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Falls

Original Editor - Bhanu Ramaswamy as part of the AGILE Project.

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Introduction

"A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level."[1]

All people who fall are at risk of injury. A person's age, gender and health can influence the type and severity of fall-related injuries.[2] Beyond the physical consequences, falls can have significant psychological effects, potentially creating a fear of falling that restricts mobility and independence.[3]

Fall prevention interventions aim to reduce a person's risk of falling, decrease injury severity and preserve a person's autonomy, dignity and quality of life.[4]

Many interventions focus on preventing falls by improving strength, balance, and flexibility. Other interventions focus on compensatory strategies. Compensatory strategies involve adapting the environment, modifying tasks, and using assistive devices to help individuals engage safely in meaningful activities.[4]

Fall Demographics

Falls are the second leading cause of unintentional injury deaths globally.[1] Each year, 684,000 people die from falls. In addition to this, 37.3 million falls cause injuries that require medical attention.[1] 80% of fatal falls occur in low- and middle-income countries.[5]

Older people are most at risk of death and serious injury from a fall. This elevated risk may be associated with age-related physical, sensory, and cognitive changes and issues in the physical environment. Younger children are also susceptible to serious injuries from falls.[1]

In some regions, it has been found that males are more likely to experience a fatal fall while females have more non-fatal falls. Globally, males have higher rates of death and disability-adjusted life years lost (DALYs) from falls. Potential causes of these high rates in men might be greater risk-taking behaviours and occupational hazards.[1]

Causes of Falls

Falls are complex and multifactorial, and they can be influenced by a range of intrinsic and extrinsic factors.[6]

Intrinsic Risk Factors

Intrinsic risk factors come from within the individual and include (1) age-related physiological changes, (2) chronic health conditions, and (3) the use of medications. Intrinsic risk factors can be the most challenging to address, as they require individual adaptation or intervention.

1. Age-Related Physiological Changes

As we age, our bodies undergo various physiological changes that can significantly increase our risk of falling. For example, reduced muscle strength and joint mobility, particularly in the lower limbs, can lead to instability and an inability to react quickly to balance disturbances.[7] Decreased flexibility can affect how a person moves and responds to their surroundings.[8] Declining vision impacts a person’s ability to detect obstacles in the environment, increasing their risk of tripping or falling.[9] Balance and posture impairments affect a person's ability to maintain an upright stance. Reduced vestibular function and a decreased ability to respond to postural shifts can also contribute to falls.[10]

2. Chronic Health Conditions

Chronic conditions often impact multiple physiological systems, increasing a person's vulnerability. Common conditions that increase fall risk include Parkinson’s, arthritis, diabetes, cognitive impairments, amputations, and cardiovascular diseases.[11]

3. Use of Medication

The use of multiple medications (polypharmacy) is a significant risk factor for falls.[12] Many commonly prescribed medications have side effects that can impair balance and coordination, including sedatives and antidepressants, antihypertensives, and anticholinergics.[13][14][15]

Extrinsic risk factors

Extrinsic risk factors are social and physical factors that relate to an external environment. They include (1) environmental hazards and (2) improper use of mobility aids. Falls in older people aged less than 75 years are more likely to be linked to extrinsic factors. In people aged 80 years or more, intrinsic factors tend to be more important. Extrinsic factors are often modifiable and can be addressed through compensatory strategies.[16]

1. Environmental Hazards

As most falls happen at home, common environmental risks include cluttered spaces, poor lighting, slippery surfaces in bathrooms and kitchens, and uneven floors.[17]

2. Improper Use of Mobility Aids

Many older adults or people with disabilities rely on mobility aids, such as canes, walkers, or wheelchairs, to improve their stability and prevent falls. However, the improper use of these devices, such as incorrect adjustment or improper techniques, can increase a person's risk of falling. Rehabilitation professionals play a vital role in educating individuals on the correct use of these devices.[18]

Fall Risk Assessment

Fall risk assessments help identify individuals at risk of falling, allowing healthcare providers to take proactive steps in preventing falls. The early identification of risks is key to reducing the incidence of falls and their consequences, such as fractures, hospitalisations, and loss of independence.

It is recommended that older adults be screened for fall risk at least once per year.[19] Anyone identified as at risk for falling through screening programmes should be fully assessed. Based on the assessment, appropriate interventions can be implemented.[19]

Interdisciplinary Collaboration

Interdisciplinary collaboration between all members of the team, including occupational therapists, physiotherapists, nurses, social workers, and other healthcare professionals, ensures that all aspects of fall risk are considered when planning fall prevention strategies.[4]

You can learn more about the multidisciplinary fall assessment in the NICE guidelines. These guidelines were developed for people aged 65 and older during a hospital stay and people aged 50-64 years who are at higher risk of falling because of underlying health conditions.

Role of Occupational Therapists in Fall Risk Assessment

Occupational therapists are involved in identifying whether a person is at risk of falling and interpreting the findings to inform client-centred interventions. This includes recommending environmental modifications, adaptive strategies, and assistive devices to reduce fall risk. They can also assess other factors that influence a person's likelihood of falling, including mobility, balance, and cognitive function.[4]

Physical and Functional Assessment

Patient history: when taking a patient's history, the clinician should cover past and present medical history and history of falls, including near misses. The subjective interview is essential as it can identify additional causes of falls that need to be addressed.[20]

Physical examination: gait, balance, joint range of motion, muscle strength, and sensation should all be assessed.

Functional ability: the subjective interview can provide information on how a person manages various activities of daily living. Observing how a person performs everyday tasks, such as standing up from a chair, highlights whether there are any safety concerns with these tasks. It's also important to assess a person's ability to dual- / multi-task, e.g. walking and carrying objects.

Fall Risk Assessment Outcome Measures

There are several fall risk assessment outcome measures. These tools help rehabilitation providers identify fall risk factors and plan targeted interventions.[4] Some common measures are listed below:

Fall Prevention Interventions

This section discusses two fall risk management strategies: (1) compensatory strategies and (2) exercise for strength and balance.

Compensatory Strategies

According to the Occupational Therapy Intervention Process Model (OTIPM), compensatory strategies adapt tasks, modify environments, or introduce assistive technologies to overcome functional or occupational limitations.[21] Key compensatory strategies in fall prevention include (1) task modification, (2) home modification, and (3) the provision of appropriate assistive technology.[4]

1. Task Modification

Task modification is a critical aspect of fall prevention in older adults. Adjusting how daily activities are performed can help a person maintain their independence while minimising their risk of falls. Task modification aims to promote safe engagement in daily activities. It’s important to ensure that the modifications still allow individuals to feel involved and empowered in their daily activities.[4] Some strategies for task modification are listed below.

Simplifying complex tasks: this involves breaking a task down into smaller, more manageable steps. For example, a person who needs to carry groceries from their car to their home might carry one bag at a time, rather than attempting to carry several bags or items at once.

Adapting techniques: modifying how a task is completed may make it safer to perform. For instance, a patient could be asked to perform a task in a different position or to alter their movement patterns (e.g. performing a task in sitting that is usually completed in standing, such as putting on shoes or preparing a meal).

Using supportive techniques: this might include using handrails or rearranging a home's layout to minimise risks.

Allowing for rest: some tasks can be physically demanding, and fatigue can contribute to falls. Allowing for rest breaks or spreading a task out over several smaller sessions can reduce the likelihood of falls related to fatigue or loss of concentration.[22]

2. Home Modification

Home modifications can significantly reduce fall risk, especially for older adults who may be dealing with mobility impairments, visual deficits, or cognitive changes.[23] When combined with other preventive measures, like exercise and education,[24] home modifications can help older adults continue to live independently and safely.[25]

Occupational therapists play a critical role in identifying hazards in the home and recommending modifications to ensure that the environment supports safe participation in daily activities.[26]

Several environmental changes can significantly reduce fall risk without the need for extra aids or equipment. These modifications typically improve safety in key home areas, such as entrances, living spaces, kitchens, bathrooms, and bedrooms.

The following optional video shows methods that occupational therapists use to help make a client's home safer:

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[27]

If you would like to see room-by-room guides to home safety, please see: Institute on Aging and Council on Aging.

3. Assistive Technology

Assistive devices are essential tools for helping individuals reduce their fall risk, especially when managing daily activities and mobility. They provide safety, increase independence, and can help individuals participate more fully in life.[28]

Physiotherapists and occupational therapists collaborate to choose an appropriate mobility aid, based on a person's physical capabilities and their fall risk assessment.

If you would like to learn more about mobility aids, please see: Assistive Technology: Mobility Products.

Assistive devices for daily activities are crucial for supporting daily tasks that may become more challenging with ageing or physical decline. These devices enhance independence and reduce fall risks during everyday activities like dressing, bathing, cooking, and toileting.[4]

If you would like to learn more about assistive technology for dressing, feeding and personal hygiene, please see: Self Care Assistive Technology.

Digital and technological assistive technology has been developed to improve home safety and prevent falls. This category of assistive technology includes wearable devices that automatically alert caregivers or emergency services of a fall and smartphone apps that track activity, gait, and balance to assess fall risk and inform interventions. Home monitoring and alert systems utilise smart home sensors to track movement and detect falls or unusual slowness, triggering alerts. Voice-activated assistants can help with daily tasks and be used to call for help. These voice-activated assistants reduce unnecessary movement and promote caution.[4]

Challenges in Implementing Compensatory Strategies

While compensatory strategies for fall prevention can significantly reduce risks and enhance quality of life, implementation has several barriers.[4]

Home modifications: a patient may be reluctant to modify their home due to perceived intrusiveness or a fear of losing independence. To overcome this barrier, it is important to build trust and involve patients in decision-making, ensuring modifications align with their preferences.[29]

The cost and accessibility of modifications: barriers to modifications, like grab bars or non-slip flooring, can be costly, and access may be limited. Community programmes and funding can help, but they are not always available.[24]

Autonomy: when implementing fall prevention programmes, it is important to respect a person's autonomy while prioritising their safety. Therapists must inform clients of risks but respect their decisions, even if they decline safety measures.

Cultural sensitivity: modifications might conflict with some patients' values or there may be systemic barriers in marginalised communities. Effective communication and understanding client values are key to navigating these ethical dilemmas.[30]

Exercise

Exercise is considered an effective intervention for preventing falls in older adults.[31] Exercise prescription for fall prevention should follow the FITT principle (Frequency, Intensity, Time, Type). Evidence suggests that exercise programmes should include strength and balance-challenging exercises. Each session should last 30 to 60 minutes, aiming for at least 2 hours of balance and strength training weekly. Exercises should focus on lower-limb strength, power, static and dynamic balance (e.g., standing on one leg, stepping over obstacles), and reactive balance training.

Balance exercises should be performed at least three times per week at a moderate intensity. Exercises need to be safe yet sufficiently difficult to stimulate improvement.[32]

It has been found that muscle power is more predictive of falls than strength in older adults.[33] Therefore, power training, such as high-speed resistance training, should be included as a fall prevention strategy.[34][35]

Long-term adherence to exercise interventions should be encouraged to maintain benefits, but all exercise interventions should be continued for at least six months.[36]

Examples of fall prevention exercises and programmes are listed below:

If you want to read more about exercises and fall prevention strategies, please see: Physical Activity in Ageing and Falls.

This optional video demonstrates five exercises that focus on balance and can help with fall prevention:

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[37]

Integrating Fall Prevention Strategies Into Practice

Fall prevention is a multi-disciplinary effort, and collaboration with other healthcare professionals is key to ensuring comprehensive care.

Caregivers play a crucial role in supporting fall prevention strategies at home. They can help implement recommended changes and monitor a client’s adherence to the plan. Educating family members and caregivers about the importance of fall prevention and how they can assist in implementing strategies can make a significant difference in outcomes.[38]

Various community resources may be available to assist with fall prevention, such as home modification programmes, support groups, or local health organisations that provide financial assistance for safety equipment. Rehabilitation professionals can help connect clients with these resources, especially when cost is a barrier to implementing necessary modifications.[4]

Monitoring Progress and Adjusting the Plan

It is important to monitor a client’s progress and make adjustments as needed. Regular re-assessment, follow-up visits or check-ins are essential to ensure that the interventions are working effectively. We can use the same fall risk assessment tools periodically to reassess the client’s progress. If a client’s needs change or new risk factors emerge, the healthcare provider can modify the intervention plan accordingly.[4]

Client feedback about their experience with the modifications and devices is invaluable. It helps ensure that the rehabilitation plan continues to meet their needs. If a particular assistive device is not comfortable or a modification is proving difficult to use, rehabilitation professionals should work with the client to find an alternative solution.

It is also vital to acknowledge and celebrate success. Celebrating success, like a person's reduced risk of falling, their ability to use a new mobility aid or navigating their home safely, can be a great motivator for continued engagement in the process.

Overcoming Barriers and Maintaining Long-Term Success

Fall prevention is not a one-time fix, but an ongoing process. Long-term success is more likely if a person's fear of falling is addressed, healthcare professionals understand a person's financial constraints, and motivation is maintained.

Addressing fear of falling: fear of falling is a significant barrier to participation in fall prevention strategies. If a client is too fearful to use a mobility aid or modify their environment, they are less likely to adhere to the plan. Providing gentle, supportive encouragement, working gradually with the client to build their confidence, acknowledging their concerns and taking small, manageable steps toward independence can be helpful strategies.[39]

Understanding the person’s financial constraints: cost can be a significant barrier. If a client cannot afford modifications or assistive devices, the healthcare provider must consider alternative options or seek funding to support the changes. Some non-profit organisations or government programmes may provide financial assistance for home modifications or medical equipment. It is essential to be aware of these resources and share them with the clients.[40]

Maintaining motivation: it is easy for clients to lose motivation over time, especially if they do not see immediate benefits. Regular check-ins and positive reinforcement can keep clients engaged. It is important to encourage clients to set realistic, achievable goals and celebrate their progress. The more they see the benefits of the strategies, the more likely they will stay committed to their safety plan.

Conclusion

Integrating fall prevention strategies into practice is a dynamic and individualised process. By conducting thorough assessments, collaborating with other healthcare professionals, and continuously adjusting the plan to meet the client’s needs, rehabilitation professionals can create a comprehensive fall prevention programme that enhances safety and promotes independence.

Fall prevention is not just about reducing the physical risk of falling. It is about empowering older adults to live independently and confidently in their own homes. Older adults can continue enjoying their lives with greater safety and security through fall prevention programmes that offer thoughtful modifications, introduce assistive devices, and provide the right support.

Resources

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Falls. World Health Organization. Geneva 2021. Available from https://www.who.int/news-room/fact-sheets/detail/falls [last access 27.4.2025]
  2. ↑ Alsaleh H, AlObaidi S, Alsaber A. Severity of Fall-Related Injuries and Older Persons' Hospital Admission in Kuwait: A Cross-Sectional Study J Frailty Aging. 2024;13(4):565-571.
  3. ↑ Alenazi AM, Alhwoaimel NA, Alqahtani BA, Alshehri MM, Alhowimel AS, Khunti K, Alghamdi MS. Multiple Long-Term Conditions and Disability are Independently Associated with Higher Risk of Fall Among Community Adults: a Cross-Sectional Study. Risk Manag Healthc Policy. 2024 May 27;17:1407-1416.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Peterko Y. Fall Prevention Strategies and Home Modification Course. Physiopedia Plus, 2025.
  5. ↑ Thakur N, Han CY. Country-specific interests towards fall detection from 2004–2021: an open access dataset and research questions. Data. 2021; 6(8):92.
  6. ↑ Iamtrakul P, Chayphong S, Jomnonkwao S, Ratanavaraha V. The Association of Falls Risk in Older Adults and Their Living Environment: A Case Study of Rural Area, Thailand. Sustainability. 2021;13(24):13756.
  7. ↑ Benichou O, Lord SR. Rationale for Strengthening Muscle to Prevent Falls and Fractures: A Review of the Evidence. Calcif Tissue Int. 2016 Jun;98(6):531-45.
  8. ↑ Medeiros HB, de Araújo DS, de Araújo CG. Age-related mobility loss is joint-specific: an analysis from 6,000 Flexitest results. Age (Dordr). 2013 Dec;35(6):2399-407.
  9. ↑ Mehta J, Czanner G, Harding S, Newsham D, Robinson J. Visual risk factors for falls in older adults: a case-control study. BMC Geriatr. 2022 Feb 17;22(1):134.
  10. ↑ Arshad Q, Seemungal BM. Age-Related Vestibular Loss: Current Understanding and Future Research Directions. Front Neurol. 2016 Dec 19;7:231.
  11. ↑ Paliwal Y, Slattum PW, Ratliff SM. Chronic Health Conditions as a Risk Factor for Falls among the Community-Dwelling US Older Adults: A Zero-Inflated Regression Modeling Approach. Biomed Res Int. 2017;2017:5146378.
  12. ↑ Xu Q, Ou X, Li J. The risk of falls among the ageing population: A systematic review and meta-analysis. Front Public Health. 2022 Oct 17;10:902599.
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  16. ↑ Falls Risk Factors. Queensland Health. Queensland Government. Available from https://www.health.qld.gov.au/__data/assets/pdf_file/0024/428460/33383_d.pdf [last access 29.4.2025]
  17. ↑ Blanchet R, Edwards N. A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: results of a scoping review. BMC Geriatr. 2018 Nov 9;18(1):272.
  18. ↑ Thies SB, Bates A, Costamagna E, Kenney L, Granat M, Webb J, Howard D, Baker R, Dawes H. Are older people putting themselves at risk when using their walking frames? BMC Geriatr. 2020 Mar 4;20(1):90.
  19. ↑ 19.0 19.1 Avin KG, Hanke TA, Kirk-Sanchez N, McDonough CM, Shubert TE, Hardage J, Hartley G; Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Management of falls in community-dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Phys Ther. 2015 Jun;95(6):815-34.
  20. ↑ Lamb S. Prevention of Falls Network Europe and Outcomes Consensus Group. Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe Consensus. JAGS 2005; 53 (9); 161-22.
  21. ↑ Fisher AG. Occupational Therapy Intervention Process Model: A model for planning and implementing top-down, client-centred, and occupation-based interventions. Ft. Collins, CO: Three Star Press; 2009.
  22. ↑ Falls prevention. Available from https://www.ageconcern.org.nz/Public/Public/Info/Health_Topics/_Falls_Prevention.aspx [last access 28.4.2025]
  23. ↑ Goddard KS, Hall JP, Greiman L, Koon LM, Gray RC. Examining the effects of home modifications on perceptions of exertion and safety among people with mobility disabilities. Disabil Health J. 2024 Feb 10:101590.
  24. ↑ 24.0 24.1 Campani D, Caristia S, Amariglio A, Piscone S, Ferrara LI, Barisone M, Bortoluzzi S, Faggiano F, Dal Molin A; IPEST Working Group. Home and environmental hazards modification for fall prevention among the elderly. Public Health Nurs. 2021 May;38(3):493-501.
  25. ↑ Stark S, Keglovits M, Somerville E, Hu YL, Barker A, Sykora D, Yan Y. Home Hazard Removal to Reduce Falls Among Community-Dwelling Older Adults: A Randomized Clinical Trial. JAMA Netw Open. 2021 Aug 2;4(8):e2122044.
  26. ↑ American Occupational Therapy Association.(2020) Occupational Therapy Practice Framework: Domain and Process (4th ed.). Am J Occup Ther. 2020;74(Suppl 2):7412410010.
  27. ↑ VCU Occupational Therapy. Falls Prevention at Home. Available from: https://www.youtube.com/watch?v=j6AWFmVxPFs [last accessed 3/5/2025]
  28. ↑ Giovannini S, Brau F, Galluzzo V, Santagada DA, Loreti C, Biscotti L, Laudisio A, Zuccalà G, Bernabei R. Falls among Older Adults: Screening, Identification, Rehabilitation, and Management. Applied Sciences. 2022; 12(15):7934.
  29. ↑ Wiseman JM, Stamper DS, Sheridan E, Caterino JM, Quatman-Yates CC, Quatman CE. Barriers to the Initiation of Home Modifications for Older Adults for Fall Prevention. Geriatr Orthop Surg Rehabil. 2021 Mar 30;12:21514593211002161.
  30. ↑ Yao L, Kridli S. Cultural Sensitivity of a Community-Based Falls Prevention Program Targeting Older Arab American. Open Journal of Nursing. 2018; 8: 835-847.
  31. ↑ Sherrington C, Whitney J, Lord S, Herbert R, Cumming R, Close J. Effective exercise for the prevention of falls: A systematic review and meta-analysis. J Am Geriatr Soc. 2008; 56 (12): 2234 - 43.
  32. ↑ Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, Cumming RG, Herbert RD, Close JC, Lord SR. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. British journal of sports medicine. 2017 Dec 1;51(24):1750-8.
  33. ↑ Simpkins C, Yang F. Muscle power is more important than strength in preventing falls in community-dwelling older adults. J Biomech. 2022 Mar;134:111018.
  34. ↑ Casas-Herrero A, Cadore EL, Zambom-Ferraresi F, Idoate F, Millor N, Martínez-Ramirez A, Gómez M, Rodriguez-Mañas L, Marcellán T, de Gordoa AR, Marques MC, Izquierdo M. Functional capacity, muscle fat infiltration, power output, and cognitive impairment in institutionalized frail oldest old. Rejuvenation Res. 2013 Oct;16(5):396-403.
  35. ↑ Jiménez-Lupión D, Chirosa-Ríos L, Martínez-García D, Rodríguez-Pérez M, Jerez-Mayorga D. Effects of power training on functional capacity related to fall risk in older adults: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2023 Sep;104(9):1514-25.
  36. ↑ Ley C, Putz P. Efficacy of interventions and techniques on adherence to physiotherapy in adults: an overview of systematic reviews and panoramic meta-analysis. Syst Rev. 2024 May 21;13(1):137.
  37. ↑ NHS Morecambe Bay CCG. Falls Prevention Exercises. Available from: https://www.youtube.com/watch?v=8oDVaYs9w7A [last accessed 3/5/2025]
  38. ↑ Ang SGM, O'Brien AP, Wilson A. Carers' concern for older people falling at home: an integrative review. Singapore Med J. 2020 May;61(5):272-280.
  39. ↑ Chandrasekaran S, Hibino H, Gorniak SL, Layne CS, Johnston CA. Fear of Falling: Significant Barrier in Fall Prevention Approaches. Am J Lifestyle Med. 2021 Nov 5;15(6):598-601.
  40. ↑ Fernandes JB, Fernandes SB, Almeida AS, Vareta DA, Miller CA. Older Adults' Perceived Barriers to Participation in a Falls Prevention Strategy. J Pers Med. 2021 May 23;11(6):450.
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