Falls risk assessment in the UK: how it works and why NICE advises against scores

What is a falls risk assessment, and who does it?

A falls risk assessment is a check, usually by a health professional, of the things that make a fall more likely for one particular person. In England, the guidance behind it is NICE guideline NG249, published on 29 April 2025. It replaces the earlier NICE guideline on falls, CG161, from 2013.¹

NG249 covers everyone aged 65 and over, and people aged 50 to 64 who are at higher risk of falls.¹ The assessment can be carried out by a single appropriately trained healthcare professional or by a multidisciplinary team, in primary care, community teams or specialist clinics.²

The NHS describes the same idea from the patient’s side. If you have had falls, or a GP thinks you may be at risk, the GP will check your balance by asking you to get up and move around, and may refer you to a specialist falls service.⁴

Notice what is missing from that description: a score. The rest of this guide explains why, and what the assessment looks at instead. For prevention itself, such as exercise and home changes, see the separate guide to falls prevention for older adults.

Why NICE says not to use falls risk prediction tools

Recommendation 1.1.1 of NG249 is short and direct. It says not to use falls risk prediction tools to predict a person’s risk of falling.²

The committee’s reasoning is set out in the rationale. It judged that such tools only sort people into high or low risk without recommending any further step, and that the evidence on the tools was of very low quality.³ A label of “high risk” or “low risk” does not, on its own, tell anyone what to do next.

NICE says the same about walking and balance tests. The committee noted that tests such as the Timed Up and Go help a clinician observe impairments, but do not predict a person’s risk of falling.³ On wearable technology, it made a recommendation for research into accuracy, because the evidence was missing.³

This matters for anyone searching for a falls risk calculator or an online score. No source read for this guide supports a public calculator that assesses the risk reliably, so this page does not offer one. What NICE asks for instead is a look at the person’s own risk factors and a plan to change those that can be changed.

What does a multifactorial assessment look at?

When a comprehensive assessment is needed, NG249 lists what it can include, depending on the person. The list is long because falls usually have several causes, not one.²

Compare that with the causes the NHS gives for falls: muscle weakness linked to age, conditions such as arthritis, stroke or Parkinson’s disease, low blood pressure, side effects of some medicines, eyesight or hearing problems, and dementia.⁴ The two lists overlap closely, which is the point: the assessment looks for the causes that apply to you.

NICE also says the person should be told that their risk depends on individual factors, that some of them can be changed (exercise, a medicines review and cataract surgery are given as examples), and what to do if they fall.²

Who gets which kind of assessment?

NICE does not sort people by a score. It sorts them by what has happened and what is found, which is easier to explain and acts as a pathway.

• Asking. NICE says people should be asked whether they have fallen in the last year, for example at routine appointments or annual health checks.²
• Comprehensive assessment. It is advised after a fall in the last year plus at least one of these: frailty, an injury that was treated, loss of consciousness, being unable to get up alone, or two or more falls in the last year.²
• Gait and balance check. If the person has fallen but meets none of those criteria, NICE advises assessing gait and balance. If there is an impairment, offer a falls prevention exercise programme and consider a home hazard assessment.²
• No fall, or a single fall with no gait or balance impairment. Offer health information and physical activity advice in line with the Chief Medical Officers’ guidelines.²
• Hospital and residential care. NICE advises a comprehensive falls assessment for everyone in hospital inpatient settings and in residential care.²

If you want to know how much exercise the Chief Medical Officers’ guidelines suggest, see the guide to strength training guidelines.

Clinical tools you may hear about: FRAT, FROP-Com, Timed Up and Go and the chair stand

Several named tools are used or studied for falls. Because NICE advises against prediction tools, treat the table below as background on what each one is and where it was tested, not as a list of what NICE recommends. The figures come from journal abstracts only; the full papers were not read.

Three points follow from the table. First, the studies are old (1999 to 2011) and none is a NICE or NHS page. Second, the same tool can look quite different depending on who was studied. Third, in the same emergency department study the Timed Up and Go had an area under the curve of 0.63, lower than the 0.68 of the FROP-Com, which its authors called a moderate capacity to predict falls.⁶

Reading a result: what a score does and does not tell you

Scores sound precise. A little arithmetic shows how much they miss, using only the figures in the table above.

Worked example: what the numbers mean

FRAT. A positive predictive value of 0.57 means that 57 in every 100 people with three or more risk factors fell within six months. So 100 minus 57 = 43 in every 100 did not fall in that time.⁸ A flag for three or more factors is therefore a reason to look more closely, not a forecast.

FROP-Com at 18/19. A sensitivity of 71.3% means the tool picked up 71.3 of every 100 people who then fell. So 100 minus 71.3 = 28.7 in every 100 fallers were missed. A specificity of 56.1% means 100 minus 56.1 = 43.9 in every 100 people who did not fall were still flagged.⁶

FROP-Com screen. With a sensitivity of 67.1%, 100 minus 67.1 = 32.9 in every 100 fallers were missed, and with a specificity of 66.7%, 100 minus 66.7 = 33.3 in every 100 non-fallers were flagged.⁷

These sums use the studies’ own populations, which were an emergency department and a primary care area. They are an illustration of how scores behave, not a statement about any one person.

There is also no universal threshold for “high risk”. Each tool has its own cut-offs, and NICE advises against prediction tools that sort people into high or low risk, and its committee found such tools not particularly useful.²³ If a letter or report gives you a risk level, ask what is being done about each factor behind it.

What can change after an assessment?

The aim of NICE’s approach is a plan for each factor that can be changed. The recommendations the sources set out are these.

• Exercise. Falls prevention exercise programmes should be progressive and tailored, with a focus on balance, coordination, strength and power.² NICE’s committee judged that qualified fitness instructors can deliver them effectively, so they do not always need to be prescribed in the NHS.³
• Medicines. NICE advises considering a structured medication review to find medicines that raise the risk of falls.²
• Home. NICE advises offering a home hazard assessment and intervention using a validated tool, and considering having an occupational therapist carry it out.²
• Eyes. Age UK advises having your eyes checked, and your glasses prescription reviewed, at least every 2 years.⁵
• Vitamin D. NICE found insufficient evidence to support vitamin D supplements specifically to lower the risk of falls, and points to NHS advice on bone and muscle health.²

Age UK describes the follow-up in similar terms: after a doctor checks balance and walking, you may be referred for a falls risk assessment or to a falls prevention service, and an action plan is then designed for your needs.⁵ The NHS adds that a falls service may check for muscle weakness, osteoporosis and eyesight, offer strength and balance work, check the home and review medicines.⁴

To stay active in between, see strength training for older adults and the Chief Medical Officers’ guidelines and strength training at home. The NHS recommends being active every day and doing strength and balance activities at least twice a week.⁴

How to ask for an assessment, and what to bring

The NHS says to see a GP if you are worried about your balance or mobility, or after a fall.⁴ In some areas you can refer yourself directly to services that can help. Ask at the GP surgery reception, look on the surgery website or ask your local integrated care board (ICB).⁴

The NHS also says you can ask your local council for a care needs assessment, which is free and open to anyone, and which can include changes to the home.⁴

Notes that make the appointment more useful

None of these is a score, and none replaces the assessment. They are the things NICE’s criteria and the assessment list turn on, written down so they are not forgotten.

• Falls. How many falls in the last year, when, and whether you could get up by yourself.²
• Injuries and blackouts. Any fall that needed treatment, or any loss of consciousness.²
• Medicines. Everything you take, including anything bought over the counter, so the GP or pharmacist can review them.²
• Eyes, ears and feet. When your eyes and hearing were last checked, and any trouble with footwear or foot pain.²⁵
• Dizziness on standing. This links to the lying and standing blood pressure check NICE lists.²
• Worries. Anything that makes you cautious at home, such as stairs or the bathroom.

Where a protective vest fits, and where it does not

An assessment is about finding and reducing risk. Nothing in this guide, and nothing in the NICE or NHS sources read, says a vest or any other wearable reduces the chance of a fall, and NICE called for research on how accurate wearable technologies are at spotting risk.³

For readers who want to know what Elder is, the short answer is in the box below. It is personal protective equipment for the moment of a detected fall. For the wider picture of airbag vests, see airbag vests for the elderly.

Frequently asked questions