1. Occupational therapy in the prevention and management of falls in adults
Practice guideline   
Royal College of Occupational Therapists
Specialist Section Older People
CPD Session: PowerPoint, notes and group activities
The slides and information in this CPD session can be used as a template, but can be adapted to reflect local need and priorities.
The overall aim of this resource is to support a continuing professional development session to explore the practice guideline Occupational therapy in the prevention and management of falls in adults (COT 2015).
The resource comprises this PowerPoint presentation and notes which can be used for a one-hour facilitated workshop, or for individual self-directed learning.
There are some interactive activities which are intended to be used to encourage reflection on current practice and to explore some areas in more detail.
Pre-requisite materials:
Guideline document: Occupational therapy in the prevention and management of falls in adults: practice guideline (COT 2015)
Implementation tools i.e.
Audit Form.
Quick Reference Guide.
It is essential that workshop facilitators familiarise themselves with the full guideline document and implementation tools in advance.

2. Learning outcomes
To explore aspects of the practice guideline recommendations in relation to current practice.
To develop an understanding of the importance of using practice guidelines to inform practice.
To explore and develop an understanding of how to use the RCOT Audit Form for use with the evidence-based recommendations.
Slide 3 Practice question
Slide 4 Guideline objective
Slide 5-6 Methodology and recommendation grading
Slide 7 Recommendation areas:
Keeping safe at home: reducing risk of falls
Keeping active: reducing fear of falling (Activity 1 and 2)
Falls management: making it meaningful
Slides Evidence overview and list of the recommendations
Slides Impact of the guideline (Activity 3)
Slide 24 Practice guideline resources
Information used in the session is taken from the full practice guideline document and the other implementation tools, particularly the audit tool.
Activities 1 and 2 can potentially be applied to any of the three recommendation areas. Choose the one that you think would yield as much discussion as possible by the group in order that they may take plenty of ideas away to think about.

3. Practice question:
What evidence is there to support occupational therapy in the prevention and management of falls in adults?

4. Key objective of guideline
To provide evidence-based recommendations that inform occupational therapists, working with adults, of their role within the multifactorial assessment and intervention required to prevent and manage falls. It addresses occupational therapy intervention at any point during a service user’s journey along the falls care pathway.

5. Methodology 2. Guideline scope defined involving stakeholders
1. Guideline development group established
5. Critically appraise articles
4. Screen findings
3. Literature search
6. Development of practice guideline recommendations
7. Peer review, stakeholder and service user consultation
The College of Occupational Therapists’ guideline development process is rigorous and is Accredited by the National Institute for Health and Care Excellence.
Selection of a topic
1. Establish the Guideline Development Group
Submit a proposal
2. Define the scope and practice question(s)
3. Literature search
4. Screen findings
5. Appraisal and grading of the evidence
6. Formulate the recommendations
Write the guideline
7. Peer review and consultation involving stakeholders (includes
occupational therapists as end users) and service users
8. Ratification by the COT Practice Publications Group
Publication and Implementation
Review – within 5 years.
Stakeholder, service user and carer engagement and involvement was fundamental to the development of the guideline.
9. Published by
COT 2015
8. Final draft approved by COT Practice Publications Group

6. Evidence-based recommendations
Recommendations are based on the evidence available within 33 critically appraised papers.
Each recommendation is assigned:
A strength scoring 1 or 2 (Strong or Conditional)
A quality grading A, B, C or D
(High, Moderate, Low or Very Low)
Each relevant article of evidence identified from the search (2003 – 2013) was critically appraised by two members of the guideline development group, and a quality of evidence grading subsequently determined based on that assessment.
The quality of evidence grading reflects the typical hierarchy given to study design. For example the highest level (A) reflects consistent results from randomized controlled trials, whilst the lowest (D) includes studies such as case studies or expert opinion. Higher level studies are perceived as being less susceptible to bias.
The strength of the recommendation is scored as either strong (1) or conditional (2). This is based on the benefits and risks of the evidence. A strong recommendation indicates that benefits appear to outweigh the risks for the majority of the target group, where as a conditional or suggested recommendation, means that the risks and benefits are more closely balanced or there is more uncertainty.
Over half of the evidence used was derived from studies of high or moderate quality: 24.3% of the evidence was graded as high (A), 33.3% as moderate (B), 39.4% as low, and 3.0% as very low (D). All fifteen of the recommendations are graded as strong.
Each recommendation is specific and is based on the appraised evidence. Details about the studies referenced can be found in the evidence tables section (Appendix 6) of the full guideline.

7. Recommendation areas Keeping safe at home: reducing risk of falls
Keeping active: reducing fear of falling
Falls management: making it meaningful
The recommendations are based on the synthesis of the best available evidence. It should, therefore, be noted that the guideline is not able to be fully reflective of the role of occupational therapy in the prevention and management of falls.
Recommendations, based on the evidence, were developed in three key areas:
Keeping safe at home: reducing risk of falls
Keeping active: reducing fear of falling
Falls management: making it meaningful

8. Keeping safe at home: reducing risk of falls
Evidence overview:
‘The evidence with respect to the effectiveness of the occupational therapist in home hazard assessments and interventions for people considered at high risk of falls (history of falling in past year, hospitalisation for a fall, severe visual impairment or functional decline) is both high quality and strong’ (COT 2015, p37).

9. Keeping safe at home: reducing risk of falls
It is recommended that:
Service users who have fallen or are at risk of falls should be offered an occupational therapist-led home hazard assessment, including intervention and follow-up, to optimise functional activity and safety.
(Campbell et al 2005 [A]; Clemson et al 2008 [A]; Clemson et al 2004 [A]; Costello and Edlestein 2008 [B]; Gillespie et al 2012 [A]; La Grow et al 2006 [A]; Nikolaus and Bach 2003 [A]; Pighills et al 2011 [A])
1 A
2. Occupational therapists should offer home safety assessment and modification for older people with a visual impairment.
(Campbell et al 2005 [A]; Clemson et al 2008 [A]; Gillespie et al [A]; La Grow et al 2006 [A])

10. Keeping safe at home: reducing risk of falls
It is recommended that:
3. Occupational therapists should consider carrying out a pre- or post- discharge home assessment to reduce the risk of falls following discharge from an inpatient rehabilitation facility, taking into account the service user’s falls risk, functional ability and diagnosis.
(Di Monaco et al 2012 [B]; Di Monaco et al 2008 [B]; Johnston et al [C])
1 B
4. Occupational therapists should offer service users who are living in the community advice, instruction and information on assistive devices as part of a home hazard assessment.
(Steultjens et al 2004 [B])
Activity 1
Prior to showing the next slide 12, ‘Keeping active: reducing fear of falling’ evidence overview, Activity 1 can be carried out.
Tell the group that the next section deals with reducing fear of falling.
Split the group into pairs and ask them to discuss what they think would be covered/recommended in this section. Prompt them to think about their own practice in this area, highlighting examples of their own best practice.
Following discussion, ask the pairs to share 1-2 examples with the group; you might want to record on a flipchart the groups’ suggestions to refer back to these ideas when you show the recommendations.
On completion of the activity present the overview of evidence (slide 12) and recommendations for reducing fear of falling which are on slides 13 and 14.

11. reducing fear of falling
Keeping active:
reducing fear of falling
Evidence overview:
‘The evidence on fear of falling highlights the integral link between fear and activity levels. Although reducing the number of falls may be a key outcome for falls prevention activities, the potential to restrict activity as a behavioural response to fear of falling can be to the detriment of activities of daily living and occupational engagement. People have different attitudes and levels of tolerance to risk. The occupational therapist therefore has a valuable role in working with service users, caregivers, family and friends to achieve a balance of risk and activity’ (COT 2015, p42).

12. reducing fear of falling
Keeping active:
reducing fear of falling
Keeping active: reducing fear of falling
It is recommended that:
5. Occupational therapists should explore with service users whether fear of falling may be restricting activity, both in and outside the home, and include the promotion of occupational activity within individualised intervention plans.
(Boltz et al 2013 [C]; Kempen et al 2009 [C]; Painter et al 2012 [C]; Wijlhuizen et al 2007 [C])
1 C
6. Occupational therapists should listen to an individual’s subjective views about their falls risk, alongside using objective functionally based outcomes, to determine the influence of fear of falling on the service user’s daily life.
(Schepens et al 2012 [B]; Wijlhuzen et al 2007 [C])
1 B

13. Keeping active: reducing fear of falling
It is recommended that:
7. Occupational therapists should seek ways of enabling service users to minimise the risk of falling when performing chosen activities, wherever possible, as this may improve confidence and enable realistic risk taking.
(Wijlhuzen et al 2007 [C]; Zijlstra et al 2007 [B])
1 B
8. Occupational therapists should facilitate caregivers, family and friends to adopt a positive approach to risk.
(Boltz et al 2013 [C])
1 C
Activity 2
Once the recommendations have been presented, the questions below can be used to encourage the group to talk about the recommendations in relation to their own suggestions:
Do they cover the best practice examples they identified?
Why might these not be the same?
You may want to refer back to the methodology of creating evidence-based guidelines and how it is based on the published literature - evidence-based practice guidelines support practice, but can only reflect current evidence.
It may be important to emphasise that just because their own examples are not covered, this does not necessarily mean they are not best practice. Occupational therapists also need to adhere to other service standards, consider the service user’s perspectives and apply their clinical judgement and reasoning when providing interventions for adults who have fallen, are at risk of falling or are fearful of falling.
The Audit Form can now be used to further consider the reducing fear of falling recommendations.
Ask the pairs/small groups to discuss each of the recommendations (give each group a different recommendation), sharing their current practice in relation to the recommendation and how they would evidence this. If the recommendation is not current practice then they should look at what an action plan might consist of to implement that recommendation.

14. Falls management: making it meaningful Evidence overview:
Occupational therapists should maximise the engagement of the service user in falls management interventions, taking into consideration the service user’s motivation, beliefs and knowledge.
A key message to be incorporated into falls prevention and management interventions is a focus on the potential benefits to the individual of interventions to improve mobility, independence and active participation, as distinct to the language used within the professional arena of ‘reducing the incidence of falls’ or ‘decreasing the risk of falls’. Service users should be made aware of the potential implications of falling, but occupational therapists should highlight the positive outcomes rather than the negative connotations associated with falls Contd:

15. Falls management: making it meaningful Evidence overview contd:
Meaningful activity can be integrally linked with motivation. Physical activity which can be incorporated into daily lifestyles is more likely to be sustainable; there is a key role here for occupational therapists given this functional approach. The value of such an occupational and activity-based approach is supported by the high-quality research by Clemson and colleagues. Although the primary research for the LiFE approach was undertaken in Australia (Clemson et al 2012, Clemson et al 2010), potentially it is easily translatable to the United Kingdom (COT 2015, p48).

16. Falls management: making it meaningful
It is recommended that:
9. Occupational therapists should share knowledge and understanding of falls prevention and management strategies with the service user. This should provide personally relevant information and take account of the service user’s individual fall risk factors, their lifestyle and preferences.
(Ballinger and Clemson 2006 [C]; de Groot and Fagerström 2011 [C]; Haines et al 2006 [C]; Haines et al 2004 [B]; Stern and Jayasekara 2009 [B])
1 B
10. Occupational therapists should take into account the service user’s perceptions and beliefs regarding their ability, and personal motivation, which may influence participation in falls intervention.
(de Groot and Fagerström 2011 [C]; Gopaul and Connelly 2012 [D]; Nyman 2011 [C])
1 C

17. Falls management: making it meaningful
It is recommended that:
11. Occupational therapists should maximise the extent to which the service user feels in control of the falls intervention.
(Currin et al 2012 [C]; Wilkins et al 2003 [C])
1 C
12. Occupational therapists should support the engagement of the service user in identifying the positive benefits of falls intervention.
(Ballinger and Clemson 2006 [C]; Nyman 2011 [C])
13. Falls prevention and management information should be available in different formats and languages to empower and engage all populations (e.g. web-based support, written information leaflets).
(Hill et al 2009 [B]; Nyman et al 2011 [C])
1 B

18. Falls management: making it meaningful
It is recommended that:
Physical and social activity, as a means of reducing an individual’s risk of falls and their adverse consequences, should be encouraged and supported through the use of activities meaningful to the individual.
(Rosendahl et al 2008 [B])
1 B
15. Activities to improve strength and balance should be incorporated into daily activities and occupations that are meaningful to the individual, to improve and encourage longer term participation in falls prevention interventions.
(Clemson et al 2012 [A]; Clemson et al 2010 [B]; Pritchard et al 2013 [B])
1 A
Activity 3 – can be carried out before moving onto the next slides
Divide into groups again and ask them to consider what they think the impact of these guidelines will be for themselves, their service managers, the users of their service, and the commissioners of services.
Obtain feedback from the groups before going through the suggested impacts on slides 19–23.

19. Impact of practice guideline for you: the practitioner
Challenges / affirms your current practice.
Informs your practice.
Provides evidence to support your practice (completion of Audit Form).
Provides a vehicle for you to justify your practice.

20. Impact of practice guideline for managers
Provides evidence of the need for occupational therapy input into services for adults who fall, are at risk of falling or are fearful of falling.
Provides a structure to audit the work of occupational therapists within the service to improve service quality.
Provides a vehicle for justifying service provision.

21. Impact of practice guideline for commissioners
Articulates the need for occupational therapy interventions within services for adults who fall, are at risk of falling or are fearful of falling.
Provides recommendations developed by a NICE Accredited process.
Can help educate commissioners to identify learning needs for the workforce.
Audit form provides a mechanism to review service delivery in accordance with the evidence.
NB: Highlight the significance of the guideline having been developed by the COT Guideline Development process which is NICE Accredited, e.g.
COT practice guidelines developed using the NICE Accredited guideline process are clearly visible in search results on NICE Evidence.
Guidelines developed via a NICE Accredited process are eligible for consideration as evidence in the development of NICE Quality Standards.
Provides robust evidence-based recommendations that can demonstrate to commissioners the benefits of occupational therapy for the community on whose behalf they are commissioning services.
Further information at:

22. Impact of practice guideline for service users
The recommendations reinforce the fundamental importance of the service user perspective
In being adopted by services and occupational therapists, the guideline should improve the consistency and quality of intervention for users of services.
Gives assurance that practitioners use the available evidence to support interventions.

23. Service user perspectives
“I had a fall on my front path and landed heavily on my knee. I have had a loss of confidence after my fall – although equipment helps, it does not restore your confidence”
“People are all different – how they express this [risk of falls] will also be different – some will need encouragement to do more, others may need holding back a bit”
“The problem with the term risk assessment is it implies all risks are the same, and they aren’t”
“When I was really unwell I had over ten falls a day. This was often terrifying. I felt disabled and scared of injury. I had many cuts and bruises and was embarrassed to be in public so stopped at home, unable to work or socialise”
Conclude the session by summarising some of the key areas of discussion and messages from the guideline recommendations.
Ask each participant to share a thought about the recommendations and to identify something they are going to do following the session.
If applicable, you may also want to identify how as a service you are going to complete and monitor the Audit Form.
Finish by reiterating the importance of a practice guideline in informing work with service users, focusing on empowering the service user to fully engage and take responsibility of achieving individual goals.

24. Practice guideline resources
College of Occupational Therapists (2015) Occupational therapy in the prevention and management of falls in adults: practice guideline. London: COT.
Audit tool
Quick Reference Guide
Feedback form
Resources are available from the Royal College’s website at: