand: A position statement. Med J Aust 2012;196(11):686–87.
  13. Hewitt J, Goodall S, Clemson L, Henwood T, Refshauge K. Progressive resistance and balance training for falls prevention in long-term residential aged care: A cluster randomized trial of the Sunbeam Program. J Am Med Dir Assoc 2018;19(4):361–69.
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