Two articles in the 19 January 2008 BMJ12 highlight tension between the clinical and public health approaches to fracture prevention among older adults. Järvinen et al1 review drug therapy for osteoporosis and conclude that “bone mineral density is a poor predictor of an individual’s fracture risk” and thus that practitioners should focus on fall prevention rather than treatment for osteoporosis as a strategy for fracture prevention. Meanwhile, Gates and colleagues2 note in their systematic review a troubling lack of evidence of efficacy for one respected falls prevention intervention, a multifactorial risk assessment with targeted management at the individual level.34 How can these apparently opposing views be reconciled?

Firstly, let’s place the review of Gates et al into a broader context. Their systematic review does not focus on all fall prevention interventions—rather it centers on interventions that screen clinically for fall risk with subsequent action or referral aimed at reducing risk for individuals. The authors note the emergence of fall prevention clinics throughout the UK, and call attention to the lack of evidence in the literature about the optimal location, skill mix, assessment, and interventions these clinics should offer. To be included in the review, an intervention had to: carry out “an assessment of multiple risk factors for falling to identify …