Miami Dade College Recommendations of a Clinical Practice Guideline Appraisal Guide

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Original Investigation | Geriatrics Evaluation of Clinical Practice Guidelines on Fall Prevention and Management for Older Adults A Systematic Review Manuel M. Montero-Odasso, MD, PhD; Nellie Kamkar, MSc; Frederico Pieruccini-Faria, PhD; Abdelhady Osman, MSc; Yanina Sarquis-Adamson, PhD; Jacqueline Close, MBBS, MD; David B. Hogan, MD; Susan Winifred Hunter, PT, PhD; Rose Anne Kenny, MBBS, PhD; Lewis A. Lipsitz, MD; Stephen R. Lord, PhD; Kenneth M. Madden, MD, MSc; Mirko Petrovic, MD, PhD; Jesper Ryg, MD, PhD; Mark Speechley, PhD; Munira Sultana, PhD; Maw Pin Tan, BMBS, MD; N. van der Velde, MD, PhD; Joe Verghese, MBBS, MS; Tahir Masud, MBBS, MSc; for the Task Force on Global Guidelines for Falls in Older Adults Abstract Key Points IMPORTANCE With the global population aging, falls and fall-related injuries are ubiquitous, and several clinical practice guidelines for falls prevention and management for individuals 60 years or older have been developed. A systematic evaluation of the recommendations and agreement level is lacking. Question What are the most common consistent recommendations in fall prevention clinical practice guidelines, across settings, for adults 60 years or older? OBJECTIVES To perform a systematic review of clinical practice guidelines for falls prevention and Findings In this systematic review of management for adults 60 years or older in all settings (eg, community, acute care, and nursing 198 recommendations across 15 homes), evaluate agreement in recommendations, and identify potential gaps. selected guidelines, most guidelines recommended fall risk stratification, EVIDENCE REVIEW A systematic review following Preferred Reporting Items for Systematic assessment tools, fractures or Reviews and Meta-analyses statement methods for clinical practice guidelines on fall prevention and osteoporosis management, management for older adults was conducted (updated July 1, 2021) using MEDLINE, PubMed, multifactorial interventions, medication PsycINFO, Embase, CINAHL, the Cochrane Library, PEDro, and Epistemonikos databases. Medical review, exercise, physiotherapy referral, Subject Headings search terms were related to falls, clinical practice guidelines, management and environment modification, and vison, prevention, and older adults, with no restrictions on date, language, or setting for inclusion. Three footwear, and cardiovascular independent reviewers selected records for full-text examination if they followed evidence- and interventions. Recommendations on consensus-based processes and assessed the quality of the guidelines using Appraisal of Guidelines vitamin D supplementation, addressing for Research & Evaluation II (AGREE-II) criteria. The strength of the recommendations was evaluated cognitive factors, and education were using Grades of Recommendation, Assessment, Development, and Evaluation scores, and inconsistent, whereas hip protectors, agreement across topic areas was assessed using the Fleiss κ statistic. digital technology, clinical applicability, and stakeholder involvement were less FINDINGS Of 11 414 records identified, 159 were fully reviewed and assessed for eligibility, and 15 were included. All 15 selected guidelines had high-quality AGREE-II total scores (mean [SD], 80.1% [5.6%]), although individual quality domain scores for clinical applicability (mean [SD], 63.4% [11.4%]) and stakeholder (clinicians, patients, or caregivers) involvement (mean [SD], 76.3% [9.0%]) were lower. A total of 198 recommendations covering 16 topic areas in 15 guidelines were identified after screening 4767 abstracts that proceeded to 159 full texts. Most (ⱖ11) guidelines strongly recommended performing risk stratification, assessment tests for gait and balance, fracture and osteoporosis management, multifactorial interventions, medication review, exercise promotion, commonly addressed. Meaning This systematic review found that agreement was high on several recommendations for fall prevention clinical practice guidelines for older adults, but certain areas, including stakeholder perspectives and clinical applicability, were often not addressed. environment modification, vision and footwear correction, referral to physiotherapy, and cardiovascular interventions. The strengths of the recommendations were inconsistent for vitamin D supplementation, addressing cognitive factors, and falls prevention education. Recommendations on use of hip protectors and digital technology or wearables were often missing. None of the examined guidelines included a patient or caregiver panel in their deliberations. + Supplemental content Author affiliations and article information are listed at the end of this article. (continued) Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 1/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults Abstract (continued) CONCLUSIONS AND RELEVANCE This systematic review found that current clinical practice guidelines on fall prevention and management for older adults showed a high degree of agreement in several areas in which strong recommendations were made, whereas other topic areas did not achieve this level of consensus or coverage. Future guidelines should address clinical applicability of their recommendations and include perspectives of patients and other stakeholders. JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 Introduction Falls and fall-related injuries are common for older adults,1 with approximately 30% of adults 60 years of age or older falling each year.2-4 Falls are more likely for older adults with greater frailty severity and among those living in nursing homes.5,6 Consequences of falls include injuries,7 fractures,8 problems with mobility, depression, loss of independence,9,10 and a substantial economic burden on health care systems.11 Falls and their concomitant injuries represent a worldwide phenomenon.12 Accordingly, several medical societies and organizations in different countries have created clinical practice guidelines for fall prevention and management.13-27 These guidelines are typically based on systematic reviews of the available evidence and consensus by experts in the fields of geriatric medicine, rehabilitation medicine, and physiotherapy, among others.28,29 Although several of these clinical practice guidelines for fall prevention have been published, little is known about the level of agreement between the recommendations made by them. Clinicians face the challenge of selecting high-quality guidelines based on robust methods with internally and externally validated recommendations applicable to their setting in informing their practice.30,31 We aimed to (1) systematically review existing clinical practice guidelines on fall prevention and management for older adults; (2) identify common areas evaluated and level of agreement in the recommendations made; (3) address fall risk stratification in each guideline, describing which assessments are recommended to guide this and inform management across settings (eg, community, acute care, and nursing homes); and (4) identify potential gaps and areas that should be addressed in future clinical practice guidelines. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and preregistered in PROSPERO (CRD42020173597). This systematic review was performed under the umbrella of the World Falls Guidelines for Prevention and Management of Falls in Older Adults.32 Identification of Guidelines Our initial search on April 2, 2020, was updated July 1, 2021, and included the following databases: MEDLINE, PubMed, PsycINFO, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Library, PEDro (Physiotherapy Evidence Database), and Epistemonikos. Three of us (M.M.M.-O., S.W.H., and T.M.) also provided consultation to include guidelines potentially not indexed in databases. Search Terms Our search used Medical Subject Headings terms pertaining to (1) falls, (2) clinical practice guidelines, (3) management and prevention, and (4) older adults (eTable 1 in Supplement 1 describes our search syntax). JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 2/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults Inclusion Criteria The inclusion criteria were (1) outcome of guidelines: fall reduction, prevention, and management; (2) study type: clinical practice guidelines for preventing or managing falls categorized as consensusor evidence-based guidelines13; and (3) target population of guidelines: older adults. There were no restrictions on date, language, or setting for inclusion. Screening, Review Process, and Quality Assessment Three of us as independent reviewers (M.M.M.-O., N.K., and Y.S.-A.) selected records for full-text examination if they followed evidence- and consensus-based processes; disagreements were resolved by consensus. Three of us as reviewers (N.K., F.P.-F., and A.O.) assessed guideline quality using the 23-item Appraisal of Guidelines for Research & Evaluation II (AGREE-II) tool31 (eTable 2 in Supplement 1). The scores for AGREE-II range from 0 to 100, with higher scores indicating higher quality. Extracted recommendations were grouped in common areas and independently appraised by 3 of us (N.K., F.P.-F., and A.O.; blinded among us 3) using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE),29,33 which reflects the strength of the recommendation (1 = strong; 2 = weak) paired with the quality of the supporting evidence (A = high; B = moderate; and C = low). Agreement across guidelines for specific recommendations was assessed using the Fleiss κ statistic. Results Our search yielded 11 414 records. There were 6647 duplicates, and 4608 records were excluded after title and abstract review, resulting in 159 records that were fully reviewed and assessed for eligibility (Figure 1).34 Of the 159 records, 144 were excluded, yielding 15 records retained for final analyses and included in the data synthesis.13-27 Table 1 shows the quality assessment characteristics using the AGREE-II tool for the 15 guidelines selected. Quality Assessment The AGREE-II total scores were high across all guidelines (mean [SD], 80.1% [5.6%]; range, 69.7%92.8%). Descriptive statistics for AGREE-II scores by domain are given in Table 1, and mean AGREE-II scores by domain are illustrated in Figure 2. Domain 6 (editorial independence, competing interests, and conflicts of interest disclosed) scored highest across guidelines. Domain 1 (guideline objectives, clinical research question being addressed, and target population) and domain 4 (clarity of presentation) also showed high mean scores. Domain 2 (representation and involvement from professional backgrounds, and by patients and stakeholders) showed moderate mean scores (mean [SD], 76.3% [9.0%]) mainly owing to involvement of only clinicians in some of the guidelines; however, none of guidelines included an exclusive panel of patients or caregivers involved in the entirety of the guideline development process. Domain 3 (systematic methods used to obtain evidence, strengths and limitations clearly outlined, and the extent to which the health benefits and adverse effects of each recommendation are considered) scores were moderately high with more variability. Domain 5 (applicability of the recommendations, descriptors of facilitators and barriers to the application of each recommendation, and advice on tools and resources for applying each recommendation) scored consistently lower (mean [SD], 63.4% [11.4%]) than the other domains mainly because only 5 guidelines provided a toolkit or a step-by-step process in how to apply the recommendations.15,18,21,24,25 Recommendations and Agreement Across Guidelines After screening 4767 abstracts that proceeded to 159 full texts, we extracted 198 recommendations from the 15 guidelines that we grouped into 16 commonly addressed topic areas (Table 2). Topic areas that were presented in more than 40% of the guidelines were included in Table 2. Each topic area in Table 2 includes an accompanying GRADE score, which reflects the strength of the JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 3/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults recommendation and the quality of the evidence. Across all areas and in all guidelines, the direction of the recommendation was in favor of the guideline (rather than recommending against its use). For definitions of the 16 commonly addressed topic areas, refer to eTable 3 in Supplement 1. The following topic areas were presented in less than 40% of the guidelines: addressing the use of canes or walking aids in the recommendations, alcohol use, depression, urinary incontinence, hearing impairment, atypical blood glucose, social isolation, and functional dependence as risk factors for falls, followed by staff education in nursing homes as part of interventions to prevent and manage falls. Of 15 guidelines, 4 addressed all 16 topic areas identified,14,17,25,27 whereas 5 addressed at least 13 of them.13,15,18,22,24 Two topic areas (use of assessment tools for individuals who screened positive in falls risk, and exercise interventions) were covered in all of the guidelines, indicating consistent support for their importance. Medication review for fall risk–increasing drugs, use of multifactorial interventions to manage falls, and environment modification to prevent falls were recommended in 14 of the guidelines. Thirteen of the guidelines recommended performing risk stratification to detect high-risk individuals if they screened positive in the case-finding step using gait and balance tests. Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-analyses Flowchart of Search Yield 11 392 Records identified through database searching 4330 Embase 2428 MEDLINE 1876 CINAHL 1029 Cochrane Library 956 PubMed 676 PsycINFO 89 Epistemonikos 8 PEDro 22 Additional records identified through other sources 19 Experta 3 Hand search 11 414 Total records identified 6647 Duplicate records 4767 Records screened in title/abstract review, after duplicates removed 4608 Records excluded in title/abstract review 159 Full-text articles assessed for eligibility 137 Records excluded (did not correspond to clinical practice guideline) 43 Commentary 35 Review 28 Protocol 14 Empirical study 4 Book 3 Magazine column 3 Conference abstract 2 Report 1 Training resource 1 Book chapter 1 Dissertation 1 Editorial 1 Symposium 5 Records excluded (not addressing falls) 2 Records excluded (not evidence based) 15 Guidelines selected for AGREE-II 15 Guidelines included in qualitative synthesis JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 AGREE-II indicates Appraisal of Guidelines for Research & Evaluation II. a Records suggested by 3 of us who are experts in the field of geriatric medicine (M.M.M.-O., S.R.L., and T.M.). December 15, 2021 4/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults Thirteen guidelines also recommended conducting vision interventions, cardiovascular interventions for falls, and referral to a physiotherapist for exercises and balance retraining. Twelve guidelines recommended footwear evaluation and intervention and falls prevention education. Concerning the strength of the recommendations and quality of the evidence supporting the recommendation, GRADE A scores were most commonly found for 9 topic areas (Table 2). Agreement across guidelines was high (κ > 0.80) for 5 areas: risk stratification, assessment tools, fractures and osteoporosis management, exercise interventions, and use of multifactorial interventions. Agreement was moderate (κ = 0.50-0.80) for 7 topic areas and low (κ < 0.5) for the remaining 4 areas (Table 2). Table 1. Quality Assessment Total and Domain-Specific Scores of the Guidelines Using AGREE-IIa AGREE-II domain scores, % Source or guideline AGREE-II total score, % 1: Scope and purpose 2: Stakeholder involvement 3: Rigor of development 4: Clarity of presentation 5: Applicability 6: Editorial independence Baraff et al,16 1997 (US) 78.5 96.3 81.5 72.2 88.9 62.5 88.9 AGILE,21 1998 (UK) 74.6 94.4 68.5 66.7 94.4 56.9 91.7 Feder et al,19 2000 (UK) 77.8 92.6 66.7 81.9 81.5 54.2 97.2 AGS/BGS/AAOS,13 2001 (US/UK) 84.5 94.4 81.5 82.6 96.3 66.7 100 Moreland et al,24 2003 (Canada) 80.0 96.3 68.5 80.6 83.3 66.7 91.7 ACSQHC,15 2009 (Australia) 81.9 94.4 83.3 68.8 94.4 79.2 100 FSGG,17 2011 (France) 78.0 92.6 74.1 75.0 85.2 59.7 100 NICE,18 2013 (UK) 92.8 98.1 94.4 91.7 92.6 86.1 100 STEADI,27 2013 (US) 74.2 90.7 81.5 66.7 81.5 58.3 88.9 97.2 Jung et al,22 2014 (Korea) 77.5 90.7 64.8 77.8 90.7 56.9 RACGP,26 2016 (Australia) 69.7 83.3 72.2 58.3 83.3 54.2 100 KAIM/KGS,23 2017 (Korea) 80.4 79.6 81.5 86.8 90.7 51.4 97.2 RNAO,25 2017 (Canada) 88.0 94.4 86.1 84.4 88.9 85.4 100 SENATOR ONTOP,20 2017 (Ireland) 79.2 94.4 61.1 86.1 85.2 52.8 100 USPSTF,14 2018 (US) 82.9 92.6 79.6 82.6 96.3 59.7 100 Mean (SD) [range] 80.1 (5.6) [69.7-92.8] 92.3 (4.8) [79.6-98.1] 76.3 (9.0) [61.1-94.4] 77.6 (9.3) [58.3-91.7] 88.7 (5.4) [81.5-96.3] 63.4 (11.4) [51.4-86.1] 96.9 (4.2) [88.9-100] Abbreviations: ACSQHC, Australian Commission on Safety and Quality in Health Care; AGILE, a recognized professional network of the Chartered Society of Physiotherapy; AGREE-II, Appraisal of Guidelines for Research & Evaluation–II; AGS/BGS/AAOS, American Geriatrics Society/British Geriatrics Society/American Academy of Orthopaedic Surgeons; FSGG, French Society of Geriatrics and Gerontology; KAIM/KGS, Korean Association of Internal Medicine/Korean Geriatrics Society; NICE, National Institute for Health and Care Excellence; RACGP, The Royal Australian College of General Practitioners; RNAO, Registered Nurses’ Association of Ontario; SENATOR ONTOP, software engine for the assessment & optimization of drug and non-drug therapy—older persons optimal evidence-based non-drug therapies in older people; STEADI, Stopping Elderly Accidents, Deaths and Injuries; USPSTF, US Preventive Services Task Force. a Scores range from 0 to 100, with higher scores indicating higher quality. Figure 2. Mean Appraisal of Guidelines for Research & Evaluation II (AGREE-II) Total and Domain-Specific Scores Across Guidelines31 Domain 6: editorial independence Domain 5: applicability Domain 4: clarity of presentation Domain 3: rigor of development Domain 2: stakeholder involvement Domain 1: scope and purpose Total AGREE-II score 0 20 40 60 80 100 AGREE-II score JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 5/15 Downloaded From: https://jamanetwork.com/ on 05/09/2022 JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) 1A 12 (80) 7 (47) Footwear evaluation and intervention Technology NA 75 ⻬ ⻬ ⻬ ⻬ ⻬ 94 1C 2C 1C 2B 1B 1B 1B 1C 1C 2C 1B 1C 2B NA 1A 1A ⻬ ⻬ 81 1B 1B 1B 2C 1B 1B 1A 1B NA NA 1B 1A 1B NA 1A 1A Abbreviations: ACSQHC, Australian Commission on Safety and Quality in Health Care; AGILE, a recognized professional network of the Chartered Society of Physiotherapy; AGS/BGS/AAOS, American Geriatrics Society/ British Geriatrics Society/American Academy of Orthopaedic Surgeons; FSGG, French Society of Geriatrics and Gerontology; GRADE, Grades of Recommendation, Assessment, Development, and Evaluation; KAIM/KGS, Korean Association of Internal Medicine/Korean Geriatrics Society; NA, not available; NICE, National Institute for Health and Care Excellence; RACGP, The Royal Australian College of General Practitioners; RNAO, Registered Nurses’ Association of Ontario; SENATOR ONTOP, software engine for the assessment & optimization of drug and Community dwelling Acute care and hospitals 50 NA NA 1B 2A NA NA 1B NA 1B NA 1B NA 1A NA 1B 1A Nursing homes ⻬ NA 69 2B 2C 2C 2B NA 1A NA NA NA 1A 1B 1A 1A 1A 1A NA 1B 1B NA 1A 1B 1B 1A NA 1A 1A 1A NA 1A 1A ⻬ 100 NA 1C 1C 1C 1C 1C 1C 1C 2C 1C 1C 1C 1C 1C 1C 1C ⻬ ⻬ ⻬ 94 NA 1A 1B 1B 1B 2C 1A 1B 2B 2C 1A 1A 1A 1A 1A 1B ⻬ 100 1C 1A 1B 1B 1A 1B 1A 1A 1A 1A 1B 1A 1C 1A 1A 1A ⻬ 94 1A NA 1A 1A 1A 1A 1A 1A 1A 1A 1A 1A 1A 2B 1A 1A ⻬ 75 NA 1A 1A NA NA 1A 1A 1A NA 1A 1A 1A 1A 1A 1A 1A Jung STEADI,27 et al,22 RACGP,26 2013 2014 2016 ⻬ ⻬ ⻬ 75 NA 1C 1C NA 1A NA 1C 1C NA 2C 1A 1C 1A 1A 1C 1C ⻬ ⻬ ⻬ 100 2B 1A NA 1A 2C 2C 1A 2C 1B 1B 1A 1A 1A 1C 1B 1A KAIM/KGS,23 RNAO,25 2017 2017 ⻬ ⻬ ⻬ 50 1B NA NA 2B 1C NA NA 1B NA NA 1B 1B 1C NA 1B NA ⻬ 100 1C 2C 1C 2B 2B 2C 2C 1B 1A 2C 1B 2C 1C 1A 1A 1A SENATOR ONTOP,20 USPSTF,14 2017 2018 b a The check mark indicates setting of intended recommendation. GRADE strength of recommendation (1 = strong; 2 = weak) and quality of evidence (A = high quality; B = moderate quality; C = low quality). non-drug therapy—older persons optimal evidence-based non-drug therapies in older people; STEADI, Stopping Elderly Accidents, Deaths and Injuries; Underrep, Underrepresented; USPSTF, US Preventive Services Task Force. ⻬ 94 NA 2C 1B 1A 1A 1C 1A 2B 1A 1A 1A 1B 1A 1A 1A 1A Feder AGS/BGS/ Moreland et al,24 AGILE,21 et al,19 AAOS,13 ACSQHC,15 FSGG,17 NICE,18 1998 2000 2001 2003 2009 2011 2013 ⻬ .78 .42 .61 .20 .50 .39 .70 .66 .69 .30 .88 .68 .82 .83 .88 .92 GRADE Baraff agreement et al,16 Fleiss κ 1997 15 Guidelines includeda ⻬ Setting of intended recommendationsb Underrep 1B 13 (87) Cardiovascular intervention Areas addressed in each guideline (of 16), % 1A Mixed 12 (80) Falls education Mixed 1A 1B Underrep Mixed 1A 1A 1A Physiotherapy referral 13 (87) 11 (73) Vitamin D supplementation Cognitive factors management 11 (73) Exercise interventions 14 (93) 15 (100) Medication review Environment modification 14 (93) Multifactorial interventions 9 (60) 14 (93) Fractures and osteoporosis management 13 (87) 11 (73) Assessment tools Vision modification 1A 15 (100) Risk stratification Hip protectors 1A 13 (87) 16 Areas identified 1A No. (%) of guidelines Mode of addressing GRADE scorea this area Table 2. Guidelines Appraised With Evidence and Strength for Each Recommendation Stratified by Topic Areas Identified JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults December 15, 2021 6/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults Inconsistent and Underrepresented Topic Areas in Recommendations Across Guidelines Recommendations on vitamin D supplementation (κ = 0.30) and education on falls prevention (κ = 0.20) had low levels of agreement across the 15 guidelines. Seven guidelines strongly recommended the use of vitamin D supplementation, 4 guidelines provided weak recommendations, and the remaining 4 guidelines did not address the topic. For education on falls prevention, 6 guidelines provided strong recommendations to offer patients and caregivers education on fall prevention and management strategies, 6 gave weak recommendations, and 3 did not address this topic area. Recommendations for addressing cognitive impairment during fall risk assessment and management were present in 11 guidelines, with low agreement across them (κ = 0.39). Physiotherapy referral was recommended in 13 guidelines but with low agreement (κ = 0.50). The use of hip protectors to prevent fall-related injuries and the use of digital technology (including wearables) to detect, prevent, or manage falls had a low level of agreement across the 15 guidelines. For recommendations on hip protectors, 7 guidelines provided strong recommendations for their use in nursing home settings, 2 guidelines provided weak recommendations, and 6 guidelines did not address their use. Recommendations on the use of digital technology had similar results. Six guidelines provided strong recommendations to use digital technology, 1 guideline provided a weak recommendation, and 8 guidelines did not address their use. Risk Stratification Most guidelines strongly recommended risk stratification using “case finding” self-reported questions, including fall history, fear of falling, and gait and balance difficulties, and reserving gait and balance testing for those who screen positive on these questions. Five guidelines included a riskstratification algorithm, but evidence validating the algorithm was not consistently presented, as described in Table 3.2-4,13-27,35,36 The majority of these algorithms followed the format proposed by the American Geriatrics Society/British Geriatrics Society/American Academy of Orthopaedic Surgeons (AGS/BGS/AAOS) guidelines.13 Individuals who had either no falls or 1 noninjurious fall in the last year and no impairment of balance and gait evident on examination were considered low risk, with a reassessment suggested sometime in the future. The interval proposed to reassess these low-risk individuals ranged from 1 year to 2 years across the guidelines examined. For individuals who screened positive in fall history, several guidelines stratified their risk by demographic factors (ie, advanced age or female sex)14,17,20,24,26 or clinical characteristics (gait and balance abnormalities).13-18,20,22-27 The assessment of balance and gait, at this step, was recommended in 13 out of 15 guidelines13-18,20,22-27 using the Timed Up and Go Test (TUG),37 the Berg Balance Scale,38 and the Tinetti Performance-Oriented Mobility Assessment Tool,39 with the TUG being the most recommended test, appearing in 6 of the 15 guidelines (Table 3).13,14,16,17,23,27 Discussion This systematic review identified 15 high-quality practice guidelines for fall prevention and management, which provided 198 recommendations for risk assessment, prevention, and management of falls for older adults. Most guidelines strongly recommended risk stratification screening using short questionnaires and reserving gait and balance testing for those who screened positive. Similarly, most guidelines strongly recommended medication review, exercise interventions, environment modifications, multifactorial approaches, and active management of fractures and osteoporosis as key elements in the prevention of falls. Vision or footwear intervention, physiotherapy referral, and cardiovascular interventions were less commonly addressed. Although all selected guidelines had high overall methodologic quality, clinical applicability and stakeholder involvement were domains missed or lacking in details. JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 7/15 JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 Algorithm Narrative Algorithm Algorithm Table Algorithm Narrative Narrative FSGG,17 2011 NICE,18 2013 STEADI,27 2013 Jung et al,22 2014 RACGP,26 2016 KAIM/KGS,23 2017 RNAO,25 2017 SENATOR ONTOP,20 2017 NA NA NA ≥65 NA NA NA ≥80 NA ≥74 NA Any previous falls: multifactorial ≥65 intervention Any previous falls: multifactorial ≥65 intervention; low risk (no fall history): group-based exercise Any previous falls: comprehensive assessment; ≥2 falls in 12 mo: clinician referral ≥2 Falls in 12 mo: multifactorial falls evaluation ≥1 Fall with multiple risk factors in 12 mo: risk factor screening and preventive activities; low risk (no fall history): yearly fall screening ≥1 Fall in 12 mo: comprehensive intervention; low risk (no fall history) regular checkups ≥1 Fall in 12 mo: multifactorial risk assessment; low risk (no fall history): patient education and referral to community exercise, balance, fitness, or fall prevention program ≥1 Fall or emergency department visit for fall: multifactorial risk assessment 1 Fall in 12 mo: gait and balance evaluation; recurrent falls in 12 mo or an acute fall or difficulty with walking and balance: fall evaluation1 and multifactorial intervention Any previous fall NA 1 Fall in 12 mo: gait and balance evaluation; recurrent falls in 12 mo or an acute fall or difficulty with walking and balance: fall evaluation1 NA NA Age, y Abbreviations: ACSQHC, Australian Commission on Safety and Quality in Health Care; AGILE, a recognized professional network of the Chartered Society of Physiotherapy; AGS/BGS/AAOS, American Geriatrics Society/ British Geriatrics Society/American Academy of Orthopaedic Surgeons; BBS, Berg Balance Scale; FSGG, French Society of Geriatrics and Gerontology; KAIM/KGS, Korean Association of Internal Medicine/Korean Geriatrics Society; NA, not applicable; NICE, National Institute for Health and Care Excellence; RACGP, The Royal Australian Table Narrative ACSQHC,15 2009 USPSTF,14 2018 Narrative Moreland et al,24 2003 NA NA Algorithm Feder et al,19 2000 AGS/BGS/AAOS,2-4,13,35 2001 NA NA AGILE,21 1998 Any previous falls Narrative Baraff,16 1997 Fall history Stratification method Guidelines identified Determination steps for risk assessment in the recommendations Table 3. Description of Risk Stratification by Guidelines and Use of an Algorithm NA NA NA NA NA NA NA NA NA NA NA NA Other TUG test Gait problems Gait, balance, or mobility difficulty TUG test and BBS Gait or balance and mobility difficulties Gait or balance problems TUG test, 4-stage balance test List of assessment tool options TUG test List of assessment tool options Physical function or mobility problems Walking aid, dizziness, muscle weakness, and polypharmacy Clinical judgment NA Clinical judgment Polypharmacy, dementia, general diseases, cognition, fallrelated symptoms, physical fitness, environmental factors, and aids Fear of falling Gait or balance problems Multiple risk factors2 NA Tinetti Performance-Oriented NA Assessments of Gait and Balance TUG test NA NA TUG test Gait, balance, and mobility assessment Adults aged 60-65 y may experience falls Unspecified assessments to determine risk Broad list of assessment tools Individuals with no fall history or low (1 fall) fall history may fall and require fall evaluation36 Broad list of assessment tools Details pertaining to assessment tools Demographic risk factors Broad list of assessment tools Individuals with no fall history or low (1 fall) fall history may fall and require fall evaluation36 Demographic risk factors Fall history is not included in risk stratification Individuals with no fall history or low (1 fall) fall history may fall and require fall evaluation36 Absence of a clear risk stratification methods algorithm Gaps and areas to expand College of General Practitioners; RNAO, Registered Nurses’ Association of Ontario; SENATOR ONTOP, software engine for the assessment & optimization of drug and non-drug therapy—older persons optimal evidence-based non-drug therapies in older people; STEADI, Stopping Elderly Accidents, Deaths and Injuries; TUG, Timed Up and Go; USPSTF, US Preventive Services Task Force. Female NA Female NA NA NA NA Sex JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults December 15, 2021 8/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults Recommendations for vitamin D supplementation showed mixed results. The strength of recommendations varied from strong to weak, with several guidelines not making any suggestions. This may reflect the inconsistent evidence about vitamin D supplementation for fall prevention and how the evidence varied based on settings: community vs residential or nursing home care.40-42 Similarly, recommendations about fall prevention education were mixed with a similar pattern seen. The use of hip protectors and digital technologies and wearables were often not included, with half of guidelines making no recommendation in these areas. The latest Cochrane meta-analyses found only weak evidence supporting the efficacy of hip protectors in preventing fractures after a fall in long-term care facilities43 and noted challenges in implementing the daily use of these protectors. This weak evidence, coupled with not all guidelines addressing falls in long-term care, likely explains the omission of hip protector recommendations.44 The underrepresentation of digital and wearable technologies is probably a reflection of their novelty.45 Risk stratification was an area addressed by most guidelines, with some proposing a specific risk stratification algorithm. Those algorithms often recommended performing gait and balance tests for individuals who screened positive.38,39 The most frequently recommended gait and balance test was the TUG, potentially owing to its simplicity, acceptance, and ease of administration. Evidence does not support acceptable predictive validity for any of the tests recommended in isolation for falls prediction,46-50 and specifically the TUG has low predictive validity.51 Consistent with the overall lower score in the applicability domain of the AGREE-II scale, details on resources, facilitators, and barriers to use of any of the recommended tests warranted more complete descriptions. In addition to gait and balance, 5 guidelines stratified risk by some demographic characteristics (ie, advanced age, female sex).14,17,20,24,26 Explicit statements within the guidelines indicating the validation of their stratification algorithms were lacking. Few studies assessed the predictive accuracy of some of the proposed algorithms and found low sensitivity to detect individuals at higher risk of falls.2,3,52 Future guidelines providing risk stratification algorithms should conduct validation studies of their effectiveness, address the adaptability of the proposed algorithm to different care or residential settings, and include validations in resource-constrained areas, such as low- and middleincome countries. Finally, only 2 guidelines recommended active interventions with follow-up care for individuals deemed low risk in their stratification strategy, including education and exercises involving balance and lower limb strengthening.20,22,26,27 Recommendations for low-risk older adults that may help prevent falls and improve their overall health are also needed. Recommendations to evaluate and manage medication-related risks for falls varied from judicious deprescribing of psychotropic and cardiovascular medications to performing a comprehensive medication review. Across all guidelines, medication review was recommended generally and in all settings. Although a search for medication review for fall risk–increasing drugs was identified in medication review recommendations, resources and tools for clinicians were lacking. This deficiency may have been attributable to the unavailability of resources. Tools such as STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) have only recently been developed.53 Specific recommendations for older adults with cognitive impairment were scarce. Although cognitive evaluation was recommended as part of the initial assessment in most of the guidelines, specific guidance for evaluating specific aspects of cognition associated with increased fall risk (such as deficits in executive function) were lacking, despite the evidence in the literature of elevated fall risk factors in this group.54,55 Consideration of specific cognitive domains is imperative because executive function deficits are a known and prominent risk factor for falls among older adults—even among individuals without a formal diagnosis of cognitive impairment or dementia.54,56-58 Executive function may be a target for fall prevention interventions, as shown in recent studies.59,60 Future guidelines should consider including specific recommendations for individuals with cognitive deficits, including executive functioning and memory.57,61 The perspectives of people with a history of falls and associated injuries were not thoroughly and consistently embedded in the appraised guidelines. Moreover, personalized approaches that JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 9/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults incorporate individual preferences in the fall prevention recommendations made to patients were also lacking.62,63 In general, patient and caregiver perspectives have not been consistently incorporated in clinical practice guidelines and related health resources.64 Clinical applicability was underrepresented in all the guidelines. Facilitators or barriers to implement recommendations were thoroughly detailed in only 3 guidelines.15,25,27 Similarly, advice or toolkits on how to implement the recommendations into practice were described in detail in only 5 guidelines,15,18,21,24,25 potential resource implications of applying the recommendations were detailed in only 2 guidelines,15,18 and monitoring or auditing criteria were discussed in only 2 guidelines.18,25 Our findings suggest that the challenges encountered in implementing recommendations should be better addressed in future clinical practice guidelines. A complementary way to address implementing recommendations is by following the example of the Stopping Elderly Accidents, Deaths and Injuries initiative from the Centers for Disease Control and Prevention, which focuses more on practical implementation with toolkits for the AGS/BGS/AAOS guidelines, as opposed to standing alone as a clinical practice guideline. Finally, all the selected guidelines in our systematic review were led by authors from developed countries. We used 60 years of age or older as the definition of older adults to be geographically inclusive in our search1; however, our search found only a limited number of clinical practice guidelines from low- and middle-income countries, which were not evidence-based or based on a formal expert consensus process. This finding may reflect the lack of guidelines for fall prevention in many regions of the developing world, which may represent inadequate attention to this phenomenon or limited resources to develop clinical practice guidelines for older adults. Limitations This systematic review has some limitations. Although no language restrictions were placed on our search, bibliographic databases of peer-reviewed papers included only journals that were indexed, which are mainly published in English. In addition, there is a possibility that we missed relevant clinical practice guidelines that were not in the databases searched, known to the experts we consulted, or on the public or health policy sites we examined. Conclusions This systematic review found high agreement across clinical practice guidelines with strong recommendations for risk stratification, the use of specific tests for gait and balance assessments, multifactorial interventions, medication review, physical exercise, vision and footwear intervention, physiotherapy referral, environment modification, management of osteoporosis and fracture risk, and cardiovascular interventions. Recommendations on vitamin D supplementation and educational programs for fall prevention and management were inconsistent, whereas recommendations on hip protectors and wearable technologies were often not included. Future clinical practice guidelines should better address the clinical applicability of their recommendations, with more explicit consideration of resources, costs, and implementation barriers. Patients’ and caregivers’ perspectives should also be better reflected in developing future fall prevention and management guidelines for older adults. Our findings may assist clinicians in choosing the best-suited guidelines and recommendations for their setting and resource availability. The gaps detected may inform future guideline development, including the recent international initiative: World Falls Guidelines.32,65 ARTICLE INFORMATION Accepted for Publication: October 7, 2021. Published: December 15, 2021. doi:10.1001/jamanetworkopen.2021.38911 JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 10/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Montero-Odasso MM et al. JAMA Network Open. Corresponding Author: Manuel Montero-Odasso, MD, PhD, Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, 550 Wellington Rd, Main Building, Room A3-116, London, ON N6C 0A7, Canada (mmontero@uwo.ca). Author Affiliations: Schulich School of Medicine and Dentistry, Division of Geriatric Medicine, Department of Medicine, The University of Western Ontario, London, Ontario, Canada (Montero-Odasso); Gait and Brain Lab, Parkwood Institute, Lawson Health Research Institute, London, Ontario, Canada (Montero-Odasso, Kamkar, Pieruccini-Faria, Sarquis-Adamson, Sultana); Department of Epidemiology and Biostatistics, The University of Western Ontario, London, Ontario, Canada (Montero-Odasso, Pieruccini-Faria, Osman, Speechley); Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, Sydney, Australia (Close); Prince of Wales Clinical School, Medicine, University of New South Wales, Sydney, Australia (Close); Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada (Hogan); Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada (Hunter); School of Physical Therapy, University of Western Ontario, London, Ontario, Canada (Hunter); Department of Medical Gerontology, Mercers Institute for Ageing, St James Hospital, Dublin, Ireland (Kenny); Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts (Lipsitz); Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, New South Wales, Australia (Lord); School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia (Lord); Division of Geriatric Medicine, Department of Medicine, Department of Internal Medicine, Section of Geriatric Medicine, University of British Columbia, Vancouver, British Columbia, Canada (Madden); Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (Madden); Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium (Petrovic); Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark (Ryg, Masud); Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark (Ryg, Masud); Schulich Interfaculty Program in Public Health, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada (Speechley); Centre for Innovation in Medical Engineering, Faculty of Engineering, University of Malaysia, Kuala Lumpur, Malaysia (Tan); Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia (Tan); Section of Geriatric Medicine, Department of Internal Medicine, Amsterdam Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands (van der Velde); Institute for Aging Research, Department of Medicine, Albert Einstein College of Medicine, Bronx, New York (Verghese); Department of Neurology, Albert Einstein College of Medicine, Bronx, New York (Verghese); Department of Geriatric Medicine, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom (Masud). Author Contributions: Dr Montero-Odasso had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Montero-Odasso, Kamkar, Pieruccini-Faria, Close, Kenny, Lord, Madden, Petrovic, Tan, Verghese. Acquisition, analysis, or interpretation of data: Montero-Odasso, Kamkar, Pieruccini-Faria, Osman, SarquisAdamson, Hogan, Hunter, Lipsitz, Lord, Ryg, Speechley, Sultana, van der Velde, Masud. Drafting of the manuscript: Montero-Odasso, Kamkar, Pieruccini-Faria, Osman, Hogan, Masud. Critical revision of the manuscript for important intellectual content: Montero-Odasso, Kamkar, Pieruccini-Faria, Sarquis-Adamson, Close, Hogan, Hunter, Kenny, Lipsitz, Lord, Madden, Petrovic, Ryg, Speechley, Sultana, Tan, van der Velde, Verghese, Masud. Statistical analysis: Montero-Odasso, Kamkar, Pieruccini-Faria, Speechley. Obtained funding: Montero-Odasso. Administrative, technical, or material support: Kamkar, Pieruccini-Faria, Osman, Sarquis-Adamson, Lipsitz, Lord, Madden, Sultana, Masud. Supervision: Montero-Odasso, Madden, Verghese. Conflict of Interest Disclosures: Dr Montero-Odasso reported receiving support through grants for his program in Gait and Brain Health from the Canadian Institutes of Health Research, the Ontario Ministry of Research and Innovation, the Ontario Neurodegenerative Diseases Research Initiative, the Canadian Consortium on Neurodegeneration in Aging, the Weston Family Foundation, and the Department of Medicine Program of Experimental Medicine Research Award, University of Western Ontario; and being the first recipient of the Schulich Clinician–Scientist Award. Dr Tan reported receiving grants from the University of Malaya Impactful Interdisciplinary, and a fundamental research grant and a long-term research grant from the Ministry of Higher JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 11/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults Education Malaysia; and personal fees from Astella, Merck, Mylan-UpJohn, Novartis, Pfizer, and Sanofi outside the submitted work. No other disclosures were reported. Funding/Support: This work was supported by project grant PTJ 153100 from the Canadian Institute of Health Research. Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Group Information: A complete list of the members of the Task Force on Global Guidelines for Falls in Older Adults appears in Supplement 2. Additional Contributions: Ms Lorraine Leff, MLIS, St. Joseph's Health Care, London, Ontario, Canada, assisted in the early stages of this review. REFERENCES 1. World Health Organization. WHO Global Report on Falls Prevention in Older Age. World Health Orgnaization; 2008. 2. Muir SW, Berg K, Chesworth B, Klar N, Speechley M. Application of a fall screening algorithm stratified fall risk but missed preventive opportunities in community-dwelling older adults: a prospective study. J Geriatr Phys Ther. 2010;33(4):165-172. doi:10.1519/JPT.0b013e3181ff23cc 3. 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PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal. pmed1000097 35. Muir SW, Berg K, Chesworth BM, Klar N, Speechley M. Modifiable risk factors identify people who transition from non-fallers to fallers in community-dwelling older adults: a prospective study. Physiother Can. 2010;62(4): 358-367. doi:10.3138/physio.62.4.358 36. Journal of the American Geriatrics Society. Falls risk stratification: when is “low risk” not low risk? Abstract S172. Published 2020. Accessed November 2, 2021. https://agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/ jgs.16431 37. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896-903. doi:10.1093/ptj/80.9.896 38. Muir SW, Berg K, Chesworth B, Speechley M. Use of the Berg Balance Scale for predicting multiple falls in community-dwelling elderly people: a prospective study. Phys Ther. 2008;88(4):449-459. doi:10.2522/ptj. 20070251 39. Abbruzzese LD. The Tinetti performance-oriented mobility assessment tool. Am J Nurs. 1998;98(12):16J-16L. 40. Murad MH, Elamin KB, Abu Elnour NO, et al. Clinical review: the effect of vitamin D on falls: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2011;96(10):2997-3006. doi:10.1210/jc.2011-1193 41. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, et al. Effect of vitamin D on falls: a meta-analysis. JAMA. 2004;291(16):1999-2006. doi:10.1001/jama.291.16.1999 JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 13/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults 42. Smith LM, Gallagher JC, Suiter C. Medium doses of daily vitamin D decrease falls and higher doses of daily vitamin D3 increase falls: a randomized clinical trial. J Steroid Biochem Mol Biol. 2017;173:317-322. doi:10.1016/j. jsbmb.2017.03.015 43. Santesso N, Carrasco-Labra A, Brignardello-Petersen R. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2014;(3):CD001255. doi:10.1002/14651858.CD001255.pub5 44. Hall A, Boulton E, Stanmore E. Older adults’ perceptions of wearable technology hip protectors: implications for further research and development strategies. Disabil Rehabil Assist Technol. 2019;14(7):663-668. doi:10.1080/ 17483107.2018.1491647 45. Pang I, Okubo Y, Sturnieks D, Lord SR, Brodie MA. Detection of near falls using wearable devices: a systematic review. J Geriatr Phys Ther. 2019;42(1):48-56. doi:10.1519/JPT.0000000000000181 46. Lima CA, Ricci NA, Nogueira EC, Perracini MR. The Berg Balance Scale as a clinical screening tool to predict fall risk in older adults: a systematic review. Physiotherapy. 2018;104(4):383-394. doi:10.1016/j.physio.2018.02.002 47. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14. doi:10.1186/ 1471-2318-14-14 48. Scott V, Votova K, Scanlan A, Close J. 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;36(2):130-139. doi:10.1093/ageing/afl165 49. Rosa MV, Perracini MR, Ricci NA. Usefulness, assessment and normative data of the Functional Reach Test in older adults: a systematic review and meta-analysis. Arch Gerontol Geriatr. 2019;81:149-170. doi:10.1016/j.archger. 2018.11.015 50. Schoene D, Wu SM, Mikolaizak AS, et al. Discriminative ability and predictive validity of the Timed Up and Go Test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc. 2013;61(2): 202-208. doi:10.1111/jgs.12106 51. Kojima G, Masud T, Kendrick D, et al. Does the timed up and go test predict future falls among British community-dwelling older people? prospective cohort study nested within a randomised controlled trial. BMC Geriatr. 2015;15:38. doi:10.1186/s12877-015-0039-7 52. Palumbo P, Becker C, Bandinelli S, Chiari L. Simulating the effects of a clinical guidelines screening algorithm for fall risk in community dwelling older adults. Aging Clin Exp Res. 2019;31(8):1069-1076. doi:10.1007/s40520018-1051-5 53. Seppala LJ, Petrovic M, Ryg J, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing. 2021;50(4):1189-1199. doi:10.1093/ageing/afaa249 54. Fernando E, Fraser M, Hendriksen J, Kim CH, Muir-Hunter SW. Risk factors associated with falls in older adults with dementia: a systematic review. Physiother Can. 2017;69(2):161-170. doi:10.3138/ptc.2016-14 55. Van Ooteghem K, Musselman K, Gold D, et al. Evaluating mobility in advanced dementia: a scoping review and feasibility analysis. Gerontologist. 2019;59(6):e683-e696. doi:10.1093/geront/gny068 56. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk factors for falls in communitydwelling older people: a systematic review and meta-analysis. Epidemiology. 2010;21(5):658-668. doi:10.1097/ EDE.0b013e3181e89905 57. Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age Ageing. 2012;41(3):299-308. doi:10.1093/ageing/afs012 58. Kearney FC, Harwood RH, Gladman JR, Lincoln N, Masud T. The relationship between executive function and falls and gait abnormalities in older adults: a systematic review. Dement Geriatr Cogn Disord. 2013;36(1-2):20-35. doi:10.1159/000350031 59. Lipardo DS, Aseron AMC, Kwan MM, Tsang WW. Effect of exercise and cognitive training on falls and fallrelated factors in older adults with mild cognitive impairment: a systematic review. Arch Phys Med Rehabil. 2017; 98(10):2079-2096. doi:10.1016/j.apmr.2017.04.021 60. Montero-Odasso M, Speechley M. Falls in cognitively impaired older adults: implications for risk assessment and prevention. J Am Geriatr Soc. 2018;66(2):367-375. doi:10.1111/jgs.15219 61. Hsu CL, Nagamatsu LS, Davis JC, Liu-Ambrose T. Examining the relationship between specific cognitive processes and falls risk in older adults: a systematic review. Osteoporos Int. 2012;23(10):2409-2424. doi:10.1007/ s00198-012-1992-z JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 14/15 JAMA Network Open | Geriatrics Clinical Practice Guidelines on Fall Prevention and Management for Older Adults 62. Sandlund M, Skelton DA, Pohl P, Ahlgren C, Melander-Wikman A, Lundin-Olsson L. Gender perspectives on views and preferences of older people on exercise to prevent falls: a systematic mixed studies review. BMC Geriatr. 2017;17(1):58. doi:10.1186/s12877-017-0451-2 63. Stevens JA, Sogolow ED. Gender differences for non-fatal unintentional fall related injuries among older adults. Inj Prev. 2005;11(2):115-119. doi:10.1136/ip.2004.005835 64. Hämeen-Anttila K, Komulainen J, Enlund H, et al. Incorporating patient perspectives in health technology assessments and clinical practice guidelines. Res Social Adm Pharm. 2016;12(6):903-913. doi:10.1016/j.sapharm. 2015.12.005 65. Montero-Odasso M, van der Velde N, Alexander NB, et al; Task Force on Global Guidelines for Falls in Older Adults. New horizons in falls prevention and management for older adults: a global initiative. Age Ageing. 2021;50 (5):1499-1507. doi:10.1093/ageing/afab076 SUPPLEMENT 1. eTable 1. Search Syntax eTable 2. Standardized Data Collection Form eTable 3. Glossary of Key Terms eReferences. SUPPLEMENT 2. Nonauthor Collaborators JAMA Network Open. 2021;4(12):e2138911. doi:10.1001/jamanetworkopen.2021.38911 (Reprinted) Downloaded From: https://jamanetwork.com/ on 05/09/2022 December 15, 2021 15/15
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APPENDIX A
Appraisal Guide:
Recommendations of a Clinical Practice Guideline
Citation:
Montero-Odasso, M. M., Kamkar, N., Pieriuccini-Faria, F; Osman, A., Sarquis-Adamson, Y.,
Close, J., Hogan, D. B., Hunter, S. W., Kenny, R. A., Lipsitz, L. A., Lord, S. R., Madden, K. M.,
Petrovic, M., Ryg, J., Speechley, M., Sultana, M., Tan, M. P., van der Velde, N., Verghese, J.,&
Masud, T. (2021). Evaluation of clinical practice guidelines on fall prevention and management
for older adults: a systematic review. JAMA Network Open, 4(12), e2138911.
Synopsis
What group or groups produced the guideline?
The guideline was produced by the Task Force on Global Guidelines for Falls in Older Adults.
What does the guideline address? Clinical questions, conditions, interventions?
The guideline addresses the recommendations provided in literature concerning fall prevention
clinical practice guidelines particularly noting that a systematic evaluation of the
recommendations and agreement level is lacking.
What po...


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