Fall Prevention and Mobility Enhancement in Older Adults

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
• Sociodemographic information: age, sex, gender identity, language, living arrangement, supports, caregiving responsibilities, health literacy, occupation or volunteer roles, and communication or access needs.

Primary concerns

• Fall and near-fall history: ask opportunistically about falls in the past year. Record number, date, place, activity, direction and mechanism; footwear or mobility aid; injury or medical attention; loss of consciousness or memory; ability and time needed to get up; time on the floor; warning symptoms; witnesses; and whether a diary or caregiver report would improve recall (NICE, 2025; Montero-Odasso et al., 2022).
• Unsteadiness and concerns about falling: ask whether the person feels unsteady while standing or walking, worries about falling, restricts activity, needs furniture or another person for support, or has changed routines because of confidence or safety (Montero-Odasso et al., 2022).
• Mobility change: onset and course of slower walking, reduced endurance, difficulty turning, stairs, transfers or rising from the floor, freezing, tripping, dragging a foot, new aid use, deconditioning after illness or admission, and fluctuation across the day.
• Symptoms before, during or after an event: dizziness or vertigo, light-headedness on standing, palpitations, chest discomfort, shortness of breath, weakness, numbness, speech or vision change, headache, seizure-like activity, confusion, fever, pain, urgency or incontinence, and post-event recovery.
• Injury, functioning and participation: head impact; bone, joint or soft-tissue pain; bruising; ability to bear weight and use the limbs; sleep; self-care; household and community mobility; work, volunteering, caregiving, recreation and social participation.
• Body systems review: neurological, cardiovascular, musculoskeletal, vestibular, vision, hearing, cognition, mood, genitourinary, gastrointestinal and nutritional, skin, foot and sensory symptoms relevant to falls, mobility or injury.
• Health, lifestyle and history: frailty; osteoporosis and fracture history; neurological, cardiovascular, metabolic and musculoskeletal conditions; recent illness, hospitalization or surgery; pain; sleep; hydration and nutrition; alcohol or substance use; physical activity; footwear; and current medications and supplements, including recent changes and adherence.
• Environment and supports: lighting, stairs, rails, bathroom setup, loose rugs or cords, uneven surfaces, pets, seasonal hazards, access to a phone or alert system, mobility-aid fit and use, transportation, caregiver availability and the person’s ability to summon help after a fall.
• Social determinants of health: housing quality, income, food security, discrimination, social isolation, caregiver strain, neighbourhood accessibility, transportation, digital access and availability or affordability of assessment, exercise, equipment and home modifications (Public Health Agency of Canada, 2026).
• Previous care and responses: fall-prevention education, exercise, rehabilitation, mobility aids, footwear or vision care, medication review, home assessment, medical investigation and what helped, did not help or was difficult to continue.
• Patient perspective: understanding of the fall or mobility change, priorities, acceptable risk, preferences, cultural context, concerns, confidence, expectations and previous experiences of care.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

​​Outcomes measures

• Use measures that are meaningful to the patient and practical to repeat. Record a baseline and reassess often enough to guide decisions. Do not use a score on its own to predict whether an individual will fall.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: WHOQOL-BREF.
• Falls and concerns: fall and near-fall count or diary, plus the Falls Efficacy Scale International (FES-I) when concerns about falling are a meaningful target.
• Mobility and lower-limb performance: a repeatable task matched to ability and goals, such as the Timed Up and Go or Five Times Sit-to-Stand Test. Record setup, aid and assistance so repeated results are comparable.
• Individual goals: agree on patient-defined goals and how progress will be recognized. SMART wording may be used when helpful.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change care. Adapt the examination to the patient’s presentation, comfort, consent and abilities.

• Consent and comfort: explain what you propose, provide choices about positioning, pace, footwear, mobility aids and caregiver involvement, and confirm ongoing consent.
• Condition-specific safety: use guarding and an appropriate environment; provide the person’s usual aid and needed assistance; stop or modify testing for chest symptoms, presyncope, marked dyspnea, acute neurological change, severe pain, unsafe fatigue or loss of control.
• Observation: alertness, posture, spontaneous movement, transfers, gait, turning, footwear, mobility-aid use, confidence, breathlessness, asymmetry and protective behaviour.
• Vital signs and cardiovascular assessment: heart rate and rhythm, blood pressure, oxygen saturation when indicated, hydration and signs of acute illness; include lying and standing blood pressure when orthostatic symptoms, unexplained falls or medication effects are plausible and the test is safe and within scope (NICE, 2025; Montero-Odasso et al., 2022).
• Gait, balance and mobility: gait initiation, speed, step length, foot clearance, turning, stopping, dual-task effect, surface or stair demands and response to an aid. Use selected tasks to describe performance and change, not to predict a fall in isolation.
• Strength, power and transfers: sit-to-stand, lower-limb and trunk strength, functional reach, bed or chair mobility and ability to rise from the floor when this can be tested safely and the person agrees.
• Neurological and cognitive examination when indicated: cranial and focal neurological findings, strength, sensation, reflexes, coordination, parkinsonism, attention, orientation, cognition, mood and delirium features.
• Vision, hearing and vestibular assessment when indicated: functional vision, eye movement, hearing, dizziness pattern, positional triggers, vestibulo-ocular findings and condition-specific tests that may change referral or care.
• Musculoskeletal, foot and footwear assessment: pain, swelling, injury, joint movement, alignment, lower-limb and spinal findings, foot sensation, skin, callus, deformity and the fit, condition and traction of footwear.
• Functional and environmental assessment: observe patient-prioritized self-care, household or community tasks and, when appropriate, the interaction among the person, aid, lighting, surfaces, stairs, bathroom setup and other hazards.
• Imaging: not routine for fall risk or uncomplicated mobility decline. Use imaging when acute injury, fracture, head or spinal injury, serious pathology or another result is likely to change care or referral.
• Repeat and adapt: repeat focused findings when needed to review progress, revisit the working presentation or decide whether further assessment or referral is appropriate.

Working clinical presentations

These presentations can overlap or change. They guide the depth of assessment and coordination rather than predicting whether an individual will fall. Falls-risk prediction tools are not used as stand-alone predictors (NICE, 2025).

• Mobility concern without a recent fall: unsteadiness, slower gait, transfer difficulty, deconditioning or concerns about falling without a reported past-year fall. Explore change, function, safety and modifiable factors, and support appropriate physical activity.
• Single fall without gait or balance impairment: one past-year fall without injury needing medical care, loss of consciousness, inability to get up, frailty or an identified gait or balance problem. Education, physical activity and safety review can be matched to the person’s context (NICE, 2025).
• Single fall with gait or balance impairment: one fall plus observed or reported gait, balance, strength or mobility difficulty. Falls-prevention exercise and home-hazard review can form part of care (NICE, 2025).
• Recurrent or consequential falls: two or more falls, frailty, injury requiring medical treatment, loss of consciousness, inability to get up or a prolonged time on the floor. A comprehensive falls assessment and coordinated management are indicated (NICE, 2025; Montero-Odasso et al., 2022).
• Post-illness or transitional mobility decline: new weakness, reduced endurance, delirium recovery, changed medications or equipment, or altered supports after illness, hospitalization or a move. Reassess health, environment, assistance and previous baseline.
• Multifactorial or complex presentation: interacting medication, cardiovascular, neurological, sensory, musculoskeletal, cognitive, environmental and social factors. Do not assume one cause. Identify which factors are most important and can be addressed safely.
• Condition-linked, atypical or uncertain presentation: the fall or mobility change may be related to syncope, vestibular disease, stroke, Parkinson disease, neuropathy, dementia, acute injury or another condition. Document the working impression and follow Red Flags or the relevant condition pathway.

Base care on the presentation, safety, goals, context and response. Use adaptable principles and options rather than a ranked sequence, and repeat meaningful outcomes to guide change.

Education, self-management and participation

• Build a practical fall plan: discuss individual risk factors, safe ways to maintain valued activity, what to do after a fall, how to summon help and which new symptoms need urgent assessment. Involve family or caregivers with the person’s agreement (NICE, 2025; World Health Organization, 2021).
• Support confidence and participation: use patient-defined goals, graded re-engagement and accessible written or demonstrated information. Avoid implying that all falls can be prevented or that the person is to blame.

Physical activity and exercise

• Falls-prevention exercise: options for community-dwelling older adults include balance-challenging and functional exercise such as stepping and sit-to-stand, with strength or resistance, gait, coordination and endurance work added to identified needs. Individualize, progress and supervise the programme to the person’s abilities, health, goals and response (Sherrington et al., 2019; Montero-Odasso et al., 2022; U.S. Preventive Services Task Force, 2024).
• Programme dose and continuity: an evidence-informed community programme can include sessions at least three times weekly for at least 12 weeks, with continued exercise for ongoing benefit. The actual starting level, progression, supervision and delivery format reflect capacity, safety, adherence, access and setting (Montero-Odasso et al., 2022).
• Delivery options: programmes can be individual or group based and delivered at home, in the community, virtually or through a hybrid model. Match instruction, progression and monitoring to the person. Higher fall risk, frailty or cognitive impairment may require closer supervision (Montero-Odasso et al., 2022).
• Floor-transfer skills: when safe and acceptable, practising how to rise from the floor and use an alert or help plan can reduce harm from being unable to get up after a fall (Montero-Odasso et al., 2022).

Mobility aids, footwear and environment

• Mobility aids: assess, fit and teach the use of a cane, walker or other aid when it may improve stability or reduce effort. Check how the person uses it in relevant settings and review it as needs change.
• Home and environmental modification: a structured home-hazard assessment and action on identified lighting, surface, stair, bathroom, furniture or access problems can form part of care, ideally with an occupational therapist or another appropriately trained provider (NICE, 2025; World Health Organization, 2021).
• Feet and footwear: address pain, skin or sensory problems and review fit, fastening, heel, sole condition and traction when these affect mobility. Foot or footwear needs beyond scope call for podiatry, orthotic, medical or other appropriate care.

Health conditions and medication coordination

• Medication review: a pharmacist or authorized prescriber can review fall-risk-increasing medicines, psychotropic medicines, polypharmacy, recent changes, adverse effects and adherence. Any change or withdrawal is individualized and coordinated rather than made abruptly outside scope (NICE, 2025; Montero-Odasso et al., 2022).
• Condition-specific care: medical, rehabilitation or specialist care can address orthostatic hypotension, syncope or arrhythmia, cataract or other vision loss, vestibular disorders, osteoporosis, continence, nutrition and hydration, hearing, cognition, mood, neurological disease, pain or other identified contributors (NICE, 2025).

Psychological, social and interdisciplinary support

• Concerns about falling: explore the relationship among confidence, gait, balance, actual risk and activity restriction. Psychologically informed education, graded activity and falls-prevention exercise can be combined; cognitive behavioural care can form part of shared care when concerns remain limiting (NICE, 2025; Montero-Odasso et al., 2022).
• Interdisciplinary and community support: primary care, geriatrics, pharmacy, physiotherapy, chiropractic, occupational therapy, nursing, optometry or ophthalmology, audiology, podiatry, nutrition, mental health, social care, community programs and caregivers can be coordinated around identified needs and the person’s priorities.
• Access and feasibility: transportation, cost, housing, caregiver availability, language, technology and community accessibility can shape the plan. Select options the person can use and revisit barriers when participation is difficult.

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review falls and near falls, mobility, relevant neurological and cardiovascular findings, functioning, participation, confidence, benefits, harms, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit the clinical presentation, differential diagnosis, referral or shared care when another fall occurs, progress differs from expectations or new safety concerns emerge.

• Expected course: fall risk and mobility can change with health, activity, medications, environment and supports. Falls are not inevitable, and appropriately designed exercise reduces falls on average in community-dwelling older adults, but no intervention guarantees that an individual will not fall (Sherrington et al., 2019; Public Health Agency of Canada, 2022).
• Factors associated with a less favourable course: previous recurrent or injurious falls, gait or balance impairment, weakness, frailty, cognitive or neurological disease, multimorbidity, fall-risk-increasing medicines, orthostatic or cardiovascular symptoms, vision impairment, concerns about falling with activity restriction, environmental hazards and inability to get up may be associated with further falls or loss of mobility. These are group-level patterns, not certain individual predictions (Montero-Odasso et al., 2022; Colón-Emeric et al., 2024).
• Potential supports for recovery: clear information about the person’s fall risks, sustained and appropriately progressed balance and functional exercise, timely management of identified health and medication factors, suitable aids and environments, confidence-building, caregiver and social support, and accessible coordinated care may help the person move and participate more safely.
• Discussing prognosis: explain that fall risk can change and cannot be predicted with certainty. Avoid promises or blame. Discuss what the person wants to do, what level of risk they accept and how the plan may change as new information and repeated outcomes become available.