Clinical Review: USPSTF on Fall Prevention in Older Adults

This report provides a comprehensive overview of the US Preventive Services Task Force (USPSTF) recommendations for preventing falls in community-dwelling adults aged 65 years or older. It highlights the importance of addressing falls as a leading cause of injury-related morbidity and mortality. The USPSTF recommends exercise interventions as a moderate benefit and selectively offering multifactorial interventions as a small benefit for individuals at increased risk of falls, while recommending against routine vitamin D supplementation. The recommendations emphasize considering individual circumstances, such as prior falls and comorbid conditions, when implementing interventions. The report also discusses risk assessment strategies, including history of falls and assessments of gait and mobility, and details effective exercise components like gait, balance, and functional training. The USPSTF concludes with moderate certainty that exercise interventions provide a moderate net benefit, multifactorial interventions provide a small net benefit, and vitamin D supplementation provides no net benefit in preventing falls in older adults.

Interventions to Prevent Falls in Community-Dwelling
Older Adults
US Preventive Services Task Force
Recommendation Statement
US Preventive Services Task Force
IMPORTANCEFalls are the leading cause of injury-related morbidity and mortality among
older adults in the United States. In 2014, 28.7% of community-dwelling adults 65 years or
older reported falling, resulting in 29 million falls (37.5% of which needed medical treatment
or restricted activity for a day or longer) and an estimated 33 000 deaths in 2015.
OBJECTIVETo update the 2012 US Preventive Services Task Force (USPSTF) recommendation
on the prevention of falls in community-dwelling older adults.
EVIDENCE REVIEWThe USPSTF reviewed the evidence on the effectiveness and harms of
primary care–relevant interventions to prevent falls and fall-related morbidity and mortality in
community-dwelling older adults 65 years or older who are not known to have osteoporosis
or vitamin D deficiency.
FINDINGSThe USPSTF found adequate evidence that exercise interventions have a moderate
benefit in preventing falls in older adults at increased risk for falls and that multifactorial
interventions have a small benefit. The USPSTF found adequate evidence that vitamin D
supplementation has no benefit in preventing falls in older adults. The USPSTF found
adequate evidence to bound the harms of exercise and multifactorial interventions as no
greater than small. The USPSTF found adequate evidence that the overall harms of vitamin D
supplementation are small to moderate.
CONCLUSIONS AND RECOMMENDATIONThe USPSTF recommends exercise interventions to
prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.
(B recommendation) The USPSTF recommends that clinicians selectively offer multifactorial
interventions to prevent falls in community-dwelling adults 65 years or older who are at
increased risk for falls. Existing evidence indicates that the overall net benefit of routinely
offering multifactorial interventions to prevent falls is small. When determining whether this
service is appropriate for an individual, patients and clinicians should consider the balance of
benefits and harms based on the circumstances of prior falls, presence of comorbid medical
conditions, and the patient’s values and preferences. (C recommendation) The USPSTF
recommends against vitamin D supplementation to prevent falls in community-dwelling
adults 65 years or older. (D recommendation) These recommendations apply to
community-dwelling adults who are not known to have osteoporosis or vitamin D deficiency.
JAMA. doi:10.1001/jama.2018.3097
Published online April 17, 2018.
Author Audio Interview
Related article
Author/Group Information: The US
Preventive Services Task Force
(USPSTF) members are listed at the
end of this article.
Corresponding Author: David C.
Grossman, MD, MPH
([e-mail])
Clinical Review & Education
JAMA |US Preventive Services Task Force |RECOMMENDATION STATEMENT
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The US Preventive Services Task Force (USPSTF) makes
recommendations about the effectiveness of specific
preventive care services for patients without obvious
related signs or symptoms.
It bases its recommendations on the evidence of both the
benefits and harms of the service and an assessment of the bal-
ance. The USPSTF does not consider the costs of providing a ser-
vice in this assessment.
The USPSTF recognizes that clinical decisions involve more
considerations than evidence alone. Clinicians should understand
the evidence but individualize decision making to the specific
patient or situation. Similarly, the USPSTF notes that policy and
coverage decisions involve considerations in addition to the evi-
dence of clinical benefits and harms.
Summary of Recommendations and Evidence
The USPSTF recommends exercise interventions to prevent falls in
community-dwelling adults 65 years or older who are at increased
risk for falls (B recommendation) (Figure 1).
The USPSTF recommends that clinicians selectively offer multi-
factorial interventions to prevent falls to community-dwelling adults
65 years or older who are at increased risk for falls. Existing evidence
indicates that the overall net benefit of routinely offering multifacto-
rial interventions to prevent falls is small. When determining whether
this service is appropriate for an individual, patients and clinicians
should consider the balance of benefits and harms based on the cir-
cumstances of prior falls, presence of comorbid medical conditions,
and the patient’s values and preferences. (C recommendation)
See the Clinical Considerations section for information on risk
assessment for falls.
The USPSTF recommends against vitamin D supplementation
to prevent falls in community-dwelling adults 65 years or older.
(D recommendation)
These recommendations apply to community-dwelling adults
not known to have osteoporosis or vitamin D deficiency.
Rationale
Importance
Falls are the leading cause of injury-related morbidity and mortality
among older adults in the United States.1In 2014, 28.7% of com-
munity-dwelling adults 65 years or older reported falling, resulting
in 29 million falls (37.5% of which needed medical treatment or re-
stricted activity for a day or longer)2and an estimated 33 000 deaths
in 2015.1-4
Detection
Effective primary care interventions to prevent falls use various ap-
proaches to identify persons at increased risk. However, no instru-
ment has been clearly identified as accurate and feasible for iden-
tifying older adults at increased risk for falls. Although many studies
used a variety of risk factors, functional tests, or both involving gait,
balance, or mobility to identify study participants, history of falls was
the most commonly used factor that consistently identified per-
sons at high risk for falls.
Benefits of Early Intervention
The USPSTF found adequate evidence that exercise interventions
have a moderate benefit in preventing falls in older adults at in-
creased risk for falls. The USPSTF found adequate evidence that mul-
tifactorial interventions have a small benefit in preventing falls in
older adults at increased risk for falls. The USPSTF found adequate
evidence that vitamin D supplementation has no benefit in prevent-
ing falls in older adults.
Harms of Early Intervention
Based on the noninvasive nature of most of the interventions, the
low likelihood of serious harms, and the available information from
studies reporting few serious harms, the USPSTF found adequate
evidence to bound the harms of exercise and multifactorial inter-
ventions as no greater than small. The USPSTF found adequate evi-
dence that the overall harms of vitamin D supplementation are small
to moderate; evidence suggests that the harms of vitamin D supple-
mentation at very high dosages may be moderate.
USPSTF Assessment
The USPSTF concludes with moderate certainty that exercise inter-
ventions provide a moderate net benefit in preventing falls in older
adults at increased risk for falls.
The USPSTF concludes with moderate certainty that multifac-
torial interventions provide a small net benefit in preventing falls in
older adults at increased risk for falls.
The USPSTF concludes with moderate certainty that vitamin D
supplementation has no net benefit in preventing falls in older adults.
Clinical Considerations
Patient Population Under Consideration
This recommendation applies to community-dwelling adults 65 years
or older who are not known to have osteoporosis or vitamin D
deficiency (Figure 2).
Brief Risk Assessment
When determining to whom these recommendations apply, pri-
mary care clinicians can reasonably consider a small number of risk
factors to identify older adults who are at increased risk for falls.
Age is strongly related to risk for falls. Studies most commonly used
a history of falls to identify increased risk for future falls; history of
falls is generally considered together or sequentially with other key
risk factors, particularly impairments in mobility, gait, and balance.
A pragmatic approach to identifying persons at high risk for falls,
consistent with the enrollment criteria for intervention trials, would
be to assess for a history of falls or for problems in physical func-
tioning and limited mobility. Clinicians could also use assessments
of gait and mobility, such as the Timed Up and Go test.5-7
Interventions
Exercise Interventions
Effective exercise interventions include supervised individual and
group classes and physicaltherapy,although most studies
reviewed by the USPSTF included group exercise. Given the
heterogeneity of interventions reviewed by the USPSTF, it is diffi-
cult to identify specific components of exercise that are particularly
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efficacious. The most common exercise component was gait, bal-
ance, and functional training (17 trials), followed by resistance train-
ing (13 trials), flexibility (8 trials), and endurance training (5 trials).
Three studies included tai chi, and 5 studies included general physi-
cal activity. The most common frequency and duration for exercise
interventions was 3 sessions per week for 12 months, although
duration of exercise interventions ranged from 2 to 42 months.8
The 2008 US Department of Health and Human Services guide-
lines recommended that older adults get at least 150 minutes per
week of moderate-intensity or 75 minutes per week of vigorous-
intensity aerobic physical activity, as well as muscle-strengthening
activities twice per week.9 It also recommended performing bal-
ance training on 3 or more days per week for older adults at risk for
falls because of a recent fall or difficulty walking.9
Multifactorial Interventions
Multifactorial interventions include an initial assessment of modifi-
able risk factors for falls and subsequent customized interventions
for each patient based on issues identified in the initial assessment.
The initial assessment could include a multidisciplinary comprehen-
sive geriatric assessment or an assessment using a combination of
various components, such as balance, gait, vision, postural blood
pressure, medication, environment, cognition, and psychological
health. In studies, nursing staff usually performed the assessment,
Figure 1. US Preventive Services Task Force (USPSTF) Grades and Levels of Certainty
What the USPSTF Grades Mean and Suggestions for Practice
Grade Definition
A The USPSTF recommends the service. There is high certainty that the net benefit is substantial.Offer or provide this service.
Suggestions for Practice
B The USPSTF recommends the service. There is high certainty that the net benefit is moderate, or
there is moderate certainty that the net benefit is moderate to substantial.
Offer or provide this service.
C
The USPSTF recommends selectively offering or providing this service to individual patients
based on professional judgment and patient preferences. There is at least moderate certainty
that the net benefit is small.
Offer or provide this service for selected
patients depending on individual
circumstances.
D The USPSTF recommends against the service. There is moderate or high certainty that the service
has no net benefit or that the harms outweigh the benefits.
Discourage the use of this service.
I statement
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits
and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of
benefits and harms cannot be determined.
Read the Clinical Considerations section
of the USPSTF Recommendation
Statement. If the service is offered,
patients should understand the
uncertainty about the balance of benefits
and harms.
USPSTF Levels of Certainty Regarding Net Benefit
Level of CertaintyDescription
High
The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care
populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be
strongly affected by the results of future studies.
Moderate
The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estim
is constrained by such factors as
the number, size, or quality of individual studies.
inconsistency of findings across individual studies.
limited generalizability of findings to routine primary care practice.
lack of coherence in the chain of evidence.
As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be larg
enough to alter the conclusion.
The USPSTF defines certainty as “likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.” The net benefit is defined
benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the
of the overall evidence available to assess the net benefit of a preventive service.
Low
The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of
the limited number or size of studies.
important flaws in study design or methods.
inconsistency of findings across individual studies.
gaps in the chain of evidence.
findings not generalizable to routine primary care practice.
lack of information on important health outcomes.
More information may allow estimation of effects on health outcomes.
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and a number of different professionals performed subsequent
interventions, including nurses, clinicians, physical therapists, exer-
cise instructors, occupational therapists, dieticians, or nutritionists.
Intervention components vary based on the initial assessment and
could include group or individual exercise, psychological interven-
tions (cognitive behavioral therapy), nutrition therapy, education,
medication management, urinary incontinence management, envi-
ronmental modification, physical or occupational therapy, social or
community services, and referral to specialists (eg, ophthalmolo-
gist, neurologist, or cardiologist). For additional details on multifac-
torial interventions reviewed by the USPSTF, please see the full evi-
dence report.8,10
Other Interventions
The following single interventions lack sufficient evidence for or
against their use to prevent falls in community-dwelling older adults
when offered alone and not in the context of a multifactorial inter-
vention: environmental modification, medication management, psy-
chological interventions, and combination interventions not cus-
tomized to an individual risk profile.
Useful Resources
Fractures are an important injury associated with falls, and the
USPSTF has issued 2 related recommendation statements on
the prevention of fractures. The USPSTF recommends screen-
ing for osteoporosis in all women 65 years or older and in younger
women at increased risk.11
In its recommendation on vitamin D
and calcium supplementation to prevent fractures, the USPSTF
states that it found insufficient evidence on vitamin D or calcium
supplementation to prevent fractures in men, premenopausal
women at any dose, and in postmenopausalwomen at doses
greater than 400 IU of vitamin D and greater than 1000 mg of cal-
cium; the USPSTF recommends against supplementation with
400 IU or less of vitamin D or 1000 mg or less of calcium in post-
menopausal women.12
The Centers for Disease Controland Prevention has pub-
lished guidance on implementing community-based interven-
tions to prevent falls.13
Other Considerations
Implementation
Although the evidence does not support routinely performing an
in-depth multifactorial risk assessment with comprehensive risk
management in all older adults, there may be reasons for provid-
ing this service to certain patients.Important items in the
patient's medical history could include the circumstances of prior
falls and the presence of comorbid medicalconditions. The
American Geriatric Society (AGS) recommends multifactorial risk
assessment with multicomponent interventions in older adults
who have had 2 falls in the past year (1 fall if combined with gait or
balance problems), have gait or balance problems, or present
with an acute fall.14According to the AGS, evaluation of balance
and mobility, vision, and orthostatic or postural hypotension are
effective components of multifactorialrisk assessment with
Figure 2. Clinical Summary: Interventions to Prevent Falls in Community-Dwelling Older Adults
Population
Recommendation
Community-dwelling adults 65 years or older at increased risk for falls, without osteoporosis or vitamin D deficiency
Do not recommend vitamin D
supplementation to prevent falls.
Recommend exercise interventions to
prevent falls.
Selectively offer multifactorial
interventions to prevent falls.
Grade: B Grade: C Grade: D
Risk Assessment
Interventions
Other Relevant
USPSTF
Recommendations
For a summary of the evidence systematically reviewed in making this recommendation, the full recommendation statement, and supporting documents, p
go to https://www.uspreventiveservicestaskforce.org.
Age is strongly related to risk for falls. A pragmatic approach to identifying older persons at high risk for falls would be to assess for
a history of falls or physical function/mobility limitation problems. Clinicians could also use assessments of gait and mobility,
such as the Timed Up and Go test.
Effective exercise interventions include supervised individual and group classes and physical therapy. Given the heterogeneity of
these interventions, it is difficult to identify specific components of exercise that are particularly efficacious.
Multifactorial interventions include an initial assessment of modifiable risk factors for falls and subsequent customized interventions
for each patient based on issues identified in the initial assessment. The initial assessment could include a multidisciplinary
comprehensive geriatric assessment or an assessment using a combination of various components, such as balance, gait, vision,
postural blood pressure, medication, environment, cognition, and psychological health.
The USPSTF found insufficient evidence on vitamin D or calcium supplementation to prevent fractures in men, premenopausal
women at any dose, and in postmenopausal women at doses >400 IU of vitamin D and >1000 mg of calcium. The USPSTF
recommends against supplementation with ≤400 IU of vitamin D or ≤1000 mg of calcium in postmenopausal women.
The USPSTF recommends screening for osteoporosis in women 65 years or older and in younger women at increased risk.
USPSTF indicates US Preventive Services Task Force.
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comprehensive management, as well as review of medication use
and home environment.14Follow-up and comprehensive man-
agement of identified risk factors are essential to the effective-
ness of this strategy.
The burden of falls on patients and the health care system is
large. Reducing the incidence of falls would also improve the social-
ization and functioning of older adults who have previously fallen
and fear falling again. Many other interventions could potentially
be useful to prevent falls, but because of the heterogeneity in the
target patient population, heterogeneity (ie, multiplicity) of predis-
posing factors, and their additive or synergistic nature, the effec-
tiveness of other interventions is not known. However, many inter-
ventions with insufficient evidence to support their use to prevent
falls have other arguments that support their use.
Research Needs and Gaps
Studies are needed on the clinical validation of primary care tools to
identify older adults at increased risk for falls. More efficacy trials
are needed on how the following interventions may help prevent
falls if offered alone and not as part of multifactorial interventions:
environmental modification, medication management, and psy-
chological interventions. Additional research is needed on the
effectiveness of interventions in different age groups, in particular
adults older than 85 years. Additional research to identify effective
components of exercise interventions would also be useful.
Discussion
Burden of Disease
In 2014, approximately 2.8 million older adults sought treatment in
emergency departments for falls; approximately 800 000 older
adults experiencing a fall were hospitalized, and more than 27 000
older adults died from a fall.1,15
More than 90% of hip fractures are
caused by falls, and 25% of older adults who sustain a hip fracture
die within 6 months.16,17
Risk for falls increases with age; in 2014, 27%
of adults aged 65 to 74 years and 37% of adults 85 years or older
reported a fall.1
Scope of Review
The USPSTF commissioned a systematic evidence review on
the effectiveness and harms of primary care–relevant interven-
tions to prevent falls and fall-related morbidity and mortality in
community-dwelling older adults 65 years or older.8,10Although
the review evaluated risk-assessment approaches used in studies
to identify patients at increased risk for falls, it did not evaluate
the evidence on the benefits and harms of screening all patients
for falls risk factors (ie, did not compare health outcomes in
screened vs unscreened groups). Studies conducted solely in
populations with specific medical diagnoses that could affect fall-
related outcomes or for which interventions could be considered
disease management (eg, osteoporosis, vitamin D deficiency,
visual impairment, and neurocognitive disorders) were excluded.
This systematic evidence review updates the 2010 review and
varies from the previous review in a few ways: additional falls out-
comes, such as number of falls and injurious falls, were included,
and studies of vitamin D supplementation conducted in popula-
tions known to be vitamin D deficient were excluded.
Brief Risk Assessment
The majority of intervention studies (40/62) reviewed by the
USPSTF targeted patients at high risk for falls.8,10
However, studies
used variable approaches to identify high-risk patients. Most com-
monly, studies used history of prior falls to identify persons at high
risk for future falls (16 studies).8 Other trials evaluated 2 or more
risk factors, such as history of prior falls, difficulty with mobility, and
use of health care, and included participants with any of these risk
factors. Studies that evaluated exercise interventions most com-
monly used physical function or mobility limitation problems to
identify high-risk populations. Therefore, history of prior falls or
physical function or mobility limitation problems may be adequate
and appropriate factors for determining high risk.
Effectiveness of Preventive Measures
The USPSTF reviewed the evidence from 62 trials on the use
of multifactorialinterventions,exercise,vitamin D supple-
mentation, environmental modifications, psychological interven-
tions, and multiple interventions to prevent falls and fall-related
morbidity and mortality.8,10The USPSTF focused on the out-
comes of reductions in falls, number of persons experiencing a
fall, reductions in injurious falls, and number of persons experi-
encing an injurious fall. Although many studies reported on mor-
tality, they were generally underpowered to detect changes in
mortality, and results were not statistically significant. The most
commonly reported outcomes were falls and number of persons
experiencing a fall; half (31/62) of the trials were powered to
detect clinically meaningful differences in these 2 outcomes. The
most commonly reported interventions included multifactorial
interventions (26 trials), exercise (21 trials), and vitamin D supple-
mentation (7 trials).
Exercise Interventions
The USPSTF found 5 good-quality and 16 fair-quality studies
(n = 7297) reporting on various exercise interventions to prevent
falls.8,10A little more than half of studies (12/21) recruited popula-
tions at high risk for falls. Physical function/mobility limitation
problems, measured objectively or self-reported by participants,
was the most common risk factor used to identify persons at high
risk. The number of study participants ranged from 55 to 1635,
and the mean age ranged from 68 to 88 years. Six studies were
conducted exclusively in women; women comprised the majority
of participants in the other studies, except for 1 study in which
42% of participants were women. Only 3 studies reported the
race/ethnicity of study participants, who were almost exclusively
white. Three studies were conducted in the United States, 1 study
in the United Kingdom, 8 studies in other parts of Europe, 7 stud-
ies in Australia or New Zealand, and 2 studies in Asia.
Studies found that exercise improved several fall-related out-
comes. Based on pooled analyses of 15 studies (n = 4926), exer-
cise interventions reduced the number of persons experiencing a
fall (relative risk [RR], 0.89 [95% CI, 0.81 to 0.97]).8 Pooled analy-
ses from 10 studies (n = 4622) found a reduction in the number
of injurious falls experienced by participants undergoing exercise
interventions (incidence rate ratio [IRR], 0.81 [95% CI, 0.73 to
0.90]).8 Although not statistically significant, pooled analyses of
14 studies (n = 4663) revealed a reduction in the number of falls
experienced by participants undergoing exercise interventions
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(IRR, 0.87 [95% CI, 0.75 to 1.00]).8 Some initial, exploratory
analyses suggest that group-based exercise (vs individual-based
exercise), multiple exercise components (vs single exercise com-
ponent), and interventions including strength or resistance exer-
cises (vs interventions without those components) were more
likely to be associated with a greater reduction in falls and num-
ber of persons experiencing a fall. However, given that these find-
ings were only exploratory analyses to evaluate causes of hetero-
geneity, they should be interpreted with caution.8 Additional
details about specific exercise interventions reviewed by the
USPSTF can be found in the full evidence report.8
Multifactorial Interventions
Seven good-quality and 19 fair-quality studies (n = 15 506)
reported on multifactorial interventions.8,10Most studies (19/26)
recruited participants at high risk for falls. Although studies used
various assessment approaches, history of falls was the most
common risk factor used to identify persons at high risk. The
number of participants ranged from 100 to 5310, and the mean
age ranged from 71.9 to 85.0 years. The percentage of women
ranged from 53.2% to 94.0%. Race/ethnicity of study partici-
pants was reported in only 1 study, in which 94% of participants
were white. Three studies were conducted in the United States;
the remaining studies were conducted in the United Kingdom,
Australia, the Netherlands, Canada, Spain, Finland, Denmark,
Switzerland, Sweden, and New Zealand.
While studies found that multifactorial interventions reduced
the number of falls,these interventions did not appear to
improve other fall-related outcomes. Pooled analyses found
reductions in the number of falls among participants who re-
ceived multifactorial interventions (IRR, 0.79 [95% CI, 0.68 to
0.91];17 studies;n = 9737) but not in the number of per-
sons experiencing a fall (RR, 0.95 [95% CI, 0.89 to 1.01]; 24 stud-
ies; n = 12 490) or experiencing an injurious fall (RR, 0.94 [95%
CI, 0.85 to 1.03]; 16 studies; n = 9445).8 Of 9 studies (n = 4306)
reporting the number of injurious falls, only 1 reported a sta-
tistically significant reduction among participants receiving multi-
factorial interventions.8 Given that studies used heterogeneous
multifactorial interventions, it is difficult to identify specific com-
ponents that may be effective. The initial assessment to screen
for modifiable falls risk factors used either a multidisciplinary
comprehensive geriatric assessment or a specific falls risk assess-
ment that evaluated any of the following: balance, gait, vision,
cardiovascular health, medication, environment, cognition, and
psychological health. Treatment interventions varied substantially
across studies and included targeted combinations of any of the
following components: exercise, psychologicalinterventions,
nutrition therapy, knowledge, medication management, urinary
incontinence management, environmentalmodification, and
referrals to physical or occupational therapy, social or community
services, or specialists (eg, ophthalmologist, neurologist, or cardi-
ologist). Most studies referred participants to or offered an exer-
cise or physicaltherapy intervention. The majority of studies
included home visits for the initial assessment, environmental
modification, or physical therapy or exercise interventions; other
services were conducted in outpatient settings. Totalcontact
time was rarely reported, precluding quantification of interven-
tion intensity.
Vitamin D Supplementation
Four good-quality and 3 fair-quality studies (n = 7531) reported on
the effect of vitamin D supplementation on the prevention of falls
in community-dwelling older adults.8,10Three studies recruited
participants at high risk for falls, most commonly based on a history
of falls. Baseline mean serum 25-hydroxyvitamin D levels ranged
from 26.4 to 31.8 ng/mL, which correspond with National Health
and Nutrition Examination Survey data on vitamin D levels in adults
60 years or older. The number of participants ranged from 204 to
3314, and the mean age ranged from 71.0 to 76.8 years. Five stud-
ies were conducted exclusively in women; women comprised
approximately half of the study population in the other 2 studies.
Only 3 studies reported the race/ethnicity of participants, who
were almost exclusively white. Two trials were conducted in the
United States, 2 in Australia, and 1 each in the United Kingdom,
Switzerland, and Finland.
Five trials (n = 3496) reported mixed findings.8 Only 1 trial
showed a statistically significant reduction in falls8,18
; however,
another study using high doses of vitamin D (500 000 IU per year)
showed a statistically significant increase in falls.8,19
Pooled analy-
ses showed neither a significant reduction in falls (IRR, 0.97 [95%
CI, 0.79 to 1.20]; 5 studies; n = 3496) nor a significant effect on the
number of persons experiencing a fall with vitamin D supplementa-
tion (RR, 0.97 [95% CI, 0.88 to 1.08]).8 Only 2 trials reported on
the number of injurious falls; 1 trial using an annual high dose of
vitamin D reported an increase in injurious falls (IRR, 1.15 [95% CI,
1.02 to 1.29]),8,19
and the other trial reported no statistically signifi-
cant difference (IRR, 0.84 [95% CI, 0.45 to 1.57]).8,20 Only 1 trial
reported on fractures and found a nonsignificant increase in frac-
tures with vitamin D supplementation (IRR, 1.25 [95% CI, 0.97 to
1.61]).19Four trials reported mixed results on the number of per-
sons experiencing a fracture.8 Vitamin D formulations and dosages
varied among trials. Five trials used cholecalciferol at doses of
700 IU per day, 800 IU per day, 150 000 IU every 3 months, or
500 000 IU per year; 1 trial used 1-hydroxycholecalciferol (1 μg per
day) and another used calcitriol (0.25 μg twice per day).8
Other Interventions
The USPSTF found evidence on other interventions, including en-
vironmental modification (3 studies; n = 2175), medication man-
agement (2 studies; n = 266), psychological interventions (2 stud-
ies; n = 929), and multiple interventions (6 studies; n = 1770).8
Multiple interventions provided at least 2 intervention compo-
nents but were not customized to individual participants. Studies
of these other interventions were too few, too small, and too hetero-
geneous for the USPSTF to draw any definitive conclusions.
Other Outcomes
The effect of interventions to prevent falls on functional status or
quality of life remains uncertain. The few trials reporting quality of
life, activities of daily living, or independent activities of daily living
showed no benefit, but these studies used different scales, and few
were adequately powered to detect differences in these outcomes.
Potential Harms of Preventive Measures
Evidence on harms was reported in a subset of trials reporting on
the effectiveness of interventions. Eight studies (n = 4107) evaluat-
ing exercise interventions reported on harms; in general, adverse
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events were minor.8,10
The most common adverse events included
pain or bruising related to exercise. One study reported 1 wrist frac-
ture in the intervention group21and another study reported a rate
of 2.6 serious fall injuries per 100 000 physical activity sessions.22
Only 2 trials reported on harms in control groups for comparison
and found no between-group difference in the rate of serious
injuries.8 For multifactorial interventions, 4 studies (n = 1466)
reported on harms.8 In general, reported harms were rare, minor,
and associated with the exercise component of the intervention.
Five studies (n = 3955) on vitamin D supplementation reported no
difference in the frequency of harms between intervention and
control groups.8 However, as mentioned previously, the study
using the highest dose of vitamin D (500 000 IU per year)
reported an increase in falls, injurious falls, and the number of per-
sons experiencing falls.19Other reported harms were rare and
included kidney stones, diabetes, transient hypercalcemia, and
hypercalciuria; it was unclear if these rare harms were attributable
to vitamin D supplementation. However, in a separate evidence
review commissioned by the USPSTF on vitamin D supplementa-
tion to prevent fractures, the incidence of kidney stones increased
with combined vitamin D and calcium supplementation (based on
evidence from 3 studies, including the large Women’s Health Initia-
tive trial).23,24Three studies (n = 810) on multiple interventions
reported no adverse or severe adverse events, although ascertain-
ment of adverse events was unclear.8 One study on a single psy-
chological intervention reported no adverse events.25The remain-
ing studies did not report on harms or adverse events.
Estimate of Magnitude of Net Benefit
The USPSTF found adequate evidence that exercise reduces the risk
for falls by a moderate amount. Studies found reductions across sev-
eral fall-related outcomes. The USPSTF found adequate evidence to
bound the harms of exercise as no greater than small. Potential harms
include pain and bruising from exercise or a paradoxical increase in
falls. The USPSTF concludes with moderate certainty that exercise
confers a moderate net benefit in the reduction of falls.
The USPSTF found adequate evidence that multifactorial inter-
ventions reduce the risk for falls by a small amount. Pooled analy-
ses revealed statistically significant reductions in 1 fall-related out-
come (number of falls) but not others (eg, number of persons
experiencing a fall). The USPSTF found adequate evidence to bound
the harms of multifactorial interventions as no greater than small.
Most reported harms seem to arise from the exercise components
of interventions. The USPSTF concludes with moderate certainty that
multifactorial interventions confer a small net benefit in the reduc-
tion of falls.
The USPSTF found adequate evidence that vitamin D supple-
mentation does not prevent falls. Pooled analyses show no effect
of vitamin D supplementation on the number of falls or the number
of persons experiencing a fall. The USPSTF found adequate evi-
dence that the harms of vitamin D supplementation are small to mod-
erate. A study of annual high-dose vitamin D supplementation
showed an increase in falls. Adequate evidence from a separate evi-
dence review on vitamin D supplementation found an increase in
the incidence of kidney stones with combined vitamin D and cal-
cium supplementation. The USPSTF concludes with moderate cer-
tainty that vitamin D supplementation offers no net benefit in the
reduction of falls.
How Does Evidence Fit With Biological Understanding?
Muscle weakness, gait disturbances, and imbalance are important
factors that contribute to increased risk for falls in older persons.
Exercise and physical therapy may improve strength and balance
and therefore may result in fewer falls. Many interrelated variables
affect the health status of older adults, some of which probably
have additive effects and may explain why multifactorialrisk
assessment with comprehensive management is effective in pre-
venting falls. Vitamin D receptors have been identified in various
celltypes, including skeletalmuscle, and stimulation of these
receptors promotes protein synthesis.26,27Although it has been
previously demonstrated that vitamin D or its metabolites may
have a beneficial effect on muscle strength and balance,28 the cur-
rent evidence shows no benefit in preventing falls. In addition, the
Institute of Medicine (now the National Academy of Medicine) con-
cluded that there may be a potentialU-shaped relationship
between 25-hydroxyvitamin D serum levels and health outcomes,
with serum levels greater than 125 nmol/L being associated with
worse health outcomes.29
Response to Public Comment
A draft version of this recommendation statement was posted for
public comment on the USPSTF website from September 26, 2017,
to October 24, 2017. In response to public comment, the USPSTF
clarified that physical therapy, which was described separately
from exercise interventions in the 2012 recommendation, is now
included among “exercise interventions” in the current recommen-
dation. Additionally, the USPSTF clarified that these recommenda-
tions apply to older adults not known to be vitamin D deficient.
The USPSTF added findings on additional outcomes, such as qual-
ity of life, as well. A few comments requested additional details
about effective exercise and multifactorial interventions. Given
the heterogeneity of included interventions, it is difficult for the
USPSTF to identify specific components that it found to be particu-
larly effective; however, the USPSTF included results from some
exploratory analyses. A few comments also requested a recom-
mendation on other interventions, such as reducing medication
prescriptions and comprehensive eye examination. The USPSTF
can only recommend the use of an intervention when it finds
adequate evidence that the benefits outweigh the harms. Although
the USPSTF may have reviewed additional interventions, it did not
find adequate evidence to issue a recommendation on all of the
reviewed interventions. Interventions that target health conditions
that may affect falls risk but have other reasons for assessment and
treatment (such as visual impairment or neurologic disorders) were
considered to be out of scope for the current review. Information
on all the interventions reviewed by the USPSTF can be found in
the full evidence report.8
Update of Previous USPSTF Recommendation
The USPSTF last issued a recommendation on interventions to pre-
vent falls in older adults in 2012. At that time, consistent with the
current recommendation statement, the USPSTF recommended ex-
ercise (B recommendation) and selectively offering multifactorial in-
terventions (C recommendation) to prevent falls in community-
dwelling older adults at increased risk for falls. At that time, the
USPSTF Recommendation: Interventions to Prevent Falls in Community-Dwelling Older AdultsUS Preventive Services Task ForceClinical Review & Education
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USPSTF also recommended vitamin D supplementation to prevent
falls (B recommendation), based on previous evidence that found
a reduction in the number of persons experiencing a fall. The cur-
rent review excluded studies considered in the previous review that
enrolled persons with vitamin D deficiency or insufficiency be-
cause, on further consideration, vitamin D supplementation in these
populations would be considered treatment rather than preven-
tion. In addition, the current review examined additionalfall-
related outcomes, including incident falls (in addition to the num-
ber of persons experiencing a fall, which was considered in the
previous review). With this revised scope of review, as well as newer
evidence from trials reporting no benefit, the USPSTF found that
vitamin D supplementation has no benefit in falls prevention in
community-dwelling older adults not known to have vitamin D
deficiency or insufficiency. Thus, the USPSTF now recommends
against vitamin D supplementation for the prevention of falls in
community-dwelling older adults.
Recommendations of Others
The National Institute on Aging outlines similar interventions for the
prevention of falls: exercise for strength and balance, monitoring for
environmental hazards, regular medical care to ensure optimized
hearing and vision, and medication management.30According to the
AGS, detecting a history of falls is fundamental to a falls reduction
program, and the AGS recommends asking all older adults once
a year about falls.14The AGS further recommends that older per-
sons who have experienced a fall should have their gait and bal-
ance assessed using one of the available evaluations; those who can-
not perform or perform poorly on a standardized gait and balance
test should be given a multifactorial falls risk assessment that in-
cludes a focused medical history, physical examination, functional
assessment, and an environmental assessment. The AGS also rec-
ommends the following interventions for falls prevention: adapta-
tion or modification of home environment; withdrawal or minimi-
zation of psychoactive or other medications; management of
postural hypotension; management of foot problems and foot-
wear; exercise (particularly balance), strength, and gait training; and
vitamin D supplementation of at least 800 IU per day for persons
with vitamin D deficiency or who are at increased risk for falls. The
AGS found insufficient evidence to recommend vision screening
alone as a single intervention for falls prevention. The Centers for
Disease Control and Prevention recommends STEADI, a coordi-
nated approach to implementing the AGS clinical practice guide-
lines for falls prevention that consists of 3 core elements: screen to
identify fall risk, assess modifiable risk factors, and intervene using
effective clinical and community strategies to reduce the identified
risk. Clinical strategies include but are not limited to physical therapy
and medication management. Community strategies include but are
not limited to evidence-based exercise programs and home
modification.31Similar to the 2012 USPSTF recommendation, the
American Academy of Family Physicians recommends exercise or
physical therapy and vitamin D supplementation to prevent falls in
community-dwelling adults 65 years or older who are at increased
risk for falls. It does not recommend automatically performing an in-
depth multifactorial risk assessment in conjunction with compre-
hensive management of identified risks.32
ARTICLE INFORMATION
Accepted for Publication: March 5, 2018.
Published Online: April 17, 2018.
doi:10.1001/jama.2018.3097
The US Preventive Services Task Force (USPSTF)
members: David C. Grossman, MD, MPH; Susan J.
Curry, PhD; Douglas K. Owens, MD, MS; Michael J.
Barry, MD; Aaron B. Caughey, MD, PhD; Karina W.
Davidson, PhD, MASc; Chyke A. Doubeni, MD, MPH;
John W. Epling Jr, MD, MSEd; Alex R. Kemper, MD,
MPH, MS; Alex H. Krist, MD, MPH; Martha Kubik,
PhD, RN; Seth Landefeld, MD; Carol M. Mangione,
MD, MSPH; Michael Pignone, MD, MPH; Michael
Silverstein, MD, MPH; Melissa A. Simon, MD, MPH;
Chien-Wen Tseng, MD, MPH, MSEE.
Affiliations of The US Preventive Services Task
Force (USPSTF) members: Kaiser Permanente
Washington Health Research Institute, Seattle
(Grossman); University of Iowa, Iowa City (Curry);
Veterans Affairs Palo Alto Health Care System,
Palo Alto, California (Owens); Stanford University,
Stanford, California (Owens); Harvard Medical
School, Boston, Massachusetts (Barry); Oregon
Health & Science University, Portland (Caughey);
Columbia University, New York, New York
(Davidson); University of Pennsylvania,
Philadelphia (Doubeni); Virginia Tech Carilion
School of Medicine, Roanoke (Epling); Nationwide
Children’s Hospital, Columbus, Ohio (Kemper);
Fairfax Family Practice Residency, Fairfax, Virginia
(Krist); Virginia Commonwealth University,
Richmond (Krist); Temple University, Philadelphia,
Pennsylvania (Kubik); University of Alabama at
Birmingham (Landefeld); University of California,
Los Angeles (Mangione); University of Texas at
Austin (Pignone); Boston University, Boston,
Massachusetts (Silverstein); Northwestern
University, Evanston, Illinois (Simon); University of
Hawaii, Honolulu (Tseng); Pacific Health Research
and Education Institute, Honolulu, Hawaii (Tseng).
Author Contributions: Dr Grossman had full access
to all of the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis. The USPSTF
members contributed equally to the
recommendation statement.
Conflict of Interest Disclosures: All authors
have completed and submitted the ICMJE Form
for Disclosure of Potential Conflicts of Interest.
Authors followed the policy regarding conflicts
of interest described at https://www
.uspreventiveservicestaskforce.org/Page/Name
/conflict-of-interest-disclosures. All members of the
USPSTF receive travel reimbursement and an
honorarium for participating in USPSTF meetings.
Funding/Support: The USPSTF is an independent,
voluntary body. The US Congress mandates that
the Agency for Healthcare Research and Quality
(AHRQ) support the operations of the USPSTF.
Role of the Funder/Sponsor: AHRQ staff assisted
in the following: development and review of the
research plan, commission of the systematic
evidence review from an Evidence-based Practice
Center, coordination of expert review and public
comment of the draft evidence report and draft
recommendation statement, and the writing and
preparation of the final recommendation statement
and its submission for publication. AHRQ staff had
no role in the approval of the final recommendation
statement or the decision to submit for publication.
Disclaimer: Recommendations made by the
USPSTF are independent of the US government.
They should not be construed as an official position
of AHRQ or the US Department of Health and
Human Services.
Additional Contributions: We thank Tina Fan, MD,
MPH (AHRQ), who contributed to the writing of the
manuscript, and Lisa Nicolella, MA (AHRQ), who
assisted with coordination and editing.
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