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Falls: Prevention in community-dwelling older persons

Falls: Prevention in community-dwelling older persons
Author:
Douglas P Kiel, MD, MPH
Section Editor:
Kenneth E Schmader, MD
Deputy Editor:
Jane Givens, MD, MSCE
Literature review current through: Dec 2022. | This topic last updated: Nov 17, 2022.

INTRODUCTION — Falls in older persons occur commonly and are major factors threatening the independence of older individuals. As is the case for many geriatric syndromes, falls usually occur when impairments in multiple domains compromise the compensatory ability of the individual [1].

Falls often go without clinical attention for a variety of reasons: the patient never mentions the event to a health care provider; there is no injury at the time of the fall; the provider fails to ask the patient about a history of falls; or either provider or patient erroneously believes that falls are an inevitable part of the aging process. Often, treatment of injuries resulting from a fall does not include investigation of the cause of the fall.

Significant morbidity and mortality may result from falls in older individuals. The importance of preventing falls is emphasized by a study that found that 80 percent of older women preferred death to a "bad" hip fracture that would result in nursing home admission [2] and that the implementation of even a single intervention to prevent falls could avert USD $94 to $442 million in direct medical costs annually [3].

A number of the physical conditions and environmental situations that predispose to falls are modifiable. Clinicians caring for older patients need to routinely inquire about falls, assess for fall risk, and address modifiable underlying risk factors.

This topic focuses on strategies to prevent falls in older persons. A discussion of risks for falls and evaluation of patients who have had falls is presented separately, as is a discussion of fall prevention in nursing facility and hospital environments. (See "Falls in older persons: Risk factors and patient evaluation" and "Falls: Prevention in nursing care facilities and the hospital setting".)

PREVENTING FALLS — Multiple preventive intervention studies have been conducted, including educational programs and interventions to improve strength or balance, optimize medications, and modify environmental factors in homes or institutions. Some interventions have targeted a single risk factor, while others have attempted to address multiple factors, either by personalizing the interventions based on an initial assessment, or by intervening on the same set of risk factors in all patients. In general, evidence suggests that interventions individually tailored to target risk factors and impairments are more effective than those applied as a standard package [4]. Nevertheless, in a network meta-analysis of studies of older adults 75 years of age and older, the single intervention of exercise was found to significantly reduce the risk of falls [5].

A limitation of the available evidence is that outcomes are not consistently reported; some report the number of people who have at least one fall (the number of persons), others report the number of falls a person has had (the fall rate) [6]. Individuals who sustain multiple falls have a different risk profile than those who sustain a single fall. The applicability of a study’s findings to a particular patient depends upon the types of outcomes measured [6,7].

Specific interventions — A 2012 systematic review evaluated 159 randomized trials of interventions to reduce the incidence of falling and involved 79,193 older persons living in the community [8]. It found benefit from group and home-based exercise programs, home safety interventions, multifactorial assessment and intervention programs and tai chi. A subsequent review, prepared to support recommendations for the US Preventive Services Task Force (USPSTF), evaluated 62 randomized trials, focusing on the most common interventions [9]. It found benefit from exercise and multifactorial interventions. Significant heterogeneity among trials was noted, with differences in populations recruited for study, interventions and intervention intensity, and outcomes measured (rate of falls, number of persons with falls, or time to subsequent fall). There was no robust evidence regarding the optimum duration or intensity of interventions.

A 2021 network meta-analysis showed that several single- and multiple-fall prevention interventions were associated with fewer falls, including exercise, quality improvement strategies (eg, patient education), assistive technologies, and environmental assessment and modifications [5].

However, even when programs for fall prevention have been successful in a controlled research setting [10], the transfer of similar protocols to real world settings has not always resulted in fall prevention [11-14]. Both patient and provider compliance with the protocol, as well as expertise in delivering services, such as balance training, are felt to be possible barriers in successful implementation [15]. On the other hand, a successful community-based program targeting clinicians, senior centers, home care providers, and outpatient rehabilitation, promoting interventions for fall prevention (medication review, balance and gait training), was implemented in one state region [16]. Compared with another region with similar demographics, rates of falls over a three-year period were lower in the intervention region (RaR 0.91, 95% CI 0.88-0.94).

Exercise — Exercise is one of the most consistently positive interventions to reduce the risk of falls and injurious falls [9,17-19]. Thus, the initiation of exercise in older persons who do not exercise and continuing exercise in those who do exercise would be expected to be beneficial.

We suggest, for individuals at risk of falls, an exercise program combining several categories of exercise for muscle strengthening and balance as a part of a multidisciplinary program (algorithm 1). This is in line with the USPSTF, which recommends exercise to prevent falls for adults aged 65 and older who live in the community and are at increased risk for falls [9,20].

Exercise interventions can be provided in a group or home-based setting. The variety of effective types of exercise provides options for older persons, depending on their abilities and preferences. Exercises that emphasize balance training with resistance training, are integrative like tai chi (incorporating elements of balance, strength, and movement), and are progressive in their intensity are most effective. Exercise programs that involve at least three hours per week are associated with the greatest effects [21].

In the absence of clear evidence about which particular exercise interventions are most effective for fall prevention, choices can be guided by clinician and patient preferences as well as the availability of specific programs. Physical therapists are most qualified to assess individuals and develop an exercise program tailored to their personal needs and limitations. Before beginning an exercise program, older adults should receive clearance from their clinician, although there are few scenarios where an exercise program would be contraindicated.

The following types of exercise have been shown to be effective in decreasing the risk of falls in randomized trials and systematic reviews [8,17,18,21]:

Gait and balance training

Strength training

Movement (such as tai chi or dance)

Aerobic

Meta-analyses of randomized trials have shown that exercise decreases the risk of falls and the rate of falls [9,17-19]. In the largest meta-analysis that evaluated exercise as a single intervention in community-dwelling older adults, exercise decreased the rate of falls by 23 percent (rate ratio 0.77, 95% CI 0.71-0.83; 108 trials, n>23,000) [19].

Various exercise interventions have been shown to reduce falls. Examples of effective interventions include integration of balance and strength training into everyday home activities (functional exercise) [22], step training (training individuals how to take correct, rapid, and well-directed steps to avoid falls) [23], addition of a virtual reality component with simulated obstacles and distractors to treadmill training [24], and physical therapist-directed home-based strength and balance retraining after an initial fall [25].

Tai chi, which contains elements of strength and balance training, was effective in several trials and systematic reviews [8,26-30]. In a meta-analysis of 10 trials in older adults who were at risk for falls, tai chi reduced the rate of falls and injurious falls at 12 months by approximately 43 and 50 percent, respectively [30]. In a randomized controlled trial among three programs of exercise, two of the programs (a therapeutically tailored Tai Chi intervention, Tai Ji Quan: Moving for Better Balance [TJQMBB; IRR 0.42; 95% CI 0.31-0.56] and a multimodal exercise (MME) program [IRR 0.60, 95% CI 0.45-0.80) were associated with lower incidence of falls compared with a stretching program [26]. Among the TQMBB group, falls were reduced by 31 percent compared with the MME group. Tai chi may be less effective in frail older adults at high risk for falls [31,32].

However, exercise may not prevent falls in all populations. In the LIFE Study, a large randomized trial of exercise to improve physical performance but not powered to address effects on falls per se, 1635 sedentary adults aged 70 to 89 years who had physical performance impairment but who were able to walk 400 m were randomly assigned to a moderate-intensity physical activity program (involving aerobic, strength, flexibility, and balance training) or a health education program [33]. There was no difference in serious fall injuries (hazard ratio [HR] 0.90; 95% CI 0.66 to 1.23), assessed every six months for up to 42 months, between the intervention and control groups overall. There was a reduction in the rate of such injuries in men, who comprised only one-third of the study sample. A study that included an exercise arm in patients recruited from practices in England also failed to demonstrate a significant reduction in fractures and falls [14] and is described in more detail below. (See 'Multifactorial interventions' below.)

A trial in Australia of a balance exercise program in relatively healthy adults aged 70 years or older, delivered by a digital tablet at home, significantly reduced the rate of falls by 16 percent [34].

Medication modification — Clinicians should annually review the medications being taken by their patients, looking for opportunities to “de-prescribe” medications that carry greater fall risk, such as psychotropic medications (benzodiazepines, other sedatives, antidepressants, and antipsychotic medications).

One placebo-controlled trial found that gradual withdrawal of psychotropic medications reduced the rate of falls (RR 0.34, 95% CI 0.16-0.73) but not the risk of falling [8]. Risk of falling was decreased (RR 0.61; 95% CI 0.41-0.91) in one trial that evaluated medication review combined with multiple other physician-focused interventions (academic detailing, provider feedback on prescriptions, and financial reward) [35]. (See "Drug prescribing for older adults".)

Vitamin D supplementation — Recommendations for supplementation with cholecalciferol (vitamin D3) vary depending on the individual’s risk of having a low level of vitamin D.

We suggest vitamin D supplementation only for at-risk older patients. An appropriate target population for vitamin D supplementation includes those with risk factors for low vitamin D based on diet, sun exposure history, history of malabsorption, or obesity, and those with slow gait speed (<0.8 m/second), difficulties rising from a chair, a slow Timed Up and Go Test (table 1), or problems with balance. For those patients, we suggest empiric supplementation rather than initial measurement of 25-OH-D serum concentrations. (See "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment", section on 'Groups at high risk' and "Vitamin D and extraskeletal health", section on 'Muscle weakness'.)

We typically suggest 800 to 1000 international units daily in agreement with guidelines from the Agency for Healthcare Research and Quality [36]. Guidelines from the American Geriatrics Society (2014) for fall prevention recommend at least 1000 international units of vitamin D daily [37,38]. Other experts, including other authors for UpToDate, would recommend a supplemental dose of 600 to 800 international units daily. It is important to ask about dietary supplements (some of which contain vitamin D) that patients may be taking, as well as assessing other contributors to vitamin D status such as dietary intake, presence of obesity, and sun exposure, before prescribing extra vitamin D, since the amount of supplemental vitamin D should take these factors into account. Higher doses of vitamin D supplements administered at less frequent intervals may increase the risk of falls [39,40]. (See "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment", section on 'Optimal intake to prevent deficiency' and "Overview of vitamin D", section on 'Recommended intake'.)

Supplementation to prevent osteoporosis is discussed separately. (See "Calcium and vitamin D supplementation in osteoporosis", section on 'Vitamin D'.)

Efficacy — For community-dwelling older adults not known to have vitamin D deficiency or insufficiency, a systematic review and trial sequential analysis, as well as a USPSTF evidence review, concluded that vitamin D supplementation has no benefit in falls prevention [20,41]. An additional trial confirmed the lack of efficacy of vitamin D to prevent falls in African-American women [42]. In a multicenter European clinical trial of generally healthy, active, and vitamin D-repleted older adults, even 2000 international units of vitamin D3 did not reduce the rate of falls over three years [43]. These findings should dissuade the routine supplementation of vitamin D for all older adults for fall prevention.

Adults over age 65 years with low serum 25-hydroxyvitamin D concentrations (<10 ng/mL [25 nmol/L]) are at greater risk for loss of muscle mass, decreased strength, and hip fractures [44,45]. However, although vitamin D supplementation may improve bone mineral density and muscle function, the effect of vitamin D on risk of falls remains unclear [39,46-53].

In a trial comparing four doses of vitamin D3 supplementation (200, 1000, 2000, or 4000 international units) among older community-dwelling adults with low serum 25-hydroxyvitamin D levels and elevated fall risk, doses of 1000 international units/day or higher did not prevent falls compared with 200 international units/day [54]. In fact, a first serious fall and a first fall with hospitalization occurred more often in the groups receiving 1000 international units/day or more than in the 200 international units/day group, further emphasizing that high dosing of vitamin D supplementation may actually increase the risk for falls.

Similarly, in a trial comparing high (60,000 international units monthly or 24,000 international units plus 300 mcg calcifediol monthly) versus low (24,000 international units monthly) doses of vitamin D supplementation in adults (mean age 78 years) with a prior fall, there was a higher incidence of falls in the high-dose vitamin D groups [39]. These results suggest that intermittent high-dose supplementation should be avoided.

Environment/assistive technology — In a meta-analysis of six studies, home safety assessment and interventions decreased the rate (RaR 0.81, 95% CI 0.68-0.97) and risk (RR 0.88, CI 0.80-0.96) of falls and were most effective for individuals at higher fall risk and when delivered by an occupational therapist [8]. In a subsequent cluster randomized trial, a standardized set of home safety interventions (installation of stair hand rails, grab rails in bathrooms, improved lighting, slip-resistant deck surfacing, nonslip bath mats, pamphlet on home safety) resulted in a 26 percent decline (RR 0.74, 95% CI 0.58-0.94) in injuries caused by falls over a three-year period, compared with study households that were wait-listed for the intervention [55]. Finally, a randomized clinical trial examined a home hazard removal intervention by trained occupational therapists versus usual care in community-dwelling older adults receiving services from the Area Agency on Aging in urban St Louis, Missouri [56]. Although there were no differences in the time to fall between groups, the rate of falls in the active intervention arm was lower than in the usual care group.

Interventions to improve vision have not been shown to reduce falls [8,57]. In fact, referral for ophthalmology treatment, mobility training, and use of canes increased the rate of falls in one trial [58], possibly related to an adjustment period needed to adapt to new corrective eyeglasses and a less sedentary lifestyle. One randomized trial found that substituting single lens for multifocal glasses during outdoor and walking activities decreased the rate of falls in active older adults [59].

Nonslip devices worn on shoes in winter weather conditions decreased the rate of falls in the outdoors (RaR 0.42, 95% CI 0.22-0.78) [60]. Individual brands of such devices have not been compared for efficacy.

Education — Educating older people about fall prevention as a sole intervention did not reduce the rate or risk of falls in a systematic review [8].

Multifactorial interventions — Multifactorial interventions individualize the combination of interventions delivered to participants, depending on individual assessment of needs (algorithm 1). This represents the classic paradigm in geriatric care.

Guidelines from the American Geriatrics Society provide advice on screening for multiple risk factors and in deciding whether to recommend multidisciplinary multifactorial intervention programs. The guidelines include the following components [61]:

Obtain a relevant medical history, physical examination, and cognitive and functional assessment

Determine multifactorial fall risk based on:

History of falls

Medication review

Gait, balance, and mobility assessment

Evaluation of visual acuity

Neurologic examination including cognitive testing

Muscle strength

Assessment of cardiovascular status (heart rate, rhythm, postural hypotension)

Feet and footwear evaluation

Environmental assessment

The risk assessment is usually performed in a clinical setting by a multidisciplinary team.

The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls for adults aged 65 and older who live in the community and are at increased risk for falls [20].

A 2018 meta-analysis of 26 trials involving multifactorial assessment and management in community-dwelling adults at high risk for falls found a reduction in falls (incidence rate ratio [IRR] 0.79, 95%CI 0.68-0.91]), but not in fall-related morbidity and mortality [9].

Subsequent to the meta-analysis in 2018, two pragmatic trials have failed to demonstrate a reduction in fractures or falls. The first was a multifactorial nurse-administered intervention delivered to over 5000 high-risk community-dwelling adults (mean age 80 years) that did not reduce the rate of serious fall-related injuries compared with enhanced usual care, which included an instructional webinar for providers (4.9 versus 5.3 events per 100 person-years, HR 0.92, 95% CI 0.80-10.6) [11]. This trial may have failed to show results for several reasons, including: low adherence to components of the intervention; that the effects may have been more modest than the trial was designed to detect; and that usual care patients may have reduced their risk by learning of the intervention, as the rates of falls were less than expected. The second pragmatic trial conducted in close to 10,000 patients 70 years and older from general practices across England randomized in clusters by practice to either the Otago Exercise Program, a multifactorial intervention, or general advice by mail also failed to demonstrate a reduction in fractures or falls [14]. This trial may have failed to reduce fractures and falls for some of the same reasons as the first trial, including very few in-person intervention sessions, unclear adherence or fidelity of implementing the entire intervention, expectation that reducing falls in adults regardless of known skeletal fragility would reduce fractures, and a retrospective fall outcome assessment as well as missing data on falls reporting. Because the evidence from explanatory multifactorial interventions and exercise interventions is more consistently favorable than these pragmatic trials, fall prevention using multifactorial approaches and using exercise may achieve better outcomes when delivered using a dedicated champion working directly with older adults and ensuring adherence to interventions carried out over a sufficient period of time.

Variable results from multifactorial falls prevention trials may reflect differences between studies in the content elements of the intervention (eg, type and length of physical therapy), the process of delivering the intervention (eg, as advice to the primary clinician to implement suggested programs, or actual institution of interventions), and participant selection (eg, degree of cognitive impairment if present, or exposure to fall prevention in the control group) [62].

Multiple component interventions — Multiple component interventions consist of combinations of more than one intervention.

A systematic review found that, compared with usual care, multiple component interventions reduce the risk of falls and the rate of falls [63]. However, when compared with exercise alone, multiple component interventions do not appear to reduce fall risk, likely because exercise is included as a component of most multiple component interventions.

Patients with comorbidities — Several interventions targeting specific morbidities have been evaluated [8]. Many of these comorbidities can be identified during the screening process recommended by the American Geriatric Society guidelines (algorithm 1).

Comorbidities with targeted interventions include:

Carotid sinus hypersensitivity – For those with carotid sinus hypersensitivity, insertion of a cardiac pacemaker decreased the rate of falls (RaR 0.42, 95% CI 0.23-0.75) [64].

Cataracts – For patients with cataracts, expedited surgery for the first eye reduced the rate of falls (RaR 0.66, 0.45-0.95), but cataract surgery for the second eye was not associated with a decrease in the rate of falls [8]. Data from a Medicare database comparing hip fracture rates in patients with cataracts who did or did not undergo cataract surgery found a 16 percent decrease in the adjusted odds ratio for hip fracture within one year in patients who had surgery and a 23 percent decrease for patients with severe cataracts [65].

Malnutrition – Compared with usual care, oral nutritional supplementation for three months for malnourished older patients (body mass index [BMI] <20 kg/m2, or significant recent unintentional weight loss) who had been recently hospitalized decreased the number of falls and number of persons with falls [66]. The intervention included vitamin D, a protein supplement, and nutritional counseling.

Postural hypotension – Postural hypotension is a fall risk, and treatment has shown benefit [61]. Treatment may include medication reduction, fluid optimization, elastic stockings, or medications such as fludrocortisone or midodrine.

Disabling foot pain – For community-dwelling older patients with disabling foot pain, a multifaceted podiatry intervention (podiatry care, orthotics, footwear subsidy, foot and ankle exercises, and falls education) led to a 36 percent reduction in the incidence of falls compared with patients who received usual care [67].

Osteoporosis – In a meta-analysis of trials testing denosumab for skeletal enhancement and fracture prevention in postmenopausal women, men with osteoporosis, women taking aromatase inhibitors, and men taking anti-androgen therapy (5030 receiving denosumab 60 mg subcutaneously once every 6 months for 12 to 36 months and 5006 receiving placebo), the risk for falls was reduced by 21 percent (HR 0.79, 95% CI 0.66-0.93; p = 0.0061). There was no obvious explanation for these findings, but they emphasize that treating osteoporosis with this medication may have additional benefits on fall reduction [68].

Assistive devices — Providers are often motivated to recommend assistive devices (walkers or canes) to their aging patients with gait and balance impairments related to decline in neuromuscular function with aging and/or chronic disease. Some individual patients are obviously benefited by such devices in terms of mobility. However, evidence that assistive devices reduce the risk of falls is lacking.

There are no randomized placebo-controlled trials of assistive devices to prevent falls. Observational studies have noted an association between the use of assistive devices and increased risk for falls [69,70]. This most likely represents an inherent bias because individuals with the most impaired gait and balance are most likely to be prescribed these devices. One study suggests that using a walker or cane can interfere with compensatory stepping, which may result in an increased risk for falling [71].

Resources and information dissemination — The US Centers for Disease Control and Prevention (CDC) has made fall prevention materials available on their website. The website contains materials for both health care providers and patients.

In addition, on a separate website, the CDC provides a Fall Risk Screening, Assessment, and Intervention algorithm for health care providers which provides a stepwise approach to decrease fall risk in older adults.

The American Geriatrics Society Foundation for Health in Aging also provides clinician and patient information on their website.

PREVENTING THE COMPLICATIONS OF FALLS — The above measures can reduce a large number of falls but do not prevent them entirely.

Hip protectors — Hip protectors have been studied as a method of preventing hip fractures. Two meta-analyses of randomized trials that included both community-dwelling and nursing home patients found no evidence that they were effective in reducing hip fractures in studies in which randomization was by individual patient within an institution or among patients living at home [72,73].

Hip protectors may fail to prevent injury because they are often not worn, or injury occurs in circumstances that would have precluded use of hip protectors [74]. In one large trial of hip protectors conducted in community dwelling women, participants in the intervention group were mailed three pairs of hip protectors [75]. There was no difference in the risk of hip fracture between groups (odds ratio [OR] 1.17, 95% CI 0.78, 1.75), although daily adherence was very low (31 percent) at 12-months’ follow-up. An observational study of nursing home residents, all prescribed hip protectors, found that hip fractures were reduced to a greater extent in those who were compliant, suggesting that efficacy depends on compliance [76].

A study tested 26 commercially available hip protectors in a standard laboratory testing device at three different impact velocities and found substantial differences that depended on the thickness, stiffness, and geometry of the device [77]. These observations imply that clinical trial results using one device may not generalize to other hip protectors with different material and geometric properties.

The majority of clinical studies on the use of hip protectors were done in the nursing home setting. (See "Falls: Prevention in nursing care facilities and the hospital setting", section on 'Hip protectors'.)

Osteoporosis screening and treatment — A pragmatic randomized trial of osteoporosis screening has shown that screening using risk factor assessment, with recommendations to patients and providers to treat osteoporosis, reduces hip fracture incidence [78]. Furthermore, following a hip or vertebral fracture, pharmacologic therapy (typically bisphosphonates) should be initiated to prevent subsequent fracture [79]. (See "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)

Call alarms — A study of 1100 individuals over age 72 found that 47 percent of the 313 who experienced non-injurious falls were unable to get up for at least one hour after falling [80]. In a study of 110 individuals over age 90, 66 individuals had 265 falls within one year [81]. Eighty percent were unable to get up after at least one fall and 30 percent had been on the floor at least one hour. Prolonged time on the floor was associated with serious injury, hospital admission, and move to long-term care.

Call alarm systems have been promoted to prevent "long lies" after falls. These systems may include alarm buttons worn on the person or in the room. Their effectiveness is uncertain. In the study of the very old discussed above, 99 percent of those who could not get up had some type of call alarm system, but the alarm was not used by 97 percent (27 of 28) of those who were unable to get up for at least one hour [81].

Anticoagulation — A decision analysis has concluded that a predisposition to falls, with potential head trauma, is rarely a contraindication to the use of anticoagulants in older adult patients with atrial fibrillation. Even when taking anticoagulants, the risk of subdural hematoma is so low that persons with an average risk of stroke from AF must fall approximately 300 times in a year for the risks of anticoagulation to outweigh its benefits [82]. This subject is discussed in depth separately. (See "Risks and prevention of bleeding with oral anticoagulants", section on 'Intracranial' and "Atrial fibrillation in adults: Use of oral anticoagulants".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Falls".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Preventing falls in adults (The Basics)")

SUMMARY AND RECOMMENDATIONS

Multiple strategies for fall prevention have been evaluated in different settings. For patients with a history of falling, we suggest instituting a multidisciplinary risk factor screening/intervention program, home hazard assessment, and an exercise program combining several categories of exercise for muscle strengthening and balance (algorithm 1) (Grade 2B). (See 'Preventing falls' above.)

Medications should be reviewed for all patients, and unnecessary drugs discontinued, with recognition that fall risk increases with the total number of drugs taken. Psychotropic medications pose a particular risk. (See 'Preventing falls' above and "Falls in older persons: Risk factors and patient evaluation".)

Older patients should be asked about dietary sources of vitamin D (oily fish, fortified juices, milk), their sun exposure, and the amount of vitamin D from multivitamins and supplements.

We suggest daily supplementation with cholecalciferol (vitamin D3) for fall prevention in older patients who are at risk for low levels of vitamin D (based on diet and sun exposure history, history of malabsorption, or obesity), or who have impairments in physical function, such as slow gait speed, trouble standing up from a chair, a slow Timed Up and Go test (table 1), or problems with balance (Grade 2C).

We use a supplemental dose of 800 to 1000 international units cholecalciferol, with the dose adjusted depending on dietary intake and availability of sun exposure. Other experts, including other authors for UpToDate, would recommend a supplemental dose of 600 to 800 international units per day. (See 'Vitamin D supplementation' above and "Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment", section on 'Optimal intake to prevent deficiency' and "Overview of vitamin D", section on 'Recommended intake'.)

We suggest that most older adult patients not use hip protectors (Grade 2B). We suggest the use of hip protectors in older adult patients who are at very high risk of falls and who are willing to comply with their use (Grade 2C). (See 'Preventing the complications of falls' above.)

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