In older people, falls are the most prominent external cause of unintentional injury. Research suggests that one third of community-dwelling people aged over 65 years fall each year and almost half of them experience recurrent falls (1)(2)(3)(4)(5)(6)(7)(8)(9)(10). Incidents of falls by older people are strongly associated with hospitalization, severe functional decline, care dependency and premature admission to institutional care (11). Nearly 15% of falls result in non-fatal injuries (12), ranging from minor bruises and wrist lacerations to hip fractures (4,5,13). More importantly, 23-40% of injury-related deaths in older people are attributable to falls (9,14).
The risk factors for falls are complex and multifactorial in nature. Evidence from longitudinal studies suggests strong interactions among multiple risk factors, such as age, sex, previous history of falls, chronic diseases and environmental factors (4,10,14). Medical conditions that increase the risk of falls include: orthostatic hypotension (6,8,10,15), musculoskeletal disease (3,5,16), visual impairment (7,17,18), low systolic blood pressure, stroke, cognitive impairments, Parkinson's disease, gait disorders, balance disorders and sensory impairments (3,4,7,10,14). Medications in general, and polypharmacy in particular, increase the risk of falls in older people (19).
In recent years, there has been an increasing level of research and policy interest in the public health impact of falls. The effectiveness of single and complex programmes for the prevention of falls and fall-related injuries was extensively tested among older people at risk of falls (20). Most intervention studies were carried out in community settings; a few were undertaken in hospitals and residential care settings (13). In this document, the evidence for fall-prevention interventions undertaken for community-dwelling older people at risk of falls has been summarized to inform the recommendations provided in the full ICOPE guidelines available at who.int/ageing/publications/guidelines-icope.

# Search strategy
The search for systematic reviews was conducted on 10 October 2015 in Ovid MEDLINE, Embase and the Cochrane Library using comprehensive search terms (Annex 1). Details of the number studies retrieved and included are presented in Annex 2.

# List of systematic reviews identified by the search process

# MODERATE CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as allocation concealment and procedure for masking outcome assessor was unclear in two included trials. Further, information of incomplete data for falls outcome was not clearly described in one of the included trial. b Risk of bias: Downgraded once as allocation concealment was unclear for one of the included trials and information on incomplete data was not clearly described in the other two trials.
GRADE  b Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau2 = 0.08; Chi2 = 104.40, df = 16 ; I2 = 85%). No subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as method of allocation concealment and procedure for masking outcome assessor were unclear in one of the trials. Randomization method was unclear in the other trial. d Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau2 = 0.36; Chi2 = 7.54, df = 1 ;
I2 = 87%). No subgroup analysis was performed and we were not able to explain the heterogeneity.

# LOW CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as allocation concealment was unclear in nine included trials and procedure for masking outcome assessor was unclear in five trials. b Inconsistency: Downgraded once as substantial heterogeneity was observed in the meta-analysis (Tau2 = 0.08; Chi2 = 97.46, df = 10 ; I2 = 90%). No subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as method of allocation concealment was unclear in six included trials and procedure for masking outcome assessor was unclear in five trials. d Inconsistency: Downgraded once as moderate heterogeneity was observed in the analysis (Tau2 = 0.03; Chi2 = 18.02, df = 8 ; I2 = 56%). No subgroup analysis was performed and we were not able to explain the heterogeneity.
ICOPE guidelines -World Health Organization GRADE. No subgroup analysis was performed and we were not able to explain the heterogeneity. c Risk of bias: Downgraded once as allocation concealment was unclear in four included trials. d Risk of bias: Downgraded once as procedure for masking outcome assessor and management of incomplete data was unclear in the trial. e Imprecision: Downgraded once as sample size was small (less than 200). f Risk of bias: Downgraded once as allocation concealment was unclear in four trials. g Inconsistency: Downgraded once as moderate heterogeneity was observed in the meta-analysis (Tau2 = 0.10; Chi2 = 14.38, df = 4 ; I2 = 72%). No subgroup analysis was performed and we were not able to explain the heterogeneity. h Risk of bias: Downgraded once as allocation concealment method was unclear in all included trials. i Risk of bias: Downgraded once as allocation concealment method and procedure for masking of outcome assessor were unclear in the trial. j Risk of bias: Downgraded once as method of allocation concealment, masking of outcome assessor, and management of incomplete data were unclear in the trial. k Imprecision: Downgraded once as sample size was small (n=222).

# GRADE table 8: Group exercise intervention versus control in older people living in the community: subgroup analysis by risk of falling at baseline

# MODERATE CRITICAL
RR: rate ratio a Risk of bias: Downgraded once as method of random allocation was unclear in five included trials and allocation concealment was unclear in seven trials. B Risk of bias: Downgraded once as allocation concealment was unclear in six included trials and procedure for masking outcome assessor was unclear in four trials.

# GRADE table 9: Group t'ai chi exercise versus control in older people living in the community: subgroup analysis by risk of falling at baseline
WHO systematic review team Date:
November 2015 Question:
What is the effectiveness of group t'ai chi exercise versus control (subgroup analysis by risk of falling at baseline) for preventing falls in older people living in the community? Setting:

# ICOPE guidelines -World Health Organization
Group exercise (multiple categories of exercise vs control): subgroup analysis (not selected for higher risk of falling) GRADE table 8, Gillespie et al. (6) Rate ratio: 0.72 (0.58 to 0.9) Favours experiment Quality of evidence: MODERATE Group exercise: t'ai chi vs control: subgroup analysis (selected for higher risk of falling) GRADE table 9, Gillespie et al. (6) Rate ratio: 0.95 (0.62 to 1.46) Quality of evidence: LOW Group exercise: t'ai chi vs control: subgroup analysis (not selected for higher risk of falling) GRADE table 9, Gillespie et al. (6) Rate ratio: 0.59 (0.45 to 0.76) Favours experiment Quality of evidence: MODERATE

# Evidence-to-recommendations table Problem Explanation
Is the problem a priority?
No Uncertain  Falls are the leading cause of injury in older people aged 65 years and over. Between 30% and 40% of community-dwelling adults aged 65 years or older fall at least once per year. Therefore, prevention of falls in older people at risk of falling is important.

# Benefits and harms Explanation
Do the desirable effects outweigh the undesirable effects? There is limited moderate-quality evidence that t'ai chi training may reduce the risk of falls in older people. However, the benefit of t'ai chi exercise (in terms of reduction in the rate of falls) was experienced by the subgroup who were not selected for a higher risk of falling, while there was no effect in the group selected for a higher risk of falling. Thus, t'ai chi training seems to be more effective in people who are not at high risk of falling. There is very limited low-quality evidence suggesting that medication reviews and modification or withdrawal of medication reduce the risk of falls in older people. The results of one trial showed that withdrawal of psychotropic medication was effective in reducing the rate of falls (Rate ratio: 0.34, 95% CI: 0.16 to 0.73). In another study, an educational programme for general practitioners on medical review and treatment modification was found to be ineffective in reducing rate of falls.
Yes No Uncertain

# Values and preferences/ acceptability Explanation
Is there important uncertainty or variability about how much people value the options?

# Major variability

# Minor variability
Fall is an important clinical outcome, which is also considered to be important by older people themselves and their family members and caregivers.
Is the option acceptable to key stakeholders?

# Major variability
The guideline development group strongly believes that recommendations for fall prevention will be valued by health care providers and acceptable to stakeholders (older people and those closet to them).
(continued next page)
Fall-preventions interventions are resource intensive. However, health benefits gained from the recommendation are likely to outweigh the burden of resources required for implementation. Intervention costs can be reduced through task shifting, engaging family members, and administering the intervention in groups.
Is the option feasible to implement?
No Uncertain  Multifactorial interventions may be difficult to implement as they may require the involvement of multiple service providers. In some countries, delivering exercise in groups might be difficult. However, exercise delivered at home to individuals might be an alternative.
Some trials (those on exercise and home safety) have utilized non-specialized health care professionals to deliver fall-prevention interventions. Drawing on this experience, the guideline development group believes that it would be feasible to implement their recommendations in both high-and low-resource health care settings.

# Equity Explanation
Would the option improve equity in health?
The guideline development group strongly believes that all recommendations for prevention of falls will increase equity in health.
- Effective primary health care interventions for falls use various approaches to identify people at increased risk. - No evidence-based instrument to accurately identify older adults who are at increased risk for falling exists. - The majority of trials were conducted in high-income countries. Further research in low-and middle-income countries is needed to understand the feasibility of implementing fall-prevention interventions in low-resource health care settings. - There is a pressing need to standardize assessments of the risk of falls to identify high-risk older people. Currently, the history of falls is the most common factor used in the majority of trials; a small proportion of trials used additional risk factors to select patients. - Vision care for older people at risk of falls should not be restricted to cataract surgery.
- Due to their high heterogeneity, multifactorial interventions were rated as low quality. This is largely due to differences in the intervention components included and the risk factors targeted for reducing falls. Future research should unpack multifactorial interventions and report treatment effect by subgroup of intervention components.