NFPCG evidence briefing: Multifactorial falls-prevention interventions

Target audience
Local and regional commissioning and strategic leads in England with a remit for falls, bone health and healthy ageing.

Background
The Cochrane Library has recently published a number of systematic reviews on falls prevention interventions updating their 2012 work in this area.^1-4 The review focusing on exercise for preventing falls in older people living in the community, published in January 2019, states that there is high-certainty evidence that well‐designed exercise programmes reduce the rate of falls and the number of older people who fall. However, the systematic reviews published in July and September 2018 suggest that there is less certainty as to the effectiveness of multifactorial interventions than previously thought.

National Falls Prevention Coordination Group (NFPCG)
Public Health England hosts the National Falls Prevention Coordination Group (NFPCG) which is made up of national organisations involved in the prevention of falls, care for falls-related injuries and the promotion of healthy ageing.⁵ It was formed to co-ordinate and support falls-prevention activity in England. Following consultation with NFPCG clinical and research leads after the publication of Cochrane Library falls-prevention systematic reviews, this key message is being sent:

It is recommended that there should be no changes in clinical practice or policy, or strategic, commissioning or service provision decisions relating to multifactorial falls prevention interventions made on the basis of the July 2018 Cochrane Library systematic review ‘Multifactorial and multiple component interventions for preventing falls in older people living in the community’ and the September 2018 systematic review ‘Interventions for preventing falls in older people in care facilities and hospitals’. These suggest that there is less certainty as to the effectiveness of multifactorial interventions than previously thought, due to the quality of the available evidence largely being rated as low or very low. However, while the emerging evidence base is being reviewed, clinical assessment to identify falls risk factors, including the presence of medical conditions that increase risk and the delivery of interventions that reduce identified risk, should continue.

Multifactorial falls prevention interventions involve the delivery of 2 or more component interventions, combined in different ways based on an assessment of a person's risk factors for falling. These component interventions can include exercise, environmental modification, medication review, and vision assessment and modification. They can take place in both the community and in hospitals and care facilities. NICE Clinical Guideline 161 ‘Falls in older people: assessing risk and prevention’ (2013) states: ‘Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be part of an individualised, multifactorial intervention.’ It goes on to note that during a hospital stay, all patients aged 65 and older and those patients aged 50 to 64 judged by a clinician to be at higher risk of falling because of an underlying condition should be considered for a multifactorial intervention.

In July 2018, the Cochrane Library published a systematic review titled ‘Multifactorial and multiple component interventions for preventing falls in older people living in the community’. This was the first of 3 updates of the 2012 Cochrane Library systematic review ‘Interventions for preventing falls in older people living in the community. The second titled ‘Exercise for preventing falls in older people living in the community’ was published in January 2019. The third on environmental modifications is forthcoming. In September 2018, the Cochrane Library published a systematic review titled ‘Interventions for preventing falls in older people in care facilities and hospitals’. This was an update of the 2012 review with the same title.  

As exercise and environmental modifications, the topics of 1 published and 1 forthcoming update, are component interventions of multifactorial falls-prevention interventions, any assessment of effectiveness of multifactorial falls-prevention interventions will need to take into account all 4 update reviews. In addition to this, NICE are reviewing their Clinical Guideline 161, ‘Falls in older people: assessing risk and prevention’, to determine if it needs updating.   

Older people living in the community, who have fallen recurrently or have been assessed as being at increased risk of falling, and older people in hospitals and care facilities still require clinical assessment to identify risk factors, including the presence of medical conditions that increase falls risk, and to receive interventions that reduce identified risk. Given that this is the case, it is recommended that there should be no changes in clinical practice or policy or strategic, commissioning or service provision decisions relating to multifactorial interventions made on the basis of the Cochrane Library systematic reviews ‘Multifactorial and multiple component interventions for preventing falls in older people living in the community’ (2018) and ‘Interventions for preventing falls in older people in care facilities and hospitals’ (2018).  

A more comprehensive assessment of the evidence base will need to be carried out and will need to include the Cochrane Library systematic reviews on exercise (published) and environmental modifications (forthcoming). As noted above, the evidence review process for NICE Clinical Guideline CG161, ‘Falls in older people: assessing risk and prevention’, is commencing.