Literature Review – Falls Prevention Interventions in Residential Aged Care

Introduction

Falls are the leading cause of injury-related hospitalisation and injury death among Australians aged 65 and over, with almost 150,000 fall-related hospitalisations recorded in 2022-23 (Australian Institute of Health and Welfare [AIHW], 2024). The risk is heavily concentrated in residential aged care, where residents fall at roughly three times the rate of community-dwelling older people and a single fall can trigger immobility, functional decline and premature death. An epidemiological analysis of Australian coronial data found that falls accounted for more than four in five premature external-cause deaths among nursing home residents (Ibrahim et al., 2017). The Royal Commission into Aged Care Quality and Safety (2021) likewise identified recurrent, unwitnessed and poorly reviewed falls as a marker of substandard clinical care.

This review synthesises research published between 2015 and 2025 on falls prevention interventions in residential aged care. Evidence is organised into five themes: exercise, medication review and deprescribing, environmental modification, multifactorial programs, and staffing and safety culture. Methodological quality is appraised throughout, and the review closes by identifying evidence gaps and implications for Australian practice under the Aged Care Quality Standards.

Search Strategy

Searches were conducted in CINAHL Complete, MEDLINE (Ovid), Embase and the Cochrane Library for literature published between January 2015 and June 2025, supplemented by grey literature from the AIHW, the Department of Health and Aged Care and the Aged Care Quality and Safety Commission. Search terms combined (“accidental falls” OR fall*) AND (“residential aged care” OR “nursing home*” OR “long-term care”) AND (prevent* OR intervention), limited to English-language, peer-reviewed studies involving adults aged 65 and over. Randomised and cluster randomised trials, systematic reviews and large controlled studies were prioritised, consistent with the upper levels of the NHMRC evidence hierarchy. The search yielded 412 unique records; 63 full texts were assessed and 15 studies met the inclusion criteria. Methodological quality was appraised using JBI critical appraisal tools, and certainty judgements draw on GRADE ratings where reported. Table 1 summarises the eight studies most central to the synthesis that follows.

Table 1: Summary of key studies included in the review

Exercise-Based Interventions

The strongest single-intervention evidence in the Australian context comes from the Sunbeam trial, a cluster randomised trial of progressive resistance and balance training across 16 residential aged care facilities (Hewitt et al., 2018). Residents completing the 25-week supervised program experienced a 55 per cent reduction in the rate of falls relative to usual care, alongside measurable gains in physical performance. As shown in Table 1, this is the largest effect reported by any study in this review. Methodologically the trial was robust: randomisation at facility level limited contamination, outcome assessors were blinded, and falls were captured through standardised incident reporting. Its principal limitation is generalisability, because residents with severe cognitive impairment were largely excluded, yet more than half of Australian permanent residents live with dementia (AIHW, 2024).

The wider evidence is less emphatic. The Cochrane review by Cameron et al. (2018), pooling 95 trials, judged the effect of exercise as a standalone intervention in care facilities to be uncertain, noting low-certainty evidence and the possibility that improved mobility transiently increases falls exposure among frail residents. The apparent contradiction is best read as a problem of dose and targeting rather than a refutation. The World Falls Guidelines recommend individualised, progressive and supervised programs rather than generic group activity (Montero-Odasso et al., 2022); exercise appears effective when sufficiently intensive, professionally delivered and matched to residents who can train safely.

Medication Review and Deprescribing

Fall-risk-increasing drugs, particularly psychotropics, are among the most modifiable risk factors in residential aged care. The meta-analysis by Seppala et al. (2018) found that antipsychotics, benzodiazepines and antidepressants were each associated with significantly increased odds of falling, with pooled odds ratios of approximately 1.4 to 1.6. Because Australian audits have repeatedly documented high rates of sedative prescribing in aged care, deprescribing is a logical prevention target.

The RedUSe project demonstrates feasibility at national scale. Across 150 Australian residential aged care facilities, a multi-strategic intervention combining prescribing audit and feedback, staff education and pharmacist champions reduced regular antipsychotic use from 21.6 per cent to 18.9 per cent and benzodiazepine use from 22.2 per cent to 17.6 per cent within six months (Westbury et al., 2018). Two appraisal points temper enthusiasm. First, RedUSe measured prescribing rather than falls, a proxy outcome. Second, Cameron et al. (2018) found that medication review as a sole intervention had an uncertain effect on falls. Deprescribing is therefore best justified on broader harm-reduction grounds, and it has acquired regulatory force through the 2021 restrictive practices reforms to the Quality of Care Principles, under which routine sedation constitutes chemical restraint requiring informed consent, regular review and reporting.

Environmental Modification

Environmental strategies range from lighting, visual contrast and decluttering to engineered solutions such as low beds and impact-absorbing flooring. The most rigorous test of the engineering approach, the Flooring for Injury Prevention (FLIP) study, randomised 150 resident rooms in a Canadian long-term care facility to compliant or standard flooring and found no significant reduction in serious fall-related injuries over four years (Mackey et al., 2019). The finding is valuable precisely because it is null: it cautions against assuming that passive environmental protection can substitute for clinical and behavioural intervention. Similar caution applies to bed and chair sensor alarms, for which reviews report little effect on falls but measurable alarm fatigue among staff (Francis-Coad et al., 2018). Environmental design nonetheless retains a supporting role, particularly dementia-enabling design that supports safe, independent movement. Appraisal of this theme must acknowledge inherent constraints: blinding is impossible, facilities differ structurally, and injurious falls are rare events requiring long follow-up, all of which depress evidence certainty.

Multifactorial Programs

Because falls in residential aged care are almost always multicausal, multifactorial programs tailor several interventions to individual risk profiles. Cameron et al. (2018) reported low-certainty evidence that multifactorial interventions reduce the rate of falls by around 12 per cent, together with moderate-certainty evidence that vitamin D supplementation reduces the falls rate in a population where deficiency is common. Reviewing complex interventions specifically within residential aged care, Francis-Coad et al. (2018) concluded that programs combining resident-level assessment with organisation-level components such as staff education and audit produced the most consistent reductions, and that implementation fidelity moderated effectiveness more strongly than intervention content. The World Falls Guidelines translate this into practice by recommending that every care home resident be treated as high risk and receive a multidomain assessment leading to tailored strategies rather than a standard checklist (Montero-Odasso et al., 2022). The certainty of the pooled evidence remains low because trials differ in components, comparators and outcome definitions, yet the consistent direction of effect strengthens confidence in the approach.

Staffing, Leadership and Safety Culture

Falls prevention is ultimately delivered, or missed, by the workforce. The Royal Commission into Aged Care Quality and Safety (2021) linked chronic understaffing to preventable harm, including unwitnessed falls and delayed post-fall assessment, and its recommendations underpin the current mandatory care minutes regime: an average of 215 care minutes per resident per day, including 44 registered nurse minutes, together with the requirement for a registered nurse on site 24 hours a day (Department of Health and Aged Care [DoHAC], 2024). These reforms create the workforce platform on which every intervention reviewed above depends.

Culture change alone, however, is not a falls intervention. The CONNECT trial across 24 United States nursing homes improved staff communication and problem-solving networks but produced no additional reduction in falls compared with falls education alone (Colon-Emeric et al., 2017). The plausible interpretation is that relational capacity is necessary but must be coupled to concrete clinical mechanisms: post-fall huddles, falls champions, escalation protocols and routine data feedback. In Australia, the National Aged Care Mandatory Quality Indicator Program, which requires quarterly reporting of falls and major injury, supplies exactly this feedback loop when governing bodies treat it as a clinical governance signal rather than a compliance exercise.

Synthesis and Gaps

Figure 1 illustrates how the five themes converge on a single organising idea: an integrated, individually tailored falls prevention program rather than a menu of isolated purchases.

Read together, the themes support three conclusions. First, no single intervention is sufficient: the strongest effects arise where adequately dosed exercise, systematic medication review and environmental attention are combined within an individually tailored program delivered by engaged staff. Second, implementation matters at least as much as intervention content, because fidelity, leadership and feedback repeatedly emerge as the moderators of success (Francis-Coad et al., 2018). Third, several widely purchased solutions, including sensor alarms and compliant flooring as standalone measures, lack convincing evidence of benefit.

The gaps are equally instructive. Residents with moderate to severe dementia are systematically under-represented in trials despite carrying the highest risk, so the strongest evidence applies least well to the residents who fall most. Cluster trials in this population suffer substantial attrition through mortality, and inconsistent outcome definitions (proportion of fallers, falls rate, injurious falls) hamper meta-analysis. There are few Australian cost-effectiveness analyses under the AN-ACC funding model, little research on sustaining intervention effects beyond trial periods, and limited work on partnering with residents and families in decisions that balance safety against dignity of risk.

Implications for Practice Under the Aged Care Quality Standards

The strengthened Aged Care Quality Standards, in force since November 2025 under the new Aged Care Act, make this evidence directly auditable. Standard 5 (Clinical Care) requires providers to assess falls risk, implement tailored prevention strategies and review every fall, while Standard 2 (The Organisation) locates accountability for clinical governance, workforce capability and continuous improvement with the governing body (Aged Care Quality and Safety Commission [ACQSC], 2025). Translated into practice, the evidence reviewed here supports five commitments: multidomain risk assessment on entry and after any incident; access to progressive resistance and balance training for residents able to participate; scheduled psychotropic review with pharmacist involvement; environmental audit as a supporting measure; and post-fall huddles feeding quality-indicator data to the board. The care minutes regime provides the registered nursing capacity required to lead each of these commitments.

Conclusion

Falls in residential aged care are frequent, harmful and, to a meaningful degree, preventable. The literature from 2015 to 2025 indicates that the most defensible strategy is an individualised multifactorial program anchored by adequately dosed exercise for residents who can participate and disciplined deprescribing of psychotropic medicines, enabled by supportive environmental design and delivered by a sufficiently staffed, well-led workforce. Australian policy settings, from mandatory care minutes to quality-indicator reporting and the strengthened Quality Standards, now align regulatory incentives with this evidence. The pressing research priorities are trials that include residents living with dementia, economic evaluation in the Australian funding context, and strategies that sustain effects after formal programs end.

References

Aged Care Quality and Safety Commission. (2025). Strengthened Aged Care Quality Standards: Guidance for providers. Australian Government.

Australian Institute of Health and Welfare. (2024). Falls in older Australians 2022-23: Hospitalisations and deaths among people aged 65 and over. Australian Government.

Cameron, I. D., Dyer, S. M., Panagoda, C. E., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2018). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, 2018(9), Article CD005465.

Colon-Emeric, C. S., Corazzini, K. N., McConnell, E. S., Pan, W., Toles, M., Hall, R., Cary, M. P., Batchelor, M., Yap, T. L., Anderson, A. L., Burd, A., Amarasekara, S., & Anderson, R. A. (2017). Effect of promoting high-quality staff interactions on fall prevention in nursing homes: A cluster randomised trial. JAMA Internal Medicine, 177(11), 1634-1641.

Department of Health and Aged Care. (2024). Care minutes and 24/7 registered nurse responsibility guide. Australian Government.

Francis-Coad, J., Etherton-Beer, C., Burton, E., Naseri, C., & Hill, A.-M. (2018). Effectiveness of complex falls prevention interventions in residential aged care settings: A systematic review. JBI Database of Systematic Reviews and Implementation Reports, 16(4), 973-1002.

Hewitt, J., Goodall, S., Clemson, L., Henwood, T., & Refshauge, K. (2018). Progressive resistance and balance training for falls prevention in long-term residential aged care: A cluster randomised trial of the Sunbeam program. Journal of the American Medical Directors Association, 19(4), 361-369.

Ibrahim, J. E., Bugeja, L., Willoughby, M., Bevan, M., Kipsaina, C., Young, C., Pham, T., & Ranson, D. L. (2017). Premature deaths of nursing home residents: An epidemiological analysis. Medical Journal of Australia, 206(10), 442-447.

Mackey, D. C., Lachance, C. C., Wang, P. T., Feldman, F., Laing, A. C., Leung, P. M., Hu, X. J., & Robinovitch, S. N. (2019). The Flooring for Injury Prevention (FLIP) study of compliant flooring for the prevention of fall-related injuries in long-term care: A cluster randomised trial. PLOS Medicine, 16(6).

Montero-Odasso, M., van der Velde, N., Martin, F. C., Petrovic, M., Tan, M. P., Ryg, J., Cameron, I. D., Close, J. C. T., Duque, G., Hogan, D. B., … Masud, T. (2022). World guidelines for falls prevention and management for older adults: A global initiative. Age and Ageing, 51(9).

Royal Commission into Aged Care Quality and Safety. (2021). Final report: Care, dignity and respect (Volume 1). Commonwealth of Australia.

Seppala, L. J., Wermelink, A. M. A. T., de Vries, M., Ploegmakers, K. J., van de Glind, E. M. M., Daams, J. G., & van der Velde, N. (2018). Fall-risk-increasing drugs: A systematic review and meta-analysis: II. Psychotropics. Journal of the American Medical Directors Association, 19(4), 371.e11-371.e17.

Westbury, J. L., Gee, P., Ling, T., Brown, D. T., Franks, K. H., Bindoff, I., Bindoff, A., & Peterson, G. M. (2018). RedUSe: Reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities. Medical Journal of Australia, 208(9), 398-403.