What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls?

Summary

The issue

Older people make up a large and increasing percentage of the population. As people grow older they are increasingly at risk of falling and consequent injuries. A fall may be the first indication of an undetected illness. The prevention of falls is of major importance because they engender considerable mortality, morbidity and suffering for older people and their families, and incur social costs due to hospital and nursing home admissions.

Findings

Approximately 30% of people over 65 fall each year, and for those over 75 the rates are higher. Between 20% and 30% of those who fall suffer injuries that reduce mobility and independence and increase the risk of premature death. Fall rates among institution residents are much higher than among community-dwellers.

Fall prevention programmes can be effective in reducing the number of people who fall and the rate of falls. Targeted strategies aimed at behavioural change and risk modification for those living in the community appear to be most promising. Multifactorial intervention programmes that include risk factor assessment and screening have been shown to be effective. However, no screening tools have been rigorously validated across countries and further work is needed in this area.

The use of physical and pharmacological restraints leads to more severe injuries from falls. Patients with cognitive impairment in hospital after a fall have not benefited from multifactorial interventions, but cognitively impaired residents of care facilities have responded to tailored fall prevention. It seems likely that fall prevention programmes can be cost effective, although more research is required.

Policy considerations

Unless concerted action is taken, the number of falls is likely to increase over the next 25 to 30 years. A number of interventions targeted to individuals have been shown to work, but population-based strategies have not been properly evaluated. This points to the need for monitoring and further evaluation.

Health and social care agencies need to work together to prioritize fall prevention as part of their overall strategy for promoting healthy ageing. Coherent multidisciplinary programmes can be developed at the national level. These should be implemented with national data collection mechanisms to evaluate interventions by outcome (e.g. fall/fracture rates) rather than process (people seen) or structure (clinics set up). Effective interventions used in a multifactorial programme include:

• home-based professionally prescribed exercise, to promote dynamic balance, muscle strengthening and walking 
• group programmes based on Tai Chi-type exercises or dynamic balance and strength training as well as floor coping strategies
• home visits and home modifications for older people with a history of falling
• medication review, particularly for those on four or more medicines and withdrawal of psychotropic medications where feasible.