Fall Prevention: Interventions for Older Adults in Care Facilities

What interventions reduce falls among older adults living in care facilities?

Multifactorial interventions not tailored to individual needs (ie, defined as two or more strategies based on general risk profiles) probably have little or no effect on fall rate and may only modestly reduce overall fall risk. In contrast, tailored interventions that are customized to residents' needs, especially those who have dementia, and are implemented with staff engagement reduce fall rate after 6 to 12 months and fall risk after 10 to 12 months.¹ (Strength of Recommendation [SOR]: B, inconsistent or limited-quality patient-oriented evidence.)

Active exercise, including moderate- or low-intensity group exercise or physical activity for more than 1 hour/week for residents who are independent and ambulatory, decreases the fall rate, but these benefits are not sustained if exercise is discontinued.¹ (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

Vitamin D supplementation, with or without calcium, probably reduces the rate of falls among institutionalized older adults with vitamin D deficiency.¹ (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

By 2030, about 1 in 5 US residents will be 65 years and older. Each year, falls among older adults lead to 3 million emergency department or inpatient visits and account for 17% of 911 calls.² Residents of care facilities face significantly higher risk, averaging 1.70 falls per person-year vs 0.65 falls per person-year among patients 65 years and older living in the community.¹ Risk factors include age, male sex, care dependency, incontinence, psychoactive medications, prior falls, and slow reaction times.³ Care facility residents are more than 5 times more likely to be hospitalized for hip fractures.¹

The authors in this Cochrane review looked for studies describing interventions to prevent falls among older adults in care facilities. They found 104 randomized controlled trials involving 68,964 participants 65 years or older living in care facilities.¹ The average age of participants was 84 years, and 72% were female. The studies were conducted in 25 countries, most of which were high-resource countries. The length of follow-up varied from 3 to 24 months. Many trials compared an intervention with usual care (meaning no intervention). Primary outcomes were rate of falling (ie, number of falls per unit time) and risk of falling (ie, risk of experiencing one or more falls). Secondary outcomes were risk of fracture, adverse events, and economic outcomes.

Overall, multifactorial interventions that are not tailored to individual needs probably have little or no effect on the rate of falling after 6 to 12 months and may only modestly reduce the overall risk of falling after 10 to 12 months.¹ In contrast, subgroup analyses using qualitative comparative methods indicate that multifactorial interventions are significantly more effective when tailored to the individual circumstances of residents—particularly those with cognitive impairment or dementia—and implemented with active engagement from facility staff. These tailored strategies consistently outperformed nontailored approaches. Specifically, multifactorial interventions involving two or more coordinated strategies, delivered with staff involvement, and customized to the needs of older adults in care facilities, probably reduce the rate of falling in residents with dementia after 6 to 12 months (rate ratio = 0.61; 95% CI, 0.54–0.69; I² = 0%; seven trials; n = 3,553; moderate-certainty evidence) and the risk of falling after 10 to 12 months (risk ratio = 0.81; 95% CI, 0.71–0.92; I² = 0%; five trials; n = 2,993; moderate-certainty evidence). However, these interventions did not appear to reduce the risk of fracture.^1,4