Key messages

• Falls in care facilities are likely reduced by: multifactorial (made up of several parts) interventions that are put in place with the help of facility staff and delivered based on residents' individual circumstances (e.g. living with dementia); exercise; and vitamin D supplementation. The number of people falling may be reduced by: increasing servings of dairy through dietitian assistance with menu design; and exercise in residents with cognitive impairment. It is unclear if single interventions aiming to increase the appropriateness of medication delivery reduce falls.

• Multifactorial and exercise interventions may be cost-effective. However, if exercise is not continued, the effect on falls is not sustained. Increasing servings of dairy through dietitian assistance with menu design may reduce the number of people with fractures from falls.

• There is now updated information on how to prevent falls in care facilities; we have mostly moderate to little confidence in the available evidence. There is still a need for further research on ways to prevent falls in people living in care facilities, particularly on the types of exercise that are most effective and on interventions to improve medication delivery.

How do we report interventions used to assess falls, and why is this important?

Falls among older people in care facilities, such as nursing homes, are common and can cause loss of independence, injuries, and sometimes death due to injury. Effective interventions to prevent falls are therefore important.

Studies of any intervention designed to reduce falls in older people compared to a group of people not receiving the intervention are grouped by type, guided by the fall prevention classification system (taxonomy) developed by the Prevention of Falls Network Europe (ProFaNE). Interventions are organised as follows:

• multifactorial interventions: two or more categories of intervention such as exercise, medication review, and vitamin D supplementation are given based on a person's risk factors for falling;

• single interventions: only one of the major categories of intervention is delivered to all participants in the group;

• multiple interventions: the same combination of interventions is delivered to all participants in the group.

What did we want to find out?

We wanted to find out which interventions reduce falls among older people living in care facilities, in terms of number of people falling and number of falls experienced. We also looked at risk of fractures, unwanted effects of the interventions, and economic outcomes.

What did we do?

We searched for studies of interventions to reduce falls among older people living in care facilities. We compared and summarised the results of the studies and rated our confidence in the evidence based on factors such as study methods and sizes.

What did we find?

We found 104 studies (68,964 older people) with an average age of 84 years, of which 72% were women. Studies took place in 25 countries, and looked at multifactorial interventions; single interventions (exercise, medication optimisation (improving medication prescribing), vitamin D supplementation, dietitian advice and menu design to increase dairy supplementation, assistive technologies (tools to help older people function), staff training, and different ways of providing care); and multiple interventions.

• Overall, multifactorial interventions probably do not lower the rate of falls (number of falls over time), but probably reduce the number of fallers. However, those multifactorial interventions put in place with the help of facility staff and delivered based on residents' individual circumstances (e.g. living with dementia) had a larger effect and probably reduce the rate of falls and number of fallers. Multifactorial interventions may also be cost-effective in reducing falls.

• Active exercise as a single intervention probably reduces the rate of falls and the number of fallers, but may have little or no effect on risk of fracture. However, if the exercise is not continued, the effect on rate of falls is not sustained, and there is probably no effect on number of fallers. Active exercise interventions may also reduce the number of fallers in residents with cognitive impairment (decline in mental abilities) and may be cost-effective for reducing falls (looked at from an Australian health service perspective).  

• Overall, interventions aiming to improve medication prescribing varied, and may make little or no difference to rate of falls and probably little or no difference to number of fallers. We are uncertain of the effect of single interventions aiming to improve the appropriateness of the medications that residents take by conducting assessments and making recommendations. Such single interventions to improve medication prescribing may not be cost-effective as a standalone intervention.

• Prescription of vitamin D (with or without calcium) probably reduces rate of falls, but probably makes little or no difference to number of fallers. The residents in these studies appeared to have low vitamin D levels.

• Increasing servings of dairy foods to residents through dietitian assistance with menu design may decrease the number of fallers and the risk of fractures from falling. No information was reported on rate of falls.

• We are uncertain of the effect of the interventions on unwanted effects, as these were overall poorly reported in the included studies.

What are the limitations of the evidence?

We have mostly moderate to little confidence in the available evidence. Our confidence was limited because people in many of the studies were aware of which treatment they were getting, and not all studies provided information about everything that we were interested in. In addition, there were often problems with the methods used in studies to collect information.

How up-to-date is the evidence?

This review updates previous versions of the review published in 2010, 2012, and 2018. The evidence here is current to 10 May 2024.