FALLS PREVENTION AMONG
OLDER ADULTS
LIVING IN THE COMMUNITY
HPB-MOH Clinical Practice Guidelines
1/2015

Academy of Medicine,Singapore

Chapter of Geriatricians,
College of PhysiciansCollege of Family Physicians,
Singapore

Ministry of Health,Singapore

Gerontological Society Singapore

Osteoporosis Society Singapore

Pharmaceutical Society of Singapore

Singapore Association of
Occupational Therapists

Singapore Nurses Association

Singapore Optometric Association

Singapore Physiotheraphy Association

may 2015

Levels of evidence and grades of recommendation
Levels of evidence
LevelsType of Evidence

1+ +High quality meta-analyses, systematic reviews of randomised controlled trials(RCTs), or RCTs with a very low risk of bias.

1+

Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with alow risk of bias.

1-

Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias.

2++High quality systematic reviews of case control or cohort studies. High quality
case control or cohort studies with a very low risk of confounding or bias anda high probability that the relationship is causal.

2+

Well conducted case control or cohort studies with a low risk of confoundingor bias and a moderate probability that the relationship is causal.

2-

Case control or cohort studies with a high risk of confounding or bias and asignificant risk that the relationship is not causal.

3

Non-analytic studies, e.g. case reports, case series

4

Expert opinion

Grades of recommendation
LevelsType of EvidenceA

At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++
and directly applicable to the target population; orA body of evidence consisting principally of studies rated as 1+, directly
applicable to the target population, and demonstrating overall consistencyof results.

B

A body of evidence including studies rated as 2++, directly applicable to thetarget population, and demonstrating overall consistency of results; orExtrapolated evidence from studies rated as 1++ or 1+

C

A body of evidence including studies rated as 2+, directly applicable to thetarget population and demonstrating overall consistency of results; orExtrapolated evidence from studies rated as 2++

D

Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

GPP
(good
practicepoints)Recommended best practice based on the clinical experience of theguideline development group.

CLINICAL PRACTICE GUIDELINESFALLS PREVENTION AMONG
OLDER ADULTS
LIVING IN THE COMMUNITY

HPB-MOH Clinical Practice Guidelines 1/2015

Published by Health Promotion Board, Singapore
3 Second Hospital Avenue
Singapore 168937
Copyright © 2015 by Health Promotion Board, Singapore
ISBN 978-981-09-4628-9
Available on the
Health Promotion Board website: http://www.hpb.gov.sg/cpg-falls-prevention
And Ministry of Health website: http://www.moh.gov.sg/cpg

Statement of Intent
These guidelines are not intended to serve as a standard of medical care. Standards of
medical care are determined on the basis of all clinical data available for an individual
case and are subject to change as scientific knowledge advances and patterns of care evolve.
The contents of this publication are guidelines to clinical practice, based on the best
available evidence at the time of development. Adherence to these guidelines may
not ensure a successful outcome in every case. These guidelines should neither beconstrued as including all proper methods of care, nor exclude other acceptable methodsof care. Each physician is ultimately responsible for the management of his/her uniquepatient, in the light of the clinical data presented by the patient and the diagnostic andtreatment options available.

CONTENT PAGECONTENTS
Executive Summary of Key Guideline Recommendations

PAGE
01

1. Introduction

04

2. Screening for falls09

3. Falls Prevention Intervention

13

4. Cost-effectiveness of Falls Prevention

20

5. Clinical Quality Improvement

22

Annexesa. Annex A: Algorithm for Assessing Fall Risk in Older Adults
Living in the Community

23

References24

Self-assessment (MCQs)

36

Workgroup Members

39

Acknowledgement

43

List of Endorsing Agencies

44Foreword
Falls and injuries related to falls are common among older adults.
Globally, one in three adults above 65 years old falls once a year. Falls
are not only associated with greater morbidity and mortality in theolder population, but are also linked to reduced overall functioning andwith early admission to long-term facilities. Reducing falls risk in older
adults is therefore an important public health objective.
In Singapore, falls are a leading cause of injury among older adults.
According to the National Registry of Diseases Office (NRDO) of
Singapore, the crude incidence rate of unintentional falls in year 2012
was 277.7 per 100,000 for adults aged 60 years and older. The incidence
rate increases sharply with age. Many of these falls happen at home.
Therefore, steps must be taken so that factors which cause a person tofall are reduced or removed.
This Clinical Practice Guidelines on Falls Prevention among Older Adults
Living in the Community incorporates the best available evidence fromthe scientific literature and provides practical recommendations relevantto the local context with the aim to assist all healthcare professionals
in the identification and prevention of falls in older adults in thecommunity to help improve quality of life.
ASSOCIATE PROFESSOR BENJAMIN ONG
DIRECTOR OF MEDICAL SERVICESMINISTRY OF HEALTH

Foreword
With an ageing population, there will be more episodes of older adults
falling either in the community or the hospital. While a proportion ofthese falls will be of minor consequence to the older adults e.g. a bruise,some falls, however, will incapacitate the older adults and reduce theirfunctional independence as they go about their daily living. Many of
the falls are also preventable and the situation where these falls occur
predictable based on analysis of falls worldwide. We need to translate
this understanding on falls into an integrated clinical and public healthapproach to prevent falls among our older Singaporeans.
The development of Clinical Practice Guidelines (CPG) is a key strategy
introduced to build the capacity of health professionals to guide theirpractice. This first CPG on Falls Prevention in the community provides
a step-by-step approach to health professionals to identify older adults
who are at risk of falls and to deliver evidence-based recommendations
on falls prevention. This guideline was produced with the health care
workers in mind, including geriatricians, psychologists, pharmacists,
occupational therapists, physiotherapists and nurses.
I would like to take this opportunity to thank the panel of health experts
drawn from different specialties who have selflessly contributed theirexpertise and time to the development of these Guidelines. We hope thatthe guidelines will prove useful for all in their daily practice.
MR ZEE YOONG KANG

CEO, HEALTH PROMOTION BOARD

Executive Summary of Key Guideline Recommendations
Details of recommendations can be found in the main text at the pages
indicated.

Falls Risk Assessment
GPP All older adults (65 years old and older) during a healthcare encountershould be asked for history of falls, and gait and balance problems. (pg 10)
GPP
D Older adults who have fallen more than once in 6 months or with gait andbalance deficits should be offered a comprehensive falls assessment. (pg 10)
Grade D, Level 3

Single Interventions

Exercise interventions
A Exercise programmes for falls prevention should consist of at least a twice-

weekly programme for more than 25 weeks, with each session lasting for 60
minutes.1, 2 (pg 13)
Grade A, Level 1+

A Exercise intensity can be pegged at a moderate level. These exercises should
be progressive and individualised to maximise the effectiveness of the
programme. (pg 14)
Grade A, Level 1+
A Exercises should consist of a mix of balance and coordination training, lower

limb strengthening (such as strengthening exercise for hip muscles, knee extensors
and ankle plantar flexors), endurance and flexibility training. (pg 14)
Grade A, Level 1+

Home modification
B Older adults assessed to have a high risk of falls, history of falls or thosewith visual impairment should be referred to occupational therapists for homeassessment and modification intervention. (pg 15)
Grade B, Level 1+1Footwear
D Older adults should be advised to wear well-fitting shoes with low heeled,slip resistant soles and a large contact area to reduce falls. (pg 15)
Grade D, Level 4
Medication review and modification
B Medication review and modification to optimise medication use should be
provided by the primary care physician in collaboration with a pharmacist (ifavailable), clinical specialist (s) (in cases where specific medications are prescribedby them), the individual older adult and his/her primary caregiver whereapplicable, for older adults who are taking medications that can increase theirrisk for falls. This can be performed either as a single intervention or part of amulti-factorial intervention. (pg 16)
Grade B, Level 1+
B Psychotropic medications (benzodiazepines and antipsychotics) should be
discontinued in older adults (if possible) to prevent falls. This should be donewith appropriate tapering of dose, close monitoring of outcomes and input fromclinical specialists if necessary. (pg 16)
Grade B, Level 1+
Vitamin D supplementation
D It may be helpful to give vitamin D supplementation to older adults if theirvitamin D level is less than 20 ng per millilitre (50 nmol per litre), if higher
levels cannot be achieved via sunlight or dietary supplementation.3 Older adults
with significant renal impairment will benefit from treatment with analogues ofvitamin D (alfacalcidol or calcitriol). (pg 17)
Grade D, Level 4
B Avoid the use of high dose cholecalciferol (500,000 IU per year).4 (pg 17)

Grade B, Level 1+

Improving vision
GPP Older adults who have impaired vision should be referred for further
evaluation of the cause of impairment. (pg 18)
GPP
2

B Persons with cataract as the main cause of vision impairment should bereferred for cataract surgery (especially for first eye). (pg 18)
Grade B, Level 1+
Cardiac pacemaker insertion
B Older adults with suspected cardiogenic falls should be referred to thecardiologist for further evaluation. Cardiac pacing is recommended for patientswith cardioinhibitory carotid sinus hypersensitivity and a history of falls.
(pg 18)Grade B, Level 1+
Education interventions
GPP Provide basic information on falls and educate older adults on the benefitsof falls prevention strategies in preventing falls and maintaining independence.
(pg 19)GPP

Multiple Interventions
B Older adults at risk of falls should be considered for referral to falls
prevention programmes consisting of exercise and other interventions, if suchprogrammes are available and accessible. (pg 19)
Grade B, Level 1+

Multi-factorial Interventions
B Older adults assessed to be at high risk of falls should receive interventions
targeted at the individually identified risk factors. (pg 19)
Grade B, Level 1+3

1. Introduction
The Health Promotion Board (HPB) has developed the Clinical Practice
Guidelines on Falls Prevention among Older Adults Living in theCommunity to provide health professionals in Singapore with evidence-based
assessments and interventions for falls prevention.

1.1 Objectives of guidelines
The aim of these guidelines is to assist health professionals to identify
and assess falls risk status of older adults living in the community and todeliver evidence-based interventions for falls prevention.

1.2 Target users
The guidelines are intended for all health professionals, including doctors,
psychologists, pharmacists, dieticians, optometrists, social workers,
occupational therapists, physiotherapists and nurses, to assist them in theassessment and prevention of falls in older adults.

1.3 Epidemiology
1.3.1 Definition of Falls
This set of clinical practice guidelines has adopted a broader definitionin order to be more sensitive in identifying falls in older adults, and has
defined a fall as “a sudden, unintentional change in position causing an
individual to land at a lower level (either on an object or on the floor)
other than as a consequence of overwhelming external force.”4

1.3.2 Incidence of falls
According to the National Registry of Diseases Office (NRDO)5 of
Singapore, the crude incidence rate of unintentional falls in year 2012
was 277.7 per 100,000 for adults aged 60 years or older. The
incidence rate increases sharply with age (Figure 1). The majority of falls(63%) occur at home.
Figure 1: Crude Rate of Unintentional Falls*

Source: National Registry Disease Office, Singapore. 2014.

58% (1,448) of unintended falls occurred among adults aged 65 years
or older according to the National Trauma Registry Report,6 in year 2012.
A local retrospective study conducted by Chan and colleagues(1997)7 found a one-year falls incidence rate of 17.2 per 100 in adults
aged 60 years and above living in the community (n=332). Of those
who fell, two-thirds (67%) had a single fall and one-third (33%) hadrecurrent falls in the past one year.
In summary, fall risk is relatively high. Asian studies, including local
ones, suggest that at least 20% of older adults (65 years and above)
would fall in a year.

* Unintentional falls includes all falls except those above 65 years old with fractured neck of femur.

5Falls in Asians compared to other ethnic groups
There is some data from Western countries that there are ethnic differences
to fall injury rates, with higher rates in whites compared to people of
Asian ethnicity.8 It is believed that the prevalence of osteoporosis (which
is higher in white populations than in Asian populations) may explainsome of these differences.
1.3.3 Risk factors
Key factors that have been identified include:a) Socio-demographic factors
Age is the main risk factor, with older adults at higher risk. There appear
also to be ethnic and gender differences. Asians in general have lower risk
compared to other ethnic groups, while females appear to be at higher
risk. Living alone and being single or widowed are also associated withhigher fall risk.
b) Past medical history
A past history of a fall is a significant predictor of future fall risk.
Neuromuscular conditions resulting in mobility impairment, gait
deficit and balance deficit such as vertigo/giddiness, arthritis, Parkinson’s
disease and strokes can predispose older adults to falls. Sensory
impairment including visual impairment and hearing loss also increases
risk of falls, as do cognitive impairment and dementia. Polypharmacy
and the use of certain medications have been associated with anincrease in the risk of falls. Drugs that have been implicated includeanti-hypertensives, hypnotics, tranquilisers/sedatives, anti-depressantsand anti-arrhythmics.
c) Extrinsic factors
The living environment also poses risks. These include use of
inappropriate footwear, inappropriate eyewear and environmental andhome hazards. Personal factors and extrinsic factors can also interact toincrease risks; and the level of risk of an environment may depend on
the person. For example, an older adult with neuromuscular conditions
and poor vision may have a higher risk of falls than an older adultwithout these intrinsic conditions living in the same housing
environment. It is therefore important when assessing home andenvironmental hazards to consider the personal risk factors of the person
who is living in the home or environment.
6

Table 1: Common risk factors for falls
Intrinsic risk factors• Age 7, 9, 10

Extrinsic risk factors• Use of 4 or more prescribeddrugs7, 11, 12• Female 7, 9, 10• Living alone10• Use of hypnotic, anti-depressants ortranquillisers11 (please refer to table
2 for further details and othercommon group of drugs)• Arthritis of knees9-12• Use of walking aid10• Stroke9• Mobility impairment7, 11, 12, 14• Parkinson’s disease9• Balance deficit11, 12, 14• Hypertension7, 10• Gait deficit10, 11, 14• Diabetes13• Inappropriate footwear & footproblems12• Not married, including single andwidowed10• Osteoporosis12• Environmental & homehazards7, 11,12• Chronic conditions10• Urinary incontinence11, 12• Cognitive impairment11, 12, 14• Depressive symptoms10, 11• Poor vision7, 11, 12, 14• Postural hypotension10, 12, 14• Weak hand grip strength• Self-perceived poor health10• Previous history of falls9-12• Fear of falling10, 11

7

Table 2: Common groups of drugs that may increase risk of falls
in older adults
Common group of drugs that increases risk of falls• Anxiolytics/hypnotics (benzodiazepines and others)15-19• Neuroleptics (dopamine D2-receptor agonists and serotonin dopamine
receptor antagonists)15-19• Antidepressants (specifically tricyclic antidepressants and selective serotonin
reuptake inhibitors, but may also include serotonin-norepinephrine reuptake
inhibitors and monoamine oxidase inhibitors)15-19• Antihypertensives (specifically diuretics, but may also include β-adenoceptor
blockers, α-adrenoceptor blockers, centrally acting antihypertensives, calcium
channel blockers, angiotensin converting enzyme inhibitors and angiotensin
receptor blockers)18-20• Antiarrhythmics (type 1a)18, 20• Digoxin14, 16• Analgesics (including opioid and non-steroidal anti-inflammatory
analgesics)15, 18, 19• Antihistamines (especially first-generation with highly sedating andanticholinergic effects)17, 18• Hypoglycaemics (especially long-acting sulfonylureas with prolonged
hypoglycaemic effects)13, 14• Skeletal muscle relaxants (anticholinergic side effects may increase risk
for falls)17• Anticonvulsants17• Nitrates and other vasodilators18• β-adrenoceptor blocking eye drops18• Urinary antispasmodics18• Antivertigo drugs18

8

2. Screening for falls
Studies have shown that risk factors for falls can be used to identify older
adults who are at risk of falling. A history of falls is a strong predictor of
future falls and those who have fallen are likely to have risk factors for falls.
Gait and balance problems may be present in both older adult fallers andnon-fallers and predict future falls in both groups.
While there are studies on screening tools to assess the risk of falling
among the older adults in community settings, no specific studies could befound on the effectiveness of fall risk factor assessment in general practice.
Recommendations on fall risk assessment in the primary care setting were thus
extrapolated from the available evidence.
There is no evidence to support population based screening for falls in the older
adults, in general.

2.1

Risk Factors for Falls
Multiple fall risk factors have been identified as predictors of falls in older
adults living in the community but a few have been shown to beconsistent in two systemic reviews.12 These are fall history, gait andbalance deficit, mobility impairment, visual impairment, urinary
incontinence, cognitive impairment and fear of falling. The risk forfalling increases with the number of risk factors; 8% for those with zerorisk factors, 19% with one risk factor, 32 % for those with two risk factors
and 60% with three risk factors.21

2.2

Identifying the At-risk Group
Case identification using some of the identified fall risk factors has beenused in many guidelines to select cases for further assessment. The
American Geriatrics Society (AGS) screening algorithm begins withenquiring for history of previous falls.22 A history of previous falls has
been shown to be an independent predictor of future falls with asensitivity of 93% and specificity of 21% for predicting single fall.
It is also a predictor for recurrent falls with a sensitivity of 77% andspecificity of 52%.23 The prevalence of fall risk factors is higher in those
who have had previous falls.21
9

Those without a self-reported history of falls have an annual fall incidenceof 27% to 45%.24 Gait and balance problems are common in the older
adults and they are independent predictors of future falls in both previous
fallers and non-fallers.9, 24, 25

GPP All older adults (65 years old and older) during a healthcare
encounter should be asked for history of falls, and gait and balance
problems.								GPPD Older adults who have fallen more than once in 6 months or with gait
and balance deficits should be offered a comprehensive falls assessment.
Grade D, Level 3

2.3 Administering Assessments
The Australian Commission for Safety and Quality in Healthcare(ACSQHC) guidelines12 recommend either general practitioners or other
healthcare professionals to utilise multi-factorial assessment tools.
General practitioners have the most contact with the population at risk.
They are thus well suited to identify older adults living in the community
who are at risk for falls.
However, the rates of detection and documentation of assessment needs
to be improved. In a study of 372 vulnerable older adults using medical
record review and telephone interview, general practitioners appear tounder-detect falls.26 Only 14% (57 of 372 subjects) had documentation of
falls, whereas 28% (68 of 245 subjects) reported falls during the interview.
Postal screening surveys followed by a telephone geriatric assessment by aphysician assistant may be useful for identifying fall events, but do nottranslate into a reduction in recurrent falls.27

2.4 Recommended Falls Risk Assessment
The ACSQHC12 and AGS/BGS guidelines22 recommend a wide range offalls risk factors for assessment, which may not be feasible or practical in a
general practice consultation.22 No strength of recommendation is given inthese guidelines.
10

The NICE guidelines11 report that it is unclear which falls risk assessment
is the most predictive or useful. It suggests that assessment tools are moresuitable for multidisciplinary team assessments.
In a systematic review for the US Preventive Services Taskforce,28
multi-factorial assessment and intervention in the primary care setting
was found to produce a non-significant decrease in fall risk in a pooled
analysis of 19 studies (7,099 subjects). The assessments were
heterogeneous. Most included medication use, visual acuity, homeenvironment, and gait and balance.
In another systematic review on multi-factorial assessment andintervention in emergency care, primary care and community settings,23
there was limited evidence that multi-factorial fall prevention
programmes could effectively reduce the number of fallers or fall
related injuries. The data was insufficient to assess fall andinjury rates. The assessments were also heterogeneous, the mostcommon being gait and balance, drug review and assessment ofhome environment.
In a prospective cohort study of 311 subjects on the risk factors forrecurrent falls,29 the best predictors were depression (using SCL90
scoring), hand grip strength (using a dynamometer), history of falls andpostural sway (originally using force plates). Apart from fall history, these
are not feasible in a general practice setting.
Refer to Annex A for a suggested algorithm for falls risk assessment.

2.5 Falls Risk Assessment Tools
The falls risk assessment tools can be classified as either Functional Mobility
Assessment (FMA) tools or Multi-factorial Assessment (MFA) tools.
For a tool to have a high predictive value it has to demonstrate sensitivity
measures above 80% and specificity above 75%.30
2.5.1 Functional Mobility Assessment (FMA) Tools
FMA tools involve assessment of functional domains of postural stability
that look at strength, balance, gait, and reaction time.
11

These tools can consist of a single measure or a scale comprising multiple
gait and balance assessments with a weighted scoring. Some examples
of commonly used tools during fall screening include the Functional
Reach, Time Up and Go (TUG) test, Single Leg Stand, 5 times chairstand,Berg Balance Scale and the Tinetti Performance Oriented Mobility
Assessment.31-33
In one large prospective study comparing TUG, One Leg Stand, Tinetti
Balance and Functional Reach in older adults living in thecommunity, TUG had the largest area under the receiver
operating characteristic (ROC) curve to predict falling (0.61). A
substantial proportion of the subjects was unable to perform theone leg stand and functional reach implying a floor effect in older adults
with lower function.34
There is a wide variation in physical function amongst older adults livingin the community and this has been shown to affect the discriminative
performance of these tools.35 Three systemic reviews on TUG found thetest to be less discriminative in persons with high or low fall risk, betterin lower functioning populations and better at predicting past falls thanfuture falls.35, 36, 37
Due to the multi-factorial nature of falls no single functional mobility
tool seems able to predict falls accurately. 31
Here we recommend that FMA be used as a functional gait and balance
assessment as part of a more comprehensive assessment rather than as asingle tool for assessing fall risk.
2.5.2 Multi-factorial Assessment (MFA) Tools
MFA tools usually include a few well known risk factors for falls and may
include a functional component. These tools are usually in the form of achecklist and have a weighted scoring system which gives the risk scores.
MFAs are sometimes used to help identify risk factors that are modifiablethrough interventions. An example of an MFA is the Fall Risk Assessment
Tool (FRAT) developed to help health or social care workers identify
older people living in the community who are at risk of falls. The tool consistsof four questions and one performance test; the presence of 3 or more risk
factors had a positive predictive value for a fall in the next 6 months of
0.57 (95 % CI 0.43-0.69) and a specificity of > 80%. 38
12

3. Falls Prevention Interventions
Interventions to prevent falls in older adults living in the community canbe implemented as a single intervention or as a component of multiple ormulti-factorial interventions.

3.1 Single Interventions
Single interventions consist of only one major category of intervention.
3.1.1 Exercise interventions
Exercise is effective as a single modal intervention in preventing falls inolder adults living in the community.1, 2, 39-42 The effectiveness of exercise in
reducing the risk and rate of falls is increased when exercise is combinedwith a multi-factorial fall risk assessment and management programme.39, 41
Exercises consisting of two or more aspects of strength, balance, flexibilityor endurance can help reduce the rate of falls in older adults living in
the community.1, 2, 40 Specifically, exercises which include a balancecomponent (including taiqi) have been shown to be beneficial in
reducing the risk and rate of falls in older adults, especially inthose identified as being at high risk of falls.1, 2 Specific exercises
such as taiqi, and balance and coordination training have also been shownto help in reducing falls rate.43-47
It was noted that older adults with higher compliance (at least 75%)42
with their exercise programme will also have further reduction in therisk of falling.42, 48 These exercises can be achieved via a home-based(individually prescribed) exercise programme and/or via a group-based
programme in a supervised setting.1, 2, 48-50
The recommended exercise structure* for prevention of falls in older
adults living in the community is as follows:

A Exercise programmes for falls prevention should consist of at least a

twice-weekly programme for more than 25 weeks, with each session
lasting for 60 minutes.1, 2
Grade A, Level 1+
13

A Exercise intensity can be pegged at a moderate level. These exercises
should be progressive and individualised to maximise the effectiveness ofthe programme.
Grade A, Level 1+

Note: Moderate intensity exercise is defined as the intensity at which aperson experiences an increase in heart rate where he or she is somewhat
breathless. Measurements that can be used to gauge moderate level
intensity of exercise include:• Heart rate measurement: 70-80% of Maximum Heart Rate (where
HRmax = 220 - current age)
• Rate of self-perceived exertion (RPE): Using RPE at a level where theperson feels that it is ‘somewhat hard to breathe’ or 5-6 on a scale of 10• Talk test: Where a person feels somewhat breathless when exercising
but is still able to talk• Metabolic Equivalent of Task: 3-6 METs

A Exercises should consist of a mix of balance and coordination training,

lower limb strengthening (such as strengthening exercise for hip muscles,
knee extensors and ankle plantar flexors), endurance and flexibility
training.
Grade A, Level 1+* It is noted that there is variance in exercise intervention duration from about 6 weeks to a yearwith a median of about 12 weeks for these studies. However some of these studies might not havemonitored the participants’ compliance with home exercise programmes. Note that the physicalactivity recommendation (for those aged 50 years and above) under http://www.hpb.gov.sg/
HOPPortal/health-article/10368 consists of aerobic activity (150 minutes of moderate intensity),strength training (twice or more per week) and balance training.

143.1.2 Home Modification
Home assessment and modification are effective in reducing the rate offalls in older adults.51-57 In particular, home assessment and modification
are effective in reducing the rate of falls in older adults at high riskof falls,53, 57 with a history of falls,55, 56 and those with visual impairment.51
Home modification interventions have not been shown to be effective
in reducing the rate of falls in older adults in studies where a researchnurse58 or a trained assessor59 conducted the home visit. Home
modification interventions are more effective in reducing the rateof falls when they are delivered by occupational therapists compared
to trained assessors. This may be due to occupational
therapists having an enhanced knowledge of the effects of theenvironment on function and greater adherence to recommendations
made by occupational therapists.57

B Older adults assessed to have a high risk of falls, history of falls or thosewith visual impairment should be referred to occupational therapist forhome assessment and modification intervention.
Grade B, Level 1+
3.1.3 Footwear
There is limited evidence for footwear as an effective single intervention
in reducing falls. There are recommendations to wear low heeled,60-62
slip resistant shoes60, 61 with a large contact area62 but these are inferredfrom studies that have weak methodology and limitations ingeneralisability and applicability.

D Older adults should be advised to wear well-fitting shoes with low

heeled, slip resistant soles and a large contact area to reduce falls.
Grade D, Level 4
3.1.4 Medication review and modification

Interventions involving active review and modification of medications
associated with increased risks of falls may be provided as a single
intervention or part of a multi-factorial intervention.18, 63, 64 Specifically,
interventions provided by physicians in collaboration with pharmacists
in the primary care setting have been shown to reduce the risk of falls
among older adults living in the community.65 The list of medications
associated with falls has been summarised in Table 2.
15

B Medication review and modification to optimise medication use should
be provided by the primary care physician in collaboration with apharmacist (if available), clinical specialist(s) (in cases where specificmedications are prescribed by them), the individual older adult andhis/her primary caregiver where applicable, for older adults who aretaking medications that can increase their risk for falls. This can be
performed either as a single intervention or part of a multi-factorialintervention.
Grade B, Level 1+
A randomised controlled trial of an intervention to actively withdraw
benzodiazepines and antipsychotics reduced the rate of falls amongolder adults living in the community.66 This intervention should be madewith appropriate dose tapering, close monitoring of outcomes andwhen necessary, input from clinical specialists, such as psychiatrists.

B Psychotropic medications (benzodiazepines and antipsychotics) should

be discontinued in older adults (if possible) to prevent falls. This should
be done with appropriate tapering of dose, close monitoring of outcomes
and input from clinical specialists if necessary.
Grade B, Level 1+
3.1.5 Vitamin D supplementation
Vitamin D deficiency is prevalent in Singapore.67 There is generally
suboptimal appreciation by both physicians and patients of theimportance of vitamin D and calcium for maintenance of bone healthas reflected in the low number of patients who reported regularly taking
these supplements.68
Performance speed and proximal muscle strength were markedly
improved when 25-hydroxyvitamin D levels increased from 4 to 16 ng
per millilitre (10 to 40 nmol per litre) and continued to improve as thelevels increased to more than 40 ng per millilitre (100 nmol per litre).69
Vitamin D therapy (200–1000 IU) resulted in fewer falls than calcium therapy
or use of a placebo. The following subgroups had significantly fewer falls:70-72
a. living in the community (aged < 80 years),b. adjunctive calcium supplementation,c. no history of fractures or falls,
d. duration longer than 6 months, cholecalciferol, and dose of 800 IU
or greater.
16

Nursing home residents receiving 800 IU of vitamin D2 per day plus
calcium had a 72% reduction in the risk of falls as compared with theplacebo group.73 Vitamin D supplementation of ≥800 IU daily is favourable
in the prevention of hip fracture and any non-vertebral fracture inpersons 65 years of age or older.74
Vitamin D (ergocalciferol) supplementation of 1200 IU a day decreases
falls and hip fractures in vascular parkinsonism but not in Parkinson’s
disease. Vitamin D (ergocalciferol) supplementation of 1000 IU a day
decreases falls in women after stroke with hemiplegia.75, 76 However,among older women living in the community, annual oral administrationof high-dose cholecalciferol (500,000 IU per year) resulted in an increased
risk of falls and fractures.4
The general approach to supplementation is to give vitamin D3 at
3000 units a day or vitamin D2 at 50,000 units a week for 2 months forevery 12.5 ng per litre improvement in serum vitamin D levels.77 The
Vitamin D3 loading dose required to reach the serum 25-OH vitamin
D3 target level of 75 nmol per litre can be calculated as follows:
Dose (IU) = 40 x (75-serum 25-OH vitamin D3) x body weight.77
Note: 2.5 nmol/L = 1 ng/ml of 25 OH vitamin D
Based on this formula, assuming an average body weight of 60kg, thegeneral approach to repletion is to give vitamin D3 at 2000 units a day
or vitamin D2 at 50,000 units a week for 1 month for every 10ng/ml
improvement in serum 25 OH vitamin D levels.

D It may be helpful to give vitamin D supplementation to older adults if

their vitamin D level is less than 20 ng per millilitre (50 nmol per litre), if
higher levels cannot be achieved via sunlight or dietary supplementation.3
Older adults with significant renal impairment will benefit from treatment
with analogues of vitamin D (alfacalcidol or calcitriol).
Grade D, Level 4

B Avoid the use of high dose cholecalciferol (500,000 IU per year).4

Grade B, Level 1+173.1.6 Improving VisionFirst eye cataract surgery can reduce the risks of falls and the rate of falls
in older adults.78-82
Except for first eye cataract surgery,78 there is no concrete evidence that
correcting vision alone through referral to appropriate professionals(including second eye cataract surgery) reduces the risk of falls.59, 83
However, vision assessment and referral can be an element for successful
multi-factorial falls prevention intervention and improve quality oflife.59, 83, 84

GPP Older adults who have impaired vision should be referred forfurther evaluation of the cause of impairment.
GPP
B Persons with cataract as the main cause of vision impairment should bereferred for cataract surgery (especially for first eye).
Grade B, Level 1+
3.1.7 Cardiac Pacemaker Insertion
Cardiac pacing can reduce the number of falls in people withcardioinhibitory carotid sinus hypersensitivity.63

B Older adults with suspected cardiogenic falls should be referred toa cardiologist for further evaluation. Cardiac pacing is recommended
for patients with cardioinhibitory carotid sinus hypersensitivity and ahistory of falls.
Grade B, Level 1+
3.1.8 Education Intervention
There is no concrete evidence that education intervention alone reduces
the rate or risk of falls in older adults living in the community.63, 85
However, providing basic information about the benefits of falls
prevention can potentially help older adults make informed choices
about engaging in falls prevention interventions and potentially improveadherence to these interventions.

18

GPP Provide basic information on falls and educate older adults on thebenefits of falls prevention strategies in preventing falls and maintaining
independence.
GPP

3.2 Multiple Interventions
Multiple interventions consist of a fixed combination of two or more major
categories of intervention. Falls prevention programmes consisting of multiple
interventions including exercise, can reduce the number of falls and riskof falls in older adults living in the community.63

B Older adults at risk of falls should be considered for referral to falls
prevention programmes consisting of exercise and other interventions, if
such programmes are available and accessible.
Grade B, Level 1+

3.3 Multi-factorial Interventions
Multi-factorial interventions consist of more than one major category ofintervention. These interventions are tailored to the individual patient
following the assessment of his/her risk of falling. There is conflicting
evidence on the effectiveness of multi-factorial interventions on theprevention of falls among older adults living in the community.23, 63, 86-88
However, individually targeted multi-factorial interventions have beenshown to reduce the number of falls in the subgroup of patients who areat high risk of falls.63 Active interventions are more effective thanprovision of education alone.63

B Older adults assessed to be at high risk of falls should receive

interventions targeted at the individually identified risk factors.
Grade B, Level 1+19

4. Cost-Effectiveness of Falls Prevention
4.1 Impact of Singapore’s Aging Population
The burden of falls in Singapore is likely to rise in time. This isbecause the incidence of falls increase very sharply with age, andSingapore faces the challenges of a rapidly aging population. According
to data from the Department of Statistics, Singapore,89 in 2011, 14.8%of the Singapore resident population were 60 years or older. By 2030 90
it is estimated that one in five Singaporeans will be above the age of 65.

4.2 Consequences and Cost of Falls - Injury and Fractures
The main consequences of a fall include head injury, fractures andsoft-tissue injury to the body. Head injury resulting from falls is an
important source of morbidity in older adults including hospitalisation.
Fractures are also a major cause of morbidity and mortality. Common
fracture sites include Colles’ fracture of the wrist, fractures of upper andlower limbs, and hip fractures. The morbidity and mortality burden
associated with hip fractures in particular is very high. Wrist fractures are
more common than hip fractures between ages 65 and 75, whereas hip
fractures predominate in ages after that.
A retrospective study91 was done in year 2002 on 274 older adult patients
aged 60 years or older. They were patients admitted to public hospitals for
hip fractures over a 3-year period (year 1991 to 1993). 58% wereintertrochanteric fractures and 42% femoral neck fractures. 66% of thepatients had significant medical co-morbidities. 264 (95%)
patients were operated upon. The mean total hospitalisation period was
17 days. 76% of these patients were living in the community before
the fracture while 22% were admitted from nursing homes. After surgery,
63% returned to their homes while 25% needed nursing home care. The
index admission mortality rate was 5.7% and mortality was 26% at 1 year.
Of those alive at one year, 28% were walking without aids, 39% werewalking with aids, 24% wheelchair bound and 9% were bedridden. The
average hospital bill was S$7,367, and the average subsidy was S$6,335.
91% of the cases were warded in subsidised B2 and C class wards.

20

Another study of patients with surgically treated osteoporotic hip
fractures found that the mean length of hospital stay was 16 days, and themean hospitalisation cost incurred was S$10,515.92
In Singapore, about 2,300 adults aged 50 years and above wereadmitted for hip fracture in 2012, and this number is expected to rise to
5,000 by 2025.93

4.3 Psychological Trauma
The psychological fear of falling in the older adults who survived a fall isreal and may lead to a self-imposed restriction of mobility. The incidenceof fear of falling is estimated to be around 40% to 70% in fallers.94 This
may potentially perpetuate the cycle where the fear of falling leads toself-imposed reduced mobility which then in turn leads to further
functional decline resulting in higher risk of falls.
Repeated fallers are also at higher risk of being institutionalised.95

4.4 Cost Effectiveness of Interventions
Interventions can be cost-effective; and international studies indicate thatmulti-factorial falls prevention programmes especially may be costeffective. 54, 96-99 The true extent of benefits is not clear. Furthermore,
there is little local data; hence a proper cost effectiveness analysis
needs to be performed in conjunction with trials of falls intervention
programmes in Singapore.

21

5. Clinical Quality Improvement
In view of the high falls incidence and the morbidity and mortality risks imposedby such falls, it is important to monitor falls rates and complications from falls
amongst the older adults. Proposed national indicators include the following:• Age-adjusted incidence rates of falls (regardless of consequences)		 among those aged 65 years and above.
• Age-adjusted admission rate for injuries resulting from falls among
		 those aged 65 years and above.
Data for these three indicators can be obtained from:• Representative cross-sectional surveys of the older adults• Hospital discharge data
• Hospital emergency department data22

Annex A

Algorithm for Assessing Fall Risk in Older Adults
Living in the Community
To ask all elderly during healthcare
encounter for history of recurrent
falls (more than 1 fall in thepast 6 months)

YES

NO
Observe for gait and balance
problem and assess lower
limb strength

The fall assessment should
include the following:
Abnormal

NormalI. Taking more than 4prescription drugs or taking
drugs associated with increased
fall risk#.
II. Check for visual acquity >6/12
using a Snellen’s Chart

Comprehensive fall assessment by
a health care professional withappropriate skills and experience,
preferably in a multidisciplinary
setting.

If all three
are positive

III. Any fall in the past 6 months

1. History of falls:
Frequency, context,
characteristics and consequence
2. Determine multi-factorial
fall risk:
Medications
Gait and postural instability
Urinary incontinence
Visual impairment
Neuromuscular impairment
Cognitive impairment
Postural Hypotension
CardiovascularSyncope syndrome
Environmental hazards
3. Determine osteoporosis
and fracture risk

If less than three
are positive
If item I is positive, perform a
medication review#.
If item II is positive, to exclude refractive
errors and/or eye disease.

Multi-factorial intervention

If item III is positive, review fall risk
again in 6 months.

#See section on medication review and modification.

Education on falls‡.

‡Falls education resources are available atwww.hpb.gov.sg.

Recommend exercise†.

†See section on exercise.

23

References
1.

Sherrington C, Tiedemann A, Fairhall N, Close JC and Lord SR.
Execise to prevent falls in older adults: an updated meta-analysis and bestpractice recommendations. New South Wales Public Health Bulletin.
2011;22(3-4):78-83. Epub 2011/06/03.

2.

Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG and
Close JC. Effective exercise for the prevention of falls: a systematic
review and meta-analysis. Journal of the American Geriatrics Society.
2008;56(12):2234-43. Epub 2008/12/20.

3.

Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE,
Stuck AE, Theiler R, et al. Fall prevention with supplemental andactive forms of vitamin D: a meta-analysis of randomised controlled
trials. BMJ. 2009;339:b3692. Epub 2009/10/03.

4.

Sanders K. ACP Journal Club: a single, annual, high dose of oral vitamin
D increased falls and fractures in older women. Annals of internal medicine.
2010;153(6):JC3-. Epub 2010/09/22.

5.

National Registry of Disease Office, Singapore. Crude rate ofunintentional falls. 2012.

6.

National Registry of Disease Office, Singapore. National Trauma Registry
Annual Registry Report 2012. 2014.

7.

Chan KM, Pang WS, Ee CH, Ding YY and Choo P. Epidemiology of falls
among the elderly community dwellers in Singapore. Singapore Medical
Journal. 1997;38(10):427-31. Epub 1998/04/08.

8.

Ellis AA and Trent RB. Hospitalized fall injuries and race in California.
Injury prevention : J ournal of the International Society for Child andAdolescent Injury Prevention. 2001;7(4):316-20. Epub 2002/01/05.

9.

Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C and Negri
E. Risk factors for falls in community-dwelling older people: asystematic review and meta-analysis. Epidemiology. 2010;21(5):658-68.
Epub 2010/06/30.
24

10. Kwan MM, Close JC, Wong AK and Lord SR. Falls incidence, risk
factors, and consequences in Chinese older people: a systematic
review. Journal of the American Geriatrics Society. 2011;59(3):536-43.
Epub 2011/03/03.
11. National Institute for Health and Care Excellence. Falls: assessment
and prevention of falls in older people 2011. Available from:http://publications.nice.org.uk/falls-assessment-and-prevention-of- fallsin-older-people-cg161.
12. Australian Commission for Safety and Quality in Healthcare. Guide bookfor Preventing Falls and Harm From Falls in Older People: AustralianCommunity Care 2009. Available from: http://www.safetyandquality.gov.
au/publications/guidebook-for-preventing-falls-and-harm-from-falls-inolder-people-australian-community-care-2009/.
13. Azidah AK, Hasniza H and Zunaina E. Prevalence of Falls and Its
Associated Factors among Elderly Diabetes in a Tertiary Center,
Malaysia. Current gerontology and geriatrics research. 2012;2012:539073.
Epub 2012/06/14.
14. Rubenstein LZ. Falls in older people: epidemiology, risk factors andstrategies for prevention. Age and ageing. 2006;35 Suppl 2:ii37-ii41. Epub
2006/08/24.
15. Bloch F, Thibaud M, Dugue B, Breque C, Rigaud AS and Kemoun G.
Psychotropic drugs and falls in the elderly people: updated literature
review and meta-analysis. Journal of Aging and Health. 2011;23(2):329-46.
Epub 2010/10/16.
16. Leipzig RM, Cumming RG and Tinetti ME. Drugs and falls in older
people: a systematic review and meta-analysis: I. Psychotropic drugs.
Journal of the American Geriatrics Society. 1999;47(1):30-9. Epub
1999/01/27.
17. The American Geriatrics Society 2012 Beers Criteria Update Expert
Panel. American Geriatrics Society Updated Beers Criteria for
Potentially Inappropriate Medication Use in Older Adults. Journal of theAmerican Geriatrics Society [Internet]. 2012; 60(4):[616-31 pp.].
Available from: http://www.americangeriatrics.org/files/documents/
beers/2012BeersCriteria_JAGS.pdf.
25

18. van der Velde N, Stricker BH, Pols HA and van der Cammen TJ. Risk offalls after withdrawal of fall-risk-increasing drugs: a prospective
cohort study. British Journal of Clinical Pharmacology. 2007;63(2):232-7.
Epub 2006/08/31.
19. Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM,
et al. Meta-analysis of the impact of 9 medication classes on falls inelderly persons. Archives of Internal Medicine. 2009;169(21):1952-60.
Epub 2009/11/26.
20. Leipzig RM, Cumming RG and Tinetti ME. Drugs and falls in older
people: a systematic review and meta-analysis: II. Cardiac andanalgesic drugs. Journal of the American Geriatrics Society. 1999;47(1):4050. Epub 1999/01/27.
21. Tinetti ME, Speechley M and Ginter SF. Risk factors for falls among
elderly persons living in the community. The New England Journal of
Medicine. 1988;319(26):1701-7. Epub 1988/12/29.
22. Summary of the Updated American Geriatrics Society/British Geriatrics
Society clinical practice guideline for prevention of falls in older
persons. Journal of the American Geriatrics Society. 2011;59(1):148-57.
Epub 2011/01/14.
23. Gates S, Fisher JD, Cooke MW, Carter YH and Lamb SE. Multi-factorialassessment and targeted intervention for preventing falls and injuries
among older people in community and emergency care settings:
systematic review and meta-analysis. BMJ. 2008;336(7636):130-3. Epub
2007/12/20.
24. Muir SW, Berg K, Chesworth B, Klar N and Speechley M. Application ofa fall screening algorithm stratified fall risk but missed preventive
opportunities in community-dwelling older adults: a prospective study.
J Geriatr Phys Ther. 2010;33(4):165-72. Epub 2011/07/02.
25. Muir SW, Berg K, Chesworth BM, Klar N and Speechley M.
Modifiable Risk Factors Identify People Who Transition from Non-fallers
to Fallers in Community-Dwelling Older Adults: A Prospective Study.
Physiotherapy Canada. Physiotherapie Canada. 2010;62(4):358-67. Epub
2011/09/03.
26

26. Rubenstein LZ, Solomon DH, Roth CP, Young RT, Shekelle PG, Chang
JT, et al. Detection and management of falls and instability in vulnerable
elders by community physicians. Journal of the American Geriatrics
Society. 2004;52(9):1527-31. Epub 2004/09/03.
27. Rubenstein LZ, Alessi CA, Josephson KR, Trinidad Hoyl M, Harker JO
and Pietruszka FM. A randomized trial of a screening, case finding, andreferral system for older veterans in primary care. Journal of theAmerican Geriatrics Society. 2007;55(2):166-74. Epub 2007/02/17.
28. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA and Gold R.
Primary care-relevant interventions to prevent falling in older adults: asystematic evidence review for the U.S. Preventive Services Task Force.
Annals of Internal Medicine. 2010;153(12):815-25. Epub 2010/12/22.
29. Stalenhoef PA, Diederiks JP, Knottnerus JA, Kester AD and
Crebolder HF. A risk model for the prediction of recurrent falls incommunity-dwelling elderly: a prospective cohort study. Journal of
Clinical Epidemiology. 2002;55(11):1088-94. Epub 2003/01/01.
30. Perell KL, Nelson A, Goldman RL, Luther SL, Prieto-Lewis N and
Rubenstein LZ. Fall risk assessment measures: an analytic review. The
journals of gerontology. Series A, Biological Sciences and Medical
Sciences. 2001;56(12):M761-6. Epub 2001/11/28.
31. Gates S, Smith LA, Fisher JD and Lamb SE. Systematic review of
accuracy of screening instruments for predicting fall risk among
independently living older adults. Journal of Rehabilitation Research andDevelopment. 2008;45(8):1105-16. Epub 2009/02/24.
32. Scott V, Votova K, Scanlan A and Close J. Multi-factorial and functional
mobility assessment tools for fall risk among older adults incommunity, home-support, long-term and acute care settings. Age andageing. 2007;36(2):130-9. Epub 2007/02/13.
33. Berg K and Norman KE. Functional assessment of balance andgait. Clinics in Geriatric Medicine. 1996;12(4):705-23. Epub 1996/11/01.

27

34. Lin MR, Hwang HF, Hu MH, Wu HD, Wang YW and Huang FC.
Psychometric comparisons of the timed up and go, one-leg stand,functional. reach, and Tinetti balance measures in community-dwellingolder people. Journal of the American Geriatrics Society. 2004;52(8):13438. Epub 2004/07/24.
35. Schoene D, Wu SM, Mikolaizak AS, Menant JC, Smith ST, Delbaere K,
et al. Discriminative ability and predictive validity of the timed up and go
test in identifying older people who fall: systematic review and metaanalysis. Journal of the American Geriatrics Society. 2013;61(2):202-8.
Epub 2013/01/29.
36. Barry E, Galvin R, Keogh C, Horgan F and Fahey T. Is the Timed Up and
Go test a useful predictor of risk of falls in community dwelling older
adults: a systematic review and meta- analysis. BMC geriatrics.
2014;14:14. Epub 2014/02/04.
37. Beauchet O, Fantino B, Allali G, Muir SW, Montero-Odasso M andAnnweiler C. Timed Up and Go test and risk of falls in older adults: asystematic review. The Journal of Nutrition, Health & Aging.
2011;15(10):933-8. Epub 2011/12/14.
38. Nandy S, Parsons S, Cryer C, Underwood M, Rashbrook E, Carter Y,
et al. Development and preliminary examination of the predictive
validity of the Falls Risk Assessment Tool (FRAT) for use in primarycare. J Public Health (Oxf). 2004;26(2):138-43. Epub 2004/07/31.
39. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp
MJ, et al. Interventions for the prevention of falls in older adults:
systematic review and meta-analysis of randomised clinical trials. BMJ.
2004;328(7441):680. Epub 2004/03/20.
40. Costello E and Edelstein JE. Update on falls prevention for communitydwelling older adults: review of single and multi-factorial intervention
programs. Journal of Rehabilitation Research and Development.
2008;45(8):1135-52. Epub 2009/02/24.
41. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S,
Cumming RG, et al. Interventions for preventing falls in older people
living in the community. The Cochrane Database of Systematic Reviews.
2009(2):CD007146. Epub 2009/04/17.
28

42. Lord SR, Ward JA, Williams P and Strudwick M. The effect of a 12-month
exercise trial on balance, strength, and falls in older women: a randomized
controlled trial. Journal of the American Geriatrics Society.
1995;43(11):1198-206. Epub 1995/11/01.
43. Choi JH, Moon JS and Song R. Effects of Sun-style Tai Chi exercise on
physical fitness and fall prevention in fall-prone older adults. Journal ofAdvanced Nursing. 2005;51(2):150-7. Epub 2005/06/21.
44. Low S, Ang LW, Goh KS and Chew SK. A systematic review of theeffectiveness of Tai Chi on fall reduction among the elderly. Archives ofGerontology and Geriatrics. 2009;48(3):325-31. Epub 2008/04/19.
45. Means KM, Rodell DE and O’Sullivan PS. Balance, mobility, and falls
among community-dwelling elderly persons: effects of a rehabilitation
exercise program. American journal of physical medicine &rehabilitation / Association of Academic Physiatrists. 2005;84(4):238-50.
Epub 2005/03/24.
46. Verhagen AP, Immink M, van der Meulen A and Bierma-Zeinstra SM.
The efficacy of Tai Chi Chuan in older adults: a systematic review. Family
Practice. 2004;21(1):107-13. Epub 2004/02/05.
47. Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C and Xu T.
Selected as the best paper in the 1990s: Reducing frailty and falls in older
persons: an investigation of tai chi and computerized balance training.
Journal of the American Geriatrics Society. 2003;51(12):1794-803. Epub
2003/12/23.
48. Thomas S, Mackintosh S and Halbert J. Does the ‘Otago exercise
programme’ reduce mortality and falls in older adults?: a systematic
review and meta-analysis. Age and ageing. 2010;39(6):681-7. Epub
2010/09/08.
49. Barnett A, Smith B, Lord SR, Williams M and Baumand A. Communitybased group exercise improves balance and reduces falls in at-risk older
people: a randomised controlled trial. Age and ageing. 2003;32(4):40714. Epub 2003/07/10.

29

50. Li F, Harmer P, Fisher KJ and McAuley E. Tai Chi: improving functionalbalance and predicting subsequent falls in older persons. Medicine andScience in Sports and Exercise. 2004;36(12):2046-52. Epub 2004/12/01.
51. Campbell AJ, Robertson MC, La Grow SJ, Kerse NM, Sanderson GF,
Jacobs RJ, et al. Randomised controlled trial of prevention of falls
in people aged > or =75 with severe visual impairment: the VIP trial.
BMJ. 2005;331(7520):817. Epub 2005/09/27.
52. Chase CA, Mann K, Wasek S and Arbesman M. Systematic reviewof the effect of home modification and fall prevention programs on
falls and the performance of community-dwelling older adults. The
American journal of occupational therapy : official publication of theAmerican Occupational Therapy Association. 2012;66(3):284-91. Epub
2012/05/03.
53. Clemson L, Mackenzie L, Ballinger C, Close JC and Cumming RG.
Environmental interventions to prevent falls in community-dwellingolder people: a meta-analysis of randomized trials. Journal of Aging and
Health. 2008;20(8):954-71. Epub 2008/09/26.
54. Close J, Ellis M, Hooper R, Glucksman E, Jackson S and Swift C.
Prevention of falls in the elderly trial (PROFET): a randomised
controlled trial. Lancet. 1999;353(9147):93-7. Epub 1999/02/19.
55. Cumming RG, Thomas M, Szonyi G, Salkeld G, O’Neill E, Westbury C,
et al. Home visits by an occupational therapist for assessment andmodification of environmental hazards: a randomized trial of falls
prevention. Journal of the American Geriatrics Society. 1999;47(12):1397402. Epub 1999/12/11.
56. Nikolaus T and Bach M. Preventing falls in community-dwelling frail
older people using a home intervention team (HIT): results from therandomized Falls-HIT trial. Journal of the American Geriatrics Society.
2003;51(3):300-5. Epub 2003/02/18.
57. Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE and Bland JM.
Environmental assessment and modification to prevent falls in older
people. Journal of the American Geriatrics Society. 2011;59(1):26-33.
Epub 2011/01/14.
30

58. Stevens M, Holman CD, Bennett N and de Klerk N. Preventing falls inolder people: outcome evaluation of a randomized controlled trial.
Journal of the American Geriatrics Society. 2001;49(11):1448-55.
Epub 2002/03/14.
59. Day L, Fildes B, Gordon I, Fitzharris M, Flamer H and Lord S.
Randomised factorial trial of falls prevention among older
people living in their own homes. BMJ. 2002;325(7356):128.
Epub 2002/07/20.
60. Menant JC, Steele JR, Menz HB, Munro BJ and Lord SR. Optimizing
footwear for older people at risk of falls. Journal of Rehabilitation
Research and Development. 2008;45(8):1167-81. Epub 2009/02/24.
61. Menz HB, Morris ME and Lord SR. Footwear characteristics and riskof indoor and outdoor falls in older people. Gerontology. 2006;52(3):17480. Epub 2006/04/29.
62. Tencer AF, Koepsell TD, Wolf ME, Frankenfeld CL, Buchner DM,
Kukull WA, et al. Biomechanical properties of shoes and risk of falls inolder adults. Journal of the American Geriatrics Society. 2004;52(11):1840-6. Epub 2004/10/28.
63. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S,
Clemson LM, et al. Interventions for preventing falls in older people
living in the community. The Cochrane Database of Systematic Reviews.
2012;9:CD007146. Epub 2012/09/14.
64. Salonoja M, Salminen M, Vahlberg T, Aarnio P and Kivela SL.
Withdrawal of psychotropic drugs decreases the risk of falls requiring
treatment. Archives of Gerontology and Geriatrics. 2012;54(1):160-7.
Epub 2011/03/23.
65. Pit SW, Byles JE, Henry DA, Holt L, Hansen V and Bowman
DA. A Quality Use of Medicines program for general practitioners
and older people: a cluster randomised controlled trial. The
Medical journal of Australia. 2007;187(1):23-30. Epub 2007/07/04.

31

66. Campbell AJ, Robertson MC, Gardner MM, Norton RN and Buchner
DM. Psychotropic medication withdrawal and a home-based exercise
program to prevent falls: a randomized, controlled trial. Journal of theAmerican Geriatrics Society. 1999;47(7):850-3. Epub 1999/07/15.
67. Tan KM, Saw S and Sethi SK. Vitamin D and its relationship withmarkers of bone metabolism in healthy Asian women. Journal of ClinicalLaboratory Analysis. 2013;27(4):301-4. Epub 2013/07/16.
68. Chan SP, Scott BB and Sen SS. An Asian viewpoint on the use ofvitamin D and calcium in osteoporosis treatment: physician andpatient attitudes and beliefs. BMC Musculoskeletal Disorders.
2010;11:248. Epub 2010/10/28.
69. Bischoff HA, Stahelin HB, Dick W, Akos R, Knecht M, Salis C, et al.
Effects of vitamin D and calcium supplementation on falls: a randomized
controlled trial. Journal of bone and mineral research : the official journalof the American Society for Bone and Mineral Research. 2003;18(2):34351. Epub 2003/02/06.
70. Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW and Crews DC.
Vitamin D treatment for the prevention of falls in older adults: systematic
review and meta-analysis. Journal of the American Geriatrics Society.
2010;58(7):1299-310. Epub 2010/06/29.
71. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, Staehelin
HB, Bazemore MG, Zee RY, et al. Effect of Vitamin D on falls:
a meta-analysis. JAMA : The Journal of the American Medical
Association. 2004;291(16):1999-2006. Epub 2004/04/29.
72. Murad MH, Elamin KB, Abu Elnour NO, Elamin MB, Alkatib AA,
Fatourechi MM, et al. Clinical review: The effect of vitamin D on falls:a systematic review and meta-analysis. The Journal of Clinical
Endocrinology and Metabolism. 2011;96(10):2997-3006. Epub 2011/07/29
73. Broe KE, Chen TC, Weinberg J, Bischoff-Ferrari HA, Holick MF and Kiel
DP. A higher dose of vitamin d reduces the risk of falls in nursing homeresidents: a randomized, multiple-dose study. Journal of the American
Geriatrics Society. 2007;55(2):234-9. Epub 2007/02/17.
32

74. Bischoff-Ferrari HA, Willett WC, Orav EJ, Lips P, Meunier PJ, Lyons RA,
et al. A pooled analysis of vitamin D dose requirements for fracture
prevention. The New England Journal of Medicine. 2012;367(1):40-9.
Epub 2012/07/06.
75. Sato Y, Iwamoto J, Honda Y and Amano N. Vitamin D reduces falls andhip fractures in vascular Parkinsonism but not in Parkinson’s disease.
Therapeutics and Clinical Risk Management. 2013;9:171-6. Epub
2013/05/03.
76. Sato Y, Iwamoto J, Kanoko T and Satoh K. Low-dose vitamin D prevents
muscular atrophy and reduces falls and hip fractures in women after
stroke: a randomized controlled trial. Cerebrovasc Dis. 2005;20(3):18792. Epub 2005/08/10.
77. van Groningen L, Opdenoordt S, van Sorge A, Telting D, Giesen A and deBoer H. Cholecalciferol loading dose guideline for vitamin D-deficient
adults. European Journal of Endocrinology / European Federation of
Endocrine Societies. 2010;162(4):805-11. Epub 2010/02/09.
78. Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A and Masud
T. Falls and health status in elderly women following first eye cataract
surgery: a randomised controlled trial. The British Journal of
Ophthalmology. 2005;89(1):53-9. Epub 2004/12/24.
79. Brannan S, Dewar C, Sen J, Clarke D, Marshall T and Murray PI. A
prospective study of the rate of falls before and after cataract surgery.
The British Journal of Ophthalmology. 2003;87(5):560-2. Epub
2003/04/26.
80. Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena LA andPike I. Vision improvement and reduction in falls after expedited
cataract surgery Systematic review and metaanalysis. Journal of Cataract
and Refractive Surgery. 2010;36(1):13-9. Epub 2010/02/02.
81. Foss AJ, Harwood RH, Osborn F, Gregson RM, Zaman A and Masud
T. Falls and health status in elderly women following second eye cataract
surgery: a randomised controlled trial. Age and ageing. 2006;35(1):6671. Epub 2005/12/21.
33

82. Tseng VL, Yu F, Lum F and Coleman AL. Risk of fractures following
cataract surgery in Medicare beneficiaries. JAMA : The Journal of theAmerican Medical Association. 2012;308(5):493-501. Epub 2012/08/02.
83. Cumming RG, Ivers R, Clemson L, Cullen J, Hayes MF, Tanzer M, et al.
Improving vision to prevent falls in frail older people: a randomized
trial. Journal of the American Geriatrics Society. 2007;55(2):175-81.
Epub 2007/02/17.
84. Coleman AL, Yu F, Keeler E and Mangione CM. Treatment of uncorrectedrefractive error improves vision-specific quality of life. Journal of
the American Geriatrics Society. 2006;54(6):883-90. Epub 2006/06/17.
85. Hill AM, Hoffmann T, McPhail S, Beer C, Hill KD, Oliver D, et al.
Evaluation of the sustained effect of inpatient falls prevention
education and predictors of falls after hospital discharge--follow-up to arandomized controlled trial. The journals of gerontology. Series A,
Biological Sciences and Medical Sciences. 2011;66(9):1001-12. Epub
2011/07/12.
86. Lee HC, Chang KC, Tsauo JY, Hung JW, Huang YC and Lin SI. Effects
of a multi-factorial fall prevention program on fall incidence andphysical function in community-dwelling older adults with riskof falls. Archives of Physical Medicine and Rehabilitation.
2013;94(4):606-15, 15 e1. Epub 2012/12/12.
87. Perula LA, Varas-Fabra F, Rodriguez V, Ruiz-Moral R, Fernandez JA,
Gonzalez J, et al. Effectiveness of a multi-factorial intervention program
to reduce falls incidence among community-living older adults: arandomized controlled trial. Archives of Physical Medicine andRehabilitation. 2012;93(10):1677-84. Epub 2012/05/23.
88. Choi M and Hector M. Effectiveness of intervention programs inpreventing falls: a systematic review of recent 10 years and meta-analysis.
Journal of the American Medical Directors Association. 2012;13(2):188
e13-21. Epub 2011/06/18.
89. Singapore Department of Statistics. Complete Life Tables 2007 - 2012 forSingapore Resident Population.
34

90. Ministry of Community Development, Youth and Sports, Singapore.
Report on the aging population. 2006.
91. Wong MK, Arjandas, Ching LK, Lim SL and Lo NN. Osteoporotic
hip fractures in Singapore--costs and patient’s outcome. Annals of
the Academy of Medicine, Singapore. 2002;31(1):3-7. Epub 2002/03/12.
92. Lee YH, Lim YW and Lam KS. Economic cost of osteoporotic hip
fractures in Singapore. Singapore Medical Journal. 2008;49(12):980-4.
Epub 2009/01/06.
93. Ministry of Health, Singapore. 2014.
94. Ismail NH. The falling elderly. The Family Physician. 2002;28(4):82.
95. Lim SC. Elderly fallers: what do we need to do? Proceedingsof Singapore Healthcare. 2010;19(2):154-8.
96. Rizzo JA, Baker DI, McAvay G and Tinetti ME. The cost-effectivenessof a multi-factorial targeted prevention program for falls amongcommunity elderly persons. Medical Care. 1996;34(9):954-69. Epub
1996/09/01.
97. Robertson MC, Devlin N, Scuffham P, Gardner MM, Buchner DM
and Campbell AJ. Economic evaluation of a community based exercise
programme to prevent falls. Journal of Epidemiology and Community
Health. 2001;55(8):600-6. Epub 2001/07/13.
98. Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL and Osterweil
D. The value of assessing falls in an elderly population. A randomized
clinical trial. Annals of Internal Medicine. 1990;113(4):308-16. Epub
1990/08/15.
99. Wu S, Keeler EB, Rubenstein LZ, Maglione MA and Shekelle PG. A
cost-effectiveness analysis of a proposed national falls prevention
program. Clinics in Geriatric Medicine. 2010;26(4):751-66.
Epub 2010/10/12.

35

Self-assessment (MCQs)
After reading the Clinical Practice Guidelines, you can claim one CME point
under Category 3A (Self-Study) of the SMC Online CME System. Alternatively,
you can claim one CME point under Category 3B (Distance Learning –Verifiable Self Assessment) if you answer at least 60% of the following MCQs
correctly. You can submit your answers through the SMJ website at this link:smjcme.sma.org.sg (the link will only be available once the May 2015 issue of
SMJ becomes available). The answers will be published in the SMJ July 2015
issue and at the MOH/HPB webpage for these guidelines after the period forsubmitting the answers is over.
Instruction: Choose the right answer(s). There may be more than one answer
for some questions.
1. Regarding incidence of falls and risk factors for falls
A. Male older adults are at higher risk of falls compared to female older
adults.
B. A significant predictor of future fall risk is a history of a fall in the past
one year.
C. Neuromuscular conditions resulting in mobility impairment, gait deficit
and balance deficit together with polypharmacy pre-disposes older
adults to falls.
D. As the number of risk factors increase, the risk for falls increases.
2. Regarding screening for falls
A. All older adults should be asked for a past history of falls.
B. General practitioners or other healthcare professionals can utilise
multi-factorial assessment tools to identify older adults who are at riskof falls.
C. If gait and balance problems are observed, a comprehensive fall
assessment is recommended.
D. Functional Mobility Assessment tools look at strength, balance, gait
and reaction time.
36

3. Regarding falls prevention interventions
A. Exercises consisting of two or more aspects of strength, balance,
flexibility or endurance is not effective in reducing the rate of falls inolder adults.
B. Home assessment and modification interventions conducted byoccupational therapists are effective in reducing the rate of falls
especially for those who have a high risk of falls, history of falls or
those with visual impairments.
C. Vitamin D deficiency is uncommon in Singapore due to the sunny
weather.
D. First eye cataract surgery can reduce the risks of falls and the rate offalls in older adults.
4. Regarding falls prevention interventions
A. Providing basic information about the benefits of falls prevention canhelp older adults make informed choices about engaging in falls
prevention interventions and improve adherence to these interventions.
B. Multi-factorial interventions that target specific risk factors have beenshown to be effective in preventing falls.
C. Older adults with high risk of falls should receive interventions
targeted at the individually identified risk factors.
D. Active review and modification of medications associated withincreased risks of falls is recommened as a form of falls prevention
intervention.
5. Regarding consequences and cost of falls
A. Besides the physiological trauma of a fall, psychological fear of
falling is real and may lead to self-imposed mobility restriction.
B. Head injury and fractures are major causes of morbidity and mortality
following a fall.
C. The most common fracture sites from falls include Colles’ fracture of
the wrist, fractures of upper and lower limbs and hip fractures.
D. Hip fractures predominate in older adults between the ages of 65 and75.
37

Answers

1. B, C, D
2. A, B, C, D
3. B, D
4. A, B, C, D
5. A, B, C

38

Workgroup Members
The members of the workgroup, who were appointed in their personal
professional capacity, are:

Chairpersons
Dr Shyamala Thilagaratnam
Director,
Regional Health and Community Outreach Division
Health Promotion Board
Dr Wong Sweet Fun
Senior Consultant,
Department of Geriatric Medicine
Khoo Teck Puat Hospital

Members (listed in alphabetical order of surname)
Dr Akila Andiappan
Senior Manager,
Screening Policy & Planning
Health Promotion Board
Dr Au Eong Kah Guan
Medical Director & Senior Consultant,Singapore International Eye Cataract Retina Centre
Mount Elizabeth Medical Centre
Dr Anu Birla BakshiManager,
Regional Health System Engagement
Health Promotion Board

39

Ms Debbie Boey
Senior Occupational Therapist,
Occupational Therapy
Tan Tock Seng Hospital
Dr Chong Tsung Wei
Consultant,
Medical Services Division
St. Luke’s Hospital
Ms Eng Hui Ping Inex
Optometrist
Singapore International Eye Cataract Retina Centre
Mount Elizabeth Medical Centre
Dr Noor Hafizah
Senior Consultant,
Department of Continuing and Community CareTan Tock Seng Hospital
A/Prof Lau Tang Ching
Associate Professor,
Department of Medicine
National University Health System
Dr Lim Wei-Yen
Assistant Professor
Saw Swee Hock School of Public HealthNational University of Singapore
Ms Wendy Lim
Rehabilitation Manager,
Department of Rehabilitation
Khoo Teck Puat Hospital
Dr Lydia Seong
Adjunct Associate Professor
Saw Swee Hock School of Public HealthNational University of Singapore
40

Dr Wong Wei Chin
Senior Consultant,
Department of Geriatric Medicine
Tan Tock Seng Hospital
Dr Yap Kai Zhen
Instructor, Department of Pharmacy
Faculty of Science
National University of Singapore
Ms Sri Yudah
Optometrist
Singapore International Eye Cataract Retina Centre
Mount Elizabeth Medical Centre

Secretariat (Health Promotion Board)
Dr Aye Mya Win
Manager
Research and Evaluation
Health Promotion Board
Ms Annie Tan
Manager
Research and Evaluation
Health Promotion Board
Ms Elizabeth Pan
Manager
Research and Evaluation
Health Promotion Board
Ms Hazyl Ng
Manager
Healthy Ageing Programme
Health Promotion Board
41

Ms Patricia Mondonedo
Senior Manager
Screening Policy & Planning
Health Promotion Board
Ms Anushka MangharamManager
Screening Policy & Planning
Health Promotion Board
Ms Siti Khadijah Idris
Executive
Research and Evaluation
Health Promotion Board

42

Acknowledgement
The workgroup committee would like to thank the following persons (listed
in alphabetical order of surname) who contributed to the development andreview of the guideline:
Dr Pwee Keng Ho
Deputy Director (Health Technology Assessment)
Ministry of Health43

List of Endorsing Agencies

Academy of Medicine,Singapore

Chapter of Geriatricians,
College of PhysiciansCollege of Family Physicians,
Singapore

Gerontological Society Singapore

Ministry of Health, Singapore

Osteoporosis Society Singapore

Pharmaceutical Society of Singapore

Singapore Association of
Occupational Therapists

Singapore Nurses Association

Singapore Optometric Association

Singapore Physiotheraphy Association

44

Copyright HPB B E 786-15 © 2015 by Health Promotion Board, Singapore