Evaluation of Clinical Practice Guidelines on Fall Prevention and Management for Older Adults

1Falls and fall-related injuries are common for older adults, with approximately 30% of adults 60 years of age or older falling each year.,, Falls are more likely for older adults with greater frailty severity and among those living in nursing homes., Consequences of falls include injuries, fractures, problems with mobility, depression, loss of independence,, and a substantial economic burden on health care systems.

2Falls and their concomitant injuries represent a worldwide phenomenon. Accordingly, several medical societies and organizations in different countries have created clinical practice guidelines for fall prevention and management.,,,,,,,,,,,,,, These guidelines are typically based on systematic reviews of the available evidence and consensus by experts in the fields of geriatric medicine, rehabilitation medicine, and physiotherapy, among others., Although several of these clinical practice guidelines for fall prevention have been published, little is known about the level of agreement between the recommendations made by them. Clinicians face the challenge of selecting high-quality guidelines based on robust methods with internally and externally validated recommendations applicable to their setting in informing their practice.,

3We aimed to (1) systematically review existing clinical practice guidelines on fall prevention and management for older adults; (2) identify common areas evaluated and level of agreement in the recommendations made; (3) address fall risk stratification in each guideline, describing which assessments are recommended to guide this and inform management across settings (eg, community, acute care, and nursing homes); and (4) identify potential gaps and areas that should be addressed in future clinical practice guidelines.

4We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and preregistered in PROSPERO (CRD42020173597). This systematic review was performed under the umbrella of the World Falls Guidelines for Prevention and Management of Falls in Older Adults.

5Our initial search on April 2, 2020, was updated July 1, 2021, and included the following databases: MEDLINE, PubMed, PsycINFO, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Library, PEDro (Physiotherapy Evidence Database), and Epistemonikos. Three of us (M.M.M.-O., S.W.H., and T.M.) also provided consultation to include guidelines potentially not indexed in databases.

6Our search used Medical Subject Headings terms pertaining to (1) falls, (2) clinical practice guidelines, (3) management and prevention, and (4) older adults (eTable 1 in Supplement 1 describes our search syntax).

7The inclusion criteria were (1) outcome of guidelines: fall reduction, prevention, and management; (2) study type: clinical practice guidelines for preventing or managing falls categorized as consensus- or evidence-based guidelines; and (3) target population of guidelines: older adults. There were no restrictions on date, language, or setting for inclusion.

8Three of us as independent reviewers (M.M.M.-O., N.K., and Y.S.-A.) selected records for full-text examination if they followed evidence- and consensus-based processes; disagreements were resolved by consensus. Three of us as reviewers (N.K., F.P.-F., and A.O.) assessed guideline quality using the 23-item Appraisal of Guidelines for Research & Evaluation II (AGREE-II) tool (eTable 2 in Supplement 1). The scores for AGREE-II range from 0 to 100, with higher scores indicating higher quality. Extracted recommendations were grouped in common areas and independently appraised by 3 of us (N.K., F.P.-F., and A.O.; blinded among us 3) using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE),, which reflects the strength of the recommendation (1 = strong; 2 = weak) paired with the quality of the supporting evidence (A = high; B = moderate; and C = low). Agreement across guidelines for specific recommendations was assessed using the Fleiss κ statistic.

9Our search yielded 11 414 records. There were 6647 duplicates, and 4608 records were excluded after title and abstract review, resulting in 159 records that were fully reviewed and assessed for eligibility (Figure 1). Of the 159 records, 144 were excluded, yielding 15 records retained for final analyses and included in the data synthesis.,,,,,,,,,,,,,, Table 1 shows the quality assessment characteristics using the AGREE-II tool for the 15 guidelines selected.

10The AGREE-II total scores were high across all guidelines (mean [SD], 80.1% [5.6%]; range, 69.7%-92.8%). Descriptive statistics for AGREE-II scores by domain are given in Table 1, and mean AGREE-II scores by domain are illustrated in Figure 2. Domain 6 (editorial independence, competing interests, and conflicts of interest disclosed) scored highest across guidelines. Domain 1 (guideline objectives, clinical research question being addressed, and target population) and domain 4 (clarity of presentation) also showed high mean scores. Domain 2 (representation and involvement from professional backgrounds, and by patients and stakeholders) showed moderate mean scores (mean [SD], 76.3% [9.0%]) mainly owing to involvement of only clinicians in some of the guidelines; however, none of guidelines included an exclusive panel of patients or caregivers involved in the entirety of the guideline development process. Domain 3 (systematic methods used to obtain evidence, strengths and limitations clearly outlined, and the extent to which the health benefits and adverse effects of each recommendation are considered) scores were moderately high with more variability. Domain 5 (applicability of the recommendations, descriptors of facilitators and barriers to the application of each recommendation, and advice on tools and resources for applying each recommendation) scored consistently lower (mean [SD], 63.4% [11.4%]) than the other domains mainly because only 5 guidelines provided a toolkit or a step-by-step process in how to apply the recommendations.,,,,

11After screening 4767 abstracts that proceeded to 159 full texts, we extracted 198 recommendations from the 15 guidelines that we grouped into 16 commonly addressed topic areas (Table 2). Topic areas that were presented in more than 40% of the guidelines were included in Table 2. Each topic area in Table 2 includes an accompanying GRADE score, which reflects the strength of the recommendation and the quality of the evidence. Across all areas and in all guidelines, the direction of the recommendation was in favor of the guideline (rather than recommending against its use). For definitions of the 16 commonly addressed topic areas, refer to eTable 3 in Supplement 1. The following topic areas were presented in less than 40% of the guidelines: addressing the use of canes or walking aids in the recommendations, alcohol use, depression, urinary incontinence, hearing impairment, atypical blood glucose, social isolation, and functional dependence as risk factors for falls, followed by staff education in nursing homes as part of interventions to prevent and manage falls.

12Of 15 guidelines, 4 addressed all 16 topic areas identified,,,, whereas 5 addressed at least 13 of them.,,,, Two topic areas (use of assessment tools for individuals who screened positive in falls risk, and exercise interventions) were covered in all of the guidelines, indicating consistent support for their importance. Medication review for fall risk–increasing drugs, use of multifactorial interventions to manage falls, and environment modification to prevent falls were recommended in 14 of the guidelines. Thirteen of the guidelines recommended performing risk stratification to detect high-risk individuals if they screened positive in the case-finding step using gait and balance tests. Thirteen guidelines also recommended conducting vision interventions, cardiovascular interventions for falls, and referral to a physiotherapist for exercises and balance retraining. Twelve guidelines recommended footwear evaluation and intervention and falls prevention education. Concerning the strength of the recommendations and quality of the evidence supporting the recommendation, GRADE A scores were most commonly found for 9 topic areas (Table 2). Agreement across guidelines was high (κ > 0.80) for 5 areas: risk stratification, assessment tools, fractures and osteoporosis management, exercise interventions, and use of multifactorial interventions. Agreement was moderate (κ = 0.50-0.80) for 7 topic areas and low (κ < 0.5) for the remaining 4 areas (Table 2).

13Recommendations on vitamin D supplementation (κ = 0.30) and education on falls prevention (κ = 0.20) had low levels of agreement across the 15 guidelines. Seven guidelines strongly recommended the use of vitamin D supplementation, 4 guidelines provided weak recommendations, and the remaining 4 guidelines did not address the topic. For education on falls prevention, 6 guidelines provided strong recommendations to offer patients and caregivers education on fall prevention and management strategies, 6 gave weak recommendations, and 3 did not address this topic area. Recommendations for addressing cognitive impairment during fall risk assessment and management were present in 11 guidelines, with low agreement across them (κ = 0.39). Physiotherapy referral was recommended in 13 guidelines but with low agreement (κ = 0.50).

14The use of hip protectors to prevent fall-related injuries and the use of digital technology (including wearables) to detect, prevent, or manage falls had a low level of agreement across the 15 guidelines. For recommendations on hip protectors, 7 guidelines provided strong recommendations for their use in nursing home settings, 2 guidelines provided weak recommendations, and 6 guidelines did not address their use. Recommendations on the use of digital technology had similar results. Six guidelines provided strong recommendations to use digital technology, 1 guideline provided a weak recommendation, and 8 guidelines did not address their use.

15Most guidelines strongly recommended risk stratification using “case finding” self-reported questions, including fall history, fear of falling, and gait and balance difficulties, and reserving gait and balance testing for those who screen positive on these questions. Five guidelines included a risk-stratification algorithm, but evidence validating the algorithm was not consistently presented, as described in Table 3.,,,,,,,,,,,,,,,,,,, The majority of these algorithms followed the format proposed by the American Geriatrics Society/British Geriatrics Society/American Academy of Orthopaedic Surgeons (AGS/BGS/AAOS) guidelines. Individuals who had either no falls or 1 noninjurious fall in the last year and no impairment of balance and gait evident on examination were considered low risk, with a reassessment suggested sometime in the future. The interval proposed to reassess these low-risk individuals ranged from 1 year to 2 years across the guidelines examined.

16For individuals who screened positive in fall history, several guidelines stratified their risk by demographic factors (ie, advanced age or female sex),,,, or clinical characteristics (gait and balance abnormalities).,,,,,,,,,,,, The assessment of balance and gait, at this step, was recommended in 13 out of 15 guidelines,,,,,,,,,,,, using the Timed Up and Go Test (TUG), the Berg Balance Scale, and the Tinetti Performance-Oriented Mobility Assessment Tool, with the TUG being the most recommended test, appearing in 6 of the 15 guidelines (Table 3).,,,,,

17This systematic review identified 15 high-quality practice guidelines for fall prevention and management, which provided 198 recommendations for risk assessment, prevention, and management of falls for older adults. Most guidelines strongly recommended risk stratification screening using short questionnaires and reserving gait and balance testing for those who screened positive. Similarly, most guidelines strongly recommended medication review, exercise interventions, environment modifications, multifactorial approaches, and active management of fractures and osteoporosis as key elements in the prevention of falls. Vision or footwear intervention, physiotherapy referral, and cardiovascular interventions were less commonly addressed. Although all selected guidelines had high overall methodologic quality, clinical applicability and stakeholder involvement were domains missed or lacking in details.

18Recommendations for vitamin D supplementation showed mixed results. The strength of recommendations varied from strong to weak, with several guidelines not making any suggestions. This may reflect the inconsistent evidence about vitamin D supplementation for fall prevention and how the evidence varied based on settings: community vs residential or nursing home care.,, Similarly, recommendations about fall prevention education were mixed with a similar pattern seen. The use of hip protectors and digital technologies and wearables were often not included, with half of guidelines making no recommendation in these areas. The latest Cochrane meta-analyses found only weak evidence supporting the efficacy of hip protectors in preventing fractures after a fall in long-term care facilities and noted challenges in implementing the daily use of these protectors. This weak evidence, coupled with not all guidelines addressing falls in long-term care, likely explains the omission of hip protector recommendations. The underrepresentation of digital and wearable technologies is probably a reflection of their novelty.

19Risk stratification was an area addressed by most guidelines, with some proposing a specific risk stratification algorithm. Those algorithms often recommended performing gait and balance tests for individuals who screened positive., The most frequently recommended gait and balance test was the TUG, potentially owing to its simplicity, acceptance, and ease of administration. Evidence does not support acceptable predictive validity for any of the tests recommended in isolation for falls prediction,,,,, and specifically the TUG has low predictive validity. Consistent with the overall lower score in the applicability domain of the AGREE-II scale, details on resources, facilitators, and barriers to use of any of the recommended tests warranted more complete descriptions.

20In addition to gait and balance, 5 guidelines stratified risk by some demographic characteristics (ie, advanced age, female sex).,,,, Explicit statements within the guidelines indicating the validation of their stratification algorithms were lacking. Few studies assessed the predictive accuracy of some of the proposed algorithms and found low sensitivity to detect individuals at higher risk of falls.,, Future guidelines providing risk stratification algorithms should conduct validation studies of their effectiveness, address the adaptability of the proposed algorithm to different care or residential settings, and include validations in resource-constrained areas, such as low- and middle-income countries. Finally, only 2 guidelines recommended active interventions with follow-up care for individuals deemed low risk in their stratification strategy, including education and exercises involving balance and lower limb strengthening.,,, Recommendations for low-risk older adults that may help prevent falls and improve their overall health are also needed.

21Recommendations to evaluate and manage medication-related risks for falls varied from judicious deprescribing of psychotropic and cardiovascular medications to performing a comprehensive medication review. Across all guidelines, medication review was recommended generally and in all settings. Although a search for medication review for fall risk–increasing drugs was identified in medication review recommendations, resources and tools for clinicians were lacking. This deficiency may have been attributable to the unavailability of resources. Tools such as STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) have only recently been developed.

22Specific recommendations for older adults with cognitive impairment were scarce. Although cognitive evaluation was recommended as part of the initial assessment in most of the guidelines, specific guidance for evaluating specific aspects of cognition associated with increased fall risk (such as deficits in executive function) were lacking, despite the evidence in the literature of elevated fall risk factors in this group., Consideration of specific cognitive domains is imperative because executive function deficits are a known and prominent risk factor for falls among older adults—even among individuals without a formal diagnosis of cognitive impairment or dementia.,,, Executive function may be a target for fall prevention interventions, as shown in recent studies., Future guidelines should consider including specific recommendations for individuals with cognitive deficits, including executive functioning and memory.,

23The perspectives of people with a history of falls and associated injuries were not thoroughly and consistently embedded in the appraised guidelines. Moreover, personalized approaches that incorporate individual preferences in the fall prevention recommendations made to patients were also lacking., In general, patient and caregiver perspectives have not been consistently incorporated in clinical practice guidelines and related health resources.

24Clinical applicability was underrepresented in all the guidelines. Facilitators or barriers to implement recommendations were thoroughly detailed in only 3 guidelines.,, Similarly, advice or toolkits on how to implement the recommendations into practice were described in detail in only 5 guidelines,,,,, potential resource implications of applying the recommendations were detailed in only 2 guidelines,, and monitoring or auditing criteria were discussed in only 2 guidelines., Our findings suggest that the challenges encountered in implementing recommendations should be better addressed in future clinical practice guidelines. A complementary way to address implementing recommendations is by following the example of the Stopping Elderly Accidents, Deaths and Injuries initiative from the Centers for Disease Control and Prevention, which focuses more on practical implementation with toolkits for the AGS/BGS/AAOS guidelines, as opposed to standing alone as a clinical practice guideline.

25Finally, all the selected guidelines in our systematic review were led by authors from developed countries. We used 60 years of age or older as the definition of older adults to be geographically inclusive in our search; however, our search found only a limited number of clinical practice guidelines from low- and middle-income countries, which were not evidence-based or based on a formal expert consensus process. This finding may reflect the lack of guidelines for fall prevention in many regions of the developing world, which may represent inadequate attention to this phenomenon or limited resources to develop clinical practice guidelines for older adults.

26This systematic review has some limitations. Although no language restrictions were placed on our search, bibliographic databases of peer-reviewed papers included only journals that were indexed, which are mainly published in English. In addition, there is a possibility that we missed relevant clinical practice guidelines that were not in the databases searched, known to the experts we consulted, or on the public or health policy sites we examined.

27This systematic review found high agreement across clinical practice guidelines with strong recommendations for risk stratification, the use of specific tests for gait and balance assessments, multifactorial interventions, medication review, physical exercise, vision and footwear intervention, physiotherapy referral, environment modification, management of osteoporosis and fracture risk, and cardiovascular interventions. Recommendations on vitamin D supplementation and educational programs for fall prevention and management were inconsistent, whereas recommendations on hip protectors and wearable technologies were often not included. Future clinical practice guidelines should better address the clinical applicability of their recommendations, with more explicit consideration of resources, costs, and implementation barriers. Patients’ and caregivers’ perspectives should also be better reflected in developing future fall prevention and management guidelines for older adults. Our findings may assist clinicians in choosing the best-suited guidelines and recommendations for their setting and resource availability. The gaps detected may inform future guideline development, including the recent international initiative: World Falls Guidelines.,