Key messages
– A psychological intervention (involving motivational interviewing (a method that aims to change behaviours by addressing uncertainties and encouraging personal commitment) and coaching) combined with tailored education (for example, advice on exercise or medication) makes little to no difference in the number of people who fall (fallers), but likely reduces the number of times people fall (though it is unclear by how much).
- There was not enough good-quality evidence to be confident in the effects of individual psychological or educational interventions.
What did we want to find out?
As we age, we are more likely to fall, and potentially hurt ourselves. It is estimated that one in three older adults fall each year, which can impact independence and years lived in good health. Falls occur for many reasons, and exercise and interventions tailored to different risk factors (such as weak muscles, eyesight, the environment, or medication) can reduce falls. If we worry about falling, we may limit activities, which could increase our fall risk. Psychological interventions aim to reduce concerns about falling, improve awareness, or motivation to take actions to prevent falls. Education aims to inform people about ways to reduce the risk of falling. We wanted to look at whether psychological or educational interventions (or combinations of these) could help reduce falls in older adults who live in their own homes.
What did we do?
We searched for studies that compared the following interventions against usual care for older adults living at home.
– Cognitive behavioural therapy (a talking therapy that can help people manage their problems by changing the way they think and behave).
– Motivational interviewing (a method that aims to increase a person's motivation to improve behaviours by looking at their doubts and encouraging personal commitment).
– Other psychological interventions, for example, guided imagery (a technique where people are taught to use their imagination to help lower negative feelings) or coaching.
– Education (tailored to a person's risk factors; covering multiple topics, such as exercise, footwear, and medication; or a single topic, such as the home environment).
– Psychological intervention combined with education.
We compared and summarised the results, and rated our confidence in the evidence. We explored the outcomes of number of falls, number of people who fell, number of people who fell and experienced a fracture, number of people who fell and needed medical attention, hospital admission, concerns about falling, and unwanted effects.
What did we find?
We found 37 studies that involved 17,478 people living at home aged in their late 60s to 80s (71% were women). The biggest study involved 4667 people and the smallest study involved 40 people. The studies were conducted worldwide, but mostly in the USA (six studies), Iran (six studies), and Australia (five studies). Fifteen studies monitored people for less than six months and 17 studies for 12 months or more. Studies tested education (24 studies), cognitive behavioural interventions (six studies), motivational interviewing (three studies), other psychological interventions (three studies), or a psychological intervention combined with education (one study). Twenty-eight of the studies were publicly funded (for example, by universities, grants, and charities).
Main results
We found that a psychological intervention (motivational interviewing/coaching) combined with tailored education makes little to no difference to the number of fallers (1 study, 430 people), probably makes little to no difference to concerns about falls (1 study, 353 people), but likely reduces the number of falls (although this could be by a small or a large amount; 1 study, 430 people). One study reported no unwanted effects (430 people).
We found that education tailored to a person's risk factors makes little to no difference to the number of falls (2 studies, 777 people), and the evidence on fall-related fractures is uncertain (2 studies, 510 people). Education covering multiple topics may improve concerns about falling (1 study, 459 people). Evidence for education on other outcomes was either very uncertain or not assessed.
Cognitive behavioural interventions may result in little to no difference on the number of fallers (4 studies, 1286 people), and a slight reduction in concerns about falls (3 studies, 1132 people).
The evidence for psychological interventions was either very uncertain or not assessed for other outcomes.
What are the limitations of the evidence?
We have moderate-to-high confidence in our results for the combined psychological and educational intervention. This is because the study was large and well-conducted.
For all other interventions, we are far less confident in our results and future research results could differ from this review. There were problems with study designs and the findings were not clear. Current studies had not measured all the outcomes we were interested in.
Most studies were conducted in high-income countries.
How up to date is this evidence?
The evidence is up to date to 6 June 2023.
The evidence suggests that a combined psychological and educational intervention likely reduces the rate of falls (but not fallers), without affecting adverse events. Overall, the evidence for individual psychological interventions or delivering education alone is of low or very-low certainty; future research may change our confidence and understanding of the effects. Cognitive behavioural interventions may improve concerns about falling slightly, but this may not help reduce the number of people who fall. Certain types of education (i.e. multiple component education) may also help reduce concerns about falling, but not necessarily reduce the number of falls.
Future research should adhere to reporting standards for describing the interventions used and explore how these interventions may work, to better understand what could best work for whom in what situation. There is a particular dearth of evidence for low- to middle-income countries.
Older adults are at increased risk of both falls and fall-related injuries. Falls have multiple causes and many interventions exist to try and prevent them, including educational and psychological interventions. Educational interventions aim to increase older people's understanding of what they can do to prevent falls and psychological interventions can aim to improve confidence/motivation to engage in activities that may prevent falls. This review is an update of previous evidence to focus on educational and psychological interventions for falls prevention in community-dwelling older people.
To assess the benefits and harms of psychological interventions (such as cognitive behavioural therapy; with or without an education component) and educational interventions for preventing falls in older people living in the community.
We searched CENTRAL, MEDLINE, Embase, four other databases, and two trials registries to June 2023. We also screened reference lists and conducted forward-citation searching.
We included randomised controlled trials of community-dwelling people aged 60 years and older exploring the effectiveness of psychological interventions (such as cognitive behavioural therapy) or educational interventions (or both) aiming to prevent falls.
We used standard methodological procedures expected by Cochrane. Our primary outcome was rate of falls. We also explored: number of people falling; people with fall-related fractures; people with falls that required medical attention; people with fall-related hospital admission; fall-related psychological outcomes (i.e. concerns about falling); health-related quality of life; and adverse events.
We included 37 studies (six on cognitive behavioural interventions; three on motivational interviewing; three on other psychological interventions; nine on multifactorial (personalised) education; 12 on multiple topic education; two on single topic education; one with unclear education type; and one psychological plus educational intervention). Studies randomised 17,478 participants (71% women; mean age 73 years). Most studies were at high or unclear risk of bias for one or more domains.
Cognitive behavioural interventions
Cognitive behavioural interventions make little to no difference to the number of fallers (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.82 to 1.02; 4 studies, 1286 participants; low-certainty evidence), and there was a slight reduction in concerns about falling (standardised mean difference (SMD) −0.30, 95% CI −0.42 to −0.19; 3 studies, 1132 participants; low-certainty evidence). The evidence is very uncertain or missing about the effect of cognitive behavioural interventions on other outcomes.
Motivational interviewing
The evidence is very uncertain about the effect of motivational interviewing on rate of falls, number of fallers, and fall-related psychological outcomes. No evidence is available on the effects of motivational interviewing on people experiencing fall-related fractures, falls requiring medical attention, fall-related hospital admission, or adverse events.
Other psychological interventions
The evidence is very uncertain about the effect of health coaching on rate of falls, number of fallers, people sustaining a fall-related fracture, or fall-related hospital admission; the effect of other psychological interventions on these outcomes was not measured. The evidence is very uncertain about the effect of health coaching, guided imagery, and mental practice on fall-related psychological outcomes. The effect of other psychological interventions on falls needing medical attention or adverse events was not measured.
Multifactorial education
Multifactorial (personalised) education makes little to no difference to the rate of falls (rate ratio 0.95, 95% CI 0.77 to 1.17; 2 studies, 777 participants; low-certainty evidence). The effect of multifactorial education on people experiencing fall-related fractures was very imprecise (RR 0.66, 95% CI 0.29 to 1.48; 2 studies, 510 participants; low-certainty evidence), and the evidence is very uncertain about its effect on the number of fallers. There was no evidence for other outcomes.
Multiple component education
Multiple component education may improve fall-related psychological outcomes (MD −2.94, 95% CI −4.41 to −1.48; 1 study, 459 participants; low-certainty evidence). However, the evidence is very uncertain about its effect on all other outcomes.
Single topic education
The evidence is very uncertain about the effect of single-topic education on rate of falls, number of fallers, and people experiencing fall-related fractures. There was no evidence for other outcomes.
Psychological plus educational interventions
Motivational interviewing/coaching combined with multifactorial (personalised) education likely reduces the rate of falls (although the size of this effect is not clear; rate ratio 0.65, 95% CI 0.43 to 0.99; 1 study, 430 participants; moderate-certainty evidence), but makes little to no difference to the number of fallers (RR 0.93, 95% CI 0.76 to 1.13; 1 study, 430 participants; high-certainty evidence). It probably makes little to no difference to falls-related psychological outcomes (MD −0.70, 95% CI −1.81 to 0.41; 1 study, 353 participants; moderate-certainty evidence). There were no adverse events detected (1 study, 430 participants; moderate-certainty evidence). There was no evidence for psychological plus educational intervention on other outcomes.