Falls Algorithm

Safety

Red flags — injuries and serious underlying causes

Done

After a fall, deal with injury and the cause of this fall before the longer-term prevention work. A fall is often the way an acute illness presents in an older person.

Head injury Loss of consciousness, amnesia, reduced consciousness, focal neurological deficit or clinically significant head injury → Emergency assessment (999 if reduced consciousness, focal neurology or instability). NICE NG232 (2023, adults 16 and over; use paediatric criteria for younger patients): aged 65+ with loss of consciousness or amnesia → CT head within 8 hours; consider CT within 8 hours for people taking anticoagulants or antiplatelets other than aspirin monotherapy, even without other CT criteria. Any head injury in someone taking an anticoagulant or an antiplatelet other than aspirin alone → refer to ED for assessment the same day (NG232). Anticoagulant/antiplatelet use does not automatically mandate admission after a normal assessment and CT

Suspected hip fracture Inability to weight-bear, new groin/hip pain after a fall, pain on passive rotation or axial loading, unexplained inability to mobilise — shortening and external rotation may be absent → Urgent hospital assessment; 999 if unstable, severe uncontrolled pain, cannot be moved safely or another medical emergency. (NICE CG124 hospital pathway: surgery on the day of, or the day after, admission — not a GP target)

Other fractures Wrist, humerus, pelvis or ribs after a low-energy fall; new back pain after a fall in someone with osteoporosis → same-day X-ray (urgent treatment centre or ED); neurological signs → 999

Blackout before the fall Establish whether consciousness was lost before falling: prodrome, posture, exertion, palpitations, chest pain, family history of sudden cardiac death, witness account. Lying/standing BP and 12-lead ECG. Exertional syncope, abnormal ECG, heart failure or structural heart disease (including a murmur), new or unexplained breathlessness, palpitations immediately before the event, family history of sudden cardiac death or injury from syncope → Urgent cardiovascular assessment within 24 hours (NICE CG109; same-day emergency if unstable) — think arrhythmia, aortic stenosis, PE, MI; an ECG alone is not enough. Aged over 65 with a blackout and no warning symptoms → consider the same assessment

Long lie On the floor for a long time or unable to get up → Same day: temperature and hypothermia, pressure injury, hydration and renal function, muscle pain/weakness, dark urine, delirium, safeguarding concerns; CK, U&E and urine dipstick for blood where prolonged immobilisation or rhabdomyolysis is suspected

New neurological signs Face, arm or leg weakness, speech disturbance, new ataxia → 999 (stroke — the fall may be a symptom, not the cause)

Acute illness Fever, new confusion (delirium), breathlessness, black stools or reduced urine output → sepsis, pneumonia, UTI, GI bleed, AKI → Same-day assessment

Hypoglycaemia On insulin or a sulfonylurea, sweaty or confused → capillary glucose now; treat if below 4 mmol/L and review the regimen

Safeguarding Unexplained or inconsistent injuries, fearfulness, controlling behaviour by another person, neglect, financial concerns, poor access to basic care, or an account inconsistent with the examination → Follow local adult safeguarding procedures (Care Act 2014). Multiple falls alone may reflect frailty, neurological disease, medicines or an unsafe environment and are not themselves a safeguarding referral criterion

Unable to cope at home now New immobility or carer breakdown → Same-day community response (urgent community response / virtual ward) to avoid a "social admission"

Older people often under-report symptoms after a fall, so the injuries and illnesses that kill after a fall need to be looked for actively. A head injury on anticoagulants can bleed slowly. NICE NG232 (2023) sets CT within 8 hours for people aged 65 and over with loss of consciousness or amnesia, and asks clinicians to consider CT within 8 hours for people on anticoagulants or antiplatelets other than aspirin monotherapy. Hip fracture needs urgent hospital assessment; NICE CG124's surgery on the day of, or the day after, admission is a hospital pathway standard rather than a GP target. A fall preceded by a blackout is a syncope assessment, not a falls assessment: cardiac causes must be excluded first. Rhabdomyolysis and pressure damage follow a long lie. NG249 lists being unable to get up after a fall as a reason for a comprehensive falls assessment.

Diagnose

Case-finding — who needs a comprehensive falls assessment

Done

NICE NG249 (Falls, 2025) covers people aged 65 and over and people aged 50–64 at higher risk. Ask about falls at routine contacts; many people don't mention them.

Falls history

How many falls in the last year; where, when and doing what; any warning; loss of consciousness; injury; able to get up; near-misses and "trips"

NG249 triggers for comprehensive assessment

Aged 65 or over, or 50–64 with relevant risk factors, with a fall in the last year plus any of: living with frailty; injury needing medical or surgical treatment; loss of consciousness related to the fall; unable to get up independently; two or more falls in the previous year. For a single fall without these features: assess gait and balance — if impaired, offer a falls-prevention exercise programme and consider a home-hazard assessment

Minimum assessment

Circumstances and symptoms before the fall · injury and ability to weight-bear · lying/standing BP and pulse · cardiovascular and neurological examination · gait, balance and strength · medication review · vision and hearing · footwear and feet · cognition, mood and delirium · continence, hydration, weight and nutrition · bone health and fracture risk · home hazards · patient goals and fear of falling

Don't rely on a single tool

NICE NG249: do not use falls risk prediction tools to predict a person's risk of falling. Use gait, balance and mobility tests as part of the comprehensive assessment, not as a stand-alone score

Gait and balance tests

Use a practical gait, balance and mobility assessment such as Timed Up and Go, gait speed, chair-rise testing or observation of turning. Use results to identify impairment and guide intervention, not to assign a numerical falls-risk category — NICE NG249 notes these tests do not accurately predict future falls

Observe walking

Wide-based or unsteady gait, shuffling, reduced arm swing, freezing (Parkinson's), high-stepping (neuropathy, foot drop), antalgic gait, use of furniture for support

Fear of falling

"Are you worried about falling?" Fear leads to restricted activity, deconditioning and more falls. NG249 includes asking about it as part of the assessment

Function

Washing, dressing, stairs, getting in and out of bed and the bath, shopping; who helps; alarms; pets underfoot

What matters to the patient

Goals (staying at home, walking to the shops) guide which interventions they will take up

NICE NG249 (2025) replaced the older falls guideline, CG161. It extends the scope to people aged 50–64 at higher risk and moves away from scoring tools. The committee found no single test predicted falls well, because most tools measure one domain such as balance or gait. So NG249 recommends against using prediction tools to predict whether an individual will fall, and asks for a comprehensive, multifactorial assessment for those who meet the criteria to identify modifiable risk factors and tailor interventions. Many people don't mention falls because they fear losing independence, so ask directly and normalise the question. In an SCA case, open with the circumstances of the fall and whether there was a blackout: that single distinction sends you down either the syncope or the falls pathway.

Diagnose

Multifactorial risk factor assessment — DAME mnemonic

Done

Falls usually have several contributing causes. Find all of them — each is a separate target for intervention.

D — Drugs

Count the medicines and look for fall-risk-increasing drugs: benzodiazepines and Z-drugs, antipsychotics, antidepressants, opioids, antiepileptics, antihypertensives, diuretics and alpha-blockers (postural drop), anticholinergics (confusion), hypoglycaemic agents. Include over-the-counter sleep aids and antihistamines, and alcohol

A — Ageing and neurology

Parkinson's disease and parkinsonism, stroke, peripheral neuropathy, cerebellar disease, dementia and delirium, normal-pressure hydrocephalus (gait, cognition, continence)

M — Mobility and musculoskeletal

Muscle weakness and sarcopenia, hip or knee osteoarthritis, foot pain and deformity, poor footwear, walking aid that is wrong height or unused, previous fracture, kyphosis

E — Environment

Loose rugs, trailing cables, poor lighting (especially at night), stairs without rails, bath or shower access, low chairs or high beds, pets, clutter

Cardiovascular

Orthostatic hypotension, arrhythmia, aortic stenosis, carotid sinus hypersensitivity, vasovagal syncope

Sensory

Poor vision (cataract, macular degeneration, glaucoma, out-of-date glasses, multifocals on stairs), hearing loss, reduced sensation in the feet

Continence

Urgency and nocturia lead to rushing to the toilet at night — a common setting for falls

Nutrition and mood

Weight loss or malnutrition (MUST screen), dehydration, depression, alcohol use

Bone health

Previous fragility fracture, steroid use, low BMI — assess fracture risk (FRAX or QFracture) as part of the falls assessment

A Cochrane review of multifactorial interventions in the community (Hopewell et al., 2018) found they may reduce the rate of falls, with a rate ratio of 0.77 (about 23% fewer falls), though the certainty of the evidence was low and results varied between trials. The benefit depends on actually acting on each risk factor found, not just listing them. Medicines are the most modifiable factor. The STOPPFall tool (Seppala et al., Age Ageing 2021) is a European expert consensus list of fall-risk-increasing drug classes to support deprescribing. Orthostatic hypotension is common, often caused by medicines and reversible.

Diagnose

Targeted examination

Done

Lying and standing BP

Supine for several minutes, then standing at 1 and 3 minutes, recording symptoms and pulse response. Orthostatic hypotension: systolic fall of 20 mmHg or more, or diastolic fall of 10 mmHg or more, or symptomatic postural hypotension even if the numerical fall is smaller

Pulse and heart

Rate and rhythm (AF, bradycardia), ejection systolic murmur (aortic stenosis)

Gait and balance

Timed Up and Go, gait speed or chair rise; watch turning, step length, foot clearance, arm swing; Romberg test. Use to identify impairment and guide intervention, not as a numerical risk score

Muscle strength

Rise from a chair without using the arms; grip strength if available. Proximal weakness suggests sarcopenia, vitamin D deficiency, steroids or thyroid disease

Neurology

Tone, rigidity and tremor (Parkinson's), power, reflexes, sensation and joint-position sense in the feet, cerebellar signs, cognition

Vision

Acuity with current glasses; fields; ask when they last had a sight test and whether they wear multifocals outdoors

Feet and footwear

Pain, deformity, nails, sensation, pulses; shoes that are loose, backless, worn or slippery

Cognition and mood

A brief validated cognitive test (e.g. 6-CIT, AMTS, MoCA) and a depression screen; look for delirium

Injuries and skin

Bruises at different stages, pressure areas after a long lie, signs of neglect

Standing BP is the examination most likely to change management, because it points to medicines you can stop or reduce. A symptomatic postural drop can be missed if you only measure sitting BP. Gait and balance testing shows which exercise or aid is needed. A positive Romberg test points to impaired proprioception (neuropathy, B12 deficiency) rather than cerebellar disease. Vision is easily overlooked, and multifocal glasses make it harder to see steps and kerbs. Cognitive impairment changes both the risk and how you deliver interventions, including the involvement of carers.

Diagnose

Investigations

Done

Bloods Targeted

Guided by history and examination, not routine after every fall. FBC if anaemia, bleeding, infection or unexplained weakness · U&E/eGFR if dehydration, renal disease, diuretics or acute illness · glucose if diabetes, hypoglycaemia risk or altered mental state · bone profile if bone disease, fractures or relevant medication · TFTs if symptoms suggest thyroid disease · B12/folate if macrocytosis, neuropathy, cognitive change or nutritional risk · LFTs if alcohol misuse, liver disease or medication concern · CK only after prolonged immobilisation, muscle pain/weakness, dark urine or concern for rhabdomyolysis

Vitamin D

25-OH vitamin D when there are features of deficiency, bone disease or before osteoporosis treatment. Royal Osteoporosis Society thresholds: below 25 nmol/L deficient, 25–50 nmol/L may be inadequate for some, above 50 nmol/L sufficient

ECG

When the fall may represent syncope, or with palpitations, bradycardia, chest pain, exertional symptoms or relevant cardiac history, or before starting or stopping rate-controlling drugs: heart block, AF, long QT, pre-excitation. Not mandatory for every clearly mechanical trip

Fracture risk

FRAX (with or without BMD) or QFracture; DXA when the result would change treatment. Interpret against the current NOGG intervention thresholds (National Osteoporosis Guideline Group, 2024)

After a long lie

CK, U&E, urine dipstick for blood (myoglobin) where prolonged immobilisation or rhabdomyolysis is suspected. A raised CK alone does not necessarily require admission — clinical state, CK trend, renal function, potassium and hydration determine urgency

Urine

Dipstick only if urinary symptoms or systemic infection signs — not as a routine "confusion screen" in older adults

Specialist tests

Ambulatory ECG monitoring, echocardiography (murmur), tilt testing and carotid sinus massage — via cardiology or a falls and syncope service

Targeted blood tests, guided by the history and examination, look for treatable contributors: anaemia, hyponatraemia (often caused by SSRIs or diuretics), hypoglycaemia, thyroid disease and B12 deficiency. The Royal Osteoporosis Society vitamin D guideline defines deficiency as below 25 nmol/L; treat deficiency according to the current local vitamin D protocol and product SPC. Fracture risk assessment is part of every falls assessment because the fracture, not the fall, is what causes most of the harm. NOGG 2024 uses risk-based intervention thresholds rather than a single fixed percentage. A falls or syncope service can do tilt testing and supervised carotid sinus massage, which do not belong in primary care.

Refer

Referral criteria

Done

999

Suspected hip fracture with inability to transfer safely or major injury; head injury with reduced consciousness, focal neurological deficit or instability; stroke symptoms; chest pain, collapse or severe breathlessness; suspected major fracture with neurovascular compromise; unable to get up and clinically unwell

Same day

Head injury requiring ED/CT assessment, including any head injury on an anticoagulant or an antiplatelet other than aspirin alone (NICE NG232); suspected hip fracture (urgent hospital assessment); blackout or possible syncope with red flags (exertional, abnormal ECG, heart failure or structural heart disease, new breathlessness, preceding palpitations, family history of sudden cardiac death, injury from syncope) → cardiovascular assessment within 24 hours (NICE CG109); long lie with dehydration, hypothermia, AKI or suspected rhabdomyolysis; acute delirium or infection; unexplained inability to mobilise; new injury not yet assessed

Falls service / community geriatrics

People meeting the NG249 criteria for comprehensive falls assessment (fall in the last year plus frailty, injury needing treatment, loss of consciousness, unable to get up independently, or two or more falls in the previous year); recurrent unexplained falls; orthostatic hypotension not improved by medicine changes

Fracture liaison / osteoporosis

Fragility fracture, or high fracture risk above NOGG thresholds needing specialist input

Physiotherapy / exercise programme

Progressive, individually tailored programme addressing balance, coordination, strength and power, delivered by an appropriately trained professional with regular review — the intervention with the strongest evidence (NICE NG249; Cochrane, Sherrington 2019)

Occupational therapy

Home hazard assessment (ideally with a validated tool) and modification, equipment, bathing and toileting aids

Other routine referrals

Optometrist (sight test); podiatry (foot pain, deformity, nails); audiology; continence service; dietitian; memory service if cognitive impairment; neurology if a new movement disorder

The Cochrane review of exercise for falls prevention in the community (Sherrington et al., 2019) found that exercise reduces the rate of falls by 23% (rate ratio 0.77, high-certainty evidence). Balance and functional exercise reduced falls by 24% (rate ratio 0.76). These are pooled estimates — the effect varies by population and programme. That makes a referral for strength and balance training the single most useful thing most patients will get from this consultation. Multifactorial falls services use the same assessment approach as NG249 and can co-ordinate several interventions at once. Referring to several services at the same time is expected, not excessive. The fracture liaison service matters because a fragility fracture strongly predicts the next one.

Treat

Treatment — medication review and pharmacological interventions

Done

Deprescribing Priority

Structured medication review (NICE NG249) to identify fall-risk-increasing medicines and consider adjustment — the goal is not simply to reduce the medicine count. Review indication, dose, duration, timing and patient priorities. Do not stop benzodiazepines, antidepressants, antipsychotics, opioids, anticonvulsants or antihypertensives abruptly; plan gradual withdrawal of psychotropics, sometimes with specialist mental-health input, and consider withdrawal effects and symptom recurrence. Correct reversible causes (dehydration, postural hypotension, hypoglycaemia, infection). STOPPFall (Seppala et al., 2021) supports, but does not replace, clinical judgement and shared decision-making. Review antipsychotics (especially in dementia), sedating antihistamines, tricyclics and anticholinergic burden

Antihypertensives

With orthostatic hypotension or symptomatic low BP, do not automatically reduce antihypertensives, diuretics or alpha-blockers: review indication, timing, volume status, renal function, postural symptoms and cardiovascular risk, then adjust where appropriate and recheck standing BP. Avoid overcorrecting BP in frail older adults. NICE NG136 uses standing BP to guide treatment in people with a postural drop

Orthostatic hypotension

Non-drug measures first: rise slowly, sit on the bed edge, adequate fluids, avoid large meals and alcohol, raise the head of the bed. Drug treatment (e.g. midodrine) is specialist-led

Vitamin D

NICE NG249: evidence is insufficient to recommend vitamin D solely to prevent falls. Follow NHS advice to take 10 micrograms (400 units) a day for bone and muscle health; treat proven deficiency according to the current local vitamin D protocol and product SPC, considering renal impairment, hypercalcaemia, malabsorption, granulomatous disease, previous vitamin D loading and calcium intake

Calcium

Avoid blanket supplementation. Assess dietary calcium intake and supplement only if intake is inadequate or there is a specific osteoporosis indication (dose per NICE/SPC). Supplements can cause gastrointestinal symptoms, constipation and renal calculi in susceptible people

Osteoporosis treatment

When above the NOGG intervention threshold: oral bisphosphonate first line (e.g. alendronic acid 70 mg once weekly, per BNF), after checking renal function, calcium and vitamin D. Review dental health where appropriate, without unnecessarily delaying urgent treatment. Duration depends on fracture risk, treatment type, age, previous fractures, glucocorticoid exposure, renal function, response and adherence — reassessment at about 5 years (oral) or 3 years (IV zoledronate) may be considered, but ongoing therapy may be appropriate at high or very high risk; follow current NOGG guidance (2024) rather than an automatic stop date

Step 1Structured medication review — adjust or gradually withdraw sedatives, psychotropics, anticholinergics, and antihypertensives causing a postural drop, with shared decision-making; avoid abrupt stopping

Step 2Treat the conditions found — cataract referral, Parkinson's optimisation, rate control for AF, pacing for heart block, continence treatment, analgesia for painful joints

Step 3Protect the bones — fracture risk assessment, bisphosphonate if indicated, vitamin D per NHS advice, calcium supplement only if dietary intake is inadequate or specifically indicated

Step 4Risk-based review — timing set by risk; sooner after medication changes or orthostatic symptoms: BP, symptoms, falls since, adherence, side effects and withdrawal effects

Next steps: see Osteoporosis · Parkinson's disease · Atrial fibrillation · Dementia · Vasovagal syncope

Psychotropic medicines are among the most important modifiable causes of falls. In a randomised trial, gradual withdrawal of psychotropic medication cut the risk of falls substantially (relative hazard 0.34; Campbell et al., J Am Geriatr Soc 1999), although many participants later restarted them. Stopping is only the first step: keeping medicines stopped needs follow-up. NICE NG249 does not recommend vitamin D purely for falls prevention because the evidence was insufficient, but it points to NHS advice on vitamin D for bone and muscle health. Bone protection addresses the consequence of falls: even the best falls programme will not prevent every fall.

Lifestyle

Exercise and environmental modification — highest-evidence interventions

Done

Strength and balance exercise Offer a progressive, individually tailored programme addressing balance, coordination, strength and power, delivered by an appropriately trained professional with regular review (NICE NG249) — e.g. Otago or FaME, through community physiotherapy or a falls service. This is the main falls-prevention intervention; effect varies by population and programme

Tai chi Can be offered as an option for people who prefer a class-based activity (low-certainty evidence; Cochrane, Sherrington 2019), but should not replace a tailored falls-prevention programme where impairment is significant

Home hazard assessment Ideally using a validated tool and involving occupational therapy where available: remove trip hazards, improve lighting (including night lights to the toilet), fit grab rails and stair rails, non-slip mats, raised toilet seat, bed and chair heights

Footwear Well-fitting, enclosed shoes with a thin firm sole and good grip; avoid walking in socks or loose slippers. Podiatry for foot pain and deformity

Getting up and alarms Teach how to get up from the floor, or how to keep warm and call for help if they can't. Personal alarm or fall detector for those living alone (via the local council or a private provider)

Nutrition Screen with MUST; enough protein and energy to maintain muscle; dietitian if malnourished or losing weight

Alcohol Keep within the UK CMO low-risk limit of 14 units a week, and less if falls or sedating medicines are an issue

Fear of falling Exercise builds confidence; NICE NG249 suggests considering cognitive behavioural interventions if fear of falling is not helped by exercise

Vision Regular sight tests; changing to single-vision distance glasses may help some people who wear multifocals and regularly walk outdoors — decide with an optometrist; cataract surgery where indicated

Exercise is the best-evidenced falls intervention for people living in the community. The 2019 Cochrane review found high-certainty evidence that exercise reduces the rate of falls, and that balance and functional training works best, although the size of the effect varies by population and programme. Programmes that combine several types of exercise may do more. For tai chi the effect is smaller and less certain (low-certainty evidence). Home hazard modification works best when delivered by an occupational therapist for people at higher risk. A personal alarm does not prevent falls, but it shortens the time on the floor and the harm that follows. Protein and energy intake support muscle strength.

Safety

Follow-up and safety-netting

Done

Risk-based review

Sooner after medication changes or orthostatic symptoms. Falls since? Medicine changes tolerated, standing BP rechecked? Referrals accepted and exercise started? Home changes made?

Later review

Exercise progress according to the service programme (repeat gait and balance assessment only if clinically needed); review fracture-risk results and bone treatment; adherence; mood and fear of falling

Ongoing

Ask about falls at routine reviews and medication reviews; review after any recurrent fall, hospital discharge or fracture, and repeat the assessment after any change in health (NICE NG249). Reassess cognition, mood, nutrition, continence and home safety where relevant

999 safety-net

"If you fall and can't get up, or you hit your head and feel drowsy, are being sick or are confused, call 999." Face drooping, arm weakness or speech problems — 999

Same day

A fall with a head injury while on a blood thinner or antiplatelet other than aspirin alone (A&E for assessment); unable to put weight on a leg or new hip/groin pain; new confusion; a blackout; a new injury that hasn't been checked

Falls diary

Ask the patient or carer to record the date, time, what they were doing and any symptoms for each fall or near-miss — the pattern often points to the cause

Carers and family

With consent, share the plan, the getting-up advice and the warning signs; make sure they know how the alarm works

Falls prevention works only if interventions happen and continue. The follow-up visit is where you find the physiotherapy referral that was never booked or the sleeping tablet that was restarted. A diary helps turn vague reports into patterns: falls on getting out of bed at night suggest postural hypotension or nocturia, and falls on the stairs point to the environment or vision. Clear, specific safety-net advice for the patient and carers covers the two biggest post-fall dangers, head injury on anticoagulants and the long lie. Recording the advice is good practice and protects everyone.