Why falls matter in the exam

Falls and poor mobility are one of the largest areas of the Geriatric Medicine SCE. Questions rarely ask you to recite a list. Instead they describe an older person who has fallen and ask which single assessment or intervention will make the biggest difference. To answer well, you need a clear framework and a good grasp of current UK guidance.

The guideline to know

In 2025 NICE replaced its long-standing falls guideline with NG249, Falls: assessment and prevention in older people and in people 50 and over at higher risk. The age range now includes people aged 50 to 64 who are at higher risk because of an underlying condition. The guideline encourages health and care professionals to ask older people about falls at routine contacts and to offer a multifactorial falls risk assessment to those who have fallen or are judged to be at risk. Read the guideline itself before the exam, because questions often turn on the exact wording of who should be assessed and what should be offered.

Multifactorial assessment: the core framework

A multifactorial assessment looks for every contributor that can be changed. Work through the history of the fall itself, including any loss of consciousness, palpitations, dizziness on standing or a trip. Then assess gait, balance and muscle strength, cognition, continence, vision, foot problems and footwear, and the home environment. Check for osteoporosis risk, because preventing a fracture is as important as preventing the fall. Finally, review every medicine the patient takes.

In the exam, a description of a fall with no warning, injury to the face and a brief loss of consciousness should make you think of syncope rather than a mechanical fall. Arrhythmia, carotid sinus hypersensitivity and orthostatic hypotension all need to be considered, and the correct next step is often an investigation such as a lying and standing blood pressure, an ECG or ambulatory monitoring.

Orthostatic hypotension

Orthostatic hypotension is commonly defined as a sustained fall in systolic blood pressure of at least 20 mmHg or diastolic pressure of at least 10 mmHg within three minutes of standing. Measure the blood pressure lying and then standing at one and three minutes. Common causes in older people include antihypertensives, diuretics, alpha blockers, nitrates, dehydration and autonomic failure, for example in Parkinson's disease or diabetes. First-line management is to review and reduce culprit medicines and to advise on slow positional change and adequate fluid intake. Drug treatment such as midodrine or fludrocortisone is reserved for persistent symptoms despite these measures.

Medicines and falls

Many SCE questions reward the candidate who stops the right drug. Sedatives, hypnotics, antipsychotics, antidepressants, opioids and medicines with a high anticholinergic burden all increase the risk of falling. When a stem lists a long medication history, look for a recently started or increased drug that explains the presentation, and remember that reducing a medicine is often safer and more effective than adding a new one.

Interventions that work

Progressive strength and balance training has the strongest evidence for reducing falls in older people living in the community. Home hazard assessment and modification by an occupational therapist helps people at higher risk, and cataract surgery or correction of vision problems can make a real difference. After a fragility fracture, assess bone health and offer treatment to reduce the risk of further fractures.

Exam tips

Read the stem for clues about the type of fall, the timing in relation to standing, meals or medicines, and any recent change in treatment. If two options both seem reasonable, choose the one that addresses the most likely modifiable cause. Practise with exam-style questions so that the framework becomes automatic under time pressure.

Practise with License Medical

The License Medical Geriatric Medicine question bank includes Best of Five questions on falls, syncope, orthostatic hypotension and medication review, each with a guideline-based explanation. You can try a free test before you subscribe at license-medical.com/question-bank-details/geriatric/.

Source: NICE guideline NG249, Falls: assessment and prevention in older people and in people 50 and over at higher risk (2025).