This meta-analysis of risk factors for falls found ORs around 2–3 for history of falls, vertigo, Parkinson disease, fear of falling, gait problems, use of walking aids, and use of antiepileptic drugs. For most other factors considered, ORs were less than 2. ORs were generally higher for recurrent fallers than for all fallers.
Although many studies have investigated risk factors for falls, a comprehensive and quantitative summary has been lacking. We included only studies with a prospective design to avoid problems of reverse causality, given that some factors (eg, fear of falling) are consequences as well as risk factors for falls. A prospective design ensures that the exposure was measured before the occurrence of the outcome. We excluded cohorts with fewer than 200 subjects to avoid studies based only on a small number of outcomes or very few exposed subjects.
Several of the studies presented crude ORs only. To investigate the role of possible confounders on the association between each factor and the risk of falling, we also calculated pooled ORs based on studies in which the OR was adjusted at least for age and sex, and other potential confounders when possible. In the 2003 review of risk factors,9 studies presenting adjusted ORs were given greater consideration. Given the strong possibility of confounding by age and sex, as well as by other correlated factors, adjusted ORs are clearly more reliable. The use of adequate statistical techniques is a further indicator of better quality of the study. However, it is also possible that in some studies a number of risk factors were investigated, and that the ones included in the multivariate analyses were only those significantly associated in the univariate ones. Considering only studies presenting adjusted ORs may thus lead to an overestimation of the overall OR. Moreover, in some instances, there were only 1 or 2 studies presenting multivariate results. In any case, the difference between the pooled estimate based on all individual ORs and the one based only on adjusted ORs was not substantial for most factors, although the pooled adjusted estimates tended to have wider confidence intervals, given that these were generally based on fewer studies. A notable exception was cognition impairment, for which multivariate ORs were higher than univariate ones for both outcomes.
When interpreting the results from this meta-analysis, one must consider the issue of heterogeneity among studies, which was substantial for some—but not all—factors. A higher heterogeneity leads to wider confidence intervals, since a random-effects model was used. For this reason, in evaluating the strength of the association of each factor with the risk of falling, one should consider the whole confidence interval of the summary OR, rather than the point estimate only. From the 31 risk factors considered, the P value of the heterogeneity test in the overall analysis was <0.10 in 23 cases for all fallers and in 19 cases for recurrent fallers. In most instances, however, results were fairly consistent in the direction of the effect (ie, pointing toward an increase or decrease in risk), even though studies differed in the estimation of the effect size. (See forest plots in eAppendix 1 [http://links.lww.com/EDE/A404]). The subgroup analyses in eAppendix 2 (http://links.lww.com/EDE/A404) explored the role of some characteristics of studies in explaining heterogeneous results. Other characteristics (eg, other design or population issues, including methodologic limitations and biases) may further explain differences in results.
Despite these potential limitations, some clear associations emerged from this analysis.
This review underscores the plethora of factors that affect the risk of falling, with a weak or moderate OR for most (generally below 2). Although most associations are not large, these factors are common in the older population, and often a person presents several factors, thus being at considerable risk of falling.
The estimated ORs were generally higher for “recurrent fallers” than for “all fallers,” indicating that the subjects who experience more than one fall are a distinct risk group. Although one fall may occur by chance alone, the repetition of the event suggests an underlying high-risk state.
Some nonspecific indicators of a high baseline risk (history of falls, fear of falling, and use of walking aids) were associated with about a 3-fold risk of falling. These factors cannot be prevented, but they may help identify persons at high risk of falling and thus likely to benefit most from preventive interventions.
Other factors showing ORs around 2 were dizziness and vertigo, gait problems, and antiepileptic drug use, plus cognition impairment when adjusted ORs only were considered. Prescriptions of newer antiepileptic drugs have been increasing in recent years in several countries, particularly for the treatment of pain.89 There is a need to explore the increased risk of falls by type of drug, given that falls may be an important adverse event that must be considered when deciding the treatment of pain in older people.
Several potentially relevant factors were not addressed in this study, either because they were considered by too few studies (eg, anemia, hypovitaminosis D, use of antidepressants, antipsychotics or insulin, footwear, use of bifocal lenses) or because the risk factor was measured in noncomparable ways (eg, muscle weakness, balance impairment, environmental hazards). For the first group of factors, there is a need for further studies to explore these associations. In the second group, there is a need for consensus on measures to evaluate the factor, to improve comparability among studies. For example, the Prevention of Falls Network Europe identified over 30 different measures of balance within the European Union (http://www.profane.eu.org/eu_map/index.php). The same problem was raised by a recent review on exercise for improving balance in older people performed within the framework of the Cochrane Collaboration.90 The authors recommended “a consensus of outcome measures for evaluating the effects of interventions of balance ability” and, we add, for the evaluation of balance ability in older people in general. With regard to muscle weakness, some studies measured upper-limb muscle strength and others lower-limb strength, using different methods, with none of the measures used in at least 5 studies.
This meta-analysis provides the first comprehensive evidence-based assessment of risk factors in community-dwelling older people. It shows the need for improved quality in reporting studies on risk factors in older people, as well as for further research on potentially important neglected factors, and for improvements in comparability of risk-factor measurement.
We thank Ivana Garimoldi for her editorial assistance.
1.Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med.
2.Lord SR, Sherrington C, Menz HB. Falls in Older People: Risk Factors and Strategies for Prevention
. 2nd ed. Cambridge, MA: Cambridge University Press; 2007.
3.Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis: part I. Psychotropic drugs. J Am Geriatr Soc.
4.Moreland JD, Richardson JA, Goldsmith CH, Clase CM. Muscle weakness and falls in older adults: a systematic review and meta-analysis. J Am Geriatr Soc.
5.American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc.
6.Connell BR. Role of the environment in falls prevention. Clin Geriatr Med.
7.Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? JAMA.
8.Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci.
9.NICE. The Assessment and Prevention of Falls in Older People Clinical Practice Guideline
. London: Royal College of Nursing; 2004.
10.Perell KL, Nelson A, Goldman RL, Luther SL, Prieto-Lewis N, Rubenstein LZ. Fall risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci.
11.Rawsky E. Review of the literature on falls among the elderly. Image J Nurs Sch.
12.Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol.
13.DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials.
14.Cawthon PM, Harrison SL, Barrett-Connor E, et al. Alcohol intake and its relationship with bone mineral density, falls, and fracture risk in older men. J Am Geriatr Soc.
15.Chu LW, Chi I, Chiu AY. Incidence and predictors of falls in the Chinese elderly. Ann Acad Med Singapore.
16.Coleman AL, Stone K, Ewing SK, et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology.
17.Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls: a prospective study. JAMA.
18.Northridge ME, Nevitt MC, Kelsey JL, Link B. Home hazards and falls in the elderly: the role of health and functional status. Am J Public Health.
19.Vellas BJ, Wayne SJ, Garry PJ, Baumgartner RN. A two-year longitudinal study of falls in 482 community-dwelling elderly adults. J Gerontol A Biol Sci Med Sci.
20.Cesari M, Landi F, Torre S, Onder G, Lattanzio F, Bernabei R. Prevalence and risk factors for falls in an older community-dwelling population. J Gerontol A Biol Sci Med Sci.
21.Covinsky KE, Kahana E, Kahana B, Kercher K, Schumacher JG, Justice AC. History and mobility exam index to identify community-dwelling elderly persons at risk of falling. J Gerontol A Biol Sci Med Sci.
22.Cumming RG, Salkeld G, Thomas M, Szonyi G. Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci.
23.Gill TM, Williams CS, Tinetti ME. Environmental hazards and the risk of nonsyncopal falls in the homes of community-living older persons. Med Care.
24.Leveille SG, Bean J, Bandeen-Roche K, Jones R, Hochberg M, Guralnik JM. Musculoskeletal pain and risk for falls in older disabled women living in the community. J Am Geriatr Soc.
25.Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc.
26.Northridge ME, Nevitt MC, Kelsey JL. Non-syncopal falls in the elderly in relation to home environments. Osteoporos Int.
27.O'Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol.
28.Tinetti ME, Inouye SK, Gill TM, Doucette JT. Shared risk factors for falls, incontinence, and functional dependence. Unifying the approach to geriatric syndromes. JAMA.
29.Tromp AM, Smit JH, Deeg DJ, Bouter LM, Lips P. Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. J Bone Miner Res.
30.Brown JS, Vittinghoff E, Wyman JF, et al. Study of Osteoporotic Fractures Research Group. Urinary incontinence: does it increase risk for falls and fractures? J Am Geriatr Soc.
31.Friedman SM, Munoz B, West SK, Rubin GS, Fried LP. Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. J Am Geriatr Soc.
32.Ensrud KE, Blackwell TL, Mangione CM, et al. Central nervous system-active medications and risk for falls in older women. J Am Geriatr Soc.
33.Stalenhoef PA, Diederiks JP, Knottnerus JA, Kester AD, Crebolder HF. A risk model for the prediction of recurrent falls in community-dwelling elderly: a prospective cohort study. J Clin Epidemiol.
34.Perracini MR, Ramos LR. Fall-related factors in a cohort of elderly community residents [in Portuguese]. Rev Saude Publica.
35.Faulkner KA, Cauley JA, Zmuda JM, et al. Higher 1,25-dihydroxyvitamin D3 concentrations associated with lower fall rates in older community-dwelling women. Osteoporos Int.
36.Orwoll E, Lambert LC, Marshall LM, et al. Endogenous testosterone levels, physical performance, and fall risk in older men. Arch Intern Med.
37.Pajala S, Era P, Koskenvuo M, Kaprio J, Viljanen A, Rantanen T. Genetic factors and susceptibility to falls in older women. J Am Geriatr Soc.
38.Salva A, Bolibar I, Pera G, Arias C. Incidence and consequences of falls among elderly people living in the community. Med Clin (Barc).
39.Schaap LA, Pluijm SM, Smit JH, et al. The association of sex hormone levels with poor mobility, low muscle strength and incidence of falls among older men and women. Clin Endocrinol (Oxf).
40.Snijder MB, van Schoor NM, Pluijm SM, van Dam RM, Visser M, Lips P. Vitamin D status in relation to one-year risk of recurrent falling in older men and women. J Clin Endocrinol Metab.
41.Stel VS, Smit JH, Pluijm SM, Lips P. Balance and mobility performance as treatable risk factors for recurrent falling in older persons. J Clin Epidemiol.
42.Stone KL, Ewing SK, Lui LY, et al. Self-reported sleep and nap habits and risk of falls and fractures in older women: the study of osteoporotic fractures. J Am Geriatr Soc.
43.Teno J, Kiel DP, Mor V. Multiple stumbles: a risk factor for falls in community-dwelling elderly: a prospective study. J Am Geriatr Soc.
44.Cauley JA, Cummings SR, Seeley DG, et al. The Study of Osteoporotic Fractures Research Group. Effects of thiazide diuretic therapy on bone mass, fractures, and falls. Ann Intern Med.
45.Tromp AM, Pluijm SM, Smit JH, Deeg DJ, Bouter LM, Lips P. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol.
46.van Schoor NM, Smit JH, Pluijm SM, Jonker C, Lips P. Different cognitive functions in relation to falls among older persons. Immediate memory as an independent risk factor for falls. J Clin Epidemiol.
47.Bergland A, Jarnlo GB, Laake K. Predictors of falls in the elderly by location. Aging Clin Exp Res.
48.Penninx BW, Pluijm SM, Lips P, et al. Late-life anemia is associated with increased risk of recurrent falls. J Am Geriatr Soc.
49.Graafmans WC, Ooms ME, Hofstee HM, Bezemer PD, Bouter LM, Lips P. Falls in the elderly: a prospective study of risk factors and risk profiles. Am J Epidemiol.
50.Bootsma-van der Wiel A, Gussekloo J, de Craen AJ, van Exel E, Bloem BR, Westendorp RG. Walking and talking as predictors of falls in the general population: the Leiden 85-Plus Study. J Am Geriatr Soc.
51.Mahoney J, Sager M, Dunham NC, Johnson J. Risk of falls after hospital discharge. J Am Geriatr Soc.
52.Duncan PW, Studenski S, Chandler J, Prescott B. Functional reach: predictive validity in a sample of elderly male veterans. J Gerontol.
53.Arden NK, Nevitt MC, Lane NE, et al. Study of Osteoporotic Fractures Research Group. Osteoarthritis and risk of falls, rates of bone loss, and osteoporotic fractures. Arthritis Rheum.
54.Luukinen H, Koski K, Laippala P, Kivela SL. Predictors for recurrent falls among the home-dwelling elderly. Scand J Prim Health Care.
55.Luukinen H, Koski K, Kivela SL, Laippala P. Social status, life changes, housing conditions, health, functional abilities and life-style as risk factors for recurrent falls among the home-dwelling elderly. Public Health.
56.Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med.
57.Weiner DK, Hanlon JT, Studenski SA. Effects of central nervous system polypharmacy on falls liability in community-dwelling elderly. Gerontology.
58.Lord SR, Ward JA, Williams P, Anstey KJ. Physiological factors associated with falls in older community-dwelling women. J Am Geriatr Soc.
59.Visvanathan R, Macintosh C, Callary M, Penhall R, Horowitz M, Chapman I. The nutritional status of 250 older Australian recipients of domiciliary care services and its association with outcomes at 12 months. J Am Geriatr Soc.
60.Stel VS, Pluijm SM, Deeg DJ, Smit JH, Bouter LM, Lips P. A classification tree for predicting recurrent falling in community-dwelling older persons. J Am Geriatr Soc.
61.Schwartz AV, Hillier TA, Sellmeyer DE, et al. Older women with diabetes have a higher risk of falls: a prospective study. Diabetes Care.
62.Fink HA, Kuskowski MA, Orwoll ES, Cauley JA, Ensrud KE. Association between Parkinson's disease and low bone density and falls in older men: the osteoporotic fractures in men study. J Am Geriatr Soc.
63.Mukamal KJ, Mittleman MA, Longstreth WT Jr, Newman AB, Fried LP, Siscovick DS. Self-reported alcohol consumption and falls in older adults: cross-sectional and longitudinal analyses of the cardiovascular health study. J Am Geriatr Soc.
64.Biderman A, Cwikel J, Fried AV, Galinsky D. Depression and falls among community dwelling elderly people: a search for common risk factors. J Epidemiol Community Health.
65.Delbaere K, Crombez G, Van Den Noortgate N, Willems T, Cambier D. The risk of being fearful or fearless of falls in older people: an empirical validation. Disabil Rehabil.
66.Delbaere K, Van den Noortgate N, Bourgois J, Vanderstraeten G, Tine W, Cambier D. The Physical Performance Test as a predictor of frequent fallers: a prospective community-based cohort study. Clin Rehabil.
67.Gallagher JC, Rapuri PB, Smith LM. An age-related decrease in creatinine clearance is associated with an increase in number of falls in untreated women but not in women receiving calcitriol treatment. J Clin Endocrinol Metab.
68.Gerdhem P, Ringsberg KA, Akesson K, Obrant KJ. Clinical history and biologic age predicted falls better than objective functional tests. J Clin Epidemiol.
69.Hanlon JT, Landerman LR, Fillenbaum GG, Studenski S. Falls in African American and white community-dwelling elderly residents. J Gerontol A Biol Sci Med Sci.
70.Pluijm SM, Smit JH, Tromp EA, et al. A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study. Osteoporos Int.
71.Reyes-Ortiz CA, Al Snih S, Loera J, Ray LA, Markides K. Risk factors for falling in older Mexican Americans. Ethn Dis.
72.van Bemmel T, Vandenbroucke JP, Westendorp RG, Gussekloo J. In an observational study elderly patients had an increased risk of falling due to home hazards. J Clin Epidemiol.
73.Capon A, Di Lallo D, Mastromattei A, Pavoni N, Simeoni S. Incidence and risk factors for accidental falls among general practice elderly patients in Latina, Central Italy [in Italian]. Epidemiol Prev.
74.Coleman AL, Cummings SR, Yu F, et al. Binocular visual-field loss increases the risk of future falls in older white women. J Am Geriatr Soc.
75.Heesch KC, Byles JE, Brown WJ. Prospective association between physical activity and falls in community-dwelling older women. J Epidemiol Community Health.
76.van der Velde N, Stricker BH, Roelandt JR, Ten Cate FJ, van der Cammen TJ. Can echocardiographic findings predict falls in older persons? PLoS ONE.
77.Bischoff-Ferrari HA, Orav EJ, Dawson-Hughes B. Additive benefit of higher testosterone levels and vitamin D plus calcium supplementation in regard to fall risk reduction among older men and women. Osteoporos Int.
78.Clough-Gorr KM, Erpen T, Gillmann G, et al. Preclinical disability as a risk factor for falls in community-dwelling older adults. J Gerontol A Biol Sci Med Sci.
79.Ensrud KE, Ewing SK, Taylor BC, et al. Frailty and risk of falls, fracture, and mortality in older women: the study of osteoporotic fractures. J Gerontol A Biol Sci Med Sci.
80.Gassmann KG, Rupprecht R, Freiberger E. Predictors for occasional and recurrent falls in community-dwelling older people. Z Gerontol Geriatr.
81.Knudtson MD, Klein BE, Klein R. Biomarkers of aging and falling: The Beaver Dam eye study. Arch Gerontol Geriatr.
82.Leclerc BS, Begin C, Cadieux E, et al. Risk factors for falling among community-dwelling seniors using home-care services: an extended hazards model with time-dependent covariates and multiple events. Chronic Dis Can.
83.Pajala S, Era P, Koskenvuo M, Kaprio J, Tormakangas T, Rantanen T. Force platform balance measures as predictors of indoor and outdoor falls in community-dwelling women aged 63–76 years. J Gerontol A Biol Sci Med Sci.
84.Stone KL, Ancoli-Israel S, Blackwell T, et al. Actigraphy-measured sleep characteristics and risk of falls in older women. Arch Intern Med.
85.Iinattiniemi S, Jokelainen J, Luukinen H. Falls risk among a very old home-dwelling population. Scand J Prim Health Care.
86.Kulmala J, Viljanen A, Sipila S, et al. Poor vision accompanied with other sensory impairments as a predictor of falls in older women. Age Ageing.
87.Srikanth V, Beare R, Blizzard L, et al. Cerebral white matter lesions, gait, and the risk of incident falls: a prospective population-based study. Stroke.
88.Cummings SR, Nevitt MC, Kidd S. Forgetting falls: the limited accuracy of recall of falls in the elderly. J Am Geriatr Soc.
89.Savica R, Beghi E, Mazzaglia G, et al. Prescribing patterns of antiepileptic drugs in Italy: a nationwide population-based study in the years 2000–2005. Eur J Neurol.
90.Howe TE, Rochester L, Jackson A, Banks PM, Blair VA. Exercise for improving balance in older people. Cochrane Database Syst Rev