Fall prevention

Falls are common in later life. About 30% of people over 65 living in the community fall each year [5]; the 2019 Cochrane review puts the figure at one-third or more [3]. The US Preventive Services Task Force describes falls as the leading cause of injury-related morbidity and mortality among older adults: in 2018, 27.5% of community-dwelling adults 65 and over reported at least one fall in the past year and 10.2% reported a fall-related injury, and in 2021 an estimated 38,742 deaths resulted from fall-related injuries [1].

Beyond deaths, falls cause fractures and head injuries, and some people are unable to get up for long periods afterwards. After a fall, many older adults reduce their activity out of fear of falling again. Reduced activity weakens muscles and balance, which raises the risk of further falls, and adds to sedentary time and loss of muscle mass.

Hip fracture, which in older adults usually follows a fall, is the fall injury most strongly linked to death. A 2010 meta-analysis of prospective studies (22 groups of women and 17 of men, all aged 50 and over) compared people after hip fracture with age- and sex-matched controls. In the first three months, the relative hazard of death was 5.75 (95% CI 4.94 to 6.67) in women and 7.95 (95% CI 6.13 to 10.30) in men [2].

The excess risk fell substantially after those first months but did not return to the level of the control groups. Using life tables, the authors estimated that white women who fracture a hip at age 80 have excess annual mortality of 8%, 11%, 18% and 22% at 1, 2, 5 and 10 years afterwards, and men of the same age 18%, 22%, 26% and 20% [2].

Part of this excess reflects poorer health before the fracture. The included studies varied in size, length of follow-up, choice of control groups and adjustment for existing illness [2].

The 2019 Cochrane review included 108 randomised trials with 23,407 people aged 60 and over living in the community (average age 76, 77% women). Compared with control, exercise reduced the rate of falls by 23%: a rate ratio (the number of falls in one group relative to another; 0.77 means 23% fewer) of 0.77, 95% CI 0.71 to 0.83, from 59 trials, rated high-certainty evidence. With a typical rate of 850 falls per 1,000 people a year, this equals about 195 fewer falls. Exercise also reduced the number of people who fell at least once by 15% (risk ratio 0.85, 95% CI 0.81 to 0.89), and the effect was similar whether or not trials selected people at high risk [3].

Balance and functional exercises reduced the rate of falls by 24% (high certainty), and programmes combining several types, usually balance plus resistance training, probably reduced it by 34% (moderate certainty). The effects of programmes consisting mainly of resistance training, dance or walking were uncertain [3]. A separate 2017 meta-analysis of 88 trials found the largest effects in programmes that challenged balance and involved more than 3 hours of exercise a week (rate ratio 0.61, 95% CI 0.53 to 0.72) [6]. These programmes are described in balance training.

Evidence on injuries is less certain. Exercise may reduce the number of people with a fall-related fracture (risk ratio 0.73, 95% CI 0.56 to 0.95; 10 trials, low-certainty evidence) and with falls needing medical attention (risk ratio 0.61, 95% CI 0.47 to 0.79; low-certainty evidence), while the effect on falls needing hospital admission was unclear. Reported side effects were mostly minor muscle and joint problems [3].

Tai chi combines slow weight shifts, turning and phases of standing on one leg. In the 2019 Cochrane review, tai chi may reduce the rate of falls by 19% (rate ratio 0.81, 95% CI 0.67 to 0.99; 7 trials, low-certainty evidence) and reduced the number of people who fell by 20% (risk ratio 0.80, 95% CI 0.70 to 0.91; 8 trials, high-certainty evidence) [3]. The earlier 2012 Cochrane review reported a similar pattern: a reduction in the risk of falling (risk ratio 0.71, 95% CI 0.57 to 0.87) and a reduction in the rate of falls that bordered on statistical significance [5].

One study has examined tai chi and mortality. Among 61,477 men in the Shanghai Men's Health Study followed for a mean of 5.5 years, those who practised tai chi had 20% lower all-cause mortality than men who did no exercise (hazard ratio 0.80, 95% CI 0.72 to 0.89), similar to walking (0.77) and jogging (0.73) [7]. It is a single observational study of men in one city. Tai chi is covered further in yoga and tai chi.

Walking, although strongly linked to lower mortality overall (see walking and steps), had no clear effect on falls in the 2019 review [3].

The 2012 Cochrane review of 159 trials with 79,193 participants assessed interventions other than exercise. Home safety assessment and modification reduced the rate of falls by 19% (6 trials) and the risk of falling by 12% (risk ratio 0.88, 95% CI 0.80 to 0.96), with larger effects in people at higher risk, including those with severe visual impairment, and when delivered by an occupational therapist [5].

Results for vision and medicines came mostly from single trials. First-eye cataract surgery in women reduced the rate of falls (rate ratio 0.66, 95% CI 0.45 to 0.95; one trial of 306 participants), but second-eye surgery did not. A general intervention to treat vision problems increased falls (rate ratio 1.57, 95% CI 1.19 to 2.06). Replacing multifocal glasses with single-lens glasses reduced outdoor falls in people who were active outdoors but increased them in people who went out little. Gradual withdrawal of psychotropic (sedating and mood-altering) medicines reduced the rate of falls (rate ratio 0.34, 95% CI 0.16 to 0.73; one trial of 93 participants), and a prescribing-review programme for family doctors reduced the risk of falling (risk ratio 0.61, 95% CI 0.41 to 0.91; one trial) [5].

Multifactorial programmes, which assess each person's risks and address several at once, reduced the rate of falls (rate ratio 0.76, 95% CI 0.67 to 0.86; 19 trials) but not the number of people who fell (risk ratio 0.93, 95% CI 0.86 to 1.02). Education about fall prevention on its own did not significantly reduce falls [5].

Vitamin D is often included in fall-prevention advice, but trials do not show a benefit for most people. The 2012 Cochrane review found that vitamin D did not reduce the rate of falls (rate ratio 1.00, 95% CI 0.90 to 1.11; 7 trials) or the risk of falling (risk ratio 0.96, 95% CI 0.89 to 1.03; 13 trials), although it may help people with low vitamin D levels before treatment [5].

A 2018 meta-analysis of 81 randomised trials with 53,537 participants reached the same conclusion. Vitamin D had no effect on falls (37 trials, 34,144 participants; relative risk 0.97, 95% CI 0.93 to 1.02), total fracture (relative risk 1.00) or hip fracture (relative risk 1.11, 95% CI 0.97 to 1.26), and results were similar for high and low doses [4].

The US Preventive Services Task Force concluded with moderate certainty that exercise gives a moderate net benefit in preventing falls and fall-related illness, and recommends exercise for community-dwelling adults 65 and over who are at increased risk of falling (a grade B recommendation). It concluded that multifactorial interventions give only a small net benefit and recommends that clinicians decide case by case whether to offer them, considering past falls, other medical conditions and the person's values and preferences (a grade C recommendation) [1].

Fall-prevention trials measure falls and injuries rather than deaths. No trial has shown that fall prevention directly lowers all-cause mortality, so its effect on lifespan is inferred from the injuries it prevents, especially hip fracture [2]. Loss of muscle with age, which makes falls both more likely and more harmful, is covered in sarcopenia.