GPAtlas🧭 When to suspect (and who to assess)
A fall is an unexpected event in which a person comes to rest on the ground, floor or a lower level. Falls become steadily more common with age: around a third of people aged 65 and over, and about half of those aged 80 and over, fall at least once a year. They are the leading cause of injury-related admission in older people, and the consequences – injury, loss of confidence, loss of independence and death – are substantial, with roughly a 30% one-year mortality after a hip fracture. Crucially, many falls are preventable.
The guidance changed in 2025. NICE NG249 (April 2025) replaced CG161 and now applies to everyone aged 65 and over, plus people aged 50–64 with one or more factors that could increase their risk of falls (for example arthritis, dementia, diabetes, Parkinson's disease, prior stroke or a learning disability). NG249 specifically advises against using falls risk prediction tools – the skill in primary care is clinical case-finding: ask, then decide who needs a fuller assessment.
Ask every older person opportunistically whether they have fallen in the last year – they routinely under-report – then triage. A previous fall is the single strongest predictor of a future fall.
| Trigger (has fallen in the last year, plus…) | Action under NG249 |
|---|---|
| Any of: living with frailty · injured in the fall and needed medical (or surgical) treatment · loss of consciousness with the fall · unable to get up unaided · 2 or more falls in the last year | Comprehensive falls assessment and management – carried out in primary care or via referral to a falls / geriatric service |
| Has fallen, but none of the above features | Assess gait and balance |
| Gait or balance impairment found on that assessment | Offer a falls-prevention exercise programme; consider a home hazard assessment |
| No fall in the last year, or a single fall with no gait/balance impairment | Health and wellbeing information and physical-activity advice (Chief Medical Officer guidelines) |
Raise suspicion in older people with gait or balance problems, muscle weakness, polypharmacy (4 or more medicines) and Falls Risk-Increasing Drugs (FRIDs) – especially psychotropics and antihypertensives – postural (orthostatic) hypotension, visual, hearing or cognitive impairment, conditions causing dizziness or syncope, relevant long-term conditions, a previous fragility fracture or osteoporosis, alcohol excess, and home hazards.
|
⚠️ Common pitfall Labelling a fall "mechanical" and stopping there. That word too often closes down the assessment and misses a treatable medical cause – orthostatic hypotension, an arrhythmia, sepsis or a culprit medicine. Treat every fall in an older person as multifactorial until proven otherwise: take a circumstantial history, check a lying and standing blood pressure, and review the drug chart. |
Source: NICE NG249
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