As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.
This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.  
Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.
Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.  
Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.
Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.  
Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.
Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.
In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.
The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

Interventions for preventing falls in older people living in the community

Summary Guidance is provided in a European setting on the assessment and treatment of postmenopausal women with or at risk from osteoporosis. Introduction The European Foundation for Osteoporosis and Bone disease (subsequently the International Osteopo- rosis Foundation) published guidelines for the diagnosis and management of osteoporosis in 1997. This manuscript updates these in a European setting. Methods The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporo- sis and assessment of fracture risk; general and pharmaco- logical management of osteoporosis; monitoring of treatment; assessment of fracture risk; case finding strategies; investigation of patients; health economics of treatment. Results and conclusions A platform is provided on which specific guidelines can be developed for national use.

/pdf/european-guidance-for-the-diagnosis-and-management-of-bexvs3o205.pdf

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Summary
This report describes the epidemiology, burden, and treatment of osteoporosis in the 27 countries of the European Union (EU27).

/pdf/osteoporosis-in-the-european-union-medical-management-5gi5e439ck.pdf

Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA).

During the past decade, major advances have been made in vitamin D research that transcend the simple concept that vitamin D is Important for the prevention of rickets in children and has little physiologic relevance for adults. Inadequate vitamin D, in addition to causing rickets, prevents children from attaining their genetically programmed peak bone mass, contributes to and exacerbates osteoporosis in adults, and causes the often painful bone disease osteomalacia. Adequate vitamin D is also important for proper muscle functioning, and controversial evidence suggests it may help prevent type 1 diabetes mellitus, hypertension, and many common cancers. Vitamin D inadequacy has been reported in approximately 36% of otherwise healthy young adults and up to 57% of general medicine inpatients in the United States and in even higher percentages in Europe. Recent epidemiological data document the high prevalence of vitamin D inadequacy among elderly patients and especially among patients with osteoporosis. Factors such as low sunlight exposure, age-related decreases in cutaneous synthesis, and diets low in vitamin D contribute to the high prevalence of vitamin D inadequacy. Vitamin D production from cutaneous synthesis or intake from the few vitamin D-rich or enriched foods typically occurs only intermittently. Supplemental doses of vitamin D and sensible sun exposure could prevent deficiency in most of the general population. The purposes of this article are to examine the prevalence of vitamin D inadequacy and to review the potential implications for skeletal and extraskeletal health.

https://www.grc.com/health/pdf/High_Prevalence_of_Vitamin_D_Inadequacy_and_Implications_for_Health.pdf

High prevalence of vitamin D inadequacy and implications for health.

Background 
Approximately 30% of people over 65 years of age living in the community fall each year.
Objectives
To assess the effects of interventions to reduce the incidence of falls in older people living in the community.
Search strategy
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials ( all to May 2008).
Selection criteria
Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.
Data collection analysis
Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.
Main results
We included 111 trials ( 55,303 participants). Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95% CI 0.71 to 0.86; risk ratio (RR) 0.83, 95% CI 0.72 to 0.97), as did Tai Chi ( RaR 0.63, 95% CI 0.52 to 0.78; RR 0.65, 95% CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise ( RaR 0.66, 95% CI 0.53 to 0.82; RR 0.77, 95% CI 0.61 to 0.97).
Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95% CI 0.65 to 0.86), but not risk of falling.
Overall, vitamin D did not reduce falls ( RaR 0.95, 95% CI 0.80 to 1.14; RR 0.96, 95% CI 0.92 to 1.01), but may do so in people with lower vitamin D levels.
Overall, home safety interventions did not reduce falls ( RaR 0.90, 95% CI 0.79 to 1.03); RR 0.89, 95% CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti- slip shoe device reduced rate of falls in icy conditions ( RaR 0.42, 95% CI 0.22 to 0.78).
Gradual withdrawal of psychotropic medication reduced rate of falls ( RaR 0.34, 95% CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling ( RR 0.61, 95% CI 0.41 to 0.91).
Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity ( RaR 0.42, 95% CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls ( RaR 0.66, 95% CI 0.45 to 0.95).
There is some evidence that falls prevention strategies can be cost saving.
Authors' conclusions
Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

Interventions for preventing falls in older people living in the community (Review)

Background: Vitamin D inadequacy has been studied extensively, due to concerns about ageing populations, associations with osteoporosis and other disorders (including non-musculoskeletal), and high prevalence.

Aim: To review recent reports on the prevalence of vitamin D inadequacy among post-menopausal women with and without osteoporosis and/or other musculoskeletal diseases.

Design: Systematic review.

Methods: We reviewed publications in the past 10 years reporting prevalence estimates for vitamin D inadequacy, reported as serum 25(OH)D values below various levels. Thirty published studies in the English language were identified, from January 1994 through April 2004.

Results: In osteoporotic populations, the prevalence of 25(OH) vitamin D concentration <12 ng/ml ranged from 12.5% to 76%, while prevalence rates reached 50% to 70% of patients with a history of fracture(s) using a cut-off of 15 ng/ml. In post-menopausal women, the prevalence of 25(OH) vitamin D concentrations ⩽20 ng/ml ranged from 1.6% to 86% for community-living and institutionalized women, respectively. The most common factors associated with inadequate vitamin D levels included limited sun exposure, lack of dietary vitamin D intake, nursing home environment, wintertime, and increasing age (over 70 years).

Discussion: The prevalence of inadequate vitamin D levels appears to be high in post-menopausal women, especially in those with osteoporosis and history of fracture. Vitamin D supplementation in this group might offer scope for prevention of falls and fracture, especially in elderly and osteoporotic populations.

/pdf/vitamin-d-inadequacy-among-post-menopausal-women-a-3xsgsfbsq6.pdf

Vitamin D inadequacy among post-menopausal women: a systematic review.

Background and methods
Fractures in elderly populations result from the combination of falls and osteoporosis. We report a systematic review of studies indexed in PubMed reporting annual rates of low-trauma falls and associated osteoporotic fractures among older community-dwelling people (age ≥ 50 years). An osteoporotic fracture was defined as either a fracture resulting from a low-impact fall in subjects with clinical osteoporosis, a fall resulting in an investigator-defined osteoporotic fracture, or a fall resulting in a low-trauma fracture. Rates are presented using descriptive statistics. Meta-analysis was conducted for statistically homogeneous data sets.

/pdf/epidemiology-of-falls-and-osteoporotic-fractures-a-3abncv2rhk.pdf

Epidemiology of falls and osteoporotic fractures: a systematic review

We evaluated the effect of supplementation with vitamin D(3) (excluding the potential effect of calcium supplementation) on the risk of fall and fracture, primarily in postmenopausal women, using a systematic literature review of MEDLINE, EMBASE, BIOSIS and the Cochrane Database of Systematic Reviews for the period January 1985 to June 2005. Studies examining the effect of vitamin D versus placebo on the risk of fall or fracture in postmenopausal females were of particular interest. Studies of vitamin D in combination with calcium were also included where the control group was treated with calcium alone. Studies of men and women where results for men and women were not presented separately were included. Nine studies met the inclusion criteria. Our primary meta-analyses examined the effect of vitamin D(3) on the risk of fall or fracture; additional analyses examined baseline and difference between baseline and final levels of several serum and urinary biochemical markers. The pooled relative risk (RR) for vitamin D(3) preventing falls was 0.88 (95%CI 0.78-1.00). For fractures, the pooled RR for vitamin D(3) preventing non-vertebral fractures was 0.96 (95%CI 0.84-1.09) and the pooled RR for vitamin D(3) preventing vertebral fractures was 1.22 (95%CI 0.64-2.31). In a subgroup analysis of post-menopausal women, the pooled RR for vitamin D(3) preventing falls was 0.92 (95%CI 0.75-1.12) and in preventing non-vertebral fractures the pooled RR was 0.81 (95%CI 0.48-1.34). There is a trend towards a reduction in the risk of fall among patients treated with vitamin D(3) alone compared with placebo, suggesting that vitamin D(3) should be an integral part of effective osteoporosis management.

/pdf/the-effect-of-cholecalciferol-vitamin-d3-on-the-risk-of-fall-3ayck7k1xk.pdf

The effect of cholecalciferol (vitamin D3) on the risk of fall and fracture: a meta-analysis.

This study assessed the proportion of patients treated with anti-osteoporotic drugs during the 1-year period after hospitalization for a fracture, and the influence of a guideline in the period 1998–2000 on the likelihood of receiving treatment for osteoporosis after a fracture. Patients were assessed retrospectively for anti-osteoporotic drug use during a 1-year period following hospitalization for non-traumatic fracture. The PHARMO system, a population-based database (n=865,000) containing drug and hospitalization data of community-dwelling inhabitants of defined areas in the Netherlands, was used. The study population comprised 1654 patients age 50 years and over who were admitted to hospital for a fracture resulting from a fall during the period 1998–2000. The treatment rate of newly treated patients and the change in treatment rate throughout the period 1998–2000 were the outcome measures. The majority of these patients were women (73%), and had femur fractures (51%). In total, 247 out of 1654 patients (15%) were prescribed anti-osteoporotic drugs within 1 year after discharge from the hospital. Of these 247 patients, 86 were newly treated, mainly with bisphosphonates in the year after discharge following the fracture, yielding a new treatment rate of 5%. The likelihood of receiving treatment for osteoporosis following fracture did not change with the calendar year of fracture (OR 0.95; 95% CI: 0.68–1.30). The result of this study shows that despite the introduction of an osteoporosis treatment guideline in 1999 recommending treatment for fracture patients, most of the time, fracture patients are not being treated for osteoporosis. Thus, to a large extent, osteoporosis remains under-treated.

/pdf/undertreatment-with-anti-osteoporotic-drugs-after-18u7k4eq77.pdf

Undertreatment with anti-osteoporotic drugs after hospitalization for fracture

Background: Risk indices have been developed to identify women at risk of low bone mineral density (BMD) who should undergo BMD testing.

Aim: To compare the performance of four risk indices in White ambulatory women in Belgium.

Design: Epidemiological cross-sectional study.

Methods: Records were analysed for 4035 postmenopausal White women without Paget's disease or advanced osteoarthritis, seen at an out-patient osteoporosis centre between January 1996 and September 1999. Osteoporosis risk index scores were compared to bone density T-scores. The ability of each risk index to identify women with low BMD (T-score < −2.0) or osteoporosis (T < −2.5) was evaluated.

Results: Using an Osteoporosis Self-Assessment Tool (OST) score <2 to recommend DXA referral, sensitivity ranged from 85% at the lumbar spine to 97% at the total hip to detect BMD T-scores of ≤ −2.5, and specificity ranged from 34% at the total hip to 37% at the femoral neck and lumbar spine. The negative predictive value was high at all skeletal sites (89–99%), demonstrating the usefulness of the OST to identify patients who have normal BMD and should not receive DXA testing. All risk indices performed similarly, although the OST had somewhat better sensitivity and somewhat lower specificity than the other indices at the cut-offs evaluated. Among the 11–12% of women who were classified as highest risk using OST or the Osteoporosis Index of Risk (OSIRIS), 81–85% had low bone mass and 68–74% had osteoporosis.

Discussion: The performance of these risk indices among women in Belgium was similar to that reported earlier for other samples in Asian countries, the US, and the Netherlands. The OST and other risk indices are effective and efficient tools to help target high-risk women for DXA testing.

Shuvayu S Sen

Papers

Vitamin D inadequacy among post-menopausal women: a systematic review.

Epidemiology of falls and osteoporotic fractures: a systematic review

The effect of cholecalciferol (vitamin D3) on the risk of fall and fracture: a meta-analysis.

Undertreatment with anti-osteoporotic drugs after hospitalization for fracture

Validation and comparative evaluation of the osteoporosis self-assessment tool (OST) in a Caucasian population from Belgium