Exercise

Physical training in community-living old individuals reduces the risk of fallingReference Cameron, Murray, Gillespie, Robertson, Hill, Cumming and Kerse^12, Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe^13, Reference Sherrington, Whitney, Lord, Herbert, Cumming and Close^19, Reference Campbell, Robertson, Gardner, Norton and Buchner^22–Reference Liu-Ambrose, Khan, Eng, Lord and McKay⁴⁹ (Fig. 2) and is generally accepted as the most effective fall-prevention strategy in the community-living population.Reference Davis, Robertson, Ashe, Liu-Ambrose, Khan and Marra^50, Reference Frick, Kung, Parrish and Narrett⁵¹ Exercise has also been reported as the most cost-effective fall-preventive strategy.Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe^13, Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb¹⁴ Among the different training strategies, multi-component exercise programmes that include balance training and muscle-strength training have been the most effective interventions, followed by flexibility and endurance training.Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe^13, Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb¹⁴ The training should be performed often and with high frequency.Reference Province, Hadley, Hornbrook, Lipsitz, Miller, Mulrow, Ory, Sattin, Tinetti and Wolf^25, Reference Li, Harmer, Fisher, McAuley, Chaumeton, Eckstrom and Wilson⁴⁴ Group training, where at least two different training components are included, has, in community-living old people above age 60 years decreased the fall rate by 22% (relative risk (RR) 0.78, 95% confidence interval (CI) 0.71–0.86) and the risk of falling by 17% (RR 0.83, 95% CI 0.72–0.97) (Fig. 2). Training classes that included gait balance alternating with functional training significantly reduced rate of falls by 27% (RR 0.73, 95% CI 0.54–0.98) (Fig. 2). RCTs comparing different types of exercise or methods of delivery have not found any differences.Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe¹³

Figure 2.

Comparison of number of falls in community-living older people exposed to intervention with different types of exercise versus controls reported in several randomized controlled trials (RCTs)

Individually designed exercise programmes with more than one exercise modality, conducted at home, is another approach that reduces the number of falls in community-living old individuals by 34% (RR 0.66, 95% CI 0.53–0.82) and the risk of falling by 23% (RR 0.77, 95% CI 0.61–0.97)Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe¹³ (Fig. 2). However, training can be beneficial even if using only one exercise modality. Such an example is Tai Chi training where the beneficial effects include both strength and balance training. In the general old population this type of training reduced the number of fallers by close to 50% in one RCT published by the FICSIT group (Frailty and Injuries: Co-operative Studies of Intervention Techniques)Reference Wolf, Barnhart, Ellison and Coogler⁵² and a meta-analysis that included unselected community-living older people supported this notion when reporting that Tai Chi reduced the number of falls by 37% (RR 0.63, 95% CI 0.52–0.78) and the number of fallers by 35% (RR 0.65, 95% CI 0.51–0.82) (Fig. 2). The beneficial effect is usually referred to the fact that Tai Chi includes both strength and balance training.Reference Voukelatos, Cumming, Lord and Rissel⁵³ Another recent published RCT showed that home-based balance and strength training in older community-living individuals aged 70 years or older, who had two or more falls or one injurious fall in the past 12 months, was followed by a 31% reduction in the number of falls (RR 0.69, 95% CI 0.48–0.99).Reference Clemson, Fiatarone Singh, Bundy, Cumming, Manollaras, O'Loughlin and Black⁵⁴ A music-based multi-task exercise programme in community-dwelling individuals older than 65 years who were at increased risk of falling was also effective, and the programme resulted in 54% fewer falls in the exercise group (RR 0.46; 95% CI 0.27–0.79).Reference Trombetti, Hars, Herrmann, Kressig, Ferrari and Rizzoli⁵⁵ The authors concluded that functional-based exercise should be a focus for interventions to protect older, high-risk individuals from falling and that the effect of physical training as a fall reductive strategy is less effective in institutionalized individuals.Reference Cameron, Murray, Gillespie, Robertson, Hill, Cumming and Kerse^12, Reference Mulrow, Gerety, Kanten, Cornell, DeNino, Chiodo, Aguilar, O'Neil, Rosenberg and Solis^56–Reference Sihvonen, Sipila, Taskinen and Era⁶² (Fig. 3). Supervised training in institutionalized individuals above age 65 years reduced the risk of falling by 56% (RR 0.44, 95% CI 0.20–0.97)Reference Cameron, Murray, Gillespie, Robertson, Hill, Cumming and Kerse¹² in one meta-analysis, but further subgroup analyses showed that the positive effect was only found in older people in sub-acute care hospitals, and not in those staying in general nursing care facilitiesReference Cameron, Murray, Gillespie, Robertson, Hill, Cumming and Kerse¹² (Fig. 3). However, it should be noted that gait, balance and co-ordination exercises utilizing a mechanical apparatus in individuals in nursing homes did reduce the rate of falls by 55% (RR 0.45, 95% CI 0.24–0.85). Therefore, we cannot exclude that specific types of training in specific groups actually can reduce the fall frequency also in older individuals staying in nursing homes or other type of institutions (Fig. 3).

Figure 3.

Comparison of number of falls in older people living in nursing home or hospitals exposed to intervention with different types of exercise versus controls reported in several RCTs

Vitamin D

Vitamin D supplements provided to unselected community-living older people did not reduce the number of falls (RR 0.95, 95% CI 0.80–1.14) (Fig. 4).Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe^13, Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb^14, Reference Latham, Anderson, Lee, Bennett, Moseley and Cameron^63–Reference Sato, Manabe, Kuno and Oizumi⁶⁹ Slightly more positive conclusions could be drawn when the supplement was given to institutionalized old individuals, where the total number of falls was reduced by 28% (RR 0.72, 95% CI 0.55–0.95) (Fig. 4).Reference Cameron, Murray, Gillespie, Robertson, Hill, Cumming and Kerse¹² In old people with low vitamin D levels, the sub-group analyses revealed that the number of falls was reduced by 43% (RR 0.57, 95% CI 0.37–0.89) (Fig. 4), as was the number of fallers by 35% (RR 0.65, 95% CI 0.46–0.91).Reference Pfeifer, Begerow, Minne, Abrams, Nachtigall and Hansen^66, Reference Dhesi, Jackson, Bearne, Moniz, Hurley, Swift and Allain⁶⁸ No fall reduction was seen in old people with normal vitamin D levels. However, the type of supplement also seems to be of importance, as calcitriol reduced the number of falls by 36% (RR 0.64, 95% CI 0.49–0.82)Reference Gallagher, Fowler, Detter and Sherman⁶⁷ while alfacalcidol did not (RR 1.08, 95% CI 0.75–1.57)Reference Sato, Kaji and Oizomi⁷⁰ (Fig. 4). Vitamin D supplements may reduce the number of falls but probably only in those with low vitamin D levels and maybe only with specific types of vitamin D drugs.

Figure 4.

Comparison of number of falls in community-living older people exposed to vitamin D supplement with or without calcium versus controls reported in several RCTs

Medication

Multi-pharmacy and combinations of specific drugs may be associated with increased fall risk in the older population. A structured prescription modification programme could therefore hypothetically reduce the fall risk. One RCT demonstrated this in the intervention group, where a gradual withdrawal of psychotropic medication resulted in a 66% reduction in the number of falls (RR 0.34, 95% CI 0.16–0.73) (Fig. 5).Reference Campbell, Robertson, Gardner, Norton and Buchner²² Fall preventive education for family physicians that included academic teaching, feedback on prescribing practices and financial rewards combined with self-assessment of medication followed by a medication review with modification of prescriptions in community-dwelling older people was found to reduce the risk of falling by 39% (RR 0.61, 95% CI 0.41–0.91)Reference Pit, Byles, Henry, Holt, Hansen and Bowman⁷¹ (Fig. 5). Modification of prescriptions could also have an effect on individuals staying in institutions, since beneficial effects were found in one RCT that evaluated a prescribing modification programme by pharmacists in nursing care facilities or hospitals, an intervention that reduced the fall frequency by 38% (RR 0.62, 95% CI 0.53–0.72).Reference Campbell, Robertson, Gardner, Norton and Buchner²²

Figure 5.

Comparison of number of falls in community-living older people exposed to drug withdrawal, surgery and foot assessment versus controls reported in several RCTs

Surgery

Surgical interventions may be effective in reducing falls in specific risk groups. Cardiac pacemakers, in patients with cardioinhibitory carotid sinus hypersensitivity, were in one published RCT reported to reduce the rate of falls by 58% (RR 0.42, 95% CI 0.23–0.75) (Fig. 5).Reference Kenny, Richardson, Steen, Bexton, Shaw and Bond⁷² Cataract surgery for the first eye was, in another RCT, found to reduce the rate of falls by 34% (RR 0.66, 95% CI 0.45–0.95) (Fig. 5).Reference Harwood, Foss, Osborn, Gregson, Zaman and Masud⁷³ Cataract surgery for the second eye was, however, not associated with a reduced fall rate (RR 0.68, 95% CI 0.39–1.17)Reference Foss, Harwood, Osborn, Gregson, Zaman and Masud⁷⁴ (Fig. 5).

Home hazards

Modification of home hazards in the general older population reduce the number of falls (RR 0.81, 95% CI 0.68–0.97) (Fig. 6) and the number of fallers (RR 0.88, 95% CI 0.80–0.96).Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb^14, Reference Lin, Wolf, Hwang, Gong and Chen^41, Reference Stevens, Holman and Bennett^75–Reference Day, Fildes, Gordon, Fitzharris, Flamer and Lord⁸⁰ Modifications of home hazards in individuals above age 75 years with visual impairment that removed or changed loose floor mats, painted the edges of steps, reduced glare, installed grab bars and stair rails, removed clutter and improved lighting where needed, was followed by a 41% fall reduction (RR 0.59, 95% CI 0.42–0.83) (Fig. 6) and 24% reduction in number of fallers (RR 0.76, 95% CI 0.62–0.95).Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe^13, Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb^14, Reference Campbell, Robertson, La Grow, Kerse, Sanderson, Jacobs, Sharp and Hale⁷⁸ A pooled sub-group analysis revealed that a home safety programme reduced the fall risk by 44% (RR 0.56, 95% CI 0.42–0.76) (Fig. 6) and the number of fallers by 22% (RR 0.78, 95% CI 0.64–0.95) in high-risk individuals, such as individuals with a history of a fall or multiple risk factors. Home hazard assessment and modification of risk factors should therefore be provided to all older people, but particularly focused on high-risk individuals as the interventions seem more effective in people at higher risk of falling.Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb¹⁴

Figure 6.

Comparison of number of falls in community-living older people exposed to intervention with home hazard assessment followed by risk factor reduction versus controls reported in several RCTs

Footwear

The type of footwear may influence the risk of falling.Reference Menant, Steele, Menz, Munro and Lord⁸¹ Anti-slip shoe devices have, in one study, been shown to reduce the rate of falls by 58% (RR 0.42, 95% CI 0.22–0.78) (Fig. 5), but only in old individuals who walked outdoors during icy conditionsReference McKiernan⁸² (Fig. 5). Anti-slip shoe devices should therefore be recommended to ambulatory old people who walk outdoors under icy conditions and multifaceted podiatry to patients with specific foot disability. Another RCT that evaluated the effect of multifaceted podiatry including foot and ankle exercise found that this intervention reduced the fall risk by 36% (RR 0.64, 95% CI 0.45–0.91) (Fig. 5) compared with standard podiatry in patients with disabling foot pain.Reference Spink, Menz, Fotoohabadi, Wee, Landorf, Hill and Lord⁸³

Individualized multifactorial intervention

In individualized multifaceted intervention programmes, each individual would be evaluated for risk factors and then be assigned to an individually designed prevention programmeReference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe^13, Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb^14, Reference Close, Ellis, Hooper, Glucksman, Jackson and Swift^21, Reference Davison, Bond, Dawson, Steen and Kenny^89–Reference Elley, Robertson, Garrett, Kerse, McKinlay, Lawton, Moriarty, Moyes and Campbell¹⁰¹ (Fig. 8). Similar programmes have been shown to reduce the rate of falls in community-dwelling old adults by 25% (RR 0.75, 95% CI 0.65–0.86) (Fig. 8).Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe^13, Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb¹⁴ In hospital settings, these multifactorial interventions reduced the rate of falls by 31% (RR 0.69, 95% CI 0.49–0.96) (Fig. 8) and the risk of falling by 27% (RR 0.73, 95% CI 0.56–0.96). The number of falls was not reduced in individuals living in nursing home facilities (RR 0.82, 95% CI 0.68–1.08), even if further sub-analysis revealed that specific types of interventions with multidisciplinary team approaches together with physical training reduced the rate of falling also in nursing home residents by 40% (RR 0.60, 95% CI 0.5–0.72).Reference Cameron, Murray, Gillespie, Robertson, Hill, Cumming and Kerse¹² It should also be noted that all multiple intervention trials that have been shown to reduce the fall risk include some type of physical training in the interventionReference Cameron, Murray, Gillespie, Robertson, Hill, Cumming and Kerse^12–Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb¹⁴ (Fig. 8) and that multi-factorial risk assessment in conjunction with comprehensive management of identified risk factors are usually recommended to focus on high-risk populations. In the recently updated American Geriatric Society (AGS) clinical practice guidelines, this especially accounts for older adults who have sustained two falls or more in the recent year, have gait or balance problems or have presented with an acute fall.

Figure 8.

Comparison of number of falls in community-living older people exposed to individualized multifactorial interventions versus controls reported in several RCTs

Interventions with harmful effects

An intervention programme can also increase the fall rate. Two RCTs have reported that intervention with vision assessment, eye examination, new spectacles and/or ophthalmology treatment in conjunction with mobility training and canes increased the fall rate by 57% (RR 1.57, 95% CI 1.19–2.06)Reference Cumming, Ivers, Clemson, Cullen, Hayes, Tanzer and Mitchell^77, Reference Day, Fildes, Gordon, Fitzharris, Flamer and Lord⁸⁰ (Fig. 6). Exercise in hospitalized individuals that included several different training modalities was in one RCT found to increase the fall rate by 172% (RR 2.72, 95% CI 1.42–5.19)Reference Schoenfelder⁵⁹ (Fig. 3) and when using pooled data from several RCTs that included different types of training modalities, by 37% in people in hospital settings (RR 1.37, 95% CI 1.01–1.85)Reference Cameron, Murray, Gillespie, Robertson, Hill, Cumming and Kerse¹² (Fig. 3). This highlights the importance of drawing inferences for fall preventive effect only in cohorts similar to the one evaluated in RCTs and not directly transfer the conclusion of beneficial effects in one cohort to other populations.

Cost benefits

In one review there were eight RCTs that included economic evaluation as an outcome.Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe^13, Reference Gillespie, Robertson, Gillespie, Sherrington, Gates, Clemson and Lamb¹⁴ These studies infer that there is weak evidence that prevention strategies for fall reduction can be cost saving during the trial period, but also during the rest of the lifespan of the participants. All reports also infer that the prevention strategies with fall-reducing effects ought to be targeted at high-risk sub-groups of old people to achieve greatest cost-beneficial effects.Reference Gillespie, Robertson, Gillespie, Lamb, Gates, Cumming and Rowe¹³

Conflict of interest

There are no competing interests for any of the authors.