Preventing falls in older people

We identified new evidence in several areas that indicates a need for an update including:

• Falls risk assessment tools – new evidence suggests that tools based on clinical characteristics lack sensitivity, specificity or both. However, the addition of new technologies to measure gait may improve on assessments based on clinical risk factors. Additionally, topic experts indicated a need to include frailty and previous fragility factors as risk factors for falls. Knowing about these characteristics may not increase prediction of future falls, yet this information is important because people with these characteristics may have more severe consequences if they fall.
• Multifactorial interventions – new evidence indicates they may not be effective. This finding contradicts current recommendations to offer multifactorial interventions. Evidence indicated that offering interventions based on individual risk factors may not be effective but offering all interventions irrespective of individual risk factors may be effective. However, the quality of evidence was rated by the authors of a Cochrane review as low or very low across analyses. Consideration of multifactorial interventions will also impact on recommendations about the individual components of interventions such as home hazard assessment and modifications.
• Exercise interventions – which appear to be effective using a wider range of types of exercise than are currently recommended. New guidance on physical activity from the Chief Medical Officer is expected in 2019. The update should consider how to encourage people at risk of falls to undertake the recommended levels of physical activity safely, and how to maintain benefits after prescribed exercise programmes end. The identified evidence addressed people living in the community and people living in residential care, indicating that the update should also consider practical ways to include people in extended care settings in exercise programmes.
• Vitamin D – which evidence suggests may be associated with fewer falls, although conversely, high doses of vitamin D may increase falls risk. The update should consider the role of vitamin D in falls prevention alongside the guideline on vitamin D supplement use in specific population groups.

Although we did not identify new published evidence for some sections of the guideline, namely cardiac pacing, encouraging participation in falls programmes and education and information giving, we decided that these should be considered in the update so that the updated guideline can reflect any changes in services since the original guideline was published.

Preventing falls in older people during a hospital stay

We identified new evidence that was consistent with current recommendations on assessing risk of falls and interventions for people in hospital. However, we decided that the update should include this section of the guideline to ensure that recommendations support continuity of care across settings.

For further details and a summary of all evidence identified in surveillance, see appendix A.

Search and selection strategy

We searched for new evidence related to the whole guideline. We conducted separate searches to identify studies of risk assessment tools (which included observational studies) and interventions to prevent falls (which included randomised controlled trials and systematic reviews).

Overall, we found 66 studies published between 30 April 2015 and 22 February 2019.

We also included:

• 0 relevant studies from a total of 9 identified by topic experts (because the 2 studies meeting
• the inclusion criteria for this surveillance review identified by topic experts were identified in the searches and are already included in the count of studies)
• 19 studies from the 2016 surveillance review.

From all sources, we considered 87 studies to be relevant to the guideline.

See appendix A for details of all evidence considered, and references.

Views of topic experts

We considered the views of topic experts who were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to the guideline.

We sent questionnaires to 19 topic experts and received 9 responses.

Seven of the 9 respondents indicated that the guideline should be updated. Issues highlighted by the topic experts included:

• The need to identify people who are frail or have had fragility fractures because these people may have more severe consequences after falling.
• Publication of new Cochrane reviews on exercise and multifactorial interventions that indicated a need to update the guideline.
• The increasing availability of technological advances that may help people to assess their risk of falling that should be considered by the update.
• The availability of new evidence on vitamin D supplementation, which should be considered in the update in conjunction with NICE’s guideline on vitamin D supplement use in specific population groups (published after the falls prevention guideline).

Other sources of information

We noted that Public Health England has established the National Falls Prevention Coordination Group. The group’s consensus statement recognises the need for effective falls prevention and reducing the variability in the quality, safety and outcomes of care. The update to the guideline therefore fits with national strategy.

Views of stakeholders

Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance decision was to update all of the guideline, we did not consult with stakeholders.

See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.

Equalities

No equalities issues were identified during the surveillance process.