JAMA CLINICAL EVIDENCE SYNOPSIS

CLINICIAN’S CORNER

Fall Prevention in Community-Dwelling
Older Adults
Clinical Question Which types of interventions reduce falls in older people living in the community?
Bottom Line Fall-prevention exercise programs, usually including muscle strengthening and balance retraining, were associated with lower fall rates in community-dwelling older people whether
or not individuals were selected on the basis of fall risk. Home safety interventions, vitamin D supplementation in people with lower vitamin D levels, and individually targeted multifactorial interventions were associated with fewer falls in community-dwelling people with risk factors for falling.

M. Clare Robertson, PhD
Lesley D. Gillespie, MMScA

PPROXIMATELY 30% OF OLDER

community-dwelling people
fall each year. Falls can result in adverse outcomes including hip fracture, fear of future falls,and nursing home admission.1,2 This
JAMA Clinical Evidence Synopsis summarizes a recent Cochrane systematic
review of 159 randomized controlled
trials testing interventions to reduce theincidence of falls in communitydwelling older people.3
SUMMARY OF FINDINGS
Pooled results from trials testing similar interventions (classified using theProFaNE taxonomy4) showed a significant reduction in falls from several typesof interventions (FIGURE).
Participants randomized to groupand home-based exercise programs withmultiple components including muscle
strengthening and balance retraining
had fewer falls than control groups (rateratio, 0.71 [95% CI, 0.63-0.82] and rate
ratio, 0.68 [95% CI, 0.58-0.80], respecAuthor Affiliations: Department of Medicine, Dunedin School of Medicine, Dunedin, New Zealand.
Corresponding Author: Lesley D. Gillespie, MMSc, Department of Medicine, Dunedin School of Medicine,
PO Box 913, Dunedin 9054, New Zealand (lesley.gillespie@otago.ac.nz).
JAMA Clinical Evidence Synopsis Section Editor: Mary
McGrae McDermott, MD, Contributing Editor. We encourage authors to submit papers for consideration
as a JAMA Clinical Evidence Synopsis. Please contact
Dr McDermott at mdm608@northwestern.edu.
1406

JAMA, April 3, 2013—Vol 309, No. 13

tively). Tai Chi classes were associated with a lower rate of falling. Pooleddata from 6 studies demonstrated thatan exercise program was associated witha lower risk of a fall-related fracture.
Individually targeted multifactorial interventions were associated with reduced fall rates (rate ratio, 0.76 [95% CI,0.67-0.86]). Multifactorial interventions are complex, usually require a multidisciplinary team, and include various types of assessments, treatment
combinations, and referral processes.
Overall, vitamin D supplementation was not associated with lower fall
rates in older community-dwelling

Figure. Rate Ratios (All Falls) for Selected Fall-Prevention Interventions vs Control in
Community-Dwelling Older People aHeterogeneity dNo. ofTrials cIntervention b
Exercise programs(multiple-component)Group classes
16
Home-based programs
7
Tai Chi classes
5
Multifactorial interventions
19Vitamin D supplementation
7
Selected for lower levels of2
serum vitamin D
Not selected for lower levels 5
Home safety assessment and6
modification
Higher risk of falling3
Not selected on fall risk
3
Cardiac pacing e
3

No. ofParticipants

Pooled Rate
Ratio (95% CI)

3622
951
1563
9503
9324
260

FavorsIntervention

FavorsControlI 2, %P Value

0.71 (0.63-0.82)
0.68 (0.58-0.80)
0.72 (0.52-1.00)
0.76 (0.67-0.86)
1.00 (0.90-1.11)
0.57 (0.37-0.89)

48
072
85
69
0.02.97.006<.001.003.799064
4208

1.02 (0.93-1.13)
0.81 (0.68-0.97)

70
64.009.02

851
3357
349

0.62 (0.50-0.77)
0.94 (0.84-1.05)
0.73 (0.57-0.93)

0051.54.44.13

0.3

1.0

2.0

Pooled Rate Ratio (95% CI)
a Based on data from Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls inolder people living in the community. Cochrane Database Sys Rev. 2012;(9):CD007146. doi:10.1002/14651858.CD007146.pub3. Absolute numbers for analyses are not provided because the absolute numberof falls in each group was not always available. For these analyses, the “absolute number” was a rate of falls,eg, falls per person-year, or in some cases a reported rate ratio.
b Control groups received no intervention, usual care, or an intervention that was not expected to reduce falls,eg, social visits.
c The number of trials does not add to 159 because not all of the trials evaluated in the Cochrane review aresummarized here.
d Variation across the results from individual studies due to clinical and/or statistical diversity. A P value ⬍.10
represents a statistically significant variation. I2 measures the variation in results between studies that is due toheterogeneity rather than sampling error (chance) (range, 0%-100%).
e For people with carotid sinus hypersensitivity and history of syncope and/or falls.

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JAMA CLINICAL EVIDENCE SYNOPSIS

Evidence Profile
No. of randomized trials: 159
Study years: 1990-2011
No. of participants: 79 193
Men: 23 758 (30%) Women: 55 435(70%)
Race/ethnicity: Unavailable
Age, mean (range): 75 (51-101) years
Setting: Community
Countries: Australia, Austria, Belgium, Brazil, Canada, Chile, China,Denmark, Finland, France, Germany,Italy, Japan, the Netherlands, New Zealand, Norway, Sweden, Switzerland, Taiwan, Thailand, United Kingdom, UnitedStatesComparison: Intervention to prevent
falls vs control group
Primary outcomes: Rate of falls; number of fallers
Secondary outcomes: No. of participants sustaining fall-related fractures

people (rate ratio, 1.00 [95% CI, 0.901.11]). However, 2 trials demonstrated that vitamin D supplements
were associated with lower fall rates inpeople with lower vitamin D levels.
Home safety interventions were associated with a reduced rate of falls (rateratio, 0.81 [95% CI, 0.68-0.97]). These
interventions were more effective in
people at higher risk of falling and when
delivered by an occupational therapist.
Cardiac pacing in people with carotid sinus hypersensitivity and a history of syncope and/or falls was associated with lower fall rates.
Expedited cataract surgery was associated with a lower fall rate compared with remaining on a waiting list
for 12 months (rate ratio, 0.66 [95% CI,0.45-0.95]; 1 trial, 306 participants).
However, an intervention that combined assessment by an optometrist
with provision of new eyeglasses, ahome visit with an occupational thera-pist, glaucoma management, or cataract surgery if indicated was associated with an increase in fall rates (rateratio, 1.57 [95% CI, 1.19-2.06]).
Gradual withdrawal of psychotropic
medications (rate ratio, 0.34 [95% CI,0.16-0.73]; 1 trial, 93 participants) andan educational program for primary care
physicians and their patients to improve medication prescribing practices(risk ratio, 0.61 [95% CI, 0.41-0.91]; 1
trial, 659 participants) were associatedwith a lower rate of falls and risk of falling, respectively.
One study showed a lower rate of falls
in people with disabling foot pain whoreceived customized orthotics, footwear
review, foot and ankle exercises, and fall
prevention education in addition to usual
podiatry care (rate ratio, 0.64 [95% CI,0.45-0.91]; 305 participants).
There is no evidence of benefit for cognitive behavioral interventions. Evidence for interventions that provide educational materials alone is inconclusive.
COMMENT
Fall-prevention exercise programs,
home safety interventions, vitamin D
supplementation in people with lower
vitamin D levels, and individually targeted multifactorial interventions wereassociated with lower fall rates in community-dwelling people.
Limitations

Results reported here may not apply topeople with dementia because they werespecifically excluded from the majority of studies. We excluded trials recruiting individuals after stroke andtrials of those with Parkinson disease.
Some pooled results show statisticallysignificant heterogeneity between included studies (Figure). Pooled datafrom studies with significant heterogeneity require cautious interpretation because it indicates the possibility of
meaningful differences between thesestudies.

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Comparison of Findings
With Current Practice GuidelinesOur findings agree with the recommendations on exercise in the recent US Preventive Services Task Force guidelines, 5 but the updated American
Geriatrics Society/British Geriatrics Society guideline only recommends a multifactorial approach to fall prevention. 6 Our review included trials
published since both of these guidelines were developed.
Areas in Need of Future Study

Additional studies are needed to address methods to increase implementation of effective interventions byhealth care professionals.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosureof Potential Conflicts of Interest and none werereported.
Funding/Support: The 2012 update of this review wasfunded by a Cochrane Incentive Award from the National Institute for Health Research, United Kingdom.
Additional Contributions: We are grateful to our Cochrane Review coauthors William Gillespie, Cathie Sherrington, Simon Gates, Lindy Clemson, and Sarah Lamb.
We also thank Helen Handoll and Lindsey Elstub fromthe Cochrane Bone, Joint and Muscle Trauma Group.
REFERENCES
1. Campbell AJ, Borrie MJ, Spears GF, Jackson SL,Brown JS, Fitzgerald JL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study.
Age Ageing. 1990;19(2):136-141.
2. Tinetti ME, Williams CS. Falls, injuries due to falls,
and the risk of admission to a nursing home. N Engl J
Med. 1997;337(18):1279-1284.
3. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people livingin the community. Cochrane Database Sys Rev. 2012;
9:CD007146. doi:10.1002/14651858.CD007146.pub3.
4. Lamb SE, Becker C, Gillespie LD, et al; Taxonomy
Investigators. Reporting of complex interventions inclinical trials: development of a taxonomy to classify
and describe fall-prevention interventions. Trials. 2011;12:125.
5. Moyer VA; US Preventive Services Task Force. Prevention of falls in community-dwelling older adults:
US Preventive Services Task Force recommendation
statement. Ann Intern Med. 2012;157(3):197204.
6. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society.
Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline forprevention of falls in older persons. J Am Geriatr Soc.
2011;59(1):148-157.

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