Definitions of the levels of the recommendations (A, B, C, U) and classification of the evidence (Class I through Class IV) are provided at the end of the "Major Recommendations" field.
Note from American Academy of Neurology (AAN): Falls are generally defined as sudden, unintentional, and unexpected events that result in a person's coming to rest on the ground or at a lower level. Usually excluded from studies of the medical risks for falls are those that result from overwhelming environmental hazards (e.g., icy walkways) or unusual activities or events (e.g., playing sports or being shoved) that would place any person at high risk. While falls frequently follow loss of consciousness due to seizures or syncope, managing the risk of falling due to these conditions is distinct from that for most other falls and is usually considered in separate publications.
Conclusions
- An increased risk of falls is established among persons with diagnoses of stroke, dementia, disorders of gait and balance, and those who use assistive devices to ambulate (Level A).
- An increased risk of falls is also probable among patients with Parkinson disease, peripheral neuropathy, lower extremity weakness or sensory loss, and substantial loss of vision (Level B).
- Other systematic, evidence-based reviews (not rated) of numerous studies have identified general risk factors for falls, including advanced age, age-associated frailty, arthritis, impairments in activities of daily living, depression, and the use of psychoactive medications including sedatives, antidepressants, and neuroleptics.
- As for screening measures that may predict or further assess fall risk, a history of recent falls is an established predictor of future falls (Level A).
- Additional screening instruments of probable value include the Get-Up-And-Go Test or Timed Up-and-Go Test, an assessment of ability to stand from a sitting position, and the Tinetti Mobility Scale (Level B). Other screening instruments of possible utility are described in appendix e-4 of the original guideline document (Level C).
- Some of these measures assess similar or overlapping neurologic functions—i.e., gait, mobility, and balance—and there is insufficient evidence to assess whether such measures offer benefits beyond that offered by a standard comprehensive neurologic examination.
Recommendations
- All of the patients with any of the fall risk factors described above should be asked about falls during the past year (Level A).
- After a comprehensive standard neurologic examination, including an evaluation of cognition and vision, if further assessment of the extent of fall risk is needed, other screening measures to be considered include the Get-Up-And-Go Test or Timed Up-and-Go Test, an assessment of ability to stand unassisted from a sitting position, and the Tinetti Mobility Scale (Level B).
- Other screening measures of possible utility described in appendix e-4 of the original guideline document may be considered (Level C).
Definitions:
Classification of Recommendations
The strength of practice recommendations is linked directly to the level of evidence:
Level A = Established as effective, ineffective, or harmful (or established as useful/predictive or not useful/predictive) for the given condition in the specified population. (Level A rating requires at least two consistent Class I studies.*)
Level B = Probably effective, ineffective or harmful (or probably useful/predictive or not useful/predictive) for the given condition in the specified population. (Level B rating requires at least one Class I study or two consistent Class II studies.)
Level C = Possibly effective, ineffective or harmful (or possibly useful/predictive or not useful/predictive) for the given condition in the specified population. (Level C rating requires at least one Class II study or two consistent Class III studies)
Level U = Data inadequate or conflicting; given current knowledge, treatment (test, predictor) is unproven. (Studies not meeting criteria for Class I–III).
* In exceptional cases, one convincing Class I study may suffice for an "A" recommendation if 1) all criteria are met, 2) the magnitude of effect is large (relative rate improved outcome >5 and the lower limit of the confidence interval is >2).
Classification of Evidence for a Prognostic Intervention
Class I = Evidence provided by a prospective study of a broad spectrum of persons who may be at risk for developing the outcome (e.g., target disease, work status). The study measures the predictive ability using an independent gold standard for case definition. The predictor is measured in an evaluation that is masked to clinical presentation, and the outcome is measured in an evaluation that is masked to the presence of the predictor. All patients have the predictor and outcome variables measured.
Class II = Evidence provided by a prospective study of a narrow spectrum of persons at risk for having the condition, or by a retrospective study of a broad spectrum of persons with the condition compared to a broad spectrum of controls. The study measures the prognostic accuracy of the risk factor using an acceptable independent gold standard for case definition. The risk factor is measured in an evaluation that is masked to the outcome.
Class III = Evidence provided by a retrospective study where either the persons with the condition or the controls are of a narrow spectrum. The study measures the predictive ability using an acceptable independent gold standard for case definition. The outcome, if not objective, is determined by someone other than the person who measured the predictor.
Class IV = Any design where the predictor is not applied in an independent evaluation OR evidence provided by expert opinion or case series without controls.
