Falls and Falls Prevention in Older Adults

Original Editor - Roberta Villar Baffa Capobiango Top Contributors - Roberta Villar Baffa Capobiango, Merve Demirayak, Kim Jackson, Khloud Shreif, Vidya Acharya, Carina Therese Magtibay, Tolulope Adeniji, Angeliki Chorti, Mohit Chand, Mohamed A Hassanin and Alexandra Stead

Definition

According to the World Health Organisation (WHO), a fall is defined as an event that results in a person coming to rest inadvertently on the ground or floor or other lower level. Falls and fall-related injuries are associated with increased mortality and morbidity.

Falls are a major health concern for older people (65+). In Australia, falls were the leading cause of injury hospitalisations in 2023–24 (43% of all injury hospitalisations) and the leading cause of injury deaths in 2022–23 (43% of all injury deaths). Females had higher falls hospitalisation rates, while males had higher falls death rates.

The financial impact of falls is also significant, for people aged 65 years or older, the average health system cost per fall injury in the Republic of Finland and Australia are US$ 3611 and US$ 1049 respectively.

Causes

Although falls are common within this population, they cannot be considered as normal. Falls can be caused by intrinsic and extrinsic factors.

Intrinsic factors are those related to the ageing process, including:

• Changes in mobility, balance, and reflexes
• Sarcopenia, functional decline, and reduced muscle strength
• Frailty
• Cognition issues , delirium and dementia
• Vision and hearing loss
• Urinary incontinence
• Medical conditions, inclusive of untreated pain, vestibular issues, cardiorespiratory issues. The most common cardiovascular problems of recurrent falls are postural hypotension, vasovagal syndrome, and arrhythmias.
• Fear of falling and previous falls
• Gender (older females are more prone to falls than older males)
• Social isolation
• Medications
• Vitamin D deficiency

Extrinsic factors are environmental, inclusive of a cluttered environment, low lighting, unsafe footwear, uneven surfaces, steps, slippery surfaces, and home hazards such as rugs and mats.

Most factors, both extrinsic and intrinsic, are modifiable and preventable with evidence-based medical and allied health intervention. Best practice on management of falls and injury prevention include a comprehensive risk and functional assessment of the individual and the implementation of standard and individualised falls prevention strategies.

As a result of falls, older adult who experience a fall or multiple falls may show an important cognitive decline. However, relation between fall and cognition is bidirectional: ongoing cognitive decline may cause fall or events of fall may accelerate cognitive impairment. The most common outcomes of falls in older adults are hip fractures, arm and head injuries.

Risk Assessment

Falls risk screening is a process of estimating an individual’s risk of falling and classifying people as being at either low or increased risk. Depending on where the individual lives, either in the community or in a residential aged care facility, their age, co-morbidities, previous falls history, and other factors, as seen above, the tools used to screen falls risk will likely differ, as individuals with different characteristics and backgrounds may have different factors impacting on their falls risk.

NICE recommends asking older people whether they have fallen in the last year and offering a comprehensive falls assessment and management to people who have fallen in the last year and meet specific criteria (for example, frailty). For those who have fallen but do not meet criteria for comprehensive assessment, assess gait and balance. If gait or balance is impaired, offer a falls prevention exercise programme and consider a home hazard assessment

• An older adult who does not have a falling history or a single non-severe fall or no gait or balance problem - "at low risk of fall"

• An older adult who have a single non-severe fall but also have gait and or balance problems - "intermediate risk of fall"

• An older adult with a fall and one or more of the following characteristics: accompanying injury, multiple falls in the previous 12 months, having frailty, unable to get up after the fall without help for at least an hour and accompanied loss of consciousness - "high risk of fall"

For community-dwelling older adults

• Falls Risk for Older People in the Community (FROP-Com)
• Timed Up and Go Test (TUG)
• Sit-to-Stand Tests, such as Five times sit-to-stand and 30 seconds sit-to-stand test
• Environmental and equipment assessment: look for hazards, lighting, barriers for mobility, are the available equipment suitable?

For older adults living in residential aged care

• FRAT
• Timed Up and Go Test
• Sit-to-Stand tests, such as Five times sit to stand and 30 Seconds Sit to Stand Test
• Environmental and equipment assessment also applies

For people with stroke

• Single question survey on FoF
• Falls Efficacy Scale
• Activities-specific Balance Confidence Scale

You may see the below as a guidance from World Falls Guidelines on assessment of falls in elderly patients;

Interventions

Falls prevention strategies can be standard and individualised, depending on an individual's needs. An effective exercise programme, inclusive of strength and balance training are proved to reduce falls risk as per WHO guidelines in 2020. The OTAGO program has shown to be beneficial to improve of balance in community-based individuals. Older adults at increased falls risk should be offered an exercise program for falls preventions. Intervantions to reduce falls include:

• Hazards removal, adequate lighting or environment modification
• Well-fit and appropriate footware
• Medication review
• Equipment review (ie gait aid, transfer aid - are they suitable? need repair/ replacement?)
• Cognitive-related interventions
• Opportunities for engagement such as activities to prevent social isolation
• Vitamin D supplementation
• In residential aged care facilities, consider frequent sightings, staff education, toilet schedule (please note toilet schedule may aggravate incontinence issue - assess risk and benefits), diversional therapy, use of alarms and sensors, and hip protectors (please note that before recommending hip protectors, clinicians should determine whether they are suitable for a particular individual, which is also part of your risk assessment).

Related Pages

Physical Activity in Ageing and Falls

Falls

Falls Risk Assessment Tool (FRAT)

Falls and Dementia