Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Recommendations

Reducing the risk of falls

Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of a
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  1. Summary of recommendations
  3. Figures and tables
  4. Appendix A. Process report
  5. Appendix B. Working group
  6. Provided under licence

Evidence statement

A Cochrane review of 159 randomised controlled trials (RCTs) reported that multiple-component group exercise significantly reduces risk of falling (relative risk [RR]: 0.85, 95% confidence interval [CI]: 0.76–0.96, 22 trials, 5333 participants), as does multiple-component home-based exercise (RR: 0.78, 95% CI: 0.64–0.94, six trials, 714 participants).1 Multifactorial interventions, which include individual risk assessment, were also found to reduce the rate of falls (Rate ratio [RaR]: 0.76, 95% CI: 0.67–0.86, 19 trials, 9503 participants).1 Another systematic review of community-based falls prevention exercise programs found a significant reduction in the risk of fracture (RR: 0.39, 95% CI: 0.22–0.66, six trials).2 A further recent meta-analysis indicates that exercise interventions prevent fall-related fractures in men and women 50 years of age and older (RR: 0.604, 95% CI: 0.453–0.840, P = 0.003, 15 studies, 3136 participants) and reduce risk factors for fall-related fractures (leg strength and balance).3 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) was found to reduce the rate of falls by 31% (RaR: 0.69, 95% CI: 0.48–0.99).12

Overall, vitamin D supplements were not found to reduce risk of falling, but may do so in people with lower vitamin D levels before treatment.1 Home-safety assessment and modification interventions were effective in reducing risk of falling (RR: 0.88, 95% CI: 0.80–0.96, seven trials, 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment and implemented by an occupational therapist. An intervention to treat vision problems (616 participants) resulted in a significant increase in the risk of falling (RR: 1.54, 95% CI: 1.24–1.91). When regular wearers of multifocal glasses (597 participants) were given single-lens glasses, both inside and outside falls were significantly reduced in the sub-group 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 (RaR: 0.73, 95% CI: 0.57–0.93, three trials, 349 participants). First eye cataract surgery in women reduced the rate of falls (RaR: 0.66, 95% CI: 0.45–0.95, one trial, 306 participants), but second eye cataract surgery did not. Gradual withdrawal of psychotropic medication reduced the rate of falls (RaR: 0.34, 95% CI: 0.16–0.73, one trial, 93 participants), but not the risk of falling.  A prescribing modification program for primary care physicians significantly reduced the risk of falling
(RR: 0.61, 95% CI: 0.41–0.91, one trial, 659 participants). One trial (305 participants) comparing multifaceted podiatry, including foot and ankle exercises, with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR: 0.64, 95% CI: 0.45–0.91) but not the risk of falling.1

A complementary Cochrane review of falls prevention interventions for people residing in residential agedcare facilities included 43 trials (30,373 participants).11 The results from 13 trials testing exercise interventions were inconsistent. Overall, there was no difference between the intervention and control

Grade: A

Recommendation 10
Conduct falls risk assessments and initiate targeted fall-prevention programs in older adults.

Most people who sustain peripheral fractures do so after a fall. There is systematic review evidence that a range of interventions significantly reduce falls1,2 and that falls prevention exercise programs significantly reduce fall-related injuries including fractures.2,3 Therefore, assessing a person’s risk of falling and implementing strategies to reduce this risk are also likely to reduce the risk of fractures.4

A falls risk screen involves asking the following three questions:5,6

  1. Have you had two or more falls in the past 12 months?
  2. Are you presenting following a fall?
  3. Are you having difficulty with walking or balance?

If the answers to any of these are positive, a falls risk assessment is indicated.5,6 This comprises obtaining relevant medical history, completion of a physical examination, and cognitive and functional assessments to determine multifactorial fall risk:

  • history of falls
  • multiple medications, and specific medications (eg psychotropic medications and opiate-containing analgesic agents)
  • impaired gait, balance and mobility
  • impaired visual acuity, including cataracts
  • issues with bifocal or multifocal spectacle use
  • reduced visual fields
  • other neurological impairment
  • muscle weakness
  • cardiac dysrhythmias
  • postural hypotension
  • foot pain and deformities and unsafe footwear
  • home hazards
  • vitamin D deficiency.

A quick screening tool is the timed up and go (TUG) test, which involves looking for unsteadiness as the older person gets up from a chair without using his or her arms, walks 3 m and returns.7 Simple alternatives to the TUG test are the repeated chair-standing test and the alternate-step test. The repeated chair-standing test measures how quickly an older person can rise from a chair five times without using his or her arms.8 A time of >12 seconds indicates an increased fall risk. The alternate-step test measures how quickly an older person can alternate steps (left, right, left, etc) onto an 18-cm-high step a total of eight times.8 A time >10 seconds indicates an increased fall risk.

To be successful, a falls prevention program needs to be tailored to the individual’s needs and may include multiple strategies. A falls prevention program may include the following:5,6

  • Education on the risk of falling and prevention strategies.
  • Prescription or referral for a home-based exercise program and/or encourage participation in a communitybased exercise program. In either case, exercise for preventing falls needs to include medium-intensity to highintensity balance training (ie exercises must be undertaken while standing and challenge balance), and be of long duration, preferably ongoing.9
  • Medications reviews and discontinuation of centrally acting medications where appropriate.
  • Prescribing of vitamin D for people with vitamin D levels <50 nmol/L for older people living in the community and prescription of vitamin D (unless contraindicated) for all older people living in residential aged care.10
  • Referral of people with painful feet or foot deformities to podiatry for intervention.
  • Provision of advice on the dangers of bifocal and multifocal glasses when walking outdoors (blurring of groundlevel obstacles) and recommendation of the wearing of single lens glasses when outdoors.
  • Identification of cataracts and referral for cataract extraction.
  • Referral of people with a history of recent falls for an occupational therapy home assessment.
  • Treatment of postural hypotension and cardiovascular disorders.
  1. Gillespie L, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;(9):CD007146.
  2. Franco MR, Pereira LS, Ferreira PH. Exercise interventions for preventing falls in older people living in the community. Br J Sports Med 2014;48(10):867–68.
  3. El-Khoury F, Cassou B, Charles MA, Dargent-Molena 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.
  4. 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. doi: 10.1007/s00223-016-0107-9.
  5. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59(1):148–57.
  6. Australian Commission on Safety and Quality in Health Care. Preventing falls and harm from falls in older people: Best practice guidelines for Australian hospitals, residential aged care facilities and community care. Darlinghurst, NSW: ACSQHC, 2009 [Accessed 1 February 2017].
  7. 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. [Accessed 1 February 2017].
  8. Tiedemann A, Shimada H, Sherrington C, Murray S, Lord S. The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing 2008;37(4):430–35. [Accessed 1 February 2017].
  9. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: A systematic review and meta-analysis. J Am Geriatr Soc 2008;56(12):2234–43. [Accessed 1 February 2017].
  10. 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. [Accessed 1 February 2017].
  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. [Accessed 1 February 2017].
  12. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev 2010;1:CD005465. [Accessed 1 February 2017].
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