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Falls Prevention: Policy, Research & Practice

April 3, 2007 1

World Heath Organization Report: Prevention of Falls in Older Age

Background Paper: Falls Prevention: Policy, Research and Practice Author: Vicky Scott, PhD, RN, Senior Advisor on Falls and Injury Prevention, British Columbia Injury Research and Prevention Unit; Assistant Clinical Professor, Faculty of Medicine, Health Care and Epidemiology University of British Columbia

Introduction Without concerted action by policy makers, researchers and practitioners, the economic and

societal burden of falls will increase by epidemic proportions in the next few decades. As

depicted in Figure 1, policy, research and practice are interconnected components necessary for

an effective and sustainable program of falls prevention for older persons. The complex and

multifactorial nature of fall risk among a rapidly aging population demands a proactive and

systematic approach to prevention. The role of policy in such an approach is to provide the

infrastructure and support essential for the integration of falls prevention into practice. Research

is required to provide evidence to support the effective application of prevention interventions.

Practice is where evidence is applied according to the standards and protocols set by policy.

Figure 1


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Policy

A policy is a governing principle that serves to guide decision-making and action that is agreed

upon by a group of people with the authority to carry it out and enforce it (1). To effectively

address the growing problem of falls in an aging society, healthy public policies are needed to

provide vision, set priorities and establish institutional standards (2). A healthy public policy is

one that is defined by social and physical environments that enable citizens to lead safe and

healthy lives (3). Such policies are shown to arise from a systematic process of building

capacity for action that draws upon available evidence, integrated with community preferences,

political realities and available resources (4).

Policies are created by various levels of government or by institutions, community organizations,

professional associations and agencies (1). The target population for public policies can be the

general population or specific population groups. In all cases, policies are most effective when

developed collaboratively by those affected by the problem and those with the jurisdiction to

bring about change, and when evaluated to ensure they bring about the desired health impact.

Leadership, partnership and education are the three consistent themes in existing guidelines for

the development of healthy public policies and national policy documents for effective falls

prevention programming for older persons (5, 1, 6, 2, 3, 7, 8). These themes are presented here

as the building blocks of healthy public policy necessary for enabling health promotion,

strengthening community action and developing personal skills (9).

Leadership

In many countries the route to effective and sustainable falls prevention at national, regional and

local levels has been impeded by a lack of strong leadership that is essential to the


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advancement of sustained, coordinated and collective policy development. Government

agencies responsible for health and social services for older persons are well placed to provide

such leadership by establishing a policy-making infrastructure, setting priorities and targets, and

overseeing and supporting national efforts to reduce falls and fall-related injuries (8).

Specific leadership roles for the development of policies for falls prevention include the following:

• Defining the problem: For policy makers to move forward on the issue of falls prevention

they must first understand the size of the problem, who it affects, the social and

economic burden, trends over time and projections for the future, what is known about

the contributors to the problem and what works to reduce or eliminate those contributors.

• Identifying relevant stakeholders: The role of a leader is to engage the right people to

partner in the development and dissemination of information that will facilitate positive

change – this includes bringing together those affected by the problem and those with

the ability to enact solutions.

• Identifying and securing resources: Long-term commitments are required for research,

integration of evidence into practice and evaluation.

• Implementing legislation: Leadership is required to determine which prevention

approaches require legislation or regulation and to work across, and within, government

departments and non-government agencies to bring about the necessary changes.

• Explicating barriers and facilitating factors: A leader must balance falls prevention

policies and programming with competing demands for resources, as well as aligning

solutions to complimentary policies and programs that are already in place. For

meaningful and inclusive policy development, leaders are required who have the ability to

put policies in place that reflect the rights of older persons to lead full and active lives as

integrated and valued members of society free from the risk of preventable injury.


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Strong leadership has been demonstrated in a number of countries that has led to effective falls

prevention policies. Examples include those from Canada, the United States and Australia.

In Canada, a turning point in policy development for falls prevention occurred when a lead policy

maker in the British Columbia (B.C.) Ministry of Health, Dr. Shaun Peck, set in place a

collaborative process for priority setting to reduce falls and fall-related injury rates for the

province. The process involved an analysis of regional data on the scope and nature of the

problem for each of the five health regions in the province combined with meetings of regional

stakeholders to identify priority areas for change. The final product was a comprehensive report

of fall-related morbidity and mortality for the province and regions, a review of the literature on

fall risk factors and proven prevention strategies, and 31 priority recommendations for policy and

prevention (10). The process of involving the stakeholders in the formation of these

recommendations was pivotal to the success of this leadership model. Since release of this

report, there has been substantial growth in the number of falls prevention programs and a

significant reduction in fall-related deaths and hospitalization in B.C. (11). This report provided

momentum for the formation of the British Columbia Falls and Injury Prevention Coalition

(BCFIPC), the publication of a subsequent report titled: the Evolution of Seniors’ Falls

Prevention in British Columbia (11) and was also the impetus for a national report on seniors’

falls in Canada (7). These reports, and an overview of the BCFIPC activities, are available on

the Internet (12).

In the United States, effective leadership by the National Safety Council, the National Home

Safety Council; the National Council on the Aging, and other members of the Falls Free Coalition

(using data from the Centers for Disease Control’s National Center for Injury Prevention and

Control), as well as leadership from politicians, such as Senator Michael Enzi has resulted in the

development and subsequent passing of a bill on falls prevention in the Senate. This bill directs


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the Secretary of Health and Human Services to expand and intensify programs with respect to

research and related activities concerning falls among older persons (13, and in a conversation

with Judy Stevenson, National Center for Injury Prevention and Control, oral communication,

October 23, 2006). A similar bill titled, H.R. 5608 The Keeping Seniors Safe from Falls Act of

2006, has been introduced into the House of Representatives by representatives Ralph Hall and

Frank Pallone (14). If passed, H.R. 5608 will create a national public education and awareness

campaign for older adults and their families, provide for professional education for health care

providers, expand research and provide demonstration projects to develop better ways to

prevent falls and to improve the treatment and rehabilitation of older persons who fall (15).

Continued strong leadership on this issue is essential as a bill must be passed by both the

House and Senate and then signed by the President before it becomes law.

The Australian Leadership Group of the National Falls Round Table, with representation from

leaders in falls prevention from each State and the Commonwealth Government, has taken

initiative in developing strategic policy direction for falls prevention as outlined in the report titled:

National Falls Prevention for Older People Plan: 2004 Onwards (16). The plan is a cohesive

and comprehensive response to the problem of falls and injuries among older persons and

builds on work well underway in community, acute care and residential settings in most regions

of Australia. Many of these programs have also expanded into major, multi-state initiatives (Pam

Albany, Manager Injury Prevention Policy Branch, NSW Health Department, email

communication, October 23, 2006). The urgent need for expansion of the Australian plan is

expressed by the authors of the NSW Management Policy to Reduce Fall Injury Among Older

People (2p.ix):

“Health systems often rely on the circulation of best practice guidelines and training of practitioners to respond to client needs. It is assumed that the service delivery system will then adjust to meet the demand. In this case, the onset of the epidemic of fall injury will be too rapid and too costly to rely on the fragmented response of Health Areas and professionals and the wide range of people and organizations that influence risk …there is a


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need for a systematic approach to funding, training and research to ensure a cohesive response”.

Partnership

A good leader will recognize that the most important allies in developing effective falls

prevention policies are those most directly impacted by the issue – older persons at risk of falling

and those who care for them. To bring about change, there must also be involvement of those

with the ability to implement solutions in all areas that affect fall risk for older persons. A first

step in effective partnerships is to gain a mutual understanding of how the problem affects each

partner, how each partner will benefit by finding a solution, and the steps needed to put the

solution in place. Partnerships and coalitions of a wide variety of organizations—including

national, regional, local, nonprofit, voluntary and charitable organizations—are pivotal in

supporting these efforts. The key to the success of these efforts is keeping the needs and

wishes of the older person in the forefront of all decision making through direct involvement in

the planning, implementation and evaluation of prevention efforts.

Potential partners for falls prevention include;

• Individuals and organizations representing older persons at risk of falling, including non-

profit foundations and societies for older persons, support groups for those with chronic

health problems, caregiver groups, etc.

• Health and social service providers, including nurses, physical and occupational

therapists, physicians, pharmacists, nutritionists, social workers, etc.

• Policy makers and legislators with jurisdiction for the health and safety of older persons,

at national, regional and local levels of government.

• Emergency service providers (who are often the first on the scene after a serious fall

incident), including ambulance attendants, police and fire fighters.


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• Researchers from disciplines including epidemiology; behavioural and social sciences;

medicine, public and allied health disciplines; as well as falls prevention experts with the

skills to translate empirical evidence into practical application.

• Health economists with the ability to determine the economic impact of falls and the cost

benefits of different prevention approaches.

• Educators with skills in the appropriate delivery of information for older persons, including

those with limited literacy, non-dominant language or representing cultural minorities.

• Those with responsibility for safety in public environments, including providers of public

transportation, city planners, architects, building trade workers, building maintenance

workers, building managers and those who design and enforce public building codes and

standards.

• Private sector businesses that produce and distribute products and services for older

people.

Strategies for developing and maintaining partnerships include the formation of falls prevention

coalitions and electronic networks. Successful examples of these include the Falls Free

Coalition in the United States and the PROFANE Network based in Europe.

The Falls Free Coalition is a collective of representatives of national organizations and state

coalitions working to reduce the growing number of falls and fall-related injuries among older

adults (17). With support from the Archstone Foundation and Home Safety Council non-profit

organizations, members of the Falls Free Coalition first convened in 2004 to write the Falls Free

National Action Plan (18). The plan outlines key strategies and action plans for fall prevention to

address the following five priority areas: 1) physical mobility; 2) medications management; 3)

home safety; 4) environmental safety in the community; and 5) cross-cutting issues, such as


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advocacy, policy, links to health care systems and integration of interdisciplinary activities. The

Falls Free web site and newsletter is found at (19).

The Prevention of Falls Network Europe (ProFaNE) can be accessed on the Internet (20) and is

a European Community-funded Thematic Network to promote effective practice in falls

prevention among older persons. The network has over 1100 website members from over 30

countries, an active discussion board, and nearly 900 resources available on the website to

download. ProFaNE disseminates good practice by making all its resources publicly available

on the ProFaNE website, including copies of presentations given by ProFaNE members, links to

published papers, reports and the Falls Efficacy Scale-International (FES-I) measure of fear of

falling. One example of their active networking is the translation of the FES-I into many different

languages and the data sharing that has ensued. ProFaNE provides contacts for organizations

across Europe that have an interest in falls prevention and links with other related national and

international networks. Information on the pathway or journey of a “faller” through Health Care

Systems across Europe is freely available to anyone who registers on the website. Publications

by ProFaNE members include a review on falls prevention for the WHO Health Evidence

Network (21) (Dawn Skelton, ProFaNE Scientific Co-ordinator, email communication, October

20, 2006).

Education

Along with good leadership and partnerships, education is the third key strategy for building

capacity for falls prevention policy development and implementation. To be effective, education

must be part of a larger strategy for falls prevention that reflects current evidence, adult learning

principles and integration of learning to practice. Learning takes time and occurs through a

series of “progressive and mutually reinforcing education and training activities” (22p295).

Educational needs for the prevention of falls include understanding who is at risk and why, what


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is known to reduce the risk and what can be done to overcome barriers to risk reduction. The

following is an outline of key learning needs for effective falls prevention programming for

individuals, communities, professionals and policy-makers.

• Learning needs for individuals at risk:

o understanding that falls are not an inevitable outcome of aging and that falls can be

prevented,

o recognizing their fall risks and understanding how to increase their ability to reduce

their risk, and

o identifying the supports and services necessary to bring about change.

• Learning needs for communities:

o knowing how to facilitate an effective exchange of information between those at risk

for falling and those with solutions for reducing risk that respects cultural and

geographic diversity,

o knowing where to find information on proven prevention strategies at the individual

and community level, and

o understanding how to influence policies that impede the ability to reduce identified

individual and community fall risks.

• Learning needs for professionals:

o knowing where to find credible sources of current, proven best practices for the

assessment and management of falls among older persons,

o knowing how to integrate evidence into practice in ways that are cost-effective,

feasible, sustainable and reflect the needs of the clients being served,

o knowing how to evaluate the effectiveness of their practice related to falls prevention,

and

o understanding how to influence policies within organizational structures to support

such actions.


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• Learning needs for policy-makers:

o understanding how to monitor the scope and nature of the problem of falls in their

jurisdiction,

o knowing how to translate evidence for prevention into healthy public policies that

reflect the needs and preferences of the target population across the lifespan,

o understanding how to collaborate effectively with multiple jurisdictions, sectors and

community members to inform and created credible and inclusive public policies to

reduce falls, and

o understanding how to apply optimal evaluation methods for determining the impact of

policies designed to reduce falls among older persons.

Methods for delivering such learning opportunities include national, regional or local education

campaigns to provide falls prevention information to older persons, family members, caregivers,

service providers, health care professionals, and others who provide health and social services

to older persons. Such campaigns could be implemented through radio, television, internet or

print media, or through continuing education programs, peer-reviewed publications, seminars

and conferences. Another approach is to develop national education and training guidelines for

health care professionals and service providers that integrate falls prevention into routine health

and social service systems.

An example an effective media campaign is the multi-faceted state-wide social marketing

strategy developed by the Australian Department of Health to raise awareness about falls

among older persons (23). The aim of this strategy is to enhance existing Stay On Your Feet

WA™ program activities by shifting attitudes and beliefs to effect positive behavioural change for

the prevention of falls.


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An example of a national policy for the support of education as a strategy for falls prevention is

the development of the Canadian Falls Prevention Curriculum© (24), funded by the Population

Health Fund of the Public Health Agency of Canada. This curriculum, to be published in the two

lead languages in Canada (French and English), is designed to provide community leaders and

those who provide health and social services to older persons with the skills needed to design,

implement and evaluate evidence-based falls prevention programs. To ensure relevance to the

target audience the process for the development, testing and dissemination of the curriculum

actively involves partners representing older persons, policy makers, educators, researchers and

health and social service providers. Included in this curriculum is a critical review of existing falls

prevention curricula for health care providers and community falls prevention programmers that

reflect current evidence on interventions for falls reduction among older persons. See Table 1,

Appendix A for a list of the most highly rated curricula.

Research

There has been a substantial increase in the past decade in research on the prevention of falls

among older persons. Considerable evidence now exists that most falls among older persons

are associated with identifiable and modifiable risk factors and that targeted prevention efforts

are shown to be effective and fiscally responsible (25).

The following section outlines a summary of key findings for falls prevention taken from

systematic reviews and meta-analyses (26, 27, 28, 29, 30, 31, 32), other reviews (25, 21) and

individual studies. In addition, a discussion on considerations for effective integration of

evidence into practice is provided with recommendations for future research in this field. For

more in-depth presentations of systematic review findings, see reviews by Gillespie et al (28),


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the National Institute for Clinical Evidence (34), the RAND report (32) and Todd and Skelton

(21).

Prevention

Most falls and resulting injuries among older persons are shown to result from a combination of

age and disease-related conditions and the individual’s interaction with their environment (25). It

is also known that risk increases exponentially for those with multiple risk factors (34).

There is good evidence to show that some interventions are more effective than others. This

information is typically reported as strength of evidence graded from A to D based the quality of

research methodology and the findings of expert review panels who balance evidence with

knowledge of clinical relevance. The following is a description of the difference between the

levels of evidence based on the Cochrane grading system:

A. at least one randomized controlled trial (RCT) or a meta-analysis of RCTs directly

concerned with reduction of falls.

B. at least one controlled study without randomization or from at least one quasi-

experimental study or extrapolated recommendation from (A) when fall risk, rather than

actual number of falls, was assessed

C. evidence from non-experimental studies or extrapolated recommendation from (A) or (B)

D. evidence from expert panels, or clinical opinion or extrapolated recommendations from

(A), (B) or (C).

The following describes interventions shown to have strong evidence presented by community,

residential and acute care settings.


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Community

i. Multifactorial approaches:

Grade A evidence exists to show that health and environment risk-factor assessment, with

interventions based on assessment results, is highly effective in reducing falls among

community-dwelling older persons who are cognitively intact (26,28). Components of successful

multifactorial approaches include environmental risk assessment and modification; balance and

gait training with appropriate use of assistive devices; medication review and modification;

managing visual concerns; and addressing orthostatic hypotension and other cardiovascular

problems.

Exercise is shown to be an important component of a multifactorial intervention, particularly

when applied consistently for ten weeks or longer (21). However, little is known about the cost

effectiveness of exercise programs for older persons and more research is needed to determine

the optimal type, duration, frequency and intensity of exercise programs (35).

Within a multifactorial approach, the components of successful health interventions focus on

post-fall clinical assessment followed by treatment involving a multidisciplinary team approach.

The following medical conditions are most often reported as target areas for fall reduction:

cardiac dysrhythmias and orthostatic hypotension; discontinuing medications that contribute to

postural hypotension or sedation and reducing the number of medications; addressing gait and

balance problems with appropriate assistive devices; rehabilitation for weakness and mobility

problems; and treatment of correctable vision and hearing deficits (25).

Environmental screening and modification programs are shown to be most effective when they

involve a multidisciplinary team and are targeted to those with a history of falling or known risk

factors (28). The precise components of successful home modification are not clearly


April 3, 2007 14

understood. Most programs target the removal hazards such as loose rugs, clutter, electrical

cords, unstable furniture and installation of bathroom grab bars, raised toilet seats, handrails on

both sides of stairways and the use of personal alarm systems to call for help if needed (25).

Evidence also exists to show that education and self-management programs when used on their

own without measures to implement change are not effective in the community setting (21). In

addition, there is a lack of evidence to show that multifactorial interventions are effective for

older persons with cognitive impairments (28).

ii. Single factor interventions:

While less effective that multifactorial approaches, there are a number of single factor

interventions shown to have a strong effect in reducing falls among community-dwelling older

persons. Single interventions that are most strongly recommended (grade A) include exercise,

home hazard assessment and modification, withdrawal of psychotropic medications and cardiac

pacing for fallers with carotid sinus hypersensitivity (26, 28)

As a single intervention strategy, the exercise approach shown to be most effective is

individually tailored muscle strength and balance retraining prescribed by a trained health

professional. Group exercise programs are shown to be less effective than individually

prescribed exercises, with the exception of a group program using the Tai Chi intervention – a

form of Chinese martial arts (36).

Home hazard assessment and modification is shown to be most effective as a single strategy

when professionally prescribed for older persons with a history of falling (28). The precise

nature of successful modifications is poorly understood and it is thought that other interventions


April 3, 2007 15

likely influenced the findings as fall reductions are observed both inside and outside of the

home.

Strategies with unknown effectiveness in single intervention approaches among older persons in

the community include cognitive and behavioural interventions, individual lower limb strength

training, home hazard modification for older persons without a history of falling, nutritional

supplementation, Vitamin D supplementation (with or without calcium), hormone replacement

therapy and correction of visual deficiency (28).

There is no clear evidence to support the use of education programs as an effective single factor

intervention but education is shown to be an important component of multifactorial interventions

(26, 31).

Residential1:

Two studies (37, 38) with grade A evidence are shown to support the effectiveness of a

multifactorial, multidisciplinary intervention in reducing falls among residents of long-term care

facilities. Interventions in these studies included staff training and guidance, changes in

medication, resident education, environmental modifications, supply and repair of aids, exercise

and use of hip protectors.

The only single interventions shown to be effective in residential settings with grade A evidence

is the use of vitamin D and calcium supplements. Those with grade B evidence include gait

training and advice on appropriate use of assistive devices; review and modification of

medications, particularly psychotropics; nutritional review and supplementation; staff education

programs; exercise programs; environmental modification; and post-fall problem solving

1 Residential setting: also known as nursing homes, care homes or long-term care facilities


April 3, 2007 16

sessions (21). The use of hip protectors as a single strategy to reduce fall-related hip fractures

in residential settings is found to have grade C evidence (21, 39).

There is no evidence to support the effectiveness of interventions to reduce falls among

residents with cognitive impairments (39).

Acute care2:

No evidence exists to support the effectiveness of multifactorial interventions in acute care

settings (28). The use of physical or pharmaceutical restraints commonly used with the intention

of reducing falls is shown not to be effective. Conversely, there is grade B evidence to support

an increased risk of injury from a fall with the use of restraints (21). Alternatives to restrains

(lower bed, mats on floor, training on exercise and safe transfers) have grade B evidence for

their effectiveness (21). Other interventions that have been tested but lack strong supporting

evidence include hospital discharge risk assessment and planning, exercise programs,

environmental modifications, use of bed alarms and the use of identification bracelets (29, 30).

The lack of evidence in acute care settings is influence by poor research methodology, small

sample sizes and the complexity of co-morbid conditions and concomitant medical treatments

(27, 29, 30). More studies are needed in this area with improved research methods.

Risk factor assessment

Risk factor assessment is an important component of multifactorial, multidisciplinary falls

interventions, yet few studies have demonstrated consistent predictive validity of such tools over

repeated testing (40, 41, 42, 43). While the authors of the RAND report on evidence-based

recommendations for falls prevention conclude that risk factor identification may be self

2 Acute care setting: also known as hospitals or rehabilitation units


April 3, 2007 17

administered or administered by a professional (32), the accuracy of such assessment is

dependent on the proven validity and reliability of the tool among the intended population. It is

well known that fall risk profiles differ considerably among well, active seniors who live in the

community; those who are frail and need support to live at home in the community; those who

require long-term care; and those who are hospitalized for acute health problems (34, 44, 45,

46, 47). A recent review of fall risk assessment tools shows that there are only a few tools with

moderate to good predictive validity and reliability that have been tested among each of these

populations – many target only subpopulations within these settings and most lack repeat testing

(43).

Future research needs

As demonstrated in the above review, there are a number of gaps and omissions in the existing

body of evidence on falls prevention. Areas identified as research priorities in falls prevention

include (48, 28, 49, 31):

• Practice-based studies conducted in ‘real-world’ settings, where evidence generated

accurately reflects the context and limitations of the setting.

• Studies to determine if falls prevention interventions are also effective in reducing fall-

related injuries.

• Studies focusing on hip protectors, special floors and other devices that minimize the

impact of injuries among older adults who fall.

• More randomized controlled trials on intervention effectiveness in residential and acute

care settings.

• Studies to uncover the contribution of culture, race/ethnicity, gender and socioeconomic

status as contributors to falls and related injury outcomes.

• Studies to identify external environmental, community and public variables that are

related to fall risk factors and remediation among older persons.


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• Studies on the effectiveness of interventions among older persons with cognitive

impairment and dementia.

• Studies in all settings to include cost/benefit analysis in evaluation of falls interventions.

• Studies on fall-related epidemiology, risk and prevention in less developed countries.

Research needs for less developed countries include improving surveillance systems for

determining the scope of the problem of falls among older persons. Of the few less developed

countries that submit data to the World Health Organization on injury, falls are shown as the

leading cause of injury-related mortality for older persons (50). Existing data also show that falls

are a major cause of hospitalization from injury in less developed countries and rank equally with

vehicle injuries in some countries (50). In addition, research is needed on the unique

contributors to falls among older people in less developed countries, including the influence of

diet, hazardous environments, the lack of accessible safety equipment and transportation, and

the role of inadequate health services of the fall risk of older persons. Injury outcome among

older persons in less developed versus more developed countries also needs to be explored,

particularly given that hip fractures are being described as an “orthopedic epidemic” in less

developed countries [Baker et al;1992: cited in (50)].

While there has been considerable growth in the number of studies there is still much to be

learned about effective and affordable falls prevention interventions. Research evidence alone

is not a solution. Consideration must also be given to the likelihood of the success of proven

interventions outside of the research context.

Practice


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Sustainable falls prevention programming depends on the successful application of policy and

research into practical implementation at the community and institutional level (51). For effective

falls prevention, older persons at risk need access to programs offered in practice settings by

those with the knowledge and resources to tailor interventions to individual risk profiles (25).

Key practice considerations for sustaining such programs include:

• the translation of research evidence into practice, and

• financial and human resources for falls prevention service delivery and evaluation

Translation of research evidence into practice:

Authors of the RAND review of evidence for falls prevention among older persons noted that all

reviewed interventions were from studies funded by research grants or demonstration projects

and none “were continued as regular programs” (32p26).

Sustainability in falls prevention will only be achieved when evidence is integrated into practice

in community and institutional settings through a process of evidence translation, defined as, “an

extended process of how research knowledge that is directly or indirectly relevant to health

behavior eventually serves the public” (52p9).

On of the barriers to effective translation of evidence exists in the traditional research process

based on the following five stages that are traditionally applied to most research (52):

1. Basic research to determine the nature of the problem and contributing factors.

2. Methods development to determine technology, equipment or research designs needed

to study the problem.

3. Efficacy trials to evaluate the desired change under ideal or laboratory conditions.

4. Effectiveness trials to evaluate the desired change under real life or usual conditions.


April 3, 2007 20

5. Dissemination research to examine and evaluate the barriers and facilitating factors to

widespread use of a proven intervention.

This staged approach is driven by scientific rigor, with little consideration of the needs of end

users until the final stage of dissemination. Examples of the application of this process in falls

prevention research where the end users are not considered include studies that test the

effectiveness of group exercise programs for community-dwelling seniors without consideration

of cost or accessibility to such programs after the study ends; or the testing of hip protectors to

reduce the risk of hip fractures from a fall without consideration to acceptability, durability,

comfort and ease of use.

While it is accepted that research is an iterative process, it is also clear that the consideration for

practical application must be addressed at each step. This can be accomplished through

partnerships between researchers, practitioners, policy makers and those directly affected by the

problem, with the goal of gaining a better understanding of each other’s context and needs.

For researchers it is important to understand that practitioners have knowledge of the

organizational culture and of the needs of those affected by the problem (52). Practitioners are

also well placed to link the application of evidence to organizational policies and to identify

supports or gaps that need to be addressed before successful adoption is possible. Translation

is also facilitated by collaboration across disciplines and sectors and with those directly affected

by the issue. This is particularly true for issues as complex as falls among older persons, where

the risk factors encompass biological, behavioural, socioeconomic and environmental

contributors.


April 3, 2007 21

A good example of collaboration for the integration of evidence to practice is found in the United

Kingdom (U.K.). Through leadership provided by the National Director for Older People,

Professor Ian Phillip, the first comprehensive framework was implemented in 2001 for health and

social services for older people. The framework, titled: Older People: National Service

Framework (5), includes the prevention of falls as one of eight overlapping and complimentary

standards for directing the quality of a comprehensive approach to person-centered health

promotion. The framework is the result of extensive consultation with older people, their

caregivers and leading professionals in the care of older persons. The framework sets out a

program of action and reform to address the problem of falls and directs action for improvements

to the quality of services to reduce fall risk among older persons. The framework includes a

process for clear accountability on the effective integration falls prevention into national

standards for health service delivery throughout the U.K. The results of this evaluation of are

provided on the Internet at (53).

An effective tool for enacting the translation of evidence into practice is the development of

clinical practice guidelines. Guidelines inform decision making and set priorities through

systematically developed statements based on an authoritative examination of current evidence.

They integrate evidence with clinical judgment and the experience of health practitioners (54). A

recent review of existing falls prevention guidelines found 21 that were consistent with this

definition, ten of which offered a complete and comprehensive guide for falls prevention clinical

decision-making, with recommendations based on a review of current evidence (55). Highlights

from this review are presented in Table 2, Appendix B.

Financial and human resources:

Adequate financial and human resources are essential to the sustainability of falls prevention

programming. As authors of the RAND report note that “Two key issues are involved in


April 3, 2007 22

sustaining falls prevention programs: obtaining and maintaining sufficient funding and availability

of programs” (32p26).

There is a consensus among those who work in the field of falls prevention that the time has

come to implement what is already well known – the most effective way to address the economic

burden of falls is to focus on prevention rather than the treatment of resulting injuries (8, 32, 56).

To accomplish this, resources need to be allocated to those who provide prevention and

intervention services (8). This can be accomplished through provision of resources for

expanding and maintaining services by the following health care professionals:

• To clinicians to conduct health-related fall risk assessments and risk factor reduction for

high risk individuals

• To pharmacists for review of medications taken by older persons, with counseling on fall

prevention

• To physiotherapists to conduct balance and gait training for older persons to reduce their

fall risk

• To occupational therapists for home assessments and modification for older persons who

have sustained falls or fall-related injuries

The need for sustainable funding for falls prevention was the conclusion of a review panel

convened at the Centres for Disease Control in Atlanta, Georgia to provide recommendations for

the future falls research agenda for the National Center for Injury Prevention and Control (NIPC).

As noted in the in the NIPC final report on the falls prevention research portfolio:

“If the nation is going to reach its falls prevention goals, what is needed now is funding to refine these strategies for populations with differing characteristics, funding to promote these strategies, research on the dissemination of these strategies, and funding for NIPC to lead the way in implementing these strategies at the federal, state, and local levels.” (49p47).


April 3, 2007 23

Funding is a policy issue that will only be supported if the programs are shown to be effective,

feasible and cost-effective. A review of the cost effectiveness of falls prevention interventions

shows that multifactorial approaches and exercise programs are cost effective (34). However,

there is a lack of consistency of indicators across studies and further investigation is needed to

standardize measures of intervention costs that include quality of life indicators, as well as

program delivery costs and costs for treating fall-related injuries (34).

Conclusions

Considerable advances have occurred over the past decade in the areas of policy, research and

practice for the prevention of falls among older persons. Examples exist in a number of

countries that demonstrate strong leadership and collaboration for the development of healthy

public policies to support falls prevention. A substantial body of knowledge exists for proven

interventions and programs, and guidelines are under development for the integration of this

knowledge into practice.

However, there are also many challenges to overcome. Policy development is sporadic, with

few examples of entrenched legislation to support stained efforts. There is a lack of evidence to

support the impact of policies and ‘real world’ practice on reducing falls and related injuries.

Significant gaps exist in research on effective prevention in institutional settings and few studies

exist that demonstrate the successful translation of evidence to practice. Few studies exist for

the prevention of falls in less developed countries and there is little attention given to challenges

faced in poorer countries to address the prevention of falls among older persons living in

poverty.


April 3, 2007 24

The effect of a fall on an older person can be a devastating event, resulting in chronic pain, loss

of independence and a reduced quality of life. The cumulative effect of falls and resulting

injuries among the growing number of older persons in most countries has the potential to reach

epidemic proportions that consume a disproportionate amount of health care resources.

Immediate action is needed to implement sound public policies through a sustained commitment

to financial and human resources to address this important issue.


April 3, 2007 25

References

1. Dodd JD, Boyd MH. Capacity building: Linking community experience to public policy. Halifax,

Nova Scotia: Population and Public Health Branch, Atlantic Regional Office, Health Canada; 2000.

2. New South Wales Department of Health. Management policy to reduce fall injury among older people: Detailed strategies and performance requirements 2003-2007 [e-book]. North Sydney, New South Wales, Australia; 2003 [cited 2006, Oct 25]. Available from: http://www.health.nsw.gov.au

3. Health Canada. The population health template: key elements and actions that define a population health approach. Strategic Policy Directoriate of the Population and Public Health; 2001 draft.

4. Nutbeam D. Health promotion glossary. WHO Collaborating Centre for Health Promotion, Department of Public Health and Community Medicine [document on the internet], University of Sydney, Australia: World Health Organization; 1998 [cited 2006, Oct 26]. Available from: http://www.who.int/hpr/NPH/docs/hp_glossary_en.pdf

5. Department of Health. National service framework for older people [document on the internet]. Department of Health, London; 2001 [cited 2006, Oct 26]. Available from: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/OlderPeoplesServices/fs/en

6. Dyson R. Preventing injury from falls: The national strategy 2005-2015. New Zealand: Accident Compensation Corporation; 2005.

7. Public Health Agency of Canada. Report on senior's falls in Canada. Ottawa: Division of Aging and Seniors; 2005. Cat. No.: HP25-1/20005E.

8. Rubenstein L, Stevens J, Scott, V. Preventing falls among older adults. In: Doll LS, Bonzo SE, Sleet DA, Mercy, JA, Haas, EN, editors. Handbook on injury and violence prevention. New York: Springer; 2006. p. 37-54.

9. Health Promotion International. Ottawa charter for health promotion. Oxford University Press. 1986;1(4): ii-v.

10. Scott VJ, Peck S, Kendall P. Prevention of falls and injuries among the elderly: a special report from the office of the provincial health officer. Victoria: Provincial Health Office, B.C. Ministry of Health Services; 2004.

11. Herman M, Gallagher E, Scott V. The evolution of seniors' falls prevention in British Columbia. Victoria: B.C. Ministry of Health; 2006.

12. British Columbia Injury Research and Prevention Unit [homepage on the Internet]. Vancouver, British Columbia: British Columbia Injury Research and Prevention Unit; 2006 [cited 2007 Feb 7]. Available from: http://www.injuryresearch.bc.ca/

13. Keeping seniors safe from falls act of 2005, S. 1531, 109th Cong. 1st session; 2005.

14. Keeping seniors safe from falls act of 2005, H.R. 5608, 109th Cong. 2nd session; 2005.


April 3, 2007 26

15. Home Safety Council. Policy makers: falls prevention [document on the Internet]. Washington, DC: Home Safety Council; 2006 [cited 2007 Feb 7]. Available from: http://www.homesafetycouncil.org/policy_makers/policy_fallslegislation_w001.aspx

16. National Public Health Partnership. National falls prevention for older people plan: 2004 onwards. Canberra, Australia: Department of Health and Ageing; 2005.

17. National Council on Aging. Center for healthy aging model health programs for communities. [homepage on the Internet]. Washington, DC: Center for Health Aging; 2007 [cited 2007 Feb 7]. Available from: http://healthyagingprograms.org/content.asp?sectionid=69

18. National Council on the Aging. Falls free: Promoting a national falls prevention action plan. Washington, DC: The National Council on the Aging; 2004

19. Fall Prevention Center of Excellence. Falls Free [homepage on the Internet]. Washington, DC: Center for Healthy Aging: 2005 [cited 2006 Oct 30]. Available from: http://www.stopfalls.org/

20. Prevention of Falls Network Europe. ProFaNE [homepage on the Internet]. Manchester, GB: ProFaNE; 2007 [cited 2007 Feb 7]. Available from: http://www.profane.eu.org/

21. Todd C, Skelton D. What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? [document on the Internet]. Copenhagen: WHO Regional Office for Europe; 2004 [cited 2007 Feb7]. Health Evidence Network report. Available from: http://www.euro.who.int/document/E82552.pdf .

22. Tang K, Nutbeam D, Kong L, Wang R, & Yan J. Building capacity for health promotion – a case study from China. Health Promot Int. 2005;20(3):285-95.

23. Stay on Your Feet WA. Stay on your feet and avoid a shattering experience [homepage on the Internet]. East Perth, WA: Gov’t of Western Australia Department of Health; 2005 [cited 2007 Feb 7]. Available from: http://www.stayonyourfeet.com.au/

24. Scott V, Lockhart S, Gallagher E, Smith D et al. Canadian Falls Prevention Curriculum©,

Vancouver, BC: BC Injury Research and Prevention Unit; [unpublished work].

25. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing, 2006;35 Suppl 2:ii37-ii41

26. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ, 2004;328(7441):680.

27. Evans D, Hodgkinson B, Lambert L, Wood J, Kawanko, I. Falls in acute hospitals - a systematic review. Adelaide, South Australia: The Joanna Briggs Institute; 1998.

28. Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev(4); 2005. CD000340.

29. Hill K, Smith R, Murray K, Sims J, Gough J, Darzins P, et al. An analysis of research on preventing falls and falls injury in older people: community, residential care and hospital settings. Australia: Prepared by the National Ageing Research Institute for the Commonwealth Department of Health and Aged Care; 2000 [2004 update]


April 3, 2007 27

30. Oliver D, Hopper A, Seed P. Do hospital fall prevention programs work? A systematic review. J Am Geriatr Soc. 2000;48(12):1679-89.

31. Scott V, Dukeshire S, Gallagher E, Scanlan A. A best practices guide for the prevention of falls among seniors living in the community (prepared on behalf of the federal/provincial/territorial committee of officials (seniors) for the ministers responsible for seniors (H39-591/2001E). Health Canada: Division of Aging and Seniors; 2001.

32. Shekelle P, Maglione M, Chang J, Mojica W, Morton S, et al. Falls Prevention Interventions in the Medicare Population. RAND Evidence Report and Evidence-Based Recommendations (Contract #500-98-0281). Baltimore: U.S. Department of Health and Human Services; 2003.

33. National Institute for Health and Clinical Excellence (NICE). Clinical practice guideline for the assessment and prevention of falls in older people [e-book]. London, England: Royal College of Nursing; 2004 [cited 2006 Oct 27]. Available from: www.nice.org.uk/page.aspx?o=cg021fullguideline

34. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-7.

35. Gardner MM, Robertson MC, Campbell AJ. Exercise in preventing falls and fall related injuries in older people: a review of randomised controlled trials. Br J Sports Med. 2000;1(34):7-17.

36. Wolf SL, Barnhart HX, Kutner NG, McNeely E, Coogler C, Xu T. Reducing frailty and falls in older persons: An investigation of tai chi and computerized balance training. J Am Geriatr Soc. 1996;44(5):489-97.

37. Becker C, Kron M, Lindemann U, Sturm E, Eichner B, Walter-Jung B, et al. Effectiveness of a multifaceted intervention on falls in nursing home residents. J Am Geriatr Soc. 2003;51(3):306-313.

38. Jensen J, Nyberg L, Gustafson Y, Lundin-Olsson L. Fall and injury prevention in residential care-effects in residents with higher and lower levels of cognition. J Am Geriatr Soc. 2003;51(5):627-35.

39. Kannus P, Parkkari J, Niemi S, Pasanen M, Palvanen M, Jarvinen M, et al. Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med. 2000;343(21):1506-13.

40. Myers H. Hospital fall risk assessment tools: a critique of the literature. Int J Nurs Pract.

2003;9(4):223-35.

41. Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004;33:122-30.

42. Perell KL, Nelson A, Goldman RL, Luther SL, Prieto-Lewis N, Rubenstein LZ. Fall risk assessment measures: an analytic review. J Gerontol A Biol Sci Med Sci. 2001;56A(12):M761-M766.


April 3, 2007 28

43. Scott V, Votova K, Scanlan A, Close J. A systematic review of multifactorial and functional mobility assessment tools for fall risk among older adults in community, home support, long-term and acute care settings. Age Ageing 2007; 33(2):130-39.

44. King MB, Tinetti ME. Falls in community-dwelling older persons. J Am Geriatr Soc. 1995;43:1146-54.

45. Brandis S, Lewis S, Simpson T, Tuite A. Falls prevention: best practices guidelines for public hospitals and state government residential aged care facilities (version 3). Queensland, Australia: Queensland Government; 2003.

46. Fleming BE, Pendergast DR. Physical condition, activity pattern, and environment as factors in falls by adult care facility residents. Arch Phys Med Rehabil. 1993;74(6):627-30.

47. Kiely DK, Kiel DP, Burrows AB, Lipsitz LA. Identifying nursing home residents at risk of falling. J Am Geriatr Soc. 1998;46:551-5.

48. Centers for Disease Control and Prevention. Peer Review of the Elderly Fall Prevention Research Portfolio April 27-28, 2006, Atlanta, Georgia: DRAFT Record of the Proceedings. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention; 2006.

49. National Center for Injury Prevention and Control. Final Report: Assessment of the CDC National Center for Injury Prevention and Control’s Older Adult Fall Prevention Research Portfolio. Atlanta: Centers for Disease Control and Prevention; 2005.

50. Barass P, Smith G, Baker S, Mohan D. Injury prevention: An international perspective. Epidemiology, surveillance, and policy. New York, Oxford: Oxford University Press; 1998.

51. Cwikel J, Barnea T. Accident prevention among the elderly: moving from HFA health policy to social strategy. J Aging Soc Policy. 1991;3(4):93-114.

52. Simons-Morton BG, Winston FK. Translational research in child and adolescent transportation safety. Eval Health Prof. 2006;29(1):33-64.

53. Department of Health. Older people’s services [list on the Internet]. London: Department of Health; 2007 [cited 2007 Feb 7]. Available from: www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/OlderPeoplesServices/fs/en.

54. National Guideline Clearinghouse. Inclusion Criteria [document on the Internet]. U.S Dept. of Health and Human Services: Agency for Healthcare Research and Quality [updated 2007 Feb 5; cited 2006 Feb 7]. Available from: www.guideline.gov/about/inclusion.aspx

55. Scott V, Duncan B. Clinical guidelines for seniors falls prevention. Vancouver: British Columbia Injury Research and Prevention Unit; 2006 [cited 2007 Feb 7]. Available from: http://www.injuryresearch.bc.ca.

56. Cloutier E, Alber T. The Economic Burden of Unintentional Injury in Canada. Toronto: Smartrisk, B.C. Injury Research and Prevention Unit; 2001.

57. American Geriatrics Society, British Geriatrics Society, & American Academy of Orthopedic Surgeons Panel on Falls Prevention. Guidelines for the prevention of falls in older


April 3, 2007 29

persons. J Am Geriatr Soc. 2001:49(5):664-72. [cited 2006 Oct 26] Available from: www.americangeriatrics.org/products/positionpapers/Falls.pdf

58. American Medical Directors Association. Falls and falls risk: clinical practice guideline. American Directors Association; 2003.

59. Australian Council for Safety and Quality in Health Care. Preventing falls and harm from falls in older people: best practice guidelines for Australian hospitals and residential aged care facilities [document from the Internet]. Canberra, Australia: Commonwealth of Australia; 2005 [cited 2006 Oct 27]. Available from NSW Falls Injury Prevention Network www.powmri.edu.au/fallsnetwork/safety_and_quality_council_docum.htm

60. Feder G, Cryer C, Donovan S, Carter Y. Guidelines for the prevention of falls in people over 65. BMJ, 2000;321:1007-11.

61. Lyons SS. Fall prevention for older adults: Evidence-based protocol. Iowa City: The University of Iowa Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core; 2004.

62. Moreland J, Richardson J, Chan DH, O'Neill J, Bellissimo A, Grum RM, Shanks L. Evidence-based guidelines for the secondary prevention of falls in older adults. Gerontology. 2003;49(2):93-116.

63. Registered Nurses’ Association of Ontario. Prevention of falls and fall injuries in the older adult. Toronto, Ontario: Registered Nurses’ Association of Ontario; 2005 [cited 2006 Oct 27]. Available from: www.rnao.org/bestpractices/PDF/BPG_Falls_rev05.pdf

64. Queensland Government. Falls prevention best practice guidelines for public hospitals and state government residential aged care facilities incorporating a community integration supplement. Queensland, Australia; 2003 [cited 2006 Oct 26]. Available from: www.health.qld.gov.au/fallsprevention/best_practice/falls_best_practice.pdf

65. Resnick B. Preventing falls in acute care. In: Zwicker D, editor. Geriatric nursing protocols for best practice (2nd ed.) New York: Springer Publishing Company; 2003. p. 141-163.

66. Chan D, Moser A. Falls in the elderly. Educational Module Vol 11(9) Practice Based Learning Programs [document from the Internet]. Hamilton, Ontario: McMaster University; 2003 [cited 2006, Oct 27]. Available from http://www.fmpe.org/en/services/modules.html

67. Butt C. Falls risk: a resource for rural health practice [document on the Internet]. Deakin West, ACT: Prince of Wales Medical Research Institute, Association for Australian Rural Nurses; 2004 [cited 2006 Oct 27]. Available from: www.aarn.asn.au/projects/FallsProject.htm

68. Mahoney JE. Falls in the post hospitalization period (continuing medical education activity) [document on the internet]. Johns Hopkins University School of Medicine. Clinical Geriatrics. 2005:13:39-48. Available from [cited 2007 Feb 7] http://www.clinicalgeriatrics.com/cg/attachments/3774.pdf

69. Laird R, Robinson B. Falls in older adults: evaluation and management in primary practice. (Tool Kit: The Practicing Physician Education Project) [document on the Internet].


April 3, 2007 30

Practicing Physician Education in Geriatrics; 2001 [cited 2007 Feb 7]. Available from: http://www.gericareonline.net/tools/eng/falls/index.html

70. VA National Center for Patient Safety (US). National center for patient safety 2004 falls toolkit [document on the Internet]. United States Department of Veterans Affairs; 2004 [cited 2007 Feb 7]. Available from: http://www.va.gov/ncps/SafetyTopics/fallstoolkit/

71. Cadzow L, Hill K, Shinners J, Dyt T, Minogue R, Batterham R. Falls prevention: it's no accident [CDRom]. Sandringham, Victoria, Australia: Central Bayside Division of General Practice; 2005.

72. Overstall PW. Falls and bone health: interactive training program [CDRom] Hereford, England: Kiss of Life Multimedia; 2002.

73. Royal College of Nursing Australia. General practice nurse falls prevention [CDRom] Australia: Royal College of Nursing; 2005.

74. Scott V, Swan L, Bawa H, Votova K, Gallagher E. Strategies and actions for independent living: 1) Falls prevention community health workers manual, 2) Falls prevention home health professionals manual. Vancouver, British Columbia: BC Injury Research and Prevention Unit; 2006.

75. Tideiksaar R. Managing falls in assisted living [CDRom]. Baltimore, MD: Essential Falls Management Series, Health Professionals Press Inc.; 2006.


April 3, 2007 31

Appendix A

Table 1: Falls Prevention Curricula (24)

Curriculum Title General Description

Falls in the elderly (66). (Chan & Moser, 2003).

Self-directed 15-page module based on case studies. For physicians. Includes a post-test. Canadian.

Falls risk: A resource for rural health practice (67). (Butt, 2004)

Resource for nurses and other health care professionals who provide services to older adults in rural and remote Australia. Linked to the “Quick Screen” clinical assessment tool by S. Lord and A. Tiedemann. Focus on early identification and prevention of fall risk within clinical practice. 92 pages.

Falls in the post hospitalization period (68). (Mahoney 2005).

One-hour self-directed course for physicians. Focused on the prevention in the post hospitalization period. American. 8 pages.

Falls in older adults: Evaluation and management in primary practice (69). (Laird & Robinson 2001).

For physicians. Based on the Guideline for the Prevention of Falls in Older Persons (American Geriatrics Society/British Geriatrics Society/American Academy of Orthopedic Surgeons, 2001) and includes a physician toolkit and handouts for use with geriatric patients.

National center for patient safety 2004 falls toolkit (70). (VA National Center for Patient Safety, 2004).

For staff of facilities at one of three stages: 1) starting new falls program 2) in beginning stages of falls program 3) comprehensive falls program in place. American. 121 pages.

Falls prevention: It's no accident (71). (CDRom) (Cadzow, Hill, Shinners et al 2005).

A CDRom for use by physicians in the community. Video component profiles two patients receiving a multi-targeted approach to risk screening, assessment and management facilitated by a physician-led, multidisciplinary health care team. Informational booklet on fall risks, risk assessment, prevention and the multidisciplinary approach. Australian.

Falls and bone health: Interactive training program (72). (CDRom) (Overstall, 2002).

An interactive CD-Rom containing approximately 3 hours of tutorial study and printable material covering approximately 4 hours of reading. This course is at a post-secondary training level and suitable for physicians, nurses and occupational therapists. From England.

General practice nurse falls prevention (73). (CDRom) (Royal College of Nursing Australia, 2005).

A 60-minute, self-paced CD course for nurses covering assessment, management and monitoring of clients who present at risk of falls or who have had a fall. 40 pages.

Strategies and actions for independent living - falls prevention for clients of home support services (74). (Scott, Swan, Bawa et al., 2006).

For home health professionals and community health workers. The program promotes a multifactorial, collaborative approach to falls risk assessment and prevention for clients of publicly-funded home support services. Two manuals of150 pages each. Canadian.

Essential Falls Management Series - Managing falls in assisted living (75). (CDRom) (Tideiksaar, 2006).

This CDRom prepares staff members in assisted living facilities to better understand and manage residents’ risks for falling. Tools are included. American.


April 3, 2007 32


April 3, 2007 33

Appendix B

Table 2: Falls Prevention Clinical Guidelines (55)

Guideline Title and Source General Description

Guidelines for the prevention of falls in older persons (57). (American Geriatrics Society, British Geriatrics Society & American Academy of Orthopedic Surgeons, 2001).

Resource to assist health professionals in the assessment and management of older persons at risk of falling. Algorithm in this guideline is frequently cites and adopted for use within other guidelines. Based on levels of evidence. 9 pages. Update in progress.

Falls and falls risk: Clinical practice guideline (58). (American Medical Directors Association, 2003)

Expert consensus on quality of care specific to residents of long-term care facilities. Core steps present in an algorithm to guide staff decision-making for fall risk assessment and prevention. Use of levels of evidence not explicit. 15 pages.

Preventing falls and harm from falls in older people: Best practice guidelines for Australian hospitals and residential aged care facilities (59). (Australian Council for Safety and Quality in Health Care, 2005).

Applicable to long-term care and acute settings. A broad approach, from the strategic level to the specifics of applying interventions at the point of care. Based on levels of evidence. 239 pages.

Guidelines for the prevention of falls in people over 65 (60). (Feder, Cryer, Donovan et al., 2000).

Compilation results from systematic reviews and updates of literature from all care settings up to 1998. 5 pages.

Fall prevention for older adults: Evidence-based protocol (61). (Lyons, 2004).

Applicable to community, long-term and acute care settings. Designed for practical application, with tools and tests available in the appendices. Designed using levels of evidence. 60 pages.

Evidence-based guidelines for the secondary prevention of falls in older adults (62). (Moreland, Richardson, Chan et al., 2003).

Analysis of limitations of other falls guidelines with aim of filling identified gaps through a search of levels of evidence and summary. 23 pages.

Clinical practice guideline for the assessment and prevention of falls in older people (33). (National Institute for Health and Clinical Excellence, 2004).

In-depth review of evidence on fall risk, prevention, assessment and clinical guidelines, profiling community and long-term care settings. Based on levels of evidence. 240 pages (approx.)

Prevention of falls and fall injuries in the older adult (63). (Registered Nurses’ Association of Ontario, 2005).

Designed for use by nurses working in long-term and acute care settings. Best practice guidelines to enhance skills and abilities of nurses for risk assessment and prevention among older persons. Use of levels of evidence not explicit. 56 pages

Falls prevention best practice guidelines for public hospitals and state government residential aged care facilities incorporating a community integration supplement (64). (Queensland Gov., 2003).

Applicable to long-term and acute care settings covering fall risk assessment and prevention, and injury prevention strategies. Includes a community integration supplement. Use of levels of evidence not explicit. 116 pages.

Preventing falls in acute care (65). (Resnick, 2003).

Designed for use by nurses working in the acute care settings. Introductory level. Includes tools. Use of levels of evidence not explicit. Book chapter.

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