World guidelines for falls prevention and management for older adults: a global initiative

Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan; Veterans Administration Ann Arbor Healthcare System Geriatrics Research Education Clinical Center, Ann Arbor, MI, USA

Clemens Becker

Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany

Hubert Blain

Department of Geriatrics, Montpellier University hospital and MUSE, Montpellier, France

Robbie Bourke

Department of Medical Gerontology Trinity College Dublin and Mercers Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland

Ian D Cameron

John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District and Faculty of Medicine and Health, University of Sydney. Department of Medicine (Neurology) and Neuroscience and Mental Health, Sydney, NSW, Australia

Richard Camicioli

Department of Medicine (Neurology), Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada

Lindy Clemson

Sydney School of Health Sciences, Faculty of Medicine & Health, The University of Sydney, Sydney, Australia

Jacqueline Close

Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, NSW, Australia

Prince of Wales Clinical School, Medicine, University of New South Wales, Sydney, NSW, Australia

Kim Delbaere

Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, NSW, Australia; School of Population Health, University of New South Wales, Kensington, NSW, Australia

Leilei Duan

National Centre for Chronic and Noncommunicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China

Gustavo Duque

Research Institute of the McGill University HealthCentre, Montreal, Quebec, Canada

Suzanne M Dyer

Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia

Ellen Freiberger

Friedrich-Alexander-University Erlangen-Nürnberg, Institute for Biomedicine of Aging, Nürnberg, Germany

David A Ganz

Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA and Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA

Fernando Gómez

Research Group on Geriatrics and Gerontology, International Association of Gerontology and Geriatrics Collaborative Center, University Caldas, Manizales, Colombia

Jeffrey M Hausdorff

Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

Department of Physical Therapy, Sackler Faculty of Medicine, and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel

Department of Orthopaedic Surgery, Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA

David B Hogan

Brenda Strafford Centre on Aging, O’BrienInstitute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

Susan M W Hunter

School of Physical Therapy, Faculty of Health Sciences, Elborn College, University of Western Ontario, London, ON, Canada

Jose R Jauregui

Ageing Biology Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

Nellie Kamkar

Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, ON, Canada

Rose-Anne Kenny

Department of Medical Gerontology Trinity College Dublin and Mercers Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland

Sarah E Lamb

Faculty of Health and Life Sciences, Mireille Gillings Professor of Health Innovation, Medical School Building, Exeter, England, UK

Nancy K Latham

Brigham and Women's Hospital, Boston, MA, USA

Lewis A Lipsitz

Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

Teresa Liu-Ambrose

Djavad Mowafaghian Centre for Brain Health, Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada

Pip Logan

School of Medicine, University of Nottingham, Nottingham, England, UK

Stephen R Lord

Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, NSW, Australia

School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia

Louise Mallet

Department of Pharmacy, Faculty of Pharmacy, McGill University Health Center, Université de Montréal, Montreal, QC, Canada

David Marsh

University College London, London, England, UK

Koen Milisen

Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium

Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium

Rogelio Moctezuma-Gallegos

Geriatric Medicine & Neurology Fellowship, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”. Mexico City, Mexico

Geriatric Medicine Program, Tecnologico de Monterrey, School of Medicine and Health Sciences. Monterrey, Nuevo León, Mexico

Meg E Morris

Healthscope and Academic and Research Collaborative in Health (ARCH), La Trobe University, Australia

Alice Nieuwboer

Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium

Monica R Perracini

Master’s and Doctoral programs in Physical Therapy, Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, Brazil

Frederico Pieruccini-Faria

Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, ON, Canada

Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada

Alison Pighills

Mackay Institute of Research and Innovation, Mackay Hospital and Health Service, Mackay, QLD, Australia

Catherine Said

Western Health, University of Melbourne, Parkville, Melbourne, VIC, Australia

Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St Albans, VIC, Australia

Melbourne School of Health Sciences The University of Melbourne, Parkville, Australia

Ervin Sejdic

Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA

Catherine Sherrington

Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia

Dawn A Skelton

School of Health and Life Sciences, Research Centre for Health (ReaCH), Glasgow Caledonian University, Cowcaddens Road, Glasgow, Scotland, UK

Sabestina Dsouza

Department of Occupational Therapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India

Mark Speechley

Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada

Schulich Interfaculty Program in Public Health, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada

Susan Stark

Program in Occupational Therapy, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA

Chris Todd

School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, England, UK

Manchester University NHS Foundation Trust, Manchester M13 9WL, UK

Bruce R Troen

Division of Geriatrics and Palliative Medicine, Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, University of Buffalo; Research Service, Veterans Affairs Western New York Healthcare System, Buffalo, New York, USA

Tischa van der Cammen

Department of Human-Centred Design, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands

Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands

Joe Verghese

Division of Geriatrics, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA

Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA

Ellen Vlaeyen

Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium

Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium

Jennifer A Watt

Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada

Department of Medicine, University of Toronto, Toronto, ON, Canada

Tahir Masud

Department of Geriatric Medicine, The British Geriatrics Society, Nottingham University Hospitals NHS Trust, Nottingham, England, UK

Manuel Montero-Odasso, Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, ON, Canada; Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada;

Acknowledgement of collaborative authors: The members of the Task Force on Global Guidelines for Falls in Older Adults are listed in Appendix 4a, available in Age and Ageing online. Devinder Kaur Ajit Singh, Sara G. Aguilar-Navarro, Edgar Aguilera Caona, Neil B. Alexander, Natalie Allen, Cedric Anweiller, Alberto Avila-Funes, Renato Barbosa Santos, Frances Batchelor, Clemens Becker, Marla Beauchamp, Canan Birimoglu, Hubert Blain, Kayla Bohlke, Robert Bourke, Christina Alonzo Bouzòn, Stephanie Bridenbaugh, Patricio Gabriel Buendia, Ian Cameron, Richard Camicioli, Colleen Canning, Carlos Alberto Cano-Gutierrez, Juan Carlos Carbajal, Daniela Cristina Carvalho de Abreu, Alvaro Casas-Herrero, Alejandro Ceriani, Matteo Cesari, Lorenzo Chiari, Lindy Clemson, Jacqueline Close, Luis Manuel Cornejo Alemǻn, Rik Dawson, Kim Delbaere, Paul Doody, Sabestina Dsouza, Leilei Duan, Gustavo Duque, Suzanne Dyer, Toby Ellmers, Nicola Fairhall, Luigi Ferrucci, Ellen Freiberger, James Frith, Homero Gac Espinola, David A. Ganz, Fabiana Giber, José Fernando Gómez, Luis Miguel Gutiérrez-Robledo, Sirpa Hartikainen, Jeffrey Hausdorff, David B. Hogan, Chek Hooi Wong, Simon Howe, Susan Hunter, Javier Perez Jara, Ricardo Jauregui, Anton Jellema, Suen Jenni, Ditte Jepson, Sebastiana Kalula, Nellie Kamkar, Devinder Kaur Ajit Singh, Rose Anne Kenny, Ngaire Kerse, Olive Kobusingye, Reto Kressig, Wing Kwok, Sallie Lamb, Nancy Latham, Mei Ling Lim, Lewis Lipsitz, Teresa Liu-Ambrose, Pip Logan, Stephen Lord, Roberto Alves Lourenço, Kenneth Madden, Louise Mallet, Pedro Marín-Larraín, David R. Marsh, Finbarr C. Martin, Diego Martínez Padilla, Tahir Masud, Sumaiyah Mat, Lisa McGarrigle, Bill McIlroy, Felipe Melgar-Cuellar, Jasmine Menant, Koen Milisen, Alberto Mimenza, Rogelio Moctezuma-Gallegos, Manuel Montero-Odasso, Meg E. Morris, Irfan Muneeb, Hossein Negahban, Alice Nieuwboer, Mireille Norris, Giulia Ogliari, Juliana Oliveira, José F. Parodi, Sergio Perez, Monica Perracini, Mirko Petrovic, José Ernesto Picado Ovares, Frederico Pieruccini-Faria, Alison Pighills, Marina Pinheiro, Eveline Poelgeest, Xinia Ramirez Ulate, Katie Robinson, Jesper Ryg, Cathy Said, Ryota Sakurai, Marcelo Schapira, Ervin Sejdic, Lotta J. Seppala, Aldo Sgaravatti, Cathie Sherrington, Dawn Skelton, Yu Song, Mark Speechley, Susan Stark, Munira Sultana, Anisha Suri, Maw Pin Tan, Morag Taylor, Katja Thomsen, Anne Tiedemann, Susana Lucia Tito, Chris Todd, Bruce Troen, Tischa Van der Cammen, Nathalie Van der Velde, Joe Verghese, Ellen Vlaeyen, Jennifer Watt, Ana-Karim Welmer, Chang Won Won, G.A. Rixt Zijlstra

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Associated Data

Abstract

Background

falls and fall-related injuries are common in older adults, have negative effects on functional independence and quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines are inconsistent, with no up-to-date, globally applicable ones present.

Objectives

to create a set of evidence- and expert consensus-based falls prevention and management recommendations applicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach that includes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previous guidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resources such as low- and middle-income countries.

Methods

a steering committee and a worldwide multidisciplinary group of experts and stakeholders, including older adults, were assembled. Geriatrics and gerontological societies were represented. Using a modified Delphi process, recommendations from 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults were reviewed and refined. The final recommendations were determined by voting.

Recommendations

all older adults should be advised on falls prevention and physical activity. Opportunistic case finding for falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered a comprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomain interventions. Other recommendations cover details of assessment and intervention components and combinations, and recommendations for specific settings and populations.

Conclusions

the core set of recommendations provided will require flexible implementation strategies that consider both local context and resources.

Keywords: falls, injury, aged, guidelines, recommendations, clinical practice, world, global, consensus, older people

Key Points

The world’s population is ageing. Falls and related injuries are increasingly common, making their prevention and management a critical global challenge.

Opportunistic case-finding is necessary as older adults may not present following a fall and may be reluctant to report falls.

Engaging older individual’s beliefs, attitudes and priorities about falls and their management is essential.

Application of some of these recommendations may need modification to meet low resource settings and country’s needs.

‘It takes a child one year to acquire independent movement and ten years

to acquire independent mobility. An old person can lose both in a day’

Professor Bernard Isaacs

(1924–1995)

Introduction

This quote from Bernard Isaacs portrays the unfortunate consequences that an older adult may experience after a single fall [1]. Falls occur at all ages and are an inevitable part of a bipedal gait and physical activity. They occur in 30% of adults aged over 65 years annually [2], for whom the consequences are more serious, despite concerted efforts of researchers and clinicians to understand, assess and manage their risks and causes. In addition to personal distress, falls and fall-related injuries are a serious health care problem because of their association with subsequent morbidity, disability, hospitalisation, institutionalisation and mortality [1, 3, 4]. In Europe, total deaths and disability-adjusted life years due to falls have increased steadily since 1990 [5]. The Global Burden of Disease study reported nearly 17 million years of life lost from falls in 2017 [3]. Related societal and economic consequences are substantial. In high-income countries, approximately 1% of health care costs are fall-related expenditures [6].

The number of falls and related injuries will likely further increase [7, 8], partly as there are more older adults, but also because of increasing prevalence of multimorbidity, polypharmacy and frailty among them. There appears to be differences in falls prevalence between and within regions of the world [3, 5]. For example, rates among ethnic Chinese populations across South East Asia have been reported as between 15 and 34% [4] and in the Latin America and Caribbean region rates ranged from 22% in Barbados to 34% in Chile [9]. These differences may be due in part to cultural and lifestyle differences [10]. There are also differences between settings with the incidence of falls being higher for older adults living in care homes or during a hospital stay [10]. This suggests that risk factors may differ across locations and settings, which could have relevance for preventative strategies.

The need for new guidelines

The World Falls Guidelines (WFG) Task Force was created following discussions in 2019 between 14 international experts to consider whether new guidelines on falls prevention were needed to reflect new evidence and clinical service challenges. A subsequent systematic review identified gaps in and inconsistencies between the existing guidelines developed nationally or by specialist international bodies and concluded that a new set of clinical practice guidelines should be created to address these issues and that the guidelines should incorporate an international perspective [7].

The National Institute for Health and Care Excellence in England (NICE) undertook a systematic assessment in 2019 of the need to update its 2013 guidelines [8] and concluded that new evidence reported up to February 2019 had likely impact on case-finding, falls risk assessments and preventative interventions. With further findings since then, there is now a substantial volume of research evidence that has not been systematically evaluated. Observational studies have clarified how to identify levels of risk among community dwelling and clinical populations [2, 11, 12]. Mechanistic and epidemiological studies have improved our understanding of falls in older adults with cognitive impairment [12–16]. The potential roles for e-health including wearables, virtual reality applications and environmental monitoring devices [17–19] have not been previously considered by prior guideline recommendations.

Falls are more common among older adults in clinical care settings, e.g. hospitals, subacute and rehabilitation units, assisted living settings and care homes. The risk factors in these settings and consensus on how to address them are not well captured in current clinical practice guidelines, but evidence specific to these settings is now available on which to base recommendations.

Perspectives of older adults with living experience, carers and other stakeholders have been inconsistently incorporated [7], but there is now emerging evidence that such views may inform the suitability and feasibility of guideline recommendations [20–22].

Purpose and scope of the guidelines

We believe that these guidelines will contribute to improving the health and well-being of older adults globally, which is the overarching aim of the United Nations Decade of Healthy Ageing (2021–2030). Healthy ageing relies on ‘the functional ability to be or to do what you have reason to value’ [23]. Reducing the incidence of falls and related injuries, notably fractures and head injuries, and enabling preserved functional mobility and reducing concerns about falling, which may limit activity, would all contribute to achieving this. Therefore, the objective of the WFG is to provide guidelines for healthcare and other professionals working with older adults on how to identify and assess the risk of falls and which interventions, alone or in combination, to offer as part of a person-centred approach. These guidelines are novel in systematically considering: (i) a person-centred approach, including the perspectives from older adults with lived experience, caregivers and other stakeholders: (ii) gaps detected in previous guidelines; (iii) recent developments in e-health and (iv) challenges of implementation across settings and locations with limited resources, including low- and middle-income countries (LMIC).

We adopted the World Health Organisation definition: a fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. Falls, trips and slips can occur on one level or from a height [24]. This definition of a fall includes syncopal events. In the health and social care systems of many countries, older adults are regarded as those aged 65 years or over, but in some circumstances, age 60 years may be more appropriate depending on the context and health expectancies. There is inconsistency in the ages of older participants in the research evidence underpinning these guidelines. There is no scientific rationale for the application of a strict chronological definition of older age when using these guidelines.

The guidelines are focused on individual person level actions. The intended beneficiaries include older adults living in the community and care homes, and hospital inpatients. We also considered the specific features of assessment and/or prevention applicable to older adults with common medical conditions associated with higher falls risk and where the evidence supported this (i.e. Parkinson’s disease [PD], post-stroke, post-hip fracture and significant cognitive impairment) we developed separate recommendations for these conditions.

The challenges of implementing falls prevention guidelines in LMIC, where barriers to accessing human and technical resources may be encountered, have not been previously considered [25]. As well, the most predictive risk factors for falls and the favoured interventions to prevent them may well differ in these countries compared with high-income ones. Accordingly, we have tried to include these considerations in the recommendations made and the advice provided for their implementation.

Management of fall-related injuries is beyond the scope of these guidelines, but as there is a close epidemiological and clinical relationship between falls and fragility fractures, explicit linkage is needed with clinicians and services that can assess bone health, identify osteoporosis and fracture risk and provide management for maintaining bone health. While details of these activities are not included in these guidelines, there are well developed multilingual ones available elsewhere [26, 27].

How should these guidelines be used?

Healthcare clinicians for whom these guidelines were developed include physicians, nurses, physiotherapists, occupational therapists, pharmacists and other allied health professionals. Application of these guidelines involves actions by non-specialist as well as specialist healthcare professionals, and service design of care pathways linking primary and community services to specialists where necessary. Therefore, optimal implementation will require actions at the operational level in healthcare and social care sectors. While adaptation to local context, healthcare arrangements and resources is inevitable, our recommendations encompass the global population of older adults. Population level approaches such as public health initiatives and community level actions such as environmental design and age-friendly communities that may directly or indirectly impact falls rates are beyond our scope.

We anticipate that the flexible application of our recommendations will support meeting the different needs of individuals with varying characteristics and priorities and residing in diverse settings and countries with variable resource availability and are consistent with the person-centred approach [28] described below.

Predictive: utilisation of available information to determine an individual’s risk of falls and fall-related injuries.

Preventative: focused on intention to prevent falls and related injuries whilst optimising functional ability.

Personalised: utilisation of identified fall risks factors and other relevant clinical information, such as cognition, to develop individualised fall prevention plans.

Participatory: intervention goals and plan developed in collaboration with the older adult, and others as they wish, to consider priorities, values and resources, such as carer support.

How were these guidelines produced?

A full description of the process is provided in Appendix 1, available in Age and Ageing online. The World Falls Guidelines Task Force assembled 96 experts from 39 countries and across 5 continents, with representation from 36 scientific and academic societies. Details how this task force was assembled have been previously described [25]. A Steering Committee developed the strategy and guided the project. Feedback from older adults was obtained through early and meaningful involvement in the consensus process, with the goal of making these guidelines better suited to the needs of older adults residing in the community and long-term care facilities. We conducted a systematic review in 2020 that examined existing falls prevention and management guidelines. The gaps identified informed the creation of specific working groups (WGs) addressing topics considered to be relevant or controversial [7]. Eleven topic specific WGs developed preliminary graded recommendations based on systematic reviews as described in detail in each of their WG Reports in Appendix 2, available in Age and Ageing online. Each WG was responsible for creating its own search strategy and their own PICO question. Details on selecting and appraising the articles are clarified in the full report for each WG in Appendix 2, available in Age and Ageing online. A further WG considered older adult’s perspectives as a cross-cutting theme. Ten ad hoc expert groups performed additional rapid reviews [29] of clinical areas not covered by the WGs. An international Experts Group provided external review and feedback on the preliminary and revised recommendations through a four-stage modified Delphi process, which culminated in a final vote on the recommendations that involved Steering Committee members and WG leaders and informed by structured feedback from an older adults’ panel.

In addition, an ad hoc WG of 8 clinician experts developed a falls assessment and management algorithm, linking risk stratification, assessment and interventions, based on the evidence provided by the WGs. The full membership lists of committees and WGs are shown in Appendix 4b, available in Age and Ageing online.

Grading of recommendations is presented according to the strength (1 strong to 2 weak-conditional) and quality of the contributing evidence (A–C, high to low) using a modified version of the widely used Grading of Recommendations, Assessment, and Evaluation (GRADE) criteria ( Table 1 ) [30]. This modified GRADE is based on the original system, where numbers are used to indicate the strength of the recommendation. Where evidence was lacking, but a recommendation considered necessary, this modified system allowed for a recommendation to be graded as ‘E’ (expert consensus advice recommendation) ( Tables 2 and ​ and3 3 ).

Table 1

Modified GRADE system description