Keywords

1 Epidemiology of Falls

Falls represent a major health problem in subjects aged 65 or older because of their high prevalence and the severity of their physical, functional, psychological and financial consequences. Indeed, approximately 30% of people living in the community aged over 65 years and 50% of those older than 80 experience at least one fall every year and one-third of fallers are repeated fallers. Falls result in injuries that require medical attention in 30%, fractures in 5%, a hip fracture (HF) in 1% or another major injury in 5–6%. Every year, around 50 million falls occur in Europe amongst community-dwelling older people, 2.3 million persons aged 65 years or older attend emergency departments for a fall-related injury, 1.4 million are admitted to hospital and 36,000 die from falls. Falls induce psychological consequences in patients, including fear of falling and loss of confidence that can result in self-restricted activity levels, reduction in physical function and social interactions, and put a major strain on the family. With the ageing of the population, fall has become the third leading cause of years living with disability in older subjects and one of the main causes of admission to a nursing home [1].

Falls represent also a major health problem in nursing homes, half of residents experiencing at least one fall every year. Fallers are most often women and repeated fallers in nursing homes. Indeed, falls prevalence is about 2 and 1.5 falls per person-year in institutionalised men and women, respectively [2, 3]. Falls are a major cause of hospital admission in nursing homes patients, 7.5–15% of residents being admitted to hospital every year after a fall and hip fractures accounting for 10% of overall admissions [3]. Falls also account for up to 70% of accidents in hospitalised patients; approximately 30% of falls occurring in inpatients result in physical injury, with 4–6% resulting in serious injury [4].

The health care expenditure for treating fall-related injuries in the European Union is estimated to be €25 billion each year, fractures accounting for about 1–1.5% of health care expenditure. The ageing of the population could result in annual fall-related expenditures exceeding €45 billion by the year 2050 [1]. Persons aged 80 years or older account for almost 50% of all fall-related emergency department visits and 66% of total costs [5]. The costs of long-term care at home and in nursing homes show the largest age-related increases and account together for 54% of the fall-related costs in older people [6]. Fractures, especially HF, that are most often caused by a fall from a standing position, account for up to 80% of the fall-related healthcare costs [1]. About 10% of patients are hospitalised for a second injury in the year after the HF [7], and the major concerns of people after a hip fracture are the fear of falling and of re-fracturing [8].

For all the above reasons, falls prevention is now widely recognised as one of the main priorities to promote active and healthy ageing in older subjects (http://profound.eu.com/wp-content/uploads/2016/12/Silver-Paper-Executive-Summary-Final.pdf).

Most guidelines for the prevention of falls in older people [AGS/BGS Clinical Practice Guideline Prevention of Falls in Older Person-2010 (https://sbgg.org.br/wp-content/uploads/2014/10/2010-AGSBGS-Clinical.pdf); Stopping Elderly Accidents, Death, and Injury (STEADI) initiative, Center for Disease Control and Prevention (https://www.cdc.gov/steadi/index.html); [9] recommend to assess regularly the older patients’ risk for a fall and to propose interventions adapted to the risk of falling, considering that patients with repeated or injurious falls, especially those who have experienced a hip fracture, are at the highest risk of new incident falls and fractures.

2 How to Assess Older Patients’ Risk of Falling

Subjects aged 65 or older at increased risk of falling can be screened:

  • By themselves or their caregivers using simple questions

    For the experts of the STEADI programme, subjects with a history of fall in the previous year, who feel unsteady when standing or walking, or subjects who scored 4/12 points or more on the stay independent brochure (https://www.cdc.gov/steadi/pdf/STEADI-Brochure-StayIndependent-508.pdf) should be considered at increased risk of falling and should require further assessment provided by a general practitioner [10, 11].

  • By healthcare providers using simple questions and tests

    Three simple questions:

    The STEADI initiative recommends healthcare providers to include in the routine examination of patients 70 and older three questions: Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? If the patient answers no to all these key screening questions, he/she can be considered at low risk of falling. If the patient answers “yes” to any of these key screening questions, further assessment is needed to distinguish subjects at moderate or high risk of falling. The AGS/BGS 2010 and the 2013 NICE guidelines (https://www.nice.org.uk/guidance/cg161) recommend accordingly that all older persons who are under the care of a health professional (or their caregivers) should be asked at least once a year about falls, frequency of falling and difficulties in gait, balance and muscle strength. This routine assessment is especially important in patients with multimorbidities that may induce falls, such as Parkinson’s disease, kidney, vision and cognitive impairment, incontinence, depression or with polypharmacy [12,13,14] and in patients admitted to the emergency room or hospitalised. Indeed, nearly half of hip fracture patients have visited the emergency room (ER) or have been admitted to hospital in the year prior to fracture, a quarter of them for a previous fall [15]. Unfortunately, very few of the patients visiting the ER or hospital receive falls counselling [15], which is a major missed opportunity since patient-centred interventions can reduce incident falls and fracture in older people presenting to the ED after a fall [16] or a fracture [17].

    Simple physical tests:

    AGS/BGS-2010 and 2013 NICE guidelines recommend to assess balance and gait using simple tests such as the timed up and go test (TUG) and the ‘turn 180°’ test (TT). These tests are indeed easy to perform in any setting and their administration requires no special equipment. Cut-off values for abnormal results remain however discussed (the risk of falling is increased when the TUG is >15 s (threshold for sarcopenia) [18] and a TUG >20 s indicates a significant gait disorder). The one-leg stand test can also easily been used, with the same limits (the risk of falling is low when >10 s and high when <5 s) (https://www.nice.org.uk/guidance/cg161; [19]). Other tests such as the Berg balance test, the Tinetti scale, the functional reach and the dynamic gait test need equipment or clinical expertise. Dual-task testing can also be used since patients who reduce their walking speed when performing a second task are more prone to falls. People with a difference of 4.5 s or more between the TUG test (simple task) and the dual manual task TUG test (TUG test while carrying a glass of water in one hand) or who need 14.7 s or over to perform the cognitive TUG (TUG test while counting backward in threes from a random start point) are at risk of falling, especially in case of Parkinson’s disease [20].

A low muscle strength is a significant but less consistent risk of falls or injurious falls than gait and balance impairments. Muscle strength can be assessed using grip strength, which requires specific equipment [19] or more easily by measuring the chair rising performance [21]. Time to perform five chair-rising stands can be considered as normal when <12 s and may be a sign of sarcopenia when >15 s [18].

The STEADI algorithm recommends to use the TUG, the 30-s chair stand and the four-stage balance test to identify people with gait/strength/balance disturbances, although cut-off values are not indicated (https://www.cdc.gov/steadi/index.html).

The Short Physical Performance Battery (SPPB), which includes sit-to-stand performance, walking speed and balance performance, can also be used since it demonstrates a significant association with fall history [21]. The Physiological Profile Assessment (PPA), which involves a series of simple tests of vision, peripheral sensation, muscle force, reaction time, postural sway and the Timed Up and Go test can also identify people at risk for falls [22].

The Downton Fall Risk Index (DFRI) that is a composite index of five groups of fall risk factors including previous falls, medications (tranquilisers, sedatives, diuretics, antihypertensives, antiparkinsonian drugs, antidepressants), sensory disability (visual or hearing impairment, impaired motor skills (reduced muscle strength or loss of function in a limb), cognitive disability (orientation to time, place, and person) and walking ability (unsafe gait) has been shown to predict hip fracture [23].

2.1 Definition of Older People at Low, Moderate or High Risk of Falling

In order to be pragmatic and based on the three above questions (history of falls and injurious falls, fear of falling or feeling of unsteadiness) and the three simples tests (TUG, one-leg stand and five chair-rising) that take less than 5 min to be asked and performed, it can be proposed that:

  • People at low risk of falling are those without any history of fall in the 12 last months, fear of falling or feeling of unsteadiness and without balance (e.g. one-leg stand test >10 s), gait (e.g. timed up and go test <12 s) and muscle strength (e.g. five sit-to-stand test in <12 s) problem.

  • People at high risk of falling are those 1. with a history of repeated or injurious falls in the six previous months or 2. with a fear of falling or a feeling of unsteadiness or a history of one fall in the 12 last months associated with a significant balance (e.g. one-leg stand test <5 s)or gait (e.g. timed up and go test >20 s) or muscle strength problem (e.g. five sit-to-stand test in >15 s).

  • People at moderate risk of falling are those who are nor at low or high risk of falling. There is a continuum among patients at moderate risk of falling, approaching low risk when the number of risk factors is low and high risk when the number of risk factors is high.

3 Fall Prevention Intervention in Patients with Low Risk of Falling

Education and exercise should be offered in older subjects at low risk of falling since people with high activity and performance are, with those with the lowest activity/worst physical performances, the subjects at the highest risk of falls [24].

Education: The STEADI initiative provides educational materials and brochures for family caregivers (https://www.cdc.gov/steadi/pdf/steadi-CaregiverBrochure.pdf) including the following educational messages: (1) A healthcare provider should be told right away in case of fall, unsteadiness or fear of falling; (2) medications, including over-the-counter medications and supplements, should be regularly reviewed by a healthcare provider or a pharmacist, especially in case of dizziness or sleepiness; (3) the interest of taking vitamin D supplements to improve bone, muscle and nerve health should be regularly discussed with an healthcare provider; (4) physical activities that improve balance and lower limbs muscle strength (like Tai Chi) should be regularly performed to prevent falls and also to improve well-being and confidence; (5) eyes should be checked by a health provider at least once a year to optimise vision (e.g. to update eyeglasses, if needed, and to optimise the treatment of condition like glaucoma or cataracts); (6) feet should be checked by a health provider at least once a year to a allow a safe and comfortable walking (to provide well-fitting shoes discuss with good support inside and outside, and ask whether seeing a foot specialist is advised). Counselling is also (7) home safety should be optimised by keeping floors clutter-free, removing small throw rugs or using double-sided tape to keep the rugs from slipping, by adding grab bars in the bathroom next to and inside the tub, and next to the toilet, and having handrails and lights installed on all staircases. A checklist is also available to find and fix hazards at home on the STEADI site (https://www.cdc.gov/steadi/pdf/steadi-Brochure-CheckForSafety-508.pdf).

Community exercise programmes to maintain or improve balance and strength: The programmes with the best evidence are the Otago Exercise Programme (OEP), Tai Chi, the Falls Management Exercise programme (FaME -sometimes called PSI), Lifestyle-integrated Functional Exercise (LiFE) and the Ossebo programme [25]. On the whole, physical activity in older people may reduce the risk of fall-related injuries by 32–40%, including severe falls requiring medical care or hospitalisation, and improves physical function in older people without or with frailty or Parkinson’s disease (http://bachlab.pitt.edu/sites/default/files/DiPietro2019.pdf). The effect on the rate of falls of resistance exercise (without balance and functional exercises), dance or walking is uncertain [26]. The NICE guidelines recommend to promote the participation of older people at low risk of falls in exercise programmes, considering also the psychological and social values of such exercise programmes in addition to their physical benefits (https://www.nice.org.uk/guidance/cg161).

Systematic vitamin D ± calcium supplements should not be recommended in subjects with low or moderate risk of falling since their effectiveness to prevent fractures or falls is not demonstrated [27, 28]. High-dose vitamin D may even have adverse effects on fall risk [29].

4 Multifactorial Interventions in Patients with Moderate Risk of Falling

A targeted intervention programme should be offered in patients at moderate risk of falling including.

Education: Interventions that aim to increase knowledge/education about fall prevention alone seem not be able to reduce significantly the rate of falls. The NICE guidelines recommend however to implement measures to enhance “fall awareness” in older people at moderate or high risk of falling and healthcare professionals (https://www.nice.org.uk/guidance/cg161). The education material provided by the STEADI initiative described previously for people at low or moderate risk of falling can be used by patients at high risk of falling and their caregivers (https://www.cdc.gov/steadi/materials.html). The Prevention of Falls Network for Dissemination (ProFouND) that is an European Commission funded initiative dedicated to the dissemination and implementation of best practice in falls prevention across Europe has also produced documents to influence policy and increase awareness of falls for health and social care authorities, the commercial sector, NGOs and the general public (http://profound.eu.com/).

Exercises supervised by a physiotherapist or in a community fall prevention programme: Exercise when challenging, progressive, regular and conducted in the long term is indeed effective to prevent falls and falls requiring medical attention and fractures (no proof for HF specifically) in older persons living in the community (http://profound.eu.com/wp-content/uploads/2016/12/Falls-Intervention-Factsheets-FinalV2.pdf; [26, 30]).

Exercises that allow to develop and mobilise sufficient attention resources to recover a stable posture following an external perturbation such as dual-task training, and exercises to improve floor-rise ability, should be included in clinical practice [31]. Tai Chi is effective to reduce falls in people at low or moderate risk of falling and there is no evidence that walking or brisk walking reduces the risk of falling [32].

Whole body vibration, through its ability of enhancing balance, improving leg and plantar flexor muscle strength, and reducing fall rate may also help reduce the risk of fracture [33, 34].

On the whole, dedicated falls prevention programmes conducted in people living in the community at low to moderate risk of falling decrease falls and fall-related injury rates by 20–40% and are cost-effective [32, 35, 36].

Modification/progressive withdrawal of fall risk-increasing drugs (FRIDs): Polypharmacy is a risk factor of falling. The most common FRIDs are—psychotropic drugs, such as sedatives, hypnotics, antidepressants, antipsychotic medications, antiepileptics, opioids and other drugs which can cause sedation, delirium or impaired balance and coordination (including those that induce hyponatremia)—cardiovascular drugs and other drugs which can cause or worsen orthostatic hypotension (such as anticholinergic drugs) and induce cardiac arrhythmias (such as drugs at risk of GT prolongation) [37,38,39].

A meta-analysis of randomised-controlled interventions aiming to prevent falls in the elderly living in the community showed that slow withdrawal of psychotropics and prescribing modification programmes for primary care physicians significantly reduce the risk of falling [32, 40].

Vision optimisation: Visual control plays a role in the assessment of the risks in the environment and in the effectiveness of protective responses to avoid a fall explaining why poor vision is associated with a risk of fall-related injuries including HF [41, 42]. Cataract surgery on the first affected eye and replacement of multifocal glasses by single lens glasses are effective in reducing the falling rate in older people living in the community [32].

Treatment of foot problems: Physical examination should include feet and footwear check and foot problems should be addressed. Indeed, one trial conducted in 305 participants has shown that multifaceted podiatry, and foot and ankle exercises reduce significantly the rate of falls in people with disabling foot pains [32].

Vitamin D supplementation at patients at risk of vitamin D deficit: The STEADI guidelines recommend vitamin D and calcium supplementation in all patients, whatever their risk of falling. Taking vitamin D supplements, however, does not appear to reduce falls in most community-dwelling older people, but may do so in those who have low vitamin D blood levels [32, 43]. Vitamin D deficiency indeed, especially when sufficiently deep to induce elevated PTH, predisposes both to falls and HF [44]. Thus, people at moderate risk of falling who are at risk of vitamin D deficits (low outdoor activity, high fat mass) should be offered vitamin D supplements without any vitamin D serum measurement during the winter season (https://www.has-sante.fr/jcms/c_1525705/fr/avis-de-la-has-concernant-l-evaluation-du-risque-de-chutes-chez-le-sujet-age-autonome-et-sa-prevention). Calcium supplementation is not recommended in patients at moderate risk of falls [45].

5 Multifactorial Falls Risk Assessment and Interventions in Patients with High Risk of Falling

The AGS/BGS 2010/ [46] and STEADI initiative recommend to offer a multifactorial fall prevention programme in complex patients with an history of recurrent or injurious falls or with a fall with significant balance, gait, or muscle strength disorders (https://www.nice.org.uk/guidance/cg161; https://www.cdc.gov/steadi/pdf/steadi-Algorithm-508.pdf). Indeed, this kind of programme that identifies modifiable risk factors and propose a personalised fall prevention programme reduces the number of falls in randomised controlled trials (RCTs) (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012221.pub2/full) and in pre-post-intervention studies [47]. The NICE recommends that individualised multifactorial assessment and intervention should be performed by healthcare professionals with appropriate skills and experience, normally in the setting of a specialist falls service (most often called falls clinics) with clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (e.g. comprehensive geriatric assessment) (https://www.nice.org.uk/guidance/cg161).

According to the STEADI initiative and the NICE guidelines, the management of patients at risk of falling starts with the management of conditions that alter gait, balance and mobility such as postural dizziness and postural hypotension, cognitive impairment, metabolic abnormalities such as hypoglycaemia [48] or hyponatraemia [49], sleep disturbances [50], muscle weakness and urinary incontinence [47] and conditions that induce fainting. Insertion of a pacemaker should be considered for older people with frequent falls associated with cardioinhibitory carotid sinus hypersensitivity, or sinus node dysfunction, conditions which cause sudden changes in heart rate and blood pressure [32, 51]. Multifaceted podiatry and foot and ankle exercises reduce significantly the rate of falls in people with disabling foot pains [32]. A falls and fracture successful multifactorial intervention programmes in older people at high risk of falling should also comprise, besides education (see above):

Modification/progressive withdrawal of fall risk-increasing drugs (FRIDs): As indicated previously, progressive withdrawal of fall risk-increasing drugs reduces the risk of falling [32, 40]. Polypharmacy and fall-risk increasing drugs remain however prevalent in patients discharged from orthogeriatric care after surgery for a hip fracture [52, 53]. FRIDs are present in two-thirds of patients visiting fracture liaison services [54], benzodiazepines and opioids being more specific risk factors of HF [55]. This suggests the interest to conduct interventions on drug use at discharge of patients admitted to hospital for a falls-related injury [52, 53].

Vision optimisation: Any history of cataracts, macular degeneration, glaucoma or visual loss should be identified in people at high risk of falling and those people should be referred to an eye doctor when no eye examination has occurred during the past year. Vision assessment and referral are therefore a component of successful multifactorial falls prevention programmes, especially when associated with home hazard intervention [32, 56].

Exercises: As indicated previously, programmes that combine balance and moderate intensity strength training either alone or with other interventions, especially vision assessment and treatment and environmental assessment and modification, are effective to prevent falls, fall-related fractures and other types of injurious falls https://www.nice.org.uk/guidance/cg161; [26, 32, 36, 57,58,59,60]). Tai Chi is not recommended in patients at high risk of falling [32].

Exercises improving medial-lateral stability are especially recommended in patients at high risk of falling and fracture since sideways falls are associated with a sixfold increased risk for hip fracture [61, 62]. Exercises enhancing anterior–posterior postural control are also warranted, given that forward falls can also result in hip impact [63]. Exercises to help reduce the hip impact during the descent stage of falling and therefore make landing safer may include exercises of forward or backward axial rotation of the torso and pelvis during descent [64] and exercises to strengthen upper extremity muscles to make protective responses during falls more effective [65, 66].

The NICE and ProFouND initiative recommend that the exercise programme in patients at high risk of falling should be individually prescribed and monitored by professionals, such as physiotherapists, sport scientists and specialist exercise instructors, who are appropriately trained in delivering falls prevention exercise programmes (http://profound.eu.com/wp-content/uploads/2016/12/Falls-Intervention-Factsheets-FinalV2.pdf; https://www.nice.org.uk/guidance/cg161).

Evidence from the 2018 PAGAC Scientific Report indicates that older people who have sustained hip fracture should benefit from weight-bearing, multicomponent activity [67]. The meta-analysis of RCT by Lee et al. reported that progressive resistance exercise significantly improved overall physical function (mobility, balance, lower limb strength or power and performance tasks) after hip fracture surgery [68].

When associated with orthogeriatric co-management and physician consultations, group exercise and vibration-therapy over a 18-month period can reduce the re-fracture rate, improve balance and mobility and reduce costs in fragility hip fracture patients [69].

Home hazard intervention: The majority of fall-related injuries occur while older people move around home. Interventions to improve home safety, such as nightlights or bathroom grab bars, appear to be effective to reduce falls, especially in people who fall at home or have received treatment in hospital following a fall (https://www.nice.org.uk/guidance/cg161), and especially when carried out by suitably trained healthcare professionals, such as occupational therapists [32]. Indeed, home assessment visits by occupational therapists prior to hospital discharge for patients recovering from hip fracture can reduce the number of readmissions to hospital, increase functional independence at 6 months and may reduce the risk of falls in the first 30 days after discharge [70].

Assuming that home safety measures reduce fall-related hip fractures in accordance with the reduction of the rate of falls, a home safety intervention to prevent falls could be cost-effective in impaired elderly people living in the community [71].

NICE and ProFouND guidelines recommend to seeking opportunities from the Information and Communication Technologies (ICT) sector to provide solutions for fall-detection and prevention (http://profound.eu.com/wp-content/uploads/2016/12/Falls-Intervention-Factsheets-FinalV2.pdf; https://www.nice.org.uk/guidance/cg161).

Vitamin D and calcium: Screening of vitamin D deficiency by measuring serum total 25(OH)D is recommended in individuals with a history of falls or nontraumatic fracture and in patients at risk of vitamin D deficiency, such as patients with diseases affecting vitamin D metabolism and absorption, and osteoporosis [72]. Measuring blood 25OHVitamin D in recurrent fallers or after a fall-related fracture helps to guide the vitamin D deficits correction. Vitamin D and calcium supplementation may reduce falls in patients with increased risk for falls and a vitamin D deficiency [32, 43, 45].

Osteoporosis screening and treatment if needed: Bone health should be assessed in patients at high risk of falls, and especially in those with sarcopenia or with an history of fracture [73]. A low bone mineral density, a poor physical function and falls are indeed the strongest independent risk factors for a subsequent nonvertebral fracture [74].

The NICE and more recently the European guidelines recommend to perform a BMD and calculate the FRAX risk (calculation without BMD if DXA is not possible) in patients at high risk of falling in order to determine if an osteoporosis treatment is required (https://www.nice.org.uk/guidance/cg161; [75]). Nevertheless, life expectancy should be taken into account when assessing the appropriateness of DXA in fallers, as osteoporosis treatments require at least 12 months to decrease the fracture risk [75].

6 Fall Assessment and Prevention in Care Settings

The 2016 NICE guidelines do not recommend to use fall risk prediction tools to assess the risk of falling in inpatients, but rather to consider that all hospitalised patients aged 65 years or older are at high risk of falling as well as patients aged 50 and older with underlying conditions (https://www.nice.org.uk/guidance/cg161;). Some tools with good sensitivity and specificity can however been used to screen patients particularly at risk of falling at hospital, including the STRATIFY tool that assesses five factors (patients who present or not to hospital with a fall or who has fallen on the ward since admission; patients agitated, visually impaired, in need of especially frequent toileting, with poor transfer and mobility, living in a nursing home or not) [76] and the Hendrich II Fall Risk Model that consists of eight variables including (confusion/disorientation/impulsivity, symptomatic depression, altered elimination, dizziness/vertigo, gender, any administered anti-epileptics, benzodiazepines and the “get up and go” test) [77].

Similarly, risk assessment tools do not add significant value to nurses’ judgment for identifying individuals at high risk of falls in daily practice [78]. Indeed, most of nursing home residents are at high risk of falling since a fall history, gait and balance instability, cognitive and functional impairment, sedating and psychoactive medications and multimorbidity are significant risk factors of falling in nursing home residents [3].

If the same guidance relating to community-dwelling older adults at high risk of falling presented above applies to acute and long-term care settings (http://profound.eu.com/), the evidence for effective falls prevention interventions in acute and subacute wards and in nursing homes is more limited [3, 79, 80].

The NICE guidelines underline the fact that architects should take into account improvements to the inpatient environment to prevent falls when designing new setting for older people (https://www.nice.org.uk/guidance/cg161). The clinical effectiveness of compliant flooring at preventing serious fall-related injuries among long-term care residents remains discussed [81]. International evidence suggests that physical restraints may increase the risk of falling by limiting mobility in this group of frail elderly persons [82].

A key component for falls prevention in care settings and for physical restraint reduction in nursing homes is the implementation of a proactive organisational strategy that includes leadership, individualised patient education programmes combined with staff education and training, careful monitoring with audit, reminders and feedback to staff, provision of equipment, supportive risk management and change agent [57, 79, 83].

7 Fall Assessment and Prevention in Patients with Cognitive Impairments

Almost two-thirds of people with dementia living in the community fall annually, i.e. a rate that is twice that of the population without cognitive impairment [84]. Falls are a major cause of injury to cognitively impaired older people [85]. The high prevalence and morbidity of falls in dementia are in part due to the relationship between low performance in attention and executive function and gait slowing, instability and future falls [86].

This explains why some recent falls prevention programmes in cognitively impaired older people include, in addition to the above conventional measures, the prescription of walking aids and training programmes targeting identified gait abnormalities and appropriate to the individuals’ cognitive capacity, non-pharmaceutical and pharmaceutical strategies to increase attention, cognitive training and behavioural change/modulation to improve planning, judgment, inhibitory control and flexibility/problem-solving skills in order to improve safely mobilisation during challenging circumstances [87]. Thus, cognitive training, dual-task training and virtual reality modalities are promising strategies to improve mobility in older adults with cognitive impairment and dementia [86]. In the advanced stage of dementia, recurrent falls can be sentinel events indicating the need for a palliative approach to care with a focus on symptom management, comfort and dignity.

8 Falls Clinics and Fracture Liaison Services

Falls clinics are one approach by which older people with high levels of falls risk can be managed. Falls clinics, that are however too seldom in the world, offer detailed multidisciplinary assessment and make recommendations or implement a range of targeted falls and falls injury-prevention strategies based on the assessment findings. Several pre–post clinic intervention studies and randomised controlled-studies have indicated substantial reductions in falls and related injuries (between 30 and 77%) in high falls–risk populations, and improvements in other outcomes such as balance and mobility, physical functioning, fear of falling and engagement with falls prevention interventions [47, 88, 89]. The number of patients to see in a fall clinic to prevent a fall or an injurious fall has been found to be 5 and 6, respectively [89].

As indicated previously, a fragility fracture is one of the strongest risk factor for a subsequent nonvertebral fracture [74, 90]. Fracture liaison services (FLS) working together with geriatric units specialised with falls prevention are probably the most efficient way of addressing primary and secondary prevention of fracture including the assessment of both bone health and falls risk [75, 91, 92], especially in frail older patients [93].

9 Conclusion

Falls are a major public health problem in the elderly population. Some simple questions related to fall and fall-related injury in the previous months, feeling of unsteadiness and fear of falling, and some simple tests that aim to assess balance/gait and muscle strength (e.g. timed up and go and sit-to-stand tests) may help distinguish people at low, moderate or high risk of falling. Balance and strength exercises and education are recommended to reduce falls in people whatever the risk of falls. A multifactorial falls and fracture risk assessment and prevention should be offered to older people at high risk of falls, i.e. those who present for medical attention because of a fall, especially after a fracture or who are recurrent fallers. This multifactorial falls risk assessment and prevention should be offered by a healthcare professional with appropriate skills and experience, normally in the setting of a falls clinic, in link with a fall liaison service in case of fall-related fracture. Individualised, targeted multifactorial interventions comprise the management of specific causes of gait/balance and muscle strength disturbances, prescription of vitamin D supplements when blood level of vitamin D is low and of BMD and FRAX risk calculation in order to determine recommendations for osteoporosis treatment, measures to improve home safety (at best delivered by an occupational therapist), a review of medications, vision optimisation, insertion of a pacemaker in case of carotid sinus hypersensitivity and multifaceted podiatry. Because falls and fracture are most often preventable, it is now crucial to overcome limited awareness and usage of solutions to prevent and monitor falls and osteoporosis and make these available (Action Group A2 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA)) (https://ec.europa.eu/eip/ageing/actiongroup/index/a2_en).