Interventions for preventing falls in older people in hospitals.

rationaleFalls in hospitals are common events that cause considerable morbidity and mortality for older people. This is an update of the hospital components of a review of interventions in hospitals and care facilities first published in 2010 and updated in 2012 and 2018.

objectivesTo evaluate the benefits and harms of interventions designed to reduce the incidence of falls in older people in hospitals, including inpatient rehabilitation facilities. SEARCH

methodsWe searched CENTRAL, MEDLINE, Embase, CINAHL, and trial registers to 28 October 2025. ELIGIBILITY CRITERIA: Randomised controlled trials of any interventions for preventing falls in older people (aged 65 years and over) in hospitals, excluding trials where falls were recorded as adverse events of the intervention and those recruiting participants post-stroke or living with Parkinson's disease. OUTCOMES: Critical outcomes were rate of falls (number of falls per unit time) and risk of falling (number of fallers). Important outcomes were risk of fracture, adverse events, and economic outcomes. RISK OF BIAS: We evaluated risk of bias in the included trials against nine items (seven in the Cochrane RoB 1 tool, plus method of ascertaining falls and baseline imbalance). SYNTHESIS

methodsTwo review authors independently performed study selection, risk of bias assessment, and data extraction. We calculated rate ratios (RaR) for rate of falls and risk ratios (RRs) for risk of falling and risk of fracture, with 95% confidence intervals (CIs). We adjusted for clustering if not undertaken by the trial authors. We pooled results where appropriate using the generic inverse variance method in RevMan. We conducted subgroup analyses according to intervention type, cognitive status, setting, and informed by an intervention component analysis. Where pooling was precluded by the nature of the data, we presented trial data in tables for illustrative purposes. We recategorised one trial considered as multifactorial in 2018 to multicomponent education for consistency within the group of trials considered as multifactorial. We used GRADE to assess the certainty of evidence for each outcome for the main comparisons. GRADE ratings of risk of bias were based on sensitivity analyses excluding trials at high risk. INCLUDED STUDIES: We included 32 new trials (35,235 participants) in this update, for a total of 55 trials (104,474 participants; mean age 79 years; 45% women). The majority of trials were at high risk of bias in one or more domains, mostly due to lack of blinding, which is not typically feasible for hospital fall prevention interventions. With few exceptions, the certainty of evidence for the critical outcomes of falls for individual interventions was rated as low or very low. We have reported outcomes for the main comparisons here. The outcomes of risk of fracture and economic outcomes were generally poorly reported and, where reported, the evidence was of very low certainty; we have not reported these data here. We only reported the outcome of adverse events when the certainty of evidence was stronger than very low. SYNTHESIS OF

resultsExercise. The effect of exercise on the rate of in-hospital falls is uncertain (RaR 0.62, 95% CI 0.28 to 1.36; I² = 0%; 3 trials, 317 participants; very low-certainty evidence). Exercise may have little or no effect on the risk of falling in hospital settings overall (RR 0.73, 95% CI 0.36 to 1.46; I² = 27%; 6 trials, 668 participants; plus 1 trial, N = 12,863, adjusted odds ratio 0.8, 95% CI 0.5 to 1.1; P = 0.52; low-certainty evidence). Medication optimisation. We are uncertain of the effect of medication optimisation as a single intervention on the rate of falls (RaR 1.71, 95% CI 0.95 to 3.07; I² = 0%; 3 trials, 2093 participants; very low-certainty evidence) and risk of falling (RR 0.94, 95% CI 0.46 to 1.90; I² = 39%; 4 trials, 2255 participants; very low-certainty evidence). Medication optimisation may have no effect on adverse events overall (data not pooled, 3 trials; low-certainty evidence). Service model change (aspect of social environment category). Service model change (a change in a model of care or organisational system targeted at falls reduction) probably reduces the rate of falls in acute settings (RaR 0.45, 95% CI 0.27 to 0.74; I² = 0%; 6 trials, 10,825 participants; moderate-certainty evidence). However, the effect of service model change on risk of falling is uncertain (RR 0.93, 95% CI 0.25 to 3.46; I² = 70%; 3 trials, 5534 participants; very low-certainty evidence). Education (aspect of social environment category). Tailored education (patient, staff or multicomponent) probably reduces the rate of falls (RaR 0.73, 95% CI 0.56 to 0.94; I² = 0%; 3 trials, 4868 participants; moderate-certainty evidence) and risk of falling (RR 0.61, 95% CI 0.40 to 0.92; I² = 45%; 5 trials, 5035 participants; plus 1 trial, N = 3121 admissions, adjusted odds ratio 0.55, 95% CI 0.38 to 0.81; P = 0.003; moderate-certainty evidence). Multifactorial interventions. Multifactorial interventions, where two or more categories of interventions are given based on a fall risk assessment, probably reduce the rate of falls (RaR 0.87, 95% CI 0.69 to 1.08; I² = 40%; 5 trials, 42,256 participants; moderate-certainty evidence) and risk of falling (RR 0.82, 95% CI 0.63 to 1.07; I² = 0%; 5 trials, 41,141 participants; moderate-certainty evidence), but the CIs include the possibility of no effect or a slight increase in falls. Any intervention. Categorisation of intervention type was often not distinct. Overall, pooled data from all trials of any intervention to prevent falls had an uncertain impact on the rate of falls (RaR 0.85, 95% CI 0.71 to 1.02; I² = 51%; 27 trials, 72,016 participants; very low-certainty evidence), but suggested that there may be a reduced risk of falling (RR 0.83, 95% CI 0.73 to 0.94; I² = 0%; 35 trials, 56,452 participants; low-certainty evidence). A subgroup analysis found that trials of interventions that include integration with the local setting, tailoring approaches to the needs and abilities of patients, and engaging patients and/or their family or carers may reduce the rate of falls (RaR 0.68, 95% CI 0.55 to 0.84; I² = 23%; 12 trials, 18,183 participants; low-certainty evidence), but the effect of trials that did not undertake these approaches on rate of falls is uncertain (RaR 1.04, 95% CI 0.84 to 1.30; I² = 39%; 15 trials, 53,833 participants; very low-certainty evidence; test for subgroup differences P = 0.006). AUTHORS'

conclusionsTailored education (staff, patient/family and multicomponent) probably reduces the rate of falls and the risk of falling. Service model change in acute hospitals probably reduces the rate of falls, but its effect on risk of falling is uncertain. Multifactorial interventions probably reduce the rate of falls and risk of falling, but the CIs include the possibility of no effect or a slight increase in falls. The effect of exercise on the rate of falls is uncertain. Exercise may have little or no effect on the risk of falling in hospital settings overall. The effect of medication optimisation as a single intervention on the rate and risk of falls is uncertain. Across all intervention types, fall prevention approaches that include features of integration with the local setting, tailoring approaches to the needs and abilities of patients, and engaging patients and/or their family or carers may reduce the rate of falls in older people in hospitals more effectively than those that do not include these elements. Interventions with these features include social environment change and education interventions plus an effective multifactorial trial. Fall prevention in hospitals is very difficult. Despite the large number of trials included in this review, the conclusions for many intervention types are uncertain.

fundingThe Australian National Health and Medical Research Council provides salary support for authors through the Centre of Research Excellence for Prevention of Falls Injuries (Dyer, Suen, Kwok). Dylan Kneale is supported in part by ARC North Thames and the National Institute for Health and Care Research ARC North Thames. REGISTRATION: Protocol (2025): Open Science Framework OSF | Cochrane update protocol: Interventions for preventing falls in older people in hospitals.