Community-Based Falls Prevention for Older People Living at Home: A Systematic Review

Background to Community-Based Falls Prevention

Falls usually result from an interaction between personal risk factors and the environment. Personal factors include muscle weakness, poor balance and gait, previous falls, cognitive impairment, continence problems, postural hypotension and medicines such as sedatives and antihypertensives. Environmental factors include poor lighting, loose rugs, clutter, stairs without rails and unsuitable footwear. Because risk is multifactorial, interventions range from single approaches, such as exercise, to individually tailored programmes that address several factors at once.

Community-based falls prevention is usually delivered through primary care, community health services, local authorities and voluntary organisations. Common components include strength and balance exercise, home hazard assessment and modification, medication review, vision assessment, management of postural hypotension and education. In the UK, national guidance recommends that older people are asked about falls when they have routine contact with health professionals and that those at risk are offered multifactorial assessment and intervention.

A falls risk assessment typically involves a history of previous falls, observation of gait and balance, review of medicines and long-term conditions, and assessment of the home environment. A home assessment may be carried out by an occupational therapist, a physiotherapist, a nurse or a trained assessor. Who carries out the assessment, and how thoroughly hazards are addressed, may influence how effective it is.

Exercise, home hazard reduction and multifactorial programmes within community-based falls prevention differ in cost, reach and acceptability. Understanding which work best, and for whom, helps nurses to target scarce resources and to give older people clear advice about what is likely to reduce their own risk.

The setting also shapes what is possible. Community-based falls prevention must work in people’s own homes and neighbourhoods, where nurses cannot supervise exercise every day and where changes to the home depend on the person’s agreement, finances and housing. Programmes therefore need to be acceptable to older people, fit with their routines and be supported by family members, voluntary groups and social care as well as by health professionals.

Search Strategy and Methods

Evidence for this example was identified through targeted searches of openly accessible bibliographic records, publisher websites and the reference lists of key reviews. Search terms combined keywords for the population and setting (“older people”, “aged”, “community-dwelling”, “living at home”) with terms for falls and interventions (“falls prevention”, “accidental falls”, “exercise”, “home hazard”, “home assessment”, “multifactorial”), joined with the Boolean operators AND and OR. A full systematic review for assessment would run the same strategy in CINAHL, PubMed/MEDLINE, the Cochrane Library and Social Care Online and report the number of records screened in a PRISMA flow diagram.

Sources were eligible if they evaluated community-based falls prevention for adults aged 60 or over living at home, with falls as an outcome. Systematic reviews of randomised controlled trials were prioritised, and a UK randomised trial was included because it compared who delivers home assessment. An international guideline was included to place the findings within current recommendations. Studies limited to hospitals or care homes were excluded.

Five sources published between 2011 and 2023 were included: three Cochrane systematic reviews, a randomised controlled trial and an international guideline (Table 1). The quality of each source was considered using the Critical Appraisal Skills Programme (CASP) checklists, drawing on the certainty ratings reported by each review, and findings were synthesised narratively.

Key Findings on Community-Based Falls Prevention

Three themes were identified: the strong evidence for exercise, the benefits of home hazard reduction and the importance of who delivers it, and the more uncertain effects of multifactorial programmes within community-based falls prevention. Table 1 summarises the included sources, and Figure 1 compares the effects of exercise and home hazard interventions on the rate of falls.

Author, year	Design	Setting and sample	Key finding
Pighills et al. (2011)	Pilot three-armed randomised controlled trial	238 adults aged 70+ who had fallen, Yorkshire, England	Home assessment by occupational therapists reduced falls (IRR 0.54); trained assessors did not (IRR 0.78, not significant).
Hopewell et al. (2018)	Cochrane systematic review	62 trials, 19,935 older people living in the community	Multifactorial interventions reduced the rate of falls but not fallers (low quality); multiple component interventions probably reduced both.
Sherrington et al. (2019)	Cochrane systematic review	108 trials, 23,407 participants, 25 countries	Exercise reduced the rate of falls by 23% (RaR 0.77) and fallers by 15% (high certainty).
Montero-Odasso et al. (2022)	International guideline (modified Delphi)	Global multidisciplinary panel including older adults	Recommends opportunistic case finding, risk stratification and multifactorial assessment for people at high risk.
Clemson et al. (2023)	Cochrane systematic review	22 trials, 8,463 people aged 60+ living in the community	Home hazard reduction reduced the rate of falls by 26% overall (RaR 0.74) and 38% in people at high risk (RaR 0.62).

Theme 1: Exercise as the Foundation of Community-Based Falls Prevention

A Cochrane review of 108 randomised controlled trials with 23,407 participants in 25 countries examined exercise for preventing falls in older people living in the community (Sherrington et al., 2019). Compared with control, exercise reduced the rate of falls by 23% (rate ratio 0.77, 95% CI 0.71 to 0.83; 59 trials) and the number of people who fell by 15% (risk ratio 0.85), both supported by high-certainty evidence.

The type of exercise mattered. Balance and functional exercise reduced the rate of falls by 24% (rate ratio 0.76, high certainty), and programmes combining several types, usually balance and functional exercise with resistance training, reduced it by about a third (rate ratio 0.66, moderate certainty). Tai Chi may also reduce falls, although the certainty of evidence for the rate of falls was low. There was insufficient evidence for walking, dance or resistance exercise alone, and adverse events were mostly minor musculoskeletal problems.

These findings make exercise the foundation of community-based falls prevention. However, most trials had unclear or high risk of bias because participants knew they were exercising, and evidence for effects on fractures and hospital admission was of low or very low certainty. Programmes must also be sustained: the benefits depend on regular, progressive exercise over months, which many frail or housebound older people find difficult without support.

Theme 2: Home Hazard Reduction and Who Delivers It

A Cochrane review of 22 trials with 8,463 participants examined environmental interventions for preventing falls in older people living in the community (Clemson et al., 2023). Home fall hazard reduction probably reduced the overall rate of falls by 26% (rate ratio 0.74, 95% CI 0.61 to 0.91; moderate certainty). In people at high risk of falling, the reduction was 38% (rate ratio 0.62, 95% CI 0.56 to 0.70; high certainty), and the number of people who fell was also reduced.

By contrast, vision improvement interventions may make little or no difference to the rate of falls, and the evidence was insufficient to judge whether education alone reduces falls. These findings suggest that a home assessment is most valuable when it is targeted at people at higher risk and when it leads to practical changes to the home and to how people carry out daily activities.

A three-armed randomised controlled trial in Yorkshire compared home assessment and modification delivered by occupational therapists, by trained non-specialist assessors and usual care for 238 people aged 70 and over who had fallen in the previous year (Pighills et al., 2011). Assessment by occupational therapists reduced falls at 12 months (incidence rate ratio 0.54, 95% CI 0.36 to 0.83), whereas assessment by trained assessors did not significantly reduce falls (0.78, 95% CI 0.51 to 1.21). Neither approach reduced fear of falling, which suggests that confidence may need to be addressed separately, for example through graded exercise and reassurance. As a pilot trial, its findings need confirmation, but they suggest that the skill of the assessor matters.

Theme 3: Multifactorial Assessment and Personalised Care

A Cochrane review of 62 trials with 19,935 older people living in the community examined multifactorial interventions, which tailor several components to each person’s assessed risk, and multiple component interventions, which give the same combination to everyone (Hopewell et al., 2018). Multifactorial interventions led to some reduction in the rate of falls but not in the number of people who fell, based on low-quality evidence. Multiple component interventions, usually including exercise, probably reduced both the rate of falls and the number of fallers.

The world guidelines for falls prevention, developed by a global panel through a modified Delphi process, recommend that all older adults are advised on falls prevention and physical activity, that opportunistic case finding for falls risk is used in the community, and that people at high risk are offered a comprehensive multifactorial falls risk assessment leading to personalised, co-designed interventions (Montero-Odasso et al., 2022). The guidelines emphasise flexible implementation according to local resources.

Together, these sources suggest that multifactorial assessment is most useful as a way of identifying and coordinating the interventions that work, particularly exercise and skilled home hazard reduction, rather than as an end in itself. Assessment that does not lead to effective action is unlikely to reduce falls, which may explain the modest effects of multifactorial programmes in trials.

Discussion

This review found high-certainty evidence that exercise, especially balance and functional exercise, reduces falls among older people living in the community, and moderate to high-certainty evidence that home hazard reduction reduces falls, particularly in people at high risk. Multifactorial interventions had smaller and less certain effects. These findings are consistent with international guidance that places exercise and targeted home hazard reduction at the centre of community-based falls prevention.

A key message for nursing is the importance of targeting. Home hazard reduction was most effective for people at high risk, and the world guidelines recommend stratifying risk so that intensive assessment is offered to those who need it most. Community nurses can use routine contacts to ask about falls, identify people at high risk and ensure that they reach effective interventions, rather than offering general advice to everyone and detailed assessment to no one.

The question of who delivers interventions is also important. The Yorkshire trial suggests that occupational therapists achieved better results than trained non-specialists, and the Cochrane review found that education alone was of uncertain benefit. Nurses therefore need clear referral pathways to occupational therapy and physiotherapy, and should not assume that a checklist-based home visit will have the same effect as a skilled assessment that adapts the home and daily routines.

Adherence is a further challenge for community-based falls prevention. Exercise works only if people take part regularly, and many older people at highest risk are frail, housebound or living with cognitive impairment. Nurses can help by explaining the benefits, addressing fear of falling and linking people with programmes that can be delivered at home. Family carers often support exercise and home changes, which adds to the demands placed on them.

This review has limitations. It drew mainly on systematic reviews, so it depends on their methods and on trials that often had high risk of bias, and the UK trial was a pilot. Few trials reported outcomes such as fractures or admissions with high certainty. This review relied on openly accessible, English-language sources and did not involve independent double screening. Future research should test nurse-led case finding and referral pathways and examine how to sustain exercise among frail people at home.

There is also a gap between evidence and routine services. Strength and balance programmes are not available everywhere, waiting lists for occupational therapy can be long, and community nursing teams under pressure may have little time for prevention. Without investment in these services, a falls risk assessment may identify needs that cannot be met. Commissioners should therefore plan community-based falls prevention as a whole pathway, from case finding to exercise and home assessment, rather than funding isolated parts of it.

Implications of Community-Based Falls Prevention Evidence for Practice

Community nurses should ask older people about falls at every routine contact, carry out a falls risk assessment for those who have fallen or have concerns, and refer people at high risk to strength and balance exercise and to occupational therapy for home assessment. Medication review, continence and postural hypotension should be addressed as part of multifactorial care. These principles build on evidence for preventing falls in hospital and are especially important for housebound patients.

Because falls prevention depends on several services working together, nurses should share risk information through care coordination with primary care, therapy and social care teams. Family members who support exercise and home changes should be involved in planning, with attention to caregiver burden, so that prevention is sustainable at home.

Conclusion

This systematic review examined the effectiveness of community-based falls prevention for older people living at home. Exercise, particularly balance and functional training, reduces falls with high certainty, and home hazard reduction is effective, especially for people at high risk and when delivered by skilled assessors. Multifactorial programmes have more modest effects.

Community nurses can make a major contribution to community-based falls prevention by finding people at risk, directing them to interventions that work and supporting them to keep going. Investment in exercise programmes, occupational therapy and clear referral pathways is needed to turn the evidence into fewer falls.

Future work should focus on reaching the people at highest risk, including those who are housebound or living with dementia, and on measuring outcomes that matter to them, such as confidence, independence and remaining at home.

References

Clemson, L., Stark, S., Pighills, A. C., Fairhall, N. J., Lamb, S. E., Ali, J., & Sherrington, C. (2023). Environmental interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, (3), CD013258. https://doi.org/10.1002/14651858.CD013258.pub2

Hopewell, S., Adedire, O., Copsey, B. J., Boniface, G. J., Sherrington, C., Clemson, L., Close, J. C. T., & Lamb, S. E. (2018). Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, (7), CD012221. https://doi.org/10.1002/14651858.CD012221.pub2

Montero-Odasso, M., van der Velde, N., Martin, F. C., et al. (2022). World guidelines for falls prevention and management for older adults: A global initiative. Age and Ageing, 51(9), afac205. https://doi.org/10.1093/ageing/afac205

Pighills, A. C., Torgerson, D. J., Sheldon, T. A., Drummond, A. E., & Bland, J. M. (2011). Environmental assessment and modification to prevent falls in older people. Journal of the American Geriatrics Society, 59(1), 26–33. https://doi.org/10.1111/j.1532-5415.2010.03221.x

Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., Michaleff, Z. A., Howard, K., Clemson, L., Hopewell, S., & Lamb, S. E. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, (1), CD012424. https://doi.org/10.1002/14651858.CD012424.pub2