Journal of Clinical Gerontology & Geriatrics| Assessment .

Special article
Strategies on fall prevention for older people living in the community:
A report from a round-table meeting in IAGG 2013
Eun Joo Kim,MD a
, Hidenori Arai,MD, PhD b
, Piu Chan,MD, PhD c
,
Liang-Kung Chen,MD, PhD d, e
, Keith D.Hill, PhD f
, Bernard Kong,MD g
, Philip Poi,MD h
,
Maw Pin Tan,MD h
, Hyung Joon Yoo,MD i , Chang Won Won,MD j , *
a Department of Rehabilitation Medicine,National Rehabilitation Center,Seoul,South Korea
b National Center for Geriatrics and Gerontology,Obu,Japan
c Department of Geriatrics of Xuanwu Hospital of Capital Medical University,Beijing,China
d Aging and Health Research Center,National Yang Ming University,Taipei,Taiwan
e Center for Geriatric and Gerontology,Taipei Veterans General Hospital,Taipei,Taiwan
f School of Physiotherapy and Exercise Science,Curtin University,Perth,Australia
g The Hong Kong Geriatrics Society,Hong Kong,Hong Kong
h Department of Medicine,University of Malaya,Kuala Lumpur,Malaysia
i Division of Endocrinology and Metabolism,Hallym University College of Medicine,Seoul,South Korea
j Department of Family Medicine,College of Medicine,Kyung Hee University,Seoul,South Korea
a r t i c l e i n f o
Article history:
Received 11 February 2015
Accepted 21 February 2015
Available online 6 May 2015
Keywords:
fall prevention
elderly
community
a b s t r a c t
Over the past decade,a number of programs and strategies have been proposed and developed in an
effort to reduce risks among the elderly in relation to falling or sustaining fall related injuries. Programs
vary in their approach,and also in their target populations.We held a round-table meeting to present
each country's research data on fallprevention in older people and summarized them in order to
formulate evidence-based suggestions on the prevention of falls in older people.Although the contents
and level of progress of each country's studies had some differences with regards to fall prevention,the
social issues of fall prevention was of particular interest in large scale cohorts studies and fall prevention
guidelines.We recommended some good practice points for the strategies on fall prevention for older
people living in the community based on clinical experience or expert consensus.
Copyright © 2015,Asia Pacific League of Clinical Gerontology & Geriatrics.Published by Elsevier Taiwan
LLC.All rights reserved.
1. Introduction
Falls are a significant cause of harm in older people. To prevent
falls, various strategies should be put in place for all elderly people.
In several countries over the past decade,a number of programs
and strategies have been proposed and developed in orderto
reduce risks among the elderly in relation to falling or sustaining
fall-related injuries.Programs vary in their approach and their
target populations. Although the importance of fall prevention has
been widely acknowledged, health care professionals from
different fields in Asia and Australia need to facilitate the design
and implementation of culturally-appropriateevidence-based
interventions, in order to significantly reduce the number of falls or
relating factors among elderly people in the community.
A round-table meeting was organized during the 20th Interna-
tional Association of Gerontology and Geriatrics(IAGG) World
Congress in Seoul(June, 2013) with the aim of collaborating on
strategies for preventing falls in the elderly living in the commu-
nities of Asia and Australia.The aims of the round-table meeting
was to present each country's’research data on fall prevention in
older people, to summarize them, and to formulate evidence-based
suggestions on the prevention of falls in older people based on the
best consensus available to the panel of experts.
2. Methods
2.1.Invitation of speakers
Nine experts panels (3 from Korea and 6 from other Asian
countries and Australia) were selected before the IAGG 2013
* Corresponding author.Department ofFamily Medicine,College of Medicine,
Kyung Hee University, 23 KyungHee-Daero Dongdaemun-Gu, Seoul 130-872, South
Korea.
E-mail addresses: [e-mail], [e-mail] (C.W. Won).
Contents lists available at ScienceDirect
Journal of Clinical Gerontology & Geriatrics
j o u r n a lhomepage: www.e-jcgg.co m
http://dx.doi.org/10.1016/j.jcgg.2015.02.004
2210-8335/Copyright © 2015,Asia Pacific League of Clinical Gerontology & Geriatrics.Published by Elsevier Taiwan LLC.All rights reserved.
Journal of Clinical Gerontology & Geriatrics 6 (2015) 39e44

meeting.They were all experts in fallprevention,and were also
geriatricians. The nationalities of the invited geriatricians from Asia
were Korean,Japanese,Chinese,Hong Kong (Cantonese),Taiwa-
nese, Malaysian,and Australian.
2.2. Preparing the round-table meeting
Each panel expert was asked to summarize research papers
from literature searches including meta-analyses,systematic liter-
ature reviews, randomized controlled trials (RCTs), controlled
before-and-after studies,and cohort studies for fallintervention.
These studies were written for each country and published in the
speaker's country.During the round-table meeting,the speakers
presented the results of the studies.Literature searches were car-
ried out with the aim of identifying the highest quality information
for each intervention [systematic reviews (SRs), particularly
Cochrane Reviews,meta-analyses,and randomized controlled tri-
als].This is in line with the recommended method for evidence-
based practice,when in an event of emergency where clinical
questions need to be answered quickly; Cochrane Reviews provide
the best quality literature for clinicians.The information retrieved
was checked and supplemented through discussionsfrom the
extensive round-table meeting of expert panels.
3. Results
3.1. Korea
Electronic literature searches were carried out using PubMed,
and three Korean medical databases (KMBase,KISS,and MEDLIS).
The search terms “fall” and “Korea” were among those that
appeared to retrieve studies that met the inclusion criteria.They
included fall prevention studies with a reduction in falls/fall-related
injuries, and a reduction in risk factors that did not necessarily lead
to a reduction in falls/fall-related injuries.The experts categorized
the studies based on the level of research evidence,and searches
generating at least 34 hits. Three SRs,1e3 six RCTs,4e9 18 controlled
clinical trials (CCTs),10e27 and seven noncontrolled pre-post trials
met the inclusion criteria, all of which had been published between
2000 and 2013.Fall prevention strategies were categorized into
three groups: exercise intervention programs,programs including
exercise, and environmental modification programs.
In the exercise program, two SRs,1,2 five RCTs,4e8 and 13
CCTs10e22 were incorporated.One SR1 covered a wide range of
conditions with regards to the effectiveness of Tai Chi from Korean,
English, and Chinese electronic databases.According to the SR,
there is relatively clear evidence suggesting that Tai Chi is effective
in fall prevention, the improvement of psychological health, and is
associated with generalhealth benefits in older people.Another
SR2 was on the muscle strengthening effects of exercise programs
for the prevention of falls among the elderly in Korea,which was
published between 1996 and 2011.In this study, the effect of
increased muscle strength on the prevention of falls can only be
indirectly suggested,because there are few studies available that
report the frequency or history of falls in Korea.Moreover, various
kinds of exercise components (balance,strengthening,stretching,
and aerobic components), the duration (from 3 weeks to 7 months),
and the intensity (30e50minutes) in RCTs, showed positive effects
on elderly people's physical health,psychological health,and also
improved fall prevention efficacy.4e8
In programs including exercise,one SR,3 one RCT,9 and five
CCTs23e27 were searched.One RCT9 examined the effects of FPEP
(fall prevention exercise program) on the physical and emotional
states of the elderly community in Korea.Components of the pro-
gram included a range ofmotion (ROM),strengthening,weight-
bearing,balance,breathing exercises,relaxation techniques,and
health education to prevent falls by incorporating self-care skills
into the home environment.As a result,the FPEP was found to be
effective in improving the physical and emotional wellbeing of the
elderly. In environmental modification,there was one pre-post
study28 regarding the effectiveness of bathroom grasp bars in fall
prevention in the elderly. Though there were no differences in the
number of people falling, the “fear of falling” score decreased after
the intervention.
In summary,exercise programs can be an effective prevention
strategy but more research is needed to determine if one type of
exercise is more effective than another type,as well as which ex-
ercises are best for the elderly living in the community.There is
insufficient evidence to conclude whether or not programs,
including exercise programs or environmentalmodification pro-
grams,are effective prevention methods.However; they all play a
role as part of a multifactorial strategy that includes clinical
assessment followed by targeted intervention.
3.2. Japan
Six RCTs were presented.Five of them were exercise inter-
vention29e34 and one of them was olfactory stimulation with
relaxation intervention.30
The exercise programs consisted of various interventions such
as balance,coordination (complex obstacle negotiation),walking,
strengthening,Tai Chi, and exercise.RCT consisted ofolfactory
stimulations with lavender odor that was carried out in nursing
homes with residents.The results all showed a lower rate of falls
and fractures, and improvement in the physical conditions of those
in the intervention groups when compared with the control group.
The experts evaluated whether or not a complex course obstacle
negotiation exercise (CC)and a 24-week exercise program can
reduce falls and fractures in older adults,compared with a simple
course obstacle negotiation exercise (SC) program.This trial was
carried out using older adults of 75 years of age from Japan.31 A
total of 157 participantswere randomized into the CC group
(n ¼ 78) and the SC group (n ¼ 79). The intervention was completed
in 24 weeks.The outcome measure was the number of falls and
fracture rates among the two groups for a period of 12 months post
exercise classes.Two participants (2.8%) in the CC group and 19
participants (26.0%) in the SC group experienced falls during the 12
month period. During the 12-month follow-up period after the
intervention,the incidence rate ratio (IRR) of falls in the SC group
compared to the CC group was 9.37% (95% confidence
interval ¼ 2.26e38.77). One participant (1.4%) in the CC group and
eight participants (10.9%) in the SC group experienced fractures
during the 12 months post exercise classes. The IRR of fractures in
the SC group compared to the CC group was 7.89% (95% confidence
interval ¼ 1.01e61.49). The results of the present trial showed that
participants who received individualized obstacle avoidance
training under complex tasks combined with traditional interven-
tion, had a lower incidence rate of falls and fractures during the 12
months after the intervention,compared to the other group.
3.3. China
Falls have a significant impact on the physical and psycholog-
ical health of the elderly population,and are highly associated
with mortality,hospitalization,and quality of life.The Ministry of
Health (MOH) of China recently published the first Fall Prevention
Guideline.However,there are few longitudinal studies on elderly
falls in community-based cohorts that can prevent the first fall and
prevent recurrent falls in the elderly.Using data from our longi-
tudinal community cohort study in Beijing,the incidence of falls
E.J.Kim et al./ Journal of Clinical Gerontology & Geriatrics 6 (2015) 39e4440

and recurrent falls was investigated in people older than 55 years,
and the data was compared with reports from other areas of
China.The incidence of falls and recurrent falls in elderly people
older than 65 years in Beijing is 7.06% and 19.27%,respectively,
according to one follow-up survey.After adjusting for age, gender,
intervention effect,living urban districts,living alone and taking
more than four medications,diabetes,depression,eye diseases,
and mental health problems were issues that were all significantly
associated with an increased risk offalls. Environmentalcondi-
tions, including stair-rail problems,and dark hallways or room
lighting can increase the risk of falls. A general community
educational intervention has been negatively associated with falls
(odds ratio ¼ 0.81,p ¼ 0.0480).Tinetti's Balance score is a good
predictor for falls.35
Two RCTs and one CCT were researched. One of the RCTs
analyzed the effectivenessof an educational intervention on
improving the knowledge level of Chinese registered nurses on the
prevention of falls in hospitalized older patients.36 The other RCT
evaluated the effectof a KAP model (Knowledge,Attitude and
Practice model) intervention that is appropriate for fall-induced
injuries among the elderly in the community.37 One CCT studied
the effectiveness of a community-based multifaceted fall preven-
tion program in older Chinese adults,and the components of the
intervention were behavioral-based,which included educational
programs and environmentalmodification programs.After inter-
vention, 7.19% of the intervention community sample reported falls,
compared with 17.86% reported falls from the control community
sample. These results were not significantly different.38 The last of
the two studies showed good psychologicalresults,whereas the
first RCT showed a reduction in fall rates compared to the control
group.
3.4. Australia
According to the 2012 Cochrane Review of fall prevention
among older people in a community setting,27 of the reported
randomized controlled trials conducted worldwide took place in
Australia.39 These include a number of studies on older people,as
well as a number of effective interventions; specifically high fall
risk groups such as elderly people presented to the emergency
room after a fall,or those returning home from hospital after hip
fracture rehabilitation. The types of fall interventions in the 27 RCTs
are exercise (12 RCTs, 42% positive fall outcomes), vision (2 RCTs, 0%
positive fall outcomes), home modification (3 RCTs, 0% positive fall
outcomes),vitamin D (2 RCTs,0% positive fall outcomes),medica-
tions (1 RCT,100% positive falloutcomes),and multifactorial(7
RCTs,57% positive fall outcomes).In the exercise intervention
program, exercise aimed to provide moderate to high challenges, or
high challenges for balance,or a total exercise program of>50
hours,which showed more reduction in the number of reported
falls in this study (Table 1).39
A number of successfulrandomised trials were discussed.
Lifestyle-integrated functional exercise (LIFE) programs led to a 31%
reduction in falls.40 Single lens glasses are responsible forthe
reduction of outdoor falls in those with regular outdoor activities.41
Cognitive-behaviorallearning reduced falls by 31%.42 The use of
quality medicine programs also reduced the risk of fall injuries.43
Multifactorial interventionsfor people returning home from a
stroke44 or in the elderly presented to the emergency room with
chronic falls showed no difference compared to other groups.45
The experts provided a snapshot of successful and nonsuccessful
randomized controlled trials conducted in Australia that contrib-
uted to our current understanding regarding effective interventions
in fall prevention. Additionally, they included brief references to the
lack of change in national indicators of fall-related hospitalizations
over the past 15 years,and also suggested a future direction for
research in this area.
3.5. Hong Kong
Studies in Hong Kong revealed that the prevalence of falls and
recurrent falls in the elderly,older than 65 years,is 20% and 6%
respectively.According to the Hospital Authority, there were
32,636 elderly people admitted to hospitalafter falls in 2008,of
which 28,539 suffered fractures,and 198 subsequently died.Fall
prevention programs are highly advocated in the community,but
the best outcomes are from those that take fall risks into consid-
eration. RCTs of Tai Chi and resistantexercises for the general
public 65e74 years of age showed no difference in their balance,
flexibility, or the number of falls. Most study populations were
recruited from acute hospitals and emergency departments,but
there was a small sample that came from local health centers with
suboptimal pick-up rates. Programs varied from out-patient
clinics,geriatric day hospitals,health education centers,exercise
classes,balance training classes,Tai Chi, case management pro-
grams,as well as more sophisticated multi-disciplinary interven-
tion programs.
One cohort study,two meta-analyses,and two CCTs were pre-
sented in this paper.46 The prospective cohortstudy is from a
multidisciplinary fall clinic with an extended step-down commu-
nity program that was composed firstly of 3 months data from fall
clinics including fall evaluation,balance training,home hazard
management program,and medicalreferrals.This was then fol-
lowed by 9 months of a community step-down program which
included fall prevention education, a weekly exercise class, and two
home visitations. After 12 months of intervention,it led to a
reduction in fall rates (74%),injurious falls (43%),fall-associated
medical consultations (47%),and an improvement in the physical
condition of patients was shown.46
Meta-analysis studies revealed thatin the elderly, Tai Chi is
beneficial for balance improvement, can lead to a fall reduction, and
can affect the whole body vibration (WBV) in areas ofbalance,
mobility, and fall reduction. The results are based on 13 RCTs which
indicate that Tai Chi is effective in improving the balance of older
adults, but may not necessarily be superior to other interventions.
The effect of WBV on other balance/mobility outcomes and fall
rates remains inconclusive.47
3.6. Malaysia
The annual prevalence of falls in the elderly population,older
than 60 years,attending primary care clinics at teaching hospitals
in Malaysia was 71/151 (47%), with 57% attending for recurrent falls
61% injury rate, and 61% due to home falls (27% of falls occurred in
the bathroom and 27% occurred on the stairs).In rural dwellers
Table 1
Randomized controlled trials using older people living in the community by types of
interventions in Australia from early 2013.
N Positive fall
outcomes (%)
Exercise 12 42
Vision 2 0a
Home modification/OT 3 0a
Vitamin D 2 0
Medication review 1 100
Multifactorial 7 57
OT ¼ occupational therapy.
a Sub group analysis indicated some positive outcomes.
E.J.Kim et al./ Journal of Clinical Gerontology & Geriatrics 6 (2015) 39e44 41

older than 60 years in Malaysia, the annual prevalence of falls was
141/256 (27%),with 27% having recurrent falls,67% due to home
falls (34% occurred in the living room and 30% occurred in the
bathroom),and there was no association found between home
safety and the falls.A 10-year follow-up of older individuals pre-
senting with falls to the emergency department revealed 1 year,3
year, 5 year, and 10 year mortality rates of 22%, 37%, 49%, and 80%.
Seventy percent of falls occurred indoors,with 50% occurring be-
tween the hours of 06.00 and 12.00. There was a significant
reduction in the Barthel ADL score at the 1 year interval compared
to prefall levels.Age,indoor falls,hospital admission,and Barthel
18 were independent predictors of mortality.48
The Malaysian Falls Assessment and Intervention Trial (MyFAIT),
a single-center randomized-controlledstudy of individually-
tailored,multifactorial intervention has been ongoing in Malaysia
since 2012.49 Inclusion criteria ofparticipants are older patients
older than 65 years with more than two falls or one injurious fall
within 12 months in the Primary Care clinic,Geriatric In-Patient
clinic, and the Emergency Department.Intervention programs
comprised ofcardiovascular investigations,strength and balance
exercises(Otago), visual assessmentsand interventions, home
hazards intervention, and medication reviews (http://www.
controlled-trials.com/isrctn11674947).The Malaysian Elders Lon-
gitudinal Research (MELoR) project consists of 3000 community-
dwelling elderly individuals older than 55 years,and is planning
to commended in 2014 in Malaysia.
3.7. Taiwan
Taiwan has become an aging country since 1993,and is esti-
mated to become a geriatric country in 2017, which makes Taiwan
one of the fastest aging countries in the world.Rapid population
aging may pose special challenges to the health care system and
the society. Falling is an important issue and deserves special
attention in local communities. A previous study in Taiwan
showed that the effectiveness ofhome-visit fall prevention pro-
grams for community-dwelling elderly people,as well as fall
prevention programs should be individualized according to the
elderly person's needs.50 Moreover,a community-based TaiChi
program is effective in preventing the decline offunctionalbal-
ance,gait,as well as the fear of falling.However,Tai Chi did not
show significant effectiveness in reducing the number offalls.51
Nevertheless,a combined Tai Chi plus education program can
significantly reduce the risk of falls and shorten the intervention
period for fall prevention.52 Multilevel community-based inter-
vention programs are considered more effective than a single
intervention program. A recent large-scale prospective study
confirmed that the multifactorial fall prevention program can
significantly improve physical function and reduce fall incidence.53
However, the control group who participated in the education
program and recommendations,also led to a reduction in the
incidence offalls even without the exercise program.In conclu-
sion, the effectivenessof fall prevention among community-
dwelling elderly in Taiwan is dependenton multifactorial in-
terventions,with or without exercises.Exercises and Tai Chi
significantly improve physical function,balance,and alleviate the
fear of falling but not the actualincidence offalls. Further pro-
spective randomized-controlled trials forcommunity-based fall
prevention programs will be of great benefit.
4. Discussion
Studies in Korea on fall prevention programsfor primary
outcome variables (mainly on the improvementof physical or
psychologicalfunction in the majority of studies) as opposed to
the frequency of falls looked at the exercise interventions that
were most widely used in fall prevention.Even though compo-
nents of the exercise program were varied according to the type of
exercises,(balance, strengthening,stretching, aerobic exercise,
etc.),exercise duration (from 3 weeks to 7 months),and exercise
intensity (30e50 minutes),most of the results showed positive
effects in physical,psychological,and fall efficacy.Intervention
studies in Japan, through decreased incidence of falls and fractures
in exercise intervention groups, showed improvements in physical
factors,especially when a variety ofdifferent types of exercise
programs were introduced. In China, educationalintervention
programs,as well as exercise intervention studies on fall preven-
tion were introduced,with the first fall prevention guideline just
recently published. According to the research conducted in
Taiwan,Tai Chi programs were effective in the treatment of bal-
ance, gait, and alleviating the fear of falling, but it was not effective
with regards to a reduction in fall incidence rates.Nevertheless,a
combined TaiChi plus education program significantly reduced
the risk of falls and shortened the intervention period for fall
prevention.
A systematic approach for fall prevention has been progressing
in some Asian countries for some time now. The prospective cohort,
a meta-analysis for the elderly in Hong Kong has been in progress,
and a reduction of falls has been reported by multifactorial inter-
vention. Malaysia is conducting the Malaysian Falls Assessment and
Intervention Trials (MyFAIT), individually-tailored intervention
programs for fallintervention,which also consists of a multifac-
torial intervention.
Compared to the other Asian countries,Australia had the most
research evidence,as well as the Cochrane Review,on fall pre-
vention methods for elderly people in the community-setting in
2012.A number of studies showed that exercise programs,drug
interventions,and multifactorialinterventions were effective in
reducing falls among community-dwelling elderly people.
Even Although the contents of the studies from each country
and their level of progress was different in terms of their fall pre-
vention programs,the social issues in fall prevention has been
particularly interesting, and has led to large scale cohort studies or
fall prevention guidelines to be worked on.In terms of national-
centered programs, community-based programs, or clinic-
centered fall prevention programsprovided to the elderly, is
dependent on each country's national health care policy and their
evaluation of the incidence of falls,physical function,social func-
tion and the psychological functions of the elderly.
In general, clinical guidelines showed the level of evidence and
levels of recommendations,but in this round-table meeting we
have decided to recommend GPPs (good practice points) for fall
prevention strategies for older people living within the community.
GPPs have been developed for clinical practice where there has not
been any studies done,and is based on clinicalexperience and
expert consensus.
Firstly, the Asian community recommendation for fall pre-
vention is necessary for the community-dwelling elderly.Sec-
ondly, the community-dwelling elderly should use an effective
fall prevention program.Thirdly, exercise programs can be an
effective single prevention strategy,but more research is needed
to determine if one type of exercise willbe more effective than
others,as well as which exercises are best for seniors.Fourthly,
environmental modifications can be effective, particularly in
high-risk older people. Fifthly, multifactorial interventions,
including exercise programs can be recommended, but more
research is needed.
In addition to the topics regarding GPPs,public health policies
and prevention programs are needed to integrate the evidence of
fall prevention into clinical practice.To effectively address the
E.J.Kim et al./ Journal of Clinical Gerontology & Geriatrics 6 (2015) 39e4442

growing problem of falls in an ageing society,public policies are
needed to provide a vision,to set priorities,and to establish insti-
tutional standards.Practice settingsare where fall prevention
programs should be translated into feasible and affordable
interventions.
In summary, the conversion of research results into clinical
practice is important,with the need of being more proactive in
carrying out a systematic approach in each individual country.
5. Conclusion
We presented each country's strategies on fall prevention in the
elderly, summarized them, and discussed GPPs on the prevention of
falls in the elderly based on the consensus reached.In the future,
progressive academic exchanges with proactive and systematic
approaches for fallprevention are expected to integrate policies,
preventive measures,and evidence-based clinical practices.
Conflicts of interest
The authors declare no conflicts of interest.
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