As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.
This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.  
Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.
Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.  
Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.
Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.  
Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.
Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.
In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.
The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

Interventions for preventing falls in older people living in the community

Summary
This report describes the epidemiology, burden, and treatment of osteoporosis in the 27 countries of the European Union (EU27).

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Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

Background 
Approximately 30% of people over 65 years of age living in the community fall each year.
Objectives
To assess the effects of interventions to reduce the incidence of falls in older people living in the community.
Search strategy
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials ( all to May 2008).
Selection criteria
Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.
Data collection analysis
Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.
Main results
We included 111 trials ( 55,303 participants). Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95% CI 0.71 to 0.86; risk ratio (RR) 0.83, 95% CI 0.72 to 0.97), as did Tai Chi ( RaR 0.63, 95% CI 0.52 to 0.78; RR 0.65, 95% CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise ( RaR 0.66, 95% CI 0.53 to 0.82; RR 0.77, 95% CI 0.61 to 0.97).
Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95% CI 0.65 to 0.86), but not risk of falling.
Overall, vitamin D did not reduce falls ( RaR 0.95, 95% CI 0.80 to 1.14; RR 0.96, 95% CI 0.92 to 1.01), but may do so in people with lower vitamin D levels.
Overall, home safety interventions did not reduce falls ( RaR 0.90, 95% CI 0.79 to 1.03); RR 0.89, 95% CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti- slip shoe device reduced rate of falls in icy conditions ( RaR 0.42, 95% CI 0.22 to 0.78).
Gradual withdrawal of psychotropic medication reduced rate of falls ( RaR 0.34, 95% CI 0.16 to 0.73), 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).
Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity ( RaR 0.42, 95% CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls ( RaR 0.66, 95% CI 0.45 to 0.95).
There is some evidence that falls prevention strategies can be cost saving.
Authors' conclusions
Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

Interventions for preventing falls in older people living in the community (Review)

The following article is a summary of the American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons (2010). This article provides additional discussion of the guideline process and the differences between the current guideline and the 2001 version and includes the guidelines' recommendations, algorithm, and acknowledgments. The complete guideline is published on the American Geriatrics Society's Web site ( http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/).

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Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons

Risk factors for falls among older adults: a review of the literature.

Background/aim: A third of elderly people fall each year Poor vision is associated with increased risk of falls The authors aimed to determine if first eye cataract surgery reduces the risk of falling, and to measure associated health gain

Methods: 306 women aged over 70, with cataract, were randomised to expedited (approximately 4 weeks) or routine (12 months wait) surgery Falls were ascertained by diary, with follow up every 3 months Health status was measured after 6 months

Results: Visual function improved in the operated group (corrected binocular acuity improved by 025 logMAR units; 8% had acuity worse than 6/12 compared with 37% of controls) Over 12 months of follow up, 76 (49%) operated participants fell at least once, and 28 (18%) fell more than once 69 (45%) unoperated participants fell at least once, 38 (25%) fell more than once Rate of falling was reduced by 34% in the operated group (rate ratio 066, 95% confidence interval 045 to 096, p = 003) Activity, anxiety, depression, confidence, visual disability, and handicap all improved in the operated group compared with the control group Four participants in the operated group had fractures (3%), compared with 12 (8%) in the control group (p = 004)

Conclusion: First eye cataract surgery reduces the rate of falling, and risk of fractures and improves visual function and general health status

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Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial

Objective first eye cataract surgery reduces the risk of falling. Most cataracts in elderly people are bilateral. Some binocular functions (e.g. stereopsis) are associated with falls. We aimed to determine if second eye cataract surgery reduces the risk of falling and to measure associated health gain. Study design and setting we randomised 239 women over 70, who had been referred to a hospital ophthalmology department, with one unoperated cataract, to expedited (approximately 4 weeks) or routine (12 months wait) surgery. Falls were ascertained by diary, with follow-up every 3 months for 12 months. We measured health status after 6 months. Results visual function (especially stereopsis) improved in the operated group. Over 12 months follow-up, 48 (40%) operated participants fell at least once, 22 (18%) fell more than once. Forty-one (34%) unoperated participants fell at least once, 22 (18%) fell more than once. Rate of falling was reduced by 32% in the operated group, but this was not statistically significant (rate ratio 0.68, 95% CI 0.39, 1.19, P = 0.18). Confidence, visual disability and handicap all improved in the operated compared with the control group. Conclusion second eye cataract surgery improves visual disability and general health status. The effect on rate of falling remains uncertain.

Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial

Aim: To evaluate the cost-effectiveness of first eye cataract surgery compared with no surgery from a health service and personal social services perspective. Methods: An economic evaluation undertaken alongside a randomised controlled trial of first eye cataract surgery in secondary care ophthalmology clinics. A sample of 306 women over 70 years old with bilateral cataracts was randomised to cataract surgery (expedited, approximately four weeks) or control (routine, 12 months wait); 75% of participants had baseline acuity of 6/12 or better. Outcomes included falls and the EuroQol EQ-5D. Results: The operated group cost a mean £2004 (bootstrapped) more than the control group over one year (95% confidence interval (CI), £1363 to £2833) (p Conclusions: First eye cataract surgery, while cost-ineffective over the trial period, was probably cost-effective over the participants’ remaining lifetime.

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Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial

The aim of this study was to evaluate the cost-effectiveness of second-eye cataract surgery for older women with minimal visual dysfunction in the eye to be operated on from a Health and Personal Social Services perspective, compared to waiting list controls who had already undergone first-eye cataract surgery. A cost-utility analysis was undertaken alongside a randomized controlled trial of second-eye cataract surgery in secondary care ophthalmology clinics. A total of 239 women over 70 years old with one unoperated cataract were randomized to cataract surgery (expedited, approximately 4 weeks) or control (routine surgery, 12 months wait). Outcomes were measured in terms of quality-adjusted life years (QALYs), with health-related quality of life estimated using the EuroQol EQ-5D. The operated group had costs which were, on average, £646 more than the control group (95% confidence interval, £16–1276, P<0.04) and had a mean QALY gain of 0.015 (95% confidence interval, −0.039 to 0.068, P=0.59) per patient over 1 year. Therefore, the incremental cost-utility ratio was £44 263 over the 1-year trial period. In an analysis modelling costs and benefits over patients’ expected lifetime, the incremental cost per QALY was £17 299, under conservative assumptions. Second-eye cataract surgery is not likely to be cost-effective in the short term for those with mild visual dysfunction pre-operation. In the long term, second-eye cataract surgery appears to be cost-effective unless carer costs are included.

Francis Osborn

Papers

Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial

Falls and health status in elderly women following second eye cataract surgery: a randomised controlled trial

Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial

Second-eye cataract surgery in elderly women: a cost-utility analysis conducted alongside a randomized controlled trial