Guidelines for the prevention of falls in people over 65 Risk Factors Associated with Falls in Older Adults with Dementia: A Systematic Review. The effect of Tai Chi Chuan in reducing falls among elderly people: design of a randomized clinical trial in the Netherlands [ISRCTN98840266] Falls After Stroke: Results From the Auckland Regional Community Stroke (ARCOS) Study, 2002 to 2003 A Population-Based Survey of Factors Relating to the Prevalence of Falls in Older People Injurious falls among middle aged and older adults with multiple sclerosis. Cost-effectiveness of a day hospital falls prevention programme for screened community-dwelling older people at high risk of falls A multicentre randomised controlled trial of day hospital-based falls prevention programme for a screened population of community-dwelling older people at high risk of falls Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus. Preventing falls with Tai Ji Quan: A public health perspective. Predisposing and precipitating factors for falls among older people in residential care. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. Minimising disability and falls in older people through a post-hospital exercise program: a protocol for a randomised controlled trial and economic evaluation Next steps for falls and fracture reduction. Understanding risk of falls in people with cognitive impairment living in residential care. Multifactorial day hospital intervention to reduce falls in high risk older people in primary care: a multi-centre randomised controlled trial [ISRCTN46584556] Factors associated with the initial acceptance of hip protectors amongst older people in residential care. Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: a randomised controlled trial. Effects of a programme of multifactorial home visits on falls and mobility impairments in elderly people at risk: randomised controlled trial Fall and Injury Prevention in Older People Living in Residential Care Facilities: A Cluster Randomized Trial Central Sydney Tai Chi Trial: methodology. Feasibility, safety and preliminary evidence of the effectiveness of a home-based exercise programme for older people with Alzheimer’s disease: a pilot randomized controlled trial Falls as a complication of diabetes mellitus in older people.
General practice p 994 Older people frequently fall . This is a serious public health problem , with a substantial impact on health and healthcare costs.1 These guidelines translate trial evidence about prevention of falls into recommendations that can be implemented in different setting s , with the aim of reducing the rate of falls and injurious falls in people over 65 ( see boxes 2 3 ) . # # # # Summary points Multifaceted interventions reduce falls in older people ( those over 65 ) Home assessment of older people at risk of falls without referral or direct intervention is not recommended Assessment of high risk residents in nursing homes with relevant referral is effective Evidence from well design ed single trials shows that assessment and modification of risk factors of older people who have presented to an accident and emergency department after a fall and the provision of hip protectors in residents of nursing homes are effective We up date d two previous systematic review s to include any new evidence up to March 1998 . 4 5 We electronically search ed Medline for all r and omised controlled trials and systematic review s by using the terms fall(s ) , accidental falls , fracture , elderly , aged , older , and senior . We followed up relevant references in papers , and we contacted research ers in prevention of falls for information about other trial evidence and about studies from journals not catalogued by the National Library of Medicine . For inclusion , studies had to be r and omised controlled trials of interventions design ed to minimise or prevent exposure to the risk factors for falling ( or fracture ) in people aged 65 years or over living in either community or residential care . Outcomes had to include the number of people who had fallen or the number of falls or fractures . We excluded drug or dietary treatments for the prevention of fractures . Trials that fulfilled the inclusion criteria were review ed and summarised Purpose : People with dementia fall more often than cognitively healthy older adults , but their risk factors are not well understood . A review is needed to determine a fall risk profile for this population . The objective was to critically evaluate the literature and identify the factors associated with fall risk in older adults with dementia . Methods : Articles published between January 1988 and October 2014 in EMBASE , PubMed , PsycINFO , and CINAHL were search ed . Inclusion criteria were participants aged 55 years or older with dementia or cognitive impairment , prospect i ve cohort design , detailed fall definition , falls as the primary outcome , and multi-variable regression analysis . Two authors independently review ed and extracted data on study characteristics , quality assessment , and outcomes . Adjusted risk estimates were extracted from the articles . Results : A total of 17 studies met the inclusion criteria . Risk factors were categorized into demographic , balance , gait , vision , functional status , medications , psychosocial , severity of dementia , and other . Risk factors varied with living setting and were not consistent across all studies within a setting . Conclusion : Falls in older adults with dementia are associated with multiple intrinsic and extrinsic risk factors , some shared with older adults in general and others unique to the disease . Risk factors vary between community- and institution-dwelling sample s of adults with dementia or cognitive impairment Background Falls are a significant public health problem . Thirty to fifty percent of the elderly of 65 years and older fall each year . Falls are the most common type of accident in this age group and can result in fractures and subsequent disabilities , increased fear of falling , social isolation , decreased mobility , and even an increased mortality . Several forms of exercise have been associated with a reduced risk of falling and with a wide range of physiological as well as psychosocial health benefits . Tai Chi Chuan seems to be the most promising form of exercise in the elderly , but the evidence is still controversial . In this article the design of a r and omized clinical trial is presented . The trial evaluates the effect of Tai Chi Chuan on fall prevention and physical and psychological function in older adults . Methods / Design 270 people of seventy years and older living at home will be identified in the files of the participating general practitioners . People will be asked to participate when meeting the following inclusion criteria : have experienced a fall in the preceding year or suffer from two of the following risk factors : disturbed balance , mobility problems , dizziness , or the use of benzodiazepines or diuretics . People will be r and omly allocated to either the Tai Chi Chuan group ( 13 weeks , twice a week ) or the no treatment control group . The primary outcome measure is the number of new falls , measured with a diary . The secondary outcome measures are balance , fear of falling , blood pressure , heart rate , lung function parameters , physical activity , functional status , quality of life , mental health , use of walking devices , medication , use of health care services , adjustments to the house , severity of fall incidents and subsequent injuries . Process parameters will be measured to evaluate the Tai Chi Chuan intervention . A cost-effectiveness analysis will be carried out alongside the evaluation of the clinical results . Follow-up measurements will be collected at 3 , 6 and 12 months after r and omization . Discussion As far as we know this is the first trial in Europe considering Tai Chi Chuan and fall prevention . This project will answer a pragmatic research question regarding the efficacy of Tai Chi Chuan regarding fall reduction Background and Purpose — Falls are an important issue in older people . We aim ed to determine the incidence , circumstances , and predictors of falls in patients with recent acute stroke . Methods — The Auckl and Regional Community Stroke ( ARCOS ) study was a prospect i ve population -based stroke incidence study conducted in Auckl and , New Zeal and ( NZ ) during 2002 to 2003 . Among 6-month survivors , the location and consequences of any falls were ascertained by self-report as part of a structured interview . Multivariable logistic regression was used to establish associations between risk factors and “ any ” and “ injurious ” falls . Results — Of 1104 stroke survivors who completed an interview , 407 ( 37 % ) reported at least 1 fall , 151 ( 37 % of fallers , 14 % of stroke survivors ) sustained an injury that required medical treatment , and 31 ( 8 % of fallers , 3 % of stroke survivors ) sustained a fracture . The majority of falls occurred indoors at home . Independent factors associated with falls were depressive symptoms , disability , previous falls , and older age . For injurious falls , the positively associated factors were female sex and NZ/European ethnicity and dependence before the stroke , whereas higher levels of activity and normal cognition were negatively associated factors . Conclusions — Falls are common after stroke , and their predictive factors are similar to those for older people in general . Falls prevention programs require implementation in stroke services Background : Research on older people ’s perception regarding their quality of life and services and supports needed to maintain their independence was identified as a priority for the South Australian Department of Health in 2000–2001 . This population survey was conducted to examine issues that older persons considered important in the areas of housing , transport , finances and information provision . Objective : The aim of this article is to present the characteristics of community-dwelling older adults who reported falling in the previous 12 months . Method : A r and om representative sample of community-dwelling adults , living in South Australia , and aged 65 years and over were selected based on a sample from the electronic white pages telephone directory . Overall , 2,619 interviews were conducted ( 70.5 % response rate ) using Computer-Assisted Telephone Interviewing technology . Results : Approximately 30 % of older adults had experienced a fall in the previous 12 months . The characteristics of people who had fallen included those in the older age groups , with fair or poor general health , whose health had worsened in the last 12 months , with lower socioeconomic status , those born in an English-speaking country , needing assistance at home , and with a home in need of repair . Of the respondents who had experienced a fall in the previous 12 months , 71.8 % did not consider that they were at risk of having another fall . Conclusion : There is a wide range of characteristics associated with community-dwelling older adults over the age of 65 who report falling in the previous 12 months . Perceptions of the risk of falling also vary . All factors need to be considered when targeting interventions to reduce the risk of both initial and multiple falls OBJECTIVE To determine the prevalence of , and risk factors for , receiving medical attention  for a recent injurious fall among middle-aged and older adults who have multiple sclerosis ( MS ) . DESIGN Survey . SETTING United States . PARTICIPANTS Seven hundred people with MS , age 55 years or older and living in the United States , were r and omly selected from the North American Research Committee on Multiple Sclerosis Registry and invited by mail to participate in the study . A total of 354 people , aged 55 to 94 years , completed the survey . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Participant 's self-report regarding receipt of medical care for a fall-related injury ( received care within the past 6mo , > 6mo ago , or never ) . RESULTS More than 50 % of study participants reported injurious falls ; 12 % , in the 6 months before the interview . Proportional odds models were used to identify factors associated with increased odds of receiving medical attention for a fall-related injury within the past 6 months . Compared with study participants who reported receiving medical attention for a fall-related injury more than 6 months ago or never , participants who reported receiving medical attention for a fall-related injury within the past 6 months were more likely to report fear of falling ( odds ratio [OR]=1.94 ; 95 % confidence interval [ CI ] , 1.27 - 2.96 ) and osteoporosis ( OR=1.65 ; 95 % CI , 1.03 - 2.62 ) . CONCLUSIONS Injurious falls were commonly reported by survey participants . Findings suggest that management of fear of falling and osteoporosis are important components of comprehensive fall-injury prevention programs for people aging with MS Background : multifactorial falls prevention programmes for older people have been proved to reduce falls . However , evidence of their cost-effectiveness is mixed . Design : economic evaluation alongside pragmatic r and omised controlled trial . Intervention : r and omised trial of 364 people aged ≥70 , living in the community , recruited via GP and identified as high risk of falling . Both arms received a falls prevention information leaflet . The intervention arm were also offered a ( day hospital ) multidisciplinary falls prevention programme , including physiotherapy , occupational therapy , nurse , medical review and referral to other specialists . Measurements : self-reported falls , as collected in 12 monthly diaries . Levels of health re source use associated with the falls prevention programme , screening ( both attributed to intervention arm only ) and other health-care contacts were monitored . Mean NHS costs and falls per person per year were estimated for both arms , along with the incremental cost-effectiveness ratio ( ICER ) and cost effectiveness acceptability curve . Results : in the base-case analysis , the mean falls programme cost was £ 349 per person . This , coupled with higher screening and other health-care costs , result ed in a mean incremental cost of £ 578 for the intervention arm . The mean falls rate was lower in the intervention arm ( 2.07 per person/year ) , compared with the control arm ( 2.24 ) . The estimated ICER was £ 3,320 per fall averted . Conclusions : the estimated ICER was £ 3,320 per fall averted . Future research should focus on adherence to the intervention and an assessment of impact on quality of life Objective : to determine the clinical effectiveness of a day hospital-delivered multifactorial falls prevention programme , for community-dwelling older people at high risk of future falls identified through a screening process . Design : multicentre r and omised controlled trial . Setting : eight general practice s and three day hospitals based in the East Midl and s , UK . Participants : three hundred and sixty-four participants , mean age 79 years , with a median of three falls risk factors per person at baseline . Interventions : a day hospital-delivered multifactorial falls prevention programme , consisting of strength and balance training , a medical review and a home hazards assessment . Main outcome measure : rate of falls over 12 months of follow-up , recorded using self-completed monthly diaries . Results : one hundred and seventy-two participants in each arm contributed to the primary outcome analysis . The overall falls rate during follow-up was 1.7 falls per person-year in the intervention arm compared with 2.0 falls per person-year in the control arm . The stratum-adjusted incidence rate ratio was 0.86 ( 95 % CI 0.73–1.01 ) , P = 0.08 , and 0.73 ( 95 % CI 0.51–1.03 ) , P = 0.07 when adjusted for baseline characteristics . There were no significant differences between the intervention and control arms in any secondary outcomes . Conclusion : this trial did not conclusively demonstrate the benefit of a day hospital-delivered multifactorial falls prevention programme , in a population of older people identified as being at high risk of a future fall The prevention of injury associated with falls in older people  is a public health target in many countries around the world . Although there is good evidence that interventions such as multifactorial fall prevention and individually prescribed exercise are effective in reducing falls , the effect on serious injury rates is unclear . Historically , trials have not been adequately powered to detect injury endpoints , and variations in case definition across trials have hindered meta- analysis . It is possible that fall-prevention strategies have limited effect on falls that result in injuries or are ineffective in population s who are at a higher risk of injury . Further research is required to determine whether fall-prevention interventions can reduce serious injuries . Prevention of Falls Network Europe ( ProFaNE ) is a collaborative project to reduce the burden of fall injury in older people through excellence in research and promotion of best practice ( www.profane.eu.org ) . The European Commission funds the network , which links clinicians , members of the public , and research ers worldwide . The aims are to identify major gaps in knowledge in fall injury prevention and to facilitate the collaboration necessary for large-scale clinical research activity , including clinical trials , comparative research , and prospect i ve meta- analysis . Work is being undertaken in a 4-year program . As a first step , the development of a common set of outcome definitions and measures for future trials or meta- analysis was considered Falls among people aged 65 and older are a significant public health problem and one that is expected to increase as the population ages . R and omized controlled trials have demonstrated that Tai Ji Quan can reduce falls and associated injuries among older adults . In this paper , we describe how Tai Ji Quan community programs are being utilized by public health and aging services organizations to reduce older adult falls . We conclude that , to have a population -level impact on reducing falls and improving the health of older adults , Tai Ji Quan interventions must be translated into community programs that meet the needs and abilities of older adults . These programs must be adapted to fit into existing community structures , disseminated through multiple delivery channels , adopted and implemented broadly by organizations , and institutionalized to ensure sustainability Falls and their consequences are serious health problems among older population s. To study predisposing and precipitating factors for falls among older people in residential care we used a cross-sectional study design with a prospect i ve follow up for falls . Fifty-eight women and 25 men , with a mean age of 79.6 y , were included and prospect ively followed up regarding falls for a period of 1 y after baseline assessment s. All those who fell were assessed regarding factors that might have precipitated the fall . The incidence rate was 2.29 falls/person years . Antidepressants ( selective serotonin reuptake inhibitors , SSRIs ) , impaired vision and being unable to use stairs without assistance were independently associated with being a ' faller ' . Twenty-eight ( 53.8 % ) of the fallers suffered injuries as a result of their falls , including 21 fractures . Twenty-seven percent of the falls were judged to be precipitated by an acute illness or disease and 8.6 % by a side effect of a drug . Acute symptoms of diseases or drug side effects were associated with 58 % of the falls which result ed in fractures . We conclude that SSRIs seem to constitute one important factor that predisposes older people to fall , once or repeatedly . Since acute illnesses and drug side-effects were important precipitating factors , falls should be regarded as a possible symptom of disease or a side-effect of a drug until it is proven otherwise OBJECTIVES To investigate relationships between the use of cardiovascular medications , including angiotensin system-blocking medications ( ASBMs ) , orthostatic hypotension ( OH ) , fall risk , and falls in community-dwelling older people . DESIGN Prospect i ve cohort study . SETTING Sydney , Australia . PARTICIPANTS Five hundred twenty community-dwelling older adults . MEASUREMENTS Medical , medication and falls history were obtained from a st and ardized question naire in all participants . Blood pressure was measured in supine , seated , and tilted positions . Fall risk was assessed using the Physiological Profile Assessment ( PPA ) . Falls data were collected prospect ively for 12 months using monthly fall calendars . Participants were defined as nonfallers ( no falls ) and fallers ( ≥ 1 falls ) at the end of the 12-month follow-up . RESULTS Participants taking medications affecting the angiotensin system had greater quadriceps strength , but after adjusting for sex , this difference became insignificant . People taking ASBMs were less likely to fall ( odds ratio = 0.68 , 95 % confidence interval = 0.48 - 0.97 ) , and the association between ASBMs and falls remained significant after adjusting for sex , body mass index , PPA score , and psychotropic medication and 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor ( statin ) use . OH was more frequently observed in participants taking alpha adrenergic receptor blockers ( α-blockers ) , but the presence of OH did not increase fall risk . CONCLUSION The use of cardiovascular medications in older people did not increase the risk of falls , and the use of ASBMs was associated with lower fall risk . The mechanisms for this apparent protective effect are unclear and appear not to be directly related to muscle strength . More research is required to eluci date the possible protective effects of certain cardiovascular medications in relation to falls in older people Background Disability and falls are particularly common among older people who have recently been hospitalised . There is evidence that disability severity and fall rates can be reduced by well- design ed exercise interventions . However , the potential for exercise to have these benefits in older people who have spent time in hospital has not been established . This r and omised controlled trial will investigate the effects of a home-based exercise program on  disability and falls among people who have had recent hospital stays . The cost-effectiveness of the exercise program from the health and community service provider 's perspective will be established . In addition , predictors for adherence with the exercise program will be determined . Methods and design Three hundred and fifty older people who have recently had hospital stays will participate in the study . Participants will have no medical contraindications to exercise and will be cognitively and physically able to complete the assessment s and exercise program .  The primary outcome measures will be mobility-related disability ( measured with 12 monthly question naires and the Short Physical Performance Battery ) and falls ( measured with 12 monthly calendars ) . Secondary measures will be tests of risk of falling , additional measures of mobility , strength and flexibility , quality of life , fall-related self efficacy , health-system and community-service contact , assistance from others , difficulty with daily tasks , physical activity levels and adverse events . After discharge from hospital and completion of all hospital-related treatments , participants will be r and omly allocated to an intervention group or usual-care control group . For the intervention group , an individualised home exercise program will be established and progressed during ten home visits from a physiotherapist . Participants will be asked to exercise at home up to 6 times per week for the 12-month study period . Discussion The study will determine the impact of this exercise intervention on mobility-related disability and falls in older people who have been in hospital as well as cost-effectiveness and predictors of adherence to the program . Thus , the results will have direct implication s for the design and implementation of interventions for this high-risk group of older people . Trial Registration The protocol for this study is registered with the Australian New Zeal and Clinical Trials Registry ACTRN12607000563460 In July the Department of Health ( DH ) in Engl and published a toolkit of re sources to promote more effective services to reduce the burden of  falls and fractures in older people . Unfortunately , there is plenty of evidence that the present provision of falls services is suboptimal . The toolkit is part of a ‘ Prevention Package ’ aim ed primarily at commissioners of care , in an attempt to achieve a more consistent and integrated approach to a range of prevention issues in older people [ 1 ] . Falls are a major international public health challenge because of the myriad effects on older individuals : direct physical and psychological injury ; fear of falling and activity limitation ; reduced social participation and quality of life ; increased dependence [ 2–5 ] ; and because of the economic impact on health and social care providers [ 6 , 7 ] . Studies from various countries have shown that about one third of people aged above 65 years fall each year . In UK primary care population s , the rate rises with age to over 60 % of nonagenarians , and is generally higher in women [ 8 ] and in socio-economically deprived population s [ 9 ] . Fragility fractures are the commonest significant injury , 300,000 annually in the UK including upwards of 70,000 hip fractures . Many falls go unreported , but nevertheless they account for 40 % of UK ambulance call-outs , with the variable proportion being conveyed to hospital accounting for one in ten Emergency Department ( ED ) attendances of the over 75s [ 6 ] , a third of whom are admitted , thus comprising about 14 % of emergency admissions . Identifying all falls related activity is challenging but recent estimates suggest that it accounts for between 10 % and 25 % of all local health and social care spending on older people [ 10 ] . Care of fragility fractures is particularly expensive , total health and social care costs in the UK being around £ 2 billion , most of which relates to hip fractures [ 11 ] . Current population and incidence projections suggest that by 2020 , this figure will rise by 50 % . Early in the development of geriatric medicine , falls were identified as a ‘ geriatric giant’—adverse in their own right but also a non-specific indicator of functional decompensation . Building on clarification of falls risk factors [ 12 ] , r and omised controlled trials demonstrated the effectiveness of risk factor based multi-factorial interventions [ 13 , 14 ] . This led to the notion of ‘ falls prevention services ’ . Based on international consensus about what constituted best clinical practice [ 15 ] , broadly similar policies have been developed by the responsible government departments of the four UK nations , and in Irel and [ 16 ] . The National Service Framework for Older People in Engl and ( NSF , 2001 ) [ 17 ] required health services and their local council partners to develop integrated services by April 2005 , incorporating case finding , assessment and referral systems and specialist falls and fragility fracture services . The NSF was launched without earmarked implementation funding , but there was plenty of activity , some enabled and directed by various government initiatives , encouraging community engagement . An independent postal question naire survey to health and social care agencies about their falls services in 2004 [ 18 ] reported most having made plans for an integrated service but implementation was patchy and focused on widely differing priorities . Only 30 % included systems for identifying high risk individuals and only 13 % of falls prevention programmes included exercise classes , the most effective prevention strategy [ 19 ] whilst interventions with little or no evidence base were promoted [ 20 ] . Implementation of these policies across Engl and , Wales and Northern Irel and has been monitored in a series of government funded national audits run by the Royal College of Physicians of London ( RCP ) . The first of these confirmed major gaps at the organisational level , particularly in case finding and referrals for secondary prevention [ 21 ] . A subsequent patient level clinical care audit of fragility fracture patients showed that most returning home from the Emergency Department were not offered a falls risk assessment and only one third were on appropriate treatment for osteoporosis 3 months later [ 22 ] . Despite intense interest among clinicians in the UK and appointment of many geriatricians with a focus on falls , syncope and orthogeriatrics , a repeat organisational audit showed that by 2008 there had been little improvement in service structure , capacity or processes [ 23 ] . Meanwhile the picture was clouded by the negative results of a DH funded systematic review with meta-analyses [ 24 ] . This suggested that the variable outcomes of clinical trials might be associated with the way that the multifactorial approach was organised . There are now several negative outcome trials employing the strategy of nurse led case finding linked to interventions intended to be provided by a range of unconnected professions acting on referral [ 25 ] . In clinical practice , it is likely that there is even more differential effectiveness depending on case finding and referral practice s and context ual differences in service delivery . Research evidence is still lacking on how to achieve much that the NSF aspired to , but there is sufficient evidence and examples of successful implementation to do much better than most are currently doing . So how will the latest government action help ? A key step is to clarify priorities and to put available re sources into the activities likely to make OBJECTIVES To better underst and fall risk factors in older adults with cognitive impairment living in residential care . DESIGN A prospect i ve observational cohort study . SETTING Residential care homes in South London , UK . PARTICIPANTS Residents older than 60 , with cognitive impairment who had a life expectancy of at least 6 months and were not bedbound or recently discharged from hospital . MEASUREMENTS Baseline assessment s were undertaken in domains of demographics , medical history , medication use , behavior , affect , gait , balance , sensorimotor performance and neuropsychological function . Participants were followed for 6 months for falls using care home reporting systems . RESULTS A total of 109 participants completed baseline assessment and had adequate falls follow-up . Fallers took more medications , were more likely to be taking antidepressants , had more functional impairment , poorer balance and gait , were more impulsive and anxious , exhibited more dementia-related behaviors , and performed worse on cognitive tests involving attention and orientation , memory , and fluency . Logistic regression analysis identified 4 significant and independent predictors of falls : poor attention and orientation , increased postural sway with eyes closed , anxiety , and antidepressant use . The AUC for this model was 0.84 ( 95 % CI 0.76 - 0.91 ) . CONCLUSIONS This study identified important risk factors for falls potentially amenable to intervention in older people with cognitive impairment living in residential care . This information may be useful in design ing effective approaches to fall prevention in this high-risk population Falls in older people are a major public health concern in terms of morbidity , mortality and cost . Previous studies suggest that multifactorial interventions can reduce falls , and many geriatric day hospitals are now offering falls intervention programmes . However , no studies have investigated whether these programmes , based in the day hospital are effective , nor whether they can be successfully applied to high-risk older people screened in primary care . The hypothesis is that a multidisciplinary falls assessment and intervention at Day hospitals can reduce the incidence of falls in older people identified within primary care as being at high risk of falling . This will be tested by a pragmatic parallel-group r and omised controlled trial in which the participants , identified as at high risk of falling , will be r and omised into either the intervention Day hospital arm or to a control ( current practice ) arm . Those participants preferring not to enter the full r and omised study will be offered the opportunity to complete brief diaries only at monthly intervals . This data will be used to vali date the screening question naire . Three day hospitals ( 2 Nottingham , 1 Derby ) will provide the interventions , and the University of Nottingham 's Departments of Primary Care , the Division of Rehabilitation and Ageing Unit , and the Trent Institute for Health Service Research will provide the method ological and statistical expertise . Four hundred subjects will be r and omised into the two arms . The primary outcome measure will be the rate of falls over one year . Secondary outcome measures will include the proportion of people experiencing at least one fall , the proportion of people experiencing recurrent falls ( > 1 ) , injuries , fear of falling , quality of life , institutionalisation rates , and use of health services . Cost-effectiveness analyses will be performed to inform health commissioners about re source allocation issues . The importance of this trial is that the results may be applicable to any UK day hospital setting .SitesGeneral practice s across Nottinghamshire and Derbyshire . Day hospitals : Derbyshire Royal Infirmary ( Southern Derbyshire Acute Hospitals NHS Trust)Sherwood Day Service ( Nottingham City Hospital Trust)Leengate Day Hospital ( Queen 's Medical Centre Nottingham University Hospital NHS Trust Factors associated with the initial acceptance of hip protectors amongst older people in residential care SIR — Hip fractures in older people are a major public health problem . Hip protectors have been advocated as a means of preventing hip fractures in this group [ 1 ] . The impact of hip fracture and methods of prevention can be found in Appendix 1 of the supplementary data on the journal website ( http://www.ageing.oxfordjournals.org/ ) . Many older people refuse hip protectors when initially offered [ 2–6 ] . Across a range of studies , initial acceptance of hip protectors ranged from 37 to 72 % with a median of 68 % [ 7 ] . Increasing acceptance rates is an important goal , therefore . The National Patient Safety Agency ( NPSA ) is interested in the use of hip protectors as a way of preventing fractures amongst older people .  ' Slips , trips and falls ' accounted for 53 % of incidents reported to the NPSA during January – June 2003 . Two per cent of all incidents result ed in serious harm ( NPSA , unpublished report ) . The NPSA commissioned this work to answer the following questions for older people living in residential care homes : ( i ) What factors influence the acceptance of hip protectors ? ( ii ) Do those factors account for the variations in acceptance between care homes ? There are published studies relating to residents of nursing homes and amongst community-dwelling older people that consider a limited range of predictive factors for initial acceptance [ 3 , 5 , 6 ] . There has been no previous published work , however , relating to residential care homes that sought answers these questions . Method This investigation used data from The East Kent Hip Protector Study , a prospect i ve study with 6 months follow-up amongst people aged 65 and over living in residential care homes with 20 or more beds . The methods used in this study were presented elsewhere [ 4 ] . A synopsis is presented in Appendix 2 in the supplementary data on the journal web-site ( http://www.ageing.oxfordjournals.org/ ) . Research ethical approval was obtained prior to the start of this work . The mean age of the study subjects was 86 , they were predominantly female ( 80 % ) , and many had difficulty with ambulation ( e.g. 55 % used a walking aid ) . Assessment Every resident was offered a single assessment ( developed for this work ) , on entry to the study by a project nurse , to identify modifiable risk factors for falling . It included questions on the demographic characteristics of the residents , long-term medical problems ( i.e. arthritis , stroke , diabetes and Parkinson 's disease ) , dizziness , ability to transfer , assistance with walking and with BACKGROUND Falls and related injuries are a major public health concern in elderly people .  Multifactorial interventions may result in significant reduction in falls but their effectiveness in prevention of fall-induced injuries at centre-based falls clinics is unclear . This study assessed the effectiveness of the multifactorial Chaos Clinic Falls Prevention Programme on rate of falls and related injuries of home-dwelling older adults . METHODS This study was a pragmatic , r and omised controlled trial concentrating on high risk individuals and their individual risk factors of falling . Home-dwelling elderly people aged 70 years or more were recruited to the Chaos falls clinics in the cities of Lappeenranta and Tampere in Finl and between January 2005 and June 2009 . 1314 participants with high-risk for falling and fall-induced injuries and fractures were r and omised into  intervention group ( n=661 ) and control group ( n=653 ) . A multifactorial , individualized 12-month falls prevention programme concentrating on strength and balance training , medical review and referrals , medication review , proper nutrition ( calcium , vitamin D ) , and home hazard assessment and modification was carried out in the intervention group . The main outcome measures were rates of falls , fallers , and fall-induced injuries . RESULTS During the one-year follow-up , 608 falls occurred in the intervention group and 825 falls in the control group . The rate of falls was significantly lower in the intervention group ( 95 falls per 100 person-years ) than in the controls ( 131 falls per 100 person-years ) , the incidence rate ratio ( IRR ) being 0.72 ( 95 % confidence interval ( CI ) 0.61 - 0.86 , p<0.001 , NNT 3 ) . In the intervention group 296 participants fell at least once . In the controls the corresponding number was 349 . The hazard ratio ( HR ) of fallers in the intervention group compared with the control group was 0.78 ( 95 % CI 0.67 - 0.91 , p=0.001 , NNT 6 ) . The number of fall-induced injuries in the intervention group was 351 with the corresponding rate ( per 100 person-years ) of 55 . In the control group , these figures were higher , 468 and 75 . The IRR of fall-induced injuries in the intervention group compared with the control group was 0.74 ( 95 % CI 0.61 - 0.89 , p=0.002 , NNT 5 ) . CONCLUSIONS The multifactorial Chaos Clinic Falls Prevention Programme is effective in preventing falls of older adults .  The programme reduces the rate of falls and related injuries by almost 30 % Abstract Objective : To evaluate whether a programme of multifactorial home visits reduces falls and impairments in mobility in elderly people living in the community . Design : R and omised controlled trial with 18 months of follow up . Setting : Six general practice s in Hoensbroek , the Netherl and s. Participants : 316 people aged 70 and over living in the community , with moderate impairments in mobility or a history of recent falls . Intervention : Five home visits by a community nurse over a period of one year . Visits consisted of screening for medical , environmental , and behavioural factors causing falls and impairments in mobility , followed by specific advice , referrals , and other actions aim ed at dealing with the observed hazards . Main outcome measures : Falls and impairments in mobility . Results : No differences were found in falls and mobility outcomes between the intervention and usual care groups . Conclusion : Multifactorial home visits had no effects on falls and impairments in mobility in elderly people at risk who were living in the community . Because falls and impairments in mobility remain a serious problem among elderly people , alternative strategies should be developed and evaluated Context In frail older people living in residential care facilities , hip protectors reduce fall-related femoral and pelvic injuries . In older people living in the community , prevention programs that target exercise and fall-related risk factors reduce falls and injuries . In older people living in residential care facilities , fall prevention programs , other than the use of hip protectors , have had mixed results . Contribution This r and omized trial shows that a multidisciplinary fall prevention program reduces falls and femoral fractures in older people living in residential care facilities . The program included general as well as resident-specific , tailored strategies . Editors ' Note The Cochrane Library ( Issue 3 , 2001 ) has two systematic review s that summarize r and omized trial evidence about interventions to prevent falls . The Editors Falls are a major problem in older people ( 1 , 2 ) . Hip fractures result ing from falls are particularly common in elderly persons living in residential care facilities ( 3 , 4 ) ; they account for a substantial proportion of dependency and mortality ( 5 ) . During the past decade , r and omized , controlled trials study ing fall prevention have shown both positive and negative results ( 6 - 8 ) . Differences in target groups , interventions , and outcome measures may explain the inconsistent results . In residential care facilities and nursing homes , only one trial demonstrated that intervention programs may help prevent falls ; however , this trial studied only people who fell repeatedly ( 9 ) . Other trials have not shown reductions in falls or injuries ( 10 - 13 ) but have shown fewer hospital admissions ( 11 ) and improvements in mobility ( 12 ) , visual acuity , and hypotension ( 13 ) . The use of hip protectors has consistently proved effective in preventing hip fractures in selected high-risk population s ( 14 ) . Some trials that have included cognitively healthier older people in the community have shown reduced falls and injuries when specific risk factors are targeted ( 15 - 18 ) . However , evidence is lacking for older people living in institutions ( 19 ) . We hypothesized that an intervention program that targeted multiple risk factors for falls in older people living in residential care facilities , in particular those with a high risk for falling , would reduce falls and fall-related injuries . We therefore conducted a cluster r and omized trial for preventing falls in nine residential care facilities . Methods Design Study participants were older people living in residential care facilities located in Ume , a city in northern Sweden . The selected facilities had to have more than 25 residents . The nine that met this criterion were divided into group A and group B. The distribution was based on the age and number of residents , type of setting ( care and service offered as well as corridor or private home design ) , and record of previous falls as routinely reported to the local authority . To keep the groups distinct from one another , the physicians , registered nurses , physical therapists , and occupational therapists who were responsible for working with the residents in group A could not also work with group B residents . Group A consisted of four facilities that accommo date d 224 residents ; the facilities had 29 to 74 residents each , and the median age by facility ranged from 82 to 85 years . Group B consisted of five facilities with a total of 215 residents ; there were 31 to 66 residents per facility , and the median age by facility ranged from 79 to 85 years . The number of falls reported to the local authorities in the 2.5 years preceding the trial was similar for both groups : 1.26 per resident per year for group A and 1.29 for group B. After baseline assessment of all residents , groups A and B were r and omly assigned by lots to an intervention or a control group ( Figure 1 ) . The r and om allocation was conducted by a person with no knowledge of the study . Two sealed , dark envelopes were used . In each envelope , a letter specified one of the groups . Before the lot was drawn , the first envelope drawn was design ated as the intervention group . The local authorities , residents , staff of the nine facilities , and the research group were then informed of the results of the r and omization . Figure 1 . Study design . All residents in the study received written and oral information . All participants ( or the relatives and guardians of participants with severe cognitive dysfunction ) gave informed consent . The administrators and staff of the nine facilities involved also received information about the study and agreed to participate . The Ethics Committee of the Medical Faculty of Ume University approved the study . Definition of a Fall and an Injury A fall was defined as an event in which the resident unintentionally came to rest on the ground or floor , regardless of whether an injury was sustained . Thus , this definition also includes falls that result ed from acute illness or epileptic seizure and incidents that result ed in a resident 's falling and being found on the floor by staff or another resident . An injury was defined according to the Abbreviated Injury Scale ( 20 ) . Classifications were minor for injuries limited to superficial wounds and bruises ; moderate for intermediate-level injuries , such as vertebral and wrist fractures ; and serious for major fractures , such as hip fractures and other femoral fractures . Participants and Setting s All residents in the nine facilities who were 65 years of age or older were selected in a cross-sectional manner . Thirty-seven of these residents declined to participate , were admitted to hospitals , or died before r and omization . Sex and age of the 37 non participants were similar to those of the remaining 402 residents . In Sweden , older people living in residential care facilities are disabled by cognitive or physical impairment and thus require supervision , functional support , or nursing care . In this study , some residents lived in private apartments and others had private rooms but shared dining and living rooms . In all facilities , residents had 24-hour daily access to assistance with activities of daily living , household issues , and medical care . The median age was 83 years ( range , 65 to 100 years ) , and most residents were female ( 72 % ) . Few residents could walk outdoors without a walking aid ( 14 % ) or shower without assistance ( 18 % ) ; few were nonambulatory ( 19 % ) or entirely dependent when eating ( 8 % ) . Additional baseline characteristics are presented in the Table . Table . Baseline Characteristics of the 402 Residents Participating in the Study All members of the permanent staff , regardless of profession , participated in the study . In addition , eight physiotherapists were employed part-time ( a total of 200 h/wk ) until the end of the intervention period , and three physiotherapists were employed part-time ( a total of 10 h/wk ) during the follow-up period . A total of 273 nurses ' aides or licensed practical nurses and 20 registered nurses worked at the nine facilities . Baseline Assessment Each resident 's physician completed a question naire regarding clinical characteristics and drugs prescribed . A registered nurse reported delirium episodes ( Table ) . Physiotherapists interviewed and assessed all residents . Hearing was rated as impaired if the resident could not hear normal speech from a distance of 1 meter or used a hearing aid . Vision was rated as impaired when the resident , with or without glasses , could not read a word written in 5-mm capital letters at reading distance . Global cognitive function was screened by using the Mini-Mental State Examination ( MMSE ) ( 21 ) . Licensed practical nurses or nurses ' aides were interviewed to determine the number of falls that had occurred during the 6 months preceding the study and the extent of use of physical restraints . Activities of daily living were assessed according to the Barthel index ( 22 , 23 ) . All residents were screened for the risk for falling . First , by using the Mobility Interaction Fall Chart ( 24 ) , a resident was classified to be at higher risk for falling if he or she stopped walking when talking to an accompanying person ( 25 ) , walked more slowly when carrying a glass of water ( 26 ) , or had impaired vision or difficulty concentrating . Second , a physiotherapist globally rated the fall risk as higher if the resident showed risk-taking behavior considered to jeopardize balance . If the residents were not classified to be at higher risk for falling by any of these described measures , they were considered to be at lower risk for falling . Residents at higher risk were likely to be older than those at lower risk ( median age , 84 years [ range , 65 to 98 years ] vs. 83 years [ range , 65 to 100 years ] ) , to have lower MMSE scores ( median score , 17 [ range , 0 to 30 ] vs. 21 [ range , 0 to 30 ] ) , and to have more medical diagnoses ( median , 4 vs. 3 ) . The main areas of each facility were also screened according to a checklist for environmental hazards , such as lighting , flooring , obstacles inside the facility , and dangerous areas outside the facility ( for example , icy areas ) . Twelve residents in the control group and six in the intervention group died or moved during the 11-week intervention period ( Figure 1 ) . Intervention Program The intervention program comprised strategies that targeted both general and resident-specific risk factors for falling . The strategies were design ed to be meaningful to the residents without compromising mobility . The 89 residents screened as being at higher risk as well as the 19 residents at lower risk who fell during the 11-week intervention period were the focus of the individualized intervention program . Increasing the staff 's knowledge about fall prevention was believed to be the starting point of a process that would produce long-term results . Staff Education All staff were invited to a 4-hour educational session , and more than half attended . The sessions were led by a physician and a physiotherapist and covered risk factors for falls and intervention Falls are a significant health risk for older people , and can result in fractures that , with increasing age , can lead to medical and social complications , which can further result in a decrease in quality of life . In NSW , dem and on health re sources due to injuries result ing from falls in older people is increasing Objective : To evaluate the feasibility and safety of a home-based exercise programme for people with Alzheimer ’s disease , and to provide preliminary evidence of programme effectiveness in improving balance and mobility and reducing falls risk . Design : A r and omized controlled trial . Setting : Community . Participants : Forty people with mild to moderate Alzheimer ’s disease ( mean age 81.9 , SD 5.72 ; 62.5 % female ) . Interventions : Participants were r and omized to a six-month home-based individually tailored balance , strengthening and walking exercise programme ( physiotherapist ) or a six-month home-based education programme ( control ) ( occupational therapist ) . Both programmes provided six home-visits and five follow-up phone calls . Main measures : Balance , mobility , falls and falls risk were measured at baseline and programme completion . Intention-to-treat analysis using a generalized linear model with group allocation as a predictor variable was performed to evaluate programme effectiveness . Feasibility and adverse events were systematic ally recorded at each contact . Results : Fifty-eight per cent of the exercise group finished the programme , completing an average of 83 % of prescribed sessions , with no adverse events reported . Functional Reach improved significantly ( P = 0.002 ) in the exercise group ( mean ( SD ) , 2.28 ( 4.36 ) ) compared to the control group ( –2.99 ( 4.87 ) ) . Significant improvement was also observed for the Falls Risk for Older People – Community score ( P = 0.008 ) and trends for improvement on several other balance , mobility , falls and falls risk measures for the exercise group compared to the control group . Conclusions : The exercise programme was feasible and safe and may help improve balance and mobility performance and reduce falls risk in people with Alzheimer ’s disease OBJECTIVES The aims of this study were to determine the incidence of falls in a group of elderly patients with diabetes and to assess for the prevalence of risk factors for falls in this population . DESIGN This is a population -based study with question naire-based interviews . SETTING The setting for this study was the London District General Hospital outpatient department . PARTICIPANTS Seventy-seven patients with diabetes , aged over 65 years , r and omly selected whilst attending for general diabetic annual review . Patients with dementia , blindness , and immobility and those who were unable to give informed consent were excluded from this study . MEASUREMENTS The incidence of falls in the last 12 months was used . Information was collected on the incidence of hypoglycaemic episodes , the presence of other medical conditions , visual impairment , and peripheral neuropathy , the use of medications and walking aids , and HbA1C and blood pressure control . RESULTS The incidence of falls was 39 % . Falls occurred more frequently in female patients and patients of increasing age . Falls occurred more frequently in patients with poor diabetic control [ risk ratio (RR)=7.83 ( 2.948 - 20.799 ) , chi2 value=6.422 ] ; patients requiring assistance with mobility : for those mobile with a stick [ RR=1.839 ( 1.048 - 3.227 ) , chi2=4.619 ] ; and those who had previously suffered a stroke [ RR=1.929 ( 1.143 - 3.257 ) , chi2=4.615 ] . CONCLUSION We provide evidence that poorly controlled diabetes and conditions associated with complications of diabetes are associated with an increased risk of falling in older people . We recommend early recognition of the multiple causes of falls in the older diabetic patient and prompt referral of this group of patients to a specialist falls clinic
Conclusions The use of sedatives and hypnotics and antidepressants including tricyclic antidepressants , selective serotonin reuptake inhibitors , and serotonin norepinephrine reuptake inhibitors appears to be related with an increased risk of falls .
It is not clear if the use of antihypertensive medications is associated with the risk of falls in older people
Purpose Falls are an important public health problem in older people .
Medication use is considered a risk factor for falls .
This study systematic ally review ed recent studies to determine the medications that might be associated with the risk of falling in older people .