Assessing Someone Referred for Falls: Key Things a Physiotherapist Should Consider (Evidence‑Based Guide)
When someone is referred to physiotherapy because they’re falling – or afraid of falling – it’s rarely “just one thing”. Age, long‑term conditions, medication, home environment and confidence all interact.
Good falls assessment is about joining the dots, not just checking balance.
Here are the key, evidence‑based areas physiotherapists should consider when assessing someone referred for falls, based on major guidelines (e.g. NICE, CSP, AGS/BGS) and current research.
This article is for information only and does not replace an individual assessment by a qualified clinician.
1. Detailed Falls History: What Actually Happened?
A careful history is one of the strongest “investigations” we have.
Key questions:
How many falls? Over what time period?
Circumstances:
What were they doing? (walking, turning, reaching, rushing to the toilet)
Where? (indoors/outdoors, stairs, bathroom, uneven ground)
Any trip/slip, or did they “just go down”?
Symptoms before the fall:
Dizziness, light‑headedness, palpitations, chest pain, visual disturbance
“Blackout” or loss of consciousness?
Injuries:
Fractures, head injury, soft‑tissue injuries
After‑effects:
Reduced activity, fear of falling, loss of confidence
Why it matters (evidence):
Recurrent falls and unexplained falls are strong predictors of future falls and fractures.
Pre‑fall symptoms (e.g. syncope, dizziness) may indicate cardiovascular or neurological causes that need medical review, not just physio.
2. Medical Background and Red Flags
Falls are often a symptom of underlying medical issues.
Key areas to review:
Diagnoses:
Stroke, Parkinson’s, dementia, peripheral neuropathy, arthritis, osteoporosis, diabetes, heart disease
Acute illness:
Infection, dehydration, delirium, recent hospitalisation
Vision and hearing:
Cataracts, macular degeneration, poor contrast sensitivity, hearing loss
Cardiovascular factors:
Postural hypotension, arrhythmias, heart failure
Neurological signs:
New weakness, asymmetry, spasticity, ataxia, tremor
Red flags needing urgent medical input:
New or rapidly worsening neurological signs
Suspected syncope or cardiac cause
Unexplained weight loss, night pain, red‑flag back pain
Recurrent unexplained falls with loss of consciousness
Why it matters (evidence):
Multifactorial assessment (including medical review) is consistently shown to reduce falls rates compared with single‑factor approaches.
Untreated medical contributors (e.g. postural hypotension, visual impairment) significantly increase fall risk.
3. Medication Review: Polypharmacy and “Fall‑Risk” Drugs
Medication is a major, modifiable risk factor.
Key points:
Number of medications:
Polypharmacy (often ≥4–5 meds) is associated with higher fall risk.
Specific drug classes linked to falls:
Psychotropics (benzodiazepines, antidepressants, antipsychotics)
Antihypertensives and nitrates
Hypoglycaemics
Opioids and other sedatives
Recent changes:
New medications, dose increases, or recent withdrawals
Physio role:
Identify potential medication‑related risks.
Communicate concerns to GP/pharmacist for formal medication review.
Why it matters (evidence):
Systematic reviews show that medication review and optimisation is a key component of effective falls‑prevention programmes, especially in older adults.
4. Strength, Balance and Gait: What Does Their Movement Really Look Like?
This is the core of the physio assessment.
Strength
Sit‑to‑stand performance (e.g. 5x Sit‑to‑Stand test)
Manual muscle testing of key groups:
Hip abductors and extensors
Knee extensors
Ankle plantarflexors/dorsiflexors
Evidence:
Lower limb weakness, particularly in the quadriceps and ankle plantarflexors, is strongly associated with falls and reduced gait speed.
Balance
Use validated tools where possible:
Timed Up and Go (TUG)
Berg Balance Scale
Functional Reach
Single‑leg stance time (if safe)
Observe:
Steady vs unsteady standing
Response to perturbations
Ability to turn, dual‑task, and negotiate obstacles
Evidence:
Impaired balance scores on standardised tests predict future falls and are responsive to targeted balance training.
Gait
Observe:
Speed, step length, symmetry
Foot clearance, shuffling, freezing, variability
Use and appropriateness of walking aids
Turning, starting and stopping
Evidence:
Slow gait speed, increased variability and poor turning are linked to higher fall risk and functional decline.
5. Functional Ability and ADLs: What Can They Actually Do?
Assess:
Transfers:
Bed ↔ chair, sit‑to‑stand, toilet, bath/shower
Mobility:
Indoors vs outdoors, stairs, uneven ground
Activities of daily living (ADLs):
Dressing, washing, meal prep, shopping
Use tools where appropriate:
Barthel Index, FIM, or similar functional scales
Patient‑reported outcome measures (PROMs)
Why it matters (evidence):
Reduced functional independence is both a consequence and predictor of falls.
Targeted rehab that improves ADLs is associated with better quality of life and reduced institutionalisation.
6. Cognition, Mood and Fear of Falling
Falls are not purely physical.
Key areas:
Cognition:
Orientation, attention, executive function (planning, dual‑tasking)
Ability to follow instructions and learn strategies
Mood:
Depression, anxiety, apathy
Fear of falling:
Ask directly:
“Are you afraid of falling?”
“Have you stopped doing things because you’re worried you might fall?”
Use scales such as the Falls Efficacy Scale (FES‑I) where appropriate.
Why it matters (evidence):
Cognitive impairment and depression are independent risk factors for falls.
High fear of falling leads to activity restriction, deconditioning and a vicious cycle of increased fall risk.
Interventions that address both physical and psychological factors are more effective.
7. Footwear, Feet and Sensation
Often overlooked, but crucial.
Assess:
Footwear:
Fit, heel height, sole grip, fastening (slip‑ons vs secure shoes)
Feet:
Pain, deformities (bunions, hammer toes), ulcers, callus
Sensation:
Peripheral neuropathy, reduced proprioception
Why it matters (evidence):
Poor footwear and foot pain are modifiable risk factors for falls.
Peripheral neuropathy is associated with impaired balance and increased falls, especially in diabetes.
8. Home and Environmental Hazards
Where and how they move day‑to‑day matters as much as clinic performance.
Key areas to explore (verbally or via home visit):
Stairs and steps:
Handrails, lighting, carpet condition
Floors and walkways:
Rugs, clutter, cables, pets
Bathroom:
Grab rails, non‑slip surfaces, toilet and bath height
Bedroom:
Bed height, night‑time lighting, access to walking aids
Outdoors:
Uneven paths, steps, lighting
Why it matters (evidence):
Multifactorial interventions that include home hazard assessment and modification show better outcomes than exercise alone in many trials.
9. Social Context and Support
Falls don’t happen in a vacuum.
Consider:
Who lives with them? Alone vs with family/carers
Availability of help for:
Shopping, cleaning, heavy tasks
Recent life changes:
Bereavement, move of home, loss of driving licence
Access to community resources:
Exercise groups, falls clinics, transport
Why it matters (evidence):
Social isolation and lack of support are linked to poorer rehab engagement and higher risk of functional decline.
Involving carers improves adherence to exercise and environmental changes.
10. Pulling It Together: A Multifactorial Falls‑Prevention Plan
The strongest evidence supports multifactorial assessment and intervention, not one‑off fixes.
A good physio‑led plan typically includes:
Targeted strength and balance training
Progressive, challenging, and done at sufficient dose (e.g. Otago, FaME‑style programmes)
Gait and mobility training
Including turning, dual‑tasking and real‑world practice
Education and confidence‑building
Strategies for getting up from the floor, pacing, safe activity
Referrals and liaison for:
Medication review (GP/pharmacist)
Vision and hearing checks
Occupational therapy for home adaptations
Specialist services (cardiology, neurology, continence, mental health) as indicated
Evidence:
Programmes combining exercise + risk‑factor modification reduce falls and fall‑related injuries more effectively than single‑component approaches.
Bringing It Back to Practice
When someone is referred to physiotherapy for falls, the key is to think beyond the last fall:
What medical, physical, psychological and environmental factors are interacting?
Which of these are modifiable?
How can we build a plan that is realistic in their home and life, not just in the clinic?
At Grace‑Link Physiotherapy Services, we provide home‑based, evidence‑informed falls assessments across Barnet, Harrow, Watford and nearby areas. We look at the whole picture – from strength and balance to medication, home hazards and confidence – and design a practical plan to reduce fall risk and keep people independent for longer.
Need a comprehensive, evidence‑based falls assessment at home? Book a 1:1 visit with a specialist physiotherapist and let’s turn “I’m worried about falling” into a clear, personalised plan.
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