Older adults, frailty and falls

Frailty describes vulnerability arising from loss of reserve across several systems. A minor infection or medicine change can produce disproportionate delirium, immobility or loss of independence. Frailty is heterogeneous and potentially modifiable; it must not become shorthand for withholding investigation or treatment. Establish baseline function, current goals and the person’s response to previous stressors.

Use a validated local case-finding approach when appropriate, but do not let a score replace clinical assessment. Electronic frailty tools can identify a population for review but may be distorted by coding. A person with stable disability is not necessarily frail; a fit older adult can still sustain a serious fall. Document what the classification changes: anticipatory planning, medication review, comprehensive geriatric assessment or service coordination.

A fall is an event with a mechanism, not a diagnosis. Reconstruct what happened before, during and after: activity, position, trip, dizziness, palpitations, chest pain, focal symptoms, loss of awareness, witness account, injury, ability to get up and time on the floor. Ask about previous falls and near misses. Distinguish a clear mechanical trip from syncope, although both may coexist with intrinsic risk.

Assess immediate harm using observations and an ABCDE approach. Examine for head, spine, hip and limb injury, pain, skin damage, dehydration and hypothermia. Check neurological status and anticoagulant or antiplatelet use. Inability to weight bear after a fall, new confusion, focal deficit, persistent vomiting, severe headache, chest symptoms or physiological instability requires urgent escalation under current injury and acute-illness guidance.

Long lies can cause pressure damage, rhabdomyolysis, dehydration, hypothermia and psychological trauma. Establish duration and whether the person could summon help. A fall without fracture may still trigger fear, self-restriction and deconditioning, which increases future risk. Address confidence and safe recovery strategies alongside medical causes.

NICE NG249 covers people aged 65 or over and those aged 50–64 at increased risk from an underlying condition. In the community, a fall in the preceding year warrants comprehensive assessment and management if there is frailty, injury needing medical treatment, associated loss of consciousness, inability to get up unaided, or at least two falls. Otherwise assess gait and balance after a fall; impairment leads to a tailored exercise programme and consideration of home hazards. People with no fall, or one fall without gait or balance impairment, receive health, wellbeing and physical-activity advice.

Comprehensive assessment includes falls history, gait, balance, muscle strength, mobility, functional ability, cognition, delirium risk, mood, dizziness, cardiovascular examination, lying and standing blood pressure, vision, hearing, feet, footwear, continence, nutrition, alcohol, osteoporosis and fracture risk, medicines and home hazards. Include the person’s beliefs: fear of falling can be as limiting as physical impairment.

Measure lying and standing blood pressure with a consistent protocol and symptoms documented. Review dehydration, autonomic disease and medicines. A fall after standing with light-headedness supports postural hypotension, but do not stop assessment if blood pressure is normal once; intermittent arrhythmia, vestibular disease, environmental obstacles or lower-limb weakness may coexist.

Medication review maps each drug to indication and fall mechanism. Sedatives can impair reaction; antihypertensives and other drugs can cause postural symptoms; glucose-lowering medicines can cause hypoglycaemia; anticholinergic burden can worsen cognition and vision. Estimate benefit and harm, change one factor where possible and monitor. Abrupt withdrawal of some medicines is unsafe, and anticoagulation should not be stopped solely because a person has fallen.

Gait and balance assessment begins by watching the person rise, turn and walk with their usual aid. Standardised tests can help monitor change but should not be used as a single threshold that predicts all falls. Check the aid’s height, brakes and use. A person who cannot stand safely needs support; do not create a test-related fall.

Exercise is a core intervention when deficits are identified. NICE specifies progressive programmes tailored to ability and preferences, with balance, coordination, strength and power components, delivered by appropriately trained professionals. Simply advising “be more active” is not an equivalent intervention. Consider adherence barriers, pain, transport, cognition and cultural acceptability, and plan how progress will be reviewed.

Home-hazard assessment should be offered where indicated and delivered by someone with appropriate skills, commonly occupational therapy or a trained practitioner. It links hazards to the person’s behaviour and ability: lighting, loose rugs, stairs, bathroom access, footwear, pets and reaching. Removing every rug without consent is neither person-centred nor necessarily sufficient.

Vision assessment and cataract referral may reduce risk in selected people, but routine multifocal-glasses change can transiently alter depth perception. Foot pain, deformity and unsafe footwear affect gait. Address continence and urgency, which can cause rushed night-time transfers, and review sleep arrangements and lighting. Vitamin D should follow deficiency, bone-health or local policy indications rather than being promised as a universal falls treatment.

Comprehensive geriatric assessment is multidimensional and interdisciplinary, covering medical, psychological, functional, social and environmental domains to produce an integrated plan. The British Geriatrics Society describes CGA as a coordinated process, not a long checklist completed by one clinician. It is particularly valuable when frailty, recurrent falls, delirium, functional decline and caregiver strain interact.

Prevention also means fracture risk assessment and osteoporosis management under current guidance, vaccination, nutrition, hearing support and advance care planning when wanted. Preserve positive risk: an informed person may value walking to the shop despite some fall risk. The clinician’s role is to reduce avoidable harm and support autonomy, not impose inactivity.

Close all loops. Document injuries excluded, baseline function, driving or occupational implications where relevant, medicine changes, exercise and home referrals and a deterioration plan. Give the person and carers clear advice on when to seek urgent help. Review whether interventions occurred and whether falls, near falls, confidence and function changed.