Interventions for preventing falls in older people living in the community

Gillespie, Lesley D.; Robertson, M. Clare; Gillespie, William J.; Sherrington, Catherine; Gates, Simon; Clemson, Lindy M.; Lamb, Sarah E.

Affiliations

¹Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand

²Hull York Medical School, University of Hull, Hull, UK

³Musculoskeletal Division, The George Institute for Global Health, University of Sydney, Sydney, Australia

⁴Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, UK

⁵Faculty of Health Sciences, University of Sydney, Lidcombe, Australia

Abstract

Background: Approximately 30% of people over 65 years of age living in the community fall each year. This is an update of a Cochrane review first published in 2009.

Objectives: To assess the effects of interventions designed to reduce the incidence of falls in older people living in the community.

Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), EMBASE (1947 to March 2012), CINAHL (1982 to February 2012), and online trial registers.

Selection criteria: Randomised trials of interventions to reduce falls in community‐dwelling older people.

Data collection and analysis: Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled data where appropriate.

Main results: We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Sixty‐two per cent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment.

Multiple‐component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple‐component home‐based exercise (RaR 0.68, 95% CI 0.58 to 0.80; 7 trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; 6 trials; 714 participants). For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; 5 trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; 6 trials; 1625 participants). Overall, exercise interventions significantly reduced the risk of sustaining a fall‐related fracture (RR 0.34, 95% CI 0.18 to 0.63; 6 trials; 810 participants).

Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).

Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; 7 trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels before treatment.

Home safety assessment and modification interventions were effective in reducing rate of falls (RaR 0.81, 95% CI 0.68 to 0.97; 6 trials; 4208 participants) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96; 7 trials; 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist.

An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls 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 rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; 3 trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; 1 trial; 306 participants), but second eye cataract surgery did not.

Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; 1 trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; 1 trial; 659 participants).

An anti‐slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; 1 trial; 109 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 to 0.91) but not the risk of falling.

There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; 1 trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; 2 trials; 350 participants).

Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; 1 trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; 4 trials; 2555 participants).

Thirteen trials provided a comprehensive economic evaluation. Three of these indicated cost savings for their interventions during the trial period: home‐based exercise in over 80‐year‐olds, home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors.

Authors' conclusions: Group and home‐based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.

Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.

Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.

Links

DOI: 10.1002/14651858.CD007146.pub3

PubMed: 22972103

PubMedCentral: PMC8095069

WoS: 000308828600027

Cited Works (1)

Year	Entry
1997	Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. NEJM. September 4, 1997;337(10):670-676.

Cited By (26)

Year	Entry
2017	Compston J, Cooper A, Cooper C, Gittoes N, Gregson C, Harvey N, Hope S, Kanis JA, McCloskey EV, Poole KES, Reid DM, Selby P, Thompson F, Thurston A, Vine N; The National Osteoporosis Guideline Group (NOGG). UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. December 2017;12(1):1-24.
2020	Chakhtoura M, Chamoun N, Rahme M, Fuleihan GE-H. Impact of vitamin D supplementation on falls and fractures: a critical appraisal of the quality of the evidence and an overview of the available guidelines. Bone. February 2020;131:115112.
2023	Devries MC, Giangregorio L. Using the specificity and overload principles to prevent sarcopenia, falls and fractures with exercise. Bone. January 2023;166:116573.
2020	Thompson MJW, Jones G, Balogun SA, Aitken DA. Skin photosensitivity is associated with 25-hydroxyvitamin D and BMD but not fractures independent of melanin density in older caucasian adults. Calcif Tiss Int. October 2020;107(4):335-344.
2016	Camacho PM, Petak SM, Binkley N, Clarke BL, Harris ST, Hurley DL, Kleerekoper M, Lewiecki EM, Miller PD, Narula HS, Pessah-Pollack R, Tangpricha V, Wimalawansa SJ, Watts NB. American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis — 2016. Endocr Pract. September 1, 2016;22(suppl 4):1-42.
2020	Camacho PM, Petak SM, Binkley N, Diab DL, Eldeiry LS, Farooki A, Harris ST, Hurley DL, Kelly J, Lewiecki EM, Pessah-Pollack R, McClung M, Wimalawansa SJ, Watts NB. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis: 2020 update. Endocr Pract. May 2020;26(suppl 1):1-46.
2020	Conley RB, Adib G, Adler RA, Åkesson KE, Alexander IM, Amenta KC, Blank RD, Brox WT, Carmody EE, Chapman‐Novakofski K, Clarke BL, Cody KM, Cooper C, Crandall CJ, Dirschl DR, Eagen TJ, Elderkin AL, Fujita M, Greenspan SL, Halbout P, Hochberg MC, Javaid M, Jeray KJ, Kearns AE, King T, Koinis TF, Koontz JS, Kužma M, Lindsey C, Lorentzon M, Lyritis GP, Michaud LB, Miciano A, Morin SN, Mujahid N, Napoli N, Olenginski TP, Puzas JE, Rizou S, Rosen CJ, Saag K, Thompson E, Tosi LL, Tracer H, Khosla S, Kiel DP. Secondary fracture prevention: consensus clinical recommendations from a multistakeholder coalition. J Bone Miner Res. January 2020;35(1):36-52.
2020	Armstrong ME, Lacombe J, Wotton CJ, Cairns BJ, Green J, Floud S, Beral V, Reeves GK; Million Women Study Collaborators. The associations between seven different types of physical activity and the incidence of fracture at seven sites in healthy postmenopausal UK women. J Bone Miner Res. February 2020;35(2):277-290.
2019	Compston JE, McClung MR, Leslie WD. Osteoporosis. Lancet. January 26, 2019;393(10169):364-376.
2014	Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. October 2014;25(10):2359-2381.
2018	Harvey NC, Odén A, Orwoll E, Lapidus J, Kwok T, Karlsson MK, Rosengren BE, Ribom E, Cooper C, Cawthon PM, Kanis JA, Ohlsson C, Mellström D, Johansson H, McCloskey E. Measures of physical performance and muscle strength as predictors of fracture risk independent of FRAX, falls, and aBMD: a meta-analysis of the osteoporotic fractures in men (MrOS) study. J Bone Miner Res. December 2018;33(12):2150-2157.
2020	Condurache CI, Chiu S, Chotiyarnwong P, Johansson H, Shepstone L, Lenaghan E, Cooper C, Clarke S, Khioe RFS, Fordham R, Gittoes N, Harvey I, Harvey NC, Heawood A, Holland R, Howe A, Kanis JA, Marshall T, O’Neill TW, Peters TJ, Redmond NM, Torgerson D, Turner D, McCloskey E; SCOOP Study Team. Screening for high hip fracture risk does not impact on falls risk: a post hoc analysis from the SCOOP study. Osteoporos Int. March 2020;31(3):457-464.
2020	Javaid MK, Sami A, Lems W, Mitchell P, Thomas T, Singer A, Speerin R, Fujita M, Pierroz DD, Akesson K, Halbout P, Ferrari S, Cooper C. A patient-level key performance indicator set to measure the effectiveness of fracture liaison services and guide quality improvement: a position paper of the IOF Capture the Fracture Working Group, National Osteoporosis Foundation and Fragility Fracture Network. Osteoporos Int. July 2020;31(7):1193-1204.
2020	de Bot RTAL, Veldman HD, Witlox AM, van Rhijn LW, Hiligsmann M. Hip protectors are cost-effective in the prevention of hip fractures in patients with high fracture risk. Osteoporos Int. July 2020;31(7):1217-1229.
2020	Thompson MJW, Jones G, Balogun S, Aitken DA. Constitutive melanin density is associated with prevalent and short-term, but not long-term, incident fracture risk in older Caucasian adults. Osteoporos Int. August 2020;31(8):1517-1524.
2020	Tanislav C, Kostev K. Factors associated with fracture after stroke and TIA: a long-term follow-up. Osteoporos Int. December 2020;31(12):2395-2402.
2019	Harding A. LIFTMOR-M: Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation for Men [PhD thesis]. Brisbane, Australia: Griffith University; December 2019.
2019	Watson S. LIFTMOR: Lifting Intervention for Training Muscle and Osteoporosis Rehabilitation [PhD thesis]. Brisbane, Australia: Griffith University; January 2019.
2020	Whorley B. A Physiology-Based Approach for Detecting Vibration Perception Threshold in the Plantar Foot [Master's thesis]. Lawrence, KS: University of Kansas; 2020.
2021	Giraldo C. Design, Validation and Assessment of Vibratory Mat for Stochastic Resonance Applications [PhD thesis]. Lawrence, KS: University of Kansas; 2021.
2017	Lachance CC. Compliant Flooring for Fall Injury Prevention in Long-Term Care [PhD thesis]. Simon Fraser University; 2017.
2018	George JK. Using Finite Element Models Under Multiple Loading Conditions to Improve the Association Between Radius and Tibia Microarchitecture and Prevalent Osteoporotic Vertebral Fracture [Master's thesis]. Calgary, AB: University of Calgary; May 2018.
2019	Du Bois AM. Golf as Therapeutic Exercise for Older Adults: A Biomechanical Analysis of Golf Swing Demands and the Effects of a Golf Training Program on Older Adult Balance and Strength [PhD thesis]. University of Southern California (USC); May 2019.
2021	El-Kotob R. Considerations for Designing and Managing Resistance Training Intervention Studies [PhD thesis]. University of Waterloo; 2021.
2021	McLaughlin EC. Cause or Consequence? The Interrelationship Between Physical Activity and Fractures [Master's thesis]. University of Waterloo; 2021.
2015	Wu X. Toward Understanding Factors Affecting Falls Among Individuals Who Are Obese [PhD thesis]. Virginia Polytechnic Institute and State University; March 27, 2015.