Falls - risk assessment

Source:
Clinical Knowledge Summaries - CKS
Publication date:
01 January 2019

Abstract

Falls - risk assessment Last revised in January 2019 Next planned review by December 2024 Summary Back to topFalls - risk assessment: Summary A fall is defined as an event which causes a person to, unintentionally, rest on the ground or other lower level.For the purpose of this CKS topic, a simple fall is defined as one occurring as a result of a chronic impairment of cognition, vision, balance, or mobility. It is distinguished from a collapse caused by an acute medical problem, such as an acute arrhythmia, transient ischaemic attack, or vertigo.Falls are common in older people, especially those aged 65 years and over, and the prevalence increases with age. The risk of falling is multifactorial, and prevention is usually based on assessing multiple risk factors. A history of falls is one of the strongest risk factors for a fall, and all older people in regular contact with healthcare professionals should be asked routinely whether they have fallen in the past year.Other risk factors for falls in older people include:Conditions that affects mobility or balance, such as arthritis, diabetes, incontinence, stroke, syncope, or Parkinson's disease.Other conditions, including muscle weakness, poor balance, visual impairment, cognitive impairment, depression, and alcohol misuse.Polypharmacy, or the use of psychoactive drugs (such as benzodiazepines) or drugs that can cause postural hypotension (such as anti-hypertensive drugs).Home hazards, such as loose rugs or mats, poor lighting, wet surfaces (especially in the bathroom), and loose fittings (such as handrails).About 40–60% of falls result in major lacerations, traumatic brain injuries, or fractures. Other complications of falls include distress, pain, loss of self-confidence, reduced quality of life, loss of independence, and mortality. Older people who present for medical attention because of a fall, report recurrent falls in the past year, or have other risk factors for falls should be assessed for gait and balance abnormalities (for example by using the Timed Up & Go test and/or the Turn 180° test).A multifactorial risk assessment by an appropriately skilled and experienced clinician (usually in a specialist falls service) should be offered to older people who have had one or more falls in the past year or demonstrate abnormalities of gait and/or balance. This assessment should be part of an individualized, multifactorial intervention.A multifactorial risk assessment may include assessing for home hazards, visual impairment, and drug treatments.Interventions commonly offered by specialist falls services include strength and balance training, home hazard assessment and intervention, vision assessment and referral, and medication review (with modification or withdrawal).People who do not have an indication to be referred for a multifactorial risk assessment should be reassessed at least annually. Have I got the right topic? Back to topHave I got the right topic? From age 65 years onwards.This CKS topic is based on the National Institute for Health and Care Excellence guideline Falls. Assessment and prevention of falls in older people [NICE, 2013a].This CKS topic covers the identification and management of the risk of falling in older people in the community.This CKS topic does not cover the identification and management of the risk of falling in older people in hospital or the management of a collapse caused by an acute medical problem, such as arrhythmias, stroke, transient ischaemic attack, or vertigo.There are separate CKS topics on Osteoporosis - prevention of fragility fractures, Stroke and TIA, Benign paroxysmal positional vertigo, Vertigo, and Palpitations.The target audience for this CKS topic is healthcare professionals working within the NHS in the UK and providing first contact or primary healthcare. How up-to-date is this topic? Back to topHow up-to-date is this topic? Back to top Changes Changes January 2019 — reviewed. A literature search was conducted in January 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made. Back to top Previous changes Previous changes January 2014 — reviewed. A literature search was conducted in January 2014 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. The following changes were made:A definition section has been added in background information to clarify that this topic covers 'simple falls' as opposed to a collapse due to an acute medical problem.The scope of this CKS topic has been revised to clarify the above, and additional links to relevant CKS topics have been included.The section on assessing the risk of falls has been rewritten for clarity.September 2008 to June 2009 — this is a new CKS topic based on the National Collaborating Centre for Nursing and Supportive Care guideline Clinical practice guideline for the assessment and prevention of falls in older people [National Collaborating Centre for Nursing and Supportive Care, 2004], commissioned by the National Institute for Health and Clinical Excellence (NICE). Back to top Update Update Back to top New evidence New evidence Evidence-based guidelinesNo new evidence-based guidelines since 1 January 2019.HTAs (Health Technology Assessments)No new HTAs since 1 January 2019.Economic appraisalsNo new economic appraisals relevant to England since 1 January 2019.Systematic reviews and meta-analysesNo new systematic reviews since 1 January 2019.Primary evidenceNo new randomized controlled trials since 1 January 2019. Back to top New policies New policies No new national policies or guidelines since 1 January 2019. Back to top New safety alerts New safety alerts No new safety alerts since 1 January 2019. Back to top Changes in product availability Changes in product availability No changes in product availability since 1 January 2019. Goals and outcome measures Back to topGoals and outcome measures Back to top Goals Goals To support primary healthcare professionals to:Make an accurate assessment of a person at risk of falling.Refer people at risk of falling for a multidisciplinary falls assessment.Ensure that people assessed as being at increased risk of falling are offered an individualised multifactorial intervention. Ensure that people who do not have an indication to be referred for a multifactorial risk assessment are reassessed at least annually.Provide appropriate information and advice on reducing the risk of falls. Back to top Outcome measures Outcome measures No outcome measures were found during the review of this topic. Back to top Audit criteria Audit criteria No audit criteria were found during the review of this topic. Back to top QOF indicators QOF indicators No QOF indicators were found during the review of this topic. Back to top QIPP - Options for local implementation QIPP - Options for local implementation No QIPP indicators were found during the review of this topic. Back to top NICE quality standards NICE quality standards NICE Quality standards: Falls in older peopleStatement 1: Older people are asked about falls when they have routine assessments and reviews with health and social care practitioners, and if they present at hospital. Statement 2:  Older people at risk of falling are offered a multifactorial falls risk assessment. Statement 3:  Older people assessed as being at increased risk of falling have an individualised multifactorial intervention. Statement 7:  Older people who present for medical attention because of a fall have a multifactorial falls risk assessment. Statement 8:  Older people living in the community who have a known history of recurrent falls are referred for strength and balance training. Statement 9:  Older people who are admitted to hospital after having a fall are offered a home hazard assessment and safety interventions. [NICE, 2017] Background information Back to topBackground information Back to top Definition What is it? A fall is defined as an event which causes a person to, unintentionally, rest on the ground or other lower level [BMJ, 2016; PHE, 2018]. For the purpose of this CKS topic, a simple fall is defined as one occurring as a result of a chronic impairment of cognition, vision, balance, or mobility. It is distinguished from a collapse caused by an acute medical problem, such as an acute arrhythmia, transient ischaemic attack, or vertigo. Back to top Prevalence How common is it? Falls are common in older people, especially those aged 65 years and over, and the prevalence increases with age [BMJ, 2016].About 30% of people aged 65 years and over have a fall at least once each year, increasing to 50% in people aged 80 years and over [NICE, 2013a; PHE, 2018].According to the Public Health Outcomes Framework (PHOF), in 2016–2017 there were around 210,553 falls-related emergency hospital admissions among people aged 65 years and over, with around 141,362 (67%) of these people aged 80 years and over. Back to top Risk factors What are the risk factors? The risk of falling is multifactorial, and prevention is usually based on assessing multiple risk factors [NICE, 2013a].A history of falls is one of the strongest risk factors for a fall, and all older people in regular contact with healthcare professionals should be asked routinely whether they have fallen in the past year.Other risk factors for falls in older people include [BMJ, 2016; PHE, 2017; Haddad, 2018; Hopewell, 2018; PHE, 2018; BMJ, 2019]:A history of falls — after a first fall, people have a 66% chance of having another fall within a year [BMJ, 2016].Conditions that affects mobility or balance, such as arthritis, diabetes, incontinence, stroke, syncope, or Parkinson's disease.Other conditions, including muscle weakness, poor balance, visual impairment, cognitive impairment, depression, and alcohol misuse.Polypharmacy, or the use of psychoactive drugs (such as benzodiazepines) or drugs that can cause postural hypotension (such as anti-hypertensive drugs).Environmental hazards, such as loose rugs or mats, poor lighting, uneven surfaces, wet surfaces (especially in the bathroom), loose fittings (such as handrails), and poor footwear.The more risk factors a person has, the greater their risk of falling. Over 65% of people aged 65 years and over have two or more long-term conditions (multimorbidity) [PHE, 2017]. Falls can also be a sign of underlying health issues, such as frailty [PHE, 2017].  Back to top Complications What are the complications? Falls are the main cause of injury, injury-related disability, and death in older people [BMJ, 2016; Moncada, 2017].About 40–60% of falls result in major lacerations, traumatic brain injuries, or fractures [BMJ, 2016].About 5% of falls in older people who live in the community result in a fracture or hospitalization [NICE, 2013a].About 95% of all hip fractures are caused by falls [BMJ, 2016]. Following a hip fracture, short and long-term outlooks are generally poor, with an increased one-year mortality of between 18–33% and negative effects on daily living activities, such as shopping and walking. A review of long-term disability found that following a hip fracture around 20% of people entered long-term care in the first year after the fracture [PHE, 2018]. The risk of getting a fragility fracture depends on the person's risk of falls, their bone strength (determined by bone mineral density [BMD]), and the presence of other risk factors, such as age (risk increases with age and is at least partly independent of BMD), use of corticosteroids, and smoking. For more information, see the CKS topic on Osteoporosis - prevention of fragility fractures.A longitudinal study that examined the consequences of falls in older men and women found that 68% of people who fell reported some injury, 24% required healthcare, 35% reported functional decline, and more than 15% of people reported impairment of social and physical activities [Stel, 2004; BMJ, 2016].Other complications of falls include distress, pain, loss of self-confidence, reduced quality of life, and loss of independence [PHE, 2017; PHE, 2018]. In addition, falls can trigger a cycle of fear of falls (in more than 25% of cases) [BMJ, 2016], leading to activity avoidance, social isolation, increasing frailty, functional decline, reduced quality of life, depression, and institutionalization [BMJ, 2016; PHE, 2017].Falls and fractures place a huge financial burden on the NHS.The total cost of fragility fractures to the UK has been estimated at £4.4 billion, which includes £1.1 billion for social care and £2 billion for hip fractures [PHE, 2017; PHE, 2018]. Unaddressed fall hazards in the home are estimated to cost the NHS in England £435 million [PHE, 2018].  Management Back to topManagement Scenario: Falls - risk assessment: covers the identification and management of the risk of falling in people aged 65 years and over. Back to top Scenario: Falls - risk assessment Scenario: Falls - risk assessment From age 65 years onwards. Back to top Assessing risk of falling How should I assess people for risk of falling? Identify people aged 65 years and over who:Have had one or more falls in the last 12 months.Ask about how often the person has fallen, the circumstances in which the fall(s) occurred (such as place, time, activity being performed, and preceding symptoms [for example light headedness or loss of consciousness]), and the consequences of the fall(s) (such as injuries, fear of falling, difficulty performing daily activities, activity restriction, and/or pain). If possible, obtain an eye-witness account.This will help to distinguish a simple fall (caused by a chronic impairment of cognition, vision, mobility, or balance) from a collapse (caused by an acute medical problem, for example, arrhythmias, transient ischaemic attack, or vertigo).Are at risk of falling because they:Have cognitive impairment.Have a visual impairment.Have a condition that affects mobility or balance, such as arthritis, diabetes, incontinence, stroke, or Parkinson's disease. For more information, see the CKS topics on Rheumatoid arthritis, Diabetes - type 1, Diabetes - type 2, Incontinence - urinary, in women, Stroke and TIA, and Parkinson's disease.Are taking multiple drugs, psychoactive drugs (such as benzodiazepines), or drugs that can cause postural hypotension (such as anti-hypertensive drugs).Have a fear of falling.Are physically frail — tools such as the Electronic Frailty Index (eFI) may be used to identify people aged 65 years and over who may be living with moderate or severe frailty.Have other risk factors for falling, such as alcohol misuse, depression, or environmental hazards. For more information, see the CKS topics on Alcohol - problem drinking and Depression.For people who have had one or more falls or are considered to be at risk of a fall, assess their gait and balance, for example by using the Timed Up & Go test and/or the Turn 180° test.Offer a multifactorial falls risk assessment by an appropriately skilled and experienced clinician (usually in a specialist falls service) to all people aged 65 years and over who:Have had two or more falls in the last 12 months, orPresent for medical attention following a fall, orCannot perform, or perform poorly on, the Timed Up & Go test and/or the Turn 180° test.For people who do not have an indication to be referred for a multifactorial risk assessment:Reassess at least annually.Provide verbal and written information on reducing the risk of falls, for example:The AgeUK (www.ageuk.org.uk) information guide Staying steady: Keep active and reduce your risk of falling.  The Chartered Society of Physiotherapy (www.csp.org.uk) booklet Get up and go - a guide to staying steady. Back to top Timed Up & Go test and Turn 180° test Timed Up & Go test and Turn 180° test Timed Up & Go testTime the person getting up from a chair without using their arms, walking 3 metres, turning around, returning to the chair, and sitting down. If the person usually uses a walking aid, this can be used during the test. During the test, observe the person's postural stability, gait, stride length, and sway [CDC, 2013].Standardized cut-off scores to predict risk of falling have not yet been established [American College of Rheumatology, 2015]. However, a score of 12—15 seconds or more (depending on the study) has been shown to indicate high risk of falls in older people. Use clinical judgement to interpret the test, and consider the time taken to complete the test as well as other factors, such as age of the person, the type of footwear, the use of a walking aid, and the general health of the person [American College of Rheumatology, 2015].The Centers for Disease Control and Prevention (CDC) has a published Timed Up & Go test assessment checklist, and the Chartered Society of Physiotherapy (CSP) has a video demonstrating the timed up and go test.Turn 180° test  Ask the person to stand up and step around until they are facing the opposite direction. If the person takes more than four steps, further assessment should be considered [Nevitt, 1989; Simpson et al, 2002]. Back to top Basis for recommendation Basis for recommendation These recommendations are based largely on the National Institute for Health and Care Excellence (NICE) guideline Falls. Assessment and prevention of falls in older people [NICE, 2013a] and are supported by expert opinion in review articles on preventing falls in older people [BMJ, 2016; Moncada, 2017; Haddad, 2018; BMJ, 2019].Identifying people who have had one or more falls or are considered to be at risk of fallingNICE found evidence suggesting that a previous fall and/or gait and balance disorders are the strongest risk factors for falls. The other risk factors were reported as statistically significant [NICE, 2013a].CKS recommends distinguishing between a simple fall and a collapse as the management for both will differ.Evidence from a systematic review of 28 observational studies and one randomized controlled trial was unable to conclusively show an association between any specific class of drug and falls. However, there was weak evidence of an association between falls and benzodiazepines, antidepressants, and antipsychotics [Hartikainen et al, 2007].The recommendation that tools such as the Electronic Frailty Index (eFI) may be used to identify people aged 65 years and over who may be living with moderate or severe frailty is based on the Updated guidance on supporting routine frailty identification and frailty care through the GP Contract 2017/2018 published by NHS England [NHS England, 2017].Assessing gait and balanceThere is a lack of evidence regarding which assessment tool is most predictive of falls and therefore most useful.NICE reviewed the evidence on the utility, feasibility, and acceptability of a range of key assessment tools and concluded that the Timed Up & Go test and the Turn 180° test are pragmatic, can be used in any setting, and require no special equipment [NICE, 2013a].Evidence from studies of older people living in the community or attending a day hospital indicates that the Timed Up & Go test [Podsiadlo and Richardson, 1991; Shumway-Cook et al, 2000; Morris et al, 2007; Alexandre et al, 2012] and the Turn 180° test [Nevitt, 1989; Simpson et al, 2002] are useful for predicting the risk of falling.Offering a multifactorial risk assessmentBased on evidence from two systematic reviews, one of which was published by the Cochrane Collaboration, NICE recommends a multifactorial falls risk assessment for older people at risk of falling, to identify and address future risks [NICE, 2013a].Reassessing falls risk annuallyExperts from the American and British Geriatrics Societies recommend that all adults aged over 65 years be screened annually for a history of falls or balance impairment [American Geriatrics Society and British Geriatrics Society, 2011].Although this is not specifically stated in the NICE guideline, it is implied by the recommendation that older people in regular contact with healthcare professionals should be asked routinely whether they have fallen in the past year [NICE, 2013a].Providing verbal and written information on reducing the risk of fallsThis recommendation is based on what CKS considers to be good clinical practice. Back to top Managing older people at risk of falling How should I manage older people assessed to be at risk of falling? Offer a multifactorial risk assessment by an appropriately skilled and experienced clinician (usually in a specialist falls service) to 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. This assessment should be part of an individualized, multifactorial intervention.A multifactorial risk assessment may include assessment of the following:History of falls.Gait, balance and mobility, and muscle weakness.Osteoporosis risk.Perceived impaired functional ability and fear relating to falling.Visual impairment.Cognitive, neurological, and cardiovascular problems.Urinary incontinence.Home hazards.Polypharmacy (the use of multiple drugs) and the use of drugs that can increase the risk of falls, for example, drugs that can cause postural hypotension (such as antihypertensive drugs) and psychoactive drugs (such as benzodiazepines and antidepressants).Interventions commonly offered by specialist falls services include:Strength and balance training — most likely to benefit older community-dwelling people with a history of recurrent falls or balance and gait deficit.Home hazard assessment and intervention — should be offered to older people who have received treatment in hospital following a fall.Vision assessment and referral.Medication review — psychotropic drugs are reviewed, with specialist input if appropriate, and discontinued if possible. Back to top Basis for recommendation Basis for recommendation These recommendations are based largely on the National Institute for Health and Care Excellence (NICE) guideline Falls. Assessment and prevention of falls in older people [NICE, 2013a] and are supported by expert opinion in review articles on preventing falls in older people [BMJ, 2016; Moncada, 2017; Haddad, 2018; BMJ, 2019].Multifactorial risk assessmentNICE recommends a multifactorial falls risk assessment for older people at risk of falling, to identify and address future risks [NICE, 2013a].An evidence-based report on falls prevention, identified by NICE, concluded that although not proven, it makes clinical sense that a comprehensive risk assessment should be targeted to people who have had a fall or are at high risk of a fall as they have most to gain [Shekelle et al, 2002].However, NICE points out that the benefit of a multifactorial assessment (that is, reduced risk of falls) only appears to be achieved if it is followed by referral for an individualized, multifactorial intervention [NICE, 2013a].A Cochrane systematic review (search date: March 2012) that assessed interventions for preventing falls in older people living in the community (n = 79,193) found that a multifactorial risk assessment followed by multifactorial interventions reduced rate of falls, but not risk of falling [Gillespie et al, 2012].Individualized, multifactorial interventionThe NICE guideline does not give specific information on what a falls service should offer a person identified to be at risk of falling. However, the guideline does state that a personalized intervention aimed at promoting independence and improving physical and psychological function should be offered. Strength and balance training, home hazard and vision assessment and intervention, and medication review are common components in successful multifactorial intervention programmes [NICE, 2013a].A Cochrane systematic review (search date: March 2012) that assessed interventions for preventing falls in older people living in the community (n = 79,193) found good evidence that these (and other interventions) reduce the rate and/or risk of falls [Gillespie et al, 2012].A second Cochrane systematic review (search date: 12 June 2017) that assessed multifactorial and multiple component interventions for preventing falls in older people living in the community  (n = 19,935) found that [Hopewell, 2018]:Multifactorial interventions may reduce the rate of falls compared with usual care or attention control. However, there may be little or no effect on other fall‐related outcomes.Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control.Interventions not recommendedNICE does not currently recommend the following interventions because there is insufficient or conflicting evidence to support their use [NICE, 2013a]:Low intensity exercise combined with incontinence programmes.Group exercise (untargeted).Cognitive/behavioural interventions.Referral for correction of visual impairment.Hip protectors.Brisk walking (no evidence).Vitamin D.A Cochrane systematic review (search date: March 2012) that assessed interventions for preventing falls in older people living in the community (n = 79,193) found that overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment [Gillespie et al, 2012]. Supporting evidence Back to topSupporting evidence This CKS topic is based largely on the National Institute for Health and Care Excellence (NICE) guideline Falls. Assessment and prevention of falls in older people [NICE, 2013a]. For a detailed discussion of the evidence NICE used to base their recommendations, see the full NICE guidance. How this topic was developed Back to topHow this topic was developed This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website. Back to top Search strategy Search strategy Scope of searchA full literature search was not required as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guideline Falls. Assessment and prevention of falls in older people [NICE, 2013b].Search datesJanuary 2014 - January 2019Key search termsThe following search strategy was used in The Cochrane Library databases to identify relevant systematic reviews. #1    MeSH descriptor: [Accidental Falls] explode all trees#2    (fall or falls or falling):ti,ab,kw#3    #1 or #2Sources of guidelines National Institute for Health and Care Excellence (NICE) Scottish Intercollegiate Guidelines Network (SIGN) Royal College of Physicians Royal College of General Practitioners Royal College of Nursing NICE Evidence Health Protection Agency World Health Organization National Guidelines Clearinghouse Guidelines International Network TRIP database GAIN NHS Scotland National Patient Pathways New Zealand Guidelines Group Agency for Healthcare Research and Quality Institute for Clinical Systems Improvement National Health and Medical Research Council (Australia) Royal Australian College of General Practitioners British Columbia Medical Association Canadian Medical Association Alberta Medical Association University of Michigan Medical School Michigan Quality Improvement Consortium Singapore Ministry of Health National Resource for Infection Control Patient UK Guideline links UK Ambulance Service Clinical Practice Guidelines RefHELP NHS Lothian Referral Guidelines Medline (with guideline filter) Driver and Vehicle Licensing Agency NHS Health at Work(occupational health practice)Sources of systematic reviews and meta-analyses The Cochrane Library: Systematic reviews Protocols Database of Abstracts of Reviews of Effects Medline (with systematic review filter) EMBASE (with systematic review filter)Sources of health technology assessments and economic appraisals NIHR Health Technology Assessment programme The Cochrane Library: NHS Economic Evaluations Health Technology Assessments Canadian Agency for Drugs and Technologies in Health International Network of Agencies for Health Technology AssessmentSources of randomized controlled trials The Cochrane Library: Central Register of Controlled Trials Medline (with randomized controlled trial filter) EMBASE (with randomized controlled trial filter)Sources of evidence based reviews and evidence summaries Bandolier Drug & amp; Therapeutics Bulletin TRIP database Central Services Agency COMPASS Therapeutic NotesSources of national policy Department of Health Health Management Information Consortium(HMIC)Patient experiences Healthtalkonline BMJ - Patient Journeys Patient.co.uk - Patient Support GroupsSources of medicines informationThe following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content. British National Formulary(BNF) electronic Medicines Compendium(eMC) European Medicines Agency(EMEA) LactMed Medicines and Healthcare products Regulatory Agency(MHRA) REPROTOX Scottish Medicines Consortium Stockley's Drug Interactions TERIS TOXBASE Micromedex UK Medicines Information Back to top Stakeholder engagement Stakeholder engagement Our policyThe external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:Clinical accuracy.Consistency with other providers of clinical knowledge for primary care.Accuracy of implementation of national guidance (in particular NICE guidelines).Usability.Principles of the consultation processThe process is inclusive and any individual may participate.To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.External reviewers are not paid for commenting on the draft topics.Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.All reviewers are invited to be acknowledged on the website.All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.StakeholdersKey stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.Stakeholders identified from the following groups are invited to review draft topics:Experts in the topic area.Professional organizations and societies(for example, Royal Colleges).Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer's Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.Guideline development groups where the topic is an implementation of a guideline.The British National Formulary team.The editorial team that develop MeReC Publications.Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.Patient engagementClarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:Topic selectionScoping of topicSelection of clinical scenariosFirst draft internal reviewSecond draft internal reviewExternal reviewFinal draft and pre-publicationOur lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals. Back to top Evidence exclusion criteria Evidence exclusion criteria Our policyScoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.Standard exclusions for scoping literature:Animal studiesOriginal research is not written in EnglishPossible exclusions for reviewed literature:Sample size too small or study underpoweredBias evident or promotional literaturePopulation not relevantIntervention/treatment not relevantOutcomes not relevantOutcomes have no clear evidence of clinical effectivenessSetting not relevantNot relevant to UKIncorrect study typeReview articleDuplicate reference Back to top Organizational, behavioural and financial barriers Organizational, behavioural and financial barriers Our policyThe CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.FeasibilityStudies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.Organizational and Financial Impact AnalysisStudies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.Eligible populationCurrent interventionsLikely uptake of new intervention or recommendationCost of the current or new intervention mixImpact on other costsCondition-related costsIn-direct costs and service impactsTime dependenciesCost-effectiveness or cost-benefit analysis studies are identified where available. We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation. Back to top Declarations of interest Declarations of interest Our policyClarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:Personal financial interestsPersonal family interestPersonal non-financial interestNon-personal financial gain or benefitAlthough particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons.An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.Who should declare competing interests?Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.Competing interests declared for this topic:None. References Back to topReferences Alexandre,T.S., Meira,D.M., Rico,N.C. and Mizuta,S.K. (2012) Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Revista Brasileira De Fisioterapia. 16(5), 381-388. [Abstract] American College of Rheumatology (2015) Timed Up and GO (TUG). American College of Rheumatology. www.rheumatology.org [Free Full-text] American Geriatrics Society, British Geriatrics Society (2011) Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Society of Geriatrics. 59(1), 148-157. [Abstract] Vieira, E.R., Palmer, R.C. and Chaves, P.H.M. (2016) Prevention of falls in older people living in the community. BMJ 353(i1419). BMJ (2019) Assessment of falls in the elderly. BMJ Best Practice. www.bestpractice.bmj.com CDC (2013) The Timed Up and Go test (TUG). Centers for Disease Control and Prevention.. www.cdc.gov [Free Full-text] Gillespie,L.D., Robertson,M.C., Gillespie,W.J., et al. (2012) Interventions for preventing falls in older people living in the community (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text] Haddad, Y.K., Bergen, G. and Feijun, L. 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