Falls Assessment and prevention of falls in older people Issued: June 2013 NICE guidance number guidance.nice.org.uk/CG161 NICE clinical guideline 161 Developed by the Centre for Clinical Practice at NICE NICE clinical guideline 161 Falls: Assessment and prevention of falls in older people You can download the following documents from www.nice.org.uk/guidance/CG161 The NICE guideline – all the recommendations. The NICE pathway – a set of online diagrams that brings together all NICE guidance and support tools. Information for the public – a summary for patients and carers. The full guideline (this document) – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales. This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. National Institute for Health and Care Excellence Level 1A, City Tower Piccadilly Plaza Manchester M1 4BT www.nice.org.uk © National Institute for Health and Care Excellence, 2013. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE. Falls: NICE clinical guideline 161 (June 2013) Page 2 of 315 This clinical guideline provides evidence and recommendations on the assessment and prevention of falls in older people. It extends and replaces ‘Falls: assessment and prevention of falls in older people’ (NICE clinical guideline 21; 2004), by including additional recommendations about preventing falls in people admitted to hospital (inpatients). This document includes all the recommendations, details of how they were developed and summaries of the evidence they were based on. This guideline has been developed following the methods and processes outlined in the ‘NICE guidelines manual’ (2009). Falls: NICE clinical guideline 161 (June 2013) Page 3 of 315 Contents Introduction ...................................................................................................... 5 Methods used to develop the guideline ........................................................ 5 Who this guideline is for ............................................................................... 6 Populations covered by this guideline .......................................................... 6 Patient-centred care ......................................................................................... 7 Strength of recommendations .......................................................................... 8 Interventions that must (or must not) be used .............................................. 8 Interventions that should (or should not) be used – a ‘strong’ recommendation ........................................................................................... 8 Interventions that could be used ................................................................... 8 Wording of 2004 recommendations .............................................................. 9 Labelling of recommendations ....................................................................... 10 Key priorities for implementation .................................................................... 11 1 Recommendations .................................................................................. 13 1.1 Preventing falls in older people ......................................................... 13 1.2 Preventing falls in older people during a hospital stay ...................... 19 2 Care pathway .......................................................................................... 22 3 The assessment and prevention of falls in older people ......................... 23 Disclaimer................................................................................................... 23 3.1 Executive summary .......................................................................... 23 3.2 Aims .................................................................................................. 29 3.3 Methods ............................................................................................ 32 3.4 Guideline recommendations with supporting evidence reviews ...... 139 3.5 Recommendations for research ...................................................... 186 3.6 Validation ........................................................................................ 187 4 Assessment and prevention of falls in older people during a hospital stay 188 4.1 Background ..................................................................................... 188 4.2 Methods used to develop this part of guideline ............................... 188 4.3 Inpatient risk prediction : evidence review and recommendations .. 189 4.4 Inpatient falls prevention interventions: evidence review and recommendations ..................................................................................... 198 4.5 Inpatient information: evidence review and recommendations ....... 245 4.6 List of research recommendations .................................................. 252 Environmental adaptions .......................................................................... 252 Prevalence of risk factors ......................................................................... 252 Unwitnessed falls ..................................................................................... 253 Inpatient falls prevention .......................................................................... 253 5 Further information ............................................................................... 254 5.1 Guideline development group information ...................................... 254 5.2 Notes on the scope of the guideline ................................................ 260 5.3 Implementation ............................................................................... 260 5.4 Other versions of this guideline ....................................................... 260 5.5 Related NICE guidance .................................................................. 261 5.6 References ..................................................................................... 262 5.7 Glossary and abbreviations ............................................................ 312 All appendices are in separate files. Falls: NICE clinical guideline 161 (June 2013) Page 4 of 315 Introduction Falls and fall-related injuries are a common and serious problem for older people. People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year. The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falling also affects the family members and carers of people who fall. Falls are estimated to cost the NHS more than £2.3 billion per year (College of Optometrists/British Geriatrics Society, 2011). Therefore falling has an impact on quality of life, health and healthcare costs. This guideline provides recommendations for the assessment and prevention of falls in older people. It is an extension to the remit of NICE clinical guideline 21 (published November 2004) to include assessing and preventing falls in older people during a hospital stay (inpatients). The 2 main parts of the guideline are as follows: Recommendations for all older people (sections 1.1 and 3). Evidence on the assessment and prevention of falls in older people has not been updated and the original 2004 recommendations remain unchanged (except for some minor wording changes for the purposes of clarification only). This part was originally developed by the National Collaborating Centre for Nursing and Supportive Care (now part of the National Clinical Guideline Centre) and published by the Royal College of Nursing. Additional recommendations for older people who are admitted to hospital (sections 1.2 and 4). New evidence has been reviewed and new recommendations have been made for assessing and preventing falls in older people during a hospital stay. This part was developed by the Internal Clinical Guidelines Programme in the Centre for Clinical Practice at NICE. Methods used to develop the guideline The methods used to develop this guideline were different for the different sections, because of the evolution of guideline development methodology. Falls: NICE clinical guideline