Falls in Older People

Introduction

Falls are the commonest cause of injury and injury-related death in people over 65 in the UK, and a leading cause of emergency hospital admission in this age group. Around a third of people over 65, and around half of people over 80, fall at least once a year, and falls are strongly associated with subsequent loss of independence, care home admission and mortality, quite apart from the immediate injury.¹

Falls are rarely due to a single cause. They typically result from the interaction of several risk factors at once - an older person with mild gait instability, on a sedating medication, with poor lighting at home, is at far higher risk than any single one of those factors alone would suggest. This multifactorial model underpins both assessment and the most effective interventions.

Underlying this is the age-related decline in the three systems that maintain balance - vision, proprioception and vestibular function - together with the loss of muscle strength and power that accompanies sarcopenia. A younger person can compensate for a perturbation with a rapid corrective step; an older person with reduced lower limb power and slowed reaction time cannot generate that response in time, so a stumble that would be trivial at 40 becomes a fall at 80.

Categorising risk factors

Case-finding: ask about every fall

NICE recommends that all older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year, given how often falls go unreported unless specifically asked about - patients often do not volunteer a fall unless it caused significant injury, sometimes from fear of the implications (e.g. losing independence or driving).³

Anyone reporting a fall should be asked about frequency, context, and associated symptoms. Anyone presenting after a fall, or with recurrent falls in the past year, or with a gait or balance abnormality, should be offered a multifactorial falls risk assessment.

The post-fall history

• Circumstances: where, when, and what the patient was doing - a fall on standing suggests postural hypotension, a fall on turning suggests balance/vestibular impairment, a fall while reaching suggests gait instability
• Prodromal symptoms: any warning (light-headedness, palpitations, chest pain) before the fall, which point towards a cardiovascular cause
• Loss of consciousness: whether the patient can recall hitting the ground, and any witness account - true loss of consciousness raises the possibility of syncope or seizure rather than a purely mechanical trip
• Injury sustained and whether the patient was able to get up unaided, and how long they were on the floor - a 'long lie' (over an hour) carries specific risks (pressure injury, hypothermia, rhabdomyolysis, pneumonia) and independently predicts poor outcome
• Frequency and pattern of previous falls
• Full medication review, specifically screening for sedatives, antihypertensives and other falls-associated drugs
• Functional impact: fear of falling, activity avoidance since the fall, and impact on confidence and independence

Examination and multifactorial assessment

Postural (orthostatic) hypotension

Defined as a drop in systolic blood pressure of 20 mmHg or more, or diastolic of 10 mmHg or more, within 3 minutes of standing from lying (or an absolute systolic under 90 mmHg). It is common in older people, exacerbated by antihypertensives, diuretics, and autonomic dysfunction (e.g. in Parkinson's disease or diabetes), and is a readily identifiable, modifiable falls risk factor that is easy to miss if lying and standing readings are not both taken.

Medications most associated with falls

Medication is the most readily modifiable falls risk factor, and reviewing it is often the single highest-yield intervention available in a falls assessment. Risk rises with the total number of drugs and, particularly, with the number of falls-risk-increasing drugs (FRIDs) taken concurrently.

Investigations

• Lying and standing blood pressure
• ECG, particularly if syncope, palpitations, or an unexplained fall without a clear mechanical trigger
• Bloods: FBC (anaemia), U&Es (dehydration, hyponatraemia - itself a falls risk), glucose (hypo/hyperglycaemia), B12/folate, calcium, TSH
• Further cardiac investigation (24-hour ECG, echocardiogram, tilt-table testing) where syncope is suspected and initial assessment is inconclusive
• Bone health assessment (DEXA/FRAX), since falls and fracture risk are managed together - see ⁴

Management: multifactorial intervention

The strongest evidence supports multifactorial intervention - addressing several identified risk factors together, tailored to the individual - over any single intervention in isolation.³

• Strength and balance training: structured, progressive exercise (e.g. Otago exercise programme) is the single most evidence-based individual component, reducing both falls rate and injurious falls
• Medication review and rationalisation, reducing or stopping high-risk drugs where possible - see the multimorbidity and deprescribing approach in ²
• Correcting postural hypotension where identified - reviewing causative medication, ensuring adequate hydration, and considering specific measures (e.g. compression stockings) if needed
• Vision correction: updated glasses prescription, cataract surgery referral where indicated
• Home hazard assessment and modification, typically via occupational therapy - removing trip hazards, improving lighting, installing grab rails and appropriate equipment
• Footwear advice
• Vitamin D and calcium supplementation where deficient, supporting bone health alongside falls prevention
• Addressing fear of falling directly, through graded activity and confidence-building rather than allowing avoidance to drive deconditioning and further risk

Cardiovascular causes of falls

A proportion of apparently 'mechanical' falls in older people are actually syncopal or presyncopal events, and missing a cardiac cause is the most dangerous error in falls assessment. Older patients frequently have amnesia for the loss of consciousness itself and will describe simply having 'ended up on the floor', so the absence of a reported blackout does not exclude syncope.

Managing the long lie and its consequences

A prolonged period on the floor after a fall (a 'long lie') is an independent marker of poor prognosis and carries specific risks that should be actively screened for: pressure injury, hypothermia, dehydration, rhabdomyolysis (check creatine kinase), pneumonia (from aspiration or prolonged immobility), and significant psychological impact including fear of falling again. Ask explicitly how long the patient was on the floor and whether they were able to raise the alarm - this also identifies whether a personal alarm or other assistive technology would reduce risk in future.

Red flags

Prognosis

Falls risk is highly modifiable: well-delivered multifactorial intervention, particularly strength and balance training, meaningfully reduces both the rate of falls and the rate of injurious falls in trial evidence. Without intervention, falls tend to recur and often precipitate a downward spiral of reduced confidence, activity avoidance, deconditioning and further falls - which is why prompt, structured assessment after even a single fall, rather than waiting for recurrence, is now the recommended standard.

The consequences of falls extend well beyond the immediate injury. Around 1 in 20 falls in older people results in a fracture, and hip fracture in particular carries substantial mortality and loss of independence. But even a fall without injury frequently causes lasting harm through fear of falling, which drives activity avoidance, accelerating the muscle weakness and balance impairment that caused the fall in the first place - a self-reinforcing cycle that ends in reduced independence and, often, care home admission.