Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the Centre for Clinical Practice at the National Institute for Health and Care Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.
Note: The wording used in the recommendations in this guideline (for example, words such as 'offer' and 'consider') denotes the certainty with which the recommendation is made (the strength of the recommendations). See the end of the "Major Recommendations" field for further descriptions of the strength of recommendations.
Labelling of recommendations: New recommendations have been added about preventing falls in older people during a hospital stay. These are labeled [new 2013]. The original recommendations from NICE clinical guideline 21 are incorporated unchanged (except for minor wording changes for the purposes of clarification only). These are labeled  or [2004, amended 2013].
Preventing Falls in Older People
Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s. 
Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. (Tests of balance and gait commonly used in the United Kingdom [UK] are detailed in Section 3.3 of the full version of the original guideline.) 
Multifactorial Falls Risk Assessment
Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention. 
Multifactorial assessment may include the following:
- Identification of falls history
- Assessment of gait, balance and mobility, and muscle weakness
- Assessment of osteoporosis risk
- Assessment of the older person's perceived functional ability and fear relating to falling
- Assessment of visual impairment
- Assessment of cognitive impairment and neurological examination
- Assessment of urinary incontinence
- Assessment of home hazards
- Cardiovascular examination and medication review 
All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention. 
In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):
- Strength and balance training
- Home hazard assessment and intervention
- Vision assessment and referral
- Medication review with modification/withdrawal 
Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function. 
Strength and Balance Training
Strength and balance training is recommended. Those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficit. A muscle-strengthening and balance programme should be offered. This should be individually prescribed and monitored by an appropriately trained professional. 
Exercise in Extended Care Settings
Multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falling. 
Home Hazard and Safety Intervention
Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer, and appropriate members of the health care team. 
Home hazard assessment is shown to be effective only in conjunction with follow-up and intervention, not in isolation. 
Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling. 
Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls. 
Encouraging the Participation of Older People in Falls Prevention Programmes
To promote the participation of older people in falls prevention programmes the following should be considered.
- Healthcare professionals involved in the assessment and prevention of falls should discuss what changes a person is willing to make to prevent falls.
- Information should be relevant and available in languages other than English.
- Falls prevention programmes should also address potential barriers such as low self-efficacy and fear of falling, and encourage activity change as negotiated with the participant. 
Practitioners who are involved in developing falls prevention programmes should ensure that such programmes are flexible enough to accommodate participants' different needs and preferences and should promote the social value of such programmes. 
Education and Information Giving
All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls assessment and prevention. 
Individuals at risk of falling, and their carers, should be offered information orally and in writing about:
- What measures they can take to prevent further falls
- How to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components
- The preventable nature of some falls
- The physical and psychological benefits of modifying falls risk
- Where they can seek further advice and assistance
- How to cope if they have a fall, including how to summon help and how to avoid a long lie 
Interventions That Cannot Be Recommended
Brisk walking. There is no evidence1 that brisk walking reduces the risk of falling. One trial showed that an unsupervised brisk walking programme increased the risk of falling in postmenopausal women with an upper limb fracture in the previous year. However, there may be other health benefits of brisk walking by older people. 
Interventions That Cannot Be Recommended Because of Insufficient Evidence
The authors do not recommend implementation of the following interventions at present. This is not because there is strong evidence against them, but because there is insufficient or conflicting evidence supporting them1. 
Low intensity exercise combined with incontinence programmes. There is no evidence1 that low intensity exercise interventions combined with continence promotion programmes reduce the incidence of falls in older people in extended care settings. 
Group exercise (untargeted). Exercise in groups should not be discouraged as a means of health promotion, but there is little evidence1 that exercise interventions that were not individually prescribed for older people living in the community are effective in falls prevention. 
Cognitive/behavioural interventions. There is no evidence1 that cognitive/behavioural interventions alone reduce the incidence of falls in older people living in the community who are of unknown risk status. Such interventions included risk assessment with feedback and counselling and individual education discussions. There is no evidence1 that complex interventions in which group activities included education, a behaviour modification programme aimed at moderating risk, advice and exercise interventions are effective in falls prevention with older people living in the community. 
Referral for correction of visual impairment. There is no evidence1 that referral for correction of vision as a single intervention for older people living in the community is effective in reducing the number of people falling. However, vision assessment and referral has been a component of successful multifactorial falls prevention programmes. 
Vitamin D. There is evidence1 that vitamin D deficiency and insufficiency are common among older people and that, when present, they impair muscle strength and possibly neuromuscular function, via central nervous system (CNS)-mediated pathways. In addition, the use of combined calcium and vitamin D3 supplementation has been found to reduce fracture rates in older people in residential/nursing homes and sheltered accommodation. Although there is emerging evidence1 that correction of vitamin D deficiency or insufficiency may reduce the propensity for falling, there is uncertainty about the relative contribution to fracture reduction via this mechanism (as opposed to bone mass) and about the dose and route of administration required. No firm recommendation can therefore currently be made on its use for this indication.2 [2004, amended 2013]
Hip protectors. Reported trials that have used individual patient randomisation have provided no evidence1 for the effectiveness of hip protectors to prevent fractures when offered to older people living in extended care settings or in their own homes. Data from cluster randomised trials provide some evidence1 that hip protectors are effective in the prevention of hip fractures in older people living in extended care settings who are considered at high risk. 
Preventing Falls in Older People During a Hospital Stay
Predicting Patients' Risk of Falling in Hospital
Do not use fall risk prediction tools to predict inpatients' risk of falling in hospital. [new 2013]
Regard the following groups of inpatients as being at risk of falling in hospital and manage their care according to recommendations below:
- All patients aged 65 years or older
- Patients aged 50 to 64 years who are judged by a clinician to be at higher risk of falling because of an underlying condition. [new 2013]
Assessment and Interventions
Ensure that aspects of the inpatient environment (including flooring, lighting, furniture and fittings such as hand holds) that could affect patients' risk of falling are systematically identified and addressed. [new 2013]
For patients at risk of falling in hospital (see recommendations above), consider a multifactorial assessment and a multifactorial intervention. [new 2013]
Ensure that any multifactorial assessment identifies the patient's individual risk factors for falling in hospital that can be treated, improved or managed during their expected stay. These may include:
- Cognitive impairment
- Continence problems
- Falls history, including causes and consequences (such as injury and fear of falling)
- Footwear that is unsuitable or missing
- Health problems that may increase their risk of falling
- Postural instability, mobility problems and/or balance problems
- Syncope syndrome
- Visual impairment [new 2013]
Ensure that any multifactorial intervention:
- Promptly addresses the patient's identified individual risk factors for falling in hospital and
- Takes into account whether the risk factors can be treated, improved or managed during the patient's expected stay. [new 2013]
Do not offer falls prevention interventions that are not tailored to address the patient's individual risk factors for falling. [new 2013]
Information and Support
Provide relevant oral and written information and support for patients, and their family members and carers if the patient agrees. Take into account the patient's ability to understand and retain information. Information should include:
- Explaining about the patient's individual risk factors for falling in hospital
- Showing the patient how to use the nurse call system and encouraging them to use it when they need help
- Informing family members and carers about when and how to raise and lower bed rails
- Providing consistent messages about when a patient should ask for help before getting up or moving about
- Helping the patient to engage in any multifactorial intervention aimed at addressing their individual risk factors [new 2013]
Ensure that relevant information is shared across services. Apply the principles in Patient experience in adult NHS services (NICE clinical guideline 138) in relation to continuity of care. [new 2013]
1 This refers to evidence reviewed in 2004.
2 The following text has been deleted from the 2004 recommendation: "Guidance on the use of vitamin D for fracture prevention will be contained in the forthcoming NICE clinical practice guideline on osteoporosis, which is currently under development." As yet there is no NICE guidance on the use of vitamin D for fracture prevention.
Strength of Recommendations
Some recommendations can be made with more certainty than others. The Guideline Development Group (GDG) makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the GDG is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations labelled [new 2013] in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).
For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also "Patient-centred care" in the original guideline document).
Interventions That Must (or Must Not) Be Used
The GDG usually uses "must" or "must not" only if there is a legal duty to apply the recommendation. Occasionally they use "must" (or "must not") if the consequences of not following the recommendation could be extremely serious or potentially life threatening.
Interventions That Should (or Should Not) Be Used – A "Strong" Recommendation
The GDG uses "offer" (and similar words such as "refer" or "advise") when they are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. The GDG uses similar forms of words (for example, "Do not offer…") when they are confident that an intervention will not be of benefit for most patients.
Interventions That Could Be Used
The GDG uses "consider" when they are confident that an intervention will do more good than harm for most patients, and be cost-effective, but other options may be similarly cost-effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.
Wording of 2004 Recommendations
NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of "The guidelines manual" (January 2009). This does not apply to any recommendations ending  (see the "Major Recommendations" field). In particular, for recommendations labelled , the word "consider" may not necessarily be used to denote the strength of the recommendation.