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date: 03 December 2022

Fall Prevention and Interventions for Older Peoplefree

Fall Prevention and Interventions for Older Peoplefree

  • Claudia MeyerClaudia MeyerBolton Clarke Research Institute
  •  and Lindy ClemsonLindy ClemsonFaculty of Medicine and Health, The University of Sydney

Summary

Across the globe, falls among older people can have grave consequences for individuals and for the healthcare and aged-care systems more broadly. The synergy between intrinsic and situational risk factors adds complexity to the identification and management of falls, as does the public health response at primary, secondary, and tertiary levels of prevention. Falls among people age 65 years and over are recognized as a geriatric syndrome and as a marker of frailty, with increasing rates among those experiencing other chronic conditions, such as Parkinson’s disease, stroke, and dementia.

Prevention or management of falls requires a combination of strategies as single or multicomponent interventions. Multimodal exercise, combining balance and functional exercise, environmental adaptation, medication reduction and withdrawal, cataract surgery, single-lens glasses, vitamin D supplementation, management of foot problems and footwear, and cardiac pacing have a degree of evidence to support their implementation. Multicomponent programs, such as i-FOCIS and PDSAFE, have important benefits for specific population groups.

Importantly, over the past few decades, falls prevention has shifted from a biomedical approach to a holistic biopsychosocial model. This model aids promotion of a whole-of-community approach through building healthy public policy, creating supportive environments, and strengthening personal skills and community action. The biopsychosocial approach also focuses attention on understanding local contexts, ensuring that falls prevention interventional research can be adapted and fit-for-purpose for low-, middle- and high-income countries.

The uptake of falls prevention evidence into practice and policy still faces challenges and new frontiers. Supporting the adoption, implementation, and sustainability of interventions is complex at the individual level, the service provider level, and the healthcare system level. Practice-change frameworks and models are useful, such as those utilized in the Stopping Elderly Accidents, Deaths and Injuries (USA), iSOLVE (Australia), and STRIDE (USA) trials.

Falls prevention is complex, yet solutions can be relatively simple. Working together with older people, health professionals and community health leaders can champion ways of bringing falls prevention activities to scale. Research collaboration between stakeholders is a crucial mechanism for drawing together unique perspectives to address ongoing gaps and concerns.

Subjects

  • Special Populations

Nobody Wishes to Fall, But Falls Are a Reality

Gina Rossi is 78 years old and lives alone, although her niece, 50 years old, is a regular visitor. At a recent annual check-up that included completing the Stay Independent checklist (Clemson et al., 2017, 2020), Gina’s physician discovered that she often feels unsteady when walking, has foot pain that lasts more than a day, and has been concerned about falling. Her physician was surprised to find out she had fallen several times. Once, as she was walking outside her house to collect her mail, Gina stumbled over loose pavement, fell, and bruised herself. Another time, at night, Gina fell in a dark hallway when she went to the bathroom. The falls reminded her of a fall a few years earlier when she fell running for the bus and ended up in the Emergency Department with a cut on her arm. She admitted that she used to be an outgoing person and enjoyed walks to the park with a few of her neighbors. However, she is now worried about falling every time she ventures out, and it would be embarrassing if someone were to see her fall. Her doctor encouraged her, telling her that there are some things she can do to reduce her chances of further falls and to maintain her independence. He examined her feet and found large bunions but no other lesions. He referred her to an exercise physiologist, prescribing balance and lower limb strength exercises and ankle/foot exercises for her foot pain. He also referred her to an occupational therapist for a home safety review and to her podiatrist for an assessment.

At a later visit, Gina reported to her physician that she had followed through with all the referrals and was feeling safer and positive. Her front path and steps are now safer, having been fitted with nonslip strips, and she has a night light in the hallway. After working with the exercise physiologist, she has graduated to a group-based exercise class, which she enjoys, and she has met some new people (iSOLVE Integrated Solutions for Sustainable Fall Prevention Project, (Clemson et al 2017, 2020).

What is a Fall?

Falls among older people (age 65 years and older) are a worldwide concern, possibly indicating a reduction in intrinsic capacity (World Health Organization [WHO], 2015) and posing risks to autonomy and independence (McMahon et al., 2011). Falls are a complex phenomenon resulting from an interplay between a person’s individual biology and predisposing and situational factors, such as the person’s behavior and environment (Rubenstein & Josephson, 2006; WHO, 2021a). A fall, as defined by the WHO, is “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (WHO, 2021a). Falls are a challenging health problem for the individual and from a public health perspective for the healthcare system.

Complex problems cannot be solved with simple solutions. The complete prevention of falls is not possible, yet a comprehensive approach to reducing the risk of falls and the harm experienced from a fall is within reach. Earlier important advances in fall-prevention research revolved around the identification and management of individual risk factors. Current research is striving to enhance this knowledge by identifying the interaction and synergy between risk factors to better understand fall risk reduction (Fox et al., 2010).

What Are the Impacts of Falls?

Approximately one in three older people living in the community will have a fall in any given year (Tinetti & Williams, 1997), with a subsequent threefold risk of falling again (Rubenstein & Josephson, 2006). From a public health and individual perspective, falls among older people account for a large proportion of injury-related hospitalizations across the globe, with falls the second leading cause of unintentional injury death (WHO, 2021a). However, these statistics can be difficult to interpret given that hospital admission details can be skewed due to the focus on episodic diagnosis and treatment of individual diseases (Tinetti et al., 2006). In Australia, falls are the predominant reason for injury-related hospitalization and a leading cause of death. This rate continues to climb for people 65 years old and older, from 2,755 fall-injury-related hospitalizations in 2008–2009 to 3,350 cases per 100,000 admissions in 2016–2017 (Australian Institute of Health and Welfare, 2021). In Canada, fall-related hospitalizations for the same age group rose between 2006 and 2011 by 15%, accounting for 85% of all injury hospitalizations for this group (Public Health Agency of Canada, 2014).

A major fall-related risk for an individual is the risk of fracture, particularly hip fractures. Ninety-two percent of all hip fractures are reported as resulting from a fall (McKay & Anderson, 2010), with 25% to 35% of people dying within the first year after hip fracture (Braithwaite et al., 2003). Complications arising from falls are the leading cause of death from injury in people over 65 years old (Aschkenasy & Rothenhaus, 2006). Across the world, 75% of fatal falls among older people occur in low- and middle-income countries (WHO, 2021b). In Australia, the average length of hospital stay is, on average, greater for fall-related injury than for other types of injury (Australian Institute of Health and Welfare, 2021), while globally 37.3 million falls are severe enough to warrant medical attention each year and account for over 38 million disability-adjusted life years lost (WHO, 2021b). Even a minor fall, or worry about falling, can have repercussions, because the risk associated with a fear of falling can lead to a downward cycle of inactivity and decreased strength, agility, and balance (Cumming et al., 2000; Friedman et al., 2002; Lavedán et al., 2018; Yardley & Smith, 2002).

Furthermore, falls affect informal caregivers—they can develop a fear of falling for the person they are caring for (Meyer et al., 2012), potentially with increased burden as a result (Kuzuya et al., 2006; Meyer et al., 2012; Schrag et al., 2006). Caregivers may feel unsupported and ill prepared to cope with falls (Davey et al., 2004), lacking awareness of factors and behaviors that may be of relevance to fall risk (Mackintosh & Sheppard, 2005). They are, however, in a unique position to provide support and advice to the person they are caring for, negotiating with them in a respectful manner to alter their fall risk (Horton & Arber, 2004), and to provide instrumental support, such as for home exercises (Suttanon et al., 2012). While informal caregiving is valuable particularly for those at high risk, such as people with dementia, consideration should be given to monitoring the level of caregiver burden.

Early Perspectives on Fall Prevention

Our understanding of falls among older people commenced with the recognition by J. H. Sheldon that falls should not be presumed to be a natural part of aging and we should be curious about the experience (Sheldon, 1960). Isaacs (1985) then went on to classify older people who had falls into high-, intermediate-, and low-risk groups, bringing forth the notion of that falls can be prevented. The Kellogg International Work Group on the Prevention of Falls by the Elderly was convened in 1987; it highlighted the various risks of falls and methods developed to prevent falls in the community and institutional settings, yet it also acknowledged the empirical evidence was limited (Kellogg International Work Group, 1987).

The evidence began to build with Cummings et al. (1988), who found that the recall of falls was problematic—some people would forget they had fallen, while others would not see a fall as a health problem if it was non-injurious, and therefore they would not report a fall to a health professional. Campbell et al. (1989) went on to identify the likelihood of multiple internal and/or external causes for falls, rather than a single cause. In the following decade, randomized controlled trial evidence began to emerge to guide interventions for fall prevention—the evidence supported withdrawal of psychotropic medications (Campbell et al., 1999), exercise (Campbell et al., 1997), home safety (Cumming et al., 1999), and multifactorial interventions (Close et al., 1999; Coleman et al., 1999; Tinetti et al., 1994).

What Causes Falls?

A risk factor is defined as “a characteristic that is found significantly more often in individuals who subsequently experience an adverse event than in individuals who do not experience the event” (Rubenstein & Josephson, 2006, p. 809). In the case of falls as the adverse event and the subsequent impacts of falls, risk factors for (or causes of) falls are numerous (Deandrea et al., 2010).

Most commonly, a convergence of numerous factors leads to a fall. There appears to be an intricate link between predisposing risk factors and precipitating or situational risk factors (Rubenstein & Josephson, 2006). Predisposing risk factors are those intrinsic to the person, such as sensory impairment (e.g., depth perception, proprioception loss) and gait abnormalities (e.g., unsteady gait, stride variability), while precipitating or situational risk factors are related to the environment, behavior, or activity (Soriano et al., 2007). Rather than “blaming” a fall on a predisposing risk factor or dismissing its impact as related to a person’s age or cognitive status, it is imperative to investigate the underlying cause of a fall (Rubenstein & Josephson, 2006). It is also important to note that not all falls can be prevented, with the goals of fall prevention perhaps better aligned with reducing fall risk, protecting against falling, and reducing fall-related injury (Campbell & Robertson, 2007; Gillespie et al., 2012; Whitehead et al., 2006).

The most common predisposing risk factors for falls are:

A history of falls, with a previous fall being one of the greatest risk factors for further falls (Deandrea et al., 2010; Rubenstein & Josephson, 2006).

Number and type of medications, with polypharmacy and use of psychotropic medication having strong evidence for risk of falls (Hill & Wee, 2012; Leipzig et al., 1999).

Impaired balance and mobility, aligned with reduced muscle strength, altered postural control, and incorrect use or inappropriate fit of walking aids (Karinkanta et al., 2010; Rubenstein & Josephson, 2006; Sherrington et al., 2020, Thies et al., 2020).

Visual impairment, linked to various eye conditions, changes in depth perception, and use of multifocal glasses (Haran et al., 2010; Harwood et al., 2005; Lord, 2006; Wood et al., 2011).

Foot problems, such as pain, weakness, and deformity (Menz et al., 2006; Spink et al., 2011).

Cognitive impairment, which causes a 60%–80% increase in falls (Allan et al., 2009).

Inadequate nutrition, likely linked to decreased muscle strength and function, and vitamin D deficiency (Kalyani et al., 2010; Thomas et al., 2008).

Other medical conditions, such as urge incontinence, dizziness, depression, stroke, and Parkinson’s disease (Batchelor et al., 2012; Drootin, 2011; Kenny et al., 2001; Soliman et al., 2016).

The most common situational risk factors for falls are:

Environmental hazards, including adaptations of the physical environment and the interaction of the person with their environment (Clemson et al., 2008).

Inadequate footwear, including high-heeled shoes and being barefoot (Menant et al., 2008).

Risk-taking behaviors, due to changes in physical and cognitive capacity (Fischer et al., 2014).

Incontinence, which entails an interaction between predisposing factors, such as urinary frequency/urgency, and situational factors, such as rushing to the toilet, physical difficulties removing clothing, and the potential for slipping when an accident has occurred (Batchelor et al., 2013).

Who is Most at Risk of Falls and Why?

The complexity of falls among older people is recognized as a geriatric syndrome and an important marker in determining frailty (Soriano et al., 2007). Fall prevention becomes more challenging the complicating aspect of other health conditions is addressed, with fall rates dependent upon other disease states that are present. Worldwide, approximately 30% of community-dwelling people over 65 years old fall within a given year, with this rate increasing with age and chronic disease (Campbell et al., 1990; Hill et al., 2018). Biological risk factors play a part in falls risk; they include age, gender, and chronic conditions (WHO, 2021b). As a person ages, multimorbidity (two or more conditions present in the same person) increases, with more than half of older people having three or more chronic conditions (Mitinski et al., 2004). Thus, the interplay among health, disability, and age is complicated by multimorbidity (Barnett et al., 2012).

The fall rate for a person with Parkinson’s disease are variably calculated between 35% and 90%, with most people (39%) experiencing recurrent falls (Allen et al., 2013). Motor symptoms, such as freezing of gait, rigidity (stiffness), and bradykinesia (slowness of movement), along with associated changes in posture, all contribute to risk of falling. Factors associated with recurrent falls include: history of falls, increased disease severity and duration, increased motor impairment, treatment with dopamine agonists, increased levodopa dosage, cognitive impairment, fear of falling, freezing of gait, impaired mobility, and reduced physical activity (Allen et al., 2013).

For people who have experienced a stroke, fall rates are estimated to be between 55% and 73% in the first year after a stroke (Verheyden et al., 2013). The risks of falls in stroke survivors are multifactorial and include impaired mobility, reduced balance, fall history (including a fall during hospitalization), assisted self-care, taking sedative or psychotropic medications, depression, and cognitive impairment (Xu et al., 2018).

People living with dementia experience up to a 90% chance of falling within a given year (Allan et al., 2009), dependent on the type of dementia. For people with a diagnosis of Alzheimer’s disease or vascular dementia, 47% will fall at least once within a 12-month period, while 77% of those with a diagnosis of dementia with Lewy bodies and 90% of those with Parkinson-related dementia will fall in a 12-month period (Allan et al., 2009). There are multiple risk factors for people with cognitive impairment; they include slower reaction times and poor balance (Taylor et al., 2018), slow and variable gait patterns, reduced sensorimotor functioning (Taylor et al., 2012), impaired judgment and executive functioning (Delbaere et al., 2012), impaired functional performance, medication use (Taylor et al., 2014), and pain and anxiety (Menant et al., 2013).

For less common conditions, fall rates can be up to 74% in people who survived polio (Bickerstaffe et al., 2010) and over 50% for people living with multiple sclerosis (Coote et al., 2020).

How Can We Prevent and/or Manage Falls?

The WHO (2021b) defines primary prevention as the prevention of injury, secondary prevention as reduction of injury severity, and tertiary prevention as reduction of the frequency and severity of disability after an injury. These three areas of prevention are relevant for fall prevention and will require a combination of strategies.

Today, evidence of pooled data from multiple trials gives us strong evidence that interventions to reduce falls in community-residing older people can work. There is high-certainty evidence that exercise as a single intervention can reduce falls (Dautzenberg et al., 2021; Sherrington et al., 2020), with most efficacy coming from exercise programs that primarily consist of balance, functional training, or coordination (Clemson et al., 2012). Challenging balance is core to these interventions and is achieved by reducing the base of support, reducing upper limb support, and, as the person stands straight and tall, moving the center of gravity of the body to the “edge of your limit” (Ng et al., 2019). The goal is to do this incrementally and progressively, so that the sense of challenge to balance is maintained safely. Strength and resistance training have not been found to be effective for reducing fall risk as a single intervention but are supported as part of a multimodal exercise, most often combined with balance and functional exercise (Sherrington et al., 2020). The concept that balance can be improved is not commonly understood, although most people are familiar with the idea of strength training to maintain function and aerobic exercise for cardiorespiratory health. However, the personal benefits of enhanced balance from an individual perspective can also translate to functional and mobility gains that have an intrinsic benefit (Reichherzer et al., 2021). While intensity is a goal, the biggest barrier to exercise is long-term adherence. To help make exercise enjoyable, group and individual exercise can be interchanged based on personal preference.

There is moderate-level evidence from pooled analysis of trials that multicomponent interventions for community-residing older people are effective when the same elements of the intervention are offered to all participants (Dautzenberg et al., 2021; Hopewell et al., 2018). The most effective programs are those that offer exercise and home-hazard intervention along with basic fall risk assessment, such as medication reviews. Examples include a 7-week self-management program where participants explore a range of fall risk reduction strategies (Clemson et al., 2004) or home-based multidisciplinary programs (Campbell et al., 2005).

Single-mode interventions that focus on reducing home hazards, carried out on a home visit, have been found to be most effective for people at higher risk of falling and for specific subgroups of people, including people with severe vision impairment, people who have a history of falling in the past year, people who have been hospitalized for a fall, and those who are experiencing functional decline (Clemson et al., 2008; Gillespie et al., 2012). Reducing the rate of falls in the high-risk group is an important goal. Interventions that are tailored to the person and their environment include a validated and comprehensive assessment of the environment, and engaging the older person in the process of identification of hazards and generating solutions is recommended (Pighills et al., 2011; Stark et al., 2021). Validated assessments include the Westmead Home Safety Assessment, which includes brief (most common fall hazards) and long (all potential hazards) versions for the occupational therapist (Clemson, 2019; Clemson et al., 1999; Mandelbaum et al., 2020), and the HSSAT (Occupational Therapy Geriatric Group, 2017; Tomita et al., 2014), a self-administered environment assessment tool. The Falls Behavioral (FaB) Scale for the Older Person (Clemson et al., 2003) was designed to identify an older person’s awareness and practice of indoor and outdoor behaviors that could potentially protect against falling.

While there have been no trials of interventions to reduce falls in public places, studies that explore pedestrian safety have demonstrated the importance of involving older people in identifying hazards and generating solutions (Chippendale & Boltz, 2014; Li et al., 2006). A study in Hong Kong used spatial mapping to identify hot spots for falls, which could be a strategy for local government engagement in fall prevention (Lai et al., 2011). A population-based study in Australia that targeted public environmental hazards, along with knowledge, attitudes, behaviors, medication use, footwear, home-hazard reduction, and other risk factors related to falls, was successful in reducing fall-related hospitalizations by 20% (Kempton et al., 2000).

A seminal and important study on reducing psychotropic medication prescriptions by general medical practitioners resulted in a huge 66% reduction in falls (Campbell et al., 1999), and it was supported by another study with a 52% reduction of fall risk (van der Velde et al., 2007). Taking multiple medications is common in older people and can increase the risk of undesirable outcomes through drug–drug and drug–disease interactions that add to fall risk. A study on medication reviews to reduce polypharmacy by general practice doctors reduced falls by 39% (Pit et al., 2007), demonstrating the feasibility and effectiveness of this approach. The focus is on routine general practitioner (GP) or community-pharmacist medication reviews, and much work is still needed on increasing awareness and approaches to deprescribing. A meta-analysis exploring consumer willingness to accept medication deprescribing (Weir et al., 2021) showed that consumers are receptive but that work is needed to accept deprescribing as a normal and positive part of patient care, particularly to support people in discontinuing a long-term medication.

Evidence has been emerging that exercise-based interventions may reduce falls for people with mild cognitive impairment or with Alzheimer’s disease and related dementias (Li et al., 2021), although there was a great deal of heterogeneity among the nine trials included in the most recent meta-analysis and many trials had small samples. Thus, current evidence is considered low-certainty and insufficient to provide clear guidance for clinical practice (Li et al., 2021). The three small but effective trials used home or group balance and resistance exercise or tai chi. Many of the trials had multiple components, such as exercise integrated with cognitive training, home safety audits or practice, or education. Involvement of caregiver support was shown to improve adherence over the longer term. Reducing falls and recurrent falls in high-risk populations is complex and is likely to require multicomponent interventions that will need to be matched to the diversity of characteristics relevant to the population and disease of interest. This was noted in one of the few trials with an adequately powered sample size (N = 309); the trial used a tailored exercise and home-hazard reduction program for older people with cognitive impairment (i-FOCIS). While the program was not effective overall, there was a significant reduction in the proportion of multiple fallers and it also reduced the rate of falling for participants with better baseline physical functioning (Taylor et al., 2021). Multimorbidity, complex care needs, and changing/declining health affect both adherence and intervention efficacy for people with cognitive impairment. The i-FOCIS home-based intervention delivered by occupational therapists and physiotherapists was tailored for individuals following an initial assessment of functional cognition and provides guidance on, for example, length of exercise session and frequency, the type of caregiver supervision, and caregiver education to support participants (Taylor et al., 2021).

For people with Parkinson’s disease, a multidimensional, individually tailored and progressive home-based program (PDSAFE) of exercise and fall-avoidance strategies was tested in a large trial in the United Kingdom (Ashburn et al., 2019; Hulbert et al., 2021). Strategies included a focus on “avoiding tripping,” “turning,” and “freezing cues.” Overall, the trial was not effective; however, there was a differential effect for those with good memory, moderate disease, and two or three falls in the previous year (i.e., they responded well to the program and had fewer falls). People with more severe Parkinson’s disease (e.g., movement problems, memory deficits, and freezing of gait) fell more often and were more likely to receive fewer challenging strategies or balance and strengthening exercises. Further research is needed on targeted groups in these high-risk populations.

Evidence on fall reduction interventions for stroke survivors is also limited and of low certainty due to issues of bias and variability in time after stroke (Denissen et al., 2019). Meta-analysis showed that exercise may be beneficial for preventing falls in stroke survivors. However, more quality research is needed, including research on multiple component interventions, such as inclusion of functional, environmental, sensory, or cognitive aspects to manage falls after rehabilitation, in addition to exercise.

A summary of evidence is presented in table 1, with a recommendation for implementation into practice, as per work undertaken by Waldron et al. (2012).

Table 1. Summary of Interventions to Reduce Falls

Fall-prevention and/or management strategies

Intervention description

Recommended for implementation

Exercise programs, particularly those that include balance and/or functional training

Exercise has been shown to be the single most effective strategy for reducing the rate of falls (Ng et al., 2019; Sherrington et al., 2020). Programs should contain balance exercises or functional training, should require exercise for at least 2 hours per week (building to a cumulative total of 50 hours), and should not include a walking program for high-risk individuals (Sherrington et al., 2011). Exercise can be home- or group/center-based. There are multiple effective exercise interventions available that offer diversity, including the Otago home-based balance and strength training (Chiu et al., 2021), tai chi, and the Lifestyle-integrated Functional Exercise (LiFE) program (Clemson et al., 2012; Jansen et al., 2021). Long-term promotion of exercise is an important consideration, and a focus on shared decision-making and attention to individual goals are needed (McPhate et al., 2013).

****

Environmental adaptation and modification

Environmental adaptation and fall-hazard reduction is undertaken via a home visit. It ideally comprises an evaluation of the person-to-environment fit, comprehensive assessment of the home, identification of hazards, and collaborative decision-making about solutions and priorities (Clemson et al., 2014). Home safety assessment and modification are most effective for those at high risk of falls, such as those with severe visual impairment, older people with a fall history and who have been recently hospitalized, or persons with a fall history and mobility limitations, and they are best delivered by an occupational therapist (Gillespie et al., 2012).

***

Multicomponent programs

Most multiple component interventions include exercise and either education or home hazard assessment. They are often carried out on home visits; for example, in the study by Day et al., although less intense than single-mode interventions, multicomponent intervention was effective when it included exercise, home safety, and vision improvement (Day et al., 2002). Multicomponent approaches may also use a group-based self-management program, such as Stepping On (Clemson et al., 2004).

**

Cataract surgery

Removal of the first cataract is successful in reducing the rate of falls in older people (Harwood et al., 2005), but removal of the second cataract does not clearly affect the rate of falls (Foss et al., 2006). It remains uncertain whether vision assessment should be part of multifactorial programs (Drootin, 2011).

**

Use of single-lens glasses

Use of single-lens glasses rather than multifocals reduced the rate of falls outside the home for regular users, but increased the rate of falls outside the home for those who were not often outside (Haran et al., 2010). Care should be taken when older people are adjusting to new glasses (Cumming et al., 2007).

**

Medication reduction and withdrawal

Using more than four medications increases the risk of recurrent falls (Campbell et al., 1999; Leipzig et al., 1999; Pit et al., 2007). Psychotropic medications are most implicated in a higher risk for falls, including antidepressants and medications used in dementia, with careful monitoring of their use required (Hill & Wee, 2012). A gradual reduction in psychotropic medication use reduces the rate of falls (Gillespie et al., 2012).

**

Assessment and treatment of postural hypotension

Orthostatic hypotension, the drop in blood pressure noted between lying down and standing up, affects up to 30% of older people (Logan & Witham, 2012). Treatment focuses on medication changes, hydration, and managing autonomic dysfunction (Drootin, 2011).

*

Cardiac pacing

Carotid sinus syndrome results in bradycardia and hypotension, with subsequent temporary loss of consciousness (Kenny et al., 2001). Cardiac pacing, with insertion of a pacemaker, may be indicated for unexplained recurrent falls (Kenny et al., 2001), reducing the rate of falls in people with carotid sinus hypersensitivity (Gillespie et al., 2012).

**

Vitamin D (800 IU)

Vitamin D can reduce the risk of falls and fractures in older people, most likely through the mechanisms of improved muscle function and bone strength (Bischoff-Ferrari et al., 2005; Kalyani et al., 2010). It is most effective in older people with low vitamin D levels (Gillespie et al., 2012).

****

Management of foot problems and footwear

Podiatry intervention is indicated for older people with disabling foot pain. Interventions include orthoses, foot and ankle exercises, and advice on footwear (Spink et al., 2011). Recommendations for footwear are designed to enhance balance, including low heels and firm, slip-resistant soles (Menant et al., 2008).

**

Assistive devices, alarms, or hip protectors

There are no specific recommendations for assistive devices, alarms, or hip protectors. Hip protectors are only effective if worn, and worn correctly, but compliance with them is particularly poor (Russell et al., 2010; Santesso et al., 2014). Hip protectors appear to provide little or no reduction in fracture rates for community-dwelling older people, and they carry a small increased risk of pelvic fractures (Santesso et al., 2014).

*

Education and information provision

There is currently no evidence for the benefits of education and information provision as part of a multifactorial program (Gillespie et al., 2012). There appears to be consensus that education and health promotion should be components of falls prevention programs (Drootin, 2011). Grol and Grimshaw (2003) also suggested that educational materials, while not showing broad results or being directly related to falls prevention, should not be dismissed, given their feasibility and low cost. A hospital inpatient education program, while showing falls reduction in cognitively intact older adults, increased falls in cognitively impaired older adults (Haines et al., 2011).

*

Assessing activities of daily living

An assessment of the need for assistance in personal or instrumental activities of daily living is recommended, as there is an association between needing assistance and an increased risk for falls (Ganz et al., 2007).

*

Multifactorial interventions

Multifactorial intervention, such as explored in Palvanen et al. (2014), should include a risk assessment, with interventions or referrals organized by an assessment team (Hopewell et al., 2018; Waldron et al., 2012). Current evidence shows a large diversity of trial effects and supports the recommendation to actively address identified risk factors rather than referral or providing information. Specialized fall clinics are more likely to use the approach of assessment and active intervention.

*

* Recommended based on expert opinion and best practice, but limited evidence.

** Recommended based on medium level evidence, with potential implementation challenges.

*** Recommended based on strong evidence for some sub-populations, with potential implementation challenges.

**** Recommended based on strong evidence and ease of implementation for all populations.

Placing Fall Prevention in a Social Model of Health and a Whole-of-Community Approach

Over the past few decades, there has been a shift from a biomedical approach to fall prevention to a more holistic biopsychosocial approach. The Ottawa Charter for Health Promotion lay down the foundations in 1986, with a commitment to international action on health as a positive concept and drawing on an individual’s strengths (WHO, 1986). The charter underpins fall prevention in Australia, by focusing on building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and strengths, and shifting the focus of health services (Australian Commission on Safety and Quality in Healthcare, 2009). The WHO promotes a whole-of-community approach, in which all sectors of the community at individual, institutional, and government levels can collaborate on fall-prevention efforts (WHO, 2021b).

Recent work by the WHO (2021b) promotes fall-prevention efforts in the three areas of “safer people,” “safer environments,” and “safer policies and legislation.” Interventions related to safer people include raising awareness about individual risk factors, as well as improving an individual’s knowledge and skills to make better choices related to their personal intrinsic capacity and products to assist safety. Interventions related to safer environments aim to eliminate hazards in the home, community, and workplace, while interventions related to safer policies and legislation act at the level of enforcement to support individual and environmental behavior change.

In countries where there are numerous immigrant groups with changing aging demographics, there is an increasing need to tailor fall-prevention programs to meet particular linguistic and cultural requirements and differences in health-seeking behaviors and attitudes (Bradley & Harrison, 2007). A review of Chinese studies showed how culture and environment can contribute to when and where falls occur and give rise to different profiles of risk (Kwan et al., 2011). In Chinese urban communities, houses are small, and people go out daily to get fresh food and to spend more time outdoors. The review found some support for the conclusion that perception and knowledge of falls and how to manage falls were protective factors. Broader efforts to make housing safer in low-income communities, such as in a study conducted in New Zealand (Keall et al., 2015, 2017), would be a useful approach to consider. In low-income countries, environmental fall risks are more complex, widespread, and context specific (Stewart Williams et al., 2015), with frequent hazards, such as narrow steps with poor lighting, the water source outside the home, earth floors, open street gutters, and unsafe walking areas. Most fall-prevention research evidence is from developed countries, with little from developing countries, including the developing nations in Asia (Hill et al., 2018; Romli et al., 2017). Local research is crucial to evaluate the local context and possible adaptations required for the translation of effective interventions from developed countries into often low-income communities.

Challenges and New Frontiers for Uptake of Strategies in Practice and Policy

Despite the strong evidence for fall prevention and supporting national guidelines, there remains a gap in implementation from research contexts to widespread implementation. Fall- prevention research has traditionally targeted the efficacy of interventions to understand what works. An increasing focus is now required on how it works, to aid understanding of the complexity of context to support adoption, implementation, and sustainability of interventions (Greenhalgh et al., 2017; Nordstrum et al., 2017; Theobold et al., 2018).

Reviews of fall-prevention implementation studies and qualitative inquiries provide some insights into challenges and facilitators for the uptake of evidence into practice. To emphasize the multidisciplinary nature of fall prevention, “fall prevention is everyone’s business” is the slogan used in Australian and New Zealand national and state programs. The slogan calls out the importance of multiple stakeholder perspectives as well as person-centered approaches inclusive of the experience of the older person and family members. Inherent in this approach is recognizing that fall prevention is complex, understanding the respective roles of all stakeholders, transparent communication, and unpacking individual client contexts (Liddle et al., 2018).

Less than half of older people who fall (24% of men and 31% of women) discuss their fall/s with a healthcare professional (Stevens et al., 2012). Primary care practitioners play a critical role in helping older people understand risk factors for falls, yet provider beliefs and practices are one of the most common barriers to effective fall risk management (McConville & Hooven, 2021; Phelan et al., 2015). Engaging GPs and other health professionals in fall prevention can be challenging, given that there are often false assumptions made regarding an older person’s interest in, and concerns about, falls (Liddle et al., 2018; Mackenzie & Clifford, 2018). There is also the difficulty of integrating fall risk management into the demands of routine practice, which is exacerbated by often fragmented or inadequate community services (Mackenzie & Clifford, 2018; McConville & Hooven, 2021).

Practice-change frameworks and models can be useful for the implementation of fall- prevention programs. In the United States, for example, the Stopping Elderly Accidents, Deaths and Injuries (STEADI) program developed by the Centers for Disease Control and Prevention (Stevens & Phelan, 2013) was implemented in a primary care setting, using the Kotter framework, with strategies that included workflow design that aligns with usual clinic practice, integration of the algorithm into electronic records, use of STEADI champions, and training sessions (Casey et al., 2017). In Australia, the iSOLVE intervention in general practice was underpinned by core components of upskilling GPs and the local allied health workforce in evidence-based strategies, clear referral pathways, and a guiding document to facilitate diffusion and dissemination of the model (Clemson et al., 2017). iSOLVE focused heavily on practice change, identifying that support tools and decision-making assistance were needed for integration into routine practice (Mackenzie et al., 2021).

An example of attempting to overcome implementation challenges is the role of state fall-prevention coalitions in the United States, a successful strategy to increase awareness of implementation issues and effective strategies, to facilitate engagement of providers, and to enhance and sustain the availability of community programs and services (Ory et al., 2017). A further example was the use of a shared decision-making tool to provide choice to people with dementia and their caregivers in fall-prevention strategies. In this small trial, Meyer et al. (2020) found solid engagement with individuals and high uptake of strategies with this approach, but no significant reduction in fall rate. Learning from larger trials that also found a negative result is important. The STRIDE trial, which utilized specially trained nurses, did not deliver the anticipated results of reduced rate of injurious falls, a result which was speculated to be partially due to the lack of uptake of recommendations based on the strongest evidence (e.g., medication review and home safety assessment), lack of monitoring of behavior modifications (e.g., exercise), and logistical challenges in implementing recommendations (e.g., transport and payments; Bhasin et al., 2020). Incorporating fall-prevention evidence into practice is multifaceted and multidisciplinary, and the engagement of the person who experiences falls and their family is core to implementation and management. Further studies are required to better understand how to increase widespread uptake of fall-prevention activities.

Implementing interventions that require participation, engagement, and behavior change can be accompanied by a loss of fidelity and effectiveness. Mahoney et al. (2020) used the Replicating Effective Programs Framework (Kilbourne et al., 2007) to evaluate the widespread implementation of a fall-prevention group-based, self-management program. They demonstrated that with attention to key elements of fidelity, the program was successfully translated into practice, and they were able to replicate the original trial’s results on risk of falling.

Economic evaluations are increasingly providing evidence of “value for money” for fall- prevention strategies, which contribute to healthcare savings, reduce the burden of years lived with disability, or increase quality-adjusted life years (Church et al., 2011). One-off interventions can often be carried out relatively cheaply, such as one or two home visits to reduce fall hazards. Cost-saving fall-prevention strategies have been noted in economic evaluations of home fall-hazard-reduction interventions when delivered to participants with a previous fall (Salkeld et al., 2000) or those with visual impairment (Campbell et al., 2005). Another single-factor intervention shown to be cost-effective and cost-saving is exercise, particularly the Otago Exercise Program for adults 80 years old and older (Davis et al., 2009).

Summary

Fall prevention is complex, yet solutions often can be simple: challenge your balance, keep doing exercise that strengthens your ankles, hips, and knees, be aware of your environment and being safe, talk with your doctor or pharmacist to review all your medications, and take care when you get a new prescription for glasses. History suggests to first start with the question, Have you had a fall? Recognizing that something can be done is the first step, then tailored guidance can be used to implement strategies. The case study of Gina Rossi illustrates the roles Gina, her doctor, and many others played in changing her life trajectory to protect against future falls and to maintain her independence. Primary health practitioners and community health leaders champion ways to bring fall-prevention activities to scale. Researchers with stakeholder partnerships continue to fill gaps: they explore the unique needs of high-risk groups who experience high rates of falls, and often at a much younger age, and who need different support and focus; they explore the role of technology in aiding decision-making; and they collaborate with experts to maximize health professional skills using behaviour-change techniques. Implementation of evidence into practice remains a high priority for everyone, and the future should also focus on low- and middle-income countries, because there are opportunities to work with communities in adapting fall prevention to meet their needs.

Further Reading

References