3 Protocol for the In Balance randomized controlled trial | 41 BACKGROUND Falls are a major cause of mortality and morbidity in older adults (67). More than one-third of community-dwelling adults aged 65 years or older falls at least once per year (10). The number of falls is expected to increase even further due to the ageing of the population (122-124). Falls in older adults often result in injury with 109,000 older adults visiting an Emergency Department due to a fall-related injury in the Netherlands in 2019 (125). Besides the risk of injuries, falls may also increase fear of falling (126). Fear of falling may result in a reduction in physical activity in daily life, which can lead to a decreased muscle strength and an increased fall risk (127-130). Falls and its sequelae can lead to a decreased quality of life up to 9 months after a fall, suggesting that even after that amount of time older adults are still suffering from their fall and its consequences (24, 131). Fall-related injuries result in considerable healthcare costs, which are estimated at more than 1 billion euros in the Netherlands (125). On top of these healthcare costs, other costs also have to be taken into account, such as individual expenses, help from family and/or friends and productivity losses due to absence from work or unpaid activities (132-134). The alarming impact of falls on older individuals, healthcare and our greying society renders the prevention of falls and fall-related injuries highly urgent (135, 136). Systematic reviews have shown fall prevention programmes to be effective in reducing the risk of falls among older adults (137, 138). Group interventions appear more effective than individual programmes, because of higher compliance of participants in the group intervention (139, 140). Despite the evidence that falls can be prevented by fall prevention programmes, barriers for practical implementation may harm the impact of these programmes. It can for example be questioned whether effectiveness maintains after adjustments in the intervention when implemented, which indicates the importance of re-evaluating implemented interventions (136-138). An effective group fall prevention intervention, that is widely implemented in the Netherlands, is the In Balance intervention. In Balance is a relatively inexpensive fourteen-week group intervention that requires minimal equipment and aims to reduce falls by increasing awareness, balance and strength in older adults at risk of falling (141). The first four weeks of In Balance include counselling and education meetings once per week on topics regarding fall prevention to increase knowledge about preventing falls, and to increase awareness of fall risk and balance disruption. The last ten weeks comprise two one-hour exercise sessions per week. Exercises are derived from principles of Tai Chi and are mainly focused on physical balance and strength.
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