c l i n i c a l p r ac t i c e g u i d e l i n e s Clinical practice guideline for the assessment and prevention of falls in older people Guidelines commissioned by the National Institute for Clinical Excellence (NICE) November 2004 c l i n i c a l p r ac t i c e g u i d e l i n e s Clinical practice guideline for the assessment and prevention of falls in older people This guideline was commissioned by the National Institute for Clinical Excellence (NICE) Published by the Royal College of Nursing, 20 Cavendish Square, London W1G 0RN November 2004 Publication code: 002 771 ISBN: 1-904114-17-2 © 2005 Royal College of Nursing.All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or a licence permitting restricted copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers National Collaborating Centre for Nursing and Supportive Care This work was undertaken by the National Collaborating Centre for Nursing and Supportive Care (NCC-NSC) and the Guideline Development Group (GDG) formed to develop this guideline Funding was received from the National Institute for Clinical Excellence (NICE) The NCC-NSC consists of a partnership between: Centre for Evidence-Based Nursing; Centre for Statistics in Medicine; Clinical Effectiveness Forum for Allied Health Professionals, College of Health; Health Care Libraries (University of Oxford); Health Economics Research Centre, Royal College of Nursing and UK Cochrane Centre NICE guideline on the management of osteoporosis – under development The NCC-NSC is currently developing a guideline for NICE on osteoporosis It is suggested that when this guideline is published in 2006, it is used in conjunction with these guidelines on falls prevention THE ASSESSMENT AND PREVENTION OF FALLS IN OLDER PEOPLE Contents Disclaimer 5.4 Fear of falling as a risk factor and tools to measure fear of falling: review methods and results 28 5.5 Interventions for the prevention of falls: review methods and results 30 5.6 Analysis of compliance with interventions for the prevention of falls 35 40 42 Guideline Development Group membership and acknowledgements Terminology Abbreviations General glossary Executive summary 5.7 Interventions to reduce the psychosocial consequences of falling: review methods and results Principles of practice, summary of recommendations 5.8 Patient views and experiences: review methods and results Background to the current guideline 12 5.9 Rehabilitation: review methods and results 45 Aims of the guideline 14 5.10 The effectiveness of hip protectors: review methods and results 48 5.11 Cost effectiveness review and modelling: methods and results 51 5.12 Submission of evidence process 57 5.13 Evidence synthesis and grading 58 4.1 Who the guideline is for 14 4.2 Groups covered by the guideline 14 4.3 Groups not covered 14 4.4 Health care setting 14 4.5 Interventions covered 14 4.6 Interventions not covered 14 4.7 Audit support within guideline 14 4.8 Guideline Development Group 5.14 Formulating and grading recommendations 58 Methods used to develop the guideline 5.2 Risk factors for falling: review methods and results 5.3 Assessment of those at high risk of falling: review methods and results Guideline recommendations with supporting evidence reviews 59 Recommendations for research 79 14 Audit criteria 80 16 Dissemination of guideline 82 10 Validation 82 11 Scheduled review of guideline 83 12 References 83 17 22 ROYAL COLLEGE OF N URSI NG Available on the attached CD-ROM Appendix A: Guideline Development Group membership and acknowledgements Appendix B: Search strategies and databases searched Appendix C: Quality checklists/data extraction forms Appendix D: Registered stakeholders Appendix E: Clinical effectiveness evidence table Appendix F: Quality assessment of trials Appendix G: Table of excluded studies Appendix H: Meta-analysis figures Appendix I: The scope THE ASSESSMENT AND PREVENTION OF FALLS IN OLDER PEOPLE Disclaimer National Collaborating Centre for Nursing and Supportive Care As with any clinical guideline, recommendations may not be appropriate for use in all circumstances A limitation of a guideline is that it simplifies clinical decision-making (Shiffman 1997) Decisions to adopt any particular recommendations must be made by the practitioners in the light of: Staff at the National Collaborating Centre for Nursing and Supportive Care who contributed to this guideline were: ✦ ✦ ✦ ✦ ✦ ✦ available resources local services, policies and protocols the patient’s circumstances and wishes available personnel and devices clinical experience of the practitioner knowledge of more recent research findings Guideline Development Group membership and acknowledgements Professor Gene Feder (group leader), St Bartholomew’s and the London Queen Mary’s School of Medicine and Dentistry Miss Margaret Clark,Alzheimer’s Society Dr Jacqueline Close, Royal College of Physicians Dr Colin Cryer, Centre for Health Services Studies, University of Kent at Canterbury Ms Carolyn Czoski-Murray, School of Health and Related Research, University of Sheffield Mr David Green, Royal Pharmaceutical Society of Great Britain Ms Jacqueline Chandler-Oatts, research associate Ms Elizabeth Gibbons, R&D fellow Dr Gill Harvey, Director Ms Jo Hunter, information specialist Ms Elizabeth McInnes, senior R&D fellow Mr Robin Snowball, information specialist (seconded from Cairns Library, John Radcliffe Hospital, Oxford) Mr Edward Weir, Centre Manager Additional assistance Dr Phil Alderson, Cochrane Centre, UK Dr Lesley Gillespie, Cochrane, UK Ms Colette Marshall, National Institute for Clinical Excellence Dr Martyn Parker, Cochrane UK Dr Lesley Smith, Centre for Statistics in Medicine Terminology Assessment refers to the evaluation of risk Where the term ‘carer’ is used, this refers to unpaid carers as opposed to paid carers (for example, care workers) Dr Steve Illiffe, Royal College of General Practitioners Cognitive impairment is defined as mini-mental state examination (MMSE)