What are the first-line and second-line interventions for fall prevention in older adults?

First-line and Second-line Interventions for Fall Prevention in Older Adults

Exercise interventions should be considered the first-line approach for fall prevention in community-dwelling older adults at increased risk for falls, followed by multifactorial interventions as second-line. 1

Risk Assessment for Falls

Before implementing interventions, clinicians should identify older adults at increased risk for falls using:

• History of falls - most predictive risk factor
• Problems in physical functioning and limited mobility
• Timed Up and Go test - observing the time it takes a person to rise from an armchair, walk 3 meters, turn, walk back, and sit down (healthy adults >60 years complete in <10 seconds) 1

First-Line Intervention: Exercise Programs

Components of Effective Exercise Programs

• Gait, balance, and functional training (most common component)
• Resistance training
• Flexibility training
• Endurance training
• Tai chi (effective in some studies) 1

Recommended Exercise Regimen

• Frequency: 3 sessions per week
• Duration: Typically 12 months (range: 2-42 months)
• Format: Supervised individual/group classes or physical therapy 1
• Specific recommendations:
  • 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous-intensity aerobic activity
  • Muscle-strengthening activities twice weekly
  • Balance training 3+ days/week for those at risk due to recent fall or difficulty walking 1

Second-Line Intervention: Multifactorial Interventions

For patients who continue to fall despite exercise interventions or have multiple risk factors, multifactorial interventions include:

1. Initial comprehensive assessment of modifiable risk factors:

   • Balance and gait evaluation
   • Vision assessment
   • Postural blood pressure measurement
   • Medication review
   • Environmental hazard assessment
   • Cognitive evaluation
   • Psychological health screening 1

2. Customized interventions based on identified risks:

   • Group or individual exercise
   • Psychological interventions (cognitive behavioral therapy)
   • Nutrition therapy
   • Education
   • Medication management (particularly high-risk medications)
   • Urinary incontinence management
   • Environmental modification
   • Physical/occupational therapy
   • Social/community services
   • Specialist referrals (ophthalmologist, neurologist, cardiologist) 1

Vitamin D Supplementation

The recommendations regarding vitamin D have changed over time:

• 2012 USPSTF recommendation: Vitamin D supplementation had moderate net benefit in preventing falls 1
• 2018 USPSTF recommendation: Vitamin D supplementation has no benefit in preventing falls in community-dwelling older adults not known to have vitamin D deficiency 1

Home Safety and Environmental Modifications

• Home safety assessments with specific modifications (removing tripping hazards, improving lighting) can reduce fall rates, especially in high-risk individuals 2
• Environmental modifications should include direct intervention, not just education, to be effective 2

Medication Management

• Comprehensive medication review is essential to identify high-risk medications
• Medication adjustment may be necessary in approximately 23% of cases to reduce fall risk 2
• Focus on reducing polypharmacy by discontinuing medications without immediate effect on symptom relief or quality of life 2

Implementation Considerations

For Primary Care Settings

• Ask all older adults yearly about falls and balance/gait problems
• Perform brief risk assessment using history of falls, mobility problems, and Timed Up and Go test
• Refer high-risk patients to appropriate exercise programs or physical therapy
• Consider multifactorial assessment for those with recurrent falls or multiple risk factors 1

Common Pitfalls to Avoid

1. Focusing only on environmental modifications without addressing physical function
2. Prescribing vitamin D solely for fall prevention in those without deficiency
3. Failing to reassess fall risk periodically
4. Not addressing fear of falling, which can lead to activity restriction and deconditioning
5. Overlooking medication review as part of fall prevention strategy

Special Considerations

• Digital health programs show promise in increasing physical activity and reducing falls (46% reduction in one study) 3
• Safe-falling strategies may help reduce impact forces and minimize injuries when falls do occur 4
• Home healthcare settings benefit from structured fall prevention programs including risk assessment, medication review, home hazard assessment, education, and individualized exercise 5

Monitoring and Reassessment

• Reassess fall risk every 1-2 years for those who are frail or pre-frail
• Monitor functional status and quality of life for improvement
• Adjust interventions based on patient's response and changing needs 2

By implementing these evidence-based interventions in a systematic way, clinicians can significantly reduce fall risk and associated morbidity and mortality in older adults.