Falls in Older People

Background

About a third of community-dwelling people over 65 fall each year, rising to about half of those over 80 and half of residential aged care residents. 40–60% of falls cause injury and 10–15% cause a serious injury such as hip fracture. Hip fracture carries a significant mortality — 10% within a month, 20% within six months, 33% within a year — and only around 20% of older people regain full mobility after a fall. Falls also drive loss of confidence, functional decline, social withdrawal, depression, and a “long lie” (unable to get up unassisted, risking hypothermia, pressure injury, rhabdomyolysis and dehydration) — ask about near-falls as well as actual falls, since they carry similar risk.

Screening

Screen all older people annually for fall risk using a validated tool — age 65+ generally, or 50+ for Aboriginal and Torres Strait Islander peoples. A quick screen identifies who needs a detailed assessment; act on the result by risk tier. Falls screening is one of the required elements of the MBS 75+ Older Person’s Health Assessment — see Preventive Activities & Health Assessments by Age.

• Low risk (no falls in the past year): encourage ongoing exercise (community classes or supervised home exercise)
• Increased risk (1+ falls in the past year): home and community safety education plus a tailored exercise programme
• High risk (2+ falls in the past year): a comprehensive fall risk assessment by a health professional to inform a tailored multifactorial prevention plan — exercise, home safety, assistive devices, medication review, vision, and addressing fear of falling, anxiety, depression or cognitive impairment as relevant

Risk factors

Intrinsic:

• Advanced age, especially ≥80; female sex; a prior fall
• Cognitive impairment and dementia — particularly Lewy body and Parkinson’s dementia, where gait disturbance adds risk
• Gait or balance disorder, Parkinson’s disease, stroke, peripheral neuropathy, muscle weakness
• Chronic pain and arthritis
• Vision impairment
• Orthostatic hypotension, neurocardiogenic syncope, arrhythmia, valvular disease
• Depression, undernutrition, urinary incontinence

Extrinsic:

• Inappropriate footwear or clothing
• Physical or chemical restraint
• Cluttered or poorly lit environment; household pets
• Alcohol
• Polypharmacy (>3 medicines) — particularly benzodiazepines, antipsychotics, antihypertensives, antidepressants, anticholinergics, class IA antiarrhythmics and hypoglycaemics

Assessment

History: the fall’s circumstances and mechanism, medications, acute and chronic medical conditions, mobility level, and any near-falls.

Examination: gait (postural stability, stride, sway, turning), Romberg test (positive in proprioceptive or vestibular dysfunction), timed up-and-go (stand, walk 3 metres, turn, return, sit — normal under 10 seconds, though the quality of movement matters more than the time), and as needed single-leg stance, sternal push, shoulder tug, tandem/heel-toe gait, and functional reach. A vision test is part of the assessment — a physiotherapist is often best placed to do a detailed gait and balance assessment and refer on.

Consider: cervical myelopathy, peripheral neuropathy, lumbar stenosis, cerebellar ataxia, Parkinson’s disease, dementia, vasovagal syndrome, orthostatic hypotension, carotid sinus hypersensitivity, arrhythmia, and vestibular disease/cervical vertigo.

Investigations where indicated: FBC, UEC, calcium/magnesium, HbA1c, TFTs, LFTs, B12/folate, ECG, echocardiogram, vitamin D, and tilt testing.

Prevention

Exercise is the best-evidenced single intervention. A Cochrane review of 108 trials (23,407 participants) found exercise reduces the rate of falls by 23% and the number of people who fall by 15%; programmes targeting balance and functional mobility work best, multi-component programmes (balance/functional plus resistance) may work better still, and Tai Chi also reduces falls. Programmes should run 2–3 hours/week ongoing, designed or supervised by a physiotherapist, exercise physiologist or appropriately trained instructor for anyone with 1 or more falls in the past year — cognitive impairment or mild-to-moderate dementia is not a reason to withhold exercise if the person is willing.

Medication review. Facilitate a collaborative GP/pharmacist medication review to minimise psychotropics and other fall-risk medicines. Review at least yearly, and again after any fall, new medicine, dose change, health status change, or hospital admission — start fall-risk medicines at an age-appropriate dose, titrate slowly, and document the plan for review.

Vision. Refer for cataract surgery when clinically significant visual impairment is primarily cataract-related. Active older people do better with single-lens distance glasses than bifocals/multifocals/progressives when mobilising outdoors, and a large prescription change should be limited where possible. Encourage annual optometry review.

Vitamin D. Support daily or weekly vitamin D supplementation for older people who are deficient or have low sun exposure — avoid high monthly/yearly mega-doses, which increase fall risk. Vitamin D helps mainly through muscle strength and bone density, not a direct effect on balance.

Postural hypotension: adequate hydration, liberalise dietary salt where appropriate, small frequent meals, slow postural changes after rising or eating, and review of contributing medications (diuretics, antihypertensives).

Home and environment: occupational therapy home assessment (flooring, furniture, lighting, handrails), podiatry for foot care and footwear, hearing assessment, and addressing incontinence and undernutrition.

Hip protectors reduce fracture risk by absorbing impact, but only help if the person actually wears them consistently — prioritise those who fall frequently, have osteoporosis or a low BMI, and check fit and skin integrity regularly; discontinued use due to discomfort is common. Manage osteoporosis (see Osteoporosis) as a parallel fracture-prevention strategy.

Post-fall assessment

After any fall: take a history of the mechanism and preceding symptoms, identify injury sites (consider head injury observations), assess whether a significant period of immobility followed (a marker for closer monitoring), examine vision, gait, balance and lower-limb joints, do a basic neurological exam, and check cardiovascular status including postural blood pressure. Use the post-fall assessment to identify what caused this fall and prevent the next one — not just to treat the immediate injury.

Referral

Refer to physiotherapy for a detailed gait and balance assessment and exercise prescription in anyone with 1 or more falls in the past year.

Refer urgently for red flags on the post-fall examination:

• New focal neurology
• Suspected fracture
• Head injury with loss of consciousness, or on anticoagulation
• New arrhythmia or a significant orthostatic drop

A high-risk older person (2+ falls a year) needs coordinated multidisciplinary care — general practice, physiotherapy, occupational therapy, pharmacy and, where relevant, geriatric medicine.