Incidence, risk factors and consequences of falls among elderly subjects living in the community

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1 Incidence, risk factrs and cnsequences f falls amng elderly subjects living in the cmmunity A criteria-based analysis PAUL A. STALENHOEF, HARRY F.J.M. CREBOLDER, J. ANDRE KNOTTNERUS, FRANS G.E.M. VAN DER HORST * In rder t btain an verview f the incidences, risk factrs and health cnsequences f falls amng elderly persns living in the cmmunity frm the available literature, a Medline cmputer search f publicatins ver the perid was carried ut. Furteen studies met the fllwing inclusin criteria: i) the study is an riginal investigatin f falls amng the elderly, ii) the study deals with the incidence, risk factrs and/r cnsequences f falls amng the elderly and ill) the study refers t a ppulatin at risk cnsisting f persns aged 60 years r ver belnging t a ppulatin relevant t general practice. The selected studies were subjected t a methdlgical assessment n the basis f 0 methdlgical criteria. All the studies were independently assessed by authr and assistant t btain a methdlgicatcnsensus. The relevant utcmes f these studies are reprted. Pling f data was nt perfrmed because f relevant differences between the studies. Tw studies met all methdlgical criteria and ther studies were secnd best. These studies were given preference. Apprximately 0% f subjects lder than 65 years fall at least nce a year and apprximately 5% fall recurrently. The main risk factrs fr falls amng the elderly belng t the intrinsic (patient-related) risk factrs: cgnitive impairment, balance and gait disrders, use f sedatives and hypntics, a histry f strke, advanced age, arthritis f the knee and a high level f dependence. Extrinsic (envirnment-related) risk factrs did nt play a significant rle in any f the studies. Nt all studies dealt with the health cnsequences f falls amng the elderly. Majr injuries were reprted in 0.5-9% and fractures in -%. Key wrds: accidental falls, aged, elderly, incidence, risk factrs, mrbidity. alls amng the elderly are a cmmn prblem in general practice. Apprximately 0% f peple aged 65 years and ver wh are living in the cmmunity fall at least nce a year. -7 This percentage rises with age. The fall rates fr peple aged 80 years and ver are apprximately 50% a year. Mst falls amng the elderly are nt reprted t a general practitiner. In a primary care-based study f the ppulatin aged 65 years and ver in general practices, 79. falls per 000 persns per year (8%) were reprted t the general practitiner. 8 Apprximately 5% f the falls result in fractures and 5% in ther injuries. Cnsidering the imprtance f the prblem f falls amng the elderly in the cntext f the increased number f cmmunity-dwelling elderly peple, it is a matter f interest fr general practice t btain a mre detailed picture f the utcmes f studies. The results f studies published n this subject vary widely. In rder t develp a slid preventive strategy fr the elderly, it is necessary t have a valid and cncise survey f the literature, particularly cncerning the incidence, risk factrs and * P_A. Stalenhef', H.FJ.M. Creblder', J.A. Knttnerus', F.G.E.M. van der Hrst Department f General Practice, University Maastricht, Maastricht, The Netherlands Crrespndence P_A_ Stalenhef, Department f General Practice, University Maastricht. P.O. Bx 66, 600 MD Maastricht, The Netherlands. tel , fax + 69 cnsequences f falls amng the elderly. Over the last few years the reprts f the first interventin trials n fall risk have been published. In general, interventin prgrammes appear t be effective. 9 " In particular, ercise reduces falls and fall-related injuries in the elderly 9 r decreases muscle weakness. 0 The risk f falling is als reduced by a multiple risk factr interventin strategy. Hwever, if the interventin is nt sufficient the effect n serius falls appeared nt t be preventable. In this paper we describe the characteristics and results f studies f falls amng elderly persns living in the cmmunity. In rder t evaluate the validity f the different studies we investigated whether the selected studies met imprtant methdlgical criteria. We had questins. What is the methdlgical quality f the selected studies n falls amng the cmmunity-dwelling elderly? What are the results f these studies with regard t incidence, risk factrs and health cnsequences f falls amng elderly peple living in the cmmunity? What is the relatinship between the methdlgical quality f the studies and their results? METHODS A literature search was perfrmed using inclusin criteria. The study had t be an riginal investigatin f falls amng the elderly, living in the cmmunity. Dwnladed frm n 6 January 08

2 Fails amng elderly subjects m The study had t deal with the incidence, risk factrs and cnsequences f falls amng the elderly. The study had t cmprise a ppulatin atriskf persns aged 60 years r ver and relevant t general practice. A Medline cmputer search was carried ut in January 99- The keywrds (Medical Subject Headings) were accidental falls, aged, elderly, incidence, risk factrs and mrbidity. The search included the perid January 98 t February 99. The key wrds yielded 7 references. Applicatin f the abve criteria led t the identificatin f publicatins which culd be subjected t methdlgical evaluatin by means f a criteria-based analysis. In rder t btain a measure fr the quality f the studies selected, all studies were checked independently by f the authrs (P.S.) and an assistant, wh is mentined in the acknwledgements (R.L.), against a criteria list. The criteria are listed in the ftnte f table. We used 0 criteria fr quality, partly based n thse used by Sackett et al. and partly arising frm ur wn bjectives. The criteria were dichtmus: each study was given a '+' r a '-' accrding t whether a particular criterin was met r nt. Disagreements were discussed t reach cnsensus. The first criterin (A) checked was whether a clear definitin f falling was given. An example f a clear definitin used by Tinetti et al. is 'A fall is defined as a subject's unintentinally cming t rest n the grund r at sme lwer level, nt as a result f a majr intrinsic event (e.g. strke r syncpe) r verwhelming hazard.' The secnd criterin (B) was whether an adequate sample size had been chsen and whether sampling prcedures had been carried ut and described in a prper manner. Fr an adequate sample size we chse a minimum number f 00 persns. The third criterin (C) was whether the utcmes were applicable t the elderly ppulatin in general practice. The furth criterin (D) was whether the design was prspective r retrspective. Prspective appraches are generally preferred ver retrspective designs, with their disadvantages f recall and selectin bias, particularly in studies f the elderly. The fifth criterin (E) was whether bth intrinsic (patient-related) and extrinsic (envirnment-related) risk factrs fr falling had been taken int accunt. Criterin (F) was whether an adequate clinical assessment had been made with the usual techniques, such as questinnaires, interviews and/r clinical examinatins during hme visits with standardized prcedures and measurements. The seventh criterin (G) was whether, in prspective studies, the duratin f the fllw-up was at least 6 mnths. The eighth criterin (H) was whether, in prspective studies, the lss during fllw-up had been less than 0%. The ninth criterin (I) was whether the data analysis, data interpretatin and data presentatin were apprpriate. This meant i) all relevant utcmes were reprted, ii) the utcme parameters were presented in an apprpriate way, and iii) the data were analysed using methds fr multivariate analysis. The tenth and final criterin (J) was whether the study culd be reprduced by ther investigatrs n the basis f the descriptin f methds and utcmes. Fr each f the abve criteria the definitive scre was nted. Cmbining all '+' and '-' then resulted in a ttal impressin which prvides a certain quality label. RESULTS Methdlgical evaluatin Table I presents the results f the methdlgical evaluatin f the studies selected. Samples had nt always been taken in the same way, differed cnsiderably in size and in sme cases evidently suffered frm selectin prcesses. The studies by Wild et al. ^' 6 and Hale et al. 5 were fficebased. The ppulatins in the studies by Wild et al. * and Nevitt et al. 6 were cnfined t elderly peple with at least fall accident in the previus year. Peple living in residential hmes were excluded frm the study by Dwn tn and Andrews. 7 In the study by Nevitt et al. 5 participants, fallers nly, were recruited frm senir centres, senir residences, churches and ut-patient clinics. In Clark et al.'s 8 study all the participants were living in a residential hme. In the studies by Prudham and Evans, 5 Campbell et al., 6 Blake et al., 7 Clark et al. 8 and Cwikel 9 the health cnsequences f falls were nt the subject f investigatin at all. Lrd et al.'s study was cnfined t wmen. Data analysis and data presentatin were incmpletely reprted in studies: Campbell et al. 6 and Cwikel et al. 9 In Wild et al.'s ' 6 studies data analysis was insufficient. Frm studies publicatins were available and were taken int accunt: Campbell et al., -'* Wild et al. l6 and Cwikel 9 and Cwikel et al. 7 This table makes it clear that nly the studies by Tinetti et al. and Campbell et al. ' met all ur methdlgical criteria. Characteristics and utcmes Table presents the main characteristics, incidences and health cnsequences f the studies selected. Characteristics We included the year f publicatin, cuntry, number f participants, age, mean age and sex rati at time f recruitment. Twelve studies were frm English-speaking cuntries, study was frm Israel 9 and ne frm Japan. The perid f publicatin was in mst cases between 988 and 99, but publicatins dated frm There was an imprtant divergence in the number f participants, varying frm 76 8 t 76 ' in die prspective studies and frm O 7 t.9 9 in the retrspective studies. Mst studies included persns f 65 years and lder ' 5 " 7 ',5,9,0 r ^. m 65 t years, althugh the study by Nevitt et al. 6 included persns aged 60 years and ver. Others included persns f 70 years and ver ' i ' 8 r even 75 years and ver. ' 7 The differences in age f the persns included shuld be taken int accunt when cnsidering the incidences,riskfactrs and cnsequences f falls reprted. The mean age f the participants ranged Dwnladed frm n 6 January 08

3 EUROPEAN JOURNAL OF PUBLIC HEALTH VOL NO. frm 7 years t 8 years, ' but was reprted in nly 7 studies (Tinetti et al., O'Lughlin et al., Hale et al., 5 Dwntn and Andrews, 7 Clark et al., 8 Cwikel 9 and Lrd et al. ^, with standard deviatins in studies (Tinetti et al., Dwntn and Andrews 7 and Clark et al. 8 ). The sex rati was missing in studies (Wild et al., Campbell et al., 6 Blake et al. 7 and Cwikel 9 ). Lrd et al's 0 study cncerned nly wmen. Incidences All studies investigated hw many persns had a fall at least nce a year. This percentage varied frm 7% in Yasumura et al's study, which excluded very aged persns, t 57% in Nevitt et al.'s study, with a ppulatin recruited frm senir centres and such like. The percentage f persns wh had mre than fall a year had an apprximately equal diversity: -%. Only8studies gave percentages f r mre falls a year. -5,5,6,8,0 j n thse studies which prvided mean ages there is a relatinship between the mean ages and incidences f falls. Risk factrs and ther determinants We nly included thse risk factrs and determinants which were labelled as significant by the authrs themselves. We clustered risk factrs and determinants int the fllwing grups: i) medicatin, ii) mental functining, iii) mbility disrders, iv) varius cmplaints, symptms and disrders, v) activity level, vi) demgraphic determinants, vii) dependence, viii) varius risk factrs and determinants, ix) fall histry and x) envirnmental risk factrs (table ). It is nt pssible t distil frm the studies selected a cmplete picture f statistically significant risk factrs and determinants, fr several reasns, i) Nt all studies included the same risk factrs and determinants fr investigatin; ii) risk factrs were expressed in different parameters, such as relative risks, dds ratis and incidence rate ratis and iii) the statistical methd used was nt always described and if it was there was a diversity f statistical techniques: a multivariate analysis, which is a valid instrument fr the analysis f a multiple factr phenmenn such as the risks f falling amng die elderly, was nt carried ut in all the studies. Risk factrs and determinants mst frequently mentined as significant were cgnitive impairment ' ' ' and balance and gait disrders ' ' '(5 times), the use f sedatives and hypntics, ^' ' 7 ' 9 a histry f strke " 5 ' and advanced age 5 ' 6 ' 9 ' ( times), arthritic knee ' ' 7 ' 6 and high level f dependence ' ( times) and the number f drugs, ^' ft prblems, ' 7 limited mbility, 5 ' 9 dizziness, ' 7 lw systlic bld pressure, ^* pr visin, 0 ' high level f activity, " number f risk factrs, ' 6 strength f the dminant hand, ' ' cntacts with general practitiner, ' and a histry f previus falls ( times). Nt a single study fund extrinsic risk factrs t be significant risk factrs fr falls amng the elderly. Health cnsequences f falls Nt all studies investigated the healdi cnsequences f falls. Five studies, all with a retrspective design 5 " 7 ' 9 ' and prspective study prvided n infrmatin abut the health cnsequences f falls. In the ther studies Table Applicatin f cnteria fr methdlgical evaluatin f studies f fells amng the elderly in the perid f Studies and reference number B c D H Wild etal. ' 6 Prudham and Evans Campbell et al. Tinetti et al. Blake et al. 7 Nevitt etal. 6 Campbell et al. ' Dwntn and Andrews Cwnkel 9 and Cwikel et al. 7 Hale etal. 5 Clark etal. 8 O'Lughlin et al. Lrd et al. 0 Yasumura et al. +* < _h AS -k Criterin with: + - yes, - n,? incnclusive, - nt applicable Criteria A: clear definitin f a fall B: adequate sample sue and prcedure G results applicable t the elderly ppulatin in general practice D: prspective study (+) r retrspective study ( ) E: bth intrinsic and extrinsic risk factn fr falling taken int accunt F: adequate clinical assessment G: fllw-up at least 6 mnths, in the case f a prspective design H: <0% lss t fllw-up, in the case f a prspective design I: adequate data analysis, data interpretatin and data presentatin J: reprducibility f the study Remarks a: fallen nly' 6-6 b excluded residential hmes c case-cntrl study 5lMl6 A cnsequences f falls nt investigated e: included mentally ill persns 7 f: residents f hstel fr the aged nly g: recruited frm senir centres, senir residences, churches and ut-patient clinics " WM> h. ffice-based selectin i: stratified selectin M7 '"- 7 j: wmen nly w k. publicatins available M' - : fllw-up f year " «-'«««Dwnladed frm n 6 January 08

4 Falls amng elderly subjects selected, we cmpared the percentages f falls with minr and majr injuries, fractures, particularly hip fractures and mrtality during a year fllw-up (table ). Majr injuries, if prvided, like laceratin widi suture, dislcatins and sprains as results f falls were reprted in % 5 f falls. The percentage f falls resulting in fractures als shwed a cnsiderable divergence:.5 - % ' 6 Hip fractures resulting frm falls shwed percentages f %. 0 The mrtality rates during a year fllw-up were nt cnfined t mrtality directly caused by falls but cmprised all mrtality during die fllw-up. Mrtality rates varied frm -5%. - 6 Finally, die lss t fllw-up is registered in table : nly Wild et al.'s study (%) exceeded 0%. Once again we find remarkable differences in utcmes, caused partly by differences between die ppulatins and partly by tlie methds f investigatin used. The cnsequence f missing data, differences in die definitin f injury and the use f different methds f investigatin is that it is nt pssible t give a valid survey f these utcmes. The data reprted by Tinetti et al., O'Lughlin et al., Campbell et al. ' and Nevitt et al. 6 are cmparable. DISCUSSION Methdlgical quality Empirical investigatins f elderly subjects living in die cmmunity encunter varius limitatins and are cmplicated in dieir nature as well as in die management f practical prblems. Studies in this area shuld be viewed widi this in mind, therwise results wuld seem disappinting. In die presented criteria-based review we used 0 criteria fr quality. The weighing f these criteria is difficult. T avid arbitrariness we did nt use a weighing with pints, but preferred a dichtmizatin int 'yes' r 'n' which has its limitatins in nt taking int accunt the differences in weight f the several criteria. ~^ We fund a great diversity f methdlgical quality amng the studies selected. It is remarkable, that studies 5 ' 9 failed t prvide a definitin f a fall. The ther studies used varius definitins mstly excluding majr intrinsic events such as strke and syncpe and accidents as well. Nt all studies gave a clear descriptin f rhe sampling prcedure used r used a sufficient sample size and nt all samples were representative f the elderly ppulatin living in the cmmunity. One study was cnfined t fallers, recruited frm senir centres, senir residents, Table Characteristics, incidences and health cnsequences f falls frm studies f falls amng the elderly in the perid Studies and Characteristics Incidences Health cnsequences reference number Wildetal. Prudham and Evans. Campbell et al. 6 Tinetti et al. Blake et al. 7 Nevitt etal. 6 Campbell et al. ' NZ USA USA NZ 5, , ± (Cl 95%) 8 (7-7) m w 0.. lm 7w.0* 6.5. m w.* m.5 w * Dwntn & Andrews Cwikel " Hale etal. 5 Clark etal. 8 O'Lughlin et al. Lrd et al. 0 Yasumura et al ISR USA AUS CAN AUS JAP 0, ± ± m 75.5 w w. 6. m.0 w m w 7 m w 6.5* * * Characterist tea : year f publicatin : cuntry : number f participants : age 5: mean age 6 female/ male rati Incidences 7: percentage f falls by subjects with r mre falls a year 8: percentage f falls by subjects with r mre falls a year Health cnsequences 9: percentage f falls with minr injury (laceratins withut suture, bruises, abrasins, and ther sft tissue injury) 0: percentage f falls wirii majr injury (laceratins with suture, dislcatins, and sprains) : percentage f falls with a fracture ther than hip fracture : percentage f falls with a hip fracture : mrtality rate during year fllw-up : number f participants at the end f the fllw-up perid Cuntry AUS: Australia CAN: Canada ISRJ Israel JAP: Japan NZ: New Zealand : United Kingdm USA: United States f America *: percentage f subjects wh had a fall : nt applicable : nt prvided m: men w: wmen Dwnladed frm n 6 January 08

5 EUROPEAN JOURNAL OF PUBLIC HEALTH VOL NO. Table Statistically significant risk factrs and ther determinants f falling amng the elderly Reference numbers: = Tinetti et al.; - CLughlin et al.;,= Campbell et al.; 5- Prudham and Evans; 6- Campbell et al.; 7- Blake et al.;,6= Wild etal; 5= Hale et al.; 6= NevittetaL; 7= Dwncn and Andrew; 8-Clark et al.; 9-Cwikel; 0= LrdetaL; = YasumuraetaL / 5 6 7, Risk factrs/determinants Ttal MB MB MB B MB MB * B M MB MB M MB MB Medicatin Sedatives/hypntics Antidepressives Diuretics/antihypertensive drugs Number f drugs Mental functining Cgnitive impairment Depressin Mbility disrders Disability f lwer extremities Balance/gait disrders Ft prblems Arthritic knee Limited mbility Truble bending dwn Strke Parkinsn's disease Vanus cmplaints/symptms/disrders Faints/black uts Dizziness Respiratry disrder Lw systlic bld pressure Palpitatins Heart disease Pr visin Duble visin Activity level Lw High Demgraphic determinants Gender F>M Age Whites Single Dependence High level Receives prfessinal supprt Receives family supprt Varius risk factrs and determinants Number f risk factrs Number f cmplaints Use f mbility aids Strength dminant hand Palmmental reflex Days with limited activity Increased bdy sway Cntacts with general practitiner Subjective fall risk Incntinence urine/bwel Fall histry Previus fell(s) Injurius fall(s) in previus year Envirnmental risk factrs xa xa xa xc x (x) (x) x x M: muluvariate analysis B: blvariate analysis n infrmatin abut statistical methd a: nly injurius falls b: nly men c wmen indr falls and men utdr falls d: nly u*men e: risk factrs fr multiple falls x: statistically significant (x): n infrmatin abut significance Dwnladed frm n 6 January 08

6 Falls amng elderly subjects churches r university ut-patient clinics. Anther study, a case-cntrl study f fallers nly, had an insufficient statistical analysis. One study was an ffice-based study f ambulatry patients f a family practice with an insufficient sample size and study was cnfined t wmen. 0 Other studies recruited their participants frm ppulatins such as a cmmunity survey, ' 7 ' 9 a reginal area, ' 5 ' 6 recrds and registers f general practices, ' 7 a municipal electral list r frm a hstel fr elderly peple. 8 Sample sizes differed cnsiderably. Retrspective studies have the disadvantages f recall bias due t memry lss and ptential selectin bias (differential lss t fllw-up) resulting in lwer incidence rates. Hwever, it is surprising that the incidence rates fund in the retrspective studies hardly differed frm thse fund in prspective studies. Tw studies reprted high incidence rates. ' In study participants with a histry f falling at least nce during the previus mnths were recruited frm senir centres and clinics. 6 This prbably cncerns a ppulatin with mre intrinsic risk factrs. In the ther study 8 the high incidence f falls can be explained frm the fact that it cncerns a ppulatin frm a hstel fr the aged, with a high mean age (8. ± 5.8 years), undubtedly a ppulatin with many intrinsic risk factrs as well. The lack f a clear descriptin f the statistical methds in many studies makes it difficult t judge their quality. Mst investigatrs ' ' 6 ' 7 ' 6 " analysed factrs using a multiple, lgistic, stepwise mdel t btain a weighing f the different, independent risk factrs. Data frm studies using nly a bivariate analysis^' are nt always cmparable, because parameters are different. Anther prblem is that studies, ' 5 with a small study sample lacked the statistical pwer t detect ptentially imprtant differences in the data. Pling f data was nt perfrmed because f majr differences between the studies selected. With all these shrtcmings and differences f methdlgy in mind it must be cncluded, that a definitive methdlgical assessment can hardly be made. Fur studies with a gd methdlgical quality may be given sme degree f pririty with regard t the utcmes: Tinetti et al., O'Lughlin et al., Campbell et al. ' and Nevitt et al. 6 All have a prspective design with a year fllw-up, give sufficient and clear descriptins f the methds and results and ffer a mre cmplete view f the subject f falls amng the elderly. Hwever, Nevitt et al.'s study suffers frm selectin deficiencies and the utcmes f Campbell et al.v' studies are described in different publicatins, which gave a disadvantage in cmparing data. Characteristics and utcmes If we cnfine this discussin t the abve-mentined studies we can try t summarize data t btain the essentials with regard t the incidences,riskfactrs and health cnsequences f falls amng the elderly. The yearly incidence rates in the studies by Tinetti et al., O'Lughlin et al. and Campbell et al. ' were similar:, 9(m)/(w) and 5% respectively. In Nevitt et al.'s 6 study, hwever, the incidence rates were cnsiderably higher: 57%, presumably due t the selectin f the study ppulatin, which cnsisted f subjects with a previus fall recrd, recruitedfrmselected settings such as senir centres and clinics. As fr risk factrs, there is hardly any similarity between the data in the studies. Balance and gait prblems are the nly risk factrs mentined as significant in all studies and a histry f strke is mentined as being a significant risk factr by O'Lughlin et al. and Campbell et al, ' althugh in Campbell et al.'s ' studies the significance was nly with regard t men. Tinetti et al. emphasized the imprtance f the use f sedatives and hypntics as an imprtant risk factr, which was cnfirmed by Campbell et al. ' fr wmen, an utcme n which preventive strategies can be based. It is striking that nly Tinetti et al. fund evidence fr cgnitive impairment as a statistically significant risk factr fr falling. It must be taken int accunt, hwever, that Nevitt et al.'s 6 study excluded peple wh were unable t respnd t questins and cgnitively impaired persns prbably belng t this grup. It seems plausible that persns with Parkinsn's disease run a higher risk f falling. Only Nevitt et al. 6 fund statistically significant evidence fr this in subjects with multiple falls. Lw bld pressure, resulting in rthstatic disturbances, was mentined as a risk factr by O'Lughlin et al. fr bth ses and by Campbell et al. ' fr wmen nly. Bth Tinetti et al. and Nevitt et al. 6 fund that the number f risk factrs is an additinal, statistically significant risk factr. Summarizing the health cnsequences f the studies selected we fund that nly 8 studies gave infrmatin abut the health cnsequences f falls. We differentiated minr and majr injuries, fractures and specifically hip fractures. Here again utcmes differed cnsiderably. Significance f ur findings Several questins remain after the present review. In view f the high incidences, the many risk factrs fr falls amng the elderly and the high risk f injury caused by a fall, effrts shuld be made in general practice t prevent falls amng the elderly as much as pssible. Preventive strategies shuld be based n the utcmes f investigatins. The present review fund a cnsiderable incidence f falls in ld age in all studies selected: per year each subject aged 65 years r ver has a prbability f at least fall f apprximately 0%, with a prbability f recurrent falling f apprximately 5% and a majr injury frm a fall f apprximately 5%. The great diversity f significant risk factrs presents a prblem in selecting risk factrs fr preventive strategies. We wuld prefer t chse the risk factrs fund t be significant in the studies by Tinetti et al., O'Lughlin et al., Campbell et al. ' and Nevitt et al., 6 n the basis f their methdlgical quality. Cnfining urselves t these studies we cnclude that preventive prgrammes shuld be directed at least at medicatin, in particular the use f sedatives and hypntics and the use f drugs in general, cgnitive Dwnladed frm n 6 January 08

7 EUROPEAN JOURNAL OF PUBLIC HEALTH VOL NO. impairment, mbility disrders such as disabilities f the lwer extremities, gait disrders due t a strke, arthritis f the knee, ft prblems and Parkinsn's disease, the level f activities, lw bld pressure, dizziness and insufficient muscle strength. It is a sinking utcme f the present review that nne f the studies selected fund a basis fr significance f envirnmental risk factrs. It may be questined which part effrts t imprve envirnmental risks shuld have in a preventive prgramme. Returning t ur aims, frmulated in the questins in the intrductin t this paper, we cautiusly cnclude that we have gained mre insight int the incidences, risk factrs and health cnsequences f falls amng the elderly, taking the methdlgical quality int accunt. Hwever, as a basis fr an interventin prgramme fr cmmunity-dwelling elderly peple, we need mre specific knwledge abut intrinsic and extrinsic risk factrs. We have therefre decided t set up a cmbined retrspective and prspective study as a basis fr preventin. Our aim is t develp a preventin prgramme, based n data btained frm a retrspective study, fllwed by a clinical assessment perfrmed in a randmly selected ppulatin with a systematic fllw-up. Data frm this study will be linked with data frm registratins by general practitiners. This study was supprted by a grant frm the Praeventie Fnds. We are indebted t Ren Lenir fr his assistance in the initial phase f this study and his check f the studies selected against the criteria list. Tinetti ME, Speechley M, Ginter SF. Risk factrs fr falls amng elderly persns living in the cmmunity. N Engl J Med 988;9:70-7. O'Lughlin JL, Rbitaille Y, Bivin J-F, Suissa S. Incidence f and risk factrs fr falls and injurius falls amng the cmmunity-dwelling elderly. Am J Epidemil 99; 7:-5. Campbell AJ, Brrie MJ, Spears GF. Risk factrs fr falls in a cmmunitybased prspective study f peple 70 years and lder. 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