Draft Recommendation Statement
Falls Prevention in Community-Dwelling Older Adults: Interventions
September 26, 2017
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
The U.S. 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 balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
Falls are the leading cause of injury in adults age 65 years or older.1 Approximately one-third of community-dwelling adults age 65 years or older fall at least once per year,1 and 20% to 30% will develop moderate to severe injuries, including fractures, lacerations, and head trauma, which can potentially decrease mobility and independence.2, 3
Effective primary care interventions to prevent falls use various approaches to identify persons at increased risk. However, no instrument has been clearly identified as accurate and feasible for identifying older adults at increased risk for falls. Although many studies used a variety of risk factors and/or functional tests of gait, balance, or mobility to identify study participants, history of falls was the one factor that consistently identified persons 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 increased risk for falls. The USPSTF found adequate evidence that multifactorial 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 preventing falls in older adults.
Harms of Early Intervention
The USPSTF found adequate evidence to bound the harms of exercise and multifactorial interventions as no greater than small 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 that the overall harms of vitamin D supplementation are small to moderate; evidence suggests that the harms of vitamin D supplementation at very high dosages may be moderate.
The USPSTF concludes with moderate certainty that exercise interventions provide a moderate net benefit in preventing falls in older adults at increased risk for falls.
The USPSTF concludes with moderate certainty that multifactorial 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.
Patient Population Under Consideration
This recommendation applies to community-dwelling adults age 65 years or older.
Brief Risk Assessment
When determining to whom these recommendations apply, primary 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 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. Studies most commonly used exercise interventions that included gait, balance, and functional training components. Exercise interventions reviewed by the USPSTF also most commonly had sessions three times per week for 12 months.4 The U.S. Department of Health and Human Services recommends 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.5 It also recommends performing balance training on 3 or more days per week for older adults at risk for falls because of a recent fall or difficulty walking.5
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. In studies, nursing staff usually performed the assessment; a number of different professionals performed subsequent interventions, including nurses, clinicians, physical therapists, exercise instructors, occupational therapists, dieticians, or nutritionists. Intervention components vary based on the initial assessment and could include group or individual exercise, psychological interventions (cognitive behavioral therapy), nutrition therapy, education, medication management, urinary incontinence management, environmental modification, physical or occupational therapy, social or community services, and referral to specialists (e.g., ophthalmologist, neurologist, or cardiologist).
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 intervention: environmental modification, medication management, psychological interventions, and combination interventions that are not customized to an individual risk profile.
Fractures are an important injury associated with falls, and the USPSTF has issued two related recommendation statements on the prevention of fractures. The USPSTF recommends screening for osteoporosis in women age 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors.6 The USPSTF is currently updating its recommendation on vitamin D and calcium supplementation to prevent fractures. In the draft recommendation statement, 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 postmenopausal women at doses greater than 400 IU of vitamin D and greater than 1,000 mg of calcium; the USPSTF recommends against supplementation with 400 IU or less of vitamin D or 1,000 mg or less of calcium in postmenopausal women.7
The Centers for Disease Control and Prevention has published guidance on implementing community-based interventions to prevent falls.8
Although the evidence does not support routinely performing an in-depth multifactorial risk assessment with comprehensive management in all older adults, there may be reasons for providing 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 medical conditions. The American Geriatric Society (AGS) recommends multifactorial risk assessment with multicomponent interventions in older adults who have had two falls in the past year (one fall if combined with gait or balance problems), have gait or balance problems, or present with an acute fall.9 According to AGS, evaluation of balance and mobility, vision, and orthostatic or postural hypotension are effective components of multifactorial risk assessment with comprehensive management, as well as review of medication use and home environment.9 Followup and comprehensive management of identified risk factors are essential to the effectiveness 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 socialization 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 (i.e., multiplicity) of predisposing factors, and their additive or synergistic nature, the effectiveness of other interventions is not known. However, many interventions 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 psychological interventions.
Burden of Disease
In 2014, approximately 2.8 million older adults sought treatment in emergency departments for falls; approximately 800,000 of older adults experiencing a fall were hospitalized, and more than 27,000 older adults died from a fall.1, 10 More than 90% of hip fractures are caused by falls, and 25% of older adults who sustain a hip fracture die within 6 months.11, 12 Risk for falls increases with age; in 2014, 27% of adults ages 65 to 74 years and 37% of adults age 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 interventions to prevent falls and fall-related morbidity and mortality in community-dwelling older adults age 65 years or older.4 Interventions that included physical therapy were considered to be exercise interventions. Studies conducted solely in populations with specific medical diagnoses that could affect fall-related outcomes or for which interventions could be considered disease management (e.g., osteoporosis, vitamin D deficiency, and neurocognitive disorders) were excluded.
Brief Risk Assessment
The majority of intervention studies (40/62) reviewed by the USPSTF targeted patients at high risk for falls.4 However, studies used variable approaches to identify high-risk patients. Most commonly, studies used history of prior falls to identify persons at high risk for future falls (16 studies).4 Other trials evaluated two 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 commonly used physical function/mobility limitation problems to identify high-risk populations. Therefore, history of prior falls or physical function/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 multifactorial interventions, exercise, vitamin D supplementation, environmental modifications, psychological interventions, and multiple interventions to prevent falls and fall-related morbidity and mortality.4 The USPSTF focused on the outcomes of reductions in falls, number of persons experiencing a fall, reductions in injurious falls, and number of persons experiencing an injurious fall. Although many studies reported on mortality, 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 difference in these two outcomes. The most commonly reported interventions included multifactorial interventions (26 trials), exercise (21 trials), and vitamin D supplementation (seven trials).
The USPSTF found five good-quality and 16 fair-quality studies (n=7,297) reporting on various exercise interventions to prevent falls.4 A little more than half of studies (12/21) recruited populations at high risk for falls. Physical function/mobility limitation problems, either 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 1,635 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 one study in which 42% of participants were women. Only three studies reported the race/ethnicity of study participants, which was almost exclusively white. Three studies were conducted in the United States, one study in the United Kingdom, eight studies in other parts of Europe, seven studies in Australia or New Zealand, and two studies in Asia.
Studies found that exercise improved several fall-related outcomes. Based on pooled analyses of 15 studies (n=4,926), exercise interventions reduced the number of persons experiencing a fall (relative risk [RR], 0.89 [95% confidence interval (CI), 0.81 to 0.97]).4 Pooled analyses from 10 studies (n=4,622) 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]).4 Although not statistically significant, pooled analyses of 14 studies (n=4,663) revealed a reduction in the number of falls experienced by participants undergoing exercise interventions (IRR, 0.87 [95% CI, 0.75 to 1.00]).4 Given the heterogeneity of included interventions, it is difficult to identify specific components of exercise that are particularly efficacious. Most of the exercise interventions included group exercise (15 trials), and the duration of exercise programs ranged from 2 to 42 months, with exercise sessions occurring most commonly three times per week (seven trials). The most common exercise component was gait, balance, and functional training (17 trials), followed by resistance training (13 trials), flexibility (eight trials), and endurance training (five trials). Three studies included tai chi and five studies included general physical activity.
Seven good-quality and 19 fair-quality studies (n=15,506) reported on multifactorial interventions.4 Most 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 5,310 and the mean age ranged from 71.9 to 85.0 years. The percentage of women participants ranged from 53.2% to 94.0%. Race/ethnicity of study participants was reported in only one 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, they did not appear to improve other fall-related outcomes. Pooled analyses found reductions in the number of falls among participants who received multifactorial interventions (IRR, 0.79 [95% CI, 0.68 to 0.91]; k=17; n=9,737) but not in the number of persons experiencing a fall (RR, 0.95 [95% CI, 0.89 to 1.01]; k=24; n=12,490) or experiencing an injurious fall (RR, 0.94 [95% CI, 0.85 to 1.03]; k=16; n=9,445).4 Of nine studies (n=4,306) reporting the number of injurious falls, only one reported a statistically significant reduction among participants receiving multifactorial interventions.4 Given that studies used heterogeneous multifactorial interventions, it is difficult to identify specific components 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 assessment 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, psychological interventions, nutrition therapy, knowledge, medication management, urinary incontinence management, environmental modification, and referrals to physical or occupational therapy, social or community services, or specialists (e.g., ophthalmologist, neurologist, or cardiologist). Most studies referred participants to or offered an exercise or physical therapy intervention. The majority of studies included home visits for the initial assessment, environmental modification, or physical therapy/exercise interventions; other services were conducted in outpatient settings. Total contact time was rarely reported, precluding quantification of intervention intensity.
Vitamin D Supplementation
Four good-quality and three fair-quality studies (n=7,531) reported on the effect of vitamin D supplementation on the prevention of falls in community-dwelling older adults.4 Three 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 age 60 years or older. The number of participants ranged from 204 to 3,314 and the mean age ranged from 71.0 to 76.8 years. Five studies were conducted exclusively in women; women comprised approximately half of the study population in the other two studies. Only three studies reported the race/ethnicity of participants, which was almost exclusively white. Two trials were conducted in the United States, two in Australia, and one each in the United Kingdom, Switzerland, and Finland.
Five trials (n=3,496) reported mixed findings.4 Only one trial showed a statistically significant reduction in falls4, 13; however, another study using high doses of vitamin D (500,000 IU per year) showed a statistically significant increase in falls.4, 14 Pooled analyses showed neither a significant reduction in falls (IRR, 0.97 [95% CI, 0.79 to 1.20]; k=5; n=3,496) nor a significant effect on the number of persons experiencing a fall with vitamin D supplementation (RR, 0.97 [95% CI, 0.88 to 1.08]).4 Only two trials reported on the number of injurious falls; one study using an annual high dose of vitamin D reported an increase in injurious falls (IRR, 1.15 [95% CI, 1.02 to 1.29]),4, 14 and the other trial reported no statistically significant difference (IRR, 0.84 [95% CI, 0.45 to 1.57]).4, 15 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; one trial used 1-hydroxycholecalciferol (1 μg per day) and another used calcitriol (0.25 μg twice per day).4
The USPSTF found evidence on other interventions, including environmental modification (three studies; n=2,175), medication management (two studies; n=266), psychological interventions (two studies; n=929), and multiple interventions (six studies; n=1,770).4 Multiple interventions provided at least two intervention components to participants but were not customized to individual participants. Studies of these other interventions were too few, too small, and too heterogeneous for the USPSTF to draw any definitive conclusions.
Potential Harms of Preventive Measures
Evidence on harms was reported in a subset of trials reporting on the effectiveness of interventions. Eight studies (n=4,107) evaluating exercise interventions reported on harms; in general, adverse events were minor.4 The most common adverse events included pain or bruising related to exercise. One study reported one wrist fracture in the intervention group,16 and another study reported a rate of 2.6 serious fall injuries per 100,000 physical activity sessions.17 Only two trials reported on harms in control groups for comparison and found no between-group difference in the rate of serious injuries.4 For multifactorial interventions, four studies (n=1,466) reported on harms.4 In general, reported harms were rare, minor, and associated with the exercise component of the intervention. Five studies (n=3,955) on vitamin D supplementation reported no difference in the frequency of harms between intervention and control groups.4 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 persons experiencing falls.14 Other 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. However, in a separate evidence review commissioned by the USPSTF on vitamin D supplementation to prevent fractures, the incidence of kidney stones increased with combined vitamin D and calcium supplementation (based on evidence from three studies, including the large Women’s Health Initiative trial).18 Three studies (n=810) on multiple interventions reported no adverse or severe adverse events, although ascertainment of adverse events was unclear.4 One study on a single psychological intervention reported no adverse events or side effects.19 The remaining 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 several 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 interventions reduce the risk for falls by a small amount. Pooled analyses revealed statistically significant reductions in one fall-related outcome (number of falls) but not others (e.g., 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 reduction of falls.
The USPSTF found adequate evidence that vitamin D supplementation 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 evidence that the harms of vitamin D supplementation are small to moderate. A study of annual high-dose vitamin D supplementation showed an increase in falls. Adequate evidence from a separate evidence review on vitamin D supplementation found an increase in the incidence of kidney stones with combined vitamin D and calcium supplementation. The USPSTF concludes with moderate certainty 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 multifactorial risk assessment with comprehensive management is effective in preventing falls. Vitamin D receptors have been identified in various cell types, including skeletal muscle, and stimulation of these receptors promotes protein synthesis.20, 21 Although it has been previously demonstrated that vitamin D or its metabolites may have a beneficial effect on muscle strength and balance,22 the current evidence shows no benefit in preventing falls. In addition, the Institute of Medicine (now the National Academy of Medicine) concluded that there may be a potential U-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.23
The USPSTF last issued a recommendation on interventions to prevent falls in older adults in 2012. At that time, consistent with the current recommendation statement, the USPSTF recommended exercise (B recommendation) and selectively offering multifactorial interventions (C recommendation) to prevent falls in community-dwelling older adults at increased risk for falls. At that time, the 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 current review excluded studies considered in the previous review that enrolled persons with vitamin D deficiency or insufficiency because, upon further consideration, vitamin D interventions in these populations would be considered treatment rather than prevention. In addition, the current review looked at additional fall-related outcomes, including incident falls (in addition to the number 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 older community-dwelling adults.
The Centers for Disease Control and Prevention maintains a compendium of effective fall interventions in the following four categories: exercise-based, home modification for hazard reduction, clinical, and multifaceted (including medical screening for vision impairment and medication review).24 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.25 According to the AGS, detecting a history of falls is fundamental to a falls reduction program, and it recommends asking all older adults once a year about falls.9 It further recommends that older persons who have experienced a fall should have their gait and balance assessed using one of the available evaluations; those who cannot perform or perform poorly on a standardized gait and balance test should be given a multifactorial fall risk assessment that includes a focused medical history, physical examination, functional assessment, and an environmental assessment. The AGS also recommends the following interventions for falls prevention: adaptation or modification of home environment; withdrawal or minimization of psychoactive or other medications; management of postural hypotension; management of foot problems and footwear; 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.
Similar 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 age 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 comprehensive management of identified risks.26
- Bergen G, Stevens MR, Burns ER. Falls and fall injuries among adults aged ≥65 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(37):993-8.
- Sterling DA, O'Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. J Trauma. 2001;50(1):116-9.
- Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health. 1992;82(7):1020-3.
- Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL, Thompson JH. Interventions to Prevent Falls in Older Adults: A Systematic Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 159. AHRQ Publication No. 17-05232-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2017.
- U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services; 2008.
- U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2011;154(5):356-64.
- U.S. Preventive Services Task Force. Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures: U.S. Preventive Services Task Force Draft Recommendation Statement. Rockville, MD: U.S. Preventive Services Task Force; 2017.
- National Center for Injury Prevention and Control. Preventing Falls: A Guide to Implementing Effective Community-Based Fall Prevention Programs. 2nd ed. Atlanta: Centers for Disease Control and Prevention; 2015.
- Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):148-57.
- Kochanek KD, Murphy SL, Xu J, Tejada-Vera B. Deaths: final data for 2014. Natl Vital Stat Rep. 2016;65(4):1-122.
- Parkkari J, Kannus P, Palvanen M, et al. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int. 1999;65(3):183-7.
- Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159-68, 2173-4.
- Gallagher JC, Fowler SE, Detter JR, Sherman SS. Combination treatment with estrogen and calcitriol in the prevention of age-related bone loss. J Clin Endocrinol Metab. 2001;86(8):3618-28.
- Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010;303(18):1815-22.
- Uusi-Rasi K, Patil R, Karinkanta S, et al. Exercise and vitamin D in fall prevention among older women: a randomized clinical trial. JAMA Intern Med. 2015;175(5):703-11.
- El-Khoury F, Cassou B, Latouche A, Aegerter P, Charles MA, Dargent-Molina P. Effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossébo randomised controlled trial. BMJ. 2015;351:h3830.
- Gill TM, Pahor M, Guralnik JM, et al; LIFE Study Investigators. Effect of structured physical activity on prevention of serious fall injuries in adults aged 70-89: randomized clinical trial (LIFE Study). BMJ. 2016;352:i245.
- Kahwati LC, Weber RP, Pan H, et al. Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Adults: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 160. AHRQ Publication No. 17-05233-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2017.
- Zijlstra GA, van Haastregt JC, Ambergen T, et al. Effects of a multicomponent cognitive behavioral group intervention on fear of falling and activity avoidance in community-dwelling older adults: results of a randomized controlled trial. J Am Geriatr Soc. 2009;57(11):2020-8.
- Pike JW. Closing in on vitamin D action in skeletal muscle: early activity in muscle stem cells? Endocrinology. 2016;157(1):48-51.
- Pojednic RM, Ceglia L, Olsson K, et al. Effects of 1,25-dihydroxyvitamin D3 and vitamin D3 on the expression of the vitamin D receptor in human skeletal muscle cells. Calcif Tissue Int. 2015;96(3):256-63.
- Bischoff-Ferrari HA, Orav EJ, Dawson-Hughes B. Effect of cholecalciferol plus calcium on falling in ambulatory older men and women: a 3-year randomized controlled trial. Arch Intern Med. 2006;166(4):424-30.
- Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011.
- Stevens JA, Burns ER. A CDC Compendium of Effective Fall Interventions: What Works for Community-Dwelling Older Adults. 3rd ed. Atlanta: Centers for Disease Control and Prevention; 2015.
- National Institute on Aging. Prevent falls and fractures. 2017. https://www.nia.nih.gov/health/prevent-falls-and-fractures. Accessed September 8, 2017.
- American Academy of Family Physicians. Clinical preventive service recommendation: fall prevention in older adults. 2012. http://www.aafp.org/patient-care/clinical-recommendations/all/fall-prevention.html. Accessed September 8, 2017.