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What actually reduces falls in a care facility

Written by

Dr. Gurpreet Singh Padda, MD, MBA, MHP

in

The 2025 Cochrane review pooled 104 trials and 68,964 residents. Exercise works while it is sustained; tailored, staff-engaged programs work; medication review alone does not.

Falls are the area of long-term care with the largest current randomized evidence base, which means there is very little excuse for guessing. There is also a widely repeated claim in this field that the evidence does not support, and it is one CareGuard has an interest in — so it gets stated plainly below.

Falls are the outcome that reorganizes a resident’s life

More than 25% of adults aged 65 and over fall each year, and falls are the leading cause of injury-related death in that age group. In long-term care the population is older, frailer and more cognitively impaired than the community samples those figures come from — one analysis of 282,518 assessments covering 75,132 residents found unstable health, unsteady gait, wandering and moderate to severe dependency in daily activities were the strongest risk factors, with cognitive impairment carrying a hazard ratio between 1.22 and 1.37.

What a facility can actually change

The short version, before the numbers: sustained exercise, a tailored program that staff are part of, vitamin D where levels are low, hip protectors for fracture risk, and the environmental work the safety review walks. The fall prevention items in the review.

And the claim that does not hold

That reviewing and reducing medication, on its own, reduces falls. It is intuitive, it is what a deprescribing-minded organization would like to be true, and three independent syntheses say it is not. The full numbers are below. The practical consequence is that medication review belongs inside a multifactorial program rather than instead of one — which is also what the strongest positive finding in the whole review points to.

The resourcing question nobody wants

A systematic review of complex falls-prevention interventions in residential aged care found no overall effect across seven pooled studies (mean difference −1.29, 95% CI −3.01 to 0.43) — but a sensitivity analysis found that interventions “delivered with additional resources at multiple levels had a significant positive effect in reducing fall rates” (mean difference −2.26, 95% CI −3.72 to −0.80).

That is the finding an off-site owner should read twice, because it is the one that costs money and is invisible from a monthly report. The visibility gap.

What the evidence says reduces falls in a care facility

This is one of the few areas of long-term care with a large, current randomized evidence base, and it is worth reading it accurately rather than generically. The 2025 Cochrane review of falls prevention in care facilities pooled 104 randomized trials and 68,964 residents.

  • Exercise. Active exercise probably reduces the rate of falls, rate ratio 0.68 (95% CI 0.51 to 0.91; 14 trials, 2,215 participants, moderate-certainty evidence). The same review reports high-certainty evidence that if the exercise is not sustained there is no effect (RaR 1.02, 95% CI 0.78 to 1.32). It is a program, not a course.
  • Multifactorial programs, done properly. Multifactorial interventions overall showed little or no effect on fall rate (RaR 0.87, 95% CI 0.68 to 1.12). But those that were tailored to the individual resident and engaged staff probably produce a large reduction: RaR 0.61 (95% CI 0.54 to 0.69; 7 trials, 3,553 participants, moderate certainty). The difference between those two numbers is the difference between having a falls policy and running one.
  • Vitamin D probably reduces the rate of falls, RaR 0.63 (95% CI 0.46 to 0.86; 5 trials, 4,603 participants) — but the review notes the population in those trials had low vitamin D levels.
  • Hip protectors in nursing and residential care produce a small reduction in hip fracture risk, RR 0.82 (95% CI 0.67 to 1.00), an absolute effect of about 11 fewer hip fractures per 1,000 people (14 studies, 11,808 participants, moderate quality).

The finding most often reported the wrong way round

Medication review on its own does not reduce falls. The 2025 Cochrane review found medication optimization as a single intervention may make little or no difference to the rate of falls (RaR 0.92, 95% CI 0.75 to 1.13; 13 trials, 4,314 participants, low certainty). A dedicated 2022 systematic review of 49 randomized trials reached the same conclusion and said so directly: these interventions “should not be implemented as a stand-alone strategy in falls prevention but included in multimodal strategies.” A 2021 meta-analysis of five trials of withdrawing fall-risk-increasing drugs found no change in fall rate (RaR 0.98, 95% CI 0.63 to 1.51).

CareGuard is a deprescribing-minded organization and this cuts against the easy version of that argument, so it is stated plainly. Reducing medication burden is worth doing on its own terms — for cognition, for sedation, for anticholinergic load, for the resident’s day. It is not a falls program by itself, and any facility told otherwise is being sold something.

Which drug classes the association actually implicates

The association between medications and falls is nonetheless large and well characterized. Three companion meta-analyses covering 131, 248 and 281 studies report adjusted odds ratios for a fall of 2.02 for SSRIs (95% CI 1.85 to 2.20), 1.81 for long-acting benzodiazepines (1.05 to 3.16), 1.60 for opioids (1.35 to 1.91), 1.57 for antidepressants overall (1.43 to 1.74), 1.55 for antiepileptics (1.25 to 1.92), 1.54 for antipsychotics (1.28 to 1.85), 1.42 for benzodiazepines overall (1.22 to 1.65), 1.36 for loop diuretics (1.17 to 1.57), and 1.75 for polypharmacy itself (1.27 to 2.41).

In one Japanese cohort of 459 residents (mean age 87) with 645 falls over a year, medication was judged to have influenced around three-quarters of all falls, and more than 80% of those involved psychotropic drugs.

References

  1. Dyer SM, et al. 2025. Interventions for preventing falls in older people in care facilities. Cochrane Database of Systematic Reviews. [Cochrane review, 104 RCTs, 68,964 residents] · PMID 40832852 · doi:10.1002/14651858.CD016064
  2. Cameron ID, et al. 2018. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews (9):CD005465. [Cochrane review, 95 trials, 138,164 participants] · PMID 30191554 · doi:10.1002/14651858.CD005465.pub4
  3. Colón-Emeric CS, McDermott CL, Lee DS, Berry SD 2024. Risk assessment and prevention of falls in older community-dwelling adults: a review. JAMA 331(16):1397-1406. [review of meta-analyses; community-dwelling, not long-term care] · PMID 38536167 · doi:10.1001/jama.2024.1416
  4. Francis-Coad J, et al. 2018. Effectiveness of complex falls prevention interventions in residential aged care settings: a systematic review. JBI Database of Systematic Reviews and Implementation Reports 16(4):973-1002. [systematic review and meta-analysis] · PMID 29634516 · doi:10.11124/JBISRIR-2017-003485
  5. Seppala LJ, et al. 2022. Medication reviews and deprescribing as a single intervention in falls prevention: a systematic review and meta-analysis. Age and Ageing 51(9):afac191. [systematic review and meta-analysis, 49 RCTs] · PMID 36153749 · doi:10.1093/ageing/afac191
  6. Lee J, et al. 2021. Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis. BMJ Open 11(2):e035978. [systematic review and meta-analysis, 5 RCTs] · PMID 33568364 · doi:10.1136/bmjopen-2019-035978
  7. de Vries M, et al. 2018. Fall-risk-increasing drugs: a systematic review and meta-analysis. I. Cardiovascular drugs. Journal of the American Medical Directors Association 19(4):371.e1-371.e9. [meta-analysis, 131 studies] · PMID 29396189 · doi:10.1016/j.jamda.2017.12.013
  8. Seppala LJ, et al. 2018. Fall-risk-increasing drugs: a systematic review and meta-analysis. II. Psychotropics. Journal of the American Medical Directors Association 19(4):371.e11-371.e17. [meta-analysis, 248 studies] · PMID 29402652 · doi:10.1016/j.jamda.2017.12.098
  9. Seppala LJ, et al. 2018. Fall-risk-increasing drugs: a systematic review and meta-analysis. III. Others. Journal of the American Medical Directors Association 19(4):372.e1-372.e8. [meta-analysis, 281 studies] · PMID 29402646 · doi:10.1016/j.jamda.2017.12.099
  10. Oya N, et al. 2022. Over half of falls were associated with psychotropic medication use in four nursing homes in Japan. International Journal of Environmental Research and Public Health 19(5):3123. [retrospective cohort, 459 residents] · PMID 35270813 · doi:10.3390/ijerph19053123
  11. Santesso N, et al. 2014. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews (3):CD001255. [Cochrane review, 19 studies] · PMID 24687239 · doi:10.1002/14651858.CD001255.pub5
  12. Cheung G, et al. 2024. Falls risk in long-term care residents with cognitive impairment: effects of COVID-19 pandemic. Journal of the American Medical Directors Association 25(1):177-182. [observational, 75,132 residents] · PMID 38104633 · doi:10.1016/j.jamda.2023.11.006
  13. Montero-Odasso M, et al. 2022. World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing 51(9). [consensus guideline] · PMID 36178003 · doi:10.1093/ageing/afac205

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