Synopsis
Identify fear of falling as a treatable interaction between perceived threat, actual risk and lost confidence, exclude unresolved medical and environmental danger, and restore valued activity through graded, progressive and psychologically informed rehabilitation.
- 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.
Key red flags
New inability to weight bear, groin pain or pain on passive hip movement after a fall requires fracture imaging.
Sudden focal weakness, speech change or persistent ataxia requires emergency stroke assessment.
Delirium, hypoxia, fever or abrupt ADL loss suggests acute illness rather than a primary anxiety response.
Syncope, palpitations, exertional collapse or marked orthostatic symptoms requires cardiovascular investigation before exposure work.
Severe depression, hopelessness, self-neglect or suicidal thinking requires urgent mental-health and safeguarding assessment.
A carer who prevents all movement, controls communication or cannot provide essential transfers requires private enquiry and proportionate safeguarding action.
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.
Investigation priorities
Identify the trigger and degree of activity loss.
Management branches
Activity has reduced after a fall, near-fall or illness.
- Reconstruct the event, baseline and stopped activities and screen injury, syncope, gait, mood, cognition and safeguarding.
- Observe mobility and the feared task and identify person, treatment and environment factors maintaining avoidance.
- Agree one meaningful goal and a positive-risk plan with aid, supervision, warning signs and review.