Fear of falling: how it shrinks a life, and how to win the ground back

NHS inform, the Scottish NHS health information service, describes the same loop: a fall leads to the fear of falls, which leads to reduced activity, and the reduced activity lowers physical ability, which raises the risk of another fall. It also says plainly that some people worry about falling even if they have never fallen.

The reason this matters is that each step feels sensible to the person taking it. Staying in the armchair feels safer than walking to the kitchen, and it is safer that afternoon. Over months it is not, because muscles that are not used get weaker and balance that is not tested gets worse. The fear is guarding against a fall, and the way it guards makes the fall more likely. That is why it is worth treating as a problem of its own, and not waiting for it to pass.

For the wider picture of why older people fall and what reduces it, the mobility and falls care guide is the place to start. If a fall has just happened, after a fall: the checklist covers the first days, and hip fracture recovery at home covers confidence after a broken hip.

None of these on its own proves that fear is the reason. A person who has stopped going upstairs may have knee pain, breathlessness or dizziness on standing, and those need the GP before anybody weighs up a stairlift, a second rail or moving downstairs. The pattern to watch for is a run of small withdrawals, each explained away, and a person who says they are fine while doing less every month.

A stick is worth a word of its own. Reaching for one is a reasonable instinct, and an aid at the wrong height or in the wrong hand gives less support than it looks. Before anything is bought, read which walking aid fits and who should set its height. A physiotherapist or occupational therapist can watch your relative walk and choose the right one.

The evidence behind exercise is strong. A Cochrane review of 108 trials found that exercise reduced the rate of falls in older people living at home by 23%, with the largest effect from programmes combining more than one type, such as balance and strength work. A separate Cochrane review found that exercise probably reduces fear of falling to a limited extent straight after a programme, without increasing falls, though it could not say whether the effect lasts. That is a reason to keep exercising once a course ends, and not a reason to skip it.

The NHS guidance for older adults says it directly: if you have fallen or are worried about falling, exercises to improve strength, balance and flexibility will help make you stronger and feel more confident on your feet. The NHS has step-by-step strength exercises and balance exercises to do near a wall or a stable chair, and it says to build up slowly.

To ask for an assessment, ring the GP surgery and say your relative is afraid of falling and has started doing less because of it. Say so even if there has been no fall, and ask about the local falls service. The NICE guideline on falls asks assessors to explore concerns about falling as part of the assessment. A review of every medicine they take is worth asking for at the same time, because some medicines cause dizziness or drowsiness. The council can do a care needs assessment if day-to-day tasks have become hard, and it is free to ask.

Our own guides on exercise for older people, how to build strength at 80 and whether climbing stairs is good for older people go into the exercises themselves in more detail.

1. 1

   Choose one thing that matters to them

   Their choice

   The walk to the paper shop, a bath upstairs or Sunday lunch with a friend. Something they miss will keep them going better than something the family wants for them.
2. 2

   Break it into small stages

   Small enough to succeed

   To the front gate, then to the corner, then to the shop and back. Upstairs once with somebody behind them, then once a day, then alone.
3. 3

   Do each stage with somebody alongside first

   Somebody beside them

   Somebody walks beside them rather than holding them up. The aim is that they manage it themselves with a person there for reassurance.
4. 4

   Repeat it until it feels ordinary

   Several times a week

   Move on only when the stage feels dull rather than frightening. A bad day is a reason to repeat the last stage, not to stop.
5. 5

   Then do it without the company

   The last stage

   The person alongside steps back, first to the next room, then out of the house. This stage is what turns it back into part of their life.

It helps to pick a time of day when your relative is at their best, and to plan the route so there is somewhere to sit halfway. Good shoes that fasten, a charged phone and a drink first all make a first attempt more likely to go well. If they use a walking aid, it should be the one fitted for them.

Expect setbacks. A cold, a stumble or a bad night can undo a week's progress, and that is part of how confidence comes back, not a sign it is not working. Going back one stage and building up again is normal. If it stalls completely, or the fear seems out of proportion to how steady they are, tell the GP or the falls service. That is the situation in which NICE says talking therapy should be considered. For how far and when to walk, see how far an 80-year-old should walk each day.

The NHS falls page sets out how somebody gets up when they are not hurt: roll onto the side, push up onto hands and knees, and find something stable to hold, such as a heavy piece of furniture, a bath or a sink. Research funded by the National Institute for Health and Care Research found that knowing how to get up made a difference to whether older people tried, and it pointed to teaching the movement in small steps, starting with the last one, as one of the things that helps. That teaching is a physiotherapist's job rather than a family's. Nobody should practise getting down onto the floor without somebody trained there.

Pendant alarms, fall detectors and key safes explains what each device does and what to ask before you sign. After a fall: the checklist covers what to check before anybody is moved, and why time on the floor matters. If the worry is mostly about the night-time walk to the toilet, night care for falls and toilet trips explains what a carer does overnight.

None of this means leaving somebody to struggle. The line is between help that lets them do something and help that does it instead. Carrying the heavy shopping bag while they walk to the shop is the first kind. Going to the shop without them is the second. If your relative resists help, or resists being encouraged, how to get someone to accept care has ideas that do not turn into a battle.

A carer in the house can do the same job when the family cannot be there. That means company on the walk to the shop, somebody in the house while they try the stairs, and a reminder that it is exercise time. What a carer does not do is replace your relative's own legs. A carer who does everything for them feeds the cycle as surely as a family who does, so say at the start that the aim is for your relative to do more, and ask the carer to work that way. A carer is not a physiotherapist either, so the exercises should be the ones the NHS or the falls service has given, and physiotherapy at home covers how a family or carer can help keep them going. Can carers take you out covers walks, shops and outings.

Carers on PrimeCarers charge £18 to £25 an hour with our fee included, and companionship visits are advertised a little lower, at £15 to £20. An hour three mornings a week at the typical £20 is £60 a week. Agencies charge £28 to £35 an hour, and what an hour of care costs sets the two side by side. If you want somebody alongside while your parent gets their confidence back, you can search for carers near you and compare their rates. Every carer's identity, right to work and enhanced DBS on the Update Service are checked and they are interviewed online before they appear, and they are insured while they work. We do not check training or qualifications, so ask the carer about their experience with falls and mobility yourself.