Recommendations | Falls: assessment and prevention in older people and in people 50 and over at higher risk | Guidance

1.1 Identifying people at risk of falls for further assessment

Falls risk prediction tools

1.1.1

Do not use falls risk prediction tools to predict a person's risk of falling.

For a short explanation of why the committee made this recommendation and how it might affect services, see the rationale and impact section on falls risk prediction tools.

Full details of the evidence and the committee's discussion are in:

Identifying the risk of falls in community settings

1.1.2

In community settings, ask people about the details of any falls. This can be done:

when a person presents after a fall or
by opportunistically asking people (for example, in routine appointments and annual health checks) whether they have fallen in the last year.

1.1.3

Offer a comprehensive falls assessment and comprehensive falls management to people who have fallen in the last year and meet any of the following criteria (this can be carried out in the same service or involve an appropriate referral):

Are living with frailty (also see the section on how to assess frailty in the NICE guideline on multimorbidity).
Were injured in a fall and needed medical (including surgical) treatment.
Have experienced a loss of consciousness related to a fall (also see the NICE guideline on transient loss of consciousness ['blackouts'] in over 16s).
Have been unable to get up independently after a fall.
Have had 2 or more falls in the last year.

See the sections on:
comprehensive falls assessment and
community settings – comprehensive falls management.

1.1.4

For people who have fallen in the last year and who do not have any of the criteria for comprehensive falls assessment and comprehensive falls management in recommendation 1.1.3, assess their gait and balance (this can be carried out in the same service or involve an appropriate referral).

1.1.5

For people who have fallen in the last year who have a gait or balance impairment:

offer a falls prevention exercise programme and
consider a home hazard assessment.

These can be carried out in the same service or involve an appropriate referral. See the section on community settings – people who have fallen once in the last year and have a gait or balance impairment.

1.1.6

Offer health and wellbeing information, and advice on physical activity in line with the Chief Medical Officer's physical activity guidelines for people who:

have not fallen in the last year or
have had a single fall in the last year and do not have a gait or balance impairment.

Also see the section on information and education for people receiving falls assessment or interventions.

Identifying the risk of falls in hospital inpatient and residential care settings

1.1.7

Offer a comprehensive falls assessment and comprehensive falls management to people in hospital inpatient settings and residential care settings. Also see the sections on:

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on identifying people at risk of falls for further assessment.

Full details of the evidence and the committee's discussion are in:

1.2 Comprehensive falls assessment

1.2.1

Offer a comprehensive falls assessment for people who:

are in community settings and meet any of the criteria in recommendation 1.1.3 or
are in hospital inpatient settings or residential care settings.

1.2.2

Include the following assessments and examinations (where appropriate) in the comprehensive falls assessment to identify the person's individual fall risk factors:

Alcohol misuse (see the section on identification and assessment in the NICE guideline on alcohol-use disorders).
Cardiovascular examination (including a lying and standing blood pressure test).
Cognition and mood.
Delirium (hospital inpatient and residential care settings only; see the section on assessment and diagnosis in the NICE guideline on delirium).
Diet, fluid intake and weight loss.
Dizziness: ask about the presence and nature of any dizziness; if the person reports symptoms of rotational vertigo, consider performing a Dix–Hallpike manoeuvre (see the section on dizziness and vertigo in adults in the NICE guideline on suspected neurological conditions).
Footwear and foot condition.
Functional ability: assess the person's perceived functional ability and explore any concerns about falling.
Gait, balance and mobility, and muscle strength assessment.
Hearing impairments.
Long-term conditions that affect the person's daily life, for example, arthritis, dementia, diabetes or Parkinson's disease
Medication review.
Neurological examination.
Osteoporosis risk assessment (see the NICE guideline on osteoporosis: assessing the risk of fragility fracture).
Urinary continence.
Visual impairments.

1.2.3

Ensure that the person's individual risk factors identified in the comprehensive falls assessment are promptly addressed with appropriate interventions to reduce their risk of falls. These interventions can be offered in the same service or involve an appropriate referral. See the sections on comprehensive falls management in:

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on comprehensive falls assessment.

Full details of the evidence and the committee's discussion are in:

1.3 Interventions to reduce the risk of falls

Community settings – comprehensive falls management

These recommendations are for people in community settings who need comprehensive falls management to reduce their risk of falls (see the section on identifying people at risk of falls for further assessment).

1.3.1

Ensure that interventions to reduce the risk of falls are tailored to the individual so they promptly address any fall risk factors (see the section on comprehensive falls assessment).

Medication review

1.3.2

Consider carrying out a structured medication review:

to identify any medicines that may increase the person's risk of falls and
consider adjusting their medicines to reduce that risk.

Also see the section on medication review in the NICE guideline on medicines optimisation and the section on reviewing medicines in the NICE guideline on medicines adherence.

1.3.3

For people taking psychotropic medicines:

review any psychotropic medicines and
discuss the increased risk of falls associated with psychotropic medicines with the person and
plan withdrawal as appropriate and consider liaising with specialist mental health services.

Also see the NICE guideline on medicines associated with dependence or withdrawal symptoms.

Vitamin D supplements

1.3.4

Although there is insufficient evidence to support taking vitamin D supplements specifically to lower the risk of falls, encourage people to follow NHS advice on taking vitamin D to maintain bone and muscle health. Also see the NICE guideline on vitamin D: supplement use in specific population groups.

Home hazard interventions

1.3.5

Offer a home hazard assessment and intervention using a validated tool.

1.3.6

Consider having the home hazard assessment and intervention from recommendation 1.3.5 carried out by an occupational therapist. If an occupational therapist does not carry out the assessment and intervention, it may be done by:

an appropriately trained healthcare professional or
an appropriately trained therapy assistant or technician, with supervision from an appropriately trained healthcare professional.

Surgical interventions

1.3.7

If the person has visual impairment caused by cataracts, refer them to an ophthalmologist (also see the NICE guideline on cataracts in adults).

1.3.8

If the person has experienced falls with an unexplained cause:

investigate possible cardioinhibitory carotid sinus hypersensitivity as a cause and
consider cardiac pacing if indicated.

Falls prevention exercise programmes

1.3.9

Consider a falls prevention exercise programme for people who need comprehensive assessment and management.

1.3.10

Falls prevention exercise programmes should:

be delivered by appropriately trained professionals
be progressive and tailored to the person's specific needs, preferences, goals and abilities
focus on functional components related to the person's risk of falls, such as balance, coordination, strength and power
include regular exercise progress reviews
be delivered in such a way, including duration of programme, to bring about behaviour change related to physical activity and sedentary habits.

1.3.11

Consider cognitive behavioural interventions for people who have concerns about falling that is not helped by strength and balance exercises.

Community settings – people who have fallen once in the last year and have a gait or balance impairment

These recommendations are for people in community settings who do not need comprehensive falls management (see the section on identifying people at risk of falls for further assessment), but may benefit from specific interventions to reduce their risk of falling.

Falls prevention exercise programmes

1.3.12

Offer a falls prevention exercise programme (see recommendations 1.3.9 and 1.3.10).

Home hazard interventions

1.3.13

Consider a home hazard assessment and intervention using a validated tool.

1.3.14

Consider having the home hazard assessment and intervention from recommendation 1.3.13 carried out by an occupational therapist. If an occupational therapist does not carry out the assessment and intervention, it may be done by:

an appropriately trained healthcare professional or
an appropriately trained therapy assistant or technician, with supervision from an appropriately trained healthcare professional.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on interventions to reduce the risk of falls – community settings.

Full details of the evidence and the committee's discussion are in evidence reviews F1 and F2: interventions for prevention of falls in community settings.

Hospital inpatient settings – comprehensive falls management

These recommendations are for people in hospital inpatient settings.

1.3.15

Ensure that interventions to reduce the risk of falls are tailored to the individual so they promptly address any falls risk factors (see the section on comprehensive falls assessment). This can be done by:

taking into account whether the risk factors can be improved or managed during the patient's expected stay and
identifying risk factors related to the ward environment and
providing individually tailored education sessions that the person is able to engage with and participate in (see the section on information and education for people receiving falls assessment or interventions).

1.3.16

At discharge from hospital, consider referring the person to community services so that risk factors identified during their hospital stay that would also be relevant in their discharge destination can be addressed.

Medication review

1.3.17

As part of a structured medication review, consider making appropriate adjustments to the person's medicines to reduce the risk of falls. Also see the section on medication review in the NICE guideline on medicines optimisation and the section on reviewing medicines in the NICE guideline on medicines adherence.

Vitamin D supplements

1.3.18

Although there is insufficient evidence to support the use of taking vitamin D supplements specifically to reduce the risk of falls while in hospital, encourage people to follow NHS advice on taking vitamin D to maintain bone and muscle health. Also see the NICE guideline on vitamin D: supplement use in specific population groups.

Physical activity and exercises

1.3.19

Encourage people to remain active during their hospital stay by:

reassuring them that they can still get up and do not need to restrict their activity (unless they have been advised not to) and
helping them to be less sedentary and more active, for example, encouraging them to get out of bed, get dressed and regularly stand up and walk around and
for people able to exercise, look for opportunities to encourage physical activity that addresses the person's risk of falls, such as balance, coordination, strength and power.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on interventions to reduce the risk of falls – hospital inpatient settings.

Full details of the evidence and the committee's discussion are in evidence review G: interventions for prevention of falls in hospital settings.

Residential care settings – comprehensive falls management

These recommendations are for people in residential care settings.

1.3.20

Ensure that interventions to reduce the risk of falls are tailored to the individual so they promptly address any fall risk factors (see the section on comprehensive falls assessment). This can be done by taking into account whether the risk factors can be resolved, improved or managed. Also see section 11D on falls and falls prevention in NHS England's providing proactive care for people living in care homes – enhanced health in care homes framework.

Medication review

1.3.21

Carry out a structured medication review as outlined in the section on reviewing medicines in the NICE guideline on managing medicines in care homes:

to identify any medicines that may increase the person's risk of falls and
consider adjusting their medicines to reduce that risk.

Also see the section on medication review in the NICE guideline on medicines optimisation and the section on reviewing medicines in the NICE guideline on medicines adherence.

1.3.22

For older people taking psychotropic medicines:

review any psychotropic medicines and
discuss the increased risk of falls associated with psychotropic medicines with the person and
plan withdrawal as appropriate and consider liaising with specialist mental health services.

Also see the NICE guideline on medicines associated with dependence or withdrawal symptoms.

Vitamin D supplements

1.3.23

Although there is insufficient evidence to support taking vitamin D supplements specifically to reduce the risk of falls, encourage people to follow NHS advice on taking a vitamin D supplement to maintain bone and muscle health. Also see the NICE guideline on vitamin D: supplement use in specific population groups.

Physical activity and exercise

1.3.24

Encourage people to remain active by:

reassuring them that they should not avoid getting up and moving around and
helping them to be less sedentary and more active by having a structured daily routine to ensure that they have opportunities to regularly stand up and walk around, as appropriate.

1.3.25

For people able to exercise, consider a programme that addresses the person's risk of falls, such as balance, coordination, strength and power. Programmes should be tailored to the person's abilities and preferences, and could be delivered on an individual or group basis.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on interventions to reduce the risk of falls – residential care settings.

Full details of the evidence and the committee's discussion are in evidence review H: interventions for prevention of falls in residential care settings.

1.4 Maximising ongoing participation in falls prevention interventions

1.4.1

In all settings, maximise the likelihood of people participating in falls prevention exercise programmes as follows:

Discuss and agree with the person what changes they are willing and able to make to reduce their risk of falls.
Encourage change and address potential barriers, for example, if a person doubts that they can complete the exercises or has concerns about falling.
Ensure the interventions are flexible enough to accommodate each person's individual needs and preferences.
Consider supervised exercises and, if these are provided, offer people a choice in how exercises are delivered, for example, individual or group exercise.
Where possible, enabling social contact and support.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on maximising ongoing participation in falls prevention interventions.

Full details of the evidence and the committee's discussion are in evidence review I: maximising participation, adherence and continuation of falls prevention interventions.

1.5 Information and education for people receiving falls assessment or interventions

In all settings

1.5.1

In all settings (community, hospital inpatient and residential care), discuss ways that people can reduce their risk of falls as well as improving their overall wellbeing, and provide information that they can take away. Involve the person's family and carers as appropriate. Topics to discuss include the following:

That a person's risk of having a fall depends on their individual risk factors (for example, increasing age, taking certain medicines, or having low blood pressure or cataracts), and that some risk factors can be modified (for example, by undertaking appropriate exercise interventions, having a medication review, or having cataract surgery).
That some falls are preventable, with suggestions and ideas to reduce the risk of falling, tailored to their individual risk and circumstances.
How interventions to prevent falls (for example, those focusing on exercise and staying active) can help, and how to stay motivated (for example, by participating in a group programme).
What to do if they have a fall, including how to get up, and when and how to seek help.
Sources of further information, for example, local and national organisations and support groups.

For more guidance on communication (including different formats and languages) and providing information, see NICE's guideline on patient experience in adult NHS services.

In hospital inpatient settings

1.5.2

In hospital inpatient settings, discuss the points in recommendation 1.5.1, and ways that people can reduce their risk of falls and improve their wellbeing in this setting. Topics to discuss include the following:

That a person's risk factors may change when they are in hospital.
How to move around safely and stay as active as possible while in hospital, and when and how to seek help (for example, if they need to call for assistance to go to the bathroom).
How to use unfamiliar equipment during their admission, for example, bed controls and the call bell.
How they, or hospital visitors such as family members, carers and friends, can alert staff about potential falls hazards.
What support may be available after they are discharged from hospital to reduce their risk of having a fall.

In residential care settings

1.5.3

In residential care settings, discuss the points in recommendation 1.5.1, and ways that people can reduce their risk of falls and improve their wellbeing in this setting. Topics to discuss include the following:

How to manage their safety concerns, including when and how to seek help if they have a fall.
How to move around safely and stay as active as possible.
How to use equipment in residential care settings, for example, bed controls, call bells and movement sensors.
How they, or visitors such as family members, carers and friends, can alert staff about potential falls hazards.

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on information and education for people receiving falls assessment or interventions.

Full details of the evidence and the committee's discussion are in evidence review A: information and support.

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Community settings

Settings where no accommodation or hospital admission is involved. This includes people's homes, community services, GP practices, hospital outpatient clinics, emergency departments and minor injuries units.

Comprehensive falls assessment

An assessment that aims to identify a person's risk factors for falling. This can be carried out by an appropriately trained single healthcare professional or a multidisciplinary team involving any of the following services, as appropriate: primary care services, community teams or specialist outpatient clinics (such as falls or geriatric medicine assessment clinics).

Comprehensive falls management

Management of falls using interventions tailored to address the risk factors identified in a comprehensive assessment. Individual interventions may be directly carried out by 1 or more health professionals in a specialist service (for example, a medication review by the team pharmacist or a home hazard modification by the team occupational therapist) or through referrals for further action (for example, a referral to ophthalmology for consideration of cataract surgery).

Factors that could increase the risk of falls

Factors that could increase the risk of falls include long-term health conditions that impact on a person's daily life such as arthritis, dementia, diabetes or Parkinson's disease; having had a stroke; and having a learning disability.

Progressive exercise

Exercise progression can be defined through a tailored (or individualised) increase in 1 or more factors involving the intensity, frequency, duration and complexity of exercise selection. This will be based on performance over the programme period.

Psychotropic medicines

Psychotropic medicines work in the brain. They affect behaviour, mood, consciousness, thoughts or perception. They include antipsychotic, antidepressant, anxiolytic, mood stabilising, and antiepileptic medicines. They are associated with an increased risk of falls.

Residential care settings

Accommodation that provides 24‑hour care. This includes:

residential care: providing personal care, such as help with washing, dressing, going to the toilet and taking medication
nursing care: providing personal care, with qualified nurses on duty at all times.

Supervised exercise

A programme is supervised when a professional or trained non-professional has regular contact to reassess performance, correct technique, suggest progressions or regressions and to motivate and inform participants. Supervised programmes could be delivered one-to-one, in a group, in‑person or online, and it is not necessary for all exercise to be directly supervised. For example, a supervised programme might include a once-weekly, instructor-led exercise class with additional home exercise carried out alone, or a home exercise programme with scheduled progress visits or telephone calls from the instructor.