WORLD GUIDELINE FOR FALLS PREVENTION - Saúde do Idoso (2024)

Prévia do material em texto

1Age and Ageing 2022; 51: 1–36https://doi.org/10.1093/ageing/afac205© The Author(s) 2022. Published by Oxford University Press on behalf of the British GeriatricsSociety. All rights reserved. For permissions, please email: journals.permissions@oup.com.This is an Open Access article distributed under the terms of the Creative Commons AttributionNon-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permitsnon-commercial re-use, distribution, and reproduction in any medium, provided the original work isproperly cited. For commercial re-use, please contact journals.permissions@oup.comGUIDELINEWorld guidelines for falls prevention andmanagement for older adults: a global initiativeManuel Montero-Odasso1,2,3,†, Nathalie van der Velde4,5,†, Finbarr C. Martin6, Mirko Petrovic7,Maw Pin Tan8,9, Jesper Ryg10,11, Sara Aguilar-Navarro12, Neil B. Alexander13, Clemens Becker14,Hubert Blain15, Robbie Bourke16, Ian D. Cameron17, Richard Camicioli18, Lindy Clemson19,Jacqueline Close20,21, Kim Delbaere22, Leilei Duan23, Gustavo Duque24, Suzanne M. Dyer25,Ellen Freiberger26, David A. Ganz27, Fernando Gómez28, Jeffrey M. Hausdorff29,30,31,David B. Hogan32, Susan M.W. Hunter33, Jose R. Jauregui34, Nellie Kamkar1, Rose-Anne Kenny16,Sarah E. Lamb35, Nancy K. Latham36, Lewis A. Lipsitz37, Teresa Liu-Ambrose38, Pip Logan39,Stephen R. Lord40,41, Louise Mallet42, David Marsh43, Koen Milisen44,45,Rogelio Moctezuma-Gallegos46,47, Meg E. Morris48, Alice Nieuwboer49, Monica R. Perracini50,Frederico Pieruccini-Faria1,2, Alison Pighills51, Catherine Said52,53,54, Ervin Sejdic55,Catherine Sherrington56, Dawn A . Skelton57, Sabestina Dsouza58, Mark Speechley3,59,Susan Stark60, Chris Todd61,62, Bruce R. Troen63, Tischa van der Cammen64,65, Joe Verghese66,67,Ellen Vlaeyen68,69, Jennifer A. Watt70,71, Tahir Masud72, the Task Force on Global Guidelines forFalls in Older Adults‡1Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, ON, Canada2Division of Geriatric Medicine, Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario,London, ON, Canada3Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London,ON, Canada4Amsterdam UMC location University of Amsterdam, Internal Medicine, Section of Geriatric Medicine, Amsterdam, TheNetherlands5Amsterdam Public Health, Aging and Later Life, Amsterdam, The Netherlands6Population Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK7Department of Internal Medicine and Paediatrics, Section of Geriatrics, Faculty of Medicine and Health Sciences,Ghent University,Ghent, Belgium8Centre for Innovation in Medical Engineering (CIME), Faculty of Engineering, University of Malaya, Kuala Lumpur 50603, Malaysia9Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia10Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark11Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark12Department of Geriatric Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico13Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan; Veterans AdministrationAnn Arbor Healthcare System Geriatrics Research Education Clinical Center, Ann Arbor, MI, USA14Department of Clinical Gerontology and Geriatric Rehabilitation, Robert Bosch Hospital, Stuttgart, Germany15Department of Geriatrics, Montpellier University hospital and MUSE, Montpellier, France16Department of Medical Gerontology Trinity College Dublin and Mercers Institute for Successful Ageing, St James’s Hospital,Dublin, Ireland17John 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, Australia18Department of Medicine (Neurology), Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada19Sydney School of Health Sciences, Faculty of Medicine & Health, The University of Sydney, Sydney, Australia20Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, NSW,Australiahttps://doi.org/10.1093/ageing/afac205https://creativecommons.org/licenses/by-nc/4.0/M. Montero-Odasso et al.21Prince of Wales Clinical School, Medicine, University of New South Wales, Sydney, NSW, Australia22Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, NSW, Australia; School of Population Health,University of New South Wales, Kensington, NSW, Australia23National Centre for Chronic and Noncommunicable Disease Control and Prevention, Chinese Centre for Disease Control andPrevention, Beijing, China24Research Institute of the McGill University HealthCentre, Montreal, Quebec, Canada25Flinders Health and Medical Research Institute, Flinders University, Adelaide, SA, Australia26Friedrich-Alexander-University Erlangen-Nürnberg, Institute for Biomedicine of Aging, Nürnberg, Germany27Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA and Veterans AffairsGreater Los Angeles Healthcare System, Los Angeles, CA, USA28Research Group on Geriatrics and Gerontology, International Association of Gerontology and Geriatrics Collaborative Center,University Caldas, Manizales, Colombia29Center for the Study of Movement, Cognition and Mobility, Neurological Institute, Tel Aviv Sourasky Medical Center, Tel Aviv,Israel30Department of Physical Therapy, Sackler Faculty of Medicine, and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv,Israel31Department of Orthopaedic Surgery, Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, USA32Brenda Strafford Centre on Aging,O’BrienInstitute for Public Health,Cumming School of Medicine,University of Calgary,Calgary,AB, Canada33School of Physical Therapy, Faculty of Health Sciences, Elborn College, University of Western Ontario, London, ON, Canada34Ageing Biology Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina35Faculty of Health and Life Sciences, Mireille Gillings Professor of Health Innovation, Medical School Building, Exeter, England, UK36Brigham and Women’s Hospital, Boston, MA, USA37Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Beth Israel Deaconess Medical Center, HarvardMedical School, Boston, MA, USA38Djavad Mowafaghian Centre for Brain Health, Center for Hip Health and Mobility, Vancouver Coastal Health Research Institute,University of British Columbia, Vancouver, BC, Canada39School of Medicine, University of Nottingham, Nottingham, England, UK40Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, NSW, Australia41School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia42Department of Pharmacy, Faculty of Pharmacy, McGill University Health Center, Université de Montréal, Montreal, QC, Canada43University College London, London, England, UK44Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium45Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium46Geriatric Medicine & Neurology Fellowship, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”. Mexico City,Mexico47Geriatric Medicine Program,Tecnologico de Monterrey,School of Medicine and Health Sciences.Monterrey,Nuevo León,Mexico48Healthscope and Academic and Research Collaborative in Health (ARCH), La Trobe University, Australia49Department of Rehabilitation Sciences, Neurorehabilitation Research Group (eNRGy), KU Leuven, Leuven, Belgium50Master’s and Doctoral1B.Strong recommendation. Use a validated, structuredscreening and assessment tool to identify FRIDs whenperforming a general medication review or medicationreview targeted to falls prevention. GRADE: 1C.Recommendation details and justification• There is strong evidence that certain medications’ useincreases fall risk in older adults, that a structured approachimproves FRID identification and that medication reviewand deprescribing of FRIDs can significantly reduce fallrisk [73–79].• Before prescribing potential FRIDs to older adults,enquire about falls and consider the relative benefits andrisks of initiating therapy. For example, the followinginitiatives have listed FRIDs: Centre for Disease Controland Prevention’s STEADI initiative [80] and STOPPFall[76].• Medication-review tools such as the STOPP/START,STOPPFall, STOPPFrail, Beers Criteria, FORTA or Web-based Meds 75+ Guide [6, 76, 81–83] are suitable tosystematically identify medication-related fall risks in olderadults and to optimise deprescribing.• STOPPFall is a screening tool used to identify drugs thatincrease the risk of falls in older adults [84]. An onlineinteractive version of the STOPPFall deprescribing toolis freely available: https://www.eugms.org/research-cooperation/task-finish-groups/frid-fall-risk-increasing-drugs.html.Cognitive assessmentStrong recommendation. Assessment of cognition shouldbe included as part of a multifactorial falls risk assessmentin older adults (Appendix 2, available in Age and Ageingonline). GRADE: 1B.Recommendation details and justification• Dementia and mild cognitive impairment double the riskof falls and falls-related injuries including hip fractures,fractures of the arm and head injuries [41].• Low cognitive performance in older adults, particularlyof executive function, even in the absence of a knowncognitive impairment or formal diagnosis of dementia, is14https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datawww.sralab.org/rehabilitation-measureswww.sralab.org/rehabilitation-measureshttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://www.eugms.org/research-cooperation/task-finish-groups/frid-fall-risk-increasing-drugs.htmlhttps://www.eugms.org/research-cooperation/task-finish-groups/frid-fall-risk-increasing-drugs.htmlhttps://www.eugms.org/research-cooperation/task-finish-groups/frid-fall-risk-increasing-drugs.htmlhttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataWorld guidelines for falls prevention and management for older adultsassociated with an increased risk of falls, justifying cogni-tive testing as part of comprehensive falls risk assessmentin all older adults [85].• Because executive dysfunction is strongly associated withfalls, global cognitive screening tests that include executivefunction components such as the Montreal CognitiveAssessment (MoCA) or specific executive function tests,such as the Trail Making Test (TMT) part B, can be used[86].• Training on the administration of the cognitive tests used,to improve execution is recommended.Concerns about falling and fallsStrong recommendation. Include an evaluation of concernsabout falling in a multifactorial falls risk assessment of olderadults (Appendix 2, available in Age and Ageing online).GRADE: 1B.Strong recommendation. Use a standardized instrumentto evaluate concerns about falling such as the Falls EfficacyScale International (FES-I) or Short FES-I in community-dwelling older adults. GRADE: 1A.Recommendation details and justification• We recommend clinicians adopt a holistic approach, com-bining concern about falling with balance and/or gaitassessment as this will help to put the degree of concernin context, when assessing older adults in the community.Concerns about falling—or the closely related notion offear of falling—shows heterogeneous results in predictingfuture falls in the community. The rationale for includingconcerns about falling as part of a comprehensive fallassessment is that this is a measure of an older adult’s per-ceptions about the falls they have experienced, the impactfalls have had on their quality of life, their openness tovarious interventions (e.g. an older adult inappropriatelyvery fearful of falling may be reluctant to increase theirphysical activity and follow an exercise programme if thisis not dealt with), and as a treatment outcome in a subsetof older adults.• The Falls Efficacy Scale International (FES-I) and the ShortFalls Efficacy Scale International (Short FES-I) have astrong to moderate level of evidence for their use in olderadults living in the community. There is evidence from arecent systematic review and meta-analysis of 59 studiesthat the FES-I and Short FES-I are reliable and valid toolswhen used with both healthy older adults and those withconditions that put them at a greater risk of a fall (e.g.multiple sclerosis, stroke, vestibular disorders, PD) [87].Both instruments demonstrate good internal consistency,test–retest reliability, inter-rater reliability and constructvalidity in these populations [87].• The complexity of the terms used for fall-related psy-chological effects arises from their different underlyingconstructs. These terms include ‘concerns about falling’,‘fear of falling’, anxiety, ‘balance-related confidence’ and‘self-efficacy’. More recent models are linking anxiety, fearof falling and self-efficacy [88, 89].• While fear of falling is the term used in much of theavailable peer-reviewed literature, making enquiries aboutconcerns offers advantages to fear of falling. It is ‘lessintense and emotional (and therefore may be more sociallyacceptable for older adults to disclose)’ [90], while fearhas ‘psychiatric connotations implying analogy to phobiaswhich may or may not be accurate’ [91].• The older adult panel we consulted about the recommen-dations preferred the term concern over fear. Based on this,we recommend that clinicians use the term concerns aboutfalling when making enquiries. This is also congruent withthe wording of the recommended FES-I questionnaires(Appendix 2, available in Age and Ageing online).• FES-I and Short FES-I are available free of charge inover 30 languages from www.fes-i.org and can be self-administered or done as part of a clinical interview. The7-item Short FES-I can be useful for clinicians for a rapidassessment.Cardiovascular assessmentStrong recommendation. Perform, as part of a multifac-torial falls risk assessment, a cardiovascular assessment thatinitially includes cardiac history, auscultation, lying andstanding orthostatic blood pressure, and surface 12-leadelectrocardiogram (Appendix 2, available in Age and Ageingonline). GRADE: 1B.Strong recommendation. In the absence of abnormalitieson initial cardiovascular assessment, no further cardiovas-cular assessment is required, unless syncope is suspected(i.e. described or witnessed syncope/pre-syncope or recurrentunexplained falls). GRADE: 1C.Strong recommendation. We recommend that the furthercardiovascular assessment for unexplained falls should be thesame as that for syncope, in addition to the multifactorialfalls risk assessment. GRADE: 1A.Recommendation details and justification• Recurrent unexplained falls are most likely associated witha cardiovascular cause [92–95].• The commonest cardiovascular causes of falls in rank orderare orthostatic hypotension, vasovagal syndrome, carotidsinus hypersensitivity, bradyarrhythmias and atrial andventricular tachyarrhythmias [96].• The investigation (and subsequent management and spe-cialist referral criteria) of syncope, and therefore, recurrentunexplained falls can be performed according to locallyapplicable guidelines such as the 2018 European Society ofCardiology Guidelines for the diagnosis and managementof syncope [94].• If orthostatichypotension is suspected but not detectedusing traditional methods—oscillometer or sphygmo-manometer, referral for beat-to-beat orthostatic mea-surement is recommended as the association of fallswith orthostatic hypotension measured using beat-to-beat methods is more consistent [97].• If vasovagal syncope or delayed orthostatic hypotension issuspected and diagnostic uncertainty remains, older adultsshould be referred for head up tilt tests [94, 98].15https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datawww.fes-i.orghttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataM. Montero-Odasso et al.• If arrhythmias are suspected after clinical assessment, basedon locally applicable guidelines individuals should bereferred for external or internal cardiac monitoring [19,94, 99].• For assessment for orthostatic hypotension, individualsshould be supine for at least 5 minutes before baselineblood pressure is recorded; on standing, blood pressureshould be taken as soon as possible (40–60 seconds),followed by measurements at 1-minute intervals up to3 minutes, or up to 5 minutes if symptoms suggested adelayed orthostatic hypotension response [94, 100].• Orthostatic hypotension most commonly occurs as a resultof dehydration, concomitant medications, autonomic dys-function and with alpha synucleopathy diseases (such asPD, dementia with Lewy Bodies or multisystem atrophy).It is also common in older adults with hypertension [96,101].• Short-term 24–48 hours cardiac rhythm monitoring isnot indicated unless events occur daily. Prolonged externalor internal ambulatory cardiac monitoring is indicated ifarrhythmias are suspected as a cause of falls or syncope,after clinical assessment [19, 94, 99].• Older adults with unexplained syncope, suspectedsyncope or unexplained falls who require carotid sinusmassage or head up tilt tests should be referred to anappropriate specialist, according to locally applicableguidelines [94].Dizziness and vestibular disorders assessmentExpert recommendation. Routinely ask about dizzinesssymptoms, and undertake follow-up assessment as neces-sary to identify cardiovascular, neurological and/or vestibularcauses (Appendix 2, available in Age and Ageing online).GRADE: E.Recommendation details and justification• Dizziness is a common complaint in older adults whofall, with different meanings between individuals, andoften no single explanatory cause. Careful history takingis of particular importance. Presyncope and observableunsteadiness or ataxia may be present.• Additionally, the vestibular system has a key role in thecontrol of posture and gait, and there is evidence of a highincidence of both benign paroxysmal positional vertigoand vestibular dysfunction in those presenting with falls[102–105]. In younger adults, such disorders can oftenbe identified in the clinical history by a reported sensa-tion of vertigo with clear positional or motion-provokedtriggers. Identifying cases of vestibular dysfunction is morechallenging in older adults due to more variable symptoms.• Where vertigo is reported, positional tests should be usedto identify cases of benign paroxysmal positional vertigofrom non-cases (e.g. Dix-Hallpike, Head Impulse Test);however, the sensitivity of case-finding algorithms basedpurely upon symptoms compared with screening withpositional testing in older adults is unknown [102–105].Vision and hearing assessmentExpert recommendation. Enquire about vision impairmentas part of a multifactorial falls risk assessment, measure visualacuity and examine for other visual impairments such ashemianopia and neglect where appropriate. GRADE: E.Expert recommendation. Enquire about hearing impair-ment as part of a multifactorial falls risk assessment, measureand examine for hearing impairments and refer to a specialistwhere appropriate. GRADE: E.Recommendation details and justification• Impaired vision is an important and independent riskfactor for falls in older adults who live in the community.Vision loss is the third most common chronic conditionin older adults, and about 20% of people aged 70 years orolder have a visual acuity of less than 6/12 [106]. Manyolder adults wear spectacles with outdated prescriptionsor no spectacles at all and would benefit from wearingnew spectacles with the correct prescription. This indicatesthe importance of regular eye examinations to preventvision-related impairment and improve the quality of life.• Visual screening should not be limited to measurementof visual acuity and should incorporate contrast sensitivityand depth perception.• Impaired hearing is an independent risk factor for falls inolder adults [107]. Possible explanations for the associationbetween hearing loss and falls include coexistent vestibularpathology that increases fall risk, reduction in cognitivecapacity for maintaining balance given the cognitive loadof hearing loss and a loss of auditory perception leadingto reduced spatial awareness [108]. Hearing loss itself is ahighly prevalent condition among older adults that can bereadily treated with amplification• Accessibility to hearing and visual assessments in LMICshould be enhanced and their additional benefit of fallsprevention should be emphasised.DeliriumDelirium, cognitive impairment and dementia are indepen-dent risk factors for falls in older adults in hospital settings,residential aged care, at home and in the community [78].The key to preventing falls in older adults with these condi-tions is to deliver evidence-based, person-centred care. Whendelirium, dementia and cognitive impairment are managedwell, falls are less prevalent [109]. Adapting the environmentto promote safety and educating caregivers in strategies forsafe mobility can also be of benefit in older adults withdelirium. There is some evidence that staff education canhelp to reduce falls of hospitalised older adults experiencingdelirium [110, 111]. Multidomain strategies which havebeen shown to reduce the risk of delirium include cogni-tive stimulation, daily orientation, early mobilisation, visionand hearing, fluid management, constipation management,feeding assistance, sleep and family involvement [112, 113].At present, there is evidence that these strategies mightreduce falls, therefore they should be considered as part of16https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataWorld guidelines for falls prevention and management for older adultsa comprehensive care package for older adults in hospital[114]. Promoting mobility to maintaining independence isimportant, yet there is a tension that needs to be managedbetween promoting mobility and preventing falls, especiallyin very frail older adults [115].Urinary symptoms and incontinence assessmentExpert recommendation. Enquire about urinary symptomsas part of a multifactorial falls risk assessment GRADE: E.Recommendation details and justification• A recent comprehensive systematic review and meta-analysis included 38 articles (total participants 230,129)and found that urinary incontinence was significantlyassociated with falls [116]. Subgroup analyses based onthe age and sex of the participants revealed a significantassociation between urinary incontinence and falls in older(≥65 years) participants, and in both men and women.• A subgroup analysis showed that a significant associationbetween urinary incontinence and falls was observed inolder adults with both urgency urinary incontinence andstress urinary incontinence [116]. A recent systematicreview and meta-analysis also showed that nocturia is asso-ciated with a 1.2-fold increased risk of falls and possibly a1.3-fold increased risk of fractures [117].• The 3IQ screening questions forurinary incontinence canhelp to differentiate between stress, urge and mixed typesof incontinence [118].Pain assessmentExpert recommendation. Enquire about pain as part of amultifactorial falls risk assessment, followed as indicated bya comprehensive pain assessment. GRADE: E.Recommendation details and justification• Pain is an established risk factor for falling [107, 119].Symptoms of pain are common in older adults, withover 60% of community dwelling older adults reportingpain, mostly in multiple sites [120]. The most preva-lent condition resulting in pain is arthritis, which is anindependent risk factor for falling [107]. Other chronicconditions resulting in pain in older adults include diabeticcomplications, cancer-related pain and post-stroke pain[121].• A comprehensive pain assessment is needed to guideappropriate management. This includes defining its cause,type (nociceptive, neuropathic) and intensity by using apain rating scale designed for older adults [122].Environmental assessmentStrong recommendation. Identification of an individual’senvironmental hazards where they live and an assessmentof their capacities and behaviours in relation to them, by aclinician trained to do so, should be part of a multifactorialfalls risk assessment. GRADE:1B.Recommendation details and justification• Environmental factors are important in many falls. Envi-ronmental risk factors are influenced by the interactionbetween a person’s exposure to environmental fall hazards(such as slippery stairs, poor lighting at entrances, lackof a grab rail), risk taking behaviour (such as clutter inwalkways, unsafe climbing on chairs or ladders) and theirphysical capacity [123].• Assessment by a clinician trained to do so (e.g. occu-pational therapists) needs to include the assessment ofenvironmental hazards, capacities and behaviours of theindividual and an understanding of the effect of the envi-ronment on function [77, 124].• Other elements considered crucial are using an assess-ment tool validated for the broad range of home fall-hazards and fall risk assessment along with considerationof the functional capacity of the person (including habitualbehaviours, functional vision, cognition and mobility)within the context of their environment [77, 124]. Rec-ommended assessment tools for hazards are the WestmeadHome Safety Assessment and the Falls Behavioural Scalefor the Older Person [125, 126].• If applicable, assess for appropriateness and proper useof walking aids including that the aid is not damaged orunsafe.• In LMIC, addressing environmental hazards by trainedclinicians is also considered a priority. Due to lack ofresources in some LMIC, training of personnel to con-duct assessments, appropriate prescription of walking aids,along with the availability of affordable equipment andmaintenance should be emphasised in LMIC settings.• The wording and grading of these recommendations areinformed by a forthcoming update of the Cochrane sys-tematic review [127].Depression assessmentExpert recommendation. Enquire about depressive symp-toms as part of a multifactorial falls risk assessment, followedby further mental state assessment if necessary and referral toa specialist where appropriate. GRADE: E.Recommendation details and justification• Depression is a common and important cause of mor-bidity and mortality in older adults worldwide, affect-ing around 10–15% of community-dwelling older adults.If left untreated, symptoms may persist for years. Bothuntreated depression and antidepressant use contribute tofall risk [107, 128]. For details on fall risk and antidepres-sant use, we refer to the outcomes and recommendationsof WG 2 (fall-risk increasing drugs, FRIDs).• Untreated depression is independently associated withincreased fall risk: a meta-analysis showed a 37% ofincreased risk [107].• The pathophysiologic mechanisms underlying theassociation between depression and falling are com-plex. Major mechanisms are psychomotor retardation,17M. Montero-Odasso et al.deconditioning, gait and balance abnormalities, impairedsleep and impaired attention. Often, multiple pathwaysinteract and co-occur. Also, excessive concern about fallingcontributes to increased fall risk in depressed older adults.It negatively influences gait and balance and therebyincreases tendency to fall [128].• Antidepressants are FRIDs and contribute to (or cause)falling through causing sedation, impaired balance/reaction time, orthostatic hypotension, hyponatremia, car-diac conduction delay/arrhythmia and/or drug-inducedParkinsonism [128].• Screening for depression as a risk factor for falls shouldbe considered in older individuals in LMIC. Strategiesto raise awareness and reduce stigma of depression andmental illness are needed in these countries. However,longitudinal and interventions studies are required beforefirm recommendations can be made in this area.Nutritional assessment including vitamin DExpert recommendation. Assess nutritional status includ-ing vitamin D intake as part of a multifactorial falls riskassessment, followed by supplementation where appropriate.GRADE: E.Recommendation details and justification• Nutritional assessment is an important part of the mul-tifactorial falls risk assessment and should include assess-ment of adequate vitamin D intake and serum 25 OHvitamin D levels, when appropriate, and substance abuseand excessive alcohol intake, as well.• A recent systematic review showed that both nutritionalstatus and body mass index (BMI) are associated with therisk of falls in community-dwelling older adults. In partic-ular, being at risk of malnutrition or being malnourishedmay increase the risk of a fall. BMI showed a U-shapedassociation with the risk of falls, and BMI values between24.5 and 30.0 were associated with the lowest risk of fall[129].• Poor nutritional status can be both a consequence ofunderlying morbid conditions and a causal factor of patho-logical ageing process and higher mortality. Underweightand undernourished individuals may both have increasedrisk of falls due to sarcopenia, impaired mobility andwalking instability, as well as worse functional and clinicalstatus. On the other hand, excess weight in obese peoplemay also have a negative impact on postural stability, self-sufficiency and physical activity, all factors that may beassociated with the falls [129].• Malnutrition assessment can be performed by using val-idated tools, such as the Mini Nutritional Assessment(MNA) [130].Assessment of fracture risk• Osteoporotic fractures are associated with high morbid-ity, mortality and cost to society in terms of the useof health and social services. Both bone fragility andpropensity to fall are important determinants of fracturerisk. International consensus advises that fracture pre-vention should include identification of older adults athigh falls risk, interventions to reduce that risk, identi-fying those with bone fragility (including osteoporosis)and instituting measures to reduce fracture risk (bothpharmacological and non-pharmacological [131]).• Adults with low trauma fractures and those with osteo-porosis should have a falls risk assessment. Fracture liaisonservices, which identify people with recent fractures, arenow in place in many areas and their remit should includeidentification of those at high falls risk in addition toinvestigating for osteoporosis [132].• Conversely, those identified as having a moderate to highfalls risk should have a bone health assessment using localprotocols. In this regard, fracture risk assessment toolssuch FRAX, Garvan and QFracture can be employedto identify older adults at high fracture risk, and bonedensitometry can be used to confirm osteoporosis [133,134]. International consensus osteoporosis managementguidelines are in place to guide treatment [135].• Individuals aged 60 years and over withpre-existingcomorbidities and increased risk of fractures should beassessed regularly for modifiable falls risk factors in LMIC.Furthermore, in individuals with fractures or increased riskof fractures within LMIC, falls risk assessments should beincorporated into their management strategies.Management and interventionsManagement of older adults at low fall riskExpert recommendation. Provide advice on how tomaintain safe mobility and optimise physical functioningto older adults at low risk of falls from a clinician trainedto do so. Such advice should consider the circumstances,priorities, preferences and resources of the older adult.This advice should reinforce health promotion/preventionmessaging relevant to falls and fracture risks such as thoseon physical activity, lifestyle habits and nutrition includingvitamin D intake (see algorithm, Figure 1). GRADE: E.Recommendation details and justification• Older adults classified as low risk by our algorithm havean incidence of a single fall in the next year of approx-imately 20–30% [2, 136], but the individual risk variesaccording to easily recognisable attributes such as vision,hearing and foot problems, but also less measurable factorssuch as: context (what does the individual need to doand in what environment?); behaviours (is the personcautious, impulsive, erratic?); and, transient factors suchas illness, or absence of usual support. Our recommen-dations promote a generic primary preventative approachwhich can be adapted to individual circumstances andcharacteristics.18World guidelines for falls prevention and management for older adults• There is a growing body of evidence showing a relationshipbetween physical activity and fall risk at a populationlevel, and evidence for effective interventions on habitualphysical activity and exercise programmes for older adultsat low to intermediate risk for falls [2, 137]. While theinterventions may well merit a higher grade, this recom-mendation on provision of advice is at Grade E, as there isinsufficient evidence on how this is best provided, takinginto consideration the potential risks, including falls, tohabitually inactive people who embark on activities suchas brisk walking.• Recommendations on types and amounts of habitualphysical activity and the avoidance of being sedentary areprovided by national and international guidelines, suchas the World Health Organisation [138] guidelines onphysical activity and sedentary behaviour, the AmericanCollege of Sports Medicine, and the UK Chief MedicalOfficers’ Physical Activity Guidelines.• The WHO and the UK Physical Activity guidelines takea life course approach and include a specific focus onfunctional mobility and falls, as well as considering themerits of various activities and sports. The American Col-lege of Sports Medicine provides a wide range of exerciseprescriptions for various situations.• The WHO and the UK Physical Activity guidelinesrecommend activities which challenge balance and includeresistance training twice per week. General physicalactivity alone (e.g. walking) is unlikely to preventfalls.• We recommend that, where possible and safe, older adultsshould aim to participate in 150–300 minutes per weekof intermediate-intensity physical activity or 75–150 min-utes per week of vigorous-intensity physical activity. Thereis evidence from observational studies that meeting phys-ical activity guidelines of moderate to vigorous intensityactivity reduces future falls risk and reduces the chanceof an individual falling, although these findings remainuncertain [139]. This promotion of healthy lifestyle canbe expected to decrease fall risk indirectly through itspositive impact on deconditioning, frailty, sarcopenia andcardiovascular health.• Uptake and adherence to exercise interventions and toincreasing habitual physical activity may be helped bybehaviour-change approaches such as coaching, supervi-sion, group activity and educational material.• Generic health promotion guidelines include advice onlifestyle habits, periodic vision and hearing checks andfootcare. WHO has provided guidelines on primary andcommunity-based assessment and first level responsesacross five key domains which are collectively predictive offuture disability [140].• Falls prevention advice in low risk older adults may includereferral to local community health promotion or ‘ageingwell’ programmes where available.• We recommend inclusion of fracture risk management(including need for osteoporosis treatment) to reduce frac-ture risk.Interventions for community dwelling older adultsat intermediate fall riskExpert recommendation. Offer an exercise programmebased on an individual assessment and according to therecommendations in the Exercise Interventions section (seealgorithm, Figure 1). GRADE: E.Recommendation details and justification• Supervised exercises that target balance and strength pre-vent falls [141]. Fall prevention exercise should focus onmaintaining balance during functional tasks needed fordaily life. The most relevant tasks for individuals varyaccording to lifestyle, domestic needs, physical function,environment and preferences.• Effective fall prevention programmes include individu-alised exercises that enable or support daily tasks or similarmovements. Such exercises include sit-to-stand, squats,reaching which standing, standing with a narrower baseof support, stepping and walking in different directions,speeds, environments and while dual tasking. Weightscan be added to some exercises to increase difficulty.Exercises should be challenging (to enhance neural,muscular and skeletal function) but safe (to preventinjuries) and achievable (for sufficient dose and sense ofmastery). Exercises should be reviewed and progressedregularly to ensure that optimal level of difficulty ismaintained.Multidomain interventions for community dwellingolder adults at high fall riskDeveloping a person-centred interventionWe recommend that a falls prevention plan be based ona holistic multifactorial falls risk assessment as previouslydescribed with shared decision being used to develop agreedgoals and interventions (see Algorithm, Figure 1). Thismeans paying attention to the entire clinical assessmentand considering the priorities, beliefs, resources of the olderperson and other relevant individuals, such as caregivers inorder to develop a feasible plan that addresses individuallyrelevant risk factors in the context of other geriatricsyndromes and conditions (Appendix 2, available in Ageand Ageing online).Strong recommendation. A care plan developed toprevent falls and related injuries should incorporate thevalues and preferences of the older adult. GRADE:1B.Strong recommendation. When creating falls preventioncare plans for older adults with cognitive impairment, boththe older adults’ and their caregivers’ perspectives shouldbe included as it improves adherence to interventions andoutcomes. GRADE: 1C.Recommendation details and justification• Engaging older adults in a discussion about their prefer-ences coupled with shared decision-making can improve19https://www.who.int/publications/i/item/9789240015128http://www.ClinicalTrials.govhttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataM. Montero-Odasso et al.adherence with recommendations and outcomes [142].The aspects identified in a scoping review of 52 studiesincluded: the meaning of falls, perceived causes, assess-ment of personal risk, reaction to this perceived risk andpriority given to falls as a health concern.• For those with cognitive and functional limitations, thedevelopment and then implementation of a care planto prevent falls and related injuries will also require theinvolvement and training of informal (unpaid) and/orformal (paid) caregivers.• Fall prevention interventions can be time-consuming,intensiveand of long duration. An older adult should beinformed of both benefits and burdens of falls preventiontherapy, to enable them to make an informed choice aboutparticipation. An older adult’s knowledge and attitudesabout falls and the priority they give to their preventionwill determine whether, or what type, of therapeuticinterventions they would be willing to engage in.Multidomain falls risk interventionStrong recommendation. Offer multidomain interven-tions, informed by a multiprofessional, multifactorialfalls risk assessment to community-dwelling older adultsidentified to be at high risk of falling (Appendix 2, availablein Age and Ageing online). GRADE: 1B.Recommendation details and justification• Multidomain interventions encompass two or more com-ponents, individually targeted to the older adult based onfindings from a multifactorial (or comprehensive) falls riskassessment. It is not a standardized set of interventionsapplied to everyone.• A multidomain intervention in older community-dwellingadults at a minimum should include: strength andbalance exercise, medication review, management oforthostatic hypotension and cardiovascular diseases,management of underlying acute and chronic diseases,optimising vision (cataract surgery for those who needit, refraction) and hearing, addressing foot problems andappropriate footwear, vitamin D supplementation, opti-mising nutrition, continence management, interventionsto address concerns about falling, individual education andenvironmental modification (including assisted devicesand use of technology).• The recommended components are derived from the fol-lowing literature: a 2021 comprehensive systematic reviewand network meta-analyses [79] on interventions for pre-venting falls in community dwelling older adults, twoCochrane systematic reviews [77, 143] assessing multido-main interventions for prevention of falls in older adultsliving in the community and two WHO summary reportson falls prevention in community dwelling older persons[24, 144].• The findings of two recent pragmatic RCTs [145, 146]suggest that both exercise and multifactorial strategies thathave been shown to reduce falls in efficacy trials cannot eas-ily be applied with sufficient fidelity through current exist-ing services (RCTs based in UK and USA, respectively) toachieve equivalent benefits. These trial outcomes suggestthe importance of the provision of sufficient resources toroll out and support high-quality sustainable delivery offall prevention programmes that are in line with previoushigh quality successful efficacy trials [147, 148]. Thoughdisappointing, the results of these two pragmatic trials didnot substantively alter network meta-analysis results or ourrecommendations [79].Component interventionsExercise and physical activity interventionsStrong recommendation. Exercise programmes for fallprevention for community-dwelling older adults that includebalance challenging and functional exercises (e.g. sit-to-stand, stepping) should be offered with sessions three timesor more weekly which are individualised, progressed inintensity for at least 12 weeks and continued longer forgreater effect (Appendix 2, available in Age and Ageingonline). GRADE: 1A.Strong recommendation. Include, when feasible, of TaiChi and/or additional individualised progressive resistancestrength training. GRADE: 1B.Recommendation details and justification• The first recommendation applies to all older adultsregardless of their assessed risk of falling or age. Werecommend programmes that include balance andfunctional exercises (e.g. sit-to-stand, stepping): GRADE:1A, programmes that include multicomponent exercise(i.e. multiple types of exercise), most commonly balanceand functional exercises with strength exercise: GRADE:1B, and Tai Chi: GRADE: 1B [137, 141].• Exercise programmes that need to be of sufficient intensityand duration should be delivered in a way that ensuressafety and considers functional abilities.• Exercise programmes should be delivered by appropriatelytrained professionals who can adapt exercises appropriatelyto functional status and co-morbidities. These profession-als could be physiotherapists, exercise physiologists orkinesiologists, trained exercise instructors or other alliedhealth professionals. We acknowledge that this will bedifficult in some settings but note that the vast majorityof interventions found to be effective in trials used trainedproviders [137, 141].• Exercise needs to be progressive initially and maintainedonce a plateau is reached.• Benefits of exercise are lost on cessation so opportunitiesto continue with appropriate activity at the end of theprogramme are important. If individuals withdraw due toconcurrent health issues or caring duties, they should beencouraged to return and programmes should be modifiedto ensure that the difficulty level and dose are appropriate[137, 141].20https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataWorld guidelines for falls prevention and management for older adults• Exercise programmes can be delivered in a group or taughtand supported as an individualised home exercise pro-gramme or a mix of both in order to achieve an effectivedose [137, 141].• Group exercise, individualised home exercise or a com-bination of both may lead to better exercise programmeadherence. In people with more severe cognitive impair-ment, smaller group or individual supervision may benecessary [149, 150].• Higher supervision levels or smaller group numbers arerecommended for those at higher risk of a fall includingthose who are frail [137, 141].• An important aspect to consider is avoiding ‘long-lies’ andharm from being unable to get up from the floor. One in8 older adults who fall report lying on the floor for morethan 1 hour [151] and in those over the age of 90, up to80% cannot rise from the floor after a fall [35]. Lying onthe floor for more than an hour is associated with dehydra-tion, electrolyte disturbance, renal failure, hypothermia,pneumonia and urinary tract infections, skin damage andpain [152, 153], and declines in mobility and restrictionsin activity, probably due to fear of a repeat fall. ‘Lift andassist’ call outs should trigger falls prevention interventions[154]. Pendent or wrist alarms, telehealth falls detectors,cord alarms or mobile telephones are also important inenabling people to call for help if they cannot get up ifthey live alone (see section on technology) [35]. However,the oldest old often still lie on the floor for a long timebefore they use a call alarm so it is important to help themregain this skill if they have had a previous long-lie.• Regaining the skill to rise from the floor is mostsuccessfully re-learnt through practice of each of thespecific movements required (often called backward-chaining) where the last step in the chain is taught first[155]. Some falls prevention exercise programmes alsohave a specific focus on this skill and have shown successin regaining this function [156].Medication interventionsStrong recommendation. A medication review and appro-priate deprescribing of FRIDs should be part of multidomainfalls prevention interventions (Appendix 2, available in Ageand Ageing online). GRADE: 1B.Strong recommendation. We recommend that in long-termcare residents, the falls prevention strategy should alwaysinclude rational deprescribing of fall-risk-increasing drugs.GRADE: 1C.Recommendation details and justification• Medication review with the aim of deprescribing FRIDsis a standard component of multidomain interventions toprevent falls, which have been proven effective in reducingthe rate of falls (for details, we refer to WG 10) [24,77]. It has also been shown to be one of the effectivecomponents of a multidomainintervention in a recentsystematic review and network meta analyses [79].• Older adults characteristics, including frailty status,polypharmacy, co-morbidities, life expectancy, individualpreferences and other geriatric syndromes, should beconsidered when performing a medication review as partof shared decision-making approach [157].• Successful implementation of deprescribing interventionsto reduce risk of falls in older adults is supported byeducation of the older adult, family members and healthcare professionals, and ongoing monitoring and documen-tation [76, 158].• Shared decision-making results in better-informed olderadults who tend to opt for deprescribing more often.Furthermore, shared decision-making improvescompliance.Cardiovascular interventionsStrong recommendation. Management of orthostatichypotension should be included as a component ofa multidomain intervention (Appendix 2, available in Ageand Ageing online). GRADE: 1A.Strong recommendation. Interventions for cardiovasculardisorders identified during assessment for risk of falls shouldbe the same as that for similar conditions when associatedwith syncope, in addition to other interventions based onthe multifactorial falls risk assessment. GRADE 1B.Recommendation details and justification• Whereas many multidomain fall prevention programmeshave included strategies to treat orthostatic hypotension,including modification of possible culprit medications,rehydration, compression garments and medications (e.g.fludrocortisone and midodrine), there are no single inter-vention studies for orthostatic hypotension in falls preven-tion. In older adults with hypertension, symptoms may beameliorated by the judicious use of antihypertensive med-ications titrated very slowly and with careful monitoringafter changing the dose.• For the management of syncope, we advise followinglocal syncope guidelines (e.g. European Cardiac SocietyTask force on Syncope [94]). Many multifactorial fallprevention programmes that have shown benefit for fallprevention have included strategies to modify orthostaticblood pressure.• The presence of more than one cardiovascular risk factorfor falls is not uncommon. Clear causality for a single riskfactor may be difficult to establish; therefore, all modifiablecardiovascular risk factors should be treated.• Interventions for bradycardic disorders (sinus node dis-ease, atrioventricular conduction disorders, vasovagal syn-drome and carotid sinus syndrome) and tachyarrhyth-mias (atrial fibrillation, supraventricular and ventriculartachycardia) include modification of culprit medications,specific anti-arrhythmic medication and, in some cases,implantable devices (such as pacemakers and implantablecardioverter-defibrillators) and are as per local syncopeguidelines.21https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataM. Montero-Odasso et al.Telehealth and technology interventionsExpert recommendation. Use telehealth and/or smart homesystems (when available) in combination with exercise train-ing as part of falls prevention programmes in the community(Appendix 2, available in Age and Ageing online). GRADE:E.Conditional recommendation. Current evidence does notsupport the use of wearables for falls prevention. However,emerging evidence show that when wearables are used inexercise programs to prevent falls, they may increase partici-pation. GRADE: 2C.Recommendation details and justification• There is emerging evidence in research settings that usingwearable technology, i.e. devices worn on the body, todetect and prevent falls, could be efficacious for detectionand prevention [159–171].• A recent systematic review and meta-analysis [172] thatincluded 31 studies and a total of 2,500 older adultsfrom 17 countries found that tele-health (telephone-basededucation) combined with exercise training were able toreduce fall risk by 16%. Notably, despite not being statis-tically significant, telehealth alone showed a point fall riskreduction of 20% in this meta-analysis [172].• A recent study showed [173] that for participants fromthe community who followed an exercise programmethat included aerobic exercise or resistance training, thoseparticipants using a wearable device for physical activitymonitoring had fewer falls compared with those notusing the wearable device, suggesting better interventionadherence.• For optimal use of resources, it is advised to withhold thisrecommendation for LMIC until evidence on effective-ness and implementation of technology in LMIC settingsbecome available.Environmental interventionsStrong recommendation. Recommendations for modifica-tions of an older adult’s physical home environment for fallhazards that consider their capacities and behaviours in thiscontext should be provided by a trained clinician, as part ofa multidomain falls prevention intervention. GRADE: 1B.Recommendation details and justification• Interventions to reduce fall-hazards in and about the homecan reduce the rate of falls and the number experiencing afall [124, 127].• The greatest reductions are seen when the intervention isdelivered to those at highest risk of falling [77, 124, 127,174, 175].• Environmental assessment should be offered to olderadults assessed as at high falls risk, such as older personswith a history of falling in the past year and an impairmentin daily living activity or recently hospitalised from a fall,and those with severe vision impairment [77, 124, 127].• Evidence from randomised trials also provides evidencethat the intervention is more effective when the aim ofthe visit, the assessment process and the intervention arehighly tailored to falls, the outcome of interest. It is alsomore likely effective when delivered by an occupationaltherapist [124, 127].• Criteria for a quality home-fall hazard intervention includethe use of a problem-solving approach involving the par-ticipant in identifying hazards and prioritising action,education relevant to falls, function and hazards; an actionplan for removing or changing hazards and modifyingrisky behaviours; and adequate follow-up and support foradaptations and modifications [124, 125].Vestibular interventionsExpert recommendation Managing vestibular issues shouldbe considerd as part of multifactorial approach. GRADE: ERecommedation details and justification• Particle repositioning (Epley) manoeuvres are an effectivetreatment for benign paroxysmal position and vertigo[176] and may reduce falls rates [177, 178], but evidenceis limited. Vestibular rehabilitation therapy improves pos-tural and gait stability in cases of vestibular dysfunction[179] although the optimal approach is still unclear as isthe effect on falls rates.• As the risks of harm are low and improvements in health-related quality of life are potentially high, therapeuticinterventions should always be sought where vestibularbenign paroxysmal position and vertigo or vestibular dys-function is identified. These treatments require trainedstaff but are low-cost and could be potentially applied inlow resource settings.Pain interventionsExpert recommendation. Adequate pain treatment shouldbe considered as part of the multidomain approach.GRADE: E.Recommendation details and justification• Adequate pain relief is likely to reduce the risk of fallingwhile physically active. A personalised approach consid-ering both non-pharmacological and pharmacologicaloptions is necessary to minimise risk of adverse events[180, 181]. Non-pharmacological approaches includephysiotherapy and cognitive behavioural therapy.• Some analgesics, and in particular opioids, increase fall risk[182]. The mechanisms of fall risk associated with opi-oids in older adults include sedation, orthostatic hypoten-sion and hyponatremia.Therefore, while the STOPP/START criteria suggest use of opioids for severe pain orwhen paracetamol and NSAIDs are ineffective [6], thesepotential adverse effects need to be anticipated, identifiedand managed. Weak opioids are preferably avoided, asthe adverse events risk may outweigh the benefit. Forneuropathic pain, first line treatment includes serotoninnorepinephrine reuptake inhibitors, gabapentinoids andtransdermal lidocaine or capsaicin [183]. For all analgesics,22https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataWorld guidelines for falls prevention and management for older adultsit is advisable to start slow, go slow and monitor efficacyand adverse effects. For general deprescribing recommen-dations, we refer to WG2 recommendations.Concerns about falling and falls interventionsStrong recommendation. We recommend exercise, cogni-tive behavioural therapy and/or occupational therapy (as partof a multidisciplinary approach) to reduce concerns aboutfalling in community-dwelling older adults (Appendix 2,available in Age and Ageing online). GRADE: 1B.Recommendation details and justification• Different types of interventions can be effective in reduc-ing concerns about falling, such as exercise interventions[184–186], cognitive behavioural therapy [187, 188] andoccupational therapy [189], with small to moderate effectsizes. Two recent systematic reviews highlighted that super-vised holistic exercise interventions in community set-tings, such as Pilates or yoga, had the largest effect sizesin reducing concerns about falling compared with otherinterventions [185, 186].• Existing fall prevention strategies, i.e. exercise interven-tions, can reduce concerns about falling in older adults.• Cognitive behavioural therapy and occupational therapyinterventions can also reduce concerns about falling andshould be considered as part of a multidomain fall preven-tion approach when available.Vision interventionsExpert recommendation. Management of impaired visionshould be considered as part of the multifactorial approach.GRADE: E.Recommendation details and justification• Evidence from randomised controlled trials and prospec-tive studies indicates cataract surgery for the first eye, [190]and both eyes [191] and achieving optimal safe func-tional vision by active older adults avoiding the wearingof multifocal glasses when outside [192] are effective fallprevention strategies.• Occupational therapy interventions involving home haz-ard reductions are also effective in preventing falls in olderadults with severe visual impairments [193].• Although interventions involving vision assessment andprovision of new spectacles undoubtedly improve per-formance in visual tests in community-dwelling olderadults, such interventions have not yet been shown toreduce the risk of falls [194]. In fact, it is recommendedthat optometrists counsel their clients about likely short-term increased fall risk when dispensing new prescriptionglasses.Vitamin D interventions• If older adults are considered at risk of deficiency, dailyvitamin D supplementation should be recommended inaccordance with national nutrition guidelines, but currentevidence does not support universal vitamin D supple-mentation for preventing falls.• Vitamin D supplementation of ≥1,000 IU daily did notreduce falls in older community dwelling adults whoachieved mean 25 (OH) vitamin D levels of ≥30 ng/mlversus those with levels 65 yearsof age. We recommend against using scored falls riskscreening tools in hospitals for multifactorial falls riskassessment in older adults (Appendix 2, available in Age andAgeing online). GRADE: 2B.Strong recommendation. We recommend using the FES-I or especially the Short FES-I for assessing concerns aboutfalling in acute care hospitals. GRADE: 1B.Expert recommendation. We recommend conducting apost-fall assessment in hospitalised older adults followinga fall in order to identify the mechanism of the fall, anyresulting injuries, any precipitating factors (such as newintercurrent illness, complications or delirium), to reassessthe individual’s fall risk factors, and adjust the interventionstrategy accordingly. GRADE: E.Recommendation details and justification• Falls risk screening tools and multifactorial falls risk assess-ments are sometimes used interchangeably, but there aresubstantial differences. There is a case for dis-investingfrom fall risk screening tool scoring in the hospital settingas it does not reduce falls and takes valuable time. Fallsrisk assessment is a more detailed process used to identifyunderlying risk factors and inform the development of acare plan to reduce falls and injuries. Falls risk assessmentsshould be reviewed if there is a change in a individualcondition or if the older adult falls.• A stepped-wedge, cluster-RCT investigating the impact ofremoving a falls risk screening tool from an overall falls risk23https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataM. Montero-Odasso et al.assessment programme found no impact on the falls rate[200].• Admission with a fall is defined as a severe fall incidentin accordance with the risk stratification section and algo-rithm. Thus, older adults admitted with a fall are con-sidered at high risk of a recurrent fall. Therefore, besidesinjury treatment, they should have the mechanism of thefall defined, and a multifactorial falls risk assessment. Fordetails on the risk stratification and the multifactorial fallsrisk assessment, we refer to the respective sections.Management and interventionsStrong recommendation. A tailored education on falls pre-vention should be delivered to all hospitalised older adults(≥65 years of age) and other high-risk groups (Appendix 2,available in Age and Ageing online). GRADE: 1A.Strong recommendation. Personalised single or multido-main falls prevention strategies based on identified riskfactors, behaviours or situations should be implemented forall hospitalised older adults (≥65 years of age), or youngerindividuals identified by health professionals as at riskof falls. GRADE: 1C (Acute care), GRADE: 1B (Sub-acutecare).Recommendation details and justification• A Cochrane review of 24 RCTs found that a multifacto-rial falls risk assessment, followed by implementation ofmultidomain interventions, may reduce the rate of falls inhospitals, but the very low-quality evidence precluded adefinite conclusion. Reduction in falls rates was judged tobe more likely in rehabilitation or geriatric ward settings[78].• The individual’s cognitive status (i.e. delirium or demen-tia) should be considered when implementing the edu-cation programmes. Use of several education modes (e.g.face-to-facediscussions, handouts, videotapes) should beconsidered [201].• There is currently no robust research evidence to recom-mend the use of (i) bed/chair alarms, (ii) grip socks/non-slip socks for the purpose of falls prevention and (iii) theuse of physical restraints when the sole purpose is fallsprevention in hospitals.• We recommend that all hospitals should have protocols,policies and/or procedures for the prevention of falls con-sistent with best practice guidelines [202–205].Falls in care homesRisk stratification and assessmentStrong recommendation. Do not perform falls risk screen-ing to identify care home residents at risk for falls as all resi-dents should be considered at high risk of falls (Appendix 2,available in Age and Ageing online). GRADE: 1A.Strong recommendation. Perform a comprehensive mul-tifactorial assessment at admission to identify factorscontributing to fall risk and implement appropriateinterventions to avoid falls and fall-related injuries in carehome older adults. GRADE: 1C.Expert recommendation. We recommend conducting apost-fall assessment in care home residents following a fallin order to identify the mechanism of the fall, any resultinginjuries, to reassess the resident’s fall risk factors, adjust theintervention strategy for the resident and avoid unnecessarytransfer to hospital. GRADE: E.Strong recommendation. We recommend using theFES-I or especially the Short FES-I for assessing concernsabout falling in long-term care facilities. GRADE: 1B.Recommendation details and justification• All care home residents have a high risk of falling andmay benefit from a multifactorial falls risk assessment andtailored intervention strategy.• A multifactorial falls risk assessment at admission shouldinclude identifying falls risk factors and be repeated at leastonce annually or when the resident’s condition changes,based on resource availability in each setting.Management and interventionsStrong recommendation. Take a multifaceted approach tofalls reduction for care home residents including care homestaff training, systematic use of a multidomain decisionsupport tool and implementation of falls prevention actions(Appendix 2, available in Age and Ageing online). GRADE:1B.Strong recommendation. Do not use of physical restraintsas a measure for falls prevention in care homes. GRADE: 1B.Strong recommendation. Perform nutritional optimisationincluding food rich in calcium and proteins, as well asvitamin D supplementation as part of a multidomain inter-vention for falls prevention in care home residents. GRADE:1B.Strong recommendation. Include the promotion of exercisetraining (when feasible and safe) as part of a multidomainfalls prevention intervention in care homes. GRADE: 1C.Recommendation details and justification• The effectiveness of the multifaceted approach is basedon one recent RCT [206]. The focus of implementationinterventions should be on modifiable barriers and facili-tators such as communication, knowledge and skills.• Examples of physical restraint devices that should beavoided for the purpose of falls prevention include lapbelts, bed rails, Posey restraints or similar, chairs with tablesattached, and chairs or mattresses that are difficult to getout of such as recliner chairs, water chairs, bean bags andcurved edge mattresses [207, 208]. Use of some of theseitems may be justified for other well-defined purposes,subject to careful assessment and review and when agreedwith the resident or their advocates.• Most residents in care homes are deficient in Vitamin D;therefore, we recommend vitamin D supplementation as24https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataWorld guidelines for falls prevention and management for older adultspart of a multidomain intervention for falls prevention incare home residents.• Individual supervised exercises in care homes as a preven-tion strategy are effective and should be offered in thosewho are willing and able to participate [138]. Programmeslikely to be the most effective when individualised toresidents’ functional abilities and preferences, incorporatea combination of exercises including balance and strength,as well as environmental modifications and staff training infalls prevention [209, 210].• Given the high level of disability in this group, wherepossible, an exercise specialist (physiotherapist, exercisephysiologist) should be consulted to provide specialist,tailored advice on exercise and physical activity [209].Specific clinical populationsOlder adults with the clinical conditions included in thissection may have specific falls risk factors and other attributesassociated with their condition, in addition to the generalrisk factors found in the older population. Identifying thesecondition-associated factors may help n deciding on themost appropriate individually tailored intervention, by (i)suggesting a focus on a specific condition-related impairmentor capacity, (ii) altering the likelihood of benefit from aneffective intervention for the general older population, or (iii)changing the feasibility or acceptability of an intervention.The recommendations in this section should be consid-ered along with the general guidelines on multifactorial fallsrisk assessment and interventions.Falls and PD and related disordersFalls are very frequent in older adults with PD and relateddisorders. Current clinical practice guidelines do not addressthis population and their distinctive risks for falls and fall-related injuries and emerging strategies to reduce falls inthis group are available but not yet represented in generalguidelines (Appendix 2, available in Age and Ageing online).AssessmentConditional recommendation. Consider a falls risk assess-ment for older adults with PD, including a self-report 3-riskfactor assessment tool, which includes a history of falls in theprevious year, freezing of gait (FOG) in the past month, andslow gait speed. GRADE: 2B.Recommendation details and justification• ‘Freezing’ is an important falls risk factor in older adultswith PD and can be targeted with specific interventions[211–216].• Both increases and decreases in falls rates have beenobserved in older adults with PD at a complex stageand/or cognitive impairment participating in exerciseinterventions [217, 218].• Frequent falls may occur at an early stage of Parkinson’sPlus syndromes and may merit specialist diagnosticassessment prior to considering a falls prevention inter-vention [219].• The self-report 3-risk factor assessment tool can be foundat A Self-Reported Clinical Tool Predicts Falls in Peoplewith Parkinson’s Disease.Management and interventionsConditional recommendation. Older adults with PDshould be offered multidomain interventions, based on PDspecific assessment and other identified falls risk factors.GRADE: 2B.Strong recommendation. Older adults with PD at an earlyto mid-stage and with mild or no cognitive impairmentshould be offered individualised exercise programmes inclu-ding balance and resistance training exercise. GRADE: 1A.Strong recommendation. Consider offering exercise train-ing, targeting balance and strength to people with complexphase PD if supervised by a physiotherapist or other suitablyqualified professional. GRADE: 1C.Recommendation details and justification• As a guide, a Movement Disorders Society UnifiedParkinson’s Disease rating Scale (MDS-UPDRS) motorscore ≥34 can be regarded as complex stage PD [220].• Supervision and modification of exercise interventionswith PD individuals at a complex stage or with moderateor severe cognitive impairment requires specialist skills[221].• Falls prevention exercise interventionsshould be inte-grated in general mobility and ADL rehabilitation [221].• The effect of exercise on falls in older adults with PD thatis more advanced (e.g. MDS-UPDRS motor score ≥ 34)and/or with substantial cognitive impairment is uncer-tain, but limited data indicate that minimally supervisedexercise may increase the risk of falls [221].• A higher level of supervision is necessary in older adultswith intermediate cognitive impairment, as such individ-uals may not be able to follow a self-directed programme,and for safety [221].• Specific subgroups of individuals (e.g. with FOG) maybenefit from specifically targeted interventions (i.e. pro-gressive balance and lower limb strengthening exercises)[212, 221].• Although preliminary evidence on the effectiveness of(pro-)cholinergic medications on falls is promising, thedesign, outcome assessment and size of clinical trials todate are inadequate to produce definitive evidence [221,222].• Optimisation of medications to maximise motor func-tion and minimise side effects (such as dyskinesia andhypotension) are critical first steps to falls prevention inPD treatment [221].StrokeConditional recommendation. Older adults after a strokeshould be offered participation in individualised exercise25https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataM. Montero-Odasso et al.programmes aimed at improving balance/strength/walkingto prevent falls. GRADE: 2C.Recommendation details and justification• The recommendation is based on systematic review evi-dence of health benefits of exercise aimed at improvingstrength/balance/walking in this clinical group [138].• Falls prevention exercise should be integrated in moregeneral mobility and ADL rehabilitation.• Higher supervision is warranted when there are moreimpairments following stroke.Mild cognitive impairment and dementiaStrong recommendation. Community-dwelling olderadults with cognitive impairment (mild cognitive impair-ment and mild to moderate dementia) should be offered anexercise programme to prevent falls. GRADE: 1B.Recommendation details and justification• It has been shown that physical activity is feasible to per-form by community-dwelling older adults with mild cog-nitive impairment or mild or moderate dementia [223–226].• Exercise interventions were found to be more effectiveto prevent falls in community dwelling older adults thanin those living in residential care suggesting that theseinterventions may be more effective for individuals withrelatively well-preserved abilities [223, 224].• Examples of effective stand-alone exercise interventionsinclude balance training (e.g. Tai Chi) and multicompo-nent exercise (resistance + balance training) [227, 228].• Clinicians can promote better adherence to a care plandesigned to reduce falls in older adults with cognitiveimpairment by involving caregivers of patients with cog-nitive impairment in (i) identifying and modifying envi-ronmental falls risk factors; (ii) modifying lifestyle in termsof diet/nutrition and exercise routines to reduce falls risks;(iii) detailed recording of falls incidents and (iv) determin-ing what is prioritised and acceptable to the adult livingwith cognitive impairment, including attitudes to risks.Hip fractureStrong recommendation. Older adults after sustaining a hipfracture should be offered an individualised and progressiveexercise programme aimed at improving mobility (i.e. stand-ing up, balance, walking, climbing stairs) as a fall preventionstrategy. GRADE: 1B.Conditional recommendation. Such programmes for olderadults after a hip fracture are best commenced in hospital(GRADE: 2C) and continued in the community (GRADE:1A).Recommendation details and justification• The strength of evidence for exercise in preventing fallsin older adults after hip fracture is moderate [229]. Thisrecommendation places a high value on preventing fallsin this population with focus on mobility rehabilitationafter hip fracture, including balance training and adequatepain control (see World Health Organisation guidelines).Furthermore, the minimal risk of harm contributes to thejustification for a strong positive recommendation [230].Falls in low- and middle- income countriesThe majority of older adults alive today reside in a low-to middle- income country (LMIC). Correspondingly, asthe population in LMIC ages at a rapid rate, the volumeof research evidence emerging from these countries is nowalso increasing rapidly. Considering the heterogeneity ofLMIC populations, as well as potential issues unique to thesecountries, this section specifically provides recommendationswhere LMIC may differ from higher income countries. Theother recommendations in these guidelines apply to LMICwith the modifications and special considerations previouslynoted (Appendix 2, available in Age and Ageing online).Strong recommendation. Local context needs to be con-sidered when implementing fall prevention programmes inLMIC. GRADE: 1BRecommendation details and justification• We advise that in LMIC, community dwelling adults aged60 years and over should be screened opportunisticallyfor fall risk during any clinical encounter, at least once ayear, by enquiring about the presence of falls in the past12 months.• Falls prevention should be included in LMIC policiesusing culturally sensitive strategies and tailored to locallevels of expertise and resource availability.Conditional recommendation. We conditionally recom-mend prioritising assessments of risk factors for cognitiveimpairment, obesity including sarcopenic obesity, diabetes,lack of appropriate footwear and environmental hazards asfalls risk factors in LMIC. GRADE: 2C.Recommendation details and justification• This recommendation highlights prominent risk factorsfor falls in LMIC which should be prioritised as part ofthe multifactorial falls risk assessment for falls.• The prevalence of obesity and diabetes is increasing rapidlyin LMIC and these two conditions are more common inolder adults. Available evidence from LMIC has linkedobesity, particularly sarcopenic obesity, with falls, whilediabetes emerges as a prominent risk factor in LMIC withhigh prevalence of diabetes [231–237].• Cognitive impairment is also rising in prevalence in LMICwith their rapidly ageing populations [238]. Multifactorialfalls risk assessments in LMIC should include cognitiveassessment using non-educationally and culturally biasedtools that have been evaluated locally.26https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataWorld guidelines for falls prevention and management for older adults• Footwear and environmental issues differ in LMIC, andhence, assessment and educational interventions shouldconsider the cultural differences in footwear practices aswell as in environmental safety [239].Expert recommendation. Clinicians and caregivers inLMIC settings should preferably use validated tools thatare freely available in their country of residence to assessmobility and fall risk. GRADE: E.Recommendation details and justification• We recommend clinicians in LMIC begin with simplequestions pertaining to fall history, followed by gait andbalance assessments in individuals who screen positive tohaving had a fall in the past year.Frailty, sarcopenia and fallsFalls are a common and important area of health care forolder adults and relate closely, clinically and epidemiolog-ically, to other common ‘geriatric syndromes.’ Here, wehighlight sarcopenia and frailty for particular attention.FrailtyFrailty is associated with an increased falls risk. Frailty is astate of increased vulnerability for developing dependencyor mortality when exposed to a stressor. The prevalence forfrailty is approximately 15% in the over 65 years of agegroup rises to more than 25% in those aged over 85 years,althoughthe prevalence varies according to the definitionand diagnostic methods used and the population studied[240]. A recent systematic review showed that frailty doublesthe risk of recurrent falls while being pre-frail increases thisrisk by 30% [241]. Frailty has been associated with moreinjuries due to falls and hip fractures. As previously noted,our falls stratification algorithm includes frailty as marker ofhigher fall risk. A task force of the International Conferenceof Frailty and Sarcopenia has developed international clinicalpractice guidelines for the identification and management ofphysical frailty [240].Further work is required to develop consensus on howto incorporate the frailty concept into management of olderadults who fall and whether such an approach will reduce therisk of falls. Due to the association between frailty status andgait speed, the latter could potentially be considered a proxyof frailty [242].Further studies are needed to assess the potential addedvalue of using frailty as a proxy for intermediate to high fallrisk and an entry point for personalised multifactorial fallsrisk assessment. From an implementation point of view, suchan approach is promising as it would enable direct linkageto existing services and care pathways that opportunisticallyscreen for frailty in the general older population.SarcopeniaSarcopenia is a condition characterised by an age-associatedloss of skeletal muscle mass and strength/function but alsoassociated with low physical activity levels, other clinicalconditions, and an increased risk of falls in older adults. Theprevalence of sarcopenia and its association with falls variesaccording to the diagnostic definition used and the popu-lation studied. In the longitudinal iLSIRENTE study, theprevalence of sarcopenia was approximately 25% in peopleaged 80 years and above, and participants with sarcopeniawere three times more likely to fall during a follow-up periodof 2 years [243]. International clinical practice guidelinesexist for the screening, diagnosis and management of sar-copenia [244, 245]. A growing number of clinicians andresearchers advocate paying more attention to diagnosingand treating sarcopenia in older adults identified as being at ahigh risk of falls, although further research is required on howthis should be conducted and whether applying non-exerciseinterventions for sarcopenia such as protein supplementationwill reduce falls.Delivery of these recommendation in thehealthcare sectorSome of the recommendations provided in these guidelinesexplicitly apply only to certain countries (e.g. LMIC), caresettings (e.g. hospitals or care homes) or populations (e.g.community-dwelling older adults).In addition to considering the above, users of these guide-lines should recognise that the ability to implement themsuccessfully depends on the available resources and incen-tive structures, organisational culture and current processesof care delivery in a healthcare system, among other fac-tors. Put simply, successful implementation requires a sup-portive organisational context, which should be assessedprior to implementing an organisational change address-ing falls. Tools exist to help guideline implementers assesscontext (e.g. Consolidated Framework for ImplementationResearch) [246].Context matters because many of the recommendationsin these guidelines involve complex interventions.There are‘multiple components or mechanisms of change’ and/or‘how the intervention generates outcomes is dependent onexogenous factors, including the characteristics of recipients,and/or the context or system within which it is implemented’[247]. For example, multifactorial programmes to preventfalls, by their nature, may involve multiple steps (screen-ing, assessment and/or intervention) and multiple interven-tion components, which add complexity. In addition, manyguideline recommendations will depend on the receptivity ofvarious stakeholders to guideline implementation, becausesuch recommendations might involve (i) reorganizing thedelivery of healthcare services (e.g. setting up a robust pro-cess for referral of older adults from healthcare systems tocommunity exercise programmes), which requires healthcareprofessional behaviour change; and (ii) asking for substantialbehaviour change on the part of older adults (e.g. olderadults’ willingness to exercise regularly and indefinitely).Implementing some recommendations may requireresources beyond what is currently available, requiringsubstantial buy-in at all levels of the healthcare system, which27M. Montero-Odasso et al.may or may not be present in a particular setting. Identifyingthe barriers and potential facilitators for changes requiredfor implementing the recommendations at individual,clinical setting and health system levels should be part ofdeveloping a successful implementation strategy. For thesereasons, guidelines should be implemented thoughtfullyand deliberately, after verification of a favourable context tobegin implementation. The implementation process shoulduse quality improvement approaches and rigorous processevaluations to iteratively refine and improve interventiondelivery, through measurement of care processes as well asregular interaction and engagement with key stakeholdersinvolved in the changes being made [248, 249]. Finally,while there are studies of the barriers and facilitators ofguideline uptake, there are very few outcome evaluations ofthe population impact of guidelines on fall occurrence. Thisresearch question poses complex methodological challengesthat should be given priority as part of future guidelinedevelopment.Dissemination and implementationsupportOur results and recommendations are accessible throughour website (www.worldfallsguidelines.com) that providesmany links to suggested resources and toolkits to facilitateimplementation in different scenarios with accompanyingdecision trees and tools. We also have linked informa-tion on ongoing initiatives with regard to knowledgedissemination, implementation and evidence building. Thisincludes links to advice and information produced byWHO and other international agencies, and eventuallydocuments and tools to support implementation of theseguidelines that will be developed in collaboration with olderadults with lived fall experience. Our initiative does notconclude with these guidelines, which we plan to updateregularly.Limitations and concluding remarksOur ambitious attempt at creating clinical practice guide-lines for falls prevention and management based on aninternational consensus of experts and other stakeholders isnot free of limitations. Although our team of experts fromall relevant disciplines has a significant worldwide represen-tation, one continent, Africa, is underrepresented. The inputfrom older adults with lived experience on our process andrecommendations was composed of English speaking olderadults residing in high-income nations. We need to obtainmore diverse feedback on our work.Although we aimed for our recommendations andaccompanying algorithm to be pragmatic and easy to applyand adaptable to older persons’ needs in different scenarios,no formal testing and validation of it was performed. Finally,we have tried to address areas where remaining knowledgegaps were detected, including e-technology, but evidencewas still too scarce to provide strong recommendations.Several key areas for future research, where evidenceis promising but inconclusive, were identified in eachWG’s full report (Appendix 2, available in Age and Ageingonline).We believe that our guidelines will help clinicians aroundthe world choose for their setting and resource availabilityeffective approaches for the assessment and management offall risk in older adults.Supplementary Data: Supplementary data mentioned inthe text are available to subscribers in Age and Ageing online.Acknowledgements:programs in Physical Therapy, Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, Brazil51Mackay Institute of Research and Innovation, Mackay Hospital and Health Service, Mackay, QLD, Australia52Western Health, University of Melbourne, Parkville, Melbourne, VIC, Australia53Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, St Albans, VIC,Australia54Melbourne School of Health Sciences The University of Melbourne, Parkville, Australia55Department of Electrical and Computer Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA,USA56Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia57School of Health and Life Sciences, Research Centre for Health (ReaCH), Glasgow Caledonian University, Cowcaddens Road,Glasgow, Scotland, UK58Department of Occupational Therapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal,Karnataka, India59Schulich Interfaculty Program in Public Health, Schulich School of Medicine & Dentistry, University of Western Ontario, London,ON, Canada60Program in Occupational Therapy, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA61School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, England, UK2World guidelines for falls prevention and management for older adults62Manchester University NHS Foundation Trust, Manchester M13 9WL, UK63Division 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, USA64Department of Human-Centred Design, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, TheNetherlands65Section of Geriatric Medicine,Department of Internal Medicine,Erasmus University Medical Center,Rotterdam,The Netherlands66Division of Geriatrics, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA67Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA68Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium69Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium70Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada71Department of Medicine, University of Toronto, Toronto, ON, Canada72Department of Geriatric Medicine, The British Geriatrics Society, Nottingham University Hospitals NHS Trust, Nottingham,England, UKAddress correspondence to: Manuel Montero-Odasso. Email: mmontero@uwo.ca†Co-principal authors.‡Acknowledgement of collaborative authors: The members of the Task Force on Global Guidelines for Falls in Older Adults arelisted in Appendix 4a, available in Age and Ageing online.AbstractBackground: falls and fall-related injuries are common in older adults, have negative effects on functional independenceand quality of life and are associated with increased morbidity, mortality and health related costs. Current guidelines areinconsistent, with no up-to-date, globally applicable ones present.Objectives: to create a set of evidence- and expert consensus-based falls prevention and management recommendationsapplicable to older adults for use by healthcare and other professionals that consider: (i) a person-centred approach thatincludes the perspectives of older adults with lived experience, caregivers and other stakeholders; (ii) gaps in previousguidelines; (iii) recent developments in e-health and (iv) implementation across locations with limited access to resourcessuch 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, recommendationsfrom 11 topic-specific working groups (WGs), 10 ad-hoc WGs and a WG dealing with the perspectives of older adults werereviewed and refined. The final recommendations were determined by voting.Recommendations: all older adults should be advised on falls prevention and physical activity. Opportunistic case findingfor falls risk is recommended for community-dwelling older adults. Those considered at high risk should be offered acomprehensive multifactorial falls risk assessment with a view to co-design and implement personalised multidomaininterventions. Other recommendations cover details of assessment and intervention components and combinations, andrecommendations for specific settings and populations.Conclusions: the core set of recommendations provided will require flexible implementation strategies that consider bothlocal context and resources.Keywords: falls, injury, aged, guidelines, recommendations, clinical practice, world, global, consensus, older peopleKey Points• The world’s population is ageing. Falls and related injuries are increasingly common, making their prevention andmanagement a critical global challenge.• Opportunistic case-finding is necessary as older adults may not present following a fall and may be reluctant to reportfalls.• Multidomain interventions tailored to individual’s risks factors, when delivered, are effective.• 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.3https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataM. Montero-Odasso et al.‘It takes a child one year to acquire independent movement and ten yearsto acquire independent mobility. An old person can lose both in a day’Professor Bernard Isaacs(1924–1995)IntroductionThis quote from Bernard Isaacs portrays the unfortunateconsequences that an older adult may experience after asingle fall [1]. Falls occur at all ages and are an inevitablepart of a bipedal gait and physical activity. They occur in30% of adults aged over 65 years annually [2], for whomthe consequences are more serious, despite concerted effortsof researchers and clinicians to understand, assess and man-age their risks and causes. In addition to personal distress,falls and fall-related injuries are a serious health care prob-lem because of their association with subsequent morbidity,disability, hospitalisation, institutionalisation and mortality[1, 3, 4]. In Europe, total deaths and disability-adjustedlife years due to falls have increased steadily since 1990[5]. The Global Burden of Disease study reported nearly17 million years of life lost from falls in 2017 [3]. Relatedsocietal and economic consequences are substantial. In high-income countries, approximately 1% of health care costs arefall-related expenditures [6].The number of falls and related injuries will likely furtherincrease [7, 8], partly as there are more older adults, butalso because of increasing prevalence of multimorbidity,polypharmacy and frailty among them. There appears to bedifferences in falls prevalence between and within regions ofthe world [3, 5]. For example, rates among ethnic Chinesepopulations across South East Asia have been reported asbetween 15 and 34% [4] and in the Latin America andCaribbean region rates ranged from 22% in Barbados to34% in Chile [9]. These differences may be due in partto cultural and lifestyle differences [10]. There are alsodifferences between settings with the incidence of falls beinghigher for older adults living in care homes or during ahospital stay [10]. This suggests that risk factors may differacross locations and settings, which could have relevance forpreventative strategies.The need for new guidelinesThe World Falls Guidelines (WFG)We would like to thank and acknowl-edge our central organisation support team composed by DrFrederico Faria, Dr Yanina Sarquis-Adamson, Surim Son,Nattasha Clements and Jackie Liu. Also, we would liketo thank and acknowledge Maureen Godfrey for offeringher insights as an older adult with lived experience on ourprotocol paper, our panel of older adults (Clarke Heidrick,Elizabeth Retzer, Walter Retzer and Gerry Treble) for com-menting and advising on the recommendations that weredeveloped, and all other adults who supported the work ofthe individual working groups.Declaration of Conflicts of Interest: The correspondingauthor declares on behalf of the group of authors that manyof the co-authors receive funding and grants but that nonepose a substantive conflict to this published work.Declaration of Sources of Funding: The WFGs initiativeis partially funded by a research grant from the St. JosephFoundation, London, Ontario, Canada (grant no. 74531)and by a CIHR Planning and Dissemination Grant from theInstitute of Ageing (RN476173-478689) obtained to fundthe Delphi process and voting, website development, work-shops, and production and publication of this guideline.References1. Bernard I. The Challenge of Geriatric Medicine. Oxford:Oxford University Press, 1992.2. Ganz DA, Latham NK. Prevention of falls in community-dwelling older adults. N Engl J Med 2020; 382: 734–43.3. James SL, Lucchesi LR, Bisignano C et al. The global burdenof falls: global, regional and national estimates of morbidityand mortality from the global burden of disease study 2017.Inj Prev 2020; 26: i3–11.4. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence,risk factors, and consequences in Chinese older people: asystematic review. J Am Geriatr Soc 2011; 59: 536–43.5. Haagsma JA, Olij BF, Majdan M et al. Falls in older agedadults in 22 European countries: incidence, mortality andburden of disease from 1990 to 2017. Inj Prev 2020; 26:i67–74.6. O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN,Ryan C, Gallagher P. STOPP/START criteria for potentiallyinappropriate prescribing in older people: version 2. AgeAgeing 2015; 44: 213–8.28www.worldfallsguidelines.comhttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataWorld guidelines for falls prevention and management for older adults7. Montero-Odasso MM, Kamkar N, Pieruccini-Faria F et al.Evaluation of clinical practice guidelines on fall preven-tion and management for older adults: a systematic review.JAMA Netw Open 2021; 4: e2138911. 10.1001/jamanet-workopen.2021.38911.8. National Instiute for Health and Care Excellence (NICE).2019 Surveillance of Falls in Older People: AssessingRisk and Prevention (NICE Guideline CG161). Lon-don: National Instiute for Health and Care Excellence,2019.9. Reyes-Ortiz CA, Al Snih S, Markides KS. Falls among elderlypersons in Latin America and the Caribbean and amongelderly Mexican-Americans. Rev Panam Salud Publica 2005;17: 362–9.10. Lipsitz LA, Nakajima I, Gagnon M et al. Muscle strength andfall rates among residents of Japanese and American nursinghomes: an International Cross-Cultural Study. J Am GeriatrSoc 1994; 42: 953–9.11. Lusardi MM, Fritz S, Middleton A et al. Determining risk offalls in community dwelling older adults: a systematic reviewand meta-analysis using posttest probability. J Geriatr PhysTher 2017; 40: 1–36. 10.1519/JPT.0000000000000099.12. Mirelman A, Herman T, Brozgol M et al. Executive functionand falls in older adults: new findings from a five-yearprospective study link fall risk to cognition. PLoS One 2012;7: e40297. 10.1371/journal.pone.0040297.13. Montero-Odasso M, Muir SW, Speechley M. Dual-taskcomplexity affects gait in people with mild cognitive impair-ment: the interplay between gait variability, dual tasking, andrisk of falls. Arch Phys Med Rehabil 2012; 93: 293–9.14. Fischer BL, Gleason CE, Gangnon RE, Janczewski J, SheaT, Mahoney JE. Declining cognition and falls: role of riskyperformance of everyday mobility activities. Phys Ther 2014;94: 355–62.15. Amboni M, Barone P, Hausdorff JM. Cognitive contribu-tions to gait and falls: evidence and implications. Mov Disord2013; 28: 1520–33.16. Montero-Odasso M, Speechley M. Falls in cognitivelyimpaired older adults: implications for risk assessment andprevention. J Am Geriatr Soc 2018; 66: 367–75.17. Robinovitch SN, Feldman F, Yang Y et al. Video capture ofthe circumstances of falls in elderly people residing in long-term care: an observational study. Lancet 2013; 381: 47–54.18. Pang I, Okubo Y, Sturnieks D, Lord SR, Brodie MA.Detection of near falls using wearable devices: a systematicreview. J Geriatr Phys Ther 2019; 42: 48–56.19. Bhangu J, McMahon CG, Hall P et al. Long-term car-diac monitoring in older adults with unexplained falls andsyncope. Heart 2016; 102: 681–6.20. Yardley L, Kirby S, Ben-Shlomo Y, Gilbert R, Whitehead S,Todd C. How likely are older people to take up different fallsprevention activities? Prev Med 2008; 47: 554–8.21. Franco MR, Howard K, Sherrington C et al. Elicitingolder people’s preferences for exercise programs: a best-worst scaling choice experiment. J Physiother 2015; 61:34–41.22. Dorresteijn TA, Rixt Zijlstra GA, Van Eijs YJ, VlaeyenJW, Kempen GI. Older people’s preferences regarding pro-gramme formats for managing concerns about falls. AgeAgeing 2012; 41: 474–81.23. World Health Organization. World Report on Ageing andHealth. Geneva: World Health Organization, 2015.24. World Health Organization. Step Safely: Strategies for Pre-venting and Managing Falls across the Life-Course. Geneva:World Health Organization, 2021.25. Montero-Odasso M, van der Velde N, Alexander NB et al.New horizons in falls prevention and management for olderadults: a global initiative. Age Ageing 2021; 50: 1499–507.26. International Osteoporosis Foundation. What Is Osteo-porosis? Switzerland: International Osteoporosis Founda-tion. Available at https://www.osteoporosis.foundation (June2022, date last accessed).27. Fragility Fracture Network. FFN Clinical Toolkit and Pol-icy Toolkit Resources. Fragility Fracture Network. Availableat https://fragilityfracturenetwork.org/about-2/resources-centre/ (June 2022, date last accessed).28. Fougere BMJ, Arai H, Bauer JM et al. Precision medicine:the future management of geriatric conditions. J Nutr HealthAging 2018. https://doi.org/10.1007/s12603-018-1045-1.29. Tricco AC, Antony J, Zarin W et al. A scoping review ofrapid review methods. BMC Med 2015; 13: 224. 10.1186/s12916-015-0465-6.30. Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerg-ing consensus on rating quality of evidence and strength ofrecommendations. BMJ 2008; 336: 924–6.31. Burns ER, Lee R, Hodge SE, Pineau VJ, Welch B, Zhu M.Validation and comparison of fall screening tools for predict-ing future falls among older adults. Arch Gerontol Geriatr2022; 101: 104713. 10.1016/j.archger.2022.104713.32. Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will mypatient fall? JAMA 2007; 297: 77–86.33. Meekes WM, Korevaar JC, Leemrijse CJ, van de Goor IA.Practical and validated tool to assess falls risk in the primarycare setting: a systematic review. BMJ Open 2021; 11:e045431. 10.1136/bmjopen-2020-045431.34. Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaroE, Adler G. Gender differences in seeking care for falls inthe aged Medicare population. Am J Prev Med 2012; 43:59–62.35. Fleming J, Brayne C, the Cambridge City over-75s Cohort(CC75C) study collaboration. Inability to get up afterfalling, subsequent time on floor, and summoning help:prospective cohort study in people over 90. BMJ 2008; 337:a2227. 10.1136/bmj.a2227.36. Bisson EJ, Peterson EW, Finlayson M. Delayed initial recov-ery and long lie after a fall among middle-aged and olderpeople with multiple sclerosis. ArchPhys Med Rehabil 2015;96: 1499–505.37. Vellas BJ, Wayne SJ, Garry PJ, Baumgartner RN. A two-year longitudinal study of falls in 482 community-dwellingelderly adults. J Gerontol A Biol Sci Med Sci 1998; 53:M264–74.38. World Bank. Life Expectancy at Birth, Total (Years) | Data(Worldbank.Org). World Bank website, 2022.39. Tiedemann A, Mikolaizak AS, Sherrington C, Segin K, LordSR, Close JC. Older fallers attended to by an ambulancebut not transported to hospital: a vulnerable population athigh risk of future falls. Aust N Z J Public Health 2013; 37:179–85.40. Mikolaizak AS, Lord SR, Tiedemann A et al. A multi-disciplinary intervention to prevent subsequent falls andhealth service use following fall-related paramedic care:a randomised controlled trial. Age Ageing 2017; 46:200–7.29https://doi.org/10.1001/jamanet-workopen.2021.38911https://doi.org/10.1519/JPT.0000000000000099https://doi.org/10.1371/journal.pone.0040297https://www.osteoporosis.foundationhttps://fragilityfracturenetwork.org/about-2/resources-centre/https://fragilityfracturenetwork.org/about-2/resources-centre/https://doi.org/10.1007/s12603-018-1045-1https://doi.org/10.1186/s12916-015-0465-6https://doi.org/10.1016/j.archger.2022.104713https://doi.org/10.1136/bmjopen-2020-045431https://doi.org/10.1136/bmj.a2227M. Montero-Odasso et al.41. Tinetti ME, Speechley M, Ginter SF. Risk factors for fallsamong elderly persons living in the community. N Engl JMed 1988; 319: 1701–7.42. Nevitt MC, Cummings SR, Kidd S, Black D. Risk factorsfor recurrent nonsyncopal falls. A prospective study. JAMA1989; 261: 2663–8.43. Karlsson MK, Vonschewelov T, Karlsson C, Coster M,Rosengen BE. Prevention of falls in the elderly: a review.Scand J Public Health 2013; 41: 442–54.44. Stevens JA. The STEADI tool kit: a fall prevention resourcefor health care providers. IHS Prim Care Provid 2013; 39:162–6.45. Centers for Disease Control and Prevention STEADI.Pocket Guide—Preventing Falls in Older Patients. Centersfor Disease Control and Prevention, 2019.46. Jepsen B, Robinson K, Ogliari G et al. Predicting falls inolder adults: an umbrella review of instruments assessing fait,balance, and functional mobility. BMC Geriatr 2022; 22.10.1186/s12877-022-03271-5.47. Fried LP, Tangen CM, Walston J et al. Frailty in older adults:evidence for a phenotype. J Gerontol A Biol Sci Med Sci2001; 56: M146–57.48. Rockwood K, Song X, MacKnight C et al. A global clinicalmeasure of fitness and frailty in elderly people. CMAJ 2005;173: 489–95.49. British Geriatrics Society. Comprehensive Geriatric Assess-ment Toolkit for Primary Care Practioners. British GeriatricsSociety, 2019.50. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatricsyndromes: clinical, research, and policy implications of acore geriatric concept. J Am Geriatr Soc 2007; 55: 780–91.51. Sillner AY, Holle CL, Rudolph JL. The overlap between fallsand delirium in hospitalized older adults: a systematic review.Clin Geriatr Med 2019; 35: 221–36.52. Nazarko L. Falls prevention in primary care. London J PrimCare (Abingdon) 2009; 2: 158–63.53. Ayton D, Morello R, Natora A, Yallop S, Barker A, Soh SE.Perceptions of falls and falls prevention interventions amongpersonal alert Victoria clients. Health Soc Care Community2018; 26: 970–8.54. Collins CE, Chandra A, Nguyen B et al. The rose-colored glasses of geriatric fall patients: inconsistenciesbetween knowledge of risk factors for and actual causes offalls. Gerontol Geriatr Med 2020; 6: 233372142096788.10.1177/2333721420967884.55. Delbaere K, Close JC, Brodaty H, Sachdev P, Lord SR.Determinants of disparities between perceived and physio-logical risk of falling among elderly people: cohort study.BMJ 2010; 341: c4165. 10.1136/bmj.c4165.56. Jagnoor J, Keay L, Jaswal N, Kaur M, Ivers R. A qualitativestudy on the perceptions of preventing falls as a healthpriority among older people in northern India. Inj Prev2014; 20: 29–34.57. Zecevic AA, Salmoni AW, Speechley M, Vandervoort AA.Defining a fall and reasons for falling: comparisons amongthe views of seniors, health care providers, and the researchliterature. Gerontologist 2006; 46: 367–76.58. Kwon S, Perera S, Pahor M et al. What is a meaningfulchange in physical performance? Findings from a clinicaltrial in older adults (the LIFE-P study). J Nutr Health Aging2009; 13: 538–44.59. Shumway-Cook A, Brauer S, Woollacott M. Predicting theprobability for falls in community-dwelling older adultsusing the timed up & go test. Phys Ther 2000; 80:896–903.60. Mathias S, Nayak US, Isaacs B. Balance in elderly patients:the “get-up and go” test. Arch Phys Med Rehabil 1986; 67:387–9.61. de Morton NA, Davidson M, Keating JL. The de MortonMobility Index (DEMMI): an essential health index for anageing world. Health Qual Life Outcomes 2008; 6: 63.10.1186/1477-7525-6-63.62. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Mea-suring balance in the elderly: validation of an instrument.Can J Public Health 1992; 83: S7–11.63. Bohannon R. Single limb stance times: a descriptive meta-analysis of data from individuals at least 60 years of age.Topics Geriatr Rehab 2006; 22: 70–7.64. Weiner DK, Duncan PW, Chandler J, Studenski SA. Func-tional reach: a marker of physical frailty. J Am Geriatr Soc1992; 40: 203–7.65. Bandinelli S, Pozzi M, Lauretani F et al. Adding challengeto performance-based tests of walking: the Walking InCHI-ANTI Toolkit (WIT). Am J Phys Med Rehabil 2006; 85:986–91.66. Tinetti ME. Performance-oriented assessment of mobilityproblems in elderly patients. J Am Geriatr Soc 1986; 34:119–26.67. Horak FB, Wrisley DM, Frank J. The Balance EvaluationSystems Test (BESTest) to differentiate balance deficits. PhysTher 2009; 89: 484–98.68. Lord SR, Delbaere K, Gandevia SC. Use of a physiologicalprofile to document motor impairment in ageing and inclinical groups. J Physiol 2016; 594: 4513–23.69. Alexander NB. Gait disorders in older adults. J Am GeriatrSoc 1996; 44: 434–51.70. Lindemann U. Spatiotemporal gait analysis of older per-sons in clinical practice and research: which parameters arerelevant? Z Gerontol Geriatr 2020; 53: 171–8.71. Ardali G, Brody LT, States RA, Godwin EM. Reliability andvalidity of the floor transfer test as a measure of readiness forindependent living among older adults. J Geriatr Phys Ther2019; 42: 136–47.72. Bergland A, Laake K. Concurrent and predictive validity of“getting up from lying on the floor”. Aging Clin Exp Res2005; 17: 181–5.73. de Vries M, Seppala LJ, Daams JG et al. Fall-risk-increasingdrugs: a systematic review and meta-analysis: I. Cardiovas-cular drugs. J Am Med Dir Assoc 2018; 19: 371.e1–9.10.1016/j.jamda.2017.12.013.74. Seppala LJ, van de Glind EMM, Daams JG et al. Fall-risk-increasing drugs: a systematic review and meta-analysis:III. Others. J Am Med Dir Assoc 2018; 19: 372.e1–8.10.1016/j.jamda.2017.12.099.75. Seppala LJ, Wermelink A, de Vries M et al. Fall-risk-increasing drugs: a systematic review and meta-analysis: II.Psychotropics. J Am Med Dir Assoc 2018; 19: 371.e11–7.76. Seppala LJ, Petrovic M, Ryg J et al. STOPPFall (screeningtool of older persons prescriptions in older adults with highfall risk): a Delphi study by the EuGMS task and finishgroup on fall-risk-increasing drugs. Age Ageing 2021; 50:1189–99.77. Gillespie LD, Robertson MC, Gillespie WJ et al. Interven-tions for preventing falls in older people living in the commu-nity. Cochrane Database Syst Rev 2012; 2021: CD007146.10.1002/14651858.CD007146.pub3.30https://doi.org/10.1186/s12877-022-03271-5https://doi.org/10.1177/2333721420967884https://doi.org/10.1136/bmj.c4165https://doi.org/10.1186/1477-7525-6-63https://doi.org/10.1016/j.jamda.2017.12.013https://doi.org/10.1016/j.jamda.2017.12.099https://doi.org/10.1002/14651858.CD007146.pub3World guidelines for falls prevention and management for older adults78. Cameron ID, Dyer SM, Panagoda CEet al. Interventionsfor preventing falls in older people in care facilities andhospitals. Cochrane Database Syst Rev 2018; 9: CD005465.10.1002/14651858.CD005465.pub479. Dautzenberg L, Beglinger S, Tsokani S et al. Interventionsfor preventing falls and fall-related fractures in community-dwelling older adults: a systematic review and network meta-analysis. J Am Geriatr Soc 2021; 69: 2973–84.80. Centeres for Disease Control and Prevention. STEADI—Older Adult Fall Prevention. Centers for Disease Controland Prevention, National Center for Injury Prevention andControl, 2020. Available at https://www.cdc.gov/steadi/steadi-rx.html (2022, date last accessed).81. By the American Geriatrics Society Beers Criteria UpdateExpert P. American Geriatrics Society 2019 updated AGSbeers criteria(R) for potentially inappropriate medication usein older adults. J Am Geriatr Soc 2019; 67: 674–94.82. Pazan F, Wehling M. The FORTA (Fit fOR The Aged)app as a clinical tool to optimize complex medicationsin older people. J Am Med Dir Assoc 2017; 18: 893.10.1016/j.jamda.2017.06.031.83. Johanna J. Meds75+. Fimea: Finnish Medicines Agency,2020. Available at https://www.fimea.fi/web/en/databases_and_registeries/medicines_information/database_of_medication_for_older_persons.84. Seppala LJ, Petrovic M, Ryg J et al. STOPPFall (screeningtool of older persons prescriptions in older adults with highfall risk): a Delphi study by the EuGMS task and finishgroup on fall-risk-increasing drugs. Age Ageing 2020; 50:189–1199.85. Muir SW, Gopaul K, Montero Odasso MM. The role ofcognitive impairment in fall risk among older adults: asystematic review and meta-analysis. Age Ageing 2012; 41:299–308.86. Montero-Odasso M, Almeida QJ, Bherer L et al. Consen-sus on shared measures of mobility and cognition: fromthe Canadian consortium on neurodegeneration in aging(CCNA). J Gerontol A Biol Sci Med Sci 2019; 74: 897–909.87. McGarrigle L, Yang Y, Lasrado R, Gittins M, Todd, C. A sys-tematic review and meta-analysis of the psychometric prop-erties of four variants of the falls efficacy scale-international(FES-I). Paper in preparation. 2022.88. Adamczewska N, Nyman SR. A new approach to fear of fallsfrom connections with the posttraumatic stress disorder lit-erature. Gerontol Geriatr Med 2018; 4: 233372141879623.10.1177/2333721418796238.89. Hughes CC, Kneebone II, Jones F, Brady B. A theoreticaland empirical review of psychological factors associated withfalls-related psychological concerns in community-dwellingold82er people. Int Psychogeriatr 2015; 27: 1071–87.90. Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C,Todd C. Development and initial validation of the FallsEfficacy Scale-International (FES-I). Age Ageing 2005; 34:614–9.91. Tinetti ME, Richman D, Powell L. Falls efficacy as a measureof fear of falling. J Gerontol 1990; 45: P239–43.92. Davies AJ, Kenny RA. Falls presenting to the accident andemergency department: types of presentation and risk factorprofile. Age Ageing 1996; 25: 362–6.93. Jansen S, Kenny RA, de Rooij SE, van der Velde N. Self-reported cardiovascular conditions are associated with fallsand syncope in community-dwelling older adults. Age Age-ing 2015; 44: 525–9.94. Brignole M, Moya A, de Lange FJ et al. 2018 ESC guidelinesfor the diagnosis and management of syncope. Eur Heart J2018; 39: 1883–948.95. Parry SW, Kenny RA. Drop attacks in older adults: system-atic assessment has a high diagnostic yield. J Am Geriatr Soc2005; 53: 74–8.96. Cronin H, Kenny RA. Cardiac causes for falls and theirtreatment. Clin Geriatr Med 2010; 26: 539–67.97. Bourke R, Doody P, Perez S, Moloney D, Lipsitz LA,Kenny R. Cardiovascular abnormalities and falls amongolder adults: a systematic review for the task force on globalguidelines for falls in older adults. Paper in preparation.2022.98. Heitterachi E, Lord SR, Meyerkort P, McCloskey I,Fitzpatrick R. Blood pressure changes on upright tiltingpredict falls in older people. Age Ageing 2002; 31: 181–6.99. Maggi R, Rafanelli M, Ceccofiglio A, Solari D, BrignoleM, Ungar A. Additional diagnostic value of implantableloop recorder in patients with initial diagnosis of real orapparent transient loss of consciousness of uncertain origin[Europace 2014; 16: 1226-1230]. Europace 2015; 17: 1847.10.1093/europace/euu308.100. Juraschek SP, Appel LJ, Mitchell CM et al. Comparison ofsupine and seated orthostatic hypotension assessments andtheir association with falls and orthostatic symptoms. J AmGeriatr Soc 2022; 70: 2310–9.101. Mattace-Raso FU, van den Meiracker AH, Bos WJ et al.Arterial stiffness, cardiovagal baroreflex sensitivity and pos-tural blood pressure changes in older adults: the Rotterdamstudy. J Hypertens 2007; 25: 1421–6.102. Oghalai JS, Manolidis S, Barth JL, Stewart MG, JenkinsHA. Unrecognized benign paroxysmal positional vertigo inelderly patients. Otolaryngol Head Neck Surg 2000; 122:630–4.103. Gazzola JM, Gananca FF, Aratani MC, Perracini MR,Gananca MM. Circumstances and consequences of falls inelderly people with vestibular disorder. Braz J Otorhino-laryngol 2006; 72: 388–92.104. Liston MB, Bamiou DE, Martin F et al. Peripheral vestibulardysfunction is prevalent in older adults experiencing multiplenon-syncopal falls versus age-matched non-fallers: a pilotstudy. Age Ageing 2014; 43: 38–43.105. Hawke LJ, Barr CJ, McLoughlin JV. The frequency andimpact of undiagnosed benign paroxysmal positional vertigoin outpatients with high falls risk. Age Ageing 2021; 50:2025–30.106. Bourne RRA, Flaxman SR, Braithwaite T et al. Magnitude,temporal trends, and projections of the global prevalenceof blindness and distance and near vision impairment: asystematic review and meta-analysis. Lancet Glob Health2017; 5: e888–97.107. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C,Negri E. Risk factors for falls in community-dwelling olderpeople: a systematic review and meta-analysis. Epidemiology2010; 21: 658–68.108. Jiam NT, Li C, Agrawal Y. Hearing loss and falls: a sys-tematic review and meta-analysis. Laryngoscope 2016; 126:2587–96.109. Damoiseaux-Volman BA, Medlock S, van der Eijk M,Romijn J, Abu-Hanna A, van der Velde N. Falls and delir-ium in older inpatients: work-as-imagined, work-as-doneand preferences for clinical decision support systems. SafetyScience 2021; 142: 105355. 10.1016/j.ssci.2021.105355.3110.1002/14651858.CD005465.pub4https://www.cdc.gov/steadi/steadi-rx.htmlhttps://www.cdc.gov/steadi/steadi-rx.htmlhttps://doi.org/0.1016/j.jamda.2017.06.031https://www.fimea.fi/web/en/databases_and_registeries/medicines_information/database_of_medication_for_older_personshttps://www.fimea.fi/web/en/databases_and_registeries/medicines_information/database_of_medication_for_older_personshttps://www.fimea.fi/web/en/databases_and_registeries/medicines_information/database_of_medication_for_older_personshttps://doi.org/10.1177/2333721418796238https://doi.org/10.1093/europace/euu308https://doi.org/10.1016/j.ssci.2021.105355M. Montero-Odasso et al.110. Morris ME, Webster K, Jones C et al. Interventions to reducefalls in hospitals: a systematic review and meta-analysis. AgeAgeing 2022; 51. 10.1093/ageing/afac077.111. Toye C, Kitchen S, Hill A, Edwards D, Sin M, Maher S.Piloting staff education in Australia to reduce falls in olderhospital patients experiencing delirium. Nurs Health Sci2017; 19: 51–8.112. Ludolph P, Stoffers-Winterling J, Kunzler AM et al. Non-pharmacologic multicomponent interventions preventingdelirium in hospitalized people. J Am Geriatr Soc 2020; 68:1864–71.113. Siddiqi N, Harrison JK, Clegg A et al. Interventionsfor preventing delirium in hospitalised non-ICU patients.Cochrane Database Syst Rev 2016; 3: CD005563. 10.1002/14651858.CD005563.pub3.114. Hshieh TT, Yang T, Gartaganis SL, Yue J, Inouye SK.Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness. Am J Geriatr Psychiatry2018; 26:1015–33.115. Growdon ME, Shorr RI, Inouye SK. The tension betweenpromoting mobility and preventing falls in the hospital.JAMA Intern Med 2017; 177: 759–60.116. Moon S, Chung HS, Kim YJ et al. The impact of uri-nary incontinence on falls: a systematic review and meta-analysis. PLoS One 2021; 16: e0251711. 10.1371/jour-nal.pone.0251711.117. Pesonen JS, Vernooij RWM, Cartwright R et al. The impactof nocturia on falls and fractures: a systematic review andmeta-analysis. J Urol 2020; 203: 674–83.118. Brown JS, Bradley CS, Subak LL et al. The sensitivity andspecificity of a simple test to distinguish between urge andstress urinary incontinence. Ann Intern Med 2006; 144:715–23.119. Stubbs B, Schofield P, Binnekade T, Patchay S, SepehryA, Eggermont L. Pain is associated with recurrent falls incommunity-dwelling older adults: evidence from a system-atic review and meta-analysis. Pain Med 2014; 15: 1115–28.120. Lehti TE, Rinkinen MO, Aalto U et al. Prevalence of muscu-loskeletal pain and analgesic treatment among community-dwelling older adults: changes from 1999 to 2019. DrugsAging 2021; 38: 931–7.121. Schwan J, Sclafani J, Tawfik VL. Chronic pain managementin the elderly. Anesthesiol Clin 2019; 37: 547–60.122. Herr K. Pain assessment strategies in older patients. J Pain2011; 12: S3–13.123. Pighills A, Clemson L. Environmental risk factors for falls.In: Lord S, Sherrington C, Naganathan V, eds. Falls in OlderPeople: Risk Factors, Strategies for Prevention and Impli-cations for Practice, 3rd edition. Cambridge: CambridgeUniversity Press, 2021; 202–10.124. Clemson L, Mackenzie L, Ballinger C, Close JC, Cum-ming RG. Environmental interventions to prevent falls incommunity-dwelling older people: a meta-analysis of ran-domized trials. J Aging Health 2008; 20: 954–71.125. Keglovits M, Clemson L, Hu YL et al. A scoping review offall hazards in the homes of older adults and developmentof a framework for assessment and intervention. Aust OccupTher J 2020; 67: 470–8.126. Clemson L, Pighills A. Environmental interventions to pre-vent falls at home and in the community. In: Lord S,Sherrington C, Naganathan V, eds. Falls in Older People:Risk Factors, Strategies for Prevention and Implications forPractice, 3rd edition. Cambridge, UK: Cambridge Univer-sity Press, 2021; 360–77.127. Clemson L, Stark S, Pighills A et al. Environmental inter-ventions for preventing falls in older people living in thecommunity (review). Cochrane Database Syst Rev 2022; inpress.128. van Poelgeest EP, Pronk AC, Rhebergen D, van der VeldeN. Depression, antidepressants and fall risk: therapeuticdilemmas-a clinical review. Eur Geriatr Med 2021; 12:585–96.129. Trevisan C, Crippa A, Ek S et al. Nutritional status, bodymass index, and the risk of falls in community-dwelling olderadults: a systematic review and meta-analysis. J Am Med DirAssoc 2019; 20: 569–582.e7.130. Guigoz Y. The Mini Nutritional Assessment (MNA) reviewof the literature—what does it tell us? J Nutr Health Aging2006; 10: 466–85 discussion 85-7.131. Blain H, Masud T, Dargent-Molina P et al. A comprehensivefracture prevention strategy in older adults: the EuropeanUnion Geriatric Medicine Society (EUGMS) statement. JNutr Health Aging 2016; 20: 647–52.132. Li N, Hiligsmann M, Boonen A et al. The impact of fractureliaison services on subsequent fractures and mortality: asystematic literature review and meta-analysis. OsteoporosInt 2021; 32: 1517–30.133. Masud T, Binkley N, Boonen S, Hannan MT, MembersFPDC. Official positions for FRAX(R) clinical regardingfalls and frailty: can falls and frailty be used in FRAX(R)?From Joint Official Positions Development Conference ofthe International Society for Clinical Densitometry andInternational Osteoporosis Foundation on FRAX(R). J ClinDensitom 2011; 14: 194–204.134. Beaudoin C, Moore L, Gagne M et al. Performance of predic-tive tools to identify individuals at risk of non-traumatic frac-ture: a systematic review, meta-analysis, and meta-regression.Osteoporos Int 2019; 30: 721–40.135. Kanis JA, Cooper C, Rizzoli R et al. European guid-ance for the diagnosis and management of osteoporo-sis in postmenopausal women. Osteoporos Int 2019; 30:3–44.136. Lamb SE, McCabe C, Becker C, Fried LP, Guralnik JM.The optimal sequence and selection of screening test itemsto predict fall risk in older disabled women: the Women’sHealth and Aging Study. J Gerontol A Biol Sci Med Sci2008; 63: 1082–8.137. Sherrington C, Fairhall N, Kwok W et al. Evidence onphysical activity and falls prevention for people aged 65+years: systematic review to inform the WHO guidelines onphysical activity and sedentary behaviour. Int J Behav NutrPhys Act 2020; 17: 144. 10.1186/s12966-020-01041-3.138. World Health Organization. WHO Guidelines on PhysicalActivity and Sedentary Behaviour. Geneva: World HealthOrganization, 2020; Contract No.: Licence: CC BY-NC-SA3.0 IGO.139. Paganini-Hill A, Greenia DE, Perry S, Sajjadi SA, KawasCH, Corrada MM. Lower likelihood of falling at age 90+is associated with daily exercise a quarter of a century earlier:the 90+ study. Age Ageing 2017; 46: 951–7.140. World Health Organization. Integrated Care for Older Peo-ple (ICOPE): Guidance for Person-Centred Assessment andPathways in Primary Care. World Health Organization,2019; Contract No.: License: CC BY-NC-SA 3.0 IGO).32https://doi.org/10.1093/ageing/afac077https://doi.org/10.1002/14651858.CD005563.pub3https://doi.org/10.1371/jour-nal.pone.0251711https://doi.org/10.1186/s12966-020-01041-3World guidelines for falls prevention and management for older adults141. Sherrington C, Fairhall NJ, Wallbank GK et al.Exercise for preventing falls in older people living inthe community. Cochrane Database Syst Rev 2019; 1:CD012424.142. Kim C, Armstrong MJ, Berta WB, Gagliardi AR. Howto identify, incorporate and report patient preferences inclinical guidelines: a scoping review. Health Expect 2020;23: 1028–36.143. Hopewell S, Adedire O, Copsey BJ et al. Multifactorial andmultiple component interventions for preventing falls inolder people living in the community. Cochrane DatabaseSyst Rev 2018; 7: CD012221.144. World Health Organization. Evidence Profile: Risk ofFalls—Integrated Care for Older People. World HealthOrganization.145. Bruce J, Hossain A, Lall R et al. Fall prevention interventionsin primary care to reduce fractures and falls in people aged70 years and over: the PreFIT three-arm cluster RCT. HealthTechnol Assess 2021; 25: 1–114. 10.3310/hta25340.146. Bhasin S, Gill TM, Reuben DB et al. A randomized trial of amultifactorial strategy to prevent serious fall injuries. N EnglJ Med 2020; 383: 129–40.147. van der Velde N, Seppala L, Petrovic M et al. Sustainablefall prevention across Europe: challenges and opportunities.Aging Clin Exp Res 2022.148. Lamb S, Lee H. Multifactorial fall prevention strategies:where to next? In: Lord S, Sherrington C, Naganathan V,eds. Alls in Older People: Risk Factors, Strategies for Preven-tion and Implications for Practice, 3rd edition. Cambridge,UK: Cambridge University Press, 2019.149. Izquierdo M, Merchant RA, Morley JE et al. Interna-tional exercise recommendations in older adults (ICFSR):expert consensus guidelines. J Nutr Health Aging 2021; 25:824–53.150. Di Lorito C, Bosco A, Booth V, Goldberg S, Harwood RH,Van der Wardt V. Adherence to exercise interventions inolder people with mild cognitive impairment and dementia:a systematic review and meta-analysis. Prev Med Rep 2020;19: 101139. 10.1016/j.pmedr.2020.101139.151. Simpson PM, Bendall JC, Tiedemann A, Lord SR, CloseJC. Epidemiology of emergency medical service responsesto older people who have fallen: a prospective cohort study.Prehosp Emerg Care 2014; 18: 185–94.152. Tinetti ME, Liu WL, Claus EB. Predictors and prognosis ofinability to get up after falls among elderly persons. JAMA1993; 269: 65–70.153. Wild D, NayakUS, Isaacs B. How dangerous are falls in oldpeople at home? Br Med J (Clin Res Ed) 1981; 282: 266–8.154. Cone DC, Ahern J, Lee CH, Baker D, Murphy T, BoguckiS. A descriptive study of the "lift-assist" call. Prehosp EmergCare 2013; 17: 51–6.155. Reece A, Simpson A. Preparing older people to cope after afall. Physiotherapy 1996; 82: 227–35.156. Skelton D, Dinan S, Campbell M, Rutherford O. Tailoredgroup exercise (Falls Management Exercise—FaME) reducesfalls in community-dwelling older frequent fallers (an RCT).Age Ageing 2005; 34: 636–9.157. Seppala LJ, van der Velde N. Fall-risk-increasing drugs:background, current evidence on deprescribing, and futureperspectives. In: Integrated Care and Fall Prevention inActive and Healthy Aging. Hershey, PA, USA: IGI Global,2021; 67–76.158. Parekh N, Gahagan B, Ward L, Ali K. They must help if thedoctor gives them to you’: a qualitative study of the olderperson’s lived experience of medication-related problems.Age Ageing 2019; 48: 147–51.159. Casilari E, Santoyo-Ramóna JA, Cano-Garcíaa JM.UMAFall: a multisensor dataset for the research onautomatic fall detection. Procedia Computer Science 2017;110: 32–9.160. Alarifi A, Alwadain A. Killer heuristic optimized con-volution neural network-based fall detection with wear-able IoT sensor devices. Measurement 2021; 167: 108258.10.1016/j.measurement.2020.108258.161. Bourke AK, Klenk J, Schwickert L et al. Temporal and kine-matic variables for real-world falls harvested from lumbarsensors in the elderly population. Annu Int Conf IEEE EngMed Biol Soc 2015; 2015: 5183–6.162. Scheurer S, Koch J, Kucera M et al. Optimization and tech-nical validation of the AIDE-MOI fall detection algorithmin a real-life setting with older adults. Sensors (Basel) 2019;19. 10.3390/s19061357.163. Saadeh W, Butt SA, Altaf MAB. A patient-specific sin-gle sensor IoT-based wearable fall prediction and detectionsystem. IEEE Trans Neural Syst Rehabil Eng 2019; 27:995–1003.164. Rescio G, Leone A, Siciliano P. Supervised machine learn-ing scheme for electromyography-based pre-fall detectionsystem. Expert Syst Appl 2018; 100: 95–105.165. Reginatto B, Taylor K, Patterson MR et al. Context awarefalls risk assessment: a case study comparison. Annu Int ConfIEEE Eng Med Biol Soc 2015; 2015: 5477–80.166. Chaudhuri S, Oudejans D, Thompson HJ, Demiris G. Real-world accuracy and use of a wearable fall detection device byolder adults. J Am Geriatr Soc 2015; 63: 2415–6.167. Marschollek M, Rehwald A, Wolf KH et al. Sensors vs.experts—a performance comparison of sensor-based fall riskassessment vs. conventional assessment in a sample of geri-atric patients. BMC Med Inform Decis Mak 2011; 11: 48.10.1186/1472-6947-11-48.168. Levy SS, Thralls KJ, Kviatkovsky SA. Validity and reliabilityof a portable balance tracking system, BTrackS, in olderadults. J Geriatr Phys Ther 2018; 41: 102–7.169. Liang S, Ning Y, Li H et al. Feature selection and predictorsof falls with foot force sensors using KNN-based algorithms.Sensors (Basel) 2015; 15: 29393–407.170. Di Rosa M, Hausdorff JM, Stara V et al. Concurrent valida-tion of an index to estimate fall risk in community dwellingseniors through a wireless sensor insole system: a pilot study.Gait Posture 2017; 55: 6–11.171. Weiss A, Herman T, Plotnik M, Brozgol M, Giladi N,Hausdorff JM. An instrumented timed up and go: the addedvalue of an accelerometer for identifying fall risk in idiopathicfallers. Physiol Meas 2011; 32: 2003–18.172. Chan JKY, Klainin-Yobas P, Chi Y, Gan JKE, ChowG, Wu XV. The effectiveness of e-interventions onfall, neuromuscular functions and quality of life incommunity-dwelling older adults: a systematic reviewand meta-analysis. Int J Nurs Stud 2021; 113: 103784.10.1016/j.ijnurstu.2020.103784.173. Harris T, Kerry SM, Limb ES et al. Effect of a primarycare walking intervention with and without nurse support onphysical activity levels in 45- to 75-year-olds: the pedometerand consultation evaluation (PACE-UP) cluster randomised33https://doi.org/10.3310/hta25340https://doi.org/10.1016/j.pmedr.2020.101139https://doi.org/10.1016/j.measurement.2020.108258https://doi.org/10.3390/s19061357https://doi.org/10.1186/1472-6947-11-48https://doi.org/10.1016/j.ijnurstu.2020.103784M. Montero-Odasso et al.clinical trial. PLoS Med 2017; 14: e1002210. 10.1371/jour–nal.pmed.1002210.174. Chu MM, Fong KN, Lit AC et al. An occupational therapyfall reduction home visit program for community-dwellingolder adults in Hong Kong after an emergency departmentvisit for a fall. J Am Geriatr Soc 2017; 65: 364–72.175. Stark S, Keglovits M, Somerville E et al. Home hazardremoval to reduce falls among community-dwelling olderadults: a randomized clinical trial. JAMA Netw Open 2021;4: e2122044. 10.1001/jamanetworkopen.2021.22044.176. Hilton MP, Pinder DK. The Epley (canalith reposition-ing) manoeuvre for benign paroxysmal positional vertigo.Cochrane Database Syst Rev 2014; 8: CD003162.177. Gananca FF, Gazzola JM, Gananca CF, Caovilla HH,Gananca MM, Cruz OL. Elderly falls associated with benignparoxysmal positional vertigo. Braz J Otorhinolaryngol2010; 76: 113–20.178. Jumani K, Powell J. Benign paroxysmal positional vertigo:management and its impact on falls. Ann Otol RhinolLaryngol 2017; 126: 602–5.179. McDonnell MN, Hillier SL. Vestibular rehabilitationfor unilateral peripheral vestibular dysfunction. CochraneDatabase Syst Rev 2015; 1: CD005397.180. American Geriatrics Society Panel on the PharmacologicalManagement of Persistent Pain in Older Persons. Pharmaco-logical management of persistent pain in older persons. PainMed 2009; 10: 1062–83.181. Gloth FM 3rd. Pharmacological management of persistentpain in older persons: focus on opioids and nonopioids. JPain 2011; 12: S14–20.182. Virnes RE, Tiihonen M, Karttunen N, van Poelgeest EP, vander Velde N, Hartikainen S. Opioids and falls risk in olderadults: a narrative review. Drugs Aging 2022; 39: 199–207.183. Pickering G, Marcoux M, Chapiro S et al. An algorithm forneuropathic pain management in older people. Drugs Aging2016; 33: 575–83.184. Kendrick D, Kumar A, Carpenter H et al. Exercise for reduc-ing fear of falling in older people living in the community.Cochrane Database Syst Rev 2014; 28: CD009848.185. Kruisbrink M, Crutzen R, Kempen G et al. Disentan-gling interventions to reduce fear of falling in community-dwelling older people: a systematic review and meta-analysisof intervention components. Disabil Rehabil 2021; 1–11.10.1080/09638288.2021.1969452.186. Kruisbrink M, Delbaere K, Kempen G et al. Interven-tion characteristics associated with a reduction in fear offalling among community-dwelling older people: a system-atic review and meta-analysis of randomized controlled trials.Gerontologist 2021; 61: e269–82.187. CHM C, Jiang Y, Lim S, Wu VX, Wang W. Effectivenessof cognitive behaviour therapy-based multicomponent inter-ventions on fear of falling among community-dwelling olderadults: a systematic review and meta-analysis. J Adv Nurs2019; 75: 3299–315.188. Liu TW, Ng GYF, Chung RCK, Ng SSM. Cognitivebehavioural therapy for fear of falling and balance amongolder people: a systematic review and meta-analysis. AgeAgeing 2018; 47: 520–7.189. De Coninck L, Bekkering GE, Bouckaert L, Declercq A,Graff MJL, Aertgeerts B. Home- and community-basedoccupational therapy improves functioning in frail olderpeople: a systematic review. J Am Geriatr Soc 2017; 65:1863–9.190. Harwood RH, Foss AJE, Osborn F, Gregson RM, Zaman A,Masud T. Falls and health status in elderly women followingfirst eye cataract surgery: a randomised controlled trial. Br JOphthalmol 2005; 89: 53–9.191. Keay L, Ho KC, Rogers K et al. The incidence of falls afterfirst and second eye cataract surgery: a longitudinal cohortstudy. Med J Aust 2022; 217: 94–9.192. Haran MJ, Cameron ID, Ivers RQ et al. Effect on falls ofproviding single lens distancevision glasses to multifocalglasses wearers: VISIBLE randomised controlled trial. BrMed J 2010; 340: c2265. 10.1136/bmj.c2265.193. Campbell AJ, Robertson MC, Grow SJL et al. Randomisedcontrolled trial of prevention of falls in people aged ≥75 withsevere visual impairment: the VIP trial. BMJ 2005; 331: 817.10.1136/bmj.38601.447731.55.194. Cumming RG, Ivers R, Clemson L et al. Improving visionto prevent falls in frail older people: a randomized trial. J AmGeriatr Soc 2007; 55: 175–81.195. Michos ED, Kalyani RR, Blackford AL et al. The relationshipof falls with achieved 25-Hydroxyvitamin D levels fromvitamin D supplementation: the STURDY trial. J EndocrSoc 2022; 6: bvac065. 10.1210/jendso/bvac065.196. LeBoff MS, Murata EM, Cook NR et al. VITamin D andOmegA-3 TriaL (VITAL): effects of vitamin D supplementson risk of falls in the US population. J Clin EndocrinolMetab 2020; 105: 2929–38.197. Dawson-Hughes B, Mithal A, Bonjour JP et al. IOF positionstatement: vitamin D recommendations for older adults.Osteoporos Int 2010; 21: 1151–4.198. Holick MF, Binkley NC, Bischoff-Ferrari HA et al. Evalu-ation, treatment, and prevention of vitamin D deficiency:an Endocrine Society clinical practice guideline. J ClinEndocrinol Metab 2011; 96: 1911–30.199. Cosman F, de Beur SJ, LeBoff MS et al. Clinician’s guideto prevention and treatment of osteoporosis. Osteoporos Int2014; 25: 2359–81.200. Jellett J, Williams C, Clayton D, Plummer V, Haines T.Falls risk score removal does not impact inpatient falls: astepped-wedge, cluster-randomised trial. J Clin Nurs 2020;29: 4505–13.201. Heng H, Jazayeri D, Shaw L, Kiegaldie D, Hill AM,Morris ME. Hospital falls prevention with patient edu-cation: a scoping review. BMC Geriatr 2020; 20: 140.10.1186/s12877-020-01515-w.202. Dykes PC, Carroll DL, Hurley A et al. Fall prevention inacute care hospitals: a randomized trial. JAMA 2010; 304:1912–8.203. Hada A, Coyer F. Shift-to-shift nursing handover inter-ventions associated with improved inpatient outcomes-falls,pressure injuries and medication administration errors: anintegrative review. Nurs Health Sci 2021; 23: 337–51.204. Milisen K, Coussement J, Arnout H et al. Feasibility ofimplementing a practice guideline for fall prevention ongeriatric wards: a multicentre study. Int J Nurs Stud 2013;50: 495–507.205. Shaw L, Kiegaldie D, Morris ME. Educating healthprofessionals to implement evidence-based falls screen-ing in hospitals. Nurse Educ Today 2021; 101: 104874.10.1016/j.nedt.2021.104874.34https://doi.org/10.1371/jour-nal.pmed.1002210https://doi.org/10.1001/jamanetworkopen.2021.22044https://doi.org/10.1080/09638288.2021.1969452https://doi.org/10.1136/bmj.c2265https://doi.org/10.1136/bmj.38601.447731.55https://doi.org/10.1210/jendso/bvac065https://doi.org/10.1186/s12877-020-01515-whttps://doi.org/10.1016/j.nedt.2021.104874World guidelines for falls prevention and management for older adults206. Logan PA, Horne JC, Allen F et al. A multidomain decisionsupport tool to prevent falls in older people: the FinCHcluster RCT. Health Technol Assess 2022; 26: 1–136.10.3310/CWIB0236.207. Sze TW, Leng CY, Lin SK. The effectiveness of physicalrestraints in reducing falls among adults in acute care hos-pitals and nursing homes: a systematic review. JBI Libr SystRev 2012; 10: 307–51.208. Brugnolli A, Canzan F, Mortari L, Saiani L, Ambrosi E,Debiasi M. The effectiveness of educational training ormulticomponent programs to prevent the use of physicalrestraints in nursing home settings: a systematic review andmeta-analysis of experimental studies. Int J Environ ResPublic Health 2020; 17. 10.3390/ijerph17186738.209. Hewitt J, Goodall S, Clemson L, Henwood T, Refshauge K.Progressive resistance and balance training for falls preven-tion in long-term residential aged care: a cluster randomizedtrial of the sunbeam program. J Am Med Dir Assoc 2018;19: 361–9.210. Logan PA, Horne JC, Gladman JRF et al. Multifactorialfalls prevention programme compared with usual care in UKcare homes for older people: multicentre cluster randomisedcontrolled trial with economic evaluation. BMJ 2021; 375:e066991.211. Pickering RM, Grimbergen YA, Rigney U et al. A meta-analysis of six prospective studies of falling in Parkinson’sdisease. Mov Disord 2007; 22: 1892–900.212. King LA, Mancini M, Smulders K et al. Cognitively chal-lenging agility boot camp program for freezing of gait inParkinson disease. Neurorehabil Neural Repair 2020; 34:417–27.213. Lindholm B, Nilsson MH, Hansson O, Hagell P.External validation of a 3-step falls prediction modelin mild Parkinson’s disease. J Neurol 2016; 263:2462–9.214. Paul SS, Canning CG, Sherrington C, Lord SR, Close JC,Fung VS. Three simple clinical tests to accurately predict fallsin people with Parkinson’s disease. Mov Disord 2013; 28:655–62.215. Pelicioni PHS, Menant JC, Latt MD, Lord SR. Falls inParkinson’s disease subtypes: risk factors, locations and cir-cumstances. Int J Environ Res Public Health 2019; 16.10.3390/ijerph16122216.216. Latt MD, Lord SR, Morris JG, Fung VS. Clinical and phys-iological assessments for elucidating falls risk in Parkinson’sdisease. Mov Disord 2009; 24: 1280–9.217. Canning CG, Sherrington C, Lord SR et al. Exercise for fallsprevention in Parkinson disease: a randomized controlledtrial. Neurology 2015; 84: 304–12.218. Chivers Seymour K, Pickering R, Rochester L et al.Multicentre, randomised controlled trial of PDSAFE, aphysiotherapist-delivered fall prevention programme forpeople with Parkinson’s. J Neurol Neurosurg Psychiatry2019; 90: 774–82.219. Parthimos TP, Schulpis KH. The progressive supranuclearpalsy: past and present aspects. Clin Gerontol 2020; 43:155–80.220. Skorvanek M, Martinez-Martin P, Kovacs N et al. Differ-ences in MDS-UPDRS scores based on Hoehn and Yahrstage and disease duration. Mov Disord Clin Pract 2017; 4:536–44.221. Allen NE, Canning CG, Almeida LRS et al. Interventionsfor preventing falls in Parkinson’s disease. Cochrane DatabaseSyst Rev 2022; 6: CD011574.222. Henderson EJ, Lord SR, Brodie MA et al. Rivastigmine forgait stability in patients with Parkinson’s disease (ReSPonD):a randomised, double-blind, placebo-controlled, phase 2trial. Lancet Neurol 2016; 15: 249–58.223. Racey M, Markle-Reid M, Fitzpatrick-Lewis D et al. Fallprevention in community-dwelling adults with mild to mod-erate cognitive impairment: a systematic review and meta-analysis. BMC Geriatr 2021; 21: 689. 10.1186/s12877-021-02641-9.224. Li F, Harmer P, Eckstrom E et al. Efficacy of exercise-based interventions in preventing falls among community-dwelling older persons with cognitive impairment: is thereenough evidence? An updated systematic review and meta-analysis. Age Ageing 2021; 50: 1557–68.225. Burton E, Cavalheri V, Adams R et al. Effectiveness of exer-cise programs to reduce falls in older people with dementialiving in the community: a systematic review and meta-analysis. Clin Interv Aging 2015; 10: 421–34.226. Suttanon P, Hill K, Said C, Dodd K. Can balance exer-cise programmes improve balance and related physicalperformance measures in people with dementia: a systematicreview. Eur Rev Aging Phys Act 2010; 7: 13–25.227. Nyman SR, Ingram W, Sanders J et al. Randomised con-trolled trial of the effect of tai Chi on postural balanceof people with dementia. Clin Interv Aging 2019; 14:2017–29.228. Pitkala KH, Poysti MM, Laakkonen ML et al. Effects ofthe Finnish Alzheimer disease exercise trial (FINALEX): arandomized controlled trial. JAMA Intern Med 2013; 173:894–901.229. Fairhall N, Dyer S, Kowk W, Mak J, Diong J, SherringtonC. Interventions for improving mobility after hip fracturesurgery in adults. Cochrane Database Syst RevUnder review.230. Sherrington C, Michaleff ZA, Fairhall N et al. Exercise toprevent falls in older adults: an updated systematic reviewand meta-analysis. Br J Sports Med 2017; 51: 1750–8.231. OzturkZA, Turkbeyler IH, Abiyev A et al. Health-relatedquality of life and fall risk associated with age-related bodycomposition changes; sarcopenia, obesity and sarcopenicobesity. Intern Med J 2018; 48: 973–81.232. Máximo R, Santos J, Perracini M, Oliveira C, Duarte Y,Alexandre T. Abdominal obesity, dynapenia and dynapenic-abdominal obesity as factors associated with falls. Braz J PhysTher 2019; 23: 497–505.233. Szlejf C, Parra-Rodriguez L, Rosas-Carrasco O. Osteosar-copenic obesity: prevalence and relation with frailty andphysical performance in middle-aged and older women. JAm Med Dir Assoc 2017; 18: 733.e1–5.234. Waters DL, Qualls CR, Cesari M, Rolland Y, Vliet-stra L, Vellas B. Relationship of incident falls with bal-ance deficits and body composition in male and femalecommunity-dwelling elders. J Nutr Health Aging 2019; 23:9–13.235. Allain TJ, Mwambelo M, Mdolo T, Mfune P. Falls andother geriatric syndromes in Blantyre, Malawi: a communitysurvey of older adults. Malawi Med J 2014; 26: 105–8.236. Wettasinghe AH, Dissanayake DWN, Allet L, Katulanda P,Lord SR. Falls in older people with diabetes: identification of35https://doi.org/10.3310/CWIB0236https://doi.org/10.3390/ijerph17186738https://doi.org/10.3390/ijerph16122216https://doi.org/10.1186/s12877-021-02641-9M. Montero-Odasso et al.simple screening measures and explanatory risk factors. PrimCare Diabetes 2020; 14: 723–8.237. Wettasinghe A, Dissanayake D, Allet L, Katulanda P, Lord S.The impact of physical, neurological and cognitive deficits onrisk of falls in people with type 2 diabetes mellitus: a review.SLJDEM 2020; 10: 18–25.238. Prince M, Acosta D, Ferri CP et al. Dementia incidence andmortality in middle-income countries, and associations withindicators of cognitive reserve: a 10/66 Dementia ResearchGroup population-based cohort study. Lancet 2012; 380:50–8.239. Chaiwanichsiri D, Janchai S, Tantisiriwat N. Foot disordersand falls in older persons. Gerontology 2009; 55: 296–302.240. Dent E, Morley JE, Cruz-Jentoft AJ et al. Physical frailty:ICFSR international clinical practice guidelines for identi-fication and management. J Nutr Health Aging 2019; 23:771–87.241. Chu W, Chang SF, Ho HY. Adverse health effects of frailty:systematic review and meta-analysis of middle-aged andolder adults with implications for evidence-based practice.Worldviews Evid Based Nurs 2021; 18: 282–9.242. Islam A, Muir-Hunter SW, Speechley M, Montero-OdassoM. Facilitating frailty identification: comparison of twomethods among community-dwelling order adults. J FrailtyAging 2014; 3: 216–21.243. Landi F, Liperoti R, Russo A et al. Sarcopenia as a risk factorfor falls in elderly individuals: results from the ilSIRENTEstudy. Clin Nutr 2012; 31: 652–8.244. Chen LK, Woo J, Assantachai P et al. Asian workinggroup for Sarcopenia: 2019 consensus update on sarcopeniadiagnosis and treatment. J Am Med Dir Assoc 2020; 21:300–307.e2.245. Cruz-Jentoft AJ, Bahat G, Bauer J et al. Sarcopenia: revisedEuropean consensus on definition and diagnosis. Age Ageing2019; 48: 16–31.246. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, AlexanderJA, Lowery JC. Fostering implementation of health servicesresearch findings into practice: a consolidated framework foradvancing implementation science. Implement Sci 2009; 4:50. 10.1186/1748-5908-4-50.247. Skivington K, Matthews L, Simpson SA et al. Framework forthe development and evaluation of complex interventions:gap analysis, workshop and consultation-informed update.Health Technol Assess 2021; 25: 1–132. .248. Vlaeyen E, Stas J, Leysens G et al. Implementation of fallprevention in residential care facilities: a systematic review ofbarriers and facilitators. Int J Nurs Stud 2017; 70: 110–21.249. Braithwaite J, Marks D, Taylor N. Harnessing implemen-tation science to improve care quality and patient safety: asystematic review of targeted literature. International J QualHealth Care 2014; 26: 321–9.Received 15 August 2022;editorial decision 26 August 202236https://doi.org/10.1186/1748-5908-4-50 World guidelines for falls prevention and management for older adults: a global initiativeIntroductionFramework of the guidelinesFalls risk stratification and algorithmAssessmentManagement and interventionsFalls in hospitalsFalls in care homesSpecific clinical populationsFalls in low- and middle- income countriesFrailty, sarcopenia and fallsDelivery of these recommendation in the healthcare sectorDissemination and implementation supportLimitations and concluding remarks14 Supplementary Data:15 Acknowledgements:16 Declaration of Conflicts of Interest:17 Declaration of Sources of Funding:Task Force was cre-ated following discussions in 2019 between 14 internationalexperts to consider whether new guidelines on falls preven-tion were needed to reflect new evidence and clinical servicechallenges. A subsequent systematic review identified gapsin and inconsistencies between the existing guidelines devel-oped nationally or by specialist international bodies and con-cluded that a new set of clinical practice guidelines shouldbe created to address these issues and that the guidelinesshould incorporate an international perspective [7].The National Institute for Health and Care Excellence inEngland (NICE) undertook a systematic assessment in 2019of the need to update its 2013 guidelines [8] and concludedthat new evidence reported up to February 2019 had likelyimpact on case-finding, falls risk assessments and preventa-tive interventions. With further findings since then, there isnow a substantial volume of research evidence that has notbeen systematically evaluated. Observational studies haveclarified how to identify levels of risk among communitydwelling and clinical populations [2, 11, 12]. Mechanisticand epidemiological studies have improved our understand-ing of falls in older adults with cognitive impairment [12–16]. The potential roles for e-health including wearables,virtual reality applications and environmental monitoringdevices [17–19] have not been previously considered by priorguideline recommendations.Falls are more common among older adults in clinicalcare settings, e.g. hospitals, subacute and rehabilitation units,assisted living settings and care homes. The risk factors inthese settings and consensus on how to address them arenot well captured in current clinical practice guidelines, butevidence specific to these settings is now available on whichto base recommendations.Perspectives of older adults with living experience, carersand other stakeholders have been inconsistently incorpo-rated [7], but there is now emerging evidence that suchviews may inform the suitability and feasibility of guidelinerecommendations [20–22].Purpose and scope of the guidelinesWe believe that these guidelines will contribute to improvingthe health and well-being of older adults globally, whichis the overarching aim of the United Nations Decade ofHealthy Ageing (2021–2030). Healthy ageing relies on ‘thefunctional ability to be or to do what you have reasonto value’ [23]. Reducing the incidence of falls and relatedinjuries, notably fractures and head injuries, and enablingpreserved functional mobility and reducing concerns aboutfalling, which may limit activity, would all contribute toachieving this. Therefore, the objective of the WFG is toprovide guidelines for healthcare and other professionalsworking with older adults on how to identify and assessthe risk of falls and which interventions, alone or in com-bination, to offer as part of a person-centred approach.These guidelines are novel in systematically considering: (i)a person-centred approach, including the perspectives fromolder adults with lived experience, caregivers and other stake-holders: (ii) gaps detected in previous guidelines; (iii) recentdevelopments in e-health and (iv) challenges of implemen-tation 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 restinadvertently 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 thehealth and social care systems of many countries, olderadults are regarded as those aged 65 years or over, but insome circumstances, age 60 years may be more appropriatedepending on the context and health expectancies. There is4larisRealcelarisRealcelarisRealcelarisNotaO objetivo do Guideline Global de Quedas é fornecer normas para os cuidados de saúde e de outros profissionais que trabalham com pessoas idosas sobre como identificar e avaliar o risco de quedas e suas intervenções, sozinhas ou combinadas, a fim de oferecer como parte de uma abordagem centrada na pessoa.O guideline é novo em considerar sistematicamente:1) a abordagem centrada no paciente, incluindo perspectivas da própria pessoa idosa com as experiências vividas, cuidadores ou outros colaboradores;2) lacunas detectadas em guidelines já existentes;3) desenvolvimentos recentes em e-health ("saúde online");4) desafios de implementação em locais com recursos limitados, incluindo países de baixa renda.larisRealcelarisRealcelarisRealcelarisRealceWorld guidelines for falls prevention and management for older adultsinconsistency in the ages of older participants in the researchevidence underpinning these guidelines. There is no scien-tific rationale for the application of a strict chronologicaldefinition of older age when using these guidelines.The guidelines are focused on individual person levelactions. The intended beneficiaries include older adults livingin the community and care homes, and hospital inpatients.We also considered the specific features of assessmentand/or prevention applicable to older adults with commonmedical conditions associated with higher falls risk andwhere the evidence supported this (i.e. Parkinson’s disease[PD], post-stroke, post-hip fracture and significant cognitiveimpairment) we developed separate recommendations forthese conditions.The challenges of implementing falls prevention guide-lines in LMIC, where barriers to accessing human and tech-nical resources may be encountered, have not been previouslyconsidered [25]. As well, the most predictive risk factors forfalls and the favoured interventions to prevent them may welldiffer in these countries compared with high-income ones.Accordingly, we have tried to include these considerationsin the recommendations made and the advice provided fortheir implementation.Management of fall-related injuries is beyond the scopeof these guidelines, but as there is a close epidemiologicaland clinical relationship between falls and fragility fractures,explicit linkage is needed with clinicians and services that canassess bone health, identify osteoporosis and fracture risk andprovide management for maintaining bone health. Whiledetails of these activities are not included in these guide-lines, there are well developed multilingual ones availableelsewhere [26, 27].How should these guidelines be used?Healthcare clinicians for whom these guidelines weredeveloped include physicians, nurses, physiotherapists,occupational therapists, pharmacists and other allied healthprofessionals. Application of these guidelines involvesactions by non-specialist as well as specialist healthcareprofessionals, and service design of care pathways linkingprimary and community services to specialists where neces-sary. Therefore, optimal implementation will require actionsat the operational level in healthcare and social care sectors.While adaptation to local context, healthcare arrangementsand resources is inevitable, our recommendations encompassthe global population of older adults. Population levelapproaches such as public health initiatives and communitylevel actions such as environmental design and age-friendlycommunities that may directly or indirectly impact falls ratesare beyond our scope.We anticipate that the flexible application of ourrecommendations will support meeting the different needsof individuals with varying characteristics and prioritiesand residing in diverse settings and countries with variableresource availability and are consistent with the person-centred approach [28] described below.Predictive: utilisation of available information to deter-mine an individual’s risk of falls and fall-related injuries.Preventative: focused on intention to preventfalls andrelated injuries whilst optimising functional ability.Personalised: utilisation of identified fall risks factors andother relevant clinical information, such as cognition, todevelop individualised fall prevention plans.Participatory: intervention goals and plan developed incollaboration with the older adult, and others as they wish,to consider priorities, values and resources, such as carersupport.How were these guidelines produced?A full description of the process is provided in Appendix 1,available in Age and Ageing online. The World FallsGuidelines Task Force assembled 96 experts from 39countries and across 5 continents, with representation from36 scientific and academic societies. Details how this taskforce was assembled have been previously described [25]. ASteering Committee developed the strategy and guided theproject. Feedback from older adults was obtained throughearly and meaningful involvement in the consensus process,with the goal of making these guidelines better suitedto the needs of older adults residing in the communityand long-term care facilities. We conducted a systematicreview in 2020 that examined existing falls prevention andmanagement guidelines. The gaps identified informed thecreation of specific working groups (WGs) addressing topicsconsidered to be relevant or controversial [7]. Eleven topicspecific WGs developed preliminary graded recommenda-tions based on systematic reviews as described in detail ineach of their WG Reports in Appendix 2, available in Ageand Ageing online. Each WG was responsible for creatingits own search strategy and their own PICO question.Details on selecting and appraising the articles are clarifiedin the full report for each WG in Appendix 2, availablein Age and Ageing online. A further WG considered olderadult’s perspectives as a cross-cutting theme. Ten ad hocexpert groups performed additional rapid reviews [29] ofclinical areas not covered by the WGs. An internationalExperts Group provided external review and feedback onthe preliminary and revised recommendations through afour-stage modified Delphi process, which culminated in afinal vote on the recommendations that involved SteeringCommittee members and WG leaders and informed bystructured feedback from an older adults’ panel.In addition, an ad hoc WG of 8 clinician experts devel-oped a falls assessment and management algorithm, linkingrisk stratification, assessment and interventions, based on theevidence provided by the WGs. The full membership lists ofcommittees and WGs are shown in Appendix 4b, availablein Age and Ageing online.Grading of recommendations is presented accordingto the strength (1 strong to 2 weak-conditional) andquality of the contributing evidence (A–C, high to low)using a modified version of the widely used Grading ofRecommendations, Assessment, and Evaluation (GRADE)5https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datalarisRealcelarisRealcelarisRealceM. Montero-Odasso et al.Table 1. Modified GRADE system descriptionStrength ofRecommendation1 Strong: benefits clearly outweigh undesirable effects2 Weak or conditional: either lower quality evidence or desirable and undesirable effects are more closely balancedQuality ofevidenceA High: ‘further research is unlikely to change confidence in the estimate of effect’B Intermediate: ‘further research is likely to have an important impact on the confidence in the estimate of effect and may changethe estimate’C Low: ‘further research is very likely to have an important impact on the confidence in the estimate of effect and is likely tochange the estimate’No evidenceAvailableE Experts: ‘When the review of the evidence failed to identify any quality studies meeting standards set or evidence was notavailable, recommendations were formulated expert consensus’criteria (Table 1) [30]. This modified GRADE is based onthe original system, where numbers are used to indicatethe strength of the recommendation. Where evidence waslacking, but a recommendation considered necessary, thismodified system allowed for a recommendation to be gradedas ‘E’ (expert consensus advice recommendation) (Tables 2and 3).Framework of the guidelines• Fall Risk Stratification: a standard approach to assess anindividual’s estimated level of risk for falls, in order toapply a proportionate detailed assessment and interventionaccording to level of risk.• Assessment: process of identifying and measuring the fallsrisk factors across multiple domains, using recommendedtools if available, to indicate potentially modifiable areasfor intervention. Combined with other components of acomprehensive geriatric assessment (CGA), this enables aperson-centred approach.• Management and Interventions: description of variousapproaches to fall prevention including recommendedtreatments or actions which can reduce the risk of falls andmay be suitable as single interventions or in combinations.• Assessment and Treatment Algorithm: this links the threestages of initial risk stratification, assessment and man-agement, and encourages a ‘person-centred’ approach todesign an individualised intervention.Key messages• The world’s population is ageing. Falls and relatedinjuries are increasingly common, making their pre-vention and management a critical global challenge.• Many falls can be prevented. Fall and injury preven-tion needs multidisciplinary management.• Engaging older adults is essential for prevention offalls and injuries: understanding their beliefs, atti-tudes and priorities about falls and their managementis crucial to successfully intervening.• Managing many of the risk factors for falls (e.g. gaitand balance problems) have wider benefits beyondfalls prevention such as improved intrinsic capacities(physical and mental health), functioning and qualityof life.• Estimates of risk of future falls can be done by trainedclinicians with simple resources.• Multidomain interventions (i.e., a combination ofinterventions tailored to the individual), when deliv-ered, are effective for reducing the rate of falls inhigh-risk community-dwelling older adults.• In care homes and hospital settings all older adultsshould be considered as high risk and a standardcomprehensive assessment followed by multidomaininterventions should be considered.• Vitamin D supplementation to prevent falls shouldbe reserved for those at risk of vitamin D deficiency.• Modification to the approaches for assessment andinterventions may be needed for older adults with cer-tain medical conditions associated with an increasedlikelihood of falling.• Application of some of these recommendations mayneed modification to meet the needs of older adultsin settings and locations with limited resources suchas LMIC.Falls risk stratification and algorithmFollowing the seminal guidelines produced by the AGS/BGS/ AAOS panel on falls prevention and managementpublished in 2001 and updated in 2011, we created a fallsprevention and management approach and algorithm to beapplied in community older adults. We stratified falls riskinto the following three categories [31, 32], which was alsoused in our falls risk detection and management algorithmfor community dwelling older adults (Figure 1):• older adults at low risk for falls who should be offerededucation about falls prevention and exercise for generalhealth and/or fall prevention if interested;• older adults at intermediate risk for falls, who in additionto the above should be offered targeted exercise or aphysiotherapist referral in order to improve balance andmuscle strength,and reduce their fall risk; and6World guidelines for falls prevention and management for older adultsTable 2. Taxonomy used in the World Falls GuidelinesFall An unexpected event in which an individual comes to rest on the ground, floor, or lower levelRecurrent falls Two or more falls reported in the previous 12 monthsUnexplained fall When no apparent cause has been found for a fall on performing a multifactorial falls risk assessment and it cannot beexplained by a failure to adapt to an environmental hazard or by any other gait or balance abnormalitySevere fall Fall with injuries that are severe enough to require a consultation with a physician; result in the person lying on theground without capacity to get up for at least one hour; prompt a visit to the emergency room (ER); associated with lossof consciousnessFall related injury An injury sustained following a fall. This includes an injury resulting in medical attention including hospitalisation for afall such as fractures, joint dislocation, head injury, sprain or strain, bruising, swelling, laceration, or other serious injuryfollowing a fallFall risk stratification A single or set of assessments performed to grade an individual’s risk of falling, to guide what further assessments orinterventions might be necessaryMultifactorial falls risk assessment A set of assessments performed across multiple domains to judge an individual’s overall level of risk of falling to identifythe individual risk factors - potentially modifiable and non-modifiable -to inform the choice of an interventionCaregiver A caregiver provides assistance in meeting the daily needs of another person. Caregivers are referred to as either ‘formal’or ‘informal.’ ‘Formal’ caregivers are paid for their services and have had training in providing care. This may includeservices from home health agencies and other trained professionals.‘Informal’ caregivers, also called family caregivers, are persons who give care to family or friends usually withoutpayment. A caregiver gives care, generally in the home environment, for an ageing parent, spouse, other relative orunrelated person, or for an ill, or disabled person. These tasks may include transportation, grocery shopping, housework,preparing meals. Also giving assistance with getting dressed, getting out of bed, help with eating and incontinence.Exercise Exercise is a subset of physical activity that is planned, structured, and repetitive and has as a final or an intermediateobjective the improvement or maintenance of physical fitness. Physical fitness is a set of attributes that are either health-or skill-relatedFall risk increasing drugs (FRIDs) Medications known to increase the risk of fallsFall risk stratification algorithm The systematic process of decision-making and intervention that should occur for falls risk case findingsLow- and Middle- income countries(LMIC)As defined by World Bank Classification for Low- and Middle- Income Countries https://blogs.worldbank.org/opendata/new-world-bank-country-classifications-income-level-2021-2022Multicomponent exercise This type of programme combines strength, aerobic, balance, gait and flexibility trainingMultidomain interventions A combination of two or more intervention components across two or more domains (e.g.: an exercise program andenvironmental modification) based on a multifactorial falls risk assessment and intended to prevent or minimise fallsand related injuriesMulticomponent interventions These are fixed combinations of two or more intervention components that are not individually tailored following amultifactorial falls risk assessment. Multicomponent interventions vary widely: for illustration, an example could be amedication review, home modifications and generic exercise advicePhysical activity Any bodily movement produced by skeletal muscles that results in energy expenditure. The energy expenditure can bemeasured in kilocalories. Physical activity in daily life can be categorised into occupational, sports, conditioning,household, or other activitiesTelehealth Involves communicating with individuals at home via telephone or video callsSmart home systems System that aims to decrease environmental hazards and forecast potentially impending falls using sensors and ArtificialIntelligence (AI) technology• older adults at high risk for falls who should be offered amultifactorial falls risk assessment to inform individualisedtailored interventions.Categorisation into these three groups should occur dur-ing either opportunistic case-finding or when older adultspresent with a fall or related injury.Opportunistic case-findingStrong recommendation. Clinicians should routinely askabout falls in their interactions with older adults, as theyoften will not be spontaneously reported. GRADE: 1A.Expert recommendation. Older adults in contact withhealthcare for any reason should be asked, at least onceyearly, if they have (i) experienced one or more falls inthe last 12 months, and (ii) about the frequency, charac-teristics, context, severity and consequences of any fall/s.GRADE: E.Expert recommendation. If resources and time are avail-able, we conditionally recommend to additionally ask (iii) ifthey have experienced dizziness, loss of consciousness or anydisturbance of gait or balance and (iv) if they experience anyconcerns about falling causing limitation of usual activities.GRADE: E.Strong recommendation. Older adults who affirm any ofthe above inquiries should be offered an objective assessmentof gait and balance for differentiating intermediate and highfrom low risk of falls as a component of initial falls riskstratification. GRADE: 1A.Recommendation details and justification• Clinicians cannot rely solely on older adults reporting falls,as studies indicate that many do not for a variety of reasons[33]. This is particularly true for men with less than a thirdmentioning them to their clinician if not directly asked(Appendix 2, available in Age and Ageing online) [34].7https://blogs.worldbank.org/opendata/new-world-bank-country-classifications-income-level-2021-2022https://blogs.worldbank.org/opendata/new-world-bank-country-classifications-income-level-2021-2022https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-dataM. Montero-Odasso et al.Table 3. List of acronyms used in the text of the WFGs3IQ Three Incontinence Questionnaire3KQ Three Key QuestionsADL Activities of Daily LivingBMI Body mass indexCFS Clinical Frailty ScaleCGA Comprehensive geriatric assessmentCST Chair Stand TestDT Dual taskingFES-I Falls Efficacy Scale InternationalFOG Freezing of gaitFP Frailty phenotypeFRIDs Fall risk increasing drugsGDS Geriatric Depression ScaleGRADE Grading of Recommendations, Assessment, and EvaluationIADL Instrumental Activities of Daily LivingICFSR International Conference on Frailty and SarcopeniaLMIC Low- and middle-income countriesMCI Mild Cognitive ImpairmentMDS-UPDRS Movement Disorders Society Unified Parkinson’s Disease Rating ScaleMNA Mini Nutritional AssessmentMoCA Montreal Cognitive AssessmentNEADL Nottingham Extended Activities of Daily LivingNICE National Institute for Health and Care ExcellenceNSAIDs Non-steroidal anti-inflammatory drugsPD Parkinson’s DiseaseRCT Randomised controlled trialShort FES-I Short Falls Efficacy Scale InternationalSNRIs Serotonin norepinephrine reuptake inhibitorsSPPB Short Physical Performance BatteryTMT Trail Making TestTMT-B Trail Making Test Part BTUG Timed Up and GoWFG World Falls GuidelinesWGs Working groupsOlder adults presenting with falls or related injuriesExpert recommendation. Older adults presenting with a fallor related injury should be asked about the details of theevent and its consequences, previous falls, transient loss ofconsciousness or dizziness and any pre-existing impairmentof mobility or concerns about falling causing limitation ofusualactivities. GRADE: E.Expert recommendation. An adult who sustains an injuryrequiring medical (including surgical) treatment, reportsrecurrent falls (≥2) in the previous 12 months, was layingon the floor unable to rise independently for at least onehour, is considered frail or is suspected to have experienced atransient loss of consciousness should be regarded as at highrisk of future falls. GRADE: E.Recommendation details and justification• These recommendations apply to the group of older indi-viduals who present to Emergency departments or anotherfacility [35, 36] such as to primary care physicians or afracture service due to a fall-related injury or are seen athome by paramedics, and also to older adults whose fallwas understood by the clinician to have been precipitatedby an acute medical illness, such as infection [28, 37].Assessment and algorithm flowOur proposed algorithm has two entry points (Figure 1):first, opportunistic case finding, case finding during a healthvisit or using ‘e-health records’, and second, when olderadults present to healthcare services as a result of a fallor related injury. Opportunistic case-finding is necessary asolder adults may not present following a fall and may bereluctant to report falls [38–41]. Furthermore, recollectionof the occurrence or date (e.g., how many months ago) ofprevious falls is unreliable [42]. Therefore, the 1-year timingis a pragmatic compromise between accuracy of recollectionand the natural history of falls risk factor progression [43].Opportunistic case finding starts with the single question‘Have you fallen in last 12 months’. This single question ishighly specific in predicting future falls [31, 32] but has alow sensitivity as it takes no account of common risk factors,and consequently, results in a high rate of false negatives.Tools that assess more than one fall risk factor, such as the‘three key questions’ (3KQ) [41], have a higher sensitivity.The questions are: (i) Have you fallen in the past year, (ii)Do you feel unsteady when standing or walking? (iii) Doyou have worries about falling. If resources are available, weconditionally recommend its use. The Stay Independent self-risk assessment consisting of 12 self-administered questions,8World guidelines for falls prevention and management for older adultsFigure 1. Algorithm for risk stratification, assessments and management/interventions for community-dwelling older adults.which is a component of the Centres for Disease Controland Prevention’s STEADI toolkit, can also be used as asensitive approach to detecting future fall risk [44, 45]. Agedistribution of the older adult population when selectinga fall risk screening tool is important, since sensitivity ofthe single question ‘Have you fallen in the past 12 months’increases from 43% in those between 65 and 74 years old, to67% in those over 85 years old. Gait or balance disturbancesshould be assessed following a positive answer to history offall or any of the 3 key questions [31].Strong recommendation. Regarding specific tests, werecommend including Gait Speed for predicting falls risk.GRADE: 1A. As an alternative, the Timed Up and Go Testcan be considered, although the evidence for fall predictionis less consistent. GRADE: 1B.Recommendation details and justification• There are several tests for assessing gait and balance impair-ment. For risk stratification, we recommend use of gaitspeed, with a cut-off value of 15 seconds, although evi-dence for fall risk stratification is mixed. There is evidencethat he TUG is predictive of falls in lower functioningadults [46].An older adult who does not have a history of falling,or who had a single non-severe fall and no gait or balance9www.worldfallsguidelines/resourceslarisRealcelarisRealcelarisRealceM. Montero-Odasso et al.problems, is deemed as being at low risk. Since low riskdoes not mean ‘no risk at all’, we recommend primaryprevention for these older adults. This ‘low risk’ group shouldbe reassessed annually. Older adults who had a single non-severe fall but also have gait and or balance problems, shouldbe considered as being at ‘intermediate risk’ and wouldbenefit from a strength and balance exercise interventionsince evidence shows that this type of exercise is effective inreducing falls risk [2]. Finally, those at ‘high risk’ includeolder adults with a fall and one or more of the followingcharacteristics: (i) accompanying injury, (ii) multiple falls(≥2 falls) in the previous 12 months, (iii) known frailty,(iv) inability to get up after the fall without help for atleast an hour and (v) accompanied by (suspected) transientloss of consciousness. These high-risk older adults shouldbe offered a multifactorial falls risk assessment. Suspicionof a syncopal fall should trigger syncope evaluation andmanagement. With regard to frailty for risk stratification,this can be either previously identified frailty or a posi-tive result on a validated instrument used for its detection.Commonly used frailty assessment instruments include theFrailty phenotype (FP) [47] and the Clinical Frailty Scale(CFS) [48]. The FP includes 5 criteria: slow gait speed,low physical activity, unintentional weight loss, exhaustionand muscle weakness; where ≥3 components categorises anindividual as ‘frail’, 1 or 2 as prefrail, and 0 as not frail.The CFS is a semi-quantitative scale with pictograms thatranges from 1 (very fit) to 9 (terminally ill).A score ≥4 isconsidered as frail (https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html). The algorithm for stratificationand management in Figure 1 summarizes this approach.AssessmentThe purposes of the assessment are to address the mechanismof the fall, the consequences of the fall (e.g., injury, func-tional deficits, psychological effects such as concerns aboutfalling), and the identification of potentially contributing fallrisk factors.Assessment with a view to reducing the risk of fallingneeds to consider the older adult’s history of falling and: theirfrequency; characteristics and context; presence of falls risksfactors; their physical, cognitive, psychological and socialresources; and, their goals, values, beliefs, and priorities.An assessment with a view to co-designing an interven-tion with the older adult requires a broad approach, asexemplified by a CGA. Our recommendations (based onthe WG evidence-based reviews) describe the assessmentsneeded to identify the key modifiable falls risk factors. InTable 4, we provide an overview of potential approaches forassessment of a number of individual modifiable fall riskfactors.We will not cover all components of a CGA, for which thereis guidance elsewhere [49], but we do note the importantassociations of falls with other geriatric syndromes [50] andconditions, the management of which may be importantfor some individuals. Falls in older adults, particularly thoseliving with frailty, should be considered a warning sign ofpotentially unidentified underlying conditions. A fall maybe the presenting feature of acute medical conditions such aspneumonia (particularly if accompanied by delirium [51])or myocardial infarction without chest pain [52]. Choiceof assessments in clinical practice should thus consider theclinical characteristics of the older adult (e.g. frail vs. non-frail), the setting (e.g. community, outpatient clinic, acutecare, long-term care) and the resources available (e.g. cost,training, equipment).Incorporating the perspective of the older adultStrong recommendation. As part of a multifactorial fallsrisk assessment clinicians should enquire about the percep-tions, theolder adult holds about falls, their causes, futurerisk and how they can be prevented (Appendix 2, availablein Age and Ageing online). GRADE: 1B.Expert recommendation. As part of a multifactorial fallsrisk assessment clinicians should enquire about the goals andpriorities; attitudes to activities, independence and risk; andwillingness and capability of older adults to inform decisionmaking on potential interventions. GRADE: E.Recommendation details and justification• Studies indicate that older adults, particularly men, arereluctant to report falls with less than a third mentioningthem to their clinician if not directly asked [34].• Many older adults have low levels of knowledge aboutcauses and prevention of falls, with erroneous beliefs aboutthe causes, their own risk of falling and how best to min-imise the likelihood of future falls [53–57]. Knowing whattheir beliefs are would allow clinicians the opportunityto answer questions, address misconceptions and provideaccurate information about falls and their prevention.Multifactorial falls risk assessmentStrong recommendation. Offer multiprofessional, multi-factorial assessment to community-dwelling older adultsidentified to be at high risk of falling, to guide tailoredinterventions (Appendix 2, available in Age and Ageingonline). GRADE: 1B.Recommendation details and justification• A multifactorial falls risk assessment for those at highrisk of falling, which enables advice for falls preventionand management interventions, includes the followingdomains: gait and balance, muscle strength, medications,cardiovascular disorders including orthostatic hypoten-sion, dizziness, functional ability and walking aids, visionand hearing, musculoskeletal disorders, foot problems andfootwear, neurocognitive disorders (including delirium,depression, dementia, behavioural issues such as impul-siveness and agitation), neurological disorders (e.g. PD,10https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.htmlhttps://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.htmlhttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datahttps://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/afac205#supplementary-datalarisRealceWorld guidelines for falls prevention and management for older adultsTable 4. Potential measurement instruments and approaches for multifactorial falls risk assessmentDomains forassessmentFall risk factor Measurement/approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Mobility Balance Screen for balance disorders for example by Tandem Stand, One Leg stand.If indicated, perform full assessment in structured manner, for example by Berg Balance Scale, Tinetti test, POMA(subscale balance), Mini-BEST test. Consider referral to physiotherapist.Gait Assess both qualitatively and quantitatively using 4-m walking length (If at high risk for deficiency (care homeresidents, home bound) measurement is not indicated as standard supplementation applies.EnvironmentalriskEnvironment Recommended assessment tools for hazards are Westmead Home Safety Assessment and the Falls Behavioural Scale forthe Older Person. In LMIC non-occupational therapists and self-administered home hazard assessment checklists areavailable11M. Montero-Odasso et al.Table 5. List of recommendations from the WFGs by Working Groups∗WG/domains Area or Domain Recommendation Grade. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .WG 1Gait and BalanceAssessment Toolsto Assess Risk forFallsStratification We recommend including gait speed for predicting falls risk.As an alternative the Timed Up and Go Test can be considered, although the evidence for fallprediction is less consistent.1A1BAssessment We recommend that Gait and Balance should be assessed. 1BWG 2Polypharmacy, FallRisk IncreasingDrugs, and FallsAssessment We recommend assessing for fall history and the risk of falls before prescribing potential fall riskincreasing drugs (FRIDs) to older adults. 1BAssessment We recommend the use of a validated, structured screening and assessment tool to identify FRIDswhen performing a medication review or medication review targeted to falls prevention in older adults.1CIntervention We recommend that medication review and appropriate deprescribing of FRIDs should be part ofmultidomain falls prevention interventions.1BIntervention We recommend that in long-term care residents, the falls prevention strategy should always includerational deprescribing of fall-risk-increasing drugs.1CWG 3CardiovascularRisk Factors forFallsAssessment We recommend, as part of a multifactorial falls risk assessment, that a cardiovascular assessment thatinitially include cardiac history, auscultation, lying and standing orthostatic blood pressure, andsurface electrocardiogram should be performed.1BAssessment In the absence of abnormalities on initial cardiovascular assessment, no further cardiovascularassessment is required, unless syncope is suspected (i.e. recurrent unexplained falls).1CAssessment We recommend that the further cardiovascular assessment for unexplained falls should be the same asthat for syncope, in addition to the multifactorial falls risk assessment.1AIntervention We recommend that management of orthostatic hypotension should be included as a component ofmultidomain intervention in fallers.1AIntervention We recommend that interventions for cardiovascular disorders identified during assessment for risk offalls should be the same as that for similar conditions when associated with syncope, in the addition toother interventions based on the multifactorial falls risk assessment.1BWG 4ExerciseInterventions forPrevention of Fallsand RelatedInjuriesExerciseInterventionWe recommend exercise programmes for fall prevention for community-dwelling older adults whichinclude balance challenging and functional exercises (e.g. sit-to-stand, stepping), with sessions threetimes or more weekly which are individualised, progressed in intensity for at least 12 weeks andcontinued longer for greater effect.1AExerciseInterventionWe recommend inclusion, when feasible, of Tai Chi and/or additional individualised progressiveresistance strength training.1BExerciseInterventionWe recommend individualised supervised exercise as a falls prevention strategy for adults living inlong-term care settings.1BExerciseInterventionWe recommend that adults with PD at an early to mid-stage and with mild or no cognitiveimpairment are offered individualised exercise programmes including balance and resistant trainingexercise1AExerciseInterventionWe conditionally recommend that adults after a stroke participate in individualised exercise aimed atimproving balance/strength/walking to prevent falls2CExerciseInterventionWe recommend that adults after sustaining a hip fracture participate in individualised and progressiveexercise aimed at improving mobility (i.e. standing up, balance, walking, climbing stairs) as a fallprevention strategy.1BExerciseInterventionWe conditionally recommend that such programmes after a hip fracture be commenced as in-patientsand be continued in the community.2C (In-patients) &1A (Community)Intervention We recommend that community-dwelling adults with cognitive impairment (mild cognitiveimpairment and mild to moderate dementia) participate in exercise to prevent falls, if willing and ableto do so.1BWG 5Falls in Hospitalsand Care HomesHospitalAssessmentWe recommend that hospitalised older adults >65 years of age have a multifactorial falls riskassessment. We recommend against using scored falls risk screening tools in hospitals for multifactorialfalls risk assessment in older adults.2BHospitalsmanagement andinterventionsWe recommend that tailored education on falls prevention should be delivered to all hospitalised olderadults (≥65 years of age) and other high-risk groups.1AHospitalsmanagement andinterventionsWe recommend that personalised single or multidomain falls prevention strategies based on identifiedrisk factors or behaviours (or situations) be implemented for all hospitalised older adults (≥65 years ofage), or younger individuals identified by the health professionals as at risk of falls.1C (Acute care) &1B (Sub-acutecare)Care homesassessmentWe recommend against falls risk screening to identify care home residents at risk for falls and werecommend that all residents should be considered at high risk of falls.1ACare homesassessmentWe recommend performing a multifactorial falls risk assessment at admission to identify factorscontributing to fall risk and implementing appropriate interventions to avoid falls and fall-relatedinjuries in care home resident older adults.1CCare homesassessmentWe recommend conducting a post-fall assessment in care home residents following a fall in order toreassess fall risk factors, adjust the intervention strategy for the resident and avoid unnecessary transferto acute care.E(Continued)12larisRealcelarisRealcelarisRealcelarisRealcelarisRealceWorld guidelines for falls prevention and management for older adultsTable 5. Continued.WG/domains Area or Domain Recommendation Grade. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Care HomesManagement andInterventionsWe recommend a multifaceted approach to falls reduction for care home residents including carehome staff training, systematic use of a multidomain decision support tool and implementation of fallsprevention actions1BCare homesmanagement andinterventionsWe recommend against the use of physical restraints as a measure for falls prevention in care homes. 1BCare homesmanagement andinterventionsWe recommend nutritional optimisation including food rich in calcium and proteins, as well asvitamin D supplementation as part of a multidomain intervention for falls prevention in care homeresidents.1BCare homesmanagement andinterventionsWe recommend including the promotion of physical activity (when feasible and safe) as part of amultidomain falls prevention intervention in care homes.1CWG 6Cognition andFallsCognitionAssessmentWe recommend that routine assessment of cognition should be included as part of multifactorial fallsrisk assessment in older adults.1BCognitionAssessmentWe recommend including both the older adult’s and caregiver’s perspectives, when creating theindividual falls prevention care plans for adults with cognitive impairment since this strategy hasshown better adherenceto interventions and outcomes.1CWG 7Falls and PD andRelated DisordersAssessment We conditionally recommend a falls risk assessment for older adults with PD, including a self-report3-risk factor assessment tool, which includes a history of falls in the previous year, FOG in the pastmonth, and slow gait speed2BManagement andInterventionWe conditionally recommend that older adults with PD be offered multidomain interventions 2BManagement andInterventionWe recommend that adults with PD at an early to mid-stage and with mild or no cognitiveimpairment are offered individualised exercise programmes including balance and resistance trainingexercise.1AManagement andInterventionWe conditionally recommend exercise training, targeting balance and strength, be offered to peoplewith complex phase PD if supervision by a physiotherapist or other suitably qualified professional isavailable.1CWG 8Falls andTechnologyAssessment andInterventionsWe conditionally recommend using telehealth and/or smart home systems (when available) incombination with physical exercise as part of the falls prevention programmes in the community.2CInterventions Current evidence does not support the use of wearables for falls prevention. Emerging evidence showthat when wearables are used in exercise programmes to prevent falls, they may increase participation.2CWG 9Falls in Low- andMiddle-IncomeCountriesImplementation Local context needs to be considered when implementing fall prevention programmes in LMIC. 1BAssessment We conditionally recommend prioritising assessments of risk factors for cognitive impairment, obesityincluding sarcopenic obesity, diabetes, lack of appropriate footwear and environmental hazards as fallsrisk factors in LMIC2CAssessment We conditionally recommend that in LMIC settings clinicians and caregivers use validated tools thatare freely available in their country of residence to assess mobility, dependent on resource availability.EWG 10MultifactorialAssessment andInterventions forFalls (Environ-mentrecommendationsinformed by thead hoc expertgroup onEnvironment andFalls)MultifactorialAssessmentWe recommend multiprofessional, multifactorial assessment should be offered to community-dwellingolder adults identified to be at high risk of falling, to guide tailored interventions.1BMultidomainInterventionsWe recommend multidomain interventions, informed by a multiprofessional, multifactorial falls riskassessment, should be offered to community-dwelling older adults identified to be at high risk offalling.1BMultifactorial(Environmental)AssessmentWe recommend identification of an individual’s environmental hazards where they live and anassessment of their capacities and behaviours in relation to them, by a clinician trained to do so,should be part of a multifactorial falls risk assessment.1BMultifactorial(Environmental)InterventionsWe recommend modifications of an older adult’s physical home environment for fall hazards thatconsider their capacities and behaviours in this context, should be provided by a trained clinician, aspart of a multidomain falls prevention intervention.1BWG 11Older Adults’Perspectives onFallsStratification We recommend clinicians should routinely ask about falls in their interactions with older adults. 1AAssessment As part of a comprehensive fall assessment, clinicians should enquire about the perceptions the olderadult holds about falls, their causes, future risk, and how they can be prevented.1BInterventions A care plan developed to prevent falls and related injuries should incorporate the goals, values andpreferences of the older adult.1BWG 12Concerns aboutFalling and FallsAssessment We recommend including an evaluation of concern about falling in a multifactorial falls riskassessment of older adults1BAssessment We recommend using a standardized instrument to evaluate concerns about falling such as the FallsEfficacy Scale International (FES-I) or Short FES-I in community-dwelling older adults.1AAssessment We recommend using the FES-I or especially the Short FES-I for assessing concerns about falling inacute care hospitals or long-term care facilities.1BAssessment We recommend exercise, cognitive behavioural therapy and/or occupational therapy (as part of amultidisciplinary approach) to reduce fear of falling in community-dwelling older adults.1B∗Note: these are the 12 original Working Groups that addressed the knowledge gaps identified from the review of previous clinical practice guidelines.13M. Montero-Odasso et al.neuropathy), underlying diseases (acute and chronic), con-cerns (fear) about falling, environmental hazards, nutri-tional status (including protein intake and vitamin D),alcohol consumption, urinary incontinence and pain.• The evidence for a multifactorial falls risk assessment fol-lows from evidence that effective multidomain interven-tions should be based on modification where possibleof the fall risks factors identified in the individual, andnot on a generic intervention regardless of individualcharacteristics.• The strength of the evidence differs per component.Details can be found below in the section addressingindividual components.Assessment details for individual componentsGait and balance assessmentStrong recommendation. Gait and Balance should beassessed as part of the risk assessment of falls (see Table 4;Appendix 2, available in Age and Ageing online). GRADE:1B.Recommendation details and justification• Gait and balance impairment is one of the domains thatmost consistently predicts future falls [32].• Physical function tests of gait and balance can help choosefall prevention exercises, prescribe level of difficulty anddose and monitor progress.• Assessment tools that are useful and commonly used inthe assessment of gait and balance include: gait speed, TheTimed Up and Go (TUG) test, the untimed Get Up AndGo test, Berg Balance Scale, the Chair Stand test (CST)and Short Physical Performance Battery (SPPB).• The SPPB includes timed tests of sit to stand, balancein standing and walking and has been found sensitive tochange in intervention studies [58]. The TUG is anotherpopular choice as it combines assessment of rising fromsitting, walking and turning [59]. The untimed Get Upand Go test provides similar qualitative information [60].• For more impaired populations, tools that include morebasic tasks will be more useful, such as the DEMMI [61],which also includes bed mobility. In more able popula-tions, tools that include more challenging tasks can be usedsuch as the Berg Balance Scale [62], which also includessingle leg stance, turning and stepping onto a stool.• It may also be useful to assess rising from the floor anddual task activity performance. Other tests used in gaitand balance assessment include the CST [42], One LegStand [63], Functional Reach [64], Dual Task tests [65],the Tinetti test/POMA (balance and gait subscales) [66],the MiniBEST Test [67] and the Physiological ProfileAssessment Performance test [68].• The choice of test will also depend on equipmentavailability, resources, space and time available as well asfamiliarity and training. The Rehabilitation MeasuresDatabase provides a useful description of options and theirclinimetric properties (www.sralab.org/rehabilitation-measures).• A structured assessment of gait by a trained cliniciancan be helpful in directing investigations for underlyingconditions that may increase falls risk by impairing gait[69, 70].• The Floor Transfer Test is a reliable and valid measurefor screening for physical disability, frailty and functionalmobility [71, 72].Medication assessmentStrong recommendation. Assess for fall history and the riskof falls before prescribing potential fall risk increasing drugs(FRIDs) to older adults (Appendix 2, available in Age andAgeing online). GRADE: