Falls Algorithm · Reasoning GP

The full reasoning pathway — a fall is a syndrome, not a diagnosis: identify the injured or acutely-unwell patient, then assess the multifactorial causes to prevent the next fall. Modify risks and safety-net.StartDecisionInvestigateActionReferStop / Admit

PresentationFalls assessment

Circumstances (before/during/after), frequency, injury, fear of falling. Lying/standing BP, ECG, medication review, gait & balance, vision, cognition.

Step 1 · Safety — injury / acute causeInjury or acute medical cause?

Head injury (esp. anticoagulated) · fracture (#NOF — shortened, externally rotated leg) · syncope/cardiac cause · acute illness (sepsis, stroke, arrhythmia, hypoglycaemia).

YES

Stop · EscalateEmergency / admit

Significant injury, suspected fracture, head injury on anticoagulant, or acute medical cause → emergency assessment.

Investigate · MultifactorialFind modifiable risks

Postural hypotension, polypharmacy, vision, footwear, environment, MSK, neurological, continence.

Step 3 · modifiable risk factors

Medication / cardiovascular

Review drugs + BP

Reduce culprit drugs (sedatives, antihypertensives, anticholinergics); treat postural hypotension; ECG for arrhythmia.

Strength & balance

Exercise programme

Strength and balance training; physiotherapy; walking aids; vision correction.

Bone health / environment

Prevent injury

Assess osteoporosis (FRAX/DXA), treat; home hazard assessment; footwear; address continence.

Step 6 · ReferEscalation

Emergency fracture / head injury / acute medical cause. Falls service / community geriatrics recurrent falls or multifactorial risk; bone health / FLS fragility fracture for osteoporosis treatment.

Step 8 · strength, balance & environment

Step 8 · Lifestyle & preventionThe active ingredients of falls prevention

Strength & balance training (e.g. Otago, tai chi) is the highest-yield intervention · home-hazard assessment and modification · vision review and single-lens distance glasses for outdoor use · appropriate footwear · vitamin D / bone protection and FRAX/DXA · deprescribe culprit drugs (sedatives, antihypertensives causing postural drop, anticholinergics) · footcare and assistive devices.

Step 9 · review & safety-net

Step 9 · Review & safety-netRecheck & urgent return advice

Review after the multifactorial intervention; re-check postural BP and medication changes. 999 / same-day for head injury (especially if anticoagulated — CT head), suspected hip/long-bone fracture, syncope with cardiac features, or a fall as the presentation of acute illness (sepsis, stroke, MI, GI bleed). Provide a get-up-after-a-fall plan and call-alarm where appropriate.

⚠️ A fall is a chance to prevent the next one: a multifactorial assessment — medication review, postural BP, strength/balance and bone health — reduces future falls and fractures. Beware head injury in anticoagulated patients.

Safety

Red flags — injuries & serious underlying causes

Done

After a fall, screen for serious injury and underlying cause BEFORE a routine falls assessment.

Head injury with LOC / confusion Loss of consciousness, amnesia, vomiting → same-day CT head (NICE head injury criteria: anticoagulation, age >65, skull fracture)

Hip fracture Unable to weight-bear, shortened/externally rotated leg, hip pain → 999 (displaced NOF fracture — surgical emergency, mortality 30% at 1 year without repair)

Vertebral fracture Acute back pain after minor trauma in >65 or osteoporosis → XR spine; if severe/neurological signs → 999

Syncope preceding fall "Blacked out" before falling, palpitations, chest pain → same-day ECG + cardiac review (cardiac syncope, arrhythmia, PE)

Long lie on floor (>1h) Unable to get up, pressure injury, dehydration, rhabdomyolysis → same-day bloods (CK, U&E, AKI risk)

New neurological symptoms New weakness, facial droop, ataxia, dysarthria at time of fall → 999 (stroke/TIA — fall was consequence of stroke)

Hypoglycaemia Known diabetes + confused/sweaty → BM stat; treat <4 mmol/L immediately

Safeguarding concern Multiple unexplained falls/bruising in care setting or with carer present → safeguarding referral (elder abuse)

Hip fracture 30-day mortality is 7–10%, rising to 30% at 1 year without surgical repair — NICE mandates surgery within 36 hours. Long lie (>1 hour) causes rhabdomyolysis in 50% of cases — AKI and hyperkalaemia can be fatal without IV fluids. Cardiac syncope is the cause in ~15% of "falls" — missing this means missing arrhythmias (Stokes-Adams attacks, HOCM, aortic stenosis).

Diagnose

Falls risk screening — identify high-risk patients proactively

Done

NICE NG191: ask all patients aged ≥65 about falls annually. Two or more falls in 12 months = high risk; offer full multifactorial assessment.

Falls history

Number in last 12 months, circumstances (indoor/outdoor, activity), time of day, witnesses, LOC, any injury. Near-miss falls count

NICE trigger

1 fall + injury OR 2+ falls in 12 months = full multifactorial falls risk assessment (NICE NG191)

Timed Up and Go (TUG)

Stand from chair, walk 3m, turn, walk back, sit. >12 seconds = high fall risk. Simple, validated, takes 1 minute

Balance/gait

Observe while walking: wide-based gait, shuffling, reduced arm swing (Parkinson's), off-balance turning (cerebellar)

Fear of falling

Assess falls efficacy — "Are you afraid of falling?" Fear itself causes activity restriction, deconditioning, and more falls (vicious cycle)

Falls are the leading cause of accidental death in over-65s in the UK. One third of adults >65 fall each year; 50% of >80s. TUG test >12 seconds has 87% sensitivity for identifying high-risk fallers. Many patients do not volunteer falls history — they fear losing independence. NICE NG191 (2023) mandates proactive annual questioning.

Diagnose

Multifactorial risk factor assessment — DAME mnemonic

Done

Falls are multifactorial. Identify ALL contributing factors — each one addressed reduces fall rate by 10–15%.

D — Drugs

Polypharmacy (>4 drugs doubles fall risk). High-risk: sedatives, opioids, antihypertensives (postural hypotension), diuretics, antiepileptics, antipsychotics, tricyclics. Review ALL medications including OTC

A — Ageing/neurological

Parkinson's (festination, freezing), cerebellar ataxia, peripheral neuropathy, dementia, stroke, Lewy body disease

M — Mobility/musculoskeletal

Muscle weakness (sarcopenia), osteoarthritis (hip/knee), foot problems, inappropriate footwear, previous hip fracture, kyphosis

E — Environmental

Loose rugs, poor lighting, slippery floors, no grab rails, high bed/chair, stairs without handrail, cluttered pathways

Cardiovascular

Postural hypotension (drop ≥20 systolic on standing), carotid sinus hypersensitivity, arrhythmia, aortic stenosis

Sensory

Visual impairment (cataracts, glaucoma, macular degeneration), peripheral neuropathy affecting proprioception

Multifactorial intervention reduces fall rate by 24% vs usual care (Cochrane 2019). Each modifiable risk factor corrected reduces falls independently. Psychotropic medication use doubles fall risk — benzodiazepines, antipsychotics and tricyclics are the highest-risk drugs. Postural hypotension is found in 30% of community-dwelling older adults and is often drug-induced and reversible.

Diagnose

Targeted examination

Done

Postural BP

Supine BP → standing at 1 min and 3 min. Drop ≥20 systolic = postural hypotension. Symptoms: dizziness, greyout on standing

Gait & balance

TUG test. Observe: foot clearance, step length, arm swing, turning. Berg Balance Scale if formal assessment needed

Muscle strength

Stand from chair without hands (chair stand test — 5 in 30s = adequate). Sarcopenia: grip strength <16 kg (F) / <27 kg (M)

Neurology

Proprioception (big toe joint position sense), vibration (tuning fork at ankle), Romberg's test, cranial nerves, cerebellar testing

Vision

Snellen chart. Refer optician if not reviewed in 2 years. Cataracts, bifocal lenses (increase fall risk on stairs)

Feet & footwear

Peripheral pulses, sensation, nail care, foot deformity. Assess footwear: non-slip sole, correct fit, laces/fastenings secure

Cognitive screen

AMT or MoCA. Cognitive impairment triples fall risk. Affects rehabilitation capacity

The 5-times sit-to-stand test predicts future falls with 86% sensitivity. Romberg's test positive (falls with eyes closed) = proprioceptive deficit not cerebellar — important for targeting vitamin D and B12. Bifocal/varifocal glasses increase falls on stairs by 40% — single-lens glasses recommended for outdoor use in high-risk patients.

Diagnose

Investigations

Done

Bloods First-line

FBC (anaemia), U&E (hyponatraemia → falls risk), glucose (hypoglycaemia), calcium, TFTs (hypothyroidism/hyperthyroidism), B12

Vitamin D Essential

25-OH vitamin D. Deficiency (<30 nmol/L) causes proximal myopathy and increases fall risk. Universal supplementation in >65s recommended

ECG

If syncope preceding fall, palpitations, or bradicardia: AF, heart block, prolonged QTc (drug-induced), Brugada

DEXA scan

Fracture risk assessment (FRAX score) for all fallen patients >50. Osteoporosis = silent co-morbidity. FRAX >20% 10yr risk = treatment threshold

Long lie bloods

If >1 hour on floor: CK (>1000 = significant rhabdomyolysis), U&E, urine dipstick (myoglobinuria)

Carotid sinus massage

Consider if unexplained/situational falls — specialist-supervised in cardiology/falls clinic (not primary care)

Vitamin D deficiency affects 1 in 5 UK adults and up to 50% of care home residents. Supplementation (800 IU daily) reduces fall rate by 19% and fracture rate by 23% (meta-analysis, Bischoff-Ferrari 2009). FRAX score changes management for most fallen older adults — osteoporosis treatment reduces re-fracture risk by 30–50%. Hyponatraemia (Na <130) triples fall risk independently of all other factors.

Refer

Referral criteria

Done

999

Hip fracture, head injury with LOC, acute stroke at time of fall, unable to weight-bear with severe pain

Same-day

Long lie >1h with AKI risk | Suspected vertebral fracture with neurology | Cardiac syncope (ECG abnormality)

Falls clinic

≥2 falls in 12 months + functional impairment | Unexplained syncope | Postural hypotension not responding to medication adjustment | Complex multifactorial falls

Routine referrals

Memory clinic

If cognitive impairment identified on screen — dementia triples fall risk and requires specific management

Specialist falls clinics reduce fall rate by 30–40% in high-risk patients (NICE NG191). Physiotherapy for strength and balance is the single most effective intervention (NNT approximately 16 to prevent one fall). Home hazard assessment by OT reduces falls by 21% in high-risk patients — especially in those who have previously fallen indoors. Referral to multiple services simultaneously is appropriate and expected.

Treat

Treatment — medication review & pharmacological interventions

Done

Deprescribing Priority

Stop/reduce: benzodiazepines (taper over 4–8 weeks), antipsychotics, tricyclic antidepressants. Switch to SSRIs if antidepressant needed. Each deprescribed drug reduces falls by ~15%

Antihypertensives

If postural hypotension: reduce dose or switch from alpha-blockers/nitrates/diuretics. Target SBP >120 mmHg standing. Do not sacrifice BP control entirely

Vitamin D Universal

Vitamin D3 800–1000 IU OD for all >65. Colecalciferol preferred. For deficiency (<30 nmol/L): loading regimen 300,000 IU over 6–10 weeks then maintenance

Calcium

Only supplement if dietary intake <700 mg/day. Calcium + Vitamin D reduces fall rate by 19% and fracture by 23%. Avoid over-supplementation (CV risk)

Osteoporosis treatment

FRAX 10yr hip fracture >3% OR major osteoporotic fracture >20% → alendronate 70mg weekly (first-line). Check renal function (eGFR >35) and dental health before bisphosphonate

Step 1Vitamin D3 800 IU OD — all patients >65 years. Calcium supplementation if dietary intake inadequate

Step 2Deprescribe high-risk medications — use STOPPFall criteria. Gradual benzodiazepine taper. Switch antidepressants if tricyclic

Step 3Bisphosphonate if osteoporosis criteria met — alendronate 70 mg PO weekly. Counsel on administration (30 min upright, fasting). Review after 5 years (drug holiday consideration)

Step 4Treat underlying conditions — Parkinson's optimisation, heart rate control if AF, cataract surgery, hearing aids, diabetic neuropathy management

STOPPFall criteria (Seppala et al 2021): 13 drug classes independently associated with falls — benzodiazepines increase fall risk 1.5x, antipsychotics 1.5x, tricyclics 2x. Structured deprescribing of psychotropics reduced falls by 66% in a Campbell RCT (1999). Cataract surgery reduces fall rate by 34% (Cochrane) — one of the most effective single interventions available.

Lifestyle

Exercise & environmental modification — highest-evidence interventions

Done

Strength & balance exercise Otago Exercise Programme or Falls Management Exercise (FaME). 2–3 sessions/week for >3 months. Reduces falls by 35–40%. Prescribe via community physiotherapy or exercise on prescription

Tai Chi Reduces falls by 23–45% in community-dwelling older adults (Cochrane 2019). Particularly effective for balance. Suitable for mild-moderate frailty. Available via community leisure centres

Home hazard assessment OT referral — remove trip hazards (loose rugs, trailing cables), improve lighting, install grab rails (bathroom, stairs), non-slip bath mat, raised toilet seat

Footwear review Non-slip soles, adequate ankle support, well-fitting. Advise against walking in socks/slippers without grip. Podiatry for foot deformity

Personal alarm / fall detector For patients living alone at high risk. Council-funded pendant alarms available. Reduces long-lie complications. Discuss with patient and family

Diet and protein intake Adequate protein (1.0–1.2 g/kg/day) slows sarcopenia. Dietitian referral if weight loss or malnutrition risk (MUST score)

Vision correction Annual optician review. Single-lens glasses for outdoor use if high risk on stairs. Cataract surgery if eligible — 34% fall reduction post-surgery

Otago Exercise Programme: NNT = 10 to prevent one fall over 12 months (Robertson 2001). Home hazard assessment by OT reduces falls by 21% in high-risk patients who have previously fallen indoors. Personal alarms do not prevent falls but dramatically reduce the consequences of long lies — reducing AKI, rhabdomyolysis, pneumonia, and psychological trauma from floor-level helplessness.

Safety

Follow-up & safety-netting

Done

4–6 weeks

Review: Falls diary — any new falls? Deprescribing tolerated? Referrals accepted? Exercise programme started? Vitamin D commenced?

3 months

Formal reassessment — TUG test repeat. Review Vitamin D level. FRAX and DXA result. Bisphosphonate adherence

6–12 months

Annual falls risk review in all >65s. Repeat postural BP. Review medication changes. Falls diary review

999 safety-net

After any fall: "If you cannot get up, call 999. Do not lie on the floor" — educate patient and carers. New facial droop/arm weakness/speech problems = 999

Same-day

Fall with head injury | Cannot weight-bear | New confusion after fall | Sustained fall injury not previously assessed

Falls diary

Provide NICE falls diary to patient — record date, time, activity, location, symptoms. Patterns guide cause (postural, nocturnal, activity-related)

Falls diaries improve recall accuracy by 50% and allow identification of patterns that change management (e.g., all falls occur on getting up from bed = postural hypotension; all falls on stairs = environmental). Vitamin D levels should be rechecked after loading dose at 3 months — up to 40% of patients require dose adjustment. Long-term bisphosphonate drug holidays reduce osteonecrosis of jaw risk after 5 years.