Grades are shown as the source states them. Modified GRADE: 1 = strong recommendation, 2 = weak or conditional; evidence quality A (high) to C (low); E = expert consensus where evidence was lacking.
Key recommendations
Ask older adults in contact with healthcare, at least once a year, whether they have fallen in the past 12 months, and about the frequency, circumstances, severity and consequences of any fall. Many people do not report falls unless asked.
1AOpportunistic case-finding; Table 5 (WG 11)
Treat as high risk anyone whose fall caused an injury needing treatment, who has fallen twice or more in 12 months, who lay on the floor unable to get up for an hour or more, who is frail, or who may have lost consciousness.
Older adults presenting with falls; Figure 1
Offer high-risk older adults in the community a multiprofessional, multifactorial falls risk assessment, followed by multidomain interventions tailored to what it finds.
1BTable 5 (WG 10)
Falls-prevention exercise should include balance-challenging and functional exercises (for example sit-to-stand and stepping), three or more sessions a week, individualised and progressed for at least 12 weeks — and continued longer for greater effect.
1ATable 5 (WG 4)
Make medication review and appropriate deprescribing of fall-risk-increasing drugs part of multidomain interventions.
1BTable 5 (WG 2)
Diagnosis
For risk stratification, measure gait speed (risk if below 0.8 m/s). The Timed Up and Go test (risk if over 15 seconds) is an alternative, although its evidence for predicting falls is less consistent.
1A, 1BTable 5 (WG 1); Falls risk stratification
Low risk: no fall, or one non-severe fall without gait or balance problems — offer education and exercise, and reassess yearly. Intermediate risk: one non-severe fall with gait or balance problems — offer strength and balance exercise. High risk: offer a multifactorial assessment.
Falls risk stratification and algorithm
Frailty used for stratification can be already known or found with a validated instrument such as the frailty phenotype or the Clinical Frailty Scale (frail at a score of 4 or more).
Falls risk stratification and algorithm
Assess recurrent unexplained falls in the same way as syncope, in addition to the multifactorial falls risk assessment.
1ATable 5 (WG 3)
Investigations
The initial cardiovascular assessment is a cardiac history, auscultation, lying and standing blood pressure and a 12-lead ECG. If these are normal, no further cardiovascular testing is needed unless syncope is suspected.
1B, 1CTable 5 (WG 3)
Measure orthostatic blood pressure lying (after at least 5 minutes' rest) and then repeatedly on standing — continuously, or every minute for at least 3 and ideally 5 minutes — and ask about symptoms.
Table 4
Multifactorial assessment covers gait, balance and strength; medicines; cardiovascular disorders; vision and hearing; feet and footwear; cognition, delirium and depression; neurological disease; concerns about falling; continence; nutrition including vitamin D; alcohol; pain; and hazards at home.
Multifactorial falls risk assessment
Include a routine assessment of cognition in every multifactorial falls risk assessment.
1BTable 5 (WG 6)
Assess concerns about falling with a standardised instrument such as the FES-I or Short FES-I.
1ATable 5 (WG 12)
Treatment
Add Tai Chi and/or individualised progressive resistance training where feasible.
1BTable 5 (WG 4)
Include management of orthostatic hypotension in the multidomain intervention for people who fall.
1ATable 5 (WG 3)
A trained clinician should identify hazards where the person lives — in relation to their abilities and behaviour — and modify the home as part of the intervention.
1BTable 5 (WG 10)
For concerns about falling, offer exercise, cognitive behavioural therapy and/or occupational therapy within a multidisciplinary approach.
1BTable 5 (WG 12)
Manage impaired vision as part of the multifactorial approach; cataract surgery (first and second eye) is an effective falls-prevention strategy.
Vision interventions
Universal vitamin D supplementation is not supported for preventing falls; recommend daily vitamin D to people at risk of deficiency, following national nutrition guidance.
Vitamin D interventions
Important geriatric considerations
In care homes, consider every resident at high risk rather than screening, and assess them on admission. In hospital, give everyone over 65 a multifactorial assessment instead of a scored risk-screening tool.
1A, 1C (care homes); 2B (hospital)Table 5 (WG 5)
Do not use physical restraints to prevent falls in care homes.
1BTable 5 (WG 5)
People with mild cognitive impairment or mild-to-moderate dementia living in the community should be offered exercise to prevent falls if willing and able. Build their care plan with both their own and their caregiver's perspective.
1B; 1CTable 5 (WG 4, WG 6)
Ask what the person believes about their falls, their causes and prevention, and build the plan around their goals, values and preferences.
1BTable 5 (WG 11)
In someone living with frailty a fall may be the first sign of an acute illness, such as pneumonia or a myocardial infarction without chest pain.
Assessment
After a hip fracture, offer individualised, progressive exercise to restore mobility, starting in hospital and continuing in the community.
1B; 2C (in-patients) & 1A (community)Table 5 (WG 4)
Offer people with early-to-mid-stage Parkinson's disease and mild or no cognitive impairment individualised balance and resistance exercise.
1ATable 5 (WG 7)
Drug doses
Vitamin D: for older adults at increased risk of deficiency, 800–1,000 IU a day is considered reasonable; 2,000 or 4,000 IU a day was not harmful in the VITAL trial.
Vitamin D interventions
When to refer
Refer according to the findings: a cardiologist or syncope specialist for suspected syncope, a physiotherapist for balance problems, a podiatrist for foot problems, an ophthalmologist or optometrist for visual problems, and audiology or ENT for hearing or vestibular problems.
Table 4
Link falls services with bone-health services that assess osteoporosis and fracture risk.
Purpose and scope of the guidelines
Red flags
A severe fall is one with an injury needing a doctor, a long lie (unable to get up for at least an hour), an emergency department visit, or loss of consciousness.
Table 2
A suspected transient loss of consciousness should trigger a syncope evaluation.
Falls risk stratification and algorithm
Recent updates
2022: the first global falls guideline, developed by 96 experts from 39 countries, with recommendations for hospitals, care homes, specific conditions and settings with limited resources.
How were these guidelines produced?