These recommendations are based on the National Collaborating Centre for Nursing and Supportive Care guideline, Clinical practice guideline for the assessment and prevention of falls in older people [National Collaborating Centre for Nursing and Supportive Care, 2004] commissioned by the National Institute for Health and Clinical Excellence (NICE).

Risk factors for falls

• The strongest risk factor for falls is a previous fall. NICE recommends that all older people in regular contact with healthcare professionals should be asked about this at least annually. Other risk factors listed by NICE and used in this guidance were reported as statistically significant [National Collaborating Centre for Nursing and Supportive Care, 2004].
• Evidence from a recent review was unable to conclusively show an association between any specific class of drug and falls. However, there was weak evidence of an association between falls and benzodiazepines, antidepressants, and antipsychotics.

Assessment of gait and balance

• There is a lack of evidence regarding which assessment tool is most predictive of falls and therefore most useful.
• NICE reviewed the evidence and assessed the utility, feasibility, and acceptability of a range of key assessment tools and concluded that the timed Up & Go test and the Turn 180° test are pragmatic, can be used in any setting, and require no special equipment [National Collaborating Centre for Nursing and Supportive Care, 2004].
• Evidence from studies of older people living in the community or attending a day hospital indicate that the timed Up & Go test and the Turn 180° test are useful for predicting falls.
• Guidelines from the American Geriatric Society suggest that people who do the timed Up & Go test with no difficulty or unsteadiness are likely to be at low risk of falling and generally need no further assessment [American Geriatrics Society, 2001].

Excluding the presence of postural hypotension

• Estimates of the prevalence of postural hypotension in the elderly range from 21% to 30%, and its prevalence increases with age [Graafmans et al, 1996; Carey and Potter, 2001].
• Postural hypotension is associated with an increase in morbidity and mortality, in part due to the increased incidence of falls. However, postural hypotension is not a diagnosis, and should lead to investigations for a possible underlying cause (such as hypovolaemia, prolonged bed rest, medication, or neurogenic failure) [Carey and Potter, 2001].

These recommendations are based on the National Collaborating Centre for Nursing and Supportive Care guideline, Clinical practice guideline for the assessment and prevention of falls in older people [National Collaborating Centre for Nursing and Supportive Care, 2004] commissioned by the National Institute for Health and Clinical Excellence (NICE).

• NICE recommends that a multifactorial risk assessment should be performed by healthcare professionals with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualized, multifactorial intervention; it might include an assessment of falls risk, a cardiovascular examination, a medication review, and assessment of:
• Gait, balance, mobility, and muscle weakness.
• Osteoporosis risk.
• Perceived functional ability and fear related to falling.
• Visual impairment.
• Cognitive impairment and neurological examination.
• Urinary incontinence.
• Home hazards.
• CKS identified no evidence of single interventions that reduce the risk of falls, but acknowledges that in some circumstances this would be good clinical practice (for example referral to an optician for visual problems).

These recommendations are based on the National Collaborating Centre for Nursing and Supportive Care guideline, Clinical practice guideline for the assessment and prevention of falls in older people [National Collaborating Centre for Nursing and Supportive Care, 2004], and were based on evidence from a Cochrane systematic review that has now been withdrawn and replaced by two reviews, Interventions for preventing falls in older people living in the community [Gillespie et al, 2009] and Interventions for preventing falls in older people living in residential care facilities and hospitals (nearing completion).

• The guideline does not give specific information on what a falls service should offer to an individual identified at risk of falling. However, the guideline does state that a personalised approach should be carried out, and management should be focused around strength and balance training, home hazard and vision assessment and intervention, and medication review.
• Evidence from the recently published Cochrane systematic review indicates that:
• Exercise interventions reduce the rate and risk of falls.
• Further research is required to clarify the contexts in which multifactorial interventions, home safety interventions, and vitamin D supplementation are effective.
• There is limited evidence to support the withdrawal of psychotropics and GP educational programmes plus medication review for reducing falls.
• For people with poor vision, there is evidence (from one study) that cataract surgery on the first eye is effective at reducing the rate of falls.
• For people with carotid sinus hypersensitivity, there is evidence (from one study) that a pacemaker s effective at reducing the rate of falls.