Falls at Home: The First Minutes, the Causes, and the Assessment to Ask For

A fall is a symptom with a list of causes behind it. It is not an accident, it is not clumsiness, and it is not simply what happens when people get older. The right response to one is an assessment of the person, and the wrong response, which almost every family reaches for first, is a tidier hallway. Around a third of people aged 65 and over, and around a half of people aged 80 and over, fall at least once a year, and the one-year mortality rate after a hip fracture is 31 percent (NICE guideline NG249, published 29 April 2025, England)¹.

The scale is easier to grasp in admissions. Between 2019 and 2020 there were around 234,800 emergency hospital admissions in England related to falls among people aged 65 and over, of which around 157,370, or 67 percent, were among people aged 80 and over¹. Globally, falls are the second leading cause of unintentional injury deaths, an estimated 684,000 people die from falls each year with over 80 percent of those deaths in low and middle income countries, and 37.3 million falls a year are severe enough to require medical attention (WHO, Falls fact sheet, page dated 26 April 2021)².

My mother went down in the kitchen at six in the morning in February 2023. She was not badly hurt, she got herself up on the chair, and by eight she was making tea and telling me not to fuss. Because she was not badly hurt, I treated the whole thing as an accident, mentioned it to nobody, and moved a rug. She went down again in the April. What I had been handed in February was information about why, and I had thrown it away in exchange for a tidier floor.

This article sits under caring for a parent at home and pairs with spotting when someone is getting worse. Everything you record about a fall belongs in a care file, dated.

What do the figures actually say, and who says what?

Two sources, and they cover different things, which matters because they are routinely conflated.

The incidence figures are British and come from NICE. The context chapter of NG249 states that around a third of people aged 65 and over, and around a half of people aged 80 and over, fall at least once a year¹. NG249 is the current guideline: its overview states verbatim that “This guideline updates and replaces the NICE guideline on falls (CG161, published 2013)“¹. If you find advice citing CG161, it is out of date by a full guideline generation, and a surprising amount of material aimed at carers still does.

The global figures come from WHO, and they are mortality and burden figures, not incidence. The WHO Falls fact sheet gives 684,000 fall deaths a year worldwide, over 80 percent of them in low and middle income countries, 37.3 million falls a year severe enough to require medical attention, and falls as the second leading cause of unintentional injury death. In the United States, 20 to 30 percent of older people who fall suffer moderate to severe injuries². What that fact sheet does not contain is any share of over-60s or over-65s who fall each year. That percentage is widely attributed to WHO and should not be: the incidence line is NICE’s.

One honesty note about the NICE figure itself. Neither NG249 nor the guideline it replaced carries an inline citation for the third and half figures, so they should be read as the guideline’s own context statement rather than as a traceable primary estimate. It is a good enough figure to plan around and not a good enough figure to quote as though its provenance were settled.

What do you do in the first minutes?

You slow down. The instinct is to get them off the floor, and that instinct causes most of the avoidable harm in the next ten minutes, to both of you.

1. Kneel down and stay there. Do not pull on an arm. Keep them still while you find out what has happened.
2. Find out whether they are hurt before you find out whether they can get up. Ask whether anything hurts, whether they can move each arm and leg, whether they hit their head, and whether they remember falling. Not remembering the fall is significant, and so is any suggestion that they blacked out.
3. Look before you move them. A limb at an odd angle, a shortened or rotated leg, a bleeding head wound, or pain in the hip, back or neck all mean do not move them and ring for an ambulance.
4. Keep them warm. A blanket and a cushion under the head, on the floor, is better than a rushed lift. Time on a cold floor makes everything worse, and the longer the lie the more it matters, so if you cannot safely get them up, get help rather than waiting to think of something.
5. Only if they are clearly uninjured, let them get themselves up in stages. Roll onto their side, onto hands and knees, up to a stable chair, resting at each stage. You steady the chair and supervise. You do not take their weight.
6. Then sit with them for a while. Watch for pain that arrives late, for confusion, and for drowsiness.

Do not attempt a lift you are not trained and equipped for. This is the point on which carers most often come to harm themselves, and the risk is well recognised: the Health and Safety Executive’s guidance for health and social care exists precisely because manual handling injuries are a leading cause of harm to the people doing the caring³. A carer with an injured back is two people needing care. Moving someone safely covers technique, equipment and the lifts nobody should attempt alone.

Afterwards, write it down while it is fresh: the time, where, what they were doing, whether they remember it, what hurt, whether anyone saw it, and what you did. That note is the thing that turns a second fall from an anecdote into a pattern.

When is a fall an emergency?

When any of the following is true, and in those cases the ambulance service is the right call rather than the surgery.

• They cannot get up, or you cannot get them up safely.
• They may have hit their head, or cannot remember falling, or lost consciousness.
• They take an anticoagulant, a blood thinner, and have hit their head or their body anywhere. This lowers the threshold considerably and should be treated as urgent even if they seem well.
• Severe pain, particularly in the hip, back, neck or chest.
• A limb looks out of shape, shortened or rotated, or they cannot bear weight.
• Bleeding that will not stop.
• Changed breathing, chest pain, one-sided weakness, changed speech, a first seizure, or they cannot be roused.

If none of that applies and they got up perfectly well, it is still a call to their own clinician the same day. Getting up tells you about the injury. It tells you nothing at all about the cause.

Why did they fall?

Because of several things at once, almost always, which is why single fixes disappoint. The useful mental model is a list of causes in the person rather than a list of hazards in the house.

• Medicines, and how many of them. The number of items is itself a risk, quite apart from what any individual one does. NICE guideline NG5 recommends considering a structured medication review for people taking multiple medicines, people with long-term conditions and older people, taking into account the person’s and carers’ views and concerns⁴. Ask for one after a fall. No page on this site will tell you to stop or change anything: that is the prescriber and the pharmacist, and managing someone else’s medication covers how to ask.
• Blood pressure dropping on standing. Getting up from a chair or out of bed and going grey or unsteady is a specific, checkable thing, and it is worth reporting in those words.
• Vision. An out of date prescription, cataracts, or new varifocals, which are a common and unglamorous cause of falls on stairs.
• Feet and footwear. Painful feet, long toenails, backless slippers. Prosaic, and more powerful than most of the environmental changes people make instead.
• Rushing to the lavatory, particularly at night and particularly with urgency. This is a continence problem presenting as a falls problem, and it is treatable. See continence and keeping dignity.
• Weakness and deconditioning, especially after any period of illness or bed rest.
• Pain, which changes how somebody moves before they ever mention it.
• Alcohol, including a level that has not changed in thirty years but now interacts with a longer medicine list.
• Cognitive change. In dementia the baseline risk is markedly higher: Alzheimer’s Disease International reports that falls that cause injury are two to three times more common in people with dementia than in peers of the same age, and that seizures are up to seven times more common (World Alzheimer Report 2025)⁵.
• Acute illness, and delirium above all. This is the cause most often missed. A fall can be the first sign of delirium as easily as its consequence, and SIGN records delirium in up to 50 percent of people who have had a hip fracture (SIGN 157, published March 2019, revalidated 2022, Scotland)⁶. NICE describes delirium as having an acute onset and a fluctuating course, usually developing over 1 to 2 days, and says plainly that “it can be prevented and treated if dealt with urgently”⁷.

Confusion plus a fall is usually one problem rather than two. Delirium or dementia sets out how to tell what you are looking at.

What can you tell from what you saw?

Quite a lot, if you notice the right things at the time. This is the table worth having in your head.

What you saw or were told	What it may mean	How fast to act
They cannot get up, or there is deformity or severe pain	Fracture	Emergency number now
Hit their head, or on a blood thinner	Bleeding risk	Emergency number now
No memory of the fall, or they blacked out	Cardiac, blood pressure, or a seizure	Emergency number now
Went grey or dizzy on standing just before	Blood pressure falling on standing	Same day
Confused, drowsy or withdrawn since	Delirium until proven otherwise	Same day
Was hurrying to the lavatory	Continence urgency, possible infection	Same day
Fell after a new or changed medicine	Medicine effect	Same day, ask for a review
Tripped, clearly, and got straight up	Still worth assessing: trips are also caused by weakness and vision	Same day call, assessment to follow
A second fall within months	A pattern, not bad luck	Same day, and press for the assessment

What assessment should you ask for afterwards?

A falls assessment, and it is worth asking for it by that name so that it is recognised as a defined request rather than a general worry. NICE guideline NG249 is titled Falls: assessment and prevention in older people and in people 50 and over at higher risk, published 29 April 2025¹, and naming the guideline changes how the request is received.

What to ask for, specifically:

• An assessment of the person, not the house. The house comes into it, but it is not the starting point.
• A medication review at the same time, under NG5⁴.
• A check of blood pressure lying and standing, if they have described dizziness on getting up.
• A referral for strength and balance work, which is the intervention with the longest-standing place in falls guidance, and which needs an actual referral rather than an encouragement to move more.
• An occupational therapy assessment of the home, which is how equipment and adaptations are unlocked in most systems. See adaptations and technology at home.
• A named person, a date, and a way to check. Ask what has been referred, to whom, and how you will know it has happened. Write it down.

Two things not to accept. The first is being told to keep an eye on things, which is not a plan. The second is the assessment being turned into a conversation about a care home. NICE’s own discharge guidance holds elsewhere that people should not have to make decisions about long-term residential care while in crisis, and the days after a fall are a crisis.

The second fall is the one to escalate hardest. Families almost universally read a first fall as an event and a second as bad luck. It is the opposite way round: the second is the pattern, and it is the point at which a request should become a firm one. That was my mistake in 2023, and it is the most common one there is.

What prevention has anything behind it?

Strength and balance work, a medication review, and a proper assessment of the person. Environmental changes come after those, not before them.

Being honest about the evidence is more useful here than a long list. This page does not give effect sizes for any falls intervention, because the figures held as canonical for this site do not include them, and quoting a number from memory in a subject this consequential is worse than quoting none. What can be said plainly is which things guidance is built around, and it is not the hallway.

• Strength and balance training is the intervention that falls guidance has been organised around for two decades. It needs a referral and a programme, not a leaflet.
• A structured medication review, as above⁴.
• Vision, feet and footwear, all three of which are checkable and fixable and all three of which get skipped.
• Treating the thing that is actually causing it, whether that is continence urgency, pain, blood pressure or an acute illness.
• Then the home. Lighting, particularly on the route to the lavatory at night. A rail where the person actually reaches for the wall. Removing the specific thing they tripped on, rather than redecorating.

The reason to put the home last is not that it does not matter. It is that families do it first, feel they have acted, and then do not pursue the assessment. Moving a rug felt to me, in February 2023, like having done something.

Do alarms and sensors help, and what about the fear of falling?

Alarms detect falls. They do not prevent them, and the distinction is worth holding onto before anyone spends money.

A pendant, a wrist device or a floor sensor can shorten the time somebody spends on the floor, which is a real benefit, particularly for a person who lives alone or where the carer is not in the house. What none of them does is address why the person is falling. They also depend on being worn rather than left on the bedside table, on being charged, on being in range, and on somebody being available to respond. Build them into a plan that includes the assessment; do not let them replace it. Adaptations and technology at home covers what this equipment realistically does and where its limits are, and if you are organising this from another city, caring from a distance covers the response plan that has to sit behind it.

The fear of falling deserves naming, because it does measurable damage of its own. After a fall people move less, and moving less produces the weakness that makes the next fall more likely. It is a loop, and the way out of it is supervised activity rather than reassurance. If somebody has stopped going out, stopped using the stairs, or moved their chair nearer the kitchen since a fall, that is worth reporting to whoever does the assessment. It is also a good moment to check what help exists: getting help in sets out what is available and how each thing is triggered, and who does what: GP, district nurse, social worker tells you who to ask. If the fall followed a hospital stay, coming home from hospital covers that window, and if you struggle to get the assessment agreed, being heard in appointments is the practical guide to pressing.

This is a call today, not something to see how it goes with

Ring the same day after any fall, including one they got up from unaided, and say that they have fallen and when. Ring today, too, if the person you look after:

• Has fallen more than once in a few months, which is a pattern rather than bad luck.
• Is confused, drowsy or withdrawn since the fall, which is the presentation most often missed⁷.
• Has pain that has arrived or worsened in the hours since, particularly in the hip, back or neck.
• Has a new bruise or swelling that is growing, or bruising that seems out of proportion to the fall.
• Has become unsteady, or has stopped walking as far, since a new or changed medicine.
• Has stopped going out or using the stairs since falling.

Who to ring: in the United Kingdom, their GP surgery, or NHS 111 out of hours. In Ireland, their GP or the out of hours GP service. In the United States, their own doctor’s office, or the nurse line their plan runs, or an urgent care centre. In Australia, their GP, or healthdirect on 1800 022 222. In Canada, their family doctor or the provincial health line, 811 in most provinces. Elsewhere in the European Union, their own clinician.

Use the emergency number immediately for changed breathing, chest pain, one-sided weakness, changed speech, a first seizure, an unrousable person, or bleeding that will not stop: 999 or 112 in the United Kingdom and Ireland, 911 in the United States and Canada, 000 in Australia, 112 across the European Union.

The thing I would tell myself in February 2023 is that a fall somebody gets up from is not a lucky escape. It is the only free warning you are going to get.