Falls prevention: tailored assessment beats usual care, and not much else

Design

Updated Cochrane systematic review and random-effects meta-analysis, GRADE assessed

Population

110 randomised trials, 48,919 community-dwelling people aged 60 and over

Primary outcome

Falls rate, risk of falling, and risk of recurrent falls

Effect

Multifactorial vs usual care: falls rate RaR 0.76 (95% CI 0.67 to 0.87, I²=92%); vs advice or education RaR 1.09 (1.00 to 1.18)

The Cochrane review of multifactorial and multiple component falls prevention now covers 110 randomised trials and 48,919 community-dwelling people aged 60 and over. Multifactorial means tailoring components to each person's risk profile; multiple component means giving everyone the same package.

Against usual care, multifactorial interventions may cut the falls rate by about a quarter and reduce recurrent falls — both low certainty, and with heterogeneity at 92 per cent for the falls rate. They did not reduce the proportion of people who fall at all. Against falls advice or education, they add nothing and probably raise the falls rate slightly. Against exercise, the evidence is too uncertain to say anything.

Multiple component interventions — the same package for everyone — showed little or no effect on the falls rate against any comparator. So the practical reading is that tailoring is what the evidence supports over doing nothing, that structured advice is a much stronger comparator than services assume, and that exercise remains the intervention against which everything else struggles to prove itself.

• Tailor the falls assessment to the individual's risk factors; do not deliver a fixed package to everyone.
• Make sure structured falls advice and education is actually being given — it performed as well as a full service in these comparisons.
• Keep strength and balance exercise at the centre; nothing here beat it.
• Count falls rate and recurrent falls, not just whether someone fell — the effects differ between those outcomes.
• Adverse effects were mild across all comparisons; safety is not the limiting factor.

Why it matters

It sets the bar for a falls service at what good advice already achieves, not at usual care.

Don't overread it

Low-certainty evidence with extreme heterogeneity; the pooled numbers describe a category of service, not a specific programme.

The statistics, in plain English

A rate ratio of 0.76 with I squared of 92 per cent means the trials disagree profoundly: the pooled estimate is an average across services that differ in what they actually delivered, and GRADE downgraded it to low certainty for exactly that reason. The comparison against advice or education (RaR 1.09, 1.00 to 1.18) touches 1.0 at its lower bound, so 'probably increases falls rate by a small amount' is the careful reading and 'no additional benefit' is the safe one. Note also the divergence between outcomes — falls rate improving while the proportion of people falling does not means the benefit concentrates in people who fall repeatedly.

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