2 Research recommendations
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline.
What environmental adaptations can be made in existing inpatient units, and should be considered when inpatient units are built, to reduce the risk of falls and injuries in older inpatients?
Dementia, delirium, poor mobility and balance, urgent or frequent toilet needs or incontinence and visual impairment are common in older hospital patients. Several multifactorial studies have included adjustments to the ward environment that have plausible mechanisms for reducing falls in patients with these risk factors (such as improved lighting, changes to flooring, furniture, handholds, walking routes, lines of sight and signposting), but the impact of these changes has not been recorded. There is a need to understand which improvements to the inpatient environment are the most effective and cost-effective for preventing falls and injuries in hospital, and the factors that architects should take into account when designing new hospitals.
Which risk factors for falling that can be treated, improved or managed during the hospital stay are most prevalent in older patients who fall in inpatient settings in the UK?
Many existing studies identify risk factors for falling in the inpatient setting, but these studies are not all relevant to a current UK hospital population. Additionally, existing studies often focus on factors that predict falls but cannot be treated, improved or managed (such as chronological age). Identifying the risk factors for falling that are most prevalent in the current UK older inpatient population underpins the development of more effective and better targeted multifactorial assessments and interventions.
What are the causes of unwitnessed falls among older inpatients?
A large proportion of inpatient falls are unwitnessed. Although staff may deduce reasons for the fall and/or the patient (if able and if asked) may describe their own perception of what happened, research is needed to establish more objectively how and why these falls occur. Research would need to encompass a qualitative exploration of why older inpatients who are vulnerable to falling mobilise without asking for help.
How can falls among older inpatients be prevented? Which patients are most likely to benefit from falls prevention interventions, and does the effectiveness of interventions relate to the patient's length of stay?
Various single and multifactorial interventions for preventing falls have been the subject of research, but their overall effectiveness in different inpatient settings (such as mental health units for older people) has not been established. The relative effectiveness of different components of a multifactorial assessment and a multifactorial intervention, and which older inpatients would benefit most from each intervention, or each component within a multifactorial assessment and intervention, is unclear. The effectiveness of falls prevention interventions in hospital patients with a short length of stay has not been established, and nor has their effectiveness in specific subgroups such as patients with dementia. High-quality randomised controlled trials conducted in the UK are required to improve the existing evidence base.
The following research gaps were identified by the GDG. Following NICE requirements, the first five are those prioritised by the GDG. 
Further analysis of existing trial data to identify which components of multifactorial interventions are important in different settings and amongst different patient groups. 
Future trials designed and analysed with the intention of identifying cost effective components of multifactorial programmes for particular groups of older people in different settings. 
Evaluation of multi-agency falls prevention programmes to measure the impact of these programmes on reducing falls, injurious falls and fractures in older people. 
Falls prevention trials with a focus on injury reduction, such as fracture outcomes and fall related outcomes. 
Research on the optimal methods of risk assessment for falls in older people and evaluation of whether fall-prone individuals can be risk stratified, in terms of whom will most benefit from assessment and intervention. 
Trials investigating the most effective strategy for preventing falls in older people with cognitive impairment and dementia. 
UK-based cost effectiveness studies of falls prevention interventions. 
Trials to investigate the effectiveness of hip protectors compared with other fracture prevention interventions in older people at high risk of falling.