2022/10/01 by Rowan Harwood · 1 voice
Medicine · #Childhood Cancer Survivors' Quality of Life #Clinical practice guidelines implementation #Musculoskeletal pain and rehabilitation
paper · pdf · doi:10.1093/ageing/afac229
openalex publication_date 2022/10/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/29
Age and Ageing welcomes publication of the new World Falls Guideline Evidence on the causes of falls and interventions to reduce risk can be difficult to interpret The new guideline synthesises evidence, expert opinion and consideration of context to produce practical advice How do we decide what to advise the patients we see? How do organisations ensure that quality and efficiency are maintained? How do healthcare professionals defend themselves when criticised or accused of poor practice? Our education, experience and reading of research evidence can take us only so far. Learning rapidly becomes out of date. Experiences may be selective or inappropriately generalised. Research evidence is ever changing. No individual practitioner can keep abreast of all developments. Instead, we look to guidelines. A clinical guideline is a systematically developed series of recommendations designed to assist decisions about appropriate health care for specific clinical circumstances [1, 2]. Guidelines should be based on evidence, but interpretation and implementation of that evidence require appreciation of its potential limitations and attention to context. Guidelines are developed by the World Health Organisation, government agencies, scholarly societies, advocacy groups and individual healthcare provider organisations. In some fields, we have multiple different guidelines, sometimes inconsistent with each other [3], and even reviews of guidelines [4]. Guidelines need authority, a sound scholarly basis and pragmatic clinical wisdom. And as new evidence emerges, they constantly need renewing. This issue of Age and Ageing welcomes the publication of a new World Falls Guideline [5, 6]. It was developed by specially assembled, multi-professional groups of experts, across 11 working groups, and assisted by patient and public contributors. The aim was to produce up-to-date, relevant and practical recommendations that could be applied throughout the world. There was a focus on a person-centred approach, addressing evidence gaps, new developments such as in information technology and the perspective of lower- and middle-income countries (LMICs), which had hitherto been neglected. LMICs have a different demographic from higher income countries, their healthcare systems and professionals face unique problems, and governments need encouragement to invest in problems associated with ageing and chronic disease. Falls are important to geriatricians. They are common, damaging and reflect a functional loss. But falls are remarkably difficult to categorise. We have a reasonably simple and accepted definition—unintentionally coming to rest on the floor or at a lower level [7]. A key diagnostic distinction is between falls involving disturbance of consciousness and those that do not, although in practice amnesia for loss of consciousness or forgetfulness among people living with cognitive disorders, makes the distinction less useful in practice. A fall is not quite a diagnosis, but represents a ‘geriatric syndrome’. Falls result from a failure of consciousness, balance, anticipation, judgement or overwhelming external force. The mechanisms that enable upright posture are a complex combination of static balance and recovery from deliberately displacing the centre of gravity into unstable positions to allow movement. If maintaining upright posture is thought of as an ability, its failure is an activity limitation or disability. But falls are also symptomatic of underlying medical disorders and represent mechanisms of injury. Falls are an inevitable consequence of physical activity; there is a tension between undertaking activity and avoiding falls, especially for those with physical impairments, such as weakness, pain or visual problems. Falls research has a long history, initially around incidence, risk factors and consequences, more recently around prevention [8]. Falls research raises interesting methodological challenges. Observational epidemiology describes associations between an exposure variable and an outcome. An association may be causal, but may also be biased, confounded, occur by chance or be reverse causal. A given factor may be cause or consequence, or the result of a non-causal alternative explanation [9]. To be practically useful, we need to know about causal relationships, and then try to abolish nor minimise the cause. Two interesting examples are gait speed and fear of falling. People who walk slowly, or who are concerned about falling, are at greater risk of future falls. But just telling people to walk faster or not to worry, will not in itself reduce risk. Concerns about falling are a problem and may inhibit performance of everyday activities or therapeutic exercise. But caution is also understandable and adaptive in those who are unsteady. The main focus has to be on improving capacity—strength, balance, vision, cerebral perfusion, reaction time and dual task performance, and imparting knowledge and skills in the safe performance of daily activities. Psychological therapies fulfil a supporting role. Concerns about falling can be widespread—family members, hospital or care home staff may restrict the lives of people living with dementia in the name of safety, requiring a more nuanced assessment of risk and ‘risk enablement’ [10]. The only sure way to identify true causes of falls, and if changing them is helpful, is through an experiment—a clinical trial. In the falls literature, we have many fine examples, but trials in older people have their limitations [11]. Populations are heterogeneous, multimorbidity common, interventions complex, comparators active, outcomes broad and context crucial [12]. We have to account for different settings, impairments, relationships and motivations. Trials, especially those involving therapy, rehabilitation, and digital intervention, may be negative even when the intervention is effective—so called ‘null bias’—through problems with implementation, compliance, withdrawals, outcome ascertainment or insufficient difference between intervention and control conditions. New methods such as realist evaluation have been developed to take this into account [13], but are as yet in their infancy, and can be difficult to use in practice. We are left with degrees of uncertainty. We know that some things can reduce the risks of falls—strength and balance exercise, medication withdrawal, visual correction, cardiovascular therapies, environmental safety [6, 8]. Falls prevention services have been developed, but perhaps have not gained the acceptance that the problem deserves. Three hours of exercise a week, indefinitely, is hard work. Services for assessment, exercise instruction, progression and motivation are labour intensive and therefore expensive. The temptation to offer cut-back services, promoting self-directed therapy and provision through non-healthcare agencies is strong. Alternatives to psychotropic medication, or access to eye-care may be lacking. This makes a focus on agreed and achievable interventions all the more important. Falls prevention has to be integrated with other healthcare goals, including promoting cardiovascular health, increasing physical activity, minimising deconditioning, promoting person-centredness and dignity. Deliberate implementation strategies and engaging with health policy at a system or government level will have an important part to play. The developer of guidelines has to assemble evidence, but also has to understand and synthesise it, and convert it into practical advice. The idea that healthcare providers should do nothing that is not supported by trial evidence is wrong and has systematically discriminated against both older patients and non-drug interventions. The World Falls Guideline authors have made use of trial, observational and qualitative findings, but where necessary have identified and filled gaps in knowledge using expert opinion. These recommendations are transparently indicated; experts are usually right, but may not be and we need to be alert to new learning. One final aspect to commend is patient and family input to the guidelines. Engagement with fall prevention programmes can be difficult due to the widespread belief among older people that they are unlikely to fall, even when they have done so previously [14, 15]. Professionals can easily lose this perspective. Health psychology is a discipline devoted to behaviour change [16]. One commonly used theory, Self-Determination Theory, refers to competence, autonomy and relatedness as key dimensions [17]. We can help build competence through prevention and therapeutic interventions, but we must understand that we cannot force people to do things, and that those around older individuals are influential and important. The goals of intervention have to be things that are important to people: activity, independence and social engagement. Falls prevention provides this, but we are not always explicit about it. The World Falls Guidelines have the potential to contribute to service development, improve quality of care, promote education on falls, support clinicians in their clinical practice and will hopefully stimulate the development of falls prevention services and further research. None. None.