Reasoning GP · Algorithm · 1-page summary
Falls in older adults
For: people aged 65+, and 50–64 at higher risk, after a fall or found by asking at routine contacts. Not for: under 16s (paediatric head injury criteria). A blackout first → syncope assessment (block 2).
Core rule: a fall is often how an acute illness presents. Deal with the injury, a blackout and the acute cause first; then find every modifiable risk, because exercise, medication review and bone protection prevent the next fall and fracture.
0Stop — call 999 now — before the falls history
- Head injury with reduced consciousness, focal neurology or instability; new face, arm or leg weakness, speech disturbance or ataxia (stroke) → 999
- Suspected hip fracture and unstable, severe uncontrolled pain or cannot be moved safely; fracture with neurovascular compromise or neurological signs → 999
- Chest pain, collapse or severe breathlessness; unable to get up and clinically unwell → 999
- While waiting: on insulin or a sulfonylurea and sweaty or confused → capillary glucose now; treat if <4 mmol/L.
1Triage — ask about every fall in the last year
| Situation | Action |
|---|---|
| Blackout first? | Prodrome, exertion, palpitations, witness. Lying/standing BP + ECG; red flags → block 2 |
| Injured / unwell | Blocks 0–2 before any prevention work |
| NG249 criteria | Fall in last year + frailty, injury needing treatment, loss of consciousness, unable to get up alone, or ≥2 falls in a year → comprehensive falls assessment |
| Single fall, none | Assess gait and balance; impaired → offer an exercise programme and consider a home-hazard assessment |
2Screen — one row is enough
- Any head injury on an anticoagulant or non-aspirin antiplatelet → Same-day ED. Aged 65+ with loss of consciousness or amnesia → CT head ≤8 h.
- Suspected hip fracture: can't weight-bear, new groin/hip pain, pain on rotation — shortening may be absent → Same-day hospital
- Wrist, humerus, pelvis or ribs after a low-energy fall; new back pain with osteoporosis → Same-day X-ray (UTC or ED)
- Blackout red flags: exertional, abnormal ECG, heart failure or structural disease, new breathlessness, preceding palpitations, family sudden cardiac death, injury → Cardiology ≤24 h
- Long lie (CK, U&E, urine blood; hypothermia, pressure areas) or acute illness (fever, new confusion, black stools, low urine output) → Same-day
- Unexplained or inconsistent injuries, neglect, controlling behaviour → local adult safeguarding procedures.
3Assess — once blocks 0–2 are answered
☐ Lying then standing BP at 1 and 3 min (drop ≥20 systolic or ≥10 diastolic, or symptomatic) ☐ Pulse, rhythm, murmur ☐ Gait, balance, chair rise ☐ Neurology, feet, vision ☐ Cognition, mood, delirium ☐ Medicines incl. over-the-counter, alcohol ☐ FRAX or QFracture
ECG if possible syncope or cardiac features. Bloods targeted. Do not use falls risk prediction tools or a routine urine dip.
4Classify — usually several causes; treat each
- Syncope / cardiac — blackout, palpitations, exertion, murmur → block 2; falls and syncope service or cardiology.
- Orthostatic hypotension — postural drop, often medicines → medication review, non-drug measures, recheck standing BP.
- Medicines — sedatives, Z-drugs, antipsychotics, antidepressants, opioids, antihypertensives, anticholinergics → structured review.
- Neurological — parkinsonism, stroke, neuropathy, dementia → optimise; neurology if new movement disorder.
- Mobility, vision, environment — weakness, arthritis, feet, hazards → exercise, OT, optometrist.
- Uncertain / recurrent unexplained — say so → falls service / community geriatrics.
5Treat today — only these
- Structured medication review: adjust or gradually withdraw fall-risk medicines; never stop psychotropics or antihypertensives abruptly.
- Offer a progressive, tailored strength and balance programme (physiotherapy or falls service) — the main intervention.
- Bone health: above the NOGG threshold → oral bisphosphonate (e.g. alendronic acid 70 mg weekly) after checking renal function, calcium, vitamin D. Vitamin D 10 micrograms daily (NHS advice), not for falls alone. Doses: NICE/SPC, BNF, local formulary.
- Unable to cope at home now → Same-day urgent community response. Teach getting up; personal alarm if alone.
6Refer routinely — urgent routes are in blocks 0–2
- Falls service: NG249 criteria, recurrent unexplained falls, orthostatic hypotension not improved by medicine changes.
- Fracture liaison / osteoporosis: fragility fracture, or high risk needing specialist input.
- OT home-hazard assessment; optometrist, podiatry, audiology, continence, dietitian, memory service as needed.
- Fear of falling not helped by exercise → consider cognitive behavioural interventions.
7Never reassure by
- A leg that is not shortened or externally rotated — hip fracture is still possible.
- A normal ECG alone when the fall may have been a blackout.
- "Just a trip" — the fall may be sepsis, stroke, GI bleed or AKI presenting.
- A sitting BP only — a symptomatic postural drop is missed.
- A falls risk score or prediction tool.
- A head injury that "seems minor" in someone on an anticoagulant.
8Safety-net — say it to the patient and carers, then document it
999 “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 “Head injury on a blood thinner (not aspirin alone) — go to A&E. Can't put weight on a leg, new hip or groin pain, new confusion, a blackout or an injury not yet checked — contact us today.” Falls diary; share the plan and getting-up advice with carers (with consent).
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies; blackout considered
Lying/standing BP, gait and balance recorded; ECG if syncope possible
Medication review done; changes gradual
Exercise, OT, bone health and falls service actioned
Safety-net, getting-up plan given; review booked (sooner after medicine changes)
Summary of the full Reasoning GP falls algorithm, which holds the case-finding, examination, investigation detail, lifestyle advice and follow-up. Sources: NICE NG249 Falls (2025); NICE NG232 Head injury (2023); NICE CG109 Transient loss of consciousness; NICE CG124 Hip fracture; NICE NG136; NOGG (2024); Royal Osteoporosis Society; Care Act 2014. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.