clinical guidancestatementof medicine, “clinical practice guide-lines are statements that include...

Management of Falls in Community-Dwelling Older Adults: ClinicalGuidance Statement From the Academyof Geriatric Physical Therapy of theAmerican Physical Therapy AssociationKeith G. Avin, Timothy A. Hanke, Neva Kirk-Sanchez, Christine M. McDonough,Tiffany E. Shubert, Jason Hardage, Greg Hartley

Background. Falls in older adults are a major public health concern due to highprevalence, impact on health outcomes and quality of life, and treatment costs.Physical therapists can play a major role in reducing fall risk for older adults; however,existing clinical practice guidelines (CPGs) related to fall prevention and manage-ment are not targeted to physical therapists.

Objective. The purpose of this clinical guidance statement (CGS) is to providerecommendations to physical therapists to help improve outcomes in the identifica-tion and management of fall risk in community-dwelling older adults.

Design and Methods. The Subcommittee on Evidence-Based Documents ofthe Practice Committee of the Academy of Geriatric Physical Therapy developed thisCGS. Existing CPGs were identified by systematic search and critically appraisedusing the Appraisal of Guidelines, Research, and Evaluation in Europe II (AGREE II)tool. Through this process, 3 CPGs were recommended for inclusion in the CGS andwere synthesized and summarized.

Results. Screening recommendations include asking all older adults in contactwith a health care provider whether they have fallen in the previous year or haveconcerns about balance or walking. Follow-up should include screening for balanceand mobility impairments. Older adults who screen positive should have a targetedmultifactorial assessment and targeted intervention. The components of this assess-ment and intervention are reviewed in this CGS, and barriers and issues related toimplementation are discussed.

Limitations. A gap analysis supports the need for the development of a physicaltherapy–specific CPG to provide more precise recommendations for screening andassessment measures, exercise parameters, and delivery models.

Conclusion. This CGS provides recommendations to assist physical therapists inthe identification and management of fall risk in older community-dwelling adults.

K.G. Avin, PT, PhD, Department ofPhysical Therapy, Indiana Univer-sity School of Health and Rehabil-itation Sciences, Indianapolis,Indiana.

T.A. Hanke, PT, PhD, PhysicalTherapy Program, College ofHealth Sciences, Midwestern Uni-versity, Downers Grove, Illinois.

N. Kirk-Sanchez, PT, PhD, Depart-ment of Physical Therapy, Univer-sity of Miami, Coral Gables,Florida.

C.M. McDonough, PT, PhD,Department of Health Policy andManagement, Health and Disabil-ity Research Institute, Boston Uni-versity School of Public Health,Boston, Massachusetts, and GeiselSchool of Medicine at Dartmouth,Hanover, New Hampshire.

T.E. Shubert, PT, PhD, ShubertConsulting, Chapel Hill, NorthCarolina.

J. Hardage, PT, DPT, DScPT, GCS,NCS, CEEAA, Outpatient Neuro-logic Rehabilitation Program,Stanford Health Care, 300 PasteurDr, Room B33, MC 5284, Stan-ford, CA 94305 (USA). Address allcorrespondence to Dr Hardage at:[email protected].

G. Hartley, PT, DPT, GCS, CEEAA,Department of Rehabilitation, StCatherine’s Rehabilitation Hospi-tal, North Miami, Florida, andDepartment of Physical Therapy,University of Miami Miller Schoolof Medicine, Coral Gables, Florida.

[Avin KG, Hanke TA, Kirk-SanchezN, et al. Management of falls incommunity-dwelling older adults:clinical guidance statement fromthe Academy of Geriatric PhysicalTherapy of the American PhysicalTherapy Association. Phys Ther.2015;95:815–834.]

© 2015 American Physical TherapyAssociation

Published Ahead of Print:January 8, 2015

Accepted: December 21, 2014Submitted: October 1, 2014

ClinicalGuidance Statement

Post a Rapid Response tothis article at:ptjournal.apta.org

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According to Sackett et al,“Evidence-based medicine isthe conscientious, explicit,

and judicious use of current best evi-dence in making decisions about thecare of individual patients. The prac-tice of evidence-based medicinemeans integrating individual clinicalexpertise with the best availableexternal clinical evidence from sys-tematic research.”1(p71) Tools forimplementing evidence-based prac-tice include documents that synthe-size available evidence, such as sys-tematic reviews, and documents thatguide decision making, such as clin-ical practice guidelines (CPGs) andclinical guidance statements (CGSs),also known as clinical practiceappraisals. According to the Instituteof Medicine, “Clinical practice guide-lines are statements that includerecommendations intended to opti-mize patient care that are informedby a systematic review of evidenceand an assessment of the benefitsand harms of alternative careoptions.”2(p2) Clinical practice guide-lines use strong methodology toguide a systematic review of all avail-able literature to develop statementsand recommendations for appropri-ate health care decisions. In contrast,the CGS systematically compares andsynthesizes CPGs of similar topicareas. Key elements of each CGS“include a discussion of areas ofagreement and difference, the majorrecommendations and the corre-sponding strength of evidence andrecommendation rating schemes,and a comparison of guidelinemethodologies.”3

Each year, approximately 30% ofadults aged 65 years or older fall,resulting in $30 billion spent annu-ally in direct and indirect medicalcosts.4 According to 2010 NationalHealth Interview Survey statistics,falls contributed to 13 million medi-cally treated injuries, with 20% ofthose falls resulting in serious injurythat was treated in emergency

departments.5 In 2005, emergencydepartment medical costs for treatedfalls totaled $6.5 billion.6 Death ratesfrom falls have increased substan-tially over the past decade,7 and thenumber of falls is projected toincrease as the baby boomers age.8

The associated costs of falls and theirimpact on quality of life havebrought fall risk management andprevention to the forefront of clini-cal and public health initiatives.

There is evidence that falls can beprevented by screening to detectrisk factors and by the prescriptionof tailored interventions, a processwithin the scope of physical thera-pist practice.9,10 There is a substan-tial body of research on risk factors,interventions, and prevention strate-gies for falls.11–16 This research hasprovided evidence for the develop-ment of best practice recommenda-tions for fall risk screening, includingthe Centers for Disease Control andPrevention’s (CDC’s) STEADI (“Stop-ping Elderly Accidents, Deaths &Injuries”) Tool Kit17 and publishedrecommendations such as thosedeveloped by the US Preventive Ser-vices Task Force (USPSTF).18 In addi-tion, CPGs for health care practitio-ners for the assessment andprevention of falls in community-dwelling older adults have beendeveloped by several organizationssuch as the National Institute forHealth and Care Excellence (NICE)19

and the American Geriatrics Society/British Geriatrics Society (AGS/BGS),20 representing a substantialinvestment of resources andexpertise.

A caveat is that these CPGs havebeen developed within the broadcontext of medical and public healthpractice. As such, they do not specif-ically address a physical therapist’sclinical decision making, which maycause ambiguity in interpreting exist-ing evidence and applying that evi-dence to diverse patient populations

and needs. Therefore, the overall aimof this project was to create a CGS toguide physical therapist practiceusing existing CPGs that address fallsin community-dwelling older adults.The specific objectives of this docu-ment were: (1) to identify and criti-cally appraise the available CPGs, (2)to synthesize appraisal findingsacross high-quality CPGs, (3) to pro-vide a clinically useful summary ofrecommendations of each CPG forthe physical therapist, and (4) toreport gaps in evidence for CPGs rel-evant to physical therapist practice.We expect that physical therapistswill use this CGS to guide clinicaldecision making related to thescreening and management ofpatients at risk for falls and ulti-mately to reduce unwarranted varia-tion in clinical practice and improvehealth outcomes.

MethodExpert Panel ProcessIn 2012, the Subcommittee onEvidence-Based Documents wasassembled by the Practice Commit-tee of the Academy of Geriatric Phys-ical Therapy. The members of theSubcommittee and one content mat-ter expert formed the core workinggroup, which was charged withdeveloping evidence-based docu-ments (EBDs) for physical therapistsfor the management of fall risk inolder adults. This working group andthe coordinator consisted of physicaltherapists with expertise in rehabili-tation science, kinesiology, motorcontrol, geriatrics, measurement,and fall prevention. Multiple panel-ists had clinical practice experiencewith community-dwelling olderadults. Although the majority ofphysical therapists’ fall-related inter-actions involve older adults identi-fied as patients, physical therapistsalso may address fall risk in olderadults who are not patients, butrather clients seeking consultationand information. For simplicity, we

Clinical Guidance Statement on Management of Falls

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use the term “patient” in this docu-ment, inclusive of both groups.

The identification and criticalappraisal of guidelines. Elevenfreely accessible CPG databaseswere systematically searched for allfall-related content (Tab. 1). Inten-tionally broad search terms included“falls,” “geriatric,” and “olderadults.” Only CPGs were included inthis document; all other types ofEBDs were excluded. Clinical prac-tice guidelines published between2000 and 2013 were included if theywere written in English and targetedadults over the age of 65 years livingin the community or in assisted-

living settings. The definition of a fallvaries in the literature.21,22 One maindifference in definitions is whetherfalls with loss of consciousness areconsidered to be falls. We aimed toaddress the broadest definition offalls; therefore, we did not excludeCPGs based on fall definition. Simi-larly, there is little consensus on thedefinition of the term “community-dwelling.” As residents of assisted-living settings have varying levels ofindependence, CPGs targeting thiscohort were included in the search.Due to differences in risk factors andmanagement approaches for fall riskin older adults in acute care, skillednursing, and long-term care settings,

these settings were excluded. Clini-cal practice guidelines wereexcluded if they were specific to aneurologic condition (eg, stroke,Parkinson disease, multiple sclero-sis) or to fracture management. Fig-ure 1 shows the flow diagram ofreviewed CPGs. Of the 4,027 EBDsidentified, 5 met the inclusion crite-ria and were selected for review bythe entire core working group.

The 5 CPGs (and associated onlinecontent where available) were inde-pendently reviewed by the coreworking group using the Appraisalof Guidelines, Research, and Evalua-tion in Europe II (AGREE II) tool.23

Table 1.Search Strategy Used for Retrieval of Clinical Practice Guidelines (CPGs)

Database DateSearchTerm

TotalResults

RelevantGuidelines

National Guideline Clearinghouse 3/15/2013 Falls 420 14

Geriatric 1,983 21

Older adult 945 7

Scottish Intercollegiate Guidelines Network 4/16/2013 All guidelines 132 0

National Institute for Health and Clinical Excellence 4/16/2013 All guidelines 158 1

Physiotherapy Evidence Database 4/16/2013 Falls 10 8

Geriatric 4 1

Older adult 14 3

Occupational Therapy Systematic Evaluation of Evidence 4/19/2013 All guidelines 31 0

Guidelines International Network 4/19/2013 Falls 6 3

Geriatric 6 0

Older adult 2 1

New Zealand Guidelines Group 4/19/2013 Falls 6 0

Geriatric 2 0

Older adult 9 0

Canadian Medical Association 4/19/2013 Falls 5 1

Geriatric 24 2

Older adult 7 2

Australian National Health and Medical Research Council CPGs 4/19/2013 Falls 1 0

Geriatric 0 0

Older adult 13 0

Royal College of Nursing 4/19/2013 Falls 35 1

Geriatric 8 1

Older adult 172 1

Ministry of Health, Singapore 4/19/2013 All guidelines 34 1

Total 4,027 68



The AGREE II tool was developed toappraise CPG quality via 23 itemsaddressing 6 key domains: scope andpurpose (3 items), stakeholderinvolvement (3 items), rigor of devel-opment (8 items), clarity of presen-tation (3 items), applicability (4items), and editorial independence(2 items). Each item was rated usinga 7-point scale ranging from 1(strongly disagree) to 7 (stronglyagree). Item values are summed foreach of the 6 domains. In addition,reviewers respond to a global qualitystatement: “I would recommend thisguideline for use.” Response optionsinclude “yes,” “yes with modifica-tions,” and “no.” Prior to review, allpanelists completed online training24

on the AGREE II method. A calibra-tion process was performed for thefirst 2 reviews (NICE19 and AGS/BGS20 CPGs), in which membersindependently conducted theAGREE II review, submitted scores,and discussed each scoring item via

teleconference. All 5 CPGs wereappraised by at least 3 reviewers, and3 CPGs (NICE,19 AGS/BGS,20 andAGILE25) were reviewed by all mem-bers. The core working group dis-cussed each CPG via a series of 4telephone conference calls and onein-person meeting. Consensus wasestablished for any item for whichgreater than a 2-point range existedamong AGREE II scores.

Stakeholder Input and ReviewStakeholder input was solicited viaseparate reviews of 2 successivedrafts of the CGS. The first reviewwas solicited from the consultinggroup, which consisted of a physicaltherapist with expertise in falls incommunity-dwelling older adults, 2laypeople who represented the pop-ulation of interest (ie, community-dwelling older adults), a physiciangeriatrician, and an exercise physiol-ogist with expertise in falls incommunity-dwelling older adults.

The core working group consideredeach comment and performed con-sensus edits to produce a revised sec-ond draft.

The second draft was then reviewedby the external review group, whichconsisted of 2 physical therapistswho were board certified in geriatricphysical therapy, a physical therapistwho was a Certified Exercise Expertfor Older Adults and a consultant onlegislative affairs and reimburse-ment, a public health policy maker, aprimary care physician, a physiciangeriatrician, and special reviewerswith specific expertise. The coreworking group considered eachcomment and performed consensusedits to produce the third draft.

The third draft, in turn, was madeavailable to the public for a 2-weekperiod of review and comment viathe website of the Academy of Geri-atric Physical Therapy, publicizedvia 2 blast emails to the membershipof the Academy of Geriatric PhysicalTherapy as well as social media plat-forms of the Academy of GeriatricPhysical Therapy and the AmericanPhysical Therapy Association. Result-ing comments were reviewed by theauthors and discussed via confer-ence call. Actionable commentswere then addressed to produce thefourth and final draft.

ResultsDescription of 3 CPGs Rated as“Recommended for Use”Reviewers obtained highly consis-tent overall scores and recommenda-tions using the AGREE II instrument(Tab. 219,20,25–27). Three CPGs wererated as “recommended for use,” and2 were rated as “not recommendedfor use.” The recommended CPGsare briefly described as follows:

CPG for assessment and pre-vention of falls in older people.Developed by the National Collabo-rating Centre for Nursing and Sup-

Figure 1.Flow diagram for clinical practice guidelines.



portive Care (NCC-NSC) and fundedby NICE, this CPG19 (hereafterreferred to as the NICE CPG) waspublished in 2004, reviewed in2011, and updated June 2013. ThisCPG was developed by a multidisci-plinary team and incorporated awide range of stakeholders, includ-ing those from a variety of healthprofessions.

Prevention of falls in olderpeople. Supported by the AGS/BGS, this CPG20 (hereafter referredto as the AGS/BGS CPG) was pub-lished in 2001 and revised in 2010.This CPG was developed by a multi-disciplinary team and incorporated awide range of stakeholders, includ-ing a Geriatrics Certified Specialistphysical therapist.

Evidence-based guidelines forthe secondary prevention of fallsin older adults. Developed byMoreland et al27 and funded by the R.Samuel McLaughlin Foundation, thisCPG (hereafter referred to as theMoreland CPG) was published in2003 and has not been updated. Incontrast to the other 2 CPGs, it doesnot address primary prevention offalls, but rather was developed as atool for clinicians and researchers toaddress evidence-based assessmentsand interventions for people whohave fallen and are at high risk forfuture falls. The characteristics of thedevelopment group were notdescribed.

Synthesis of CPG Strength ofEvidence and Levels ofRecommendationThe included CPGs used differentdefinitions and criteria for theirgrades of recommendations and lev-els of evidence (Tabs. 3 and 4). Also,the actions associated with the rec-ommendations put forth were notuniform and required interpretationof the working group. Therefore, ourexpert opinion comprised synthesiz-ing the specific recommendation orrecommendations, strength of therecommendations, and levels of evi-dence. To determine the strength ofrecommendation for this CGS, weconsidered the recommendationstrength, grades of levels of evi-dence, evidence tables, and ourinterpretation of the balance

Table 2.AGREE II Domain Scores and Recommendations for Use for Each Falls CPGa

CPG ReviewerScope andPurpose

StakeholderInvolvement

Rigor ofDevelopment

Clarity ofPresentation Applicability

EditorialIndependence

Recommendedfor Use?

AGS/BGS20 1 19 13 40 21 8 14 Yes

2 18 12 41 20 9 14 Yes

3 16 12 37 21 8 10 Yes

4 16 15 38 19 11 13 Yes

5 17 13 40 21 12 8 Yes

AGILE25 1 15 10 17 11 7 5 No

2 16 9 13 12 4 3 No

3 19 10 15 17 6 2 No

4 15 9 17 9 8 4 No

5 16 11 15 13 5 3 No

NICE19 1 21 19 52 20 21 11 Yes

2 21 21 50 20 21 13 Yes

3 20 19 49 21 23 13 Yes

4 21 21 51 20 22 13 Yes

5 21 20 51 21 22 10 Yes

FSGG26 1 15 12 20 11 4 7 No

2 15 13 25 14 5 9 No

5 16 13 24 13 4 9 No

Moreland et al27 2 17 6 37 16 6 2 Yes

4 19 7 35 16 4 2 Yes

5 20 7 37 18 7 2 Yes

a Scores were calculated by summing individual item scores included in each domain. CPG�clinical practice guideline, AGS/BGS�American GeriatricsSociety/British Geriatrics Society,20 FSGG�French Society of Geriatrics and Gerontology,26 NICE�National Institute for Health and Care Excellence.19



between benefit and harm. This doc-ument refers to the grades of therecommendations from this workinggroup as CGS Grades, and these aredescribed in Table 4.

The recommendations from theCPGs are summarized as follows:general recommendations (Tab. 5),the components of a multifactorialassessment for older adults atincreased risk (Tab. 6), and the rec-ommendations related to multifacto-rial interventions (Tab. 7). The rec-ommendations are organized usingthe World Health Organization Inter-national Classification of Function-ing, Disability and Health (ICF)framework.28 A summary of actionstatements is presented in Figure 2.

➢ Screening RecommendationsThe intention of the screening pro-cess is to determine if a multifactorialassessment is necessary. The order in

which the screening process shouldtake place is outlined in Figure 3.

1. Physical therapists should routinelyask older adult patients if they havefallen in the previous 12 months(CGS Grade C: Strong recommen-dation based on Level III evidence).

Screening should include:a. History and context of falls over

the previous 12 monthsb. At least one question about the

patient’s perception of difficultywith balance or walking

2. For each patient who reports a fallor falls or reports difficulty with bal-ance or walking, the physical ther-apist should screen by observing forgait or balance impairment (CGSGrade C: Strong recommendationbased on Level III evidence). Ascreening is positive when either ofthe following conditions is found:a. The patient reports multiple

falls regardless of balance andgait impairments

b. The patient reports one fall, anda balance or gait impairment isobserved

Rationale. Overall, the NICE19 andAGS/BGS20 CPG screening recom-mendations are similar (Tab. 5); theMoreland27 CPG does not addressscreening. The NICE and AGS/BGSCPGs recommend screening all olderadults by asking them if they havefallen in the previous year. The fallinquiry recommendations includefrequency, context, fall characteris-tics, and, according to the AGS/BGSCPG, self-reported difficulties withbalance or walking. The NICE CPGrecommends assessing the ability tostand, turn, and sit as being adequatefor a first-level screening. The AGS/BGS CPG does not describe an initialscreening tool but does suggestincluding one measure of balance,gait, or both. Examples from theAGS/BGS CPG include the Timed

Table 3.Level of Evidence Rating Systems Used in the Development of This Clinical Guidance Statementa

Level NICE19 AGS/BGS20 Moreland et al27

I Evidence from meta-analysis ofRCT or at least one RCT

At least one properly done RCT For prospective studies with greater than 80%follow-up, evidence levels range from 1 (best) to6 (least). Levels are added for each criterion, asdescribed below:

Is there a statistically significant adjusted estimateor meta-analysis?1�yes2�no, but all studies are statistically significant3�no, but at least one study is statistically

significant4�no, no studies are statistically significant

Are lower bound confidence intervals consistentlygreater than a clinical important level?0�yes1�no

Is there a point estimate of effect greater than 2.0?0�yes1�no

II Evidence from at least onecontrolled trial withoutrandomization or at leastone other type of quasi-experimental study

II-1–Well-designed controlledtrial without randomization

II-2–Well-designed cohort orcase-control analytic study,preferably from more thanone source

II-3–Multiple time seriesevidence with or withoutintervention, dramatic resultsof uncontrolled experiment

III Evidence fromnonexperimental studies,such as comparative studies,correlation studies, andcase-control studies

Opinion of respectedauthorities, descriptivestudies, case reports, andexpert committees

IV Evidence from expertcommittee reports ofopinions and clinicalexperience of respectedauthorities

N/A

V N/A N/A

VI N/A N/A

a RCT�randomized controlled trial, AGS/BGS�American Geriatrics Society/British Geriatrics Society,20 NICE�National Institute for Health and CareExcellence, N/A�not applicable.19



Table 4.Strength of Recommendation Rating System Used in the Development of This Clinical Guidance Statementa

Grade Description NICE19 AGS/BGS20 Moreland et al27

A Strong recommendation based onLevel I or Level II evidence, andbenefits substantially outweighharms

Directly based on Category I evidence A strong recommendation thatthe clinicians provide theintervention to eligiblepatients; Grade I or II-1evidence that interventiondirectly improves healthoutcomes, and benefitssubstantially outweigh harm

Single RCT or meta-analysisof RCTs in which thelower limit of the CI forthe treatment effectexceeds the MCID

B Recommendation based on Level Ior Level II evidence, andbenefits outweigh harms

Directly based on Category II evidenceor extrapolated recommendationfrom Category I evidence

A recommendation that theclinicians provide theintervention to eligiblepatients; Grade I or II-1evidence that interventionimproves intermediatehealth outcomes or GradeII-2 or II-3 evidence thatintervention directlyimproves health outcomes,and benefits outweigh harm

Single RCT or meta-analysisof RCTs in which the CIfor the treatment effectoverlaps the MCID, butthe point estimate isclinically important

C Recommendation based on LevelIII evidence or extrapolationfrom Level I or II evidence, andbenefits outweigh harms

Directly based on Category IIIevidence or extrapolatedrecommendation from Category I orII evidence

No recommendation for oragainst the routine provisionof the intervention is made;Grade I or II-1 evidence thatintervention directlyimproves outcomes orimproves intermediatehealth outcomes or GradeII-2 or II-3 evidence thatintervention directlyimproves health outcomes,but balance of benefits andharms is too close to justifya general recommendation

Expert opinion

D N/A Directly based on Category IVevidence or extrapolatedrecommendation from Category I,II, or III evidence

Recommendation is madeagainst routinely providingthe intervention toasymptomatic patients;Grade I or II evidence thatintervention is ineffective orthat harm outweighsbenefits

N/A

I N/A N/A? Evidence is insufficient torecommend for or againstroutinely providing theintervention; evidence islacking or of poor quality orconflicting, and balance ofbenefits and harms cannotbe determined

N/A?

a CGS�clinical guidance statement, AGS/BGS�American Geriatrics Society/British Geriatrics Society,20 CI�confidence interval, MCID�minimal clinicallyimportant difference, NICE�National Institute for Health and Care Excellence,19 RCT�randomized controlled trial, N/A�not applicable.



“Up & Go” Test,29 the Berg BalanceScale,30 and the Performance-Oriented Mobility Assessment.31

Although the NICE CPG recommen-dation is Grade C based on Level IIIevidence, our recommendation usesstronger language because the bene-fit of these screening activities faroutweighs the associated harms.

The CPGs do not address the situa-tion in which an older adult has obvi-ous balance and gait impairmentsbut does not report having had a fallin the previous 12 months. The AGS/BGS further comments that multifac-torial fall risk assessment should notbe applied to older adults who (1)report only a single fall and (2) dem-onstrate no unsteadiness or difficultywith balance or gait.20

➢ AssessmentRecommendation

1. Physical therapists should providean individualized assessmentwithin the scope of physical thera-pist practice that contributes to amultifactorial assessment of fallsand fall risk. Additional potentialrisk factors may need to beaddressed by the appropriate pro-vider as indicated (CGS Grade A:Strong recommendation based onLevel II evidence). This assessmentshould include:a. Medication review with empha-

sis on polypharmacy andpsychoactive drugs

b. Medical history with emphasison new or unmanaged riskfactors:

i. osteoporosisii. depressioniii. cardiac disease, including

signs or symptoms ofcardioinhibitory carotidsinus hypersensitivity

c. Body functions and structure,activity and participation, envi-ronmental factors, and personalfactors:

i. strengthii. balanceiii. gait

iv. activities of daily livingv. footwearvi. environmental hazardsvii. cognitionviii. neurological functionix. cardiovascular function,

including posturalhypotension

x. visionxi. urinary incontinence

Health ConditionsMedication review. All of the 3CPGs19,20,27 recommend a medica-tion review as part of the multifacto-rial assessment. The AGS/BGS20 CPGrecommends identification of allmedications with dosages. TheNICE19 and Moreland et al27 CPGsspecifically recommend the identifi-cation of psychotropic and cardiacmedications, as well as polyphar-macy, as risk factors for falls. TheMoreland27 CPG identified the fol-lowing medication classes as psycho-tropic: benzodiazepines, hypnotics,antidepressants, and major tranquil-izers. The term “polypharmacy” isnot defined in the CPGs but is oftenused to represent medication usethat is excessive, inappropriate, orboth. This term is operationallydefined as the use of multiple medi-cations concurrently, excludingpreparations that include more thanone drug.

Osteoporosis. The NICE19 andAGS/BGS20 CPGs recommend thatosteoporosis risk or diagnosis beassessed as part of the identificationof risk factors for falls.

Depression. The Moreland27 CPGidentifies depression as a potentiallymodifiable risk factor for falls and,therefore, recommended assess-ment. The Geriatric DepressionScale32 is mentioned as a screeningtool for depression in older adults.

Body Functions and StructureStrength. All 3 CPGs19,20,27 iden-tify muscular weakness as a risk fac-tor for falls. Accordingly, each CPG

includes an assessment of musclestrength as part of a multifactorialassessment. The AGS/BGS20 andMoreland27 CPGs specify inclusionof lower extremity strength.

Balance. All 3 CPGs19,20,27 recom-mend balance assessment, but nospecific procedures or methods arerecommended.

Cognitive and neurologic func-tion. All 3 CPGs19,20,27 address theassessment of cognitive and neuro-logic function. The AGS/BGS20 CPGspecifies testing lower extremityperipheral nerve function, proprio-ception, reflexes, and cortical,extrapyramidal, and cerebellar func-tion. The NICE19 CPG recommendsassessing for cognitive impairmentsbut does not identify the specificitems that should be included. TheMoreland27 CPG recommends assess-ing mental status, peripheral neuro-muscular function, and dizziness.

Cardiovascular function. TheNICE19 and AGS/BGS20 CPGs recom-mend a cardiovascular assessment bya health care professional with spe-cialized skills. The NICE CPG specif-ically recommends the need to iden-tify anti-arrhythmic medications. TheAGS/BGS CPG recommends assess-ing heart rate and rhythm, posturalpulse, blood pressure, and posturalhypotension, all of which can beconducted by a physical therapist.However, heart rate and blood pres-sure responses to carotid sinus stim-ulation should be performed by aqualified medical professional. TheMoreland27 CPG recommends identi-fying the use of cardiac drugs andpresence of postural hypotension.

Vision. The AGS/BGS20 CPG rec-ommends an assessment of visualacuity. While also recommending anassessment of vision, neither theNICE19 CPG nor the Moreland27 CPGidentifies the aspects of vision (eg,acuity, contrast sensitivity, depth



perception, peripheral vision,eyewear) that should be addressed.

Urinary function and incon-tinence. Assessing for urinaryincontinence was recommended byall 3 CPGs,19,20,27 with the NICE19

CPG specifically identifying urge andstress incontinence.

Activity and ParticipationGait. All 3 CPGs19,20,27 identify gaitdeficits or abnormalities as a risk fac-tor for falls and recommend a thor-ough assessment of gait. However,no specific procedures or methodsare provided. Moreland et al27 rec-ommended assessing for the useof walking aids. The NICE19 CPGacknowledges that many tests of bal-ance and gait exist and states that theindividual provider should identifyappropriate measures for each olderadult.

Activities of daily living. TheAGS/BGS20 CPG recommends assess-ment of activities of daily living(ADL), including use of adaptiveequipment and mobility aids. TheMoreland27 CPG recommends assess-ment of ADL and instrumental ADLas well as transfers.

Physical activity. The Moreland27

CPG is the only CPG to recommendan assessment of physical activity.Specifically, it identifies moderateactivity levels as having a protectiveeffect and high (not defined) and low(less than once per week) activitylevels as risk factors.

Environmental FactorsEnvironmental assessment. All 3CPGs19,20,27 identify home safety andhazards as risk factors for falls andrecommend an assessment of thehome for hazards. The NICE19 CPGrecommends that specific attentionbe paid to loose rugs and mats andcarpet folds or other trip hazards.

Personal FactorsFear and health perception.The NICE19 and AGS/BGS20 CPGsrecommend an assessment of per-ceived functional ability and fear offalling.

Social support. The Moreland27

CPG recommends an assessment ofthe quality of the older adult’s socialnetwork.

Alcohol use. The Moreland27 CPGrecommends an assessment of “inap-propriate alcohol use”; however, itdoes not define “inappropriate.”

Feet and footwear. The AGS/BGS20 CPG recommends the assess-ment of feet and footwear.

➢ InterventionRecommendations

1. Physical therapists must provideindividualized interventions thataddress all positive risk factorswithin the scope of physical thera-pist practice (CGS Grade A: Strongrecommendation based on Level Ievidence). Components of theintervention should include:a. Strength training that is individ-

ually prescribed, monitored,and adjusted (CGS Grade A:Strong recommendation basedon Level I evidence)

b. Balance training that is individ-ually prescribed, monitored,and adjusted (CGS Grade A:Strong recommendation basedon Level I evidence)

c. Gait training (CGS Grade A:Strong recommendation basedon Level I evidence)

d. Correction of environmentalhazards (CGS Grade A: StrongRecommendation based onLevel I evidence)

e. Correction of footwear or struc-tural impairments of the feet(CGS Grade B: Recommenda-tion based on Level II evidence)

Rationale. The recommendationsabove describe the physical therapy–related components of the multidis-ciplinary fall risk managementinterventions represented within theCPGs. Overall, recommendationsacross the CPGs are similar. There isagreement that an individualizedexercise program, including bothstrength and balance training, shouldbe implemented for those at risk forfalls (Grade A). Recommendationsfor the multidisciplinary interven-tions are shown in Table 7, and thephysical therapy components ofthe interventions are summarizedbelow.

Body Functions and StructureStrength and balance training.Both NICE19 and AGS/BGS20 CPGsrecommend that an individualizedprogram be prescribed and moni-tored by an appropriately trainedhealth professional (Grade A). TheNICE CPG recommends a strengthand balance training program,whereas the AGS/BGS CPG recom-mends strength, balance, coordina-tion, and gait training. The AGS/BGSCPG recommends individual andgroup exercises as well as tai chi andphysical therapy. It further recom-mends offering flexibility and endur-ance exercises but not as sole inter-ventions. The Moreland27 CPGprovides more narrow recommenda-tion of individualized strength andbalance training for community-dwelling women over the age of 80years. It further recommends tai chior “equilibrium control” exercisesusing foam and firm surfaces.

Activity and ParticipationWalking. With respect to fall pre-vention interventions, there is noevidence that unsupervised, briskwalking decreases fall risk. However,it is well documented that walkingprograms convey other types ofhealth benefits.33 The NICE19 CPGfound insufficient evidence to rec-ommend brisk walking to reduce



falls but noted that other benefits ofbrisk walking should be considered.The Moreland27 CPG recommendsagainst brisk walking in community-dwelling women who are postmeno-pausal and have a history of fracture.The NICE CPG indicates that unsu-pervised, brisk walking may actuallyhave a detrimental effect in somepopulations, depending on thepatient’s impairments and abilities.

Gait training. The AGS/BGS20

CPG recommends gait training foradults at risk for falls. The More-land27 CPG specifically recommendsindividualized gait training com-bined with strength and balancetraining for community-dwellingwomen over the age of 80 years. TheMoreland CPG also recommendsreferral to a physical therapist forthose who demonstrate unsteadygait or require a walking aid.

ADL training. The AGS/BGS20 andMoreland27 CPGs recommend ADLtraining for those with difficulty per-forming ADL.

Nonspecific exercise. The NICE19

found insufficient evidence to rec-ommend low-intensity exercise andgeneric group exercise programsthat do not target impairmentsknown to be related to fall risk.

Education and information giv-ing. Although not included as rec-ommendations in this CGS becauseof low strength of evidence, theNICE19 CPG recommends providinginformation verbally and in writingon fall prevention, effective mea-sures, motivation to engage in exer-cise, and benefits of engaging in fallrisk reduction (Tab. 7) (Grade D).Additional recommendations rele-vant to the educational interventioninclude adherence to and motivationto perform exercise programs,where to seek further advice andassistance, how to summon helpshould a fall occur, and avoidance of

use of multifocal lenses while walk-ing (particularly on stairs). The AGS/BGS20 CPG recommends that tai-lored education be included in amultifactorial intervention but notprovided as a sole intervention(Grade D). Moreland et al27 foundinsufficient evidence to recommendtargeted or untargeted educationalprograms about falls or fear of fallingwithout subsequent follow-up onrecommendations, but the MorelandCPG does recommend educationrelated to specific risk factors foundduring the assessment, includingrisky activity level and inappropriatealcohol use.

Environmental FactorsHome hazard modification. All 3CPGs19,20,27 recommend a home haz-ard assessment and modification forolder people who have fallen andthose who are at risk for falls. Boththe NICE19 and Moreland27 CPGsspecify that home hazard assessmentshould not be conducted withoutfollow-up and modification. TheCPGs do not specify the componentsof a home hazard assessment or rec-ommend particular home assess-ment tools.

Personal FactorsFootwear. The AGS/BGS20 CPGrecommends treatment of foot prob-lems identified in a multifactorialassessment and advice to includelow heel height and high surfacecontact area (Grade C). Neither theNICE19 CPG nor the Moreland27 CPGmakes recommendations regardingfootwear.

Hip protectors. The NICE19 foundinsufficient evidence to recommendhip protectors for fall prevention.However, the NICE CPG makes thedistinction that hip protectors maynot be effective for fall preventionbut have been shown to preventfractures from falling.

Gap AnalysisExisting CPGs19,20,27 are clear that (1)all older adults should be screenedfor fall risk, (2) multifactorial assess-ments targeting an individual’s riskfactors should be conducted onthose who screen positive, and (3)tailored interventions should beimplemented to address the risk fac-tors that are identified. Physical ther-apists can address many aspects offall risk management inherent withinthese 3 areas of screening, assess-ment, and intervention; however,knowledge gaps exist across all 3areas.

ScreeningPhysical therapists should play a rolein questioning older adults about thepresence, frequency, and circum-stances surrounding falls and inscreening for balance impairmentsand gait limitations. Although takinga fall history seems relatively straight-forward, research is limited. It is notclear which are the key questionsregarding the specific circumstancesor factors linked to the fall historythat can be used to guide a physicaltherapist’s clinical decision making.The NICE19 CPG mentions a few bal-ance and gait screening tools. How-ever, not all of the measures havevalidated cut-points for fall predic-tion. More research is needed to syn-thesize evidence and validate cut-points that indicate increased fallrisk. There is a need for evidence-based recommendations to describethe predictive performance (eg, sen-sitivity, specificity, likelihood ratios)and clinical feasibility of fall riskscreening tools.

AssessmentA multifactorial assessment is recom-mended for older adults who screenpositive for fall risk (Tab. 5). TheNICE19 CPG addresses overarchingorganizational changes needed todecrease fall risk across the spec-trum of care. In that context, it sug-gests that assessment should occur



within a specialized falls service.Research is needed to identify themost effective and efficient deliverymodel or models for fall risk assess-ment and management across popu-lations at varying levels of risk.Implementation of these recommen-dations may vary depending on prac-tice setting.

Existing CPGs recommend compo-nents of a multidisciplinary assess-ment. The information obtainedfrom the assessment tools guidestreatment decision making beyondsimply identifying risk for falls. How-ever, more research is needed toidentify the pertinent characteristicsof assessment tools for people whoare at risk for falls. For example,objective measures are needed toassess the impact of factors such asADL limitations and cognitive, lowerextremity, and balance impairmentsand the corresponding implicationsfor the development of optimalinterventions.

InterventionsTo address recommendations relatedto cardiac pacing, postural hypoten-sion, medication modification, vita-min D supplementation, and visionreferral, physical therapists need toconsult with and refer patients toappropriate health care practition-ers. In contrast, interventions spe-cific to balance and gait impairmentscan be directly and effectively man-aged by a physical therapist. How-ever, current recommendations thatguide practice require greater speci-ficity, including (1) optimal mode,intensity, and frequency of balanceand strength training; (2) optimalstrategies for delivery of exerciseprograms; (3) optimal strategies forindividualization of exercise pro-grams; and (4) characteristics ofolder adults who may benefit fromspecific exercise regimens. Furtherguidance as to mode of informationdelivery and methods to increaseadherence also is needed. Finally,

greater specificity is warranted onthe prioritization of the componentsof home hazard modification basedon economic and clinical feasibility.

DiscussionThe purposes of this CGS are: (1) toidentify, critically appraise, and com-pare published CPGs on fall riskmanagement; (2) to make recom-mendations for physical therapistpractice in screening, assessing, andmanaging fall risk in community-dwelling older adults; and (3) to ana-lyze gaps in the existing CPGs toguide future research and the devel-opment of additional EBDs to facili-tate physical therapy and policy deci-sion making.

The recommendations presented inthis CGS are the result of a thoroughsystematic review and criticalappraisal process. The 3 CPGs thatwere identified provided recommen-dations for fall risk screening, assess-ment, and intervention. The com-mon recommendations were that (1)all older adults should be screenedfor fall risk by asking questions aboutfalls and difficulties in gait and bal-ance and briefly observing the pres-ence of difficulties in gait and bal-ance; (2) a positive screening shouldprompt a comprehensive, multidisci-plinary fall risk assessment; and (3)the multifactorial assessment shouldbe followed by an intervention thataddresses identified risk factors. Themultidisciplinary nature of thisassessment lends to some factorsrequiring a referral to other qualifiedhealth care professionals, whereasother factors fall within the scope ofphysical therapist practice.

The USPSTF34 is an independentexpert body that provides evidence-based recommendation statementsfor preventive services and primarycare for clinicians and health sys-tems. Through the MedicareImprovement for Patients and Pro-viders Act of 2008, which governs

policy for preventive services, theDepartment of Health and HumanServices is authorized to reimbursepreventive services receiving a levelA or B rating from the USPSTF. Reim-bursement policies that dictate pay-ment and practice are broadly influ-enced by the largest payer for UShealth care services, the Medicareprogram. Therefore, the USPSTFrecommendations have a tremen-dous impact on the implementationof preventive care.35 The USPSTF hasdeveloped recommendations relatedto fall risk screening and manage-ment which include a Grade B rec-ommendation for exercise or physi-cal therapy and vitamin Dsupplementation to prevent falls incommunity-dwelling adults over 65years of age.18 The USPSTF can beconsidered a high-quality EBD rele-vant to fall risk management incommunity-dwelling older adults.Compared with the USPSTF, thisCGS narrows recommendations tocommunity-dwelling older adults butexpands on recommended compo-nents of a multifactorial assessmentand intervention.

It is not recommended to automati-cally conduct a multifactorial fall riskassessment for all people aged 65years or older.18,20 This CGS sup-ports the need for all older adults tobe screened for fall risk when theycome into contact with a physicaltherapist. Our recommendations areconsistent with the USPSTF state-ment18 that history of falls or mobil-ity problems and poor performanceon the Timed “Up & Go” Test29 beused to identify older people atincreased risk for falls. However,more information is needed on theextent to which strength and bal-ance impairments are associatedwith fall risk and the amount ofchange that is associated withreduced fall risk. In particular, evi-dence is needed to guide cliniciansin appropriately matching patientcharacteristics and ability levels to



available exercise interventions andevidence-based programs, for exam-ple; criteria for or predictors of suc-cess in specific home-based, group-based, one-on-one facility-basedinterventions are lacking.

Consistent with this CGS, the USP-STF18 reports that effective exerciseincludes group-based classes, home-based physical therapy, or both andspecifies that the effective dose ofintervention ranges from 9 to 75hours. This wide range is a major gapthat can lead to confusion and prac-tice variation regarding how muchexercise would be required toachieve the optimal reduction in fallrate and fall risk. In addition, neitherthis CGS nor the USPSTF providesrecommendations for the most effec-tive types of exercise or componentsof physical therapy intervention.

Evidence from systematic reviews,some of which have been publishedsince the development of existingCPGs, provides useful information toaddress this gap and guide theevidence-based implementation ofguidelines. Sherrington et al14 sum-marized evidence related to themode of delivery and type and inten-sity of physical activity most effec-tive in reducing the risk for falls inolder adults by conducting a meta-analysis of trials in which exercisewas the stand-alone intervention.This synthesis provides evidence ofthe effectiveness of an exercise doseof at least 2 hours per week for atleast 6 months, with a total dose ofmore than 50 hours. Their analysisalso supports programs that focus onbalance training, defined as exer-cises conducted in a standing posi-tion in which participants aim tostand with their feet close togetheror on one leg, minimize use of theirhands for support, and move thebody’s center of mass in a controlledmanner. Consistent with the CGS,Sherrington and colleagues alsofound that neither walking nor

strength training alone, nor simplyencouraging older adults to increaseactivity, is effective in lowering fallrate or risk, highlighting the need tointegrate both strength and balancetraining into the intervention.Depending on the patient’s level offunctional ability, the plan of caremay include interventions to addressimpairments or limitations in endur-ance, coordination, flexibility, mobil-ity, gait, feet and footwear, homesafety and environmental hazards,and safe and appropriate use ofmobility aids.14

Similarly, a 2012 Cochrane Reviewand meta-analysis by Gillespie et al16

provides evidence that multifactorialhome-based and group-based inter-ventions that include strength andbalance training and tai chi reduceboth fall rate and fall risk. Programsthat focused on only strength train-ing or increasing level of physicalactivity did not affect rate or risk.

The plan of care should include sup-port for behavior change and opti-mal adherence.14 Physical therapistsshould elicit and incorporatepatients’ values and preferences andpartner with them in interventiondesign. Promoting adherence alsomay require assessing a patient’s self-efficacy and fear of falling as poten-tial barriers and connecting thepatient with appropriate resourcesand community providers ofevidence-based programs to helpsupport successful behavior change.Physical therapists must ensure thattheir patients understand theselected interventions and theirresponsibility to engage in andadhere to the program to the great-est possible degree. Physical thera-pists working with patients withhigh fall risk should emphasize theimportance of ongoing physicalactivity and structured exercise, andpatients should be empowered toself-manage their fall risk or transi-tion to community-based exercise

programs to maintain the gains madein physical therapy.

Implications for Clinical Practiceand Next StepsThis CGS supports that all olderadults should be screened for fallrisk, and this screening may trigger amultifactorial fall risk assessment.Policies that relate to either screen-ing or assessment of the older adultinclude the following: (1) fall riskscreening is a reimbursable servicefor physicians when it is included inthe introductory “Welcome to Medi-care” wellness visit but not in subse-quent wellness visits, (2) fall screen-ing is a quality indicator forphysicians and practices participat-ing in Meaningful Use and Account-able Care Organization initiatives butis not reimbursed under Medicare,and (3) fall assessment is a reimburs-able service as well as a PhysicianQuality Reporting Initiative (PQRI)36

indicator. From these initiatives, it isclear that attempts are being made tofocus on fall risk screening andassessment practices in primarycare, but these initiatives do not spe-cifically target physical therapists.Policy makers should understand theimportant role that physical thera-pists can play in fall risk screeningand management. Physical therapistshave education and expertise inchoosing and administering assess-ment instruments for fall risk assess-ment. They are specifically educatedin assessment and management ofrisk factors such as strength and bal-ance impairment, gait and ADL limi-tations, and home hazards and feetand footwear.

The CDC has recently released theSTEADI Tool Kit,17 based on theAGS/BGS20 CPG. The STEADI pro-vides implementation resources forall stages of fall risk management.Screening resources in the STEADITool Kit include the Timed “Up &Go” Test,29 30-second Chair StandTest,37 and 4-Stage Balance Test.38



These tests were selected based ontheir performance as fall risk screen-ing measures. The STEADI Tool Kitincludes a list of recommended inter-ventions for older adults at increasedfall risk. These interventions includeevidence-based programs in thecommunity such as tai chi,39 Step-ping On,40 and the Otago ExerciseProgram.41 Tai chi and Stepping Onare programs that are available in thecommunity (eg, senior centers,YMCAs), delivered by trained layleaders, and are most appropriate forolder adults who are higher function-ing. The Otago Exercise Program isdelivered by a physical therapist andis most appropriate for frail,community-dwelling older adults athigh risk for falls. The Otago Exer-cise Program is designed to be deliv-ered in 6 to 9 visits over a 1-yearperiod and has demonstrated a 35%reduction in falls in randomized con-trolled trials.42 The STEADI Tool Kitis a useful fall risk managementimplementation tool and is consis-tent with this CGS. The programssuggested by the STEADI Tool Kithave demonstrated effectiveness inreducing falls and are importantoptions for achieving a dose of 50 ormore hours of challenging exercise.However, there remains a paucity ofevidence to guide the clinician inmatching individual patient impair-ments, functional level, and fall riskto the appropriate evidence-basedexercise program to maximize thebenefits of participation and mini-mize the risk of adverse effects.

LimitationsThis CGS has several limitations.First, it is specific to older peoplewithout neurologic dysfunction wholive in the community and presentfor care in a clinical setting. This CGSshould not be used to guide assess-ment or interventions for those inacute care hospitals or skilled nurs-ing facilities. Second, it is possiblethat not all relevant CPGs were iden-tified. However, given the level of

redundancy in other databases, webelieve that we have minimized thisproblem to a reasonable degree.

Also, in the process of developingthis CGS, several complexities ofintegrating findings into clinicalpractice became apparent. The CPGsincluded in this CGS did not explic-itly consider the economic impact ofrecommendations or the range ofdelivery models and settings thatcould be involved in implementa-tion. Therefore, the economic andresource implications of theserecommendations are unknown. Evi-dence to demonstrate the health andeconomic impact of preventive pro-grams across payment and servicedelivery models is needed to facili-tate policy change related to cover-age of fall prevention programs bythird-party payers across health caresettings.

ConclusionsIn summary, existing CPGs are clearthat every older adult should bescreened for fall risk at least once peryear and that consideration of bal-ance impairment and gait and mobil-ity limitations is integral to fall riskscreening. Fall risk screening maytrigger a multifactorial risk assess-ment, parts of which would bedirectly implemented by the physi-cal therapist in consultation withother health care providers. Exer-cise, including structured physicaltherapy, is an effective componentof a fall prevention program, and thephysical therapist also may directlyprovide home hazard and footwearmodification and education aboutfall risk. Current recommendationslack the specificity required to tailordecision making by the physical ther-apist, highlighting the need for bothadditional research and a future CPGthat is directed at physical therapists.Nevertheless, this CGS synthesizescurrent recommendations to providedirection for physical therapists aswell as descriptions of evidence-

based programs provided in thecommunity that might be useful tofacilitate long-term exercise partici-pation following discharge from aphysical therapy episode of care.

This CGS highlights the current stateof the evidence for managing fall riskand identifies gaps in knowledge.The resulting gap analysis demon-strates that more programs need tobe developed and studied for spe-cific subpopulations of older adults,including those with dementia,those with chronic disease, andthose in institutional settings. Also,there is a need for additionalresearch and tools specifically forphysical therapist assessment andintervention. Finally, more researchis needed to optimize componentsrelated to exercise interventions,including strength and balancetraining.

Standards for CPG and CGS develop-ment are evolving rapidly accordingto the Institute of Medicine stan-dards,2 and new databases are beingconstructed at multiple levels ofanalysis, such as the Guidelines Inter-national Network43 for CPGs, theRehabilitation Measures Database,44

and APTA’s Evaluation Database toGuide Effectiveness (EDGE)45 initia-tive for outcome measures. To max-imize resources, minimize clinicianconfusion and variation, andimprove quality of care, physicaltherapists should work to integratestandards and guideline develop-ment processes of diverse entitiesand the associated technologies.This process requires careful deliber-ation and investment by the physicaltherapy profession. The develop-ment of a CPG specific to the phys-ical therapist management of fall riskto complement this CGS is an impor-tant initiative and a significant steptoward improving the quality of carefor and quality of life of community-dwelling older adults.



Table 5.General Recommendations from 3 High-Quality Clinical Practice Guidelinesa

Measure NICE19 AGS/BGS20 Moreland et al27

Screening for fall risk For all older people, HCPs should askwhether they have fallen in theprevious year, including frequency,context, and fall characteristics(C, Level III)

Assessment of ability to stand, turn,and sit is adequate for first-levelscreening (NG)

All older people under the care of an HCPshould be asked, at least once per year,whether they have fallen in theprevious year, including frequency,context, fall characteristics, anddifficulties with walking or balance(NG)

Older people who report a single fallshould be evaluated for balance andgait using one of the availableevaluations (NG)

Did not address screening(secondary prevention)

Evaluation of people at risk All older people reporting a fall orconsidered at risk for falling shouldbe assessed for deficits of balanceand gait and considered forinterventions to address thesedeficits (C)

Multifactorial risk assessment shouldbe provided to older people whopresent for medical attentionbecause of a fall, report recurrentfalls in the previous year, ordemonstrate abnormalities ofbalance, gait, or both (C)

Multifactorial risk assessment shouldbe performed by an HCP withappropriate skills and experiencein the setting of a specialized fallsservice. This assessment should bepart of an individualizedmultifactorial intervention (C)

See Table 6 for components ofmultifactorial risk assessment

Multifactorial risk assessment should beprovided to older people who presentto an HCP due to a fall, answerpositively to screening questions, ordemonstrate unsteadiness (NG)

Multifactorial risk assessment should beprovided to older people who cannotperform or perform poorly on a test ofbalance, gait, or both (NG)

Multifactorial risk assessment should NOTbe provided to older people reportingonly a single fall and reporting ordemonstrating no difficulty orunsteadiness during the evaluation ofbalance and gait (NG)



Multifactorial interventions Individualized multifactorialintervention should be consideredfor older people with recurrentfalls or assessed as being atincreased risk for falls (A)

Individualized multifactorialintervention aimed at promotingindependence and improvingphysical and psychologicalfunction should be offeredfollowing treatment for injuriousfalls (A)

Fall prevention programs shouldaccommodate participants’different needs and preferences(D)

HCPs involved in fall preventionprograms should discuss whichchanges a person is willing tomake, address potential barrierssuch as low self-efficacy and fearof falling, and encouragenegotiated activity change.Information should be available inlanguages other than English (NG)

The HCP who conducted the fall riskassessment should implement theintervention or ensure that it isimplemented by a qualified HCP (NG)

Interventions should promote safeperformance of daily activities (NG)

Multifactorial interventionstargeting identified deficitsand environmental hazardsare effective for community-dwelling adults (A)

Interventions should betailored to identified riskfactors and should includean exercise program (A)

a AGS/BGS�American Geriatrics Society/British Geriatrics Society,20 NICE�National Institute for Health and Care Excellence,19 HCP�health care provider,NG�not graded. See Table 4 for explanation of recommendation grades.



Table 6.Components of Multifactorial Assessment as Recommended by Reviewed Clinical Practice Guidelinesa

Measure NICE19 (Grade C, Level III) AGS/BGS20 (NG) Moreland et al27

Health Conditions

Falls Identification of fall history History of fall circumstances, frequency,symptoms at time of fall, injuries,other consequences

Medication Medication review All prescribed and over-the-countermedications with dosages

Psychotropic drugs (Level I), multipledrugs (Level II)

Osteoporosis Assessment of osteoporosis risk Osteoporosis

Depression Depression using GDS (Level V)

Body Functions and Structure

Strength andbalance

Assessment of balance, gait, mobility,and muscle weakness

Lower extremity strength Lower-extremity strength (Level II),lower-extremity coordination (LevelIII), assessment of balance (Level II)

Cognitive andneurologic

Cognitive impairments and neurologicexamination

Neurologic function: cognitiveevaluation, lower-extremityperipheral nerves, proprioception,reflexes, and tests of cortical,extrapyramidal, and cerebellarfunction

Mental status (Level I), peripheralneuromuscular function (Level II),dizziness (Level III)

Cardiovascular Cardiovascular examination Heart rate and rhythm, postural pulse,blood pressure (posturalhypotension), heart rate and bloodpressure responses to carotid sinusstimulation

Postural hypotension (Level III)

Incontinence Urinary continence Urinary continence Incontinence (Level III)

Visual Visual impairments Assessment of visual acuity Vision (Level III)

Activity and Participation

Gait Assessment of gait Assessment of gait (Level IV), use ofwalking aid (Level II)

ADL ADL skills, including use of adaptiveequipment and mobility aids

ADL/IADL (Level II), transfers (NG)

Physical activitylevel

Too high (Level III) or too low (LevelIV), moderate activity (Level II,protective)

Environmental Factors

Environmental andhome hazards

Home hazards Environmental assessment, includinghome safety

Environmental safety hazards (Level II)

Personal Factors

Health perceptionsand fear

Perceived functional ability and fearrelated to falling

Assess objective and subjectiveperspectives

Social support Social network poor or good (Level IV)

Alcohol use Increased risk with inappropriate use(NG), alcohol consumption,protective (Level II)

Feet and footwear Examine

a AGS/BGS�American Geriatrics Society/British Geriatrics Society,20 NICE�National Institute for Health and Care Excellence,19 ADL�activities of daily living,IADL�instrumental activities of daily living, GDS�Geriatric Depression Scale, NG�not graded. See Tables 3 and 4 for explanation of evidence levels andrecommendation grades.



Tab

le7.

Sum

mar

yof

Inte

rven

tion

Reco

mm

enda

tions

for

Com

mun

ity-D

wel

ling

Old

erA

dults

From

Revi

ewed

Clin

ical

Prac

tice

Gui

delin

esa

Mea

sure

NIC

E19

AG

S/B

GS2

0M

ore

lan

det

al2

7

Hea

lth

Co

nd

itio

ns

Car

diac

cond

ition

sFo

rp

eop

lew

hoha

veun

exp

lain

edfa

llsan

dca

rdio

inhi

bito

ryca

rotid

sinu

shy

per

sens

itivi

ty,

card

iac

pac

ing

shou

ldbe

cons

ider

ed(B

)

For

peo

ple

who

have

falle

nan

dw

hoha

veca

rdio

inhi

bito

ryca

rotid

sinu

shy

per

sens

itivi

ty,

dual

cham

ber

card

iac

pac

ing

shou

ldbe

cons

ider

ed

Post

ural

hyp

oten

sion

Trea

tmen

tof

pos

tura

lhyp

oten

sion

(C)

Patie

nts

with

pos

tura

lhyp

oten

sion

shou

ldbe

trea

ted

and

educ

ated

(NG

)

Med

icat

ion

revi

eww

ithm

odifi

catio

n/w

ithdr

awal

Psyc

hotr

opic

med

icat

ions

shou

ldbe

revi

ewed

and

disc

ontin

ued,

ifp

ossi

ble

(B)

With

draw

orm

inim

ize

psy

choa

ctiv

em

edic

atio

n(B

)an

dot

her

med

icat

ions

(C)

With

draw

psy

choa

ctiv

em

edic

atio

nsan

dm

inim

ize

num

ber

ofm

edic

atio

ns(N

G)

Cog

nitiv

eim

pai

rmen

tIm

pai

red

cogn

itive

stat

usas

mea

sure

dby

the

MM

SEsh

ould

bein

vest

igat

edan

dtr

eate

d(N

G)

Dep

ress

ion

Dep

ress

ion

asm

easu

red

byth

eG

DS

shou

ldbe

inve

stig

ated

and

trea

ted

(NG

)

Vita

min

Din

suffi

cien

cyVi

tam

inD

sup

ple

men

tsof

atle

ast

800

IUp

erda

ysh

ould

bep

rovi

ded

tool

der

peo

ple

with

pro

ven

vita

min

Dde

ficie

ncy

(A)

orsu

spec

ted

vita

min

Dde

ficie

ncy

orw

hoar

eot

herw

ise

atin

crea

sed

risk

for

falls

(B)

Bo

dy

Fun

ctio

ns

and

Stru

ctu

re

Stre

ngth

and

bala

nce

For

olde

rp

eop

lew

itha

hist

ory

ofre

curr

ent

falls

,ba

lanc

ean

dga

itde

ficit,

orbo

th,

ast

reng

then

ing

and

bala

nce

pro

gram

shou

ldbe

offe

red.

The

pro

gram

shou

ldbe

indi

vidu

aliz

edan

dp

resc

ribed

and

mon

itore

dby

anap

pro

pria

tely

trai

ned

HC

P.(A

)

For

olde

rp

eop

leat

risk

for

falli

ng,

anex

erci

sep

rogr

amin

clud

ing

bala

nce,

stre

ngth

,an

dco

ordi

natio

nsh

ould

beof

fere

d.(A

)Bo

thin

divi

dual

and

grou

pex

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ses

can

beus

ed(B

)Ta

ichi

and

phy

sica

lthe

rap

yar

ere

com

men

ded

inte

rven

tions

(A)

Flex

ibili

tyan

den

dura

nce

shou

ldbe

offe

red

but

not

asst

and-

alon

eco

mp

onen

ts(A

)Pr

ogra

msh

ould

bein

divi

dual

ized

acco

rdin

gto

heal

thp

rofil

ean

dp

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ilitie

san

dp

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and

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byan

app

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aine

dH

CP

(I)

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nce

exer

cise

sar

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ive

(B)

For

wom

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80ye

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with

nosp

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indi

vidu

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Figure 2.Summary of action statements.



Dr Avin, Dr Hanke, Dr Kirk-Sanchez, DrMcDonough, and Dr Shubert, Dr Hardageprovided concept/idea/research design andwriting. Dr Avin, Dr Hanke, Dr Kirk-Sanchez,Dr McDonough, and Dr Shubert provideddata collection and analysis. Dr Kirk-Sanchez, Dr McDonough, Dr Hardage, andDr Hartley provided project managementand fund procurement. Dr Kirk-Sanchez, DrMcDonough, and Dr Shubert provided insti-tutional liaisons. Dr Hanke, Dr Kirk-Sanchez,and Dr Hartley provided consultation(including review of manuscript beforesubmission).

The Academy of Geriatric Physical Therapygratefully acknowledges the members of theconsulting group: Holly Jean Coward, MD,CMD (physician geriatrician); Jodi Jancze-wski, DPT (physical therapist with expertisein falls in community-dwelling older adults);Dixon and Landy Qualls (community-dwelling older adults); and Debbie Rose,PhD (exercise physiologist with expertise infalls in community-dwelling older adults).

The Academy of Geriatric Physical Therapygratefully acknowledges the members of theexternal review group: (Bonita) Lynn Beattie,PT, MPT, MHA (public health policymaker);Sandra L. Kaplan, PT, DPT, PhD (specialreviewer with expertise in methods); Jon D.Lurie, MD, MS (primary care physician);Michelle M. Lusardi, PT, DPT, PhD (specialreviewer with expertise in methods and geri-atrics); Mindy Oxman Renfro, PhD, DPT,GCS, CPH (Geriatric Certified Specialist);Cathie Sherrington, PhD, MPH, BAppSc(special reviewer with expertise in falls incommunity-dwelling older adults); EllenStrunk, PT, MS, GCS, CEEAA (Certified Exer-cise Expert for Aging Adults and consultanton legislative affairs and reimbursement);Stephanie A. Studenski, MD, MPH (physiciangeriatrician); and Vicki Tilley, PT, GCS (Geri-atric Certified Specialist).

The Academy of Geriatric Physical Therapyextends its appreciation to those whoresponded to the call for public review andcomment.

This work was supported by a grant from theDepartment of Practice of the AmericanPhysical Therapy Association.

Dr Shubert is part owner of the Evidence inMotion Fall Prevention Application availablefor the Android and iPhone/iPad platforms.

DOI: 10.2522/ptj.20140415

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http://www.agreetrust.org/resource-centre/agree-ii-training-tools/



http://agile.csp.org.uk/documents/guidelines-physiotherapy-management-older-people-risk-falling?networkid=338430




http://www.uspreventiveservicestaskforce.org

http://www.uspreventiveservicestaskforce.org

http://www.facs.org/~/media/files/advocacy/pqrs/2013/2010experience%20report.ashx




http://www.g-i-n.net/

http://www.rehabmeasures.org/default.aspx

http://www.rehabmeasures.org/default.aspx

http://www.apta.org/OutcomeMeasures/

http://www.apta.org/OutcomeMeasures/