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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 2  |  Page : 58-67

Factors contributing to falls and the effect of a multipronged approach on the incidence of falls in the older person in an outpatient setting in South India


Department of Geriatrics, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission14-Mar-2022
Date of Decision07-May-2022
Date of Acceptance20-May-2022
Date of Web Publication15-Jul-2022

Correspondence Address:
Jini Chirackel Thomas
Department of Geriatrics, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_13_22

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  Abstract 


Background: A fall is an important predictor of morbidity and mortality in an older adult. Objectives: The aim of this study was to enumerate the various factors contributing to falls and assess the effect of a multipronged approach on the incidence of falls in older individuals who are at a risk of falls. Methodology: In this prospective interventional trial, we recruited sixty subjects, who presented to the Geriatrics Outpatient department of a tertiary care hospital in South India. Using the Stop elderly accidents, deaths, and injuries protocol, we included subjects who presented with a history of fall in the year preceding the study, those with fear of fall and those who felt unsteady while standing or walking. These subjects were subjected to a detailed assessment and an individualized multipronged interventional program was initiated. The subjects were followed up telephonically after 1 and 3 months to assess compliance and the details of incident fall (if any). Results: At baseline, 48.3% had fallen in the year prior to enrolment, of whom 16.7% were recurrent fallers. Various contributory factors for falls were identified - including older age, polypharmacy, sedatives, and anticholinergic drugs. Following a multipronged intervention, 3.6% and 5.3% of the subjects reported falls after 1 and 3 months, respectively. Subjective improvement was reported by 80% and 78.2% of the subjects at 1 and 3 months' follow-up and the compliance with exercises during the follow-up period was good (73%). Conclusion: Identifying the subjects at risk for falls and implementing a tailored approach contributed to a reduction in the incidence of falls.

Keywords: Falls, fear of fall, gait speed, older people


How to cite this article:
Thomas JC, Viggeswarpu S. Factors contributing to falls and the effect of a multipronged approach on the incidence of falls in the older person in an outpatient setting in South India. J Indian Acad Geriatr 2022;18:58-67

How to cite this URL:
Thomas JC, Viggeswarpu S. Factors contributing to falls and the effect of a multipronged approach on the incidence of falls in the older person in an outpatient setting in South India. J Indian Acad Geriatr [serial online] 2022 [cited 2022 Aug 18];18:58-67. Available from: http://www.jiag.com/text.asp?2022/18/2/58/351067




  Introduction Top


A fall is defined as “an unintentional event in which a person comes to rest on the floor or ground that is not caused by loss of consciousness, stroke, seizure, or overwhelming force.”[1],[2] A fall often contributes to morbidity and mortality in the older person.[3] The prevalence of a fall increases as one ages, as problems with vision, balance, and musculoskeletal integrity set in. This is considered a marker of declining function and poor health and results in injuries, disabilities, pain, prolonged immobilization, increase in caretaker burden, and a heightened risk of institutionalization in older people.

Among community-dwelling adults over the age of 65 years, the prevalence of a fall is about 30%–40%.[4] In India, the prevalence of falls among older adults is reported to be between 14% and 53%.[5] Published multifactorial interventions address the modifiable factors for falls.[6] In the present study, we looked at the various intrinsic and extrinsic factors which contributed to a fall in the older person and initiated an appropriate, individualized, multifactorial intervention program. Our goal was to send every patient back to a safe environment with a reduced falls risk.


  Methodology Top


This was a prospective interventional trial done over a period of 10 months from October 2017 to July 2018. Consenting participants, aged 60 years and above, who presented to the Geriatrics Outpatient in a tertiary center in South India were included in the study. The study was approved by the Institutional Review Board.

We used the stop elderly accidents, deaths, and injuries toolkit, developed by the Center for Disease Control and Prevention, for identifying the older persons at risk for falls. Subjects who responded with a “Yes” to any one of the followings:

  • Fear of fall
  • Imbalance or feeling unsteady while standing or walking
  • Presented with a fall or had a history of falls in the past 1 year was recruited for the study.


Subjects with severe neurodegenerative, musculoskeletal, or visual problems which limited mobility and others with major organ dysfunction and terminal illnesses were excluded from the study [Figure 1].
Figure 1: Flow of participants through the trial

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Following inclusion in the study, the patient's demographic profile and current medications were documented. Details of risk factors and comorbidities contributing to falls were collected. The number of falls in the last year along with the time and site of fall, prodromal symptoms, and injuries, if any, were documented. A detailed geriatric assessment was done. In the general physical examination, the presence of postural hypotension, irregular pulse,  Parkinsonism More Details, or peripheral neuropathy were documented. Gait and balance assessments were done and we included the following in our evaluation:

  1. Functional status was assessed using the Barthel index
  2. Body mass index – calculated by body weight (kilograms) divided by height squared (meters)
  3. Snellen's chart was used to test visual acuity. Study participants were asked for a history of vision loss, recent change in vision, eye examination in the past 1 year, and past history of cataract surgeries
  4. A hearing assessment was done with the Whisper test. Subjects were also asked for any hearing loss and use of hearing aids
  5. Mini–Cog
  6. Gait and gait speed
  7. Mini nutritional assessment
  8. Handgrip was checked using a Jamar Hand dynamometer
  9. Timed up and go test
  10. The berg balance test was done to stratify the study participants into the low, intermediate, or high risk for falls groups
  11. Monofilament test: The monofilament test done to assess peripheral neuropathy and for this, a 10 g monofilament was used to check 10 different sites on each foot. It was considered positive if there was loss of sensation in <8 sites checked
  12. In the physical examination – the vitals were recorded and a note was made of the rate and rhythm of pulse, baseline blood pressure in the supine position, and blood pressures in the standing position at 1 and 3 min. Orthostatic hypotension was defined as a fall in the systolic blood pressure by 20 mmHg or more and/or the diastolic blood pressure by 10 mmHg or more when the patient was upright for 3 min.


A clinical examination of the central nervous system was done and abnormal findings were documented.

Blood investigations ordered included Hemoglobin, Mean Corpuscular Volume, blood sugars, Vitamin D, and albumin. A routine electrocardiography was done. Then, a falls prevention program was initiated. This was individualized for each patient and included drug optimization, exercises, Vitamin D supplementation, dietary modification, prescription of appropriate footwear and addressing home safety hazards. ENT and ophthalmology referrals were given for appropriate patients. Oral dosing and duration of Vitamin D supplementation were given based on the serum Vitamin D levels. The ones with severe deficiency <12 ng/ml were administered 60,000 IU per week for 6–8 weeks. The subjects for ENT evaluation were given hearing assessment; otoprotective measures and hearing aids were prescribed appropriately. The subjects with ophthalmology referrals were evaluated for refractive errors, cataracts and retinal screening. Appropriate subjects were given prescriptions for spectacles, referrals for cataract surgery, and laser treatments. Drugs were rationalized and this included dose optimization, deprescribing fall risk-increasing drugs (FRIDs), and removing other potentially inappropriate medications (PIM) as defined by the BEERS criteria. Advice regarding calorie and protein supplementation in subjects at risk for malnutrition was given by a trained dietician. Physiotherapy referrals were given for gait and balance training and quadriceps strengthening and handouts given for an individualized home exercise program [Appendix 1]. The subjects were asked to do 3–5 repetitions twice a day throughout the week. These exercises were to be followed daily until review. Education regarding falls prevention was given to all patients. Occupational therapy inputs were taken on board, and the patients and carers were educated regarding safety measures at home. Appropriate footwear was prescribed for the subjects when needed.

Follow-up

Follow-up was done 1 and 3 months later telephonically and the subject was queried regarding any subjective improvement in gait and balance, falls if any, compliance with exercises, and any recent changes in medications.

Descriptive statistics was used for number and percentage for categorical variables and mean and standard deviation or median for all the continuous variables. To find the association between falls and demographic and clinical variables, Chi-square test/Fisher's exact test was used. Univariate logistic regression model was used to estimate the odds ratio (OR) and 95% confidence interval (CI) for the risk factors. A P < 0.05 was statistically significant. All the analyses were carried out using SPSS 21.0 version (IBM Corp, Armonk, NY, USA).


  Results Top


During the study, a total of 60 participants were recruited. The mean age of the study population was 68.22 (standard deviation = 6.48) years. The majority of the study population (70%) were between 61 and 70 years, 25% (n = 15) were between 71 and 80 years and 5% (n = 3) were above 80 years of age. The gender distribution was almost equal (31 males and 29 females). Among the participants, who were currently working, 40% of them were farmers or daily wage laborers (16%). Among the recruited subjects, hypertension was the most prevalent (66.7%), followed by subjects who had visual problems (48.3%) [Table 1]. About half of them (46.7%) were on more than four prescription drugs. 51.7% followed a regular exercise program, which included walking, cycling, and yoga.
Table 1: Demographic profile and characteristics of the study population

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Among those who presented with falls, 17% were recurrent fallers. Most of the falls were reported during the daytime (63.3%) and within the home (63.3%). Only 43.3% of them remembered tripping over something. Among those who fell, 50% (n = 15) of them had sustained some form of injury following the fall, and half of the subjects needed assistance to get up [Figure 2]. Four of the study participants were lost to follow-up and one expired.
Figure 2: Falls at baseline

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Among the study participants, it was noted that the older individuals (>70 years) were at a higher risk of falls (OR 2.10 [95% CI, 0.68–6.47]) compared to the younger counterparts.

Gender did not play a role in the risk of falls

Polypharmacy was another factor which contributed to falls (OR 2.67 [95% CI, 0.55–12.88]). Among the various classes of medications, insulin (OR 3.02 [95%CI, 0.54–16.98]), anticholinergics (OR 2.43 [95% CI 0.55–10.82]), sedatives (OR 2.54, [95% CI 0.79–8.16]) and antiparkinsonian medications (OR 2.22 [95% CI, 0.19–25.91]) contributed to the risk of falls. These factors though not statistically significant, are clinically meaningful [Table 2].
Table 2: Clinical parameters and the frequency of falls in study participants

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Among the comorbidities analyzed, 26 (43.33%) of the study participants were diagnosed to have type 2 diabetes mellitus, of whom 48.3% of them had reported falls. This was not statistically significant (P = 0.455). Patients who had undergone cataract surgery in one eye (OR 0.23 [95% CI (0.05–0.96)]) were associated with a lower risk of falls and this was statistically significant.

The various tests done for falls risk assessment revealed that the subjects with a slower gait speed, increased Timed Up and Go test and those who were at a high risk for falls on the Berg balance scale had greater chances of falling than those who scored lesser on these tests with the odds ratio being 1.33 (95%CI, 0.39–4.54), 1.15 (0.41–3.19), and 1.33 (0.27–6.56), respectively. The limitation in sample size may have contributed to these not being statistically significant.

A logistic regression analysis of the various risk factors associated with falls showed that subjects who had a mini-cog of ≥3 had a three times higher chance of falling when compared those with a score <3 [Table 3]. This could have been secondary to restricted mobility in those with cognitive impairment. Subjects with polypharmacy and a lower Vitamin D level had a higher chance of falling. However, this was not statistically significant.
Table 3: Logistic regression analysis for the risk factors associated with falls (n=60)

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All the patients were educated about home safety measures. Gait and balance training and dietary changes were advised. Drug optimization was done in 86.7% of the subjects, which included deprescribing FRIDs and removing other PIM [Table 4]. Those deficient in Vitamin D were given supplements (75%). Ophthalmology and ENT referrals were given for appropriate subjects and appropriate footwear was prescribed in 45 (75%) of our subjects.
Table 4: Interventions

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At the 1 month follow-up, 80% of the study participants reported a subjective improvement in balance and a decreased fear of falls. Four were lost to follow-up [Table 5]. Two of the study subjects sustained trivial falls during this time frame. Among those who reported no improvement, about 17.86% were noncompliant with their medications and 7.14% were noncompliant with the exercise protocol [Figure 3].
Figure 3: Follow up subjects at 1 month (n = 56)

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Table 5: Falls and compliance with exercises at first follow-up (P>0.999)

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Among the two subjects who reported a fall, both of them had reported a recent change in drug prescriptions. The compliance to exercise was reiterated at this point.

Three months' follow up

At the 3 months' follow-up, 78.2% of study participants reported a subjective improvement and there were three subjects who had trivial, mechanical falls during this time [Table 6]. About 10.91% were noncompliant with their medications and 9% were noncompliant with exercise in those who reported no subjective improvement [Figure 4]. Among the subjects who had a fall, one was noncompliant with exercises and two had reported change in drug prescriptions.
Figure 4: Follow up subjects at 3 months (n = 56)

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Table 6: Falls and compliance with exercises at second follow-up

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At our 1 and 3 month follow–ups, there were two and three falls reported respectively and the compliance to exercises was about 73.2% at both the follow-ups. There was a subjective improvement reported by 80% and 78.2% of the study participants at the follow-up of 1 and 3 months, respectively.


  Discussion Top


This was a prospective interventional trial done among the older individuals attending the geriatrics outpatient department. A study conducted by Joshi et al. among two hundred older persons in North India showed that 51.3% had fallen in 1 year.[7] This was comparable to our study where 48.3% presented with a history of fall. D'souza et al. observed that 30.5% of the falls had occurred outside the home,[5] which was similar to our study where 63.3% of the falls occurred inside homes and 30% had occurred in the community. The previous research by Bird et al. showed that older subjects fell more often than their younger counterparts due to age-related changes in balance, coordination, and muscle strength.[9],[10] This was akin to our study, where we found the older individuals (>70 years) to be at a greater risk of falls (OR 2.10 [95% CI, 0.68–6.47]) in comparison to the young-old.

Polypharmacy and a high comorbidity burden have both been long known as major contributors to falls risk among older subjects according to the English Longitudinal Study and The Irish Longitudinal study on Ageing in a study which had similar results to our study (OR 2.67 [95% CI, 0.55–12.88] and 1.24 [95% CI, 0.80–1.93]) respectively).[8],[11] Among the various comorbidities, a higher falls risk is seen among diabetics and hypertensives.[12],[13] In our study, 48.3% of the fallers were diabetics and 62.1% were hypertensives, but an insignificant association could be attributed to the limited sample size.

Berlie et al.[14] demonstrated a greater falls risk with the use of insulin and the Women's Health Initiative study had demonstrated an association between anticholinergic medications and falls in postmenopausal women.[15] In our study population, a similar added risk was found with the use of insulin (OR 3.02 [95% CI, 0.54–16.98]) and anticholinergics (OR 2.43 [95% CI 0.55–10.82]). An increased likelihood of falls was found with the use of sedatives in our study, which is similar to the findings in a study done by de Jong et al.[16]

Tools such as Berg Balance test and Timed Up and Go tests have been long identified as screening test for falls risk on an outpatient basis and poor performance on these scales predict an added risk,[9],[10] which was mirrored in our study as well. Verghese et al. identified a 54% risk of falling in older individuals with a slower gait speed < 0.7 m/s.[17] This finding is identical to our study, where subjects with a slower gait speed had a higher falls risk.

In our study, the subjects with a better cognition (Minicog >3) were found to be at a greater risk of falls [OR 2.7, 95% CI (0.8, 9.3)]. Although the cognitive decline is thought to be a risk factor for falls,[18] restriction of mobility may be protective against falls in those with cognitive impairment. Subjects with recent changes in the vision had fallen more often [OR 3.78, 95% CI (0.70–20.52)]. This finding was comparable to previous research done by Zhang et al.[19]

48.3% of our study participants had presented with a history of fall in the year prior to enrolment into the study. Following a multipronged intervention, at our 1 and 3-month follow-ups there were two (3.6%) and three (5.3%) falls reported, respectively. Subjective improvement was reported by 80% and 78.2% of the subjects at 1 and 3 months follow-up. Studies done by Tinnetti et al. proved the effectiveness of a multifactorial intervention by showing a reduction in falls in the intervention group at 1 year follow-up.[20] Research done by Hendrick et al. determined that the incidence of falls at baseline was 31%, and after a multipronged intervention which lasted for 6 months, 46% of the subjects fell.[21] In a similar study done by Oscar et al., 51.9% of the study participants had fallen at the end of 1 year, despite a multifactorial intervention.[22] The present study lacked this time length of follow-up.

Limitations

In our study, although not statistically significant, the falls at follow-up can were attributed to selecting patients at a greater risk of fall at baseline.

This study was not observed. The follow-up was telephonic and the adherence which was reported may not have been true. Targeting multiple modifiable risk factors and poor compliance to exercises may have contributed to the outcome.

The study subjects were not called back for reassessment or to reassess the falls risk as the subjects belonged to different parts of the country.

This study was done in a tertiary center and hence these observations cannot be generalized to the community-dwelling older individuals. Our study population belonged to the “young old” age group (the mean age of the study population was 68.22 years). Some patients who fulfilled the inclusion criteria may have been missed in the busy Geriatrics OPD. The falls were self-reported at inclusion and follow-up and it was possible that the subjects had forgotten the fall or events preceding the fall. The home environment was not assessed for the risk of falls. A longer follow-up with a much larger sample size is needed to completely assess the benefits of such multipronged individualized interventions.


  Conclusion Top


This was a one-of-a-kind study done among the older individuals attending a routine Geriatrics OPD. It helped in understanding the various intrinsic falls risk factors and in implementing a fall prevention program for these subjects in the most cost-effective way. In a busy OPD, the various assessments included in this study are often a part of the Geriatric comprehensive assessment and required no additional equipment. It throws light into how a good history and a thorough physical examination would help a physician in identifying these falls risk factors and in resulting in an improved quality of life for this age group. The assessments performed and the interventions initiated can be incorporated into a routine Geriatric Outpatient clinic at minimal added costs. In our study, 48.3% had fallen in the past 1 year, of whom 16.7% were recurrent fallers. Older age, polypharmacy, higher comorbidity burden, certain medications, slower gait speed, and lower scores on the Berg Balance scale were associated with a higher risk of falls. These contributors though not statistically significant in this study, are clinically meaningful. Following a multipronged intervention, 3.6% and 5.3% of the subjects reported falls after 1 and 3 months respectively. Subjective improvement was reported by 80% and 78.2% of the subjects at 1 and 3 months follow-up and the compliance to exercises during the follow-up period was good (73%). Implementing an individualized fall prevention program proved beneficial to the older person at falls risk.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Appendix Top


Appendix 1: Exercises for fall prevention in elderly

Home Activity Program

You should only do the exercises you feel safe and comfortable doing

  • Start slowly
  • Begin with a few repetitions of one or two exercises at a time
  • Try a few in the morning, afternoon and evening
  • If any activity causes you pain or significant shortness of breath-stop. Consult your doctor immediately
  • Gradually decrease the amount of support your hands giving you.


#1-Slow toe taps (may also be done while seated)



  1. Stand facing the table. Hold it with both hands
  2. Keep your heel on floor and lift the toes of one of your legs off the floor
  3. Hold 2 seconds and then relax
  4. Slowly repeat the same with other foot
  5. Alternate, repeat 3 to 5 times with each foot
  6. Gradually increase till you can hold for 2 min with each foot.


#2-Up on toes (may also be done while seated)



  1. Stand facing the table. Hold on to the table with both hands
  2. Go up on toes with both feet
  3. Come down slowly
  4. Repeat for 3 to 5 times, 2 to 3 times a day
  5. Gradually add one more repetition every few days until you can do this 10 times, 2 to 3 times a day.


#3-Walking on the spot (may also be done while seated)



  1. Stand facing the table. Hold onto the table with both hands
  2. March slowly on the same spot for 10 seconds (as shown)
  3. Gradually increase this march time up to 2 min.


Progression:

  1. Begin walking at home for 3 to 4 min without stopping
  2. Use a walking aid, if prescribed
  3. Every 3rd or 4th day, gradually increase the time spent walking by 1 min.


#4-Alternate leg out and in



  1. Stand facing the table. Hold on to the table with both hands
  2. Keeping your toes pointing forward, not sideways

    lift one leg out to one side (as shown)
  3. Hold this position for a few seconds, and then slowly lower the leg
  4. Repeat the same with other leg
  5. Continue to alternate each leg
  6. Repeat the exercise 3 to 5 times with each leg
  7. Gradually increase this every few days or week until you can do it 10 times with each leg


#5-Alternate leg behind



  1. Stand facing the table
  2. Hold on to the table with both hands
  3. Lift one leg behind you, keeping knee straight
  4. Return to starting position
  5. Repeat with other leg
  6. Continue to alternate each leg, repeating 3 to 5 times with each
  7. Gradually increase this every few days or week until you can do 10 times with each leg.


#6-Sit to stand



  1. Sit on a firm chair with arm rests
  2. Bring your bottom a little closer to the front of the chair if needed
  3. Bring your feet in close to the chair, put hands on armrests if needed
  4. Lean forward and stand up
  5. Stand tall for a few seconds, holding onto armrest of the chair if needed for support
  6. Lean forward and slowly lower yourself to sit down
  7. Stand up and sit down 3 to 5 times
  8. Gradually increase this every few days until you can do 10 times with each leg.


Progression: Gradually try to decrease the amount of support your hands are giving you until you can stand up and sit down, without using your arms.



 
  References Top

1.
Jeffrey B. Halter JG. Hazzard's Geriatric Medicine and Gerontology. 6th ed. USA, McGraw Hill; 2009.  Back to cited text no. 1
    
2.
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-7.  Back to cited text no. 2
    
3.
Microsoft Word – Revised-on29-03-07onFalls.doc – SEARO.pdf. Available from: http://www.who.int/ageing/projects/SEARO.pdf. [Last accessed on 2017 Jan 26].  Back to cited text no. 3
    
4.
World Health Organization, editor. WHO Global Report on Falls Prevention in Older Age. Geneva, Switzerland: World Health Organization; 2008. p. 47.  Back to cited text no. 4
    
5.
Dsouza SA, Rajashekar B, Dsouza HS, Kumar KB. Falls in Indian Older Adults: A Barrier to Active Ageing. Available from: http://ajgg.org/AJGG/V9N1/2013-164-RA.pdf. [Last accessed on 2017 Mar 31].  Back to cited text no. 5
    
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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;59:148-57.  Back to cited text no. 6
    
7.
Joshi K, Kumar R, Avasthi A. Morbidity profile and its relationship with disability and psychological distress among elderly people in Northern India. Int J Epidemiol 2003;32:978-87.  Back to cited text no. 7
    
8.
Zaninotto P, Huang YT, Di Gessa G, Abell J, Lassale C, Steptoe A. Polypharmacy is a risk factor for hospital admission due to a fall: Evidence from the English Longitudinal Study of Ageing. BMC Public Health 2020;20:1804.  Back to cited text no. 8
    
9.
Jácome C, Cruz J, Oliveira A, Marques A. Validity, reliability, and ability to identify fall status of the berg balance scale, BESTest, Mini-BESTest, and Brief-BESTest in patients with COPD. Phys Ther 2016;96:1807-15.  Back to cited text no. 9
    
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Podsiadlo D, Richardson S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142-8.  Back to cited text no. 10
    
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Richardson K, Bennett K, Kenny RA. Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. Age Ageing 2015;44:90-6.  Back to cited text no. 11
    
12.
Yang Y, Hu X, Zhang Q, Zou R. Diabetes mellitus and risk of falls in older adults: A systematic review and meta-analysis. Age Ageing 2016;45:761-7.  Back to cited text no. 12
    
13.
Gangavati A, Hajjar I, Quach L, Jones RN, Kiely DK, Gagnon P, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: The maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc 2011;59:383-9.  Back to cited text no. 13
    
14.
Berlie HD, Garwood CL. Diabetes medications related to an increased risk of falls and fall-related morbidity in the elderly. Ann Pharmacother 2010;44:712-7.  Back to cited text no. 14
    
15.
Marcum ZA, Wirtz HS, Pettinger M, LaCroix AZ, Carnahan R, Cauley JA, et al. Anticholinergic medication use and falls in postmenopausal women: findings from the women's health initiative cohort study. BMC Geriatr 2016;16:76.  Back to cited text no. 15
    
16.
de Jong MR, Van der Elst M, Hartholt KA. Drug-related falls in older patients: Implicated drugs, consequences, and possible prevention strategies. Ther Adv Drug Saf 2013;4:147-54.  Back to cited text no. 16
    
17.
Verghese J, Holtzer R, Lipton RB, Wang C. Quantitative gait markers and incident fall risk in older adults. J Gerontol A Biol Sci Med Sci 2009;64:896-901.  Back to cited text no. 17
    
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Shaw FE. Falls in cognitive impairment and dementia. Clin Geriatr Med 2002;18:159-73.  Back to cited text no. 18
    
19.
Zhang XY, Shuai J, Li LP. Vision and relevant risk factor interventions for preventing falls among older people: A network meta-analysis. Sci Rep 2015;5:10559.  Back to cited text no. 19
    
20.
Tinetti ME, Baker DI, McAvay G, Claus EB, Garrett P, Gottschalk M, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-7.  Back to cited text no. 20
    
21.
Hendriks MR, Bleijlevens MH, van Haastregt JC, Crebolder HF, Diederiks JP, Evers SM, et al. Lack of effectiveness of a multidisciplinary fall-prevention program in elderly people at risk: A randomized, controlled trial. J Am Geriatr Soc 2008;56:1390-7.  Back to cited text no. 21
    
22.
de Vries OJ, Peeters GM, Elders PJ, Muller M, Knol DL, Danner SA, et al. Multifactorial intervention to reduce falls in older people at high risk of recurrent falls: A randomized controlled trial. Arch Intern Med 2010;170:1110-7.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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