People have the right to be involved in discussions and make informed decisions about their care as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity) and safeguarding.

Terms used in this guideline

Extended care

A care setting such as a nursing home or supported accommodation.

Multifactorial assessment or multifactorial falls risk assessment

An assessment with multiple components that aims to identify a person's risk factors for falling.

Multifactorial intervention

An intervention with multiple components that aims to address the risk factors for falling that are identified in a person's multifactorial assessment.

Older people

In section 1.1, older people are people aged 65 years and older. In section 1.2, older people are people aged 50 years and older.

Older people living in the community

Older people living in their own home or in extended care.

Risk prediction tool

A tool that aims to calculate a person's risk of falling, either in terms of 'at risk/not at risk', or in terms of 'low/medium/high risk', etc.

1.1 Preventing falls in older people

1.1.1 Case/risk identification

Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. [2004]

Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. (Tests of balance and gait commonly used in the UK are detailed in section 3.3 of the full guideline.) [2004]

1.1.2 Multifactorial falls risk assessment

Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. [2004]

Multifactorial assessment may include the following:

  • identification of falls history

  • assessment of gait, balance and mobility, and muscle weakness

  • assessment of osteoporosis risk

  • assessment of the older person's perceived functional ability and fear relating to falling

  • assessment of visual impairment

  • assessment of cognitive impairment and neurological examination

  • assessment of urinary incontinence

  • assessment of home hazards

  • cardiovascular examination and medication review. [2004]

1.1.3 Multifactorial interventions

All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention. [2004]

In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):

  • strength and balance training

  • home hazard assessment and intervention

  • vision assessment and referral

  • medication review with modification/withdrawal. [2004]

Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function. [2004]

1.1.4 Strength and balance training

Strength and balance training is recommended. Those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficit. A muscle-strengthening and balance programme should be offered. This should be individually prescribed and monitored by an appropriately trained professional. [2004]

1.1.5 Exercise in extended care settings

1.1.6 Home hazard and safety intervention

Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer, and appropriate members of the health care team. [2004]

Home hazard assessment is shown to be effective only in conjunction with follow-up and intervention, not in isolation. [2004]

1.1.7 Psychotropic medications

Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling. [2004]

1.1.8 Cardiac pacing

Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls. [2004]

1.1.9 Encouraging the participation of older people in falls prevention programmes

To promote the participation of older people in falls prevention programmes the following should be considered.

  • Healthcare professionals involved in the assessment and prevention of falls should discuss what changes a person is willing to make to prevent falls.

  • Information should be relevant and available in languages other than English.

  • Falls prevention programmes should also address potential barriers such as low self-efficacy and fear of falling, and encourage activity change as negotiated with the participant. [2004]

Practitioners who are involved in developing falls prevention programmes should ensure that such programmes are flexible enough to accommodate participants' different needs and preferences and should promote the social value of such programmes. [2004]

1.1.10 Education and information giving

All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls assessment and prevention. [2004]

Individuals at risk of falling, and their carers, should be offered information orally and in writing about:

  • what measures they can take to prevent further falls

  • how to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components

  • the preventable nature of some falls

  • the physical and psychological benefits of modifying falls risk

  • where they can seek further advice and assistance

  • how to cope if they have a fall, including how to summon help and how to avoid a long lie. [2004]

1.2 Preventing falls in older people during a hospital stay

1.2.1 Predicting patients' risk of falling in hospital

Do not use fall risk prediction tools to predict inpatients' risk of falling in hospital. [new 2013]

Regard the following groups of inpatients as being at risk of falling in hospital and manage their care according to recommendations to

  • all patients aged 65 years or older

  • patients aged 50 to 64 years who are judged by a clinician to be at higher risk of falling because of an underlying condition. [new 2013]

1.2.2 Assessment and interventions

Ensure that aspects of the inpatient environment (including flooring, lighting, furniture and fittings such as hand holds) that could affect patients' risk of falling are systematically identified and addressed. [new 2013]

Ensure that any multifactorial assessment identifies the patient's individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay. These may include:

  • cognitive impairment

  • continence problems

  • falls history, including causes and consequences (such as injury and fear of falling)

  • footwear that is unsuitable or missing

  • health problems that may increase their risk of falling

  • medication

  • postural instability, mobility problems and/or balance problems

  • syncope syndrome

  • visual impairment. [new 2013]

Ensure that any multifactorial intervention:

  • promptly addresses the patient's identified individual risk factors for falling in hospital and

  • takes into account whether the risk factors can be treated, improved or managed during the patient's expected stay. [new 2013]

Do not offer falls prevention interventions that are not tailored to address the patient's individual risk factors for falling. [new 2013]

1.2.3 Information and support

Provide relevant oral and written information and support for patients, and their family members and carers if the patient agrees. Take into account the patient's ability to understand and retain information. Information should include:

  • explaining about the patient's individual risk factors for falling in hospital

  • showing the patient how to use the nurse call system and encouraging them to use it when they need help

  • informing family members and carers about when and how to raise and lower bed rails

  • providing consistent messages about when a patient should ask for help before getting up or moving about

  • helping the patient to engage in any multifactorial intervention aimed at addressing their individual risk factors. [new 2013]