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
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.