01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Ask what the person believes will happen, how likely it feels, which places or tasks are avoided and what matters enough to regain. Explore the index event, injury, time on the floor, witness response and messages received from clinicians and carers. Quantify present walking, transfers, bathing, stairs and community activity against baseline. Someone who says they do not want to be a burden may be concealing fear or depression.
Reassess actual risk before psychological formulation. Examine injury, gait, strength, sensation, vision, vestibular signs, feet and joints; measure lying-standing pressure when relevant and review sedation and hypoglycaemia. Check the home route and aid. Fear can be entirely understandable when brakes fail, the toilet route is dark or recurrent syncope remains unexplained.
Use the Falls Efficacy Scale–International or a shorter validated version to record concern during specific tasks and monitor change, but interpret cognition, language and opportunity. A low activity level can conceal severe fear because feared activities are no longer attempted. Pair the score with actual activity, falls, near-falls and observed performance.
Build a shared formulation. An index fall produces threat; avoidance produces short-term relief; reduced practice and strength increase instability; assistance reinforces the belief that independent movement is impossible. Pain, dizziness and carer alarm may sustain the cycle. Explain this without implying symptoms are imagined or encouraging unsafe exposure.
Set one meaningful functional goal and divide it into testable steps. For example, practise sit-to-stand with a fitted aid and therapist, then walk to the bathroom with planned supervision, then repeat at the usual time, then reduce cueing. Define warning symptoms and stopping criteria. Progress when the task is performed safely and confidence grows; adjust after a fall without returning automatically to complete avoidance.
Exercise must create adaptation. Use progressive balance challenges, lower-limb resistance, gait, turning, stepping and reactive tasks matched to ability, delivered by trained staff and continued long enough. Add endurance and dual-task work when safe. Home practice needs a clear dose and safe setup; generic advice to keep active is rarely sufficient after entrenched avoidance.
Cognitive behavioural methods can be integrated into physical rehabilitation. Elicit the prediction, rate fear, use paced breathing or attentional strategies, perform the planned task and compare predicted with actual outcome. Address all-or-nothing beliefs such as one fall means I can never walk alone. Relapse planning normalises fluctuations and specifies how to respond to a near-fall.
Occupational therapy takes practice into meaningful settings: bed-to-toilet route, shower, stairs, entrance, kitchen and outdoor threshold. Modify lighting, rails, footwear and furniture only where they improve the task. Equipment can enable exposure, but excessive commodes, alarms and supervision can shrink activity if never reviewed.
Include carers in agreed roles with the person's consent. Teach safe cueing, how to avoid pulling on an arm, when to assist and when to allow practice. Explore the carer's own fear and capacity. Positive risk-taking does not mean accepting preventable harm; it balances autonomy, rehabilitation benefit and clearly described risk.
Screen mood, anxiety, trauma symptoms, cognition, capacity and safeguarding. Offer evidence-based psychological treatment for a diagnosable condition and review medicine-related posture, hyponatraemia and sedation. An SSRI can be appropriate for depression or anxiety, but not as a stand-alone medicine for fear of falling and not without early monitoring in a fall-prone older person.
Review outcomes beyond fall counts. Increased walking can temporarily create more exposure while independence improves. Track confidence, feared-task completion, strength, gait, near-falls, activity, social participation and carer assistance. If progress stalls, reconsider pain, vestibular or cardiovascular diagnosis, exercise dose, cognition, depression, home barriers and whether the goal belongs to the person.
Key points
- Ask directly about fear, confidence and which activities have stopped; people may report being careful rather than describe anxiety.
- First-line assessment treats acute injury, syncope, gait, vision, vestibular, pain, medicine and home hazards before concluding fear is the main limiter.
- The Falls Efficacy Scale–International can quantify concern across activities, but it does not replace history or prove that actual risk is low.
- Distinguish adaptive caution from disproportionate restriction: safe pacing after injury is useful, whereas avoiding all standing perpetuates loss of capacity.
- First-line rehabilitation combines progressive balance and strength exercise with goal-based graded exposure to feared tasks in the real environment.
- Cognitive behavioural techniques identify catastrophic predictions, refocus attention, plan coping and test safer alternative beliefs during rehabilitation.
- Use a shared positive-risk plan: specify task, aid, supervision, warning symptoms and progression rather than simply saying mobilise or do not walk alone.
- Occupational therapy addresses stairs, bathroom, kitchen, thresholds and confidence with everyday tasks; physiotherapy progresses gait, balance, power and reactions.
- Do not prescribe benzodiazepines for fear of falling: sedation, dependence and impaired balance can worsen the core problem.
- Treat a separately diagnosed depressive or anxiety disorder with age-appropriate psychological and, when indicated, pharmacological care while monitoring falls and posture.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Post-fall threat learning
Pain, injury, a long lie or a frightening witnessed fall conditions walking and related environments as dangerous.
Pre-existing anxiety or low confidence
Generalised anxiety, panic, depression, trauma history and low self-efficacy can amplify anticipated harm and reduce willingness to practise.
Real unresolved risk
Poor balance, vestibular disease, postural hypotension, visual loss, pain, unsafe footwear and home hazards appropriately generate concern until treated.
Social reinforcement
Overprotective advice, carer fear, alarms and repeated warnings can unintentionally reward avoidance and remove opportunities for mastery.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Fear-avoidance cycle
Anticipated falling leads to avoidance, which reduces strength, balance and exposure, increases instability and then confirms the perceived threat.
- 2Attentional interference
Hypervigilance to each step consumes executive resources, stiffens movement and can impair the automatic postural responses needed for safe walking.
- 3Loss of self-efficacy
Repeated assistance or failed attempts reduce belief in personal control, so progressively smaller tasks feel unsafe.
- 4Physiological arousal
Anxiety can cause dizziness, tachycardia, breathlessness and visual narrowing that are interpreted as evidence of imminent collapse.
- 5Contextual learning
Fear can become tied to stairs, bathing, outdoor surfaces or crowds; safe practice in only a clinic may not generalise to those settings.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
The person modifies a genuinely hazardous task while continuing safe activity and rehabilitation.
Activities contract beyond assessed danger, with repeated reassurance-seeking, stiff gait and short-term relief after avoidance.
No recent falls occur because the person no longer stands, bathes or leaves home, masking severe disability.
Family provide escalating hands-on help or forbid movement despite a rehabilitation plan, often from understandable fear.
Abrupt fear with pain, focal signs, delirium or collapse symptoms indicates medical reassessment.
Hopelessness, severe withdrawal, poor intake or suicidal thinking requires urgent mental-health and safeguarding assessment.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Event and baseline reconstructionFirst step - Why
- Identify the trigger and degree of activity loss.
- Interpretation and limitations
- Compare pre-event and current transfers, ADLs, walking and participation using the person, witnesses and care records.
- 02
Falls Efficacy Scale–International - Why
- Quantify concern across real activities.
- Interpretation and limitations
- Use as a monitoring aid alongside actual activity and cognition; avoidance can hide concern and no threshold diagnoses cause.
- 03
Observed gait and feared task - Why
- Find physical and attentional mechanisms.
- Interpretation and limitations
- Assess gait, turning and a relevant task with the usual aid, recording pain, symptoms, cueing, safety behaviours and confidence.
- 04
Multifactorial falls assessment - Why
- Identify actual modifiable fall danger.
- Interpretation and limitations
- Review posture, medicines, vision, vestibular symptoms, strength, balance, cognition, feet, continence and home hazards.
- 05
Mood, anxiety and cognition assessment - Why
- Detect comorbidity that affects rehabilitation.
- Interpretation and limitations
- Use validated tools with clinical interview, collateral, capacity and suicide assessment rather than assuming fear is an isolated disorder.
- 06
Home and carer assessment - Why
- Test whether the plan can work outside clinic.
- Interpretation and limitations
- OT reviews task routes, equipment, lighting, stairs and carer assistance and identifies overprotection or unmet care needs.
- 07
Targeted medical tests - Why
- Investigate specific unresolved medical symptoms.
- Interpretation and limitations
- Use ECG, postural pressure, imaging, vestibular or laboratory tests only from the event, examination and red flags.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Unresolved fall mechanism
Orthostatic hypotension, arrhythmia, gait disease, vision loss and medicines may explain rational fear and need direct treatment.
Persistent injury or pain
Occult fracture, vestibular injury, arthritis and neuropathic pain limit movement and require diagnosis before psychological attribution.
Depression or anxiety disorder
Pervasive low mood, anhedonia, generalized worry, panic or trauma symptoms may coexist and merit condition-specific assessment.
Delirium or dementia
Fluctuating inattention or impaired visuospatial judgement can appear as refusal, while still requiring communication and environmental adaptation.
Functional neurological or vestibular disorder
Persistent postural-perceptual dizziness and functional gait symptoms need specialist formulation after structural danger is excluded. The explanation should remain positive, specific and linked to appropriate rehabilitation.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01First-line formulationMake fear and actual risk visibleFirst stepFirst lineActivity has reduced after a fall, near-fall or illness.+
- 1Reconstruct the event, baseline and stopped activities and screen injury, syncope, gait, mood, cognition and safeguarding.
- 2Observe mobility and the feared task and identify person, treatment and environment factors maintaining avoidance.
- 3Agree one meaningful goal and a positive-risk plan with aid, supervision, warning signs and review.
02Graded rehabilitationCreate repeated safe masteryAcute danger is treated but confidence and capacity remain limited.+
- 1Begin progressive resistance and balance exercise at a safe effective challenge.
- 2Break the feared real-world task into graded steps and use cognitive behavioural prediction-and-review techniques.
- 3Reduce unnecessary cueing or supervision as performance improves and rehearse recovery from setbacks.
03Carer and home routeAlign support with independenceHousehold fear, layout or equipment prevents practice.+
- 1Assess the home task with OT and physiotherapy and correct specific lighting, surface, rail, footwear or aid problems.
- 2Teach carers safe assistance and agree when to supervise, step back or seek help.
- 3Review equipment and restrictions so temporary safety measures do not become permanent dependency.
04Non-response or deteriorationReopen causes rather than blaming motivationFear, falls or function do not improve or suddenly worsen.+
- 1Repeat injury, cardiovascular, vestibular, neurological, pain, medicine, mood and cognitive assessment.
- 2Check whether exercise and exposure were sufficiently dosed, delivered and relevant to the person's goal.
- 3EscalationEscalate specialist rehabilitation, psychology, mental-health, safeguarding or social support according to findings.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Sertraline
For depression, the licensed adult starting dose is 50 mg orally once daily. For panic disorder, PTSD or social anxiety, use 25 mg once daily for one week then 50 mg once daily; if needed, increase in 50 mg steps no more often than weekly to a maximum 200 mg daily.Monitor early agitation, gastrointestinal effects, hyponatraemia, bleeding, posture, falls and interactions; continue non-drug rehabilitation and review diagnosis and benefit.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Deconditioning and sarcopenia
Avoidance rapidly reduces lower-limb power, endurance and orthostatic tolerance, making falls objectively more likely. Progressive loading and restored activity are required to reverse this physical consequence.
ADL restriction and isolation
Bathing, stairs, shopping and social contact contract, increasing dependency, loneliness and depression. Reduced exposure then reinforces the belief that ordinary movement is unsafe.
Falls despite caution
Stiffened gait, divided attention and unpractised reactions can increase trips even when activity is reduced. Task-specific practice can restore more adaptable balance and movement strategies.
Carer strain and conflict
Continuous supervision demands and disagreement about acceptable risk can damage relationships and precipitate care crisis. Shared positive-risk planning clarifies roles, limits and escalation arrangements.
Institutionalisation
Lost confidence and support can drive placement even when potential for rehabilitation remains. Timely rehabilitation and support review can preserve a preferred living arrangement.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Track confidence for specific tasks and actual task completion, not reassurance statements alone.
- Record falls and near-falls with activity exposure, injury and response.
- Measure gait, chair rise, balance, walking range and rehabilitation dose and progression.
- Review carer assistance, supervision and strain and whether temporary restrictions have been withdrawn.
- Monitor mood, anxiety, cognition, sleep, nutrition and suicidal or self-neglect risk.
- After any psychotropic change, review posture, sodium risk, sedation and falls early.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
No falls may mean no walking
A falling count improves when someone becomes chairbound, so activity and participation must accompany it.
Validate before challenging
Fear often follows real danger; acknowledging that event makes graded testing credible rather than dismissive.
Exposure belongs in the task
Corridor success may not transfer to a dark toilet route or busy pavement without contextual practice.
Support can become a safety behaviour
Hands-on help reduces fear immediately but can prevent the mastery needed for independence.
A near-fall is usable data
Analyse the task and recovery response rather than treating it as proof that all progress is unsafe.
Confidence is a rehabilitation outcome
Strength without willingness to use it leaves everyday function unchanged.
11Common pitfallsFrequent interpretation and management errors.
- 01
Labelling fear before excluding occult fracture, syncope or focal neurological disease.
- 02
Reassuring verbally without observing the feared task.
- 03
Using fall count as the only outcome when activity has collapsed.
- 04
Prescribing only low-challenge seated exercise without progression or task exposure.
- 05
Adding equipment or supervision without a plan to review and reduce it.
- 06
Giving a benzodiazepine for mobility-related anxiety.
- 07
Treating a carer's overprotection as obstruction without exploring their fear and training needs.
- 08
Assuming reluctance is lack of motivation rather than pain, cognition, depression or an inaccessible goal.