Prevention of falls in older people living in the communityBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1419 (Published 28 April 2016) Cite this as: BMJ 2016;353:i1419
All rapid responses
The benefits of vitamin D for bone and muscle strength and its multiple other extra skeletal advantages are one of the major medical breakthroughs of the past decade. Yet, we continue to see new trials and meta-analyses trying to cast doubts on this important nutrient that works as a hormone on all the systems of the body. One of the examples of controversial studies quoted by this article is a study by Heike A. Bischoff-Ferrari, MD and et al starts without any working hypothesis and ends with the statement that "the physiology behind a possible detrimental effect of a high monthly bolus dose of vitamin D on muscle function and falls remains unclear and needs further investigation.
Reviewing the full study protocol of the above study, the weak foundation and the design flaws of this study are on full display. The following disorders and drugs must be exclusion criteria for every trial or meta- analysis: hypertension, hyperlipidemia and diseases of autonomic nervous system (or drugs affecting this system). Statins are commonly used in geriatric population with major detrimental effect on the proximal muscles of the lower extremities predisposing such patients to falls. Diuretics, vasodilators, including alpha blockers, nitrates, drugs for benign prostate hypertrophy, drugs used in erectile dysfunction, widely used anti-cholinergic medications, and anti-histamines (including anti-depressants and drugs for overactive bladder) must be all in exclusion criteria. Diabetes must also be included as exclusion criteria. Most patients with advanced type 1 or type 2 diabetes do have a certain degree of autonomic dysfunction, which includes orthostatic hypotension, a major risk factor for falls. Uncontrolled diabetes causes volume depletion and osthostasis and increases the risk of falls. The new-generation of anti-diabetes drugs such as canagliflozin, causes volume depletion and increases risk of falls. Past and present use of steroids, with known detrimental effects on the proximal muscles of the legs such as the quadriceps, must be also an exclusion criterion. Vitamin D supplements strengthen the musculo-skeletal system especially the proximal muscles of the lower extremities. This is a clear clinical outcome that we see daily in our practice. I have taken hundreds of frail elderly with proximal myopathy off walkers and prevented falls by judicious supplemtation of vitamin D. The opposite claim, that vitamin D increases falls or has no effect on falls, does not have a plausible biological explanation. In my opinion, most studies, if not all, similar to this study, fail to show the benefit of vitamin D on falls, do so because they have serious design flaws; mostly neglecting very important exclusion criteria.
Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline. Bischoff-Ferrari, HA et al. JAMA Intern Med. 2016;176(2)
Competing interests: No competing interests
I am grateful to Prof Vieira and colleagues for a review which might, just might, be studied (and followed?) by NHS England.
It is interesting that up in Scotland and in West London, something seems to have been done (rapid responses by Simey et al and Ms Goodare).
Waiting for NHS in the backwaters of the Fens, and the old market town of Peterborough to catch up.
Or, maybe the money has all been spent in reorganisations and re- re- re- organisations? And the staff? Playing musical chairs?
A start could be made by following the Edinburgh example, open access clinic-cum-gymnasium for the over 80s, then lower the entry age to 70, then 65?
Perhaps Age UK could help? Or, a major business located in Peterborough? A generation ago (1980s) Marks and Spencer gave us some money for a study on hearing loss in the elderly (Anand JK, Court I, BMJ, 1989, 1429-30).
Yours in hope.
Competing interests: Dottery old man
Dear Dr. Simey and colleagues,
Thank you for the commendation and additional information on this important topic. Yes, “a dose of at least 50 hours of challenging balance and progressive strength training, delivered by trained professionals” is recommended. What we meant was that they specific types and duration of balance, strength and endurance exercises for older adults with varying characteristics and functional capacities still need to be defined. Currently, we use clinical judgement without specific protocols tested for different groups.
Dear Dr. Hai Kiang,
Thank you for acknowledging the relevance of our article and for the insightful comments.
Dear Dr. Seemungal,
We appreciate your very pertinent considerations. Yes, vertigo is a well-known risk for falls (e.g. OR = 1.8, Silvia et al., 2010), and Benign Paroxysmal Positional Vertigo (BPPV) is a cause of balance impairment, which can lead to falls. Whilst symptomatic patients are often seen initially in primary care, diagnostic studies, including the Dix-Hallpike maneuver, and particularly treatment approaches, including the Epley maneuver, are often best performed by specialists in secondary or tertiary care (Maarsingh et al 2010, Annals Journal Club: Causes of Persistent Dizziness in Elderly Patients in Primary Care Ann Fam Med 2010 8:196-205). Currently, systematic screening approach for asymptomatic BPPV in all community-dwelling older adults who experienced falls has not been traditionally included in multifactorial interventions shown to be effective for falls (USPSTF, NICE, Cochrane). Research seeking to optimize the clinical evaluation and management of BPPV in symptomatic and asymptomatic older adults by general practitioners and geriatricians in the context of falls is warranted.
Dear Ms. Goodare,
We were glad to hear you found our article to be “a really thorough treatment of an important subject”. We apologize for the typos. This was a literature review, but we agree that patient views are important to be included in primary studies. In a previous study in long term care facility, we video-recorded residents during transfers (e.g. going from bed to wheelchair), watched the videos with them and asked them what where potential risks for falls during that transfer and what could be done to reduce the risk of falls during that transfer (Vieira et al., 2014). The residents had very insightful information.
Vieira, E. R., O’Rourke, H. M., Hunter, K., & Marck, P. B. (2014). Using video-elicitation to assess risks and potential falls reduction strategies in long term care. Disability and Rehabilitation, 36(10), 855-864.
Dear Dr. Caronni,
Good to hear you found our review to be insightful. Yes, we need to consider pain control in falls prevention.
Dear Dr. Bolland,
We concur that major methodological differences and varying observed results impact in different population subsets constitute a major challenge for evident synthetization and broad inference-making regarding the impact of vitamin D supplementation on fall risk. Investigation of the clinical impact of vitamin D supplementation on health outcomes remains a very fruitful area of research, with novel findings constantly being added to the literature. In our review, we listed important studies that provide major support for current recommendations now in place in support of some level of vitamin D supplementation in the context of falls prevention by important (AGS/BGS, USPSTF, Cochrane), though not all organizations (NICE 2013). Controversy and unanswered questions in the field do remain, and will certainly be further addressed as new evidence becomes available.
Ed Vieira on behalf of the authors
Competing interests: No competing interests
Vieira, Palmer, and Chaves, 2016 present an excellent article which addresses many of the issues that present a falls risk for elderly people. One important factor not addressed is vitamin B12 deficiency, which has a prevalence in the elderly of up to 24.8% (Moore et al, 2014), as a consequence of both ageing and co-morbidity. The literature has described the impact of B12 deficiency on the brain and spinal cord (demyelination) for over 100 years (McCaddon, 2013) and this can present clinically with paraesthesia of peripheral neuropathy to subacute combined cord degeneration. Neuropsychiatric symptoms may also present before anaemia (Smith, 1960). Signs can include: loss of vibration and/or position sense; ataxic gait; reduced sensation with a sensory level; positive Romberg’s test and muscle weakness. These symptoms and signs are obviously risk factors for falls in the elderly, even in the absence of anaemia. A large prospective Swedish study has also shown low cobalamin levels are associated with incident fractures (Lewerin et al, 2013).
The increased risk of falls with polypharmacy is well recognised but it is less well known that certain drugs commonly prescribed to the elderly, such as proton pump inhibitors (Au, Power and Gilmore, 2015) and metformin for type II diabetes (Niafar et al, 2014), are associated with vitamin B12 deficiency. Long term use of metformin is particularly associated with B12 deficiency (Aroda et al., 2016) and a recent systematic review and meta-analysis by Chapman, Darling, and Brown (2016) showed that patients on metformin had lower levels of B12 (by 57 pmol/l), which can lead to frank/borderline deficiency, so they recommend screening of patients on metformin. A recent study found that elderly patients over 75 years on metformin were less likely to be tested for vitamin B12 deficiency than their younger counterparts (Fogelman et al, 2016).
Orthostatic hypotension is a recognised risk factor for falls in the elderly and often cardiovascular causes are investigated, although it is recognised that B12 deficiency is also a prominent cause of autonomic dysfunction in the elderly (Kearney, Moore, and Donegan, 2007). Moreover, treatment of B12 deficiency in the elderly has been shown to be beneficial for orthostatic hypotension in a controlled trial (Moore et al, 2004). To complicate matters further, patients with B12 deficiency have been shown to have similar autonomic dysfunction to patients with diabetic neuropathy in a systematic case-controlled study (Beitzke et al., 2002).
B12 deficiency is common in the elderly but, if tested for, may be mistakenly overlooked as a potential risk factor for falls in the absence of the classical macrocytic anaemia. Twenty-five percent of patients with B12 deficiency may present with neurological symptoms and normal MCV (Devalia et al, 2014). A large population screening study conducted in Sweden of 1048 elderly patients discovered 97 cases of undiagnosed B12 deficiency, only 2 of whom would have been discovered if B12 levels were only checked after demonstration of macrocytic anaemia (Loikas et al, 2007).
Unfortunately there is no gold standard test to establish B12 deficiency, although methylmalonic acid and homocysteine can be used to confirm B12 deficiency in a hospital setting. It is recommended that treatment should be based on clinical symptoms/signs if there is ‘discordance of results’ as neurological impairment may be permanent after 6 months (Hunt et al, 2014).
I would suggest that the first step is thinking about B12 deficiency as a potential modifiable risk factor for falls. Testing B12 (and folate levels) and giving a treatment trial if the B12 level is <200ng/l (or if symptoms/signs are highly suggestive and the B12 result is borderline or MMA/homocysteine are elevated in the absence of other causes) using the neurological protocol of alternate day injections of hydroxocobalamin 1mg until no further improvement in neurological symptoms/signs (review after 3 weeks) followed by 2 monthly maintenance injections for life, when there has been a clinical response, is recommended by the British Committee for Standards in Haematology guidelines (Devalia et al, 2014).
Aroda, V.R., Edelstein, S.L., Goldberg, R.B., Knowler, W.C., Marcovina, S.M., Orchard, T.J., Bray, G.A., Schade, D.S., Temprosa, M.G., White, N.H. and Crandall, J.P. (2016) ‘Long-term Metformin use and vitamin B12 deficiency in the diabetes prevention program outcomes study’, The Journal of Clinical Endocrinology & Metabolism, 101(4), pp. 1754–1761. doi: 10.1210/jc.2015-3754.
Au, Minnie, Power, Jacinta, and Gilmore, David (2015) Proton pump inhibitors and vitamin B12 deficiency in older adults: a systematic review of clinical studies. Annals of the Australasian College of Tropical Medicine, 17 (1). p. 17.
Beitzke, M., Pfister, P., Fortin, J. and Skrabal, F. (2002) ‘Autonomic dysfunction and hemodynamics in vitamin B12 deficiency’, Autonomic Neuroscience, 97(1), pp. 45–54. doi: 10.1016/s1566-0702(01)00393-9.
Chapman, L.E., Darling, A.L. and Brown, J.E. (2016) ‘Association between metformin and vitamin B12 deficiency in patients with type 2 diabetes: A systematic review and meta-analysis’, Diabetes & Metabolism, . doi: 10.1016/j.diabet.2016.03.008.
Devalia, V., Hamilton, M.S. and Molloy, A.M. (2014) ‘Guidelines for the diagnosis and treatment of cobalamin and folate disorders’, British Journal of Haematology, 166(4), pp. 496–513. doi: 10.1111/bjh.12959.
Fogelman, Y., Kitai, E., Blumberg, G., Golan-Cohen, A., Rapoport, M. and Carmeli, E. (2016) ‘Vitamin B12 screening in metformin-treated diabetics in primary care: Were elderly patients less likely to be tested?’, Aging Clinical and Experimental Research, . doi: 10.1007/s40520-016-0546-1.
Hunt, A., Harrington, D. and Robinson, S. (2014) ‘Vitamin B12 deficiency’, BMJ, 349(sep04 1), pp. g5226–g5226. doi: 10.1136/bmj.g5226.
Kearney, F., Moore, A. and Donegan, C. (2007) ‘Orthostatic hypotension in older patients’, Reviews in Clinical Gerontology, 17(04), p. 259. doi: 10.1017/s0959259808002554.
Lewerin, C., Nilsson-Ehle, H., Jacobsson, S., Johansson, H., Sundh, V., Karlsson, M.K., Ljunggren, Ö., Lorentzon, M., Kanis, J.A., Lerner, U.H., Cummings, S.R., Ohlsson, C. and Mellström, D. (2013) ‘Low holotranscobalamin and cobalamins predict incident fractures in elderly men: The MrOS Sweden’, Osteoporosis International, 25(1), pp. 131–140. doi: 10.1007/s00198-013-2527-y.
Loikas, S., Koskinen, P., Irjala, K., Lopponen, M., Isoaho, R., Kivela, S.. and Pelliniemi, T.. (2007) ‘Vitamin B12 deficiency in the aged: A population-based study’, Age and Ageing, 36(2), pp. 177–183. doi: 10.1093/ageing/afl150.
McCaddon, A. (2013) ‘Vitamin B12 in neurology and ageing; clinical and genetic aspects’, Biochimie, 95(5), pp. 1066–1076. doi: 10.1016/j.biochi.2012.11.017.
Moore, A., Ryan, J., Watts, M., Pillay, I., Clinch, D. and Lyons, D. (2004) ‘Orthostatic tolerance in older patients with vitamin B12 deficiency before and after vitamin B12 replacement’, Clinical Autonomic Research, 14(2), pp. 67–71. doi: 10.1007/s10286-004-0142-x.
Moore, E., Pasco, J., Mander, A., Sanders, K., Carne, R., Jenkins, N., Black, M., Schneider, H., Ames, D. and Watters, D. (2014) ‘The prevalence of vitamin B12 deficiency in a random sample from the Australian population’, Journal of Investigational Biochemistry, 3(3), p. 95. doi: 10.5455/jib.20140716041521.
Niafar, M., Hai, F., Porhomayon, J. and Nader, N.D. (2014) ‘The role of metformin on vitamin B12 deficiency: A meta-analysis review’, Internal and Emergency Medicine, 10(1), pp. 93–102. doi: 10.1007/s11739-014-1157-5.
Smith, A.D.M. (1960) ‘Megaloblastic madness’, BMJ, 2(5216), pp. 1840–5. doi: 10.1136/bmj.1.5223.427-a.
Vieira, E.R., Palmer, R.C. and Chaves, P.H.M. (2016) ‘Prevention of falls in older people living in the community’, BMJ, , p. i1419. doi: 10.1136/bmj.i1419.
Competing interests: No competing interests
In their state of the art review on falls, Vieira and colleagues conclude that the strategy of supplementing calcium and vitamin D reduces the risk of falls.1 But their conclusion is based on contradictory evidence. They cite two meta-analyses from 2009 and 2010 of 7 and 9 trials respectively reporting that vitamin D reduced falls, but another from 2012 of 7 trials reporting no reduction in fall rates with vitamin D.
The analyses cited by Vieira and colleagues have been superseded. Meta-analyses now include 23 trials of >30,000 participants, and report no effect of vitamin D with or without calcium supplements on falls (RR 0.98, 95%CI 0.94-1.02, P=0.25).2 These results reliably exclude a clinically important 10% reduction in falls from vitamin D supplementation.3 Similar data show that vitamin D with or without calcium does not reduce total fractures by 10%,4 but co-administered calcium and vitamin D prevented hip fractures in 2 trials in frail elderly women living in residential care.5
Interpreting meta-analyses of vitamin D is fraught. There are more than 50 meta-analyses published on vitamin D with or without calcium and falls or fracture. Comparing these meta-analyses highlights important differences in trial selection, outcome definition, and analytic methods that lead to markedly different conclusions between the meta-analyses.6,7 The best available evidence from recent meta-analyses, that include data from all available trials analyzed in a standard intention-to-treat manner, is that vitamin D supplementation does not prevent falls.
1. Vieira ER, Palmer RC, Chaves PH. Prevention of falls in older people living in the community. BMJ 2016;353:i1419.
2. Bolland MJ, Grey A, Reid IR. Should we prescribe calcium or vitamin D supplements to treat or prevent osteoporosis? Climacteric 2015;18(sup2):22-31.
3. Bolland MJ, Grey A, Gamble GD, et al. Vitamin D supplementation and falls: a trial sequential meta-analysis. Lancet Diabetes Endocrinol 2014;2(7):573-80.
4. Bolland MJ, Grey A, Gamble GD, et al. The effect of vitamin D supplementation on skeletal, vascular, or cancer outcomes: a trial sequential meta-analysis. Lancet Diabetes Endocrinol 2014;2(4):307-20.
5. Avenell A, Mak JC, O'Connell D. Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. Cochrane database of systematic reviews (Online) 2014;4:CD000227.
6. Bolland MJ, Grey A. A case study of discordant overlapping meta-analyses: vitamin d supplements and fracture. PloS one 2014;9(12):e115934.
7. Bolland MJ, Grey A, Reid IR. Differences in overlapping meta-analyses of vitamin d supplements and falls. J Clin Endocrinol Metab 2014;99(11):4265-72.
Competing interests: We have published and analysed meta-analyses of vitamin D on falls and fractures.
In their insightful review about falls prevention in community dwelling older people, Vieira and colleagues  list pain (such as lower limb pain or foot pain) as a risk factor for falls. In this regard, the association between pain and falls is well known and backed by data from large cohorts of patients .
Drugs (and other treatments) can reduce pain and thus pain appears a “modifiable risk factor for falls” . In this scenario, the reduction of pain not only improves older people's quality of life, but also reduces their risk of falls.
However, the efficacy of acetaminophen, i.e. the common first-line therapy for chronic pain, has been recently questioned  and oral non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended for long-term use in the elderly . Opioid analgesics are effective for chronic pain , but opioids are a falls risk factor per se , possibly because of their sedative effect. Moreover, opioids are associated with some other important adverse events in elderly patients . Finally, adding (at least) a new pill for pain control increases the total number of drugs (at least) by one and the use of more than three drugs is a risk factor for falls by itself .
I feel it is important to emphasise one major point raised by Vieira and colleagues. The multifactorial assessment and intervention for fall prevention in older people should also cover the “systematic assessment and management of pain” . Pain assessment and management is taken into consideration only by a minority of guidelines for falls prevention among older people, as effectively shown by Figure 2 of the review by Vieira et al.. Research is needed to find the best possible compromise between oral drugs for pain and fall risk in older people. Effectiveness in fall prevention of topical drugs and non-pharmacological therapies with recognised efficacy in pain control (such as topical NSAIDs  and strength training  in osteoarthritis) remains to be clarified as well.
 Vieira E, Palmer R, Chaves P. Prevention of falls in older people living in the community. BMJ 2016;:i1419. doi:10.1136/bmj.i1419
 Leveille S. Chronic Musculoskeletal Pain and the Occurrence of Falls in an Older Population. JAMA 2009;302:2214. doi:10.1001/jama.2009.1738
 Machado G, Maher C, Ferreira P et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ 2015;350:h1225-h1225. doi:10.1136/bmj.h1225
 Makris U, Abrams R, Gurland B et al. Management of Persistent Pain in the Older Patient. JAMA 2014;312:825. doi:10.1001/jama.2014.9405
 Pharmacological Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society 2009;57:1331-1346. doi:10.1111/j.1532-5415.2009.02376.x
 Söderberg K, Laflamme L, Möller J. Newly Initiated Opioid Treatment and the Risk of Fall-Related Injuries. CNS Drugs 2013;27:155-161. doi:10.1007/s40263-013-0038-1
 Jena A, Goldman D, Weaver L et al. Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims. BMJ 2014;348:g1393-g1393. doi:10.1136/bmj.g1393
 Derry S, Conaghan P, Da Silva J et al. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews Published Online First: 2016. doi:10.1002/14651858.cd007400.pub3
 Uthman O, van der Windt D, Jordan J et al. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ 2013;347:f5555-f5555. doi:10.1136/bmj.f5555
Competing interests: No competing interests
This article is most welcome, as a really thorough treatment of an important subject. However, we note that 'No patients were asked for input in the creation of this article.' If they had been, it might have been even better. (I did notice a couple of typos!)
Although the setting for the article is the USA, many features apply to the UK. Yearly physical examinations are obviously a good idea, together with medication review. One thing that would also be helpful, particularly for elderly people with chronic conditions, is yearly reassessment for stability. Even better, a recent development in Edinburgh has been the availability of direct patient referral to Social Care Direct for 'a non-urgent falls assessment' within seven working days, involving a physiotherapist and an occupational therapist.
Unfortunately patients don't always know about this possibility: in early 2013 we didn't ourselves. In the case of my husband, disabled after a stroke in 2007, I noticed he was becoming more unsteady, and asked his GP for a re-assessment. Three months later we were still waiting for one, when he did in fact have a serious fall, which meant calling out the community alarm service, who skilfully helped him up and administered basic first aid: he was badly bruised but did not need to go to hospital.
The very next day, after another call to his GP, a joint team of physiotherapist and OT came along and helped greatly with fitting up new aids and suggesting exercises, illustrating good combined working between NHS (the physiotherapist) and Social Care (the OT). The community alarm service is another great idea: it works with an alarm round the patient's neck, which he only has to press to gain help at home: it is a huge relief to me to know that if I am out and my husband has a fall he will be helped appropriately. It costs us £4 a month, and is well worth it. (The service is means-tested and for some it is free.)
For a wholly different reason, about a year later, with his GP's permission, my husband discontinued two of the drugs (statins and beta-blockers) he had been on for the previous six years, since his stroke. Although he had had minor falls before the episode described above, since then he has had none. It is interesting to note that once more polypharmacy may be the culprit. (1)
Heather Goodare (retired counsellor)
Patient consent obtained.
1. Goodare H. Discontinuing drug treatments (rapid response). BMJ 2014; 349:g7013.
Competing interests: No competing interests
Screening for BPPV in falls: an easy but big clinical 'win'. Re: Prevention of falls in older people living in the community
To the Editor,
It is surprising that Vieira and colleagues  do not mention Benign Paroxysmal Positional Vertigo (BPPV) in their article on falls’ prevention in older people. BPPV causes falls ; it is common, affecting circa 10% of the elderly population ; it can be cured in over 80% of cases  with standard 2-minute clinical manoeuvres; and treating BPPV in older people reduces falls .
A key consideration is that the history may be unreliable in many elderly patients who may not have a sensation of vertigo with BPPV , partially explaining why 10% of unbalanced elderly patients in the community had unrecognised BPPV . Additionally, some clinicians may be hesitant to use the clinical manoeuvres that diagnose (and treat) BPPV in elderly patients on safety grounds. These clinical manoeuvres, however, can be adapted to accommodate for frailty without sacrificing clinical efficacy  [8 – online video resource for treating dizziness including BPPV].
It is time that local and national guidelines  recognise this missed clinical opportunity and explicitly call for the screening of BPPV in all older people with falls.
EMAIL - firstname.lastname@example.org
1. Vieira ER, Palmer RC, Chaves PHM. Prevention of falls in older people living in the community. BMJ 2016;353:i1419.
2. Oghalai JS, Manolidis S, Barth JL, Stewart MG, Jenkins HA. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg. 2000;122(5):630-4.
3. von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, Neuhauser H. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78(7):710-5.
4. Prokopakis E, Vlastos IM, Tsagournisakis M, Christodoulou P, Kawauchi H, Velegrakis G. Canalith repositioning procedures among 965 patients with benign paroxysmal positional vertigo. Audiol Neurootol. 2013;18(2):83-8.
5. Ganança FF, Gazzola JM, Ganança CF, Caovilla HH, Ganança MM, Cruz OL. Elderly falls associated with benign paroxysmal positional vertigo. Braz J Otorhinolaryngol. 2010;76(1):113-20.
6. Imbaud Genieys S. [Vertigo, dizziness and falls in the elderly]. Ann Otolaryngol Chir Cervicofac. 2007;124(4):189-96.
7. Kollén L, Frändin K, Möller M, Fagevik Olsén M, Möller C. Benign paroxysmal positional vertigo is a common cause of dizziness and unsteadiness in a large population of 75-year-olds. Aging Clin Exp Res. 2012;24(4):317-23.
Competing interests: No competing interests
MEEF: Caring for the older people away from falls. Re: Prevention of falls in older people living in the community
The State-of-the-Art Review  addresses an important issue of preventing falls as the population aging. Indeed, falls might be one of the top indications of Orthopaedic surgery for people aged 65 years other than degenerative diseases. Hip fractures , cervical spinal cord injuries with neurologic deficits , dens fractures  can result in morbidity and mortality threatening the welfare of the elders. Salient prevention measures yield twice the result with half the effort in terms of clinical outcome and economic burden. Fortunately, scientific community are paying more and more attention to the prevention .
The Review proposes targeting the modifiable risk factors and exercises as efficacious prevention measures with convincing lines of evidence. The issue is the implementation of the scientific essence in practice. After all, the aim of scientific research is from bench to bedside, from bedside to public. Accordingly, mindfulness, education, exercise and fitness (MEEF) might be the implementation principles for prevention of falls and pain for the elders.
There has been an increasing tread for mindfulness meditation, in particular for non-pharmacologic treatments. As the representatives of the tread, Mindfulness-Based Stress Reduction (MBSR) and Cognitive Behavioral Therapy (CBT) have been validated for prevention of low back pain [6 7]. These programs might be helpful to eliminate the risk factors for falls, including fear of falling, balance problems and pain. Accumulating evidence indicates that exercise alone or in combination of education is effective for preventing low back pain . In addition to the Otago Exercise Programme and the FaME programme in the Review, Mensendieck Exercise Program  and Active Back School Program  supplement the options of exercise.
Tailored for the elders in the community, “the 10 keys to healthy aging” is an excellent model for the fulfillment of Education and Fitness . The 10 keys have been validated as follows: (a) blood pressure control (systolic blood pressure, <140 mmHg), (b) cholesterol control, (c) glucose control, (d) smoking cessation, (e) flu and pneumonia immunization, (f) breast and colon cancer screening, (g) osteoporosis screening and adequate muscle strength, preventive for osteoporotic fractures due to falls, (h) maintaining physical activity over 2.5 hr weekly, (i) participating social and community activities weekly, (j) optimism rather than depression.
As the academic editor-in-chief of Orthopedic Channel of DXY (Simplified Chinese pinyin as DingXiangYuan), the biggest professional network in China, we have been working on the academic transmission of updated information from bedside to the public. In China, Internet and WeChat have replaced the traditional mass media as newspapers, TV and radio. Usually, we distill the essence of the updated scientific information into essays and circulate them via the new mass media. At this time, we will bring the essence of the Review to the public in China as usual, sharing the advanced concepts with Chinese elder people in the community, as well as the adults. After all, the young are aging year by year and will ultimately be the elder in the future.
1. Vieira ER, Palmer RC, Chaves PH. Prevention of falls in older people living in the community. Bmj 2016;353:i1419 doi: 10.1136/bmj.i1419[published Online First: Epub Date]|.
2. Perry DC, Metcalfe D, Griffin XL, et al. Inequalities in use of total hip arthroplasty for hip fracture: population based study. Bmj 2016;353:i2021 doi: 10.1136/bmj.i2021[published Online First: Epub Date]|.
3. Ruegg TB, Wicki AG, Aebli N, et al. The diagnostic value of magnetic resonance imaging measurements for assessing cervical spinal canal stenosis. Journal of neurosurgery Spine 2015;22(3):230-6 doi: 10.3171/2014.10.SPINE14346[published Online First: Epub Date]|.
4. Joestl J, Lang NW, Tiefenboeck TM, et al. Management and Outcome of Dens Fracture Nonunions in Geriatric Patients. The Journal of bone and joint surgery American volume 2016;98(3):193-8 doi: 10.2106/JBJS.O.00101[published Online First: Epub Date]|.
5. Steffens D, Maher CG, Pereira LS, et al. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. JAMA internal medicine 2016;176(2):199-208 doi: 10.1001/jamainternmed.2015.7431[published Online First: Epub Date]|.
6. Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. Jama 2016;315(12):1240-9 doi: 10.1001/jama.2016.2323[published Online First: Epub Date]|.
7. Morone NE, Greco CM, Moore CG, et al. A Mind-Body Program for Older Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA internal medicine 2016;176(3):329-37 doi: 10.1001/jamainternmed.2015.8033[published Online First: Epub Date]|.
8. Soukup MG, Glomsrod B, Lonn JH, et al. The effect of a Mensendieck exercise program as secondary prophylaxis for recurrent low back pain. A randomized, controlled trial with 12-month follow-up. Spine 1999;24(15):1585-91; discussion 92
9. Glomsrod B, Lonn JH, Soukup MG, et al. "Active back school", prophylactic management for low back pain: three-year follow-up of a randomized, controlled trial. Journal of rehabilitation medicine 2001;33(1):26-30
10. Newman AB, Bayles CM, Milas CN, et al. The 10 keys to healthy aging: findings from an innovative prevention program in the community. Journal of aging and health 2010;22(5):547-66 doi: 10.1177/0898264310363772[published Online First: Epub Date].
Competing interests: No competing interests
This State of the Art Review  is a welcome affirmation of the evidence on effective approaches to preventing falls in community-dwelling older people. Common and repetitive, falls can have major impact on the quality of life and disability experienced by older people. It is clear that tailored exercise integrated within a small basket of key evidence based interventions is the most effective approach to addressing this silent epidemic.
But at a practical level, we take issue with the review’s assertion that “the specific types and amount of exercise are still to be determined”. The specific elements of an effective exercise prescription were reported in 2011 in an in-depth review of the evidence : a dose of at least 50 hours of challenging balance and progressive strength training, delivered by trained professionals. There is no mystery here.
In the UK, two specific programmes mentioned in the CDC Compendium  are commonplace - the Otago Exercise Programme (OEP)  and the FaME programme [5 & 6]. OEP and FaME were first implemented through a service in South West London in 2000, as reported in the BMJ . A recent audit suggested that falls services nationally are employing appropriately trained professionals, but many services are not meeting the 50 hour effective prescription requirement. 
This review identifies key barriers encountered by a population level approach which resonate with the current UK situation: (a) short-term funding; (b) consistency and fidelity of delivery; (c) availability of providers; (d) clear protocols and quality assessments; (e) training and supervision of professionals; and (f) patient education. These can be addressed, but require system wide action.
All Clinical Commissioning Groups will have finalised plans to address local gaps in finance, quality of care, and health outcomes by the end of June. These Sustainability and Transformation Plans provide the opportunity to translate the potent potential of falls prevention research into local programmes that address avoidable disability and costs, at scale.
 Vieira ER, Palmer RC, Chaves PHM. Prevention of falls in older people living in the community. BMJ 2016;353:i1419.
 Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR. Exercise to
prevent falls in older adults: an updated meta-analysis and best practice
recommendations. NSW Public Health Bull 2011;23:78-83.
 Centers for Disease Control and Prevention. A CDC compendium of effective fall interventions: what works for community-dwelling older adults. Washington, US: CDC, 2015.
 Campbell AJ, Robertson MC, Gardener MM, Norton RN, Tilyard MW, Buchner DM. Randomised control trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997;315:1065-9.
 Skelton D, Dinan S, Campbell M, Rutherford O. Tailored group exercise (Falls Management Exercise - FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age and Ageing. 2005;34(6): 636-39.
 Iliffe S, Kendrick D, Morris R, Masud T, Gage H, Skelton D, et al. Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care. Health Tech Assess 2014;18(49).
 Simey P, Skelton D, Dinan S, Laventure R. Tailored exercise is key to preventing falls. British Medical Journal 2002; 325:1177.
 Royal College of Physicians. Older people's experience of therapeutic exercise as part of a falls prevention service. London: RCP, 2012.
Competing interests: Dawn Skelton is Director of Later Life Training, a not for profit provider of exercise training to health and fitness professionals