Intended for healthcare professionals

Practice Uncertainties

What type of environmental assessment and modification prevents falls in community dwelling older people?

BMJ 2019; 364 doi: (Published 14 March 2019) Cite this as: BMJ 2019;364:l880
  1. Alison Pighills, principal research fellow, adjunct associate professor1,
  2. Avril Drummond, professor2,
  3. Shelley Crossland, occupational therapist3,
  4. David J Torgerson, professor4
  1. 1Mackay Institute of Research and Innovation, Queensland Health, Mackay Base Hospital, Queensland 4740/College of Healthcare Sciences, James Cook University, Townsville, Queensland, Australia
  2. 2School of Health Sciences, University of Nottingham, Nottingham, UK
  3. 3Mental Health Services for Older People, Leicestershire Partnership NHS Trust, Leicester, UK
  4. 4York Trials Unit, Department of Health Sciences, University of York, York, UK
  1. Correspondence to A Pighills alison.pighills{at}

What you need to know

  • Evidence suggests that environmental interventions can prevent falls in older people at high risk of falls, but they have little or no benefit in people at low risk

  • Offer environmental assessment and modification led by an occupational therapist to people over 65 who have had a fall in the past year, use a mobility aid, need assistance with any activities of daily living, take psychoactive medications, or are concerned about falling

  • Environmental assessment and modification encompasses a comprehensive, validated functional assessment of the individual in their home environment, a joint problem solving approach, and follow-up as required

One third of people over the age of 65 experience a fall.1 The health and social care costs of falls are increasing with longevity.23 Falls are one of the leading causes of morbidity and death caused by injury in people over 75. Nearly a quarter of older people who fall are concerned about further falls, and some restrict activity. This can result in physical deconditioning, increased risk of future falls, institutionalisation, and reduced quality of life.4

Box 1 lists features that predispose older people to falls.5

Box 1

Risk factors for falls in community dwelling older people

  • Age (≥ 65)

  • History of falls in the past year

  • Use of mobility device, such as a walking aid

  • Requiring assistance for any activities of daily living

  • Use of psychoactive medications

  • Fear of falling

We categorise falls risk as

  • High falls risk— ≥65 years, have a history of falls, and also possess one or more of the other risk factors for falls

  • Moderate risk of falls— ≥65 years and possess one of the above additional risk factors

  • Low falls risk—Possess only one falls risk factor


Risk factors for falls can be categorised as

  • Intrinsic (personal risk factors such as age and gender)

  • Extrinsic (environmental risk factors/environmental hazards)

  • Behavioural (activity related risk factors).67

Environmental …

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