= Older people in contact with health professionals should be asked routinely about falls in the past year and about their frequency, characteristics, and context.

= Such people should be observed for deficits in gait and balance and considered for suitability to benefit from interventions to improve strength and balance.

= Older people who present for medical attention after a fall, report recurrent falls in the past year, or demonstrate gait and balance abnormalities should be offered a multifactorial assessment of their risk of further falls. This should be performed by a health professional with appropriate skills and experience normally, in the setting of a specialist service for falls.

= This assessment may include:

• History of falls
• Gait, balance, mobility, muscle weakness
• Risk of osteoporosis
• Functional ability and fear related to falling
• Visual impairment
• Cognitive impairment and neurological deficits
• Urinary incontinence
• Home hazards
• Cardiovascular examination and review of medication

= Successful multifactorial interventions (against a background of the general diagnosis and management of causes and recognised risk factors) often include:

• Strength and balance training
• Home hazard assessment and intervention
• Vision assessment and referral to a specialist
• Medication review and withdrawal

= Individuals at risk of falling and their carers should be offered information about measure to prevent falls measures.

= All healthcare professionals dealing with patients at risk of falls should develop basic professional competence in assessment and prevention.

= There are also specific recommendations on:

• Review and withdrawal of psychotropic medication
• Cardiac pacing in cardioinhibitory carotid sinus syndrome
• Exercise in extended care settings
• Encouraging participation in falls prevention

= And statements on a number of areas where evidence is insufficient, including

• Hip protectors
• Vitamin D (alone)
• Low intensity exercise
• Untargeted group exercise
• Cognitive behavioural interventions

Box 2: Summary of NICE technology appraisal guidance 87: Bisphosphonates, selective oestrogen receptor modulators and parathyroid hormone for the secondary prevention of osteoporotic fragility fractures in postmenopausal women

Guidance applies only to postmenopausal women who have had a clinically apparent osteoporotic fracture.

Bisphosphonates (alendronate, etidronate and risedronate) are recommended as treatment options for the secondary prevention of fractures due to osteoporotic fragility:

• in women aged 75 years and older, without the need for prior dual energy X-ray absorptitometry (DXA) scanning
• in women aged between 65 and 74 years if the presence of osteoporosis is confirmed by DXA scanning, and
• in postmenopausal women younger than 65, if they have a very low bone mineral density (BMD, that is with a T-score of approximately –3 SD or below, established by a DXA scan), or if they have confirmed osteoporosis plus one, or more, additional age-independent risk factor (see guidance for details).

• Raloxifene is recommended as an alternative treatment for women for whom bisphosphonates are contraindicated, who cannot comply with recommendations for use, or who have an unsatisfactory response to or are intolerant of bisphosphonates (see guidance for details).

• Teriparatide is only recommended in women who are 65 and over who either have an unsatisfactory response to bisphosphonates or are intolerant to bisphosphonates and who have a bone density T score of –4 SD or below or have a bone density T score of –3 SD or below and multiple fracture or other risk factors (see guidance for details).

Note: This guidance gives no advice on who should have DXA scanning or on how other patient groups should be managed (eg. primary prevention of osteoporosis in postmenopausal women, individuals with steroid-induced osteoporosis, osteoporosisamong men, or primary prevention of falls and fractures in frail older people using calcium and vitamin D)