Key messages
For older adults at a higher risk of having a fall, such as having had a fall in the past year and recently hospitalised or needing support with daily activities, removing environmental fall hazards in the home can reduce the number of falls by 38%. Examples of environmental fall hazards are a stairway without railings, a slippery pathway, or poor lighting.
Why is it important to consider environmental hazards as part of a fall prevention programme?
Falls are common and can be deadly, but they are preventable. Approximately one-third of people age 65 years and older fall each year. Most falls occur in the home, and more than 30% of all falls are caused by environmental hazards. Environmental fall-hazard removal programmes are interventions delivered by professionals that identify and remove environmental fall hazards.
What did we want to find out?
We wanted to find out:
• which types of environmental programmes work best to prevent falls.
We also wanted to find out for these programmes that prevent falls:
• the best ways to deliver programmes that reduce environmental fall hazards; and
• if such programmes can prevent falls that result in serious injury.
We examined four types of programmes, including those that:
• focused on removing fall hazards in and about the home;
• only provided assistive devices such as up-to-date glasses or special footwear;
• only provided education about environment-related fall risk; and
• focused on home modifications to enable independence and performance of daily tasks in the home.
What did we do?
We searched for studies that investigated different types of environmental fall-hazard programmes for older adults who live in the community. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sample sizes.
What did we find?
We found 22 studies involving 8463 older adults that lived in the community. The study participants were on average 78 years of age, and 65% were women. The studies were conducted in 10 countries. Most studies followed up participants for 12 months.
Main results
A programme that removes fall hazards in the home given to older adults that live in the community can reduce the number of falls.
We are not certain if assistive devices (such as checking prescription for glasses, special footwear, or bed alarm systems) can reduce the risk of a fall.
We are not certain if just giving an older adult who lives in the community education about fall risk has any impact on reducing risk of falls.
We found no completed studies that helped us answer our question about fall reduction for home modification programmes targeting independence in daily activity performance.
We found little evidence to determine if environmental fall-hazard removal programmes of any kind reduce the risk of serious injury.
How up-to-date is the evidence?
The evidence is current to January 2021.
We found high-certainty evidence that home fall-hazard interventions are effective in reducing the rate of falls and the number of fallers when targeted to people at higher risk of falling, such as having had a fall in the past year and recently hospitalised or needing support with daily activities. There was evidence of no effect when interventions were targeted to people not selected for risk of falling. Further research is needed to examine the impact of intervention components, the effect of awareness raising, and participant-interventionist engagement on decision-making and adherence.
Vision improvement interventions may or may not impact the rate of falls. Further research is needed to answer clinical questions such as whether people should be given advice or take additional precautions when changing eye prescriptions, or whether the intervention is more effective when targeting people at higher risk of falls.
There was insufficient evidence to determine whether education interventions impact falls.
Falls and fall-related injuries are common. A third of community-dwelling people aged over 65 years fall each year. Falls can have serious consequences including restricting activity or institutionalisation. This review updates the previous evidence for environmental interventions in fall prevention.
To assess the effects (benefits and harms) of environmental interventions (such as fall-hazard reduction, assistive technology, home modifications, and education) for preventing falls in older people living in the community.
We searched CENTRAL, MEDLINE, Embase, other databases, trial registers, and reference lists of systematic reviews to January 2021. We contacted researchers in the field to identify additional studies.
We included randomised controlled trials evaluating the effects of environmental interventions (such as reduction of fall hazards in the home, assistive devices) on falls in community-residing people aged 60 years and over.
We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls.
We included 22 studies from 10 countries involving 8463 community-residing older people. Participants were on average 78 years old, and 65% were women. For fall outcomes, five studies had high risk of bias and most studies had unclear risk of bias for one or more risk of bias domains. For other outcomes (e.g. fractures), most studies were at high risk of detection bias. We downgraded the certainty of the evidence for high risk of bias, imprecision, and/or inconsistency.
Home fall-hazard reduction (14 studies, 5830 participants)
These interventions aim to reduce falls by assessing fall hazards and making environmental safety adaptations (e.g. non-slip strips on steps) or behavioural strategies (e.g. avoiding clutter).
Home fall-hazard interventions probably reduce the overall rate of falls by 26% (rate ratio (RaR) 0.74, 95% confidence interval (CI) 0.61 to 0.91; 12 studies, 5293 participants; moderate-certainty evidence); based on a control group risk of 1319 falls per 1000 people a year, this is 343 (95% CI 118 to 514) fewer falls. However, these interventions were more effective in people who are selected for higher risk of falling, with a reduction of 38% (RaR 0.62, 95% CI 0.56 to 0.70; 9 studies, 1513 participants; 702 (95% CI 554 to 812) fewer falls based on a control risk of 1847 falls per 1000 people; high-certainty evidence). We found no evidence of a reduction in rate of falls when people were not selected for fall risk (RaR 1.05, 95% CI 0.96 to 1.16; 6 studies, 3780 participants; high-certainty evidence).
Findings were similar for the number of people experiencing one or more falls. These interventions probably reduce the overall risk by 11% (risk ratio (RR) 0.89, 95% CI 0.82 to 0.97; 12 studies, 5253 participants; moderate-certainty evidence); based on a risk of 519 per 1000 people per year, this is 57 (95% CI 15 to 93) fewer fallers. However, for people at higher risk of falling, we found a 26% decrease in risk (RR 0.74, 95% CI 0.65 to 0.85; 9 studies, 1473 participants), but no decrease for unselected populations (RR 0.99, 95% CI 0.92 to 1.07; 6 studies, 3780 participants) (high-certainty evidence).
These interventions probably make little or no important difference to health-related quality of life (HRQoL) (standardised mean difference 0.09, 95% CI −0.10 to 0.27; 5 studies, 1848 participants; moderate-certainty evidence). They may make little or no difference to the risk of fall-related fractures (RR 1.00, 95% 0.98 to 1.02; 2 studies, 1668 participants), fall-related hospitalisations (RR 0.96, 95% CI 0.87 to 1.06; 3 studies, 325 participants), or in the rate of falls requiring medical attention (RaR 0.91, 95% CI 0.58 to 1.43; 3 studies, 946 participants) (low-certainty evidence). The evidence for number of fallers requiring medical attention was unclear (2 studies, 216 participants; very low-certainty evidence). Two studies reported no adverse events.
Assistive technology
Vision improvement interventions may make little or no difference to the rate of falls (RaR 1.12, 95% CI 0.84 to 1.50; 3 studies, 1489 participants) or people experiencing one or more falls (RR 1.09, 95% CI 0.79 to 1.50) (low-certainty evidence). We are unsure of the evidence for fall-related fractures (2 studies, 976 participants) and falls requiring medical attention (1 study, 276 participants) because the certainty of the evidence is very low. There may be little or no difference in HRQoL (mean difference 0.40, 95% CI −1.12 to 1.92) or adverse events (falls while switching glasses; RR 1.00, 95% CI 0.98 to 1.02) (1 study, 597 participants; low-certainty evidence).
Results for other assistive technology - footwear and foot devices, and self-care and assistive devices (5 studies, 651 participants) - were not pooled due to the diversity of interventions and contexts.
Education
We are uncertain whether an education intervention to reduce home fall hazards reduces the rate of falls or the number of people experiencing one or more falls (1 study; very low-certainty evidence). These interventions may make little or no difference to the risk of fall-related fractures (RR 1.02, 95% CI 0.96 to 1.08; 1 study, 110 participants; low-certainty evidence).
Home modifications
We found no trials of home modifications that measured falls as an outcome for task enablement and functional independence.