Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect services.
Falls risk prediction tools
Why the committee made the recommendation
Limited evidence was found on assessment tools that identify people at risk of falls in hospital, residential care or community settings. The evidence related to tools was very low quality and did not reach an acceptable threshold of sensitivity or specificity. They were also impractical to use in some settings.
The committee discussed the complexity around assessing the risk of falling, including how the environment and individual risk factors can lead to falls, and agreed that it is not possible to predict a fall with any accuracy. They agreed that risk assessment tools are not particularly useful and can be a distraction because they only stratify people into high- or low-risk categories without recommending any further intervention.
In community settings, a number of studies assessing gait and balance (such as the Timed Up and Go [TUG)] test) were identified. Although the committee agreed that these tests are helpful in observing gait and balance problems, they do not predict a person's risk of falling. The committee acknowledged that case-finding of people who have had a previous injury from a fall or have had multiple falls, are living with frailty or have gait or balance problems, is useful to identify those who may need a more detailed assessment and would benefit from a more comprehensive management approach. The committee agreed that the same recommendations for community settings should apply to hospital outpatients.
The committee noted that risk assessment tools are not generally used in a hospital setting because the resources required to carry out assessments are often not available, and the results are not used to make management decisions.
Many people in residential care settings are likely to have frailty and are already considered at risk of falls. For both hospital inpatient and residential settings, it is usual practice to carry out a comprehensive falls risk assessment because the person is considered as being at high risk of falling.
The committee were aware that wearable technologies are available that aim to predict a person's falls risk, but did not identify any evidence related to risk assessment tools or technologies for this update. The committee made a recommendation for research about the accuracy of wearable technologies in identifying the risk of falls.
How the recommendation might affect services
The recommendation reflects current practice and will have a minimal resource impact.
Identifying people at risk of falls for further assessment
Recommendations 1.1.2 to 1.1.7
Why the committee made the recommendations
The only evidence identified on how to clinically assess a person's risk of falls came from studies that investigated clinical judgement or the healthcare professional's knowledge of the patient. No evidence was identified on the most accurate methods of assessment. Evidence was only available for hospital and residential settings.
A few studies reported history of falls as a prognostic factor. The committee agreed that this is a good indicator, and a previous fall would trigger a referral for further assessment. The risk of falls is commonly picked up in community and hospital outpatient settings, where a healthcare professional will use the opportunity of the person presenting for an appointment or health check to identify people at risk of falls, for example, if a person has an unsteady gait, or if their knowledge of the person and their medical condition suggests they could be at higher risk of falls. However, the committee also acknowledged that, because of the short consultation time (for example, in a GP appointment), a healthcare professional will have limited opportunity and time to assess a person's falls risk. They also noted that it is current practice in community settings to assess risk based on observation and ask a person about any history of falls, often during appointments with a nurse or physiotherapist.
The committee agreed with the current practice of a falls risk assessment for people who report having had a fall in the last year, and clarified the criteria about who should be offered a comprehensive falls assessment and comprehensive falls management. For people who have fallen but do not meet the criteria, the committee agreed they should have a gait and balance assessment in line with current practice.
The committee acknowledged that it would not always be practical to do an assessment in every scenario because not every service would have the expertise or time to carry this out. Therefore, sometimes an appropriate referral may be needed. For example, should a risk factor be identified at a hospital outpatient appointment, this could be noted in the letter usually sent to the GP to update them about the person's appointment.
How the recommendations might affect services
The recommendations reflect current practice and will have a minimal resource impact.
Comprehensive falls assessment
Recommendations 1.2.1 to 1.2.3
Why the committee made the recommendations
Limited evidence was found on the accuracy of individual risk factor assessment in identifying the risk of falls in older adults. Risk tools including minimum data set, comprehensive assessments, balance and gait assessments or wearable technologies, were included.
The committee agreed that the evidence did not identify which methods of assessment are most useful at predicting risk of falls. The tests tended to only assess 1 aspect associated with falls risk, such as balance or gait, and did not assess or examine other possible predictors. The committee agreed that any risk assessment tools should be used in conjunction with a comprehensive falls assessment, to reflect the multifactorial nature of falls, and recommended a range of assessments and examinations to carry out, as appropriate. The complex nature of comprehensive falls assessment means that clinical judgement would be needed to determine what to assess and when for each individual person.
The committee agreed that components of the comprehensive falls assessment could be carried out by an appropriately trained single healthcare professional or a multidisciplinary team involving any of the following services, primary care services, community teams or specialist outpatient clinics (such as falls or geriatric outpatient services or assessment units). For example, some assessments could easily be done in primary care (for example, blood pressure and medication checks), whereas others may require referral to a specialist.
There was little evidence on wearable assessment technologies that met the inclusion criteria, because most of the studies identified were laboratory-based studies and therefore were not included. The committee agreed that further research in a real-world setting is required, and made a recommendation for research about the accuracy of wearable technologies in identifying the risk of falls.
How the recommendations might affect services
The recommendations reflect current practice and are unlikely to have a resource impact.
Interventions to reduce the risk of falls – community settings
Recommendations 1.3.1 to 1.3.14
Why the committee made the recommendations
Interventions to reduce the risk of falls for people presenting in community settings depend on the person's individual factors, and the characteristics and context of any falls that they have had. The committee agreed the criteria that would make a person eligible for a comprehensive falls management approach, and each of the following interventions are discussed in this context.
There was evidence on the clinical benefits of a medication review and withdrawing psychotropic medication in the community setting. It is current practice to carry out a review of a person's medicines for some people living in the community, but this is not specifically to reduce falls. The committee agreed that a person's medication should be reviewed and potentially changed to reduce symptoms and adverse events, or to improve quality of life. The committee also agreed that it is important to highlight to the person that psychotropic medicines are associated with an increased risk of falling, and withdrawal of these, if appropriate, would be beneficial. Therefore, they recommended discussing whether the benefits of those treatments are outweighed by the risks of continuing with them would help the person make an informed decision. Withdrawal of psychotropic medicines is difficult and needs to be reduced very slowly. This may need to be done in consultation with mental health services.
Most of the evidence for vitamin D showed no difference in the rate or number of falls, and the committee agreed that the clinical evidence did not support using vitamin D supplementation as an intervention to prevent falls in an older population. Vitamin D is part of standard care for people with a deficiency. The committee agreed the need to follow national public health guidance on vitamin D supplementation.
The evidence showed a clinical benefit of home hazard interventions to reduce falls. In most studies, this was a hazard assessment with modifications carried out in the home. The committee noted the greater clinical benefit seen in people who had fallen at least once in the last year. Greater benefit was shown when interventions were delivered by an occupational therapist although the evidence was low quality. Based on this evidence, health economic modelling found that home hazard assessment and modifications carried out by an occupational therapist compared with those carried out by a therapy assistant or technician are less costly and more effective.
Based on their knowledge and experience of current practice, the committee recognised that other healthcare professionals such as physiotherapists or nurses deliver home hazard assessments and interventions. They agreed that, in practice, therapy assistants or technicians may also carry out some aspects of home hazard assessments, but they acknowledged that this is under the supervision of a healthcare professional such as an occupational therapist (without the need for the healthcare professional to attend every visit). Due to the low quality of evidence and taking into account the likely resource impact, the committee could not recommend that home hazard assessments should only be conducted by occupational therapists. However, they agreed that consideration should be given to using an occupational therapist because this would be the optimal method of service delivery.
The committee agreed that anyone carrying out home hazard assessments and interventions should have training to do so. They also agreed the importance of supervision for staff such as therapy assistants and technicians.
Limited evidence, in terms of quantity and quality, found a clinical benefit for cardiac pacing and cataract surgery in reducing the rate of falls. The committee agreed with the existing practice around cardiac pacing. They agreed that cataract surgery is a simple and effective intervention, and that people should be referred to an ophthalmologist, in line with the NICE guideline on cataracts in adults.
Overall, the large body of evidence showed some benefit for exercise as an intervention to reduce falls. The type of exercise included in the studies varied, but often included functional components related to the risk of falls, such as balance, coordination and strength. The committee agreed that exercise programmes should be individualised, based on an assessment, be progressive and tailored according to the level of risk of falling. A person's progression and continuing benefit from the exercise programmes should ideally be reviewed regularly. This would also include discussing with the person the importance of continuing to exercise beyond the structured programme, and explaining that exercise should be made part of everyday activity for life to maintain benefit.
The committee discussed the small amount of evidence for psychological interventions, all of which were for cognitive behavioural therapy (CBT), which showed some benefit although results were mixed. The committee discussed that in their experience, a small number of people who have concerns about falling may be referred for CBT. The evidence did not include concerns about falling, but the committee discussed how this can have a significant detrimental effect on quality of life. Although there was not enough evidence to support a CBT programme, the committee agreed that cognitive behavioural interventions could be considered for people who have concerns about falling and that have not been alleviated by strength and balance exercises.
People who have not met the criteria for a comprehensive falls assessment and management, but who have fallen in the last year and have been identified as having a gait or balance impairment, may benefit from specific interventions to reduce their risk of falling. The committee agreed that the evidence supports a falls prevention exercise programme for this population. People at lower risk are more likely to experience falls due to gait and balance impairments. Therefore, the priority is to get this group into the most effective intervention, exercise, without having to wait for a comprehensive assessment, which is less likely to yield any further modifiable risk factors.
A recommendation to consider a home hazard assessment and intervention was made for people who had fallen at least once in the previous year. Greater benefit was shown when interventions were delivered by an occupational therapist although the evidence was low quality. Health economic modelling confirmed that home hazard assessment and modifications carried out by an occupational therapist are less costly and more effective.
There was not enough evidence on assistive technologies such as footwear and foot devices, self-care and assistive devices, so the committee made a recommendation for research on whether assistive technologies in community settings reduce the incidence of falls.
How the recommendations might affect practice
Home hazard assessments and modifications delivered by an occupational therapist have been shown to be cost effective, but there is likely to be an impact on resourcing and implementation in terms of staff capacity. Delivering exercise programmes may incur extra cost; however, the committee agreed that these can be effectively delivered by qualified fitness instructors and do not need to be prescribed through NHS settings in all cases. The remaining recommendations reflect current practice and will have a minimal resource impact.
Interventions to reduce the risk of falls – hospital inpatient settings
Recommendations 1.3.15 to 1.3.19
Why the committee made the recommendations
Limited evidence was found on medication review in hospital inpatient settings. A medication review would typically be carried out if a person was prescribed medicines known to increase the risk of falls, or they had a condition that could increase their risk of falling. Adjustments to a person's medication may need be made as a result of a review, and this would usually be part of a comprehensive falls risk assessment.
Limited evidence was identified for vitamin D and nutritional support. The committee agreed the evidence was not sufficient to recommend these for falls prevention. However, vitamin D is already recommended in NHS advice and other NICE guidelines for maintaining bone and muscle health, so the committee referred to these sources.
There was limited evidence on the use of exercise interventions in hospitals, so the committee did not recommend specific exercises or exercise programmes. The committee noted that this is likely to be because most people are not in hospital long enough for an exercise intervention to have an effect on preventing falls. While they did not make a recommendation for a falls prevention exercise programme, they agreed that it is important to encourage people to remain as active as possible to prevent deconditioning and falls. This can be done simply through usual movement, such as standing or walking, rather than structured exercise. The committee also agreed that at discharge, referral to community services should be considered.
The range of environmental interventions included the type of flooring, low beds, identification bracelets and bed alarms, but the evidence was only in small, single studies. No benefit was found for identification bracelets that indicate if a person has previously fallen, but the committee acknowledged that 'tagging' is commonly used in hospital to enable staff to closely observe people identified at risk of falls, and provide more support with, for example, eating, getting out of bed and going to the bathroom. The committee agreed the need for more research on enhanced supervision interventions such as bay tagging and identification bracelets, and interventions addressing the ward environment such as ward layout, flooring, beds and alarms, because inpatient falls are a leading cause of hospital-related harm.
The committee made a recommendation for research on whether interventions addressing the ward environment reduce the risk of falls in hospital settings, and a further recommendation for research on whether enhanced supervision leads to a reduction in the incidence of falls in hospital settings.
How the recommendations might affect practice
The recommendations reflect current practice and will have a minimal resource impact.
Interventions to reduce the risk of falls – residential care settings
Recommendations 1.3.20 to 1.3.25
Why the committee made the recommendations
No evidence in residential care settings was identified for medication review. However, the committee referred to the NHS England guidance on providing enhanced care for residential settings. The committee agreed, based on their knowledge and experience, that in residential care settings, it is current practice to carry out a review of a person's medicines, although this is not specifically to reduce falls. The committee agreed that a person's medication should be reviewed and potentially changed to reduce symptoms and adverse events, or to improve quality of life. The committee also agreed that it is important to highlight to the person that psychotropic medicines are associated with an increased risk of falling, and therefore withdrawal of these, if appropriate, would be beneficial. Therefore, they recommended discussing whether the benefits of those treatments are outweighed by the risks of continuing with them would help the person make an informed decision. Withdrawal of psychotropic medicines is difficult and needs to be reduced very slowly. This may need to be done in consultation with mental health services.
Limited evidence showed a benefit in vitamin D and calcium supplementation in reducing fracture rates. The committee discussed the benefit of vitamin D supplements and acknowledged that this is standard care for people known to have a vitamin D deficiency, in line with existing guidance.
There was no evidence that any particular type of exercise was better than another, but there was evidence about the effectiveness of exercise in reducing the rate of falls. Exercises offered in residential care settings typically focus on strength, gait and balance. A high level of supervision is often required because people in residential settings often have frailty or a cognitive impairment. The committee agreed that residents who are more mobile are likely to see a greater benefit from exercise interventions, although being mobile does increase the exposure to risk of falling.
There was a lack of evidence on interventions for people with dementia. Cognitive impairment caused by dementia is common in residential care settings, and this population has an increased risk of falls because they are more likely to have gait and balance impairments and be taking medication that increases falls risk. Because no studies were identified that evaluated specific pharmacological or non-pharmacological interventions targeting behavioural and psychological symptoms related to dementia, the committee made a recommendation for research on interventions for people in residential care settings with dementia.
Limited evidence showed some benefit for 2 different types of environmental interventions (assisted home technology and wireless position-monitoring patch); however, the committee agreed this was not enough to make a recommendation. Therefore, they made a recommendation for research on environmental interventions in residential care settings.
How the recommendations might affect practice
The recommendations reflect current practice and will have a minimal resource impact.
Maximising ongoing participation in falls prevention interventions
Why the committee made the recommendation
Limited evidence was found for methods of improving participation in, adherence to, or continuation of falls prevention interventions. All the studies were carried out in community settings and had low numbers of participants. Although most of the interventions used in the studies showed some benefit in terms of improving adherence or participation, the evidence was very low quality, so the committee based the recommendations on their experience and consensus.
For supervised exercise, benefits were seen in terms of participation or adherence in interventions delivered by group sessions or remotely via live video compared with those delivered with no support. This was reflected in the committee's experience. The committee noted that the social aspects of group activity can have a beneficial effect and help relieve loneliness or feelings of isolation. In their experience, people are more likely to continue with exercise as part of a group rather than when exercising individually. However, they also recognised that some would prefer individual exercise sessions, so a personalised approach is needed, and people should be offered choice in how exercise is delivered. In-person sessions may be more suitable for people with more frailty and could require more supervision.
How the recommendation might affect practice
There is variation in how falls prevention exercise programmes are delivered. The recommendations may result in more people adhering to supervised exercise interventions, and this could require more staff time to provide supervision. However, there is flexibility in how supervision can be undertaken. Often, a supervised exercise programme can be a mixture of supervised and unsupervised exercises. For example, a programme can start as face-to-face then people can do it themselves with regular telephone check-ins. The committee agreed that, in their experience, not everyone would opt for supervised exercise. Some people may not feel comfortable exercising in front of others or find attending regular classes difficult to manage or travel to, and consequently would choose online exercise programs. Also, any additional costs would be offset by the reduced falls and associated cost savings resulting from improved adherence to fall prevention exercises. As a result, the resource impact is unlikely to be significant.
Information and education for people receiving falls assessment or interventions
Recommendations 1.5.1 to 1.5.3
Why the committee made the recommendations
A qualitative review examined the information and education needs of people at risk of falls. Overall, the themes reported in the evidence aligned with the committee's knowledge and experience of NHS-based practice and falls prevention interventions in the UK. Therefore, the committee were confident in making recommendations based on these findings and supplemented any gaps in the evidence base with their consensus opinion and their knowledge and experience.
One of the most prevalent themes to emerge from the evidence related to empowerment. Discussions that are positive and include information about falls prevention were found to be helpful, but discussions that inadvertently give the wrong messages can create fear and anxiety, and lead to people avoiding activity.
The most common information need identified in the evidence was about risk factors. The committee echoed this and recommended that these should be discussed with the person and agreeing what changes would help reduce their risk of falls. The committee agreed it is important to make people aware of their individual risk factors, and to give personalised information about falls prevention. Prevention strategies for other specific falls risks may include review of a person's medications, and referral, for example, to podiatry for gait issues, an optician if vision is a problem, or an ophthalmologist, if the person has cataracts. People should also be offered information and support to reduce the risk of falling in the home, for example, checking there is adequate lighting, removing trip hazards, and installing equipment such as grab rails or fall alarms.
Information on the value of exercise or strength and balance interventions and how to engage with these safely should be included in discussions or written information. The evidence showed the benefit of engagement with social networks and community groups, and that older people are more likely to adhere to group-based falls prevention activities because they promote encouragement and support from peers to maintain activities and improve motivation.
In hospital settings, people need additional information about operating and navigating unfamiliar equipment and environments. Falls prevention in hospital is largely dependent on factors such as call bells, supervision, bed rails and walking aids. These are likely to be unfamiliar to patients who will need advice on how they work and when to use them. The committee agreed that discharge planning from hospital, including ensuring people know about what support is available to reduce falls risk after discharge, is important, particularly if a person is not going back to their usual setting, or their falls risk or mobility needs have changed.
The committee agreed that people's information needs are similar regardless of the setting. One of the main points discussed by the committee is the importance of maintaining an active lifestyle and ensuring that people are staying safe while being as active as possible. They recognised that in residential care settings, there is a fine balance between maintaining safety of residents to avoid falls and promoting exercise and encouraging engagement in activities. Activity can be promoted by providing information and education for people and their families on the benefits of exercise, and advice on how to maintain an active lifestyle safely in the specific setting.
How the recommendations might affect services
Although the recommendations are for different settings, in terms of resource impact, they are unlikely to be significantly different. The recommendations reflect current good practice.