CME. Medical Practice| Assessment 1
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165Hong Kong Med J ⎥ Volume 21 Number 2 ⎥ April 2015 ⎥ www.hkmj.org
A B S T R A C T
Falls are a common problem in the elderly. A common
error in their management is that injury from the fall
is treated, without finding its cause. Thus a proactive
approach is important to screen for the likelihood of
fall in the elderly. Fall assessment usually includes a
focused history and a targeted examination. Timed
up-and-go test can be performed quickly and is able
to predict the likelihood of fall. Evidence-based fall
prevention interventions include multi-component
group or home-based exercises, participation in
Tai Chi, environmental modifications, medication
review, management of foot and footwear problems,
vitamin D supplementation, and management of
cardiovascular problems. If possible, these are
best implemented in the form of multifactorial
intervention. Bone health enhancement for
residential care home residents and appropriate
community patients, and prescription of hip
Falls prevention in the elderly: translating
evidence into practice
Introduction
Falls and imbalance occur commonly in the elderly
and fall/instability is indeed one of the ‘giants’ in
geriatric medicine. 1 A fall is often defined as an event
that results in the patient or a body part of the patient
coming to rest inadvertently on the ground or other
surface lower than the body. 2 In Hong Kong, the
prevalence in the elderly of having at least one fall in
the preceding 12 months is between 18% and 19.3%,
with 75.2% sustaining injuries and 7.2% having a
serious injury. 3,4 Those who fall have significantly
more hospitalisations and clinic visits as well as
accident and emergency department visits than
those who do not. Fear of falling, loss of confidence
in walking, social isolation, and depression can also
occur. Fall is a predictor for decreased functional
state and risk factor for institutionalisation, 5 and
the elderly who are prone to falling consume more
health care resources than non-fallers each year. 6
Pitfalls in fall management
Despite the potentially severe consequences of
falls, under-reporting by the elderly is common. 7
Individuals may attribute falling to the ageing
process or they may not report falls because of the
fear of being restricted in their activities or being
institutionalised following a fall. Some older people,
especially those with cognitive impairment, may
Hong Kong Med J 2015;21:165–71
DOI: 10.12809/hkmj144469
James KH Luk *, TY Chan, Daniel KY Chan
1 JKH Luk *, FHKCP, FHKAM (Medicine)
2 TY Chan, FHKCP, FHKAM (Medicine)
3 DKY Chan, MD, FRACP
1 Department of Medicine and Geriatrics, Fung Yiu King Hospital, Hong
Kong
2 Department of Medicine and Geriatrics, Kwong Wah Hospital, Yaumatei,
Hong Kong
3 Faculty of Medicine, University of New South Wales, Ingham Institute;
Aged Care & Rehab, Bankstown Hospital, Australia
* Corresponding author: lukkh@ha.org.hk
This article was
published on 27 Feb
2015 at www.hkmj.org.
forget the event and consequently fail to inform the
health care team. Alternatively, in the absence of an
obvious injury, physicians may be unaware of falls.
A drawback to the management of falls is that the
consequences, such as fractures or head injuries, are
treated without finding the cause of the fall. Unless
all the underlying risk factors are addressed, falls are
very likely to recur.
Knowing the risk/precipitating
factors for falls
The first step in fall prevention is to identify the
risk or precipitating factors for falls. Age by itself
is an important risk factor, but not the only one.
Falls in the elderly are often due to the interaction
of multiple risk factors. One practical way to help
clinicians identify risk or precipitating factors is to
use a mnemonic. One such mnemonic is shown in
the Table. 8
Fall assessment
As falls are usually under-reported, a proactive
approach is to ask “Have you had a fall in the past
6 months?” at every encounter with an elderly
patient. Initial medical assessment involves a
focused history-taking, detailing the circumstances
of fall, precipitating factors, and consequences. A
witness can be helpful to identify unrecognised
MEDICAL PRACTICEC M E
protectors for residential care home residents are
also recommended. Multifactorial intervention
may also be useful in a hospital and residential
care home setting. Use of physical restraints is not
recommended for fall prevention.
A B S T R A C T
Falls are a common problem in the elderly. A common
error in their management is that injury from the fall
is treated, without finding its cause. Thus a proactive
approach is important to screen for the likelihood of
fall in the elderly. Fall assessment usually includes a
focused history and a targeted examination. Timed
up-and-go test can be performed quickly and is able
to predict the likelihood of fall. Evidence-based fall
prevention interventions include multi-component
group or home-based exercises, participation in
Tai Chi, environmental modifications, medication
review, management of foot and footwear problems,
vitamin D supplementation, and management of
cardiovascular problems. If possible, these are
best implemented in the form of multifactorial
intervention. Bone health enhancement for
residential care home residents and appropriate
community patients, and prescription of hip
Falls prevention in the elderly: translating
evidence into practice
Introduction
Falls and imbalance occur commonly in the elderly
and fall/instability is indeed one of the ‘giants’ in
geriatric medicine. 1 A fall is often defined as an event
that results in the patient or a body part of the patient
coming to rest inadvertently on the ground or other
surface lower than the body. 2 In Hong Kong, the
prevalence in the elderly of having at least one fall in
the preceding 12 months is between 18% and 19.3%,
with 75.2% sustaining injuries and 7.2% having a
serious injury. 3,4 Those who fall have significantly
more hospitalisations and clinic visits as well as
accident and emergency department visits than
those who do not. Fear of falling, loss of confidence
in walking, social isolation, and depression can also
occur. Fall is a predictor for decreased functional
state and risk factor for institutionalisation, 5 and
the elderly who are prone to falling consume more
health care resources than non-fallers each year. 6
Pitfalls in fall management
Despite the potentially severe consequences of
falls, under-reporting by the elderly is common. 7
Individuals may attribute falling to the ageing
process or they may not report falls because of the
fear of being restricted in their activities or being
institutionalised following a fall. Some older people,
especially those with cognitive impairment, may
Hong Kong Med J 2015;21:165–71
DOI: 10.12809/hkmj144469
James KH Luk *, TY Chan, Daniel KY Chan
1 JKH Luk *, FHKCP, FHKAM (Medicine)
2 TY Chan, FHKCP, FHKAM (Medicine)
3 DKY Chan, MD, FRACP
1 Department of Medicine and Geriatrics, Fung Yiu King Hospital, Hong
Kong
2 Department of Medicine and Geriatrics, Kwong Wah Hospital, Yaumatei,
Hong Kong
3 Faculty of Medicine, University of New South Wales, Ingham Institute;
Aged Care & Rehab, Bankstown Hospital, Australia
* Corresponding author: lukkh@ha.org.hk
This article was
published on 27 Feb
2015 at www.hkmj.org.
forget the event and consequently fail to inform the
health care team. Alternatively, in the absence of an
obvious injury, physicians may be unaware of falls.
A drawback to the management of falls is that the
consequences, such as fractures or head injuries, are
treated without finding the cause of the fall. Unless
all the underlying risk factors are addressed, falls are
very likely to recur.
Knowing the risk/precipitating
factors for falls
The first step in fall prevention is to identify the
risk or precipitating factors for falls. Age by itself
is an important risk factor, but not the only one.
Falls in the elderly are often due to the interaction
of multiple risk factors. One practical way to help
clinicians identify risk or precipitating factors is to
use a mnemonic. One such mnemonic is shown in
the Table. 8
Fall assessment
As falls are usually under-reported, a proactive
approach is to ask “Have you had a fall in the past
6 months?” at every encounter with an elderly
patient. Initial medical assessment involves a
focused history-taking, detailing the circumstances
of fall, precipitating factors, and consequences. A
witness can be helpful to identify unrecognised
MEDICAL PRACTICEC M E
protectors for residential care home residents are
also recommended. Multifactorial intervention
may also be useful in a hospital and residential
care home setting. Use of physical restraints is not
recommended for fall prevention.
# Luk et al #
166 Hong Kong Med J ⎥ Volume 21 Number 2 ⎥ April 2015 ⎥ www.hkmj.org
預防老年人跌倒：從證據到實踐
陸嘉熙、陳德揚、陳錦賢
跌倒是老年人常見的問題。醫治因跌倒造成的損傷，卻沒有找出導致
跌倒的原因，是經常會犯的錯誤。採取積極態度找出老年人跌倒的可
能性相當重要。評估老年人跌倒通常包括了解其病史和進行針對性
檢查。「起立—行走計時測試」（timed up-and-go test）可以快速進
行，並能預測老年人跌倒的機會率。歸納相關實證研究後得出預防跌
倒的方法包括綜合性運動的集體鍛鍊或家居練習、打太極拳、環境調
適或改裝、用藥風險評估、矯正腳部和鞋子的問題、維生素D的補充
和心血管疾病的處理。可以的話，最好綜合多方面的因素來處理跌倒
的方法。建議為居住安老院和適合的社區老年人提升其骨骼健康，以
及為居住安老院的老年人提供髖關節保護器。多因素干預可能對醫院
和居住安老院的老年人有用，但不建議為預防跌倒而使用身體約束。
syncope. Other relevant history includes living
environment, social support, past medical illnesses,
medication, history of falls or near falls, and mobility
and functional status. Comprehensive geriatric
assessment should follow documentation of history. 9
Testing of gait, balance, and lower limb and joint
function, alongside cardiovascular and neurological
examination should be performed where relevant.
Postural blood pressure, vision, feet, and footwear
should also be checked. Measurement of postural
blood pressure requires a wait of at least 3 minutes
between sitting and standing (or lying and sitting),
and is often omitted or not done properly. Simple
bedside investigations such as electrocardiography
should be performed as arrhythmia may be the cause
of falls due to syncope. Further investigations should
be guided by the history and examination.
One simple screening test for mobility is the
timed up-and-go test. 10 The patient is timed while
rising from a 46-cm high armchair, walking 3
metres, turning around, and returning to sit in the
chair (total 6 metres). The assessment should be
repeated with a walking aid if the patient is found
to be unsteady. Patients who require more than 20
seconds to complete the task are at risk of fall. It is
prudent to refer ‘fallers’ with multiple risk factors
to geriatricians for professional assessment and
management. Risk factors, once identified, should
then be managed with inter-disciplinary intervention
to reduce the risks as soon as possible. For example,
if impaired vision due to cataract is identified, an
expedited eye consultation and cataract treatment is
desirable to reduce the chance of recurrent falls.
Practical evidence-based strategies
in fall prevention
Exercise
Multi-component exercises, including strength,
endurance and balance training, either in a group
or home-based, have been shown to reduce both
rate and risk of falling. 11 The exercises need to be
of sufficient intensity to improve muscle strength.
Balance retraining appears to be the more important
component of any exercise programme designed to
decrease falls. 12 The balance training can either be
specific dynamic balance retraining exercises or a
component of a movement programme such as Tai
Chi. 13 Exercises should be regular and sustainable,
and be a part of multifactorial intervention (MFI;
see below). One should be aware that prescribing
inappropriate exercise may increase falls in the
elderly.
Tai Chi
The anecdote of Tai Chi in fall prevention is
generally well known to the public. Similar to multi-
component exercises, Tai Chi reduces both the
rate of fall and falling risk according to a Cochrane
Review. 11 Wolf et al 14 also reported the benefit of
TABLE. Mnemonic (A E I O U, A B B C C C) of risk or precipitating factors for falls (A is shared between vowels and ABC) 8
A Anti-depressants, anti-psychotics, anti-cholinergics, anti-epileptics, antihypertensives
E Environmental hazards, eg home, outdoors
I Infectious diseases, eg urinary tract infection, chest infection, and others
O Osteoarthritis and musculoskeletal problems
U Unwell patients are more prone to falls
B Blindness and visual impairment, eg refractive, cataract, macular degeneration, glaucoma, visual field defect, hemi-
spatial neglect after cortical stroke
B Biochemical abnormalities, eg hyponatraemia, hypokalaemia, hypoglycaemia
C Cardiovascular problems, eg postural hypotension, heart block, arrhythmias, carotid sinus hypersensitivity
C Central nervous system or peripheral nervous system disorders, Parkinsonism
C Cognitive impairment, eg dementia, delirium
166 Hong Kong Med J ⎥ Volume 21 Number 2 ⎥ April 2015 ⎥ www.hkmj.org
預防老年人跌倒：從證據到實踐
陸嘉熙、陳德揚、陳錦賢
跌倒是老年人常見的問題。醫治因跌倒造成的損傷，卻沒有找出導致
跌倒的原因，是經常會犯的錯誤。採取積極態度找出老年人跌倒的可
能性相當重要。評估老年人跌倒通常包括了解其病史和進行針對性
檢查。「起立—行走計時測試」（timed up-and-go test）可以快速進
行，並能預測老年人跌倒的機會率。歸納相關實證研究後得出預防跌
倒的方法包括綜合性運動的集體鍛鍊或家居練習、打太極拳、環境調
適或改裝、用藥風險評估、矯正腳部和鞋子的問題、維生素D的補充
和心血管疾病的處理。可以的話，最好綜合多方面的因素來處理跌倒
的方法。建議為居住安老院和適合的社區老年人提升其骨骼健康，以
及為居住安老院的老年人提供髖關節保護器。多因素干預可能對醫院
和居住安老院的老年人有用，但不建議為預防跌倒而使用身體約束。
syncope. Other relevant history includes living
environment, social support, past medical illnesses,
medication, history of falls or near falls, and mobility
and functional status. Comprehensive geriatric
assessment should follow documentation of history. 9
Testing of gait, balance, and lower limb and joint
function, alongside cardiovascular and neurological
examination should be performed where relevant.
Postural blood pressure, vision, feet, and footwear
should also be checked. Measurement of postural
blood pressure requires a wait of at least 3 minutes
between sitting and standing (or lying and sitting),
and is often omitted or not done properly. Simple
bedside investigations such as electrocardiography
should be performed as arrhythmia may be the cause
of falls due to syncope. Further investigations should
be guided by the history and examination.
One simple screening test for mobility is the
timed up-and-go test. 10 The patient is timed while
rising from a 46-cm high armchair, walking 3
metres, turning around, and returning to sit in the
chair (total 6 metres). The assessment should be
repeated with a walking aid if the patient is found
to be unsteady. Patients who require more than 20
seconds to complete the task are at risk of fall. It is
prudent to refer ‘fallers’ with multiple risk factors
to geriatricians for professional assessment and
management. Risk factors, once identified, should
then be managed with inter-disciplinary intervention
to reduce the risks as soon as possible. For example,
if impaired vision due to cataract is identified, an
expedited eye consultation and cataract treatment is
desirable to reduce the chance of recurrent falls.
Practical evidence-based strategies
in fall prevention
Exercise
Multi-component exercises, including strength,
endurance and balance training, either in a group
or home-based, have been shown to reduce both
rate and risk of falling. 11 The exercises need to be
of sufficient intensity to improve muscle strength.
Balance retraining appears to be the more important
component of any exercise programme designed to
decrease falls. 12 The balance training can either be
specific dynamic balance retraining exercises or a
component of a movement programme such as Tai
Chi. 13 Exercises should be regular and sustainable,
and be a part of multifactorial intervention (MFI;
see below). One should be aware that prescribing
inappropriate exercise may increase falls in the
elderly.
Tai Chi
The anecdote of Tai Chi in fall prevention is
generally well known to the public. Similar to multi-
component exercises, Tai Chi reduces both the
rate of fall and falling risk according to a Cochrane
Review. 11 Wolf et al 14 also reported the benefit of
TABLE. Mnemonic (A E I O U, A B B C C C) of risk or precipitating factors for falls (A is shared between vowels and ABC) 8
A Anti-depressants, anti-psychotics, anti-cholinergics, anti-epileptics, antihypertensives
E Environmental hazards, eg home, outdoors
I Infectious diseases, eg urinary tract infection, chest infection, and others
O Osteoarthritis and musculoskeletal problems
U Unwell patients are more prone to falls
B Blindness and visual impairment, eg refractive, cataract, macular degeneration, glaucoma, visual field defect, hemi-
spatial neglect after cortical stroke
B Biochemical abnormalities, eg hyponatraemia, hypokalaemia, hypoglycaemia
C Cardiovascular problems, eg postural hypotension, heart block, arrhythmias, carotid sinus hypersensitivity
C Central nervous system or peripheral nervous system disorders, Parkinsonism
C Cognitive impairment, eg dementia, delirium
# Falls prevention in the elderly #
167Hong Kong Med J ⎥ Volume 21 Number 2 ⎥ April 2015 ⎥ www.hkmj.org
10-form Tai Chi in a randomised controlled trial
(RCT). Tai Chi is a combination of strength and
balance training, with a certain aerobic element. 15
In Hong Kong, most people practise the full form
that should theoretically be at least effective, if not
better. This can be promoted as a territory-wide
health recommendation. Nonetheless, not all Tai
Chi programmes improve balance. One local RCT
revealed no difference in the number of falls between
a Tai Chi group and controls after 12 months. 16
Environmental interventions
Home modifications can effectively reduce risk
of falls in the community, 11 and include removal
of floor mats, painting the edge of steps, reducing
glare, installing handles, and improving lighting.
Occupational therapists can provide expert advice
in this area. For older people with fall risk who live
at home, especially those who are usually alone,
installation of a safety alarm is recommended so help
can be summoned should an accident occur.
Medication review
Polypharmacy is common among older people
who often have multiple co-morbidities, and is an
independent variable that has been linked to falls in
older people. 17 Many drugs, psychotropic medications
and antihypertensive agents in particular, are related
to falls. The use of psychotropic medication should
be confined to patients who do not respond to non-
pharmacological intervention and the lowest dosage
should be prescribed. Periodic review of indications
and side-effects should be undertaken: gradual
withdrawal of psychotropic medication can reduce
rate of falls in community-dwelling elderly people. 11
Nonetheless drug withdrawal is a complicated
intervention that should be implemented by an
experienced clinician after carefully weighing the
risks and benefits. A standardised and explicit
medicine review tool such as the Beers Criteria
for Potentially Inappropriate Medication Use in
Older Adults and STOPP (Screening Tool of Older
Person’s potentially inappropriate Prescriptions)
may be useful in reducing falls in older people but
the effectiveness of these approaches has not been
proven by RCTs. 18,19 Although drug withdrawal
is beneficial, studies that include RCTs show that
many withdrawals (eg sleeping pills) are reversed
and patients resume previous therapy. Ongoing
monitoring is therefore essential. 20
Foot and footwear
Foot and footwear problems are common but are
often ignored. Footwear influences balance and
risk of falls. High-heeled shoes have been shown
to increase falls in older people. Anti-slip shoe
devices effectively reduce outdoor falls in slippery
conditions. 21 A systematic review recommends that
elderly individuals wear shoes with a low heel and
firm slip-resistant soles, both inside and outside the
home. 22 Podiatrists, and prosthetics and orthotics
professionals can give valuable advice in this
respect. A recent RCT has shown that multifaceted
podiatry intervention with foot orthoses, footwear
advice, education, and foot and ankle exercises can
reduce the rate of falls in community-dwelling older
people. 23
Vitamin D supplement
The benefit of vitamin D in falls/fractures extends
beyond improved bone health. Vitamin D can
strengthen muscle and hence reduce falls. Meta-
analysis has shown that supplemental vitamin D at
a dose of 700 IU to 1000 IU a day reduces the risk of
falling among older individuals by 19%. 24 The current
opinion is that in community-dwelling elderly,
vitamin D supplementation reduces the rate of falls
or risk of falling in a subgroup of people with low
vitamin D levels but its benefit is absent in people
without deficiency. 11 In the institutionalised elderly,
vitamin D supplementation appears to be more
effective in reducing falls and the recommendation
is to prescribe vitamin D with or without calcium
supplements to older people with low vitamin D
levels or those who are institutionalised. 11 Despite
these recommendations, most studies have been
conducted in western countries that experience a
quite different duration and intensity of sunshine to
Hong Kong. Whether the benefit of vitamin D in fall
prevention applies equally to Hong Kong Chinese
population is not known. Most public hospital
laboratories in Hong Kong do not have the means
to investigate vitamin D levels and clinicians are
required to send blood samples to private laboratories
for vitamin D level assay at a cost. Thus in the public
health sector, mass screening of the elderly for
vitamin D deficiency prior to supplementation is
impractical. The pragmatic approach is to encourage
a healthy balanced diet that is rich in vitamin D. For
older people who are at risk of fall, especially those
in residential care home for the elderly (RCHE), a
dose of 800 IU of vitamin D3 per day with or without
calcium supplementation is recommended, provided
there is no contra-indication. 11 The clinician should
also ask whether the older person is taking any over-
the-counter vitamin D–containing drugs before
commencing supplementation, as excess vitamin D
may result in hypercalcaemia.
Correction of vision
Poor visual acuity caused by presbyopia, cataract,
macular degeneration or glaucoma, reduction in
depth perception and contrast sensitivity are risk
factors for falls. 25 Maximising vision with cataract
surgery is effective in fall prevention. In a UK RCT
167Hong Kong Med J ⎥ Volume 21 Number 2 ⎥ April 2015 ⎥ www.hkmj.org
10-form Tai Chi in a randomised controlled trial
(RCT). Tai Chi is a combination of strength and
balance training, with a certain aerobic element. 15
In Hong Kong, most people practise the full form
that should theoretically be at least effective, if not
better. This can be promoted as a territory-wide
health recommendation. Nonetheless, not all Tai
Chi programmes improve balance. One local RCT
revealed no difference in the number of falls between
a Tai Chi group and controls after 12 months. 16
Environmental interventions
Home modifications can effectively reduce risk
of falls in the community, 11 and include removal
of floor mats, painting the edge of steps, reducing
glare, installing handles, and improving lighting.
Occupational therapists can provide expert advice
in this area. For older people with fall risk who live
at home, especially those who are usually alone,
installation of a safety alarm is recommended so help
can be summoned should an accident occur.
Medication review
Polypharmacy is common among older people
who often have multiple co-morbidities, and is an
independent variable that has been linked to falls in
older people. 17 Many drugs, psychotropic medications
and antihypertensive agents in particular, are related
to falls. The use of psychotropic medication should
be confined to patients who do not respond to non-
pharmacological intervention and the lowest dosage
should be prescribed. Periodic review of indications
and side-effects should be undertaken: gradual
withdrawal of psychotropic medication can reduce
rate of falls in community-dwelling elderly people. 11
Nonetheless drug withdrawal is a complicated
intervention that should be implemented by an
experienced clinician after carefully weighing the
risks and benefits. A standardised and explicit
medicine review tool such as the Beers Criteria
for Potentially Inappropriate Medication Use in
Older Adults and STOPP (Screening Tool of Older
Person’s potentially inappropriate Prescriptions)
may be useful in reducing falls in older people but
the effectiveness of these approaches has not been
proven by RCTs. 18,19 Although drug withdrawal
is beneficial, studies that include RCTs show that
many withdrawals (eg sleeping pills) are reversed
and patients resume previous therapy. Ongoing
monitoring is therefore essential. 20
Foot and footwear
Foot and footwear problems are common but are
often ignored. Footwear influences balance and
risk of falls. High-heeled shoes have been shown
to increase falls in older people. Anti-slip shoe
devices effectively reduce outdoor falls in slippery
conditions. 21 A systematic review recommends that
elderly individuals wear shoes with a low heel and
firm slip-resistant soles, both inside and outside the
home. 22 Podiatrists, and prosthetics and orthotics
professionals can give valuable advice in this
respect. A recent RCT has shown that multifaceted
podiatry intervention with foot orthoses, footwear
advice, education, and foot and ankle exercises can
reduce the rate of falls in community-dwelling older
people. 23
Vitamin D supplement
The benefit of vitamin D in falls/fractures extends
beyond improved bone health. Vitamin D can
strengthen muscle and hence reduce falls. Meta-
analysis has shown that supplemental vitamin D at
a dose of 700 IU to 1000 IU a day reduces the risk of
falling among older individuals by 19%. 24 The current
opinion is that in community-dwelling elderly,
vitamin D supplementation reduces the rate of falls
or risk of falling in a subgroup of people with low
vitamin D levels but its benefit is absent in people
without deficiency. 11 In the institutionalised elderly,
vitamin D supplementation appears to be more
effective in reducing falls and the recommendation
is to prescribe vitamin D with or without calcium
supplements to older people with low vitamin D
levels or those who are institutionalised. 11 Despite
these recommendations, most studies have been
conducted in western countries that experience a
quite different duration and intensity of sunshine to
Hong Kong. Whether the benefit of vitamin D in fall
prevention applies equally to Hong Kong Chinese
population is not known. Most public hospital
laboratories in Hong Kong do not have the means
to investigate vitamin D levels and clinicians are
required to send blood samples to private laboratories
for vitamin D level assay at a cost. Thus in the public
health sector, mass screening of the elderly for
vitamin D deficiency prior to supplementation is
impractical. The pragmatic approach is to encourage
a healthy balanced diet that is rich in vitamin D. For
older people who are at risk of fall, especially those
in residential care home for the elderly (RCHE), a
dose of 800 IU of vitamin D3 per day with or without
calcium supplementation is recommended, provided
there is no contra-indication. 11 The clinician should
also ask whether the older person is taking any over-
the-counter vitamin D–containing drugs before
commencing supplementation, as excess vitamin D
may result in hypercalcaemia.
Correction of vision
Poor visual acuity caused by presbyopia, cataract,
macular degeneration or glaucoma, reduction in
depth perception and contrast sensitivity are risk
factors for falls. 25 Maximising vision with cataract
surgery is effective in fall prevention. In a UK RCT
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