Maturitas 82 (2015) 85–93

Contents lists available at ScienceDirect

Maturitas
journal homepage: www.elsevier.com/locate/maturitas

Review

Falls and Fractures: A systematic approach to screening and

prevention
Anne Felicia Ambrose ∗ , Lisanne Cruz, Geet Paul
Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, United States

a r t i c l e i n f o a b s t r a c t

Article history: Falls are one of the major causes of mortality and morbidity in older adults. Every year, an estimated
Received 21 June 2015 30–40% of patients over the age of 65 will fall at least once. Falls lead to moderate to severe injuries,
Accepted 23 June 2015 fear of falling, loss of independence and death in a third of those patients. Falls account for 87 % of all
fractures in the elderly. These fractures are almost always due to low impact injuries in osteoporotic
Keywords: bones. Several organizations have recommended screening older patients to identify those with a high
Falls
risk of falling and, or fractures. The present review provides a brief summary and update of the relevant
Eldely
literature, summarizing screening tools and interventions to prevent falls and fractures. The major risk
Fall risk
Fracture risk
factors identified are impaired balance and gait, polypharmacy, and history of previous falls. Other risk
factors include advancing age, female gender, visual impairments, cognitive decline especially attention
and executive dysfunction, and environmental factors. Recommendations for the clinician to screen and
prevent falls in older patients are also summarized.
© 2015 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
3. Epidemiology of fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
4. Falls and osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
5. Screening and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6. History taking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.1. Patient history and history of fall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.2. Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
6.3. Questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7. Physical examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
7.1. Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
7.2. Mental health and cognitive capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
7.3. Footwear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
7.4. Balance tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
7.5. Gait evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
8. Functional assessment tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
9. Clinical assessment of fracture risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
10. Laboratory testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
11. Home assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
12. Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
13. Supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
14. Summary of recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

∗ Corresponding author. Fax: +1 212 369 6389.

E-mail address: anne.ambrose@mssm.edu (A.F. Ambrose).

http://dx.doi.org/10.1016/j.maturitas.2015.06.035
0378-5122/© 2015 Elsevier Ireland Ltd. All rights reserved.
86 A.F. Ambrose et al. / Maturitas 82 (2015) 85–93

Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Author contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

1. Introduction tibial fractures carry higher mortality rates and have been associ-
ated with long-term bisphosphonate.
Falls are a leading cause of morbidity and mortality among older
adults [1]. One in three adults over the age of 65 [2] and one in
two adults over the age of 80 fall annually [3]. However, less than 4. Falls and osteoporosis
half their physicians are aware of the falls or the circumstances [4].
In 2013, there were 2.5 million nonfatal falls among older adults Falls are the most common mechanism of fractures among older
treated in emergency departments and 734,000 hospitalization, adults, especially in those with osteoporosis [14]. This population
costing $30 billion in direct medical costs [1,5]. Twenty to thirty often sustains falls with low impact forces such as falling from a
percent of people who fall suffer moderate to severe injuries such standing height. In the elderly this can result in “fragility fractures”.
as lacerations, fractures and traumatic brain injuries [6,7] resulting There were an estimated nine million osteoporotic fractures world-
in reduced independence, early death and development of a fear wide in 2000, of which 1.6 million were hip, 1.7 million forearm,
of falling [8]. Falls account for 87% of all fractures in the elderly and 1.4 million clinical vertebral fractures [21]. The World Health
[9]. Fractures are associated with major complications such deep Organization operationally defines osteoporosis as a hip bone min-
vein thromboembolism (40%) and delirium (10–40%) which in turn eral density (BMD) of 2.5 or more standard deviations (SD) below
leads to prolonged hospital stays, increased mortality and risk of the mean for young adult reference population. Each 1 SD decrease
nursing home placement. The mortality following a hip fracture in BMD is associated with a 1.5- to 2.5-fold increase in risk of frac-
is about 20% and is mainly due to pneumonia, cardiac disease, ture [22]. Women ages 65–69 have a BMD loss at the hip of 0.32%
pulmonary embolism and surgical complications [10]. The most per year and this numbers increases to 1.64% per year in ages 85 and
common fractures occur in post-menopausal women with osteo- older. This leads to an increase in hip fractures by 20–25% over a
porosis. Age affects the type of fracture sustained. Women under 5-year period. Men account for 30% of hip fractures worldwide but
the age of sixty, tend to extend their arms as they fall resulting in a have a higher mortality than women [23,24,12]. Other risk factors
higher incidence of forearm fractures. After that age, women tend for osteoporosis include being Caucasian, having a petite frame,
to fall sideways and have a higher incidence of hip fractures [11]. low body weight, family history or prior history of osteoporosis,
cigarette smoking, heavy alcohol use, diseases such as rheumatoid
2. Method arthritis and medications such as steroids.

In this narrative review, we aimed to identify the epidemi- 5. Screening and Prevention
ology, etiology and risk factors of fall-related fractures in the
elderly population. Screening tools and interventions to prevent As the number of elderly increases, the ability to identify those
falls and fractures are also presented. The bibliographic search at risk of falls and subsequent fractures has become increasingly
strategy focused on articles published in peer-reviewed, English important. The American Geriatrics Society published guidelines
language journals up to December 2014. The databases used in 2010 urging practitioners to screen older patients for fall risk
included PubMed, CINAHL and Scopus. When they existed, RCT and at least annually [25]. Similarly, the CDC recommends screening
meta-analyses were selected preferentially and, in their absence, for falls at each visit by using the Staying Independent Brochure
we used clinical trials. Editorial, case reports, letter or other type as part of their Stopping Elderly Accidents, Deaths and Injuries
of commentaries were not considered. We did not apply formal (STEADI) initiative [see Fig. 1] [26]. A comprehensive fall assess-
meta-analysis methods. ment is prompted when a patient Scores 4 or more on the Stay
Independent Brochure or answers yes to having fallen in the past
3. Epidemiology of fractures year, feeling unsteady or have a fear of falling [26]. This initial
screening tool is a self-assessment, but there are also tools that
After the age of 50, 4 in 10 women can expect to have a hip, can be used by the physician.
vertebral or forearm fracture in their remaining lifetime, and are
more likely to die from its complications than from breast can-
cer [12,13]. Women aged 65 years and older accounted for 74% 6. History taking
of all fractures and bore the overwhelming share (89%) of related
total costs. Approximately 300,000 hip fractures, and 90,000 frac- 6.1. Patient history and history of fall
tures [14] of the distal radius, occur annually, the majority of which
was a result of falls [15–17]. Among the elderly, vertebral fractures Details of the injury and mechanism of fall are helpful in under-
are also common. However, the true incidence is unclear because standing the circumstances around any past falls. A focused history
patients are less likely to recognize that the back pain following a should include prodromal symptoms (lightheadedness, dizziness,
trivial fall is a vertebral fracture and thus less likely to present to palpitations) and environmental factors such as poor lighting, car-
the emergency room. Most of the spinal fractures occur at T8–T12, pets, uneven terrain, or stairs. A complete review of medications
L1 and L4 and can result in spinal deformity, chronic pain and taken or changed, is also warranted. Identifying underlying chronic
incomplete paraplegia [18]. Falls are the leading cause of spinal diseases that increase risk of fall or fracture, such as postural
cord injury among persons aged above 60 [19]. Proximal humerus hypotension, Parkinson’s disease, diabetes, osteoporosis, stroke, or
fractures account for four to five percent of all fractures and are cognitive impairments, is also necessary. Other risk factors such as
the third most common fracture in elderly patients after those of urinary incontinence, visual impairment, alcohol consumption, and
the hip and distal radius [20]. Although less common in the elderly, footwear should be evaluated.
 A.F. Ambrose et al. / Maturitas 82 (2015) 85–93 87

Fig. 1. CDC’s Stopping Elderly Accidents, Deaths & Injuries (STEADI) Algorithm providing tools and educational material for health care providers.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention.
Available from: http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html.

6.2. Medications 6.3. Questionnaires

Medications are known to be significant risk factor in falls. Psy-
chotropic medications have been shown to increase the risk of
falling by 47% in older adults living in the community [27]. Cardio-
vascular medications are also commonly associated with increased
risk of falling, specifically digoxin, type 1a anti-arrhythmic, and
diuretics [28]. Other medications that have been implicated in
fall risk include insulin, nonsteroidal anti-inflammatory drugs
(NSAIDs), and anti-epileptics [29]. Polypharmacy is a risk factor for
falls in itself. Helgadóttir et al. showed that the use of even more
than one medication, leads to almost a two-fold increase in the risk
of falling [30]. See Table 1 for a list of several drugs that increase
risk of falling adapted from Chen and colleagues [31].
The Falls Risk for Older People in the Community scale (FROP-
Com) is a 26-item clinician rated scale [32]. It requires no
equipment and can be done in 10–15 min. The FROP-Com was val-
idated in a longitudinal study of 344 community-dwelling older
adults who presented to the emergency room following a fall. It
was found to be a sensitive predictor of future falls (66% sensitivity
and 65% specificity).
The St. Thomas Risk Assessment Tool for Fall in elderly (STRAT-
IFY) was designed to assess the risk of falls in hospitalized patients
[33]. It consists of five items including past history of falls, agita-
tion, visual impairment, need for frequent toileting and transfer
ability and mobility. A meta-analysis utilizing STRATIFY in elderly
inpatients in rehabilitation hospitals found that it has a pooled
sensitivity of 73% and pooled specificity of 42% [34]. Another
88 A.F. Ambrose et al. / Maturitas 82 (2015) 85–93
Table 1
Drugs associated with increasing fall risk.
Category Risk description
CNS-acting agents Patients receiving CNS-acting
agents were ten times more
likely to have a fall risk.
Inpatient falls were
significantly associated with
patients taking
anit-Parkinson’s medications
Cough Preparation Known to cause sedation as
well as bladder-outlet
obstruction in elderly men
leading to more frequent visits
to the bathroom and thus
increasing the chances of
falling.
NSAIDs Associated with a tenfold
increase in the likelihood of
falling
Anti-Alzheimer’s agents Associated with higher
incidence of fall in patients on
this agents
Antiplatelet agents Hospitalized patients on
antiplatelet agents were more
likely to fall
Calcium antagonist The probability of falls
increased when patients used
calcium antagonists
Diuretics There is an increased rick of
falls on the day following a
new prescription or increased
dose of a loop diuretic. Extra
fall precautions should be
undertaken in individuals that
have been recently prescribed
diuretics or have had changes
to their existing diuretic
medication.
∝-blocker Associated with an increased
risk of hip/femur fracture,
common due to falls.
Digoxin Digoxin therapy was more
common in hospitalized
elderly patient who had fallen
than in control patients
Anti-diabetic agents Significantly associated with
and increased risk of falling
Adapted from [31].
meta-analysis found that it could be used in community dwellers
if the cut-off was lowered by 2 points [35].
The National Center for Patient Safety recommended 2 risk
assessment tools for inpatients. The Morse Fall Scale (MFS) is better
researched and more widely used, both in hospital and long-term
care inpatient settings [36]. It requires systematic, reliable assess-
ment of a client’s fall risk factors upon admission, after a fall, with
a change in status, and at discharge or transfer to a new setting.
The Hendrich Fall Risk Assessment, developed by nurses, is recom-
mended for inpatients in long-term care settings [37]. It focuses
on eight independent risk factors: altered mental status; symp-
tomatic depression; altered elimination; dizziness or vertigo; male
sex; administration of antiepileptics; benzodiazepines; and poor
performance in rising from a seated position in the Get-Up-and-Go
test.
7. Physical examinations
A complete physical exam should include a neurological assess-
ment as well as an evaluation for vision, cognitive deficits, and
orthostatic blood pressure.
7.1. Vision
Vision makes an important contribution to balance, and
impaired vision is a significant independent risk factor for falls. The
CDC recommends testing vision in all elderly with two or more falls
or injury from a single fall [26]. Despite this association, studies
suggest that vision assessment and correction does not reduce risk
or rate of falls. In one such study, a comprehensive vision assess-
ment with appropriate treatment actually increased the risk of falls
and fractures [38]. This suggests that in addition to treatment of
vision impairments, gait training with new visual aids is necessary
to prevent fall risk. One study that was successful in decreasing the
rate of falls in older adults substituted multifocal glasses for single
lenses during outdoor and walking activities [39,40], suggesting
that multifocal lenses pose a risk of falling in and of themselves.
7.2. Mental health and cognitive capacity
Depressive illness in the elderly population is a serious health
concern. A cohort study of community dwelling older individuals
showed common risk factors between falls and depression includ-
ing poor self-rated health and cognitive status, and slow walking
[41]. A two-question screener is easily administered and likely to
identify patients at risk if both questions are answered affirma-
tively [42]. The questions are: “During the past month, have you
been bothered by feeling down, depressed or hopeless?” and “Dur-
ing the past month, have you been bothered by little interest or
pleasure in doing things?” This screen is sensitive, but not specific,
thus a positive screen should be followed by a full evaluation.
Fear of falling is not only a consequence of a previous fall, but
also an independent risk factor for future falls [43]. Activity restric-
tion is associated with fear of falling in elderly populations and is a
predictor of decline in physical function [44]. A screening tool easily
used in the office is the Activities-specific Balance Confidence Scale
(ABC Scale) [45]. This is a 16-item scale that asks adults to rate their
confidence that they will lose their balance or become unsteady in
the course of daily activities.
Cognitive functioning can be assessed with use of the Mini
Mental Status Exam, a well-validated screening tool for cognitive
impairment in the elderly [46].
7.3. Footwear
Footwear affects postural stability and can influence the inci-
dence of falls. Many older individuals prefer to wear slippers at
home, which are shown to have higher incidence of falls compared
to the individuals that walk barefoot [47]. For individuals with gait
or balance impairment, the safest choice is to wear athletic or can-
vas shoes [29]. Under icy conditions, anti-slip shoes have shown to
reduce falls and are recommended for elderly individuals that are
walking outdoors during severe weather conditions [48].
7.4. Balance tests
Tinetti Mobility Test (TMT) also known as the Performance Ori-
ented Mobility Assessment (POMA) is a reliable and valid clinical
test to assess static, dynamic, reactive and anticipatory balance,
ambulation and transfers [49]. It has been validated in community-
dwelling older people [50].
The Berg Balance Scale is a performance-based measure of a
person’s ability to complete 14 mobility tasks that are thought to
represent typical daily undertakings [51]. Although useful in pre-
dicting falls in institutionalized patients, its ability to predict falls
in community-dwelling older adults has been limited, especially in
higher functioning elderly patients due to the ceiling effect [52].
 A.F. Ambrose et al. / Maturitas 82 (2015) 85–93
The CDC recommends the Timed Up And Go Test [53] the Four
Stage Balance Test (FSBT) and the 30 Second Chair Test as part of the
STEADI initiative [26]. In the FSBT, the patient must stand in 4 pro-
gressively more difficult stances; feet side-by-side, partial tandem,
tandem and the standing on one foot. An elderly adult who cannot
hold the tandem position for at least 10 s is at risk of falling. In the
30 Second Chair Test, the number of times that a patient can stand
up from a seated position is measured. If the patient falls below the
age-rated average, they are at greater risk of falling.
7.5. Gait evaluation
Researchers have turned to more quantifiable measures with
the use of gait laboratories to better understand movement infor-
mation during daily living tasks using tools such as force sensitive
insoles, 3-D imaging, and inertial sensors. In a prospective study
of community-living, ambulatory adults, Hausdorff and colleagues
found that stride-to-stride measure of gait timing could augment
the evaluation of fall risk and that stride time predicted falls [54].
This technology has proven to be effective in early identification
of older adults at risk of falling, however, accessibility is prohibitive
and it is unclear if the results will translate to the real world. To
address these issues, Stone and colleagues developed a system
to measure average in-home gait speed over an 11-month period
with passive infrared motion sensors [55]. The results of this study
suggest that measurement of gait during an individual’s normal,
everyday activity in their own home could provide clinicians with
a more reliable assessment of mobility and fall risk on a continuous
basis.
8. Functional assessment tools
The “Get Up and Go” test is performed by observing abnormali-
ties in gait and balance when the subject rises from a standard arm
chair, walks 3 meters or 10 feet, turns around, walks back, and sits
down. The patient’s performance was observed for abnormalities
in gait and balance. The test was revised to employ a timed perfor-
mance approach called the Timed Up and Go (TUG). Any individual
with a time greater than 13.5 s is considered to be at an increased
risk of falls. This was found to be a sensitive (87%) and specific (87%)
[56]. A systematic review in 2010 showed that the TUG is associ-
ated with a history of past falls, but its predictive ability for future
falls was limited [56]. Similarly, a 2013 meta-analysis of 53 studies
(n = 12,832) showed that the TUG test in adults ≥60 years of age
did not show a difference in scores between fallers and non-fallers
who were living independently [57]. The test was better at predict-
ing multiple falls and discriminates better between faller groups
in lower-functioning populations. A Brazilian prospective study of
community dwelling elderly found that a 12.47 s cut off had a better
predictive value [58]. The CDC now recommends a 12 s cut off.
The Five Times Sit to Stand (FSST) test was found to be a signif-
icant predictor of recurrent fallers in a community dwelling older
population with 55% recurrent fallers failing this test compared to
single (35%) and non-fallers (38%) [59]. Further results showed that
the FTSS was a better predictor of falls than the TUG or One Legged
stance test [59].
9. Clinical assessment of fracture risk
Dual-energy X-ray absorptiometry (DEXA) is the most widely
used method for measuring BMD because it gives very precise mea-
surements at clinically relevant skeletal sites. The United States
Preventive Services Task Force (USPSTF) found insufficient evi-
dence to make a recommendation for screening men, but does
recommend BMD screening in women younger than 65 years with
89
a risk for osteoporosis [60]. The DEXA, however, is costly and is
impractical as a screening tool in most parts of the world. The World
Health Organization introduced the FRAXTM score as a tool that can
be used without the BMD to assess patients that have higher sus-
ceptibility to fracture [61]. The FRAXTM score takes into account
the following risk factors: age, prior fragility fracture, parental his-
tory of hip fracture, smoking, use of systemic corticosteroids, excess
alcohol intake and rheumatoid arthritis. This validated test can be
used in an office setting. Taken from the British Columbia guide-
lines on Fracture Prevention, Fig. 2 delineates a screening process
to assess risk of fracture [62]. Stratifying patients’ risk allows prac-
titioners to determine treatment and prevention strategies.
10. Laboratory testing
Given the association between osteoporosis and risk of frac-
tures, it is suggested that at a minimum, measurement of serum
calcium, creatinine, alkaline phosphatase, liver enzymes and com-
plete blood count are done [63]. Other tests, such as serum protein
electrophoresis, thyroid function tests, 24-h urine, parathyroid hor-
mone and 25-OH vitamin D levels have a low yield when applied
routinely to older people. In men who are more likely to have an
underlying cause for osteoporosis, particularly hypogonadism,
Free testosterone may be assessed, but providing routine testos-
terone supplements to older men without symptoms of severe
hypogonadism is not recommended. Free serum testosterone may
be assessed, but providing routine testosterone supplements to
older men without symptoms of severe hypogonadism is not rec-
ommended may [64].
Vitamin D deficiency is now recognized as a common prob-
lem in older adults, with prevalence ranging from 6% in healthy
community-dwelling older adults to 85% in medical inpatients
[65,66]. In addition to causing osteomalacia, vitamin D deficiency
has been associated with increased fall rates which in turn increase
the risk of further fractures [67].
Primary and secondary prevention is key to reducing mortality
and morbidity following fractures. Despite this knowledge, 10–14%
of those with hip fractures will suffer another fracture each subse-
quent year, and less than 25% receive any therapy to prevent further
fracture [68,69]. This practice is even worse among men [70].
11. Home assessment
A large percentage of falls occur at home, therefore careful
assessment and modifications of fall hazards done by a trained
rehabilitation provider has been shown to decrease the rate of
falls [48]. Important modifiable environmental risk factors include
lighting, stair and bath rails, clutter, gait aids, and wet surfaces. A
meta-analysis done by Clemson et al. showed that providing home
environmental intervention can decrease the risk of falls by 21%
and as high as 39% among populations that are at high risks of
falls [71]. Karlsson et al. recommends home modifications such as
removal of loose floor mats, painting the edges of steps, reducing
glare, installing grab bars, removing clutter and improving lighting
decreased falls by 41% [48].
12. Exercise
Implementing a proper exercise program especially those that
focus on strength training and balance are the most effective in
reducing falls [72]. Specifically, it has been shown that improving
muscle strength and power may mitigate the effects of sarcope-
nia, and resistance training in the lower extremities may improve
balance recovery performance [73]. Flexibility and endurance have
also found to be effective [48]. An increasingly popular exercise
90 A.F. Ambrose et al. / Maturitas 82 (2015) 85–93

Fig. 2. Recommendations for evaluation and management of osteoporotic and fragility fracture risk
BC Guidelines Osteoporosis: Diagnosis, Treatment and Fracture Prevention developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services
Commission. Available from: http://www2.gov.bc.ca/gov/topic.page?id=F8231A43423D4AF5B173EECE777FA911#Step1.

among older adults, Tai Chi consists of slow, rhythmic movements
that emphasize trunk rotation, weight shifting, and coordination
which can improve postural sway, single leg stance, tandem stance,
lateral stability, and reaching. In a study done by Voukelatos et al.,
participants who were enrolled in a community-based Tai Chi
classes for 16 weeks had reduced frequency of falls along with sig-
nificant improvements in their balance [74]. Studies have showed
that walking alone does not reduce the risk of falls [48]. However
most studies that demonstrate improvement in falls with exer-
cise exclude the frail elderly. More research needs to be done on
the optimal frequency and intensity of the exercise required for
reducing falls [75].
13. Supplements
Calcium and vitamin D supplementation in older adults is
an effective means of preventing fractures, and possibly falls,
regardless of BMD or fracture history. Practical issues include
ensuring absorption of calcium, which requires an acidic envi-
ronment, in older patients with achlorhydria or who are taking
 A.F. Ambrose et al. / Maturitas 82 (2015) 85–93
Table 2
Screening and Prevention of Falls and Fractures
History and physical Fall details, prodromal symptoms,
environmental factors, Review of
medications, Chronic diseases, urinary
incontinence, visual impairment,
alcohol consumption, footwear
neurological assessment, vision,
cognitive deficits, and orthostatic
blood pressure.
Questionnaires Falls Risk for Older People in the
Community scale (FROP-Com)
St. Thomas Risk Assessment Tool for
Fall in elderly (STRATIFY)
Morse Fall Scale (MFS)
Hendrich Fall Risk Assessment
Balance tests Tinetti Mobility Test (TMT)
Berg Balance Scale
Test the Four Stage Balance Test(FSBT)
Functional assessment tools Timed Up and Go
30 Second Chair Test
The Five Times Sit to Stand (FSST)
Gait evaluation Clinical assessment
Gait laboratory assessment
In home video monitoring
Assessment of fracture risk DEXA scan
FRAX score
Laboratory testing In all patients-serum calcium,
creatinine, alkaline phosphatase, liver
enzymes and complete blood count
In selected patients-serum protein
electrophoresis, thyroid function tests,
24-h urine, parathyroid hormone and
25-OH vitamin D level,serum
testosterone level
Home assessment Lighting, stair and bath rails, clutter,
gait aids, and wet surfaces.
Exercise Strength training and balance exercises
Flexibility and endurance exercises
Tai chi exercises
Vision Assesing and correcting vision
impairments,
Gait training with new visual aids
Medication Psychotropic medications
Cardiovascular medications
Insulin,
Nonsteroidal anti-inflammatory drugs
(NSAIDs
Anti-epileptics.
Polypharmacy
Mental health and cognitive capacity Depression
Fear of Falling
Cognitive impairment
Footwear Avoid slippers
Wear athletic shoes
Wear anti-skid shoes
Supplements Calcium and vitamin D
supplementation
Bisphosphonate medications
Raloxifene
acid-suppressing drugs [76,77]. Administration of calcium supple-
ments with meals or in the form of calcium citrate may be helpful
for such patients. The daily recommended dose is 800–1000 IU to
keep serum levels at 50 nmol/L [78]. For those with vitamin D defi-
ciency or insufficiency, a more aggressive approach to vitamin D
repletion should be used prior to initiating daily supplements [79].
The bisphosphonate medications reduce the relative risk of both
vertebral and non-vertebral fractures in patients with established
osteoporosis by 40–50%, even in the oldest and frailest populations
[80–83]. Daily, weekly and monthly oral preparations should be
considered. Special considerations have to be given to the elderly as
the oral medications have to be taken fasting and the patient be able
to remain upright for at least 1 h after the dose to maximize absorp-
tion and minimize risk for upper gastrointestinal complications.
91
Hypocalcaemia, common in older patients, should be corrected
prior to beginning therapy.
In women with osteoporosis, the relative risk of vertebral frac-
tures is reduced by 40% in patients taking calcitonin [84]. However,
calcitonin has not been proved to reduce fractures at non-vertebral
sites and is thus considered by many to be a second- or third-line
agent. Calcitonin has also been found to have beneficial short-term
effect on acute pain relief in patients who have sustained a ver-
tebral fracture, as illustrated by the findings of a meta-analysis of
10 trials comparing calcitonin (nasal or parenteral) with placebo in
patients with acute (onset <10 days) or chronic (>3 months) pain
due to an osteoporotic compression fractures [85]. Long-term use
of calcitonin for osteoporosis has been associated with an increase
in cancer rates and, therefore, comes with a black box warning [86].
The selective oestrogen receptor modulator raloxifene reduces
the relative risk of vertebral fractures by 50% in women with osteo-
porosis [87]. However, it significantly increases the risk of DVT and
has to be carefully monitored. In The Health Outcomes and Reduced
Incidence with Zoledronic Acid Once Yearly (HORIZON) Recurrent
Fracture Trial, the primary end point was new clinical fractures,
which included even minor ones such as vertebral fractures, the
absolute risk reduction was a significant 5.3% [88]. However, the
risk reduction for the clinically important hip fractures was only
1.5%, which failed to reach statistical significance [89].
14. Summary of recommendation
A fall usually occurs due to a combination of multiple risk factors.
An individualized screening and prevention interventions should
be instituted. The CDC has developed an algorithm to develop
multifactorial interventions according to the identified risk fac-
tors and number of previous falls [see Fig. 1] [26]. Tinetti et al.
showed that targeted multifactorial strategies (medication adjust-
ment, behavioral instruction, and exercise programs) result in
significant reduction in risk of falling among elderly persons living
in the community [90]. Similarly, exposing clinicians to interven-
tions to change clinical practice such as adopting effective risk
assessments and strategies for the prevention of falls reduced seri-
ous fall-related injuries from 31.9 to 28.6 (per 1000 person-years)
[91]. A prospective study done by Walderon et al. showed that
establishing a proper referral pathway for Geriatric care post dis-
charge substantially increased the quality of care [92]. Risk factors
that should be addressed include medication review, correction of
orthostatic hypotension, environmental safety evaluations, balance
and strengthening exercises, correction of sensory deficits, and pro-
vision of ambulatory aids [see Table 2].
Conflict of interest
None.
Funding
The authors of this article, Anne Ambrose, Lisanne Cruz and Geet
Paul have not received any funding with connection to this article
or journal.
Author contribution
Anne Felicia Ambrose created concept and framework for the
paper, lead the team, reviewed references and wrote the final draft.
Lisanne Cruz did the preliminary database searches, wrote the
preliminary draft, gathered references and formatted the paper to
fit into journals requirements.
92 A.F. Ambrose et al. / Maturitas 82 (2015) 85–93
Geet Paul did the preliminary database searches and wrote the
sections on medications (5.2), vision (6.1) footwear (6.3) and for-
matted the references.
References
[1] Centers for disease control and prevention, national center for injury
prevention and control. Web–based injury statistics query and reporting
system (WISQARS) [cited April 20, 2015]. Available from: http://www.cdc.
gov/injury/wisqars/
[2] M.E. Tinetti, M. Speechley, S.F. Ginter, Risk factors for falls among elderly
persons living in the community, N. Engl. J. Med. 319 (26) (1988) 1701–1707.
[3] J. O’Loughlin, Y. Robbitaille, J. Boivin, et al., Incidence of and risk factors for
falls and injurious falls among community-dwelling elderly, Am. J. Epidemiol.
137 (1993) 342–354.
[4] J.A. Stevens, M.F. Ballesteros, K.A. Mack, R.A. Rudd, E. DeCaro, G. Adler, Gender
differences in seeking care for falls in the aged Medicare Population, Am. J.
Prev. Med. 43 (2012) 59–62.
[5] J.A. Stevens, P.S. Corso, E.A. Finkelstein, T.R. Miller, The costs of fatal and
nonfatal falls among older adults, Inj. Prevent. 12 (2006) 290–295.
[6] D.A. Sterling, J.A. O’Connor, J. Bonadies, Geriatric falls: injury severity is high
and disproportionate to mechanism, J. Trauma 50 (1) (2001) 116–119.
[7] B.H. Alexander, F.P. Rivara, M.E. Wolf, The cost and frequency of
hospitalization for fall-related injuries in older adults, Am. J. Public Health 82
(7) (1992) 1020–1023.
[8] B.J. Vellas, S.J. Wayne, L.J. Romero, R.N. Baumgartner, P.J. Garry, Fear of falling
and restriction of mobility in elderly fallers, Age Ageing 26 (1997) 189–193.
[9] D. Fife, J.I. Barancik, Northeastern Ohio Trauma Study III. Incidence of
fractures, Ann. Emerg. Med. 14 (1985) 244–248.
[10] J. Panula, H. Pihlajamäki, V.M. Mattila, P. Jaatinen, T. Vahlberg, P. Aarnio, et al.,
Mortality and cause of death in hip fracture patrients aged 65 or older: a
population-based study, BMC Musculoskelet Disord 12 (2011) 105.
[11] M.C. Nevitt, S.R. Cummings, Type of fall and risk of hip and wrist fractures: the
study of osteoporotic fractures. The study of osteoporotic fractures research
group, J. Am. Geriatr. Soc. 41 (1993) 1226–1234.
[12] T.H. Diamond, S.W. Thornley, R. Sekel, P. Smerdely, Hip fracture in elderly
men: prognostic factors and outcomes, Med. J. Aust. 167 (1997) 412–415.
[13] US Department of Health and Human Services, Bone Health and Osteoporosis:
A Report of the Surgeon General, US Department of Health and Human
Services, Office of the Surgeon General, Rockville, MD, 2004.
[14] T.E. Jager, H.B. Weiss, J.H. Coben, P.E. Pepe, Traumatic brain injuries evaluated
in U.S. emergency departments, 1992–1994, Acad. Emerg. Med. 7 (2) (2000)
134–140.
[15] M.J. Shauver, H. Yin, M. Banerjee, K.C. Chung, Current and future national
costs to medicare for the treatment of distal radius fracture in the elderly, J.
Hand Surg. Am. 36 (8) (2011) 1282–1287.
[16] L.J. Melton, Epidemiology of fractures, in: B.L. Riggs, L.J. Melton (Eds.),
Osteoporosis Etiology, Diagnosis and Management, 2nd ed., Lippincott-Raven,
Philadelphia, PA, 1995, pp. 225–248.
[17] W.C. Hayes, E.R. Myers, J.N. Morris, T.N. Gerhart, H.S. Yett, L.A. Lipsitz, Impact
near the hip dominates fracture risk in elderly nursing home residents who
fall, Calcif Tissue Int. 52 (1993) 192–198.
[18] J.L. Old, M. Calvert, Vertebral compression fractures in the elderly, Am. Fam.
Phys. 69 (1) (2004) 111–116.
[19] National Spinal Cord Injury Statistical Centre (NSCISC) [homepage on the
Internet]. Birmingham, Alabama; 2010 [cited 2011 Dec 20]. Annual Statistical
Report, 2010 Complete public Version, Available from: https://www.nscisc.
uab.edu/public content/annual stat report.aspx
[20] C.M. Court-Brown, A. Garg, M.M. McQueen, The epidemiology of proximal
humeral fractures, Acta Orthop. Scand. 72 (4) (2001) 365–371.
[21] O. Johnell, J.A. Kanis, An estimate of the worldwide prevalence and disability
associated with osteoporotic fractures, Osteoporos. Int. 17 (12) (2006) 1726.
[22] D. Marshall, O. Johnell, H. Wedel, Meta-analysis of how well measures of bone
mineral density predict occurrence of osteoporotic fractures, BMJ 312 (1996)
1254–1259.
[23] C. Cooper, G. Campion, L. Melton, Hip fractures in the elderly: a world-wide
projection, Osteoporos. Int. 2 (1992) 285–289.
[24] C. Cooper, L.J. Melton 3rd, Epidemiology of osteoporosis, Trends Endocrinol.
Metab. 3 (1992) 224–229.
[25] American Geriatrics Society [website]. AGS/BGS clinical practice guideline:
prevention of falls in older persons (2010). New York, NY: American Geriatrics
Society, 2011. Availabla from http://www.americangeriatrics.org/health care
professionals/clinical practice/clinical guidelines recommendations/2010
[26] Centers for Disease Control and Prevention, National Center for Injury
Prevention and Control, Division of Unintentional Injury Prevention. Available
from: http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.
html
[27] J.C. Woolcott, K.J. Richardson, M.O. Wiens, B. Patel, J. Marin, K.M. Khan, et al.,
Metaanalysis of the impact of 9 medication classes on falls in elderly persons,
Arch. Intern. Med. 169 (21) (2009) 1952–1960.
[28] A.R. Huang, L. Mallet, C.M. Rochefort, T. Eguale, D.L. Buckeridge, R. Tamblyn,
Medication-related falls in the elderly: causative factors and preventive
strategies, Drugs Aging 29 (5) (2012) 359–376.
[29] A.F. Ambrose, G. Paul, J.M. Hausdorff, Risk factors for fall among older adults:
a review of literature, Maturitas 75 (May (1)) (2013) 51–61.
[30] B. Helgadóttir, L. Laflamme, J. Monárrez-Espino, J. Möller, Medication and fall
injury in the elderly population; do individual demographics, health status
and lifestyle matter? BMC Geriatr. 14 (2014) 92.
[31] Y. Chen, L.L. Zhu, Q. Zhou, Effects of drug
pharmacokinetic/pharmacodynamics properties, characteristics of
medication use, and relevant pharmacological interventions on fall risk in
elderly patients, Ther. Clin. Risk Manage. 10 (2014) 437–448.
[32] M.A. Russell, K.D. Hill, I. Blackberry, L.M. Day, S.C. Dharmage, The reliability
and predictive accuracy of the falls risk for older people in the community
assessment (FROP-Com) tool, Age Ageing 37 (2008) 634–639.
[33] D. Oliver, M. Britton, P. Seed, F.C. Martin, A.H. Hopper, Development and
evaluation of evidenced based risk assessment tool (STRATIFY) to predict
which elderly inpatients will fall: case-control and cohort studies, BMJ 315
(1997) 1049–1053.
[34] B.R. da Costa, A.W. Rutjes, A. Mendy, R. Freund-Heritage, E.R. Vieira, Can falls
risk prediction tools correctly identify fall-prone elderly rehabilitation
inpatients? A systematic review and meta-analysis, PLoS One 7 (7) (2012)
e41061.
[35] J. Billington, T. Fahey, R. Galvin, Diagnostic accuracy of the STRATIFY clinical
prediction rule for falls: a systematic review and meta-analysis, BMC Fam
Pract 13 (Aug 7) (2012) 76.
[36] R. Schwendimann, S. De Geest, K. Milisen, Evaluation of the Morse Fall Scale in
hospitalised patients, Age Ageing 35 (3) (2006) 311–313.
[37] A.L. Hendrich, P.S. Bender, A. Nyhuis, Validation of the Hendrich II Fall Risk
Model: a large concurrent case/control study of hospitalized patients, Appl.
Nurs. Res. 16 (1) (2003) 9–21.
[38] R.G. Cumming, R. Ivers, L. Clemson, J. Cullen, M.F. Hayes, M. Tanzer, P.
Mitchell, Improving vision to prevent falls in frail older people: a randomized
trial, J. Am. Geriatr. Soc. 55 (2) (2007) 175–181.
[39] L. Johnson, J.G. Buckley, A.J. Scally, D.B. Elliott, Multifocal spectacles increase
variability in toe clearance and risk of tripping in the elderly, Invest.
Ophthalmol. Visual Sci. 48 (2007) 1466–1471.
[40] S.R. Lord, J. Dayhew, A. Howland, Multifocal glasses impair edge-contrast
sensitivity and depth perception and increase the risk of falls in older people,
J. Am. Geriatr. Soc. 50 (2002) 1760–1766.
[41] A. Biderman, J. Cwikel, A.V. Fried, D. Galinsky, Depression and falls among
community dwelling elderly people: a search for common risk factors, J.
Epidemiol. Commun. Health 56 (8) (2002) 631–636.
[42] B. Arroll, N. Khin, N. Kerse, Screening for depression in primary care with two
verbally asked questions: cross sectional study, BMJ 327 (7424) (2003)
1144–1146.
[43] M.E. Tinetti, C.F. Mendes de Leon, J.T. Doucette, D.I. Baker, Fear of falling and
fall-related efficacy in relationship to functioning among community-living
elders, J. Gerontol. 49 (3) (1994) M140–M147.
[44] N. Deshpande, E.J. Metter, F. Lauretani, S. Bandinelli, J. Guralnik, Ferrucci.
Activity restriction induced by fear of falling and objective and subjective
measures of physical function: a prospective cohort study, J. Am. Geriatr. Soc.
56 (4) (2008) 615–620.
[45] L.E. Powell, A.M. Myers, The Activities-specific Balance Confidence (ABC)
Scale, J. Gerontol. A Biol. Sci. Med. Sci. 50 (1) (1995) M28–M34.
[46] V.C. Pangman, J. Sloan, L. Guse, An examination of psychometric properties of
the mini-mental state examination and the standardized mini-mental state
examination: implications for clinical practice, Appl. Nurs. Res. 13 (4) (2000)
209–213.
[47] J.C. Menant, J.R. Steele, H.B. Menz, B.J. Munro, S.R. Lord, Optimizing footwear
for older people at risk of falls, J. Rehabil. Res. Dev. 45 (8) (2008)
1167–1181.
[48] M.K. Karlsson, T. Vonschewelov, C. Karlsson, M. Cöster, B.E. Rosengen,
Prevention of falls in the elderly: a review, Scand. J. Public Health 41 (July (5))
(2013) 442–454.
[49] M.E. Tinetti, Performance-oriented assessment of mobility problems in
elderly patients, J. Am. Geriatr. Soc. 34 (1986) 119–126.
[50] M.R. Lin, H.F. Hwang, M.H. Hu, H.D.I. Wu, Y.W. Wang, F.C. Huang,
Psychometric comparisons of the timed up and go, one-leg stand, functional
reach, and Tinetti balance measures in community-dwelling older people, J.
Am. Geriatric Soc. 52 (8) (2004), 134.
[51] K.O. Berg, S.L. Wood-Dauphinee, J.I. Williams, D. Gayton, Measuring balance in
elderly: preliminary development of an instrument, Physiother. Can. 41
(1989) 304–311.
[52] S.G. Brauer, Y.R. Burns, P. Galley, A prospective study of laboratory and clinical
measures of postural stability to predict community dwelling fallers, K.
Gerontol. 55 (2000) M469–476.
[53] A. Shumway-Cook, S. Brauer, M. Woolacott, Predicting the probablility for
falls in community-dwelling older adults using the Timed Up & GoTest, Phys.
Ther. 80 (September (9)) (2000) 896–903.
[54] J.M. Hausdorff, D.A. Rios, H.K. Edelberg, Gait variability and fall risk in
community-living older adults: a 1-year prospective study, Arch. Phys. Med.
Rehabil. 82 (8) (2001) 1050–1056.
[55] E. Stone, M. Skubic, M. Rantz, C. Abbott, C. Miller, Average in-home gait speed:
investigation of a new metric for mobility and fall risk assessment of elder,
Gait Posture 41 (1) (2015) 57–62.
[56] O. Beauchet, B. Fantino, G. Allali, S.W. Muir, M. Montero-Odasso, C. Annweiler,
Timed Up and Go test and risk of falls in older adults: a systematic review, J.
Nutr. Health Aging 15 (December (10)) (2011) 933–938.
 A.F. Ambrose et al. / Maturitas 82 (2015) 85–93
[57] D. Schoene, S.M. Wu, A.S. Mikolaizak, J.C. Menant, S.T. Smith, K. Delbaere, S.R.
Lord, Discriminative ability and predictive validity of the timed up and go test
in identifying older people who fall: systematic review and meta-analysis, J.
Am. Geriatr. Soc. 61 (February (2)) (2013) 202–208.
[58] T.S. Alexandre, D.M. Meira, N.C. Rico, S.K. Mizuta, Accuracy of Timed Up and
Go Test for screening risk of falls among community dwelling elderly, Rev.
Bras. Fisioter 16 (September–October (5)) (2012) 381–388.
[59] M.A. Murphy, S.L. Olson, E.J. Protas, A.R. Overby, Screening for falls in
community-swelling elderly, J. Aging Phys. Act 11 (2003) 66–80.
[60] U.S. Preventive Services Task Force, Screening for osteoporosis: U.S.
preventive services task force recommendation statement, Ann. Intern. Med.
154 (5) (2011) 356.
[61] S. Toyabe, 17 World Health Organization fracture risk assessment tool in the
assessment of fractures after falls, BMC Health Serv. Res. 10 (2010) 106.
[62] BC Guidelines Osteoporosis. Diagnosis, Treatment and Fracture Prevention
developed by the Guidelines and Protocols Advisory Committee on behalf of
the Medical Services Commission. Available from: http://www2gov.bc.ca/
gov/topic.page?id=F8231A43423D4AF5B173EECE777FA911#Step1
[63] H.D. Nelson, C.D. Morris, D.F. Kraemer, S. Mahon, N. Carney, P.M. Nygren, M.
Helfand, Osteoporosis in Postmenopausal Women: Diagnosis and Monitoring,
Evid. Rep. Technol. Assess (Summ) 28 (2001) 1–2.
[64] N. Kelepouris, K.D. Harper, F. Gannon, F.S. Kaplan, J.G. Haddad, Severe
osteoporosis in men, Ann. Intern. Med. 123 (1995) 452–460.
[65] M.K. Thomas, D.M. Lloyd-Jones, R.I. Thadhanai, A.C. Shaw, D.J. Deraska, B.T.
Kitch, et al., Hypovitaminosis D in medical inpatients, N. Engl. J. Med. 338
(1998) 777–783.
[66] R.D. Semba, E. Garrett, B.A. Johnson, J.M. Guralnik, L.P. Fried, D. Vitamin,
deficiency among older women with and without disability, Am. J. Clin. Nutr.
72 (2000) 1529–1534.
[67] H.A. Bischoff-Ferrari, B. Dawson-Hughes, W.C. Willet, H.B. Staehelin, M.G.
Bazemore, R.Y. Zee, et al., Effect of vitamin D on falls: a meta-analysis, JAMA
291 (2004) 1999–2006.
[68] C. Colon-Emeric, M. Kuchibhatla, C. Pieper, W. Hawkes, L. Fredman, J.
Magaziner, et al., The contribution of hip fracture to risk of subsequent
fractures: data from two longitudinal studies, Osteoporos. Int. 11 (2003)
879–883.
[69] D.J. Torgerson, P. Dolan, Prescribing by general practitioners after an
osteoporotic fracture, Ann. Rheum. Dis. 57 (1998) 378–379.
[70] C. Colon-Emeric, L. Yballe, R. Sloane, C.F. Peiper, K.W. Lyles, Expert physician
recommendations and current practice patterns for evaluating and treating
men with osteoporotic hip fracture, J. Am. Geriatr. Soc. 48 (2000) 1261–1263.
[71] L. Clemson, L. Mackenzie, C. Ballinger, J.C. Close, R.G. Cumming, Environmental
interventions to prevent falls in community-dwelling older people: a
meta-analysis of randomized trials, J. Aging Health 20 (8) (2008) 954–971.
[72] F. El-Khoury, B. Cassou, M.A. Charles, P. Dargent-Molina, The effect of fall
prevention exercise programmes on fall induced injuries in community
dwelling older adults: systematic review and meta-analysis of randomised
controlled trials, BMJ 347 (2013) f6234.
[73] D.N. Pamukoff, E.C. Haakonssen, J.A. Zaccaria, M.L. Madigan, M.E. Miller, A.P.
Marsh, The effects of strength and power training on single-step balance
recovery in older adults: a preliminary study, Clin. Interv. Aging 9 (2014)
697–704.
[74] A. Voukelatos, R.G. Cumming, S.R. Lord, C. Rissel, A randomized, controlled
trial of tai chi for the prevention of falls: the Central Sydney tai chi trial, J. Am.
Geriatr. Soc. 55 (8) (2007) 1185–1191.
93
[75] K.J. Hill Schwartz, Assessment and management of fall in older people, Intern.
Med. J. 34 (9–10 September–October) (2004) 557–564.
[76] M. Chapuy, M. Arlot, F. Duboeuf, J. Brun, B. Crouzet, S. Arnaud, et al., Vitamin
D3 and calcium to prevent hip fractures in elderly women, N. Engl. J. Med. 327
(23) (1992) 1637–1642.
[77] B. Dawson-Hughes, S.S. Harris, E.A. Krall, G.E. Dallal, Effect of calcium and
vitamin D supplementation on bone density in men and women 65 years of
age or older, N. Engl. J. Med. 337 (10) (1997) 670–676.
[78] Institute of Medicine, Food, Nutrition Board, Dietary Reference Intakes for
Calcium and Vitamin D, National Academy Press, Washington, DC, 2010.
[79] C.S. Colón-Emeric, K.G. Saag, Osteoporotic fractures in older adults, Best Pract
Res Clin Rheumatol 20 (4) (2006) 695–706.
[80] C.H. Chestnut III, A. Skag, C. Christiansen, R. Recker, J.A. Stakkkestad, A.
Hoiseth, et al., Effects of oral ibandronate administered daily or intermittently
on fracture risk in postmenopausal women, J. Bone Miner Res. 19 (2004)
1241–1249.
[81] A. Cranney, L. Waldegger, N. Zytaruk, B. Shea, B. Weaver, A. Papaioannou,
et al., Risedronate for the prevention and treatment of postmenopausal
osteoporosis, Cochrane Database Syst. Rev. 4 (2003) CD004523.
[82] H.G. Bone, D. Hosking, J.P. Devogelaer, J.R. Tucci, R.D. Emkey, R.P. Tonino, et al.,
Ten years’ experience with alendronate for osteoporosis in postmenopausal
women, N. Engl. J. Med. 350 (2004) 1189–1199.
[83] S. Boonen, M. McClung, R. Eastell, G. El-Hajj Fuleihan, I.P. Barton, P. Delmas,
Safety and efficacy of risedronate in reducing fracture risk in osteoporotic
women aged 80 and older: implications for the use of antiresorptive agents in
the old and oldest old, J. Am. Geriatr. Soc. 52 (2004) 1832–1839.
[84] C.H. Chestnut 3rd, S. Silverman, K. Andriano, H. Genant, A. Gimona, S. Harris, A
randomized trial of nasal spray salmon calcitonin in postmenopausal women
with established osteoporosis: the prevent recurrence of osteoporotic
fractures study, Am. J. Med. 109 (2000) 267–276.
[85] J.A. Knopp-Sihota, C.V. Newburn-Cook, J. Homik, G.G. Cummings, D.
Voaklander, Calcitonin for treating acute and chronic pain of recent and
remote osteoporotic vertebral compression fractures: a systematic review
and meta-analysis, Osteoporos Int 23 (1) (2012) 17–38, 2012.
[86] European Medicines Agency recommends limiting long-term use of calcitonin
medicines. Available from: http://www.ema.europa.eu/ema/index.
jsp?curl=pages/medicines/human/public health alerts/2012/07/human pha
detail 000065jsp&mid=WC0b01ac058001d126
[87] B. Ettinger, D. Black, B. Mitlak, R.K. Knickerbocker, T. Nickelsen, T. Genant,
et al., Reduction of vertebral fracture risk in postmenopausal women with
osteoporosis treated with raloxifene: results from a 3-year randomized
clinical trial, JAMA 282 (1999) 637–645.
[88] K.W. Lyles, C.S. Colon-Emeric, J.S. Magaziner, et al., Zoledronic acid and
clinical fractures and mortality after hip fracture, N. Engl. J. Med. 357 (2007)
1799–1809.
[89] P. Zoledronate van den Berg, Fractures, and mortality after hip fracture, N.
Engl. J. Med. 358 (2008) 967–969.
[90] M.E. Tinetti, et al., A multifactorial intervention to reduce the risk of falling
among elderly people living in the community, N. Engl. J. Med. 33113 (1994)
821–827.
[91] M.E. Tinetti, et al., Effect of Dissemination of Evidence in Reducing Injuries
from Falls, N. Engl. J. Med. 359 (2008) 252–261.
[92] N. Waldron, I. Dey, Y. Nagree, J. Xiao, L. Flicker, A multi-faceted intervention to
implement guideline care and improve quality of care for older people who
present to the emergency department with falls, BMC Geriatr. 11 (2011) 6.