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There is no universal consensus among clinicians, researchers or persons who fall, on the definition of a fall. A fall has been defined as an involuntary change from standing, walking, bending, reaching, etc. to no longer being supported by both feet, accompanied by (partial or full) contact with the ground or floor.1 The World Health Organization defines a fall as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.2 Many past research studies have not specified an operational definition of falls, and the interpretation of what constitutes a fall may be different among researchers, research participants, healthcare professionals, clinicians, patients, and caregivers.3 This inconsistency can bring into question the validity of research findings, the ability to identify falls and risk factors, and accurately and appropriately target interventions to prevent falling. In communication between health care providers and seniors, a consistent and specific definition of a fall increases the possibility for early detection of seniors in greater need of care and services. Research reports and prevention programs should always provide an operational definition of a fall.4

Other related definitions found in the literature on falls include:

Injurious fall: A fall associated with any detectable residual adverse physical change persisting after the fall.1 The definition and severity of injurious falls may vary among researchers and healthcare professionals (ex. falls associated with pain, bruises, or abrasions versus falls only resulting in radiographically confirmed fractures). This can lead to substantial differences in study results, which limits the comparability of findings. Similar to the definition of a fall, use of a standardized methodology including a comprehensive system for categorizing and defining injurious falls and standardized methods of collecting and reporting on injurious falls data has been recommended.5

Syncopal fall: A fall associated with or resulting from a loss of full consciousness, such as from fainting or a seizure. Most falls are non-syncopal.1


The etiologies of an individual fall are not always obvious to the person falling or to others and most falls are unobserved and under-recognized. Falls in older persons are usually multifactorial, resulting from the accumulation of multiple modest impairments, rather than any single deficit.1 It may be difficult to know the precise etiology or “cause” of any given fall. Therefore, when investigating the etiology of falls, it may be better to identify the possible factors that an individual may have and to determine what factors could have actively contributed to the fall.

The most important categories of contributing factors include:

  • Intrinsic: Examples – age >80 years, prior fall in the past year, lower extremity muscle weakness, gait/balance deficits, cognitive impairment, depression, visual or hearing impairment, poor health status. Poor health status, symptoms such as syncope, dizziness as well as specific diagnoses including Parkinson’s, stroke, and/or peripheral neuropathy.1,6
  • Extrinsic: Polypharmacy (>4; especially antihypertensives, benzodiazepines and sedatives), environmental hazards (e.g., slippery surfaces, obstacles, stairs, poor lighting, unstable furniture, clutter, loose throw rugs, pets), ill-fitting clothing, and inappropriate footwear.1,6
  • Situational: inattention, divided attention, rushing, impulsivity, poor safety awareness, extreme or unusual activity, unfamiliar setting, and risk-taking behavior.1

Epidemiology including risk factors and primary prevention

The population is rapidly aging, with the number of older adults projected to outnumber children by 2030. As the elderly population grows, the number of elderly patients experiencing traumatic injuries increases.7 Unintentional injuries are the 5th leading cause of death in older adults; Falls are responsible for 2/3rd of the mortalities from unintentional injuries. 75% of fall related deaths affect the elderly.1 Older adults are hospitalized for fall-related injuries five times more than they are for injuries from other causes. Risk of fracture is 5%; risk of other injuries 10-20%. Hip fracture mortality is approximately 15% and is the seventh leading cause of death in older persons.1,6

Approximately 1/3rd of community-dwelling people over the age of 65 fall annually; one half of this group falls multiple times.8 The true incidence of falls in the elderly is likely underestimated due to limited reporting. Approximately 25% of falls in older adults result in moderate to severe injuries (bone fracture, head injury).9 Each year, 3 million older adults are treated in emergency departments for fall injuries and over 800,000 older patients a year are hospitalized because of a fall injury. More than 300,000 older people are hospitalized annually for hip fractures each year and >95% of these hip fractures are caused by falling. Falls are the most common cause of traumatic brain injuries.8

Falls among adults age 65 and older are very costly. In 2015, the annual U.S. medical costs related to non-fatal fall injuries was $50 billion and $754 million was spent on costs related to fatal falls.10 As the number of older Americans increase, the number of fall injuries and the cost to treat these injuries is expected to soar.

Risk of falling in a nursing home is nearly three times that of older persons living in the community, and this population has the highest fall-related injury percentage. Elderly hospitalized patients have 35-40% fall incidence.

Older adults who fall have a two- to six-fold increased risk of falling again. Also, risk of falling increases with age non-linearly as health deteriorates; thus, an 80-year-old may have 8 times the risk of a 65-year-old.1

Gait and balance disorders affect 20-50% of individuals >65 yrs.

Table 1: Risk Factors for Falls9

Fear of falling can cause significant social isolation, institutionalization, and depression. Low self-efficacy/self-esteem is increased among fallers. Falls result in an increased incidence of disability; the presence of a disability increases fall risk.11,12


Falls occur as a result of a complex interaction amongst intrinsic, extrinsic, and situational factors. As the number of risk factors increase, the likelihood of falls is also increased.

Medical comorbidities like diabetes mellitus (DM), Parkinson’s disease, incontinence, depression, or cognitive impairment/dementia increase the risk of falls. Weak knee extensors and ankle dorsiflexors, decreased ankle flexibility, impaired proprioception, visual impairment (e.g., decreased visual acuity and altered depth perception), and weight loss/low body mass index (BMI) are all associated with falls.9 Postural hypotension leads to loss of balance, and is usually caused by dehydration, concomitant medication use, or autonomic neuropathy. Common cardiovascular disorders associated with falls include carotid sinus hypersensitivity, vasovagal syndrome, bradyarrhythmia, and tachyarrhythmia.13 Previous studies have indicated that vitamin D deficiency can impair muscle strength and neuromuscular function.14,15

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  • New onset/acute: May be related to an isolated non-recurring event or may occur in relatively short-lived clusters, perhaps from an acute illness or exposure to a new drug or environmental hazard.16
  • Subacute: Falls may increase in frequency over time, possibly due to the progression of a disease or disability.16
  • Chronic/stable: People with chronic, recurrent falls have the highest rate of injurious falls and fractures and seem to occur in people with multiple co-morbidities and depressive symptoms.16 Older persons should be screened at least annually regarding falls, and a multifactorial intervention initiated as appropriate.9

Specific secondary or associated conditions and complications

Complications from falls include lacerations, fractures, spinal cord/head injuries, hypothermia, pneumonia, pressure ulcers, rhabdomyolysis, venous thromboembolism, and dehydration. Falls can also lead to hospitalization, greater dependence, loss of autonomy, and depression as well as nursing home residency. Persons hospitalized for falls are more likely discharged to nursing homes and to need more in-home services; they are less likely to regain pre-injury mobility status. Fear of falling alone can result in functional decline.1

Essentials of Assessment


All older persons should be asked at least annually if they have fallen.9,14 A positive response to falls screening questions (>2 falls in past 12 months, medical evaluation for an acute fall, difficulty with walking or balance) should prompt a multifactorial falls risk assessment.6,9

Focused history including when and how the fall occurred, location of the fall, if patient has fallen multiple times is there a pattern, and any fall associated symptoms (syncope, dizziness, vertigo, generalized or lower limb weakness, pain, visual problems etc.)5 Conduct a medication review including over-the-counter and herbal medications. Social history should include alcohol use, activity history, and use of assistive device.1,6

Physical examination

The physical examination should focus on the following areas:

  • Vital signs: Pulse rate/rhythm, blood pressure with orthostatic assessment
  • Vision: Acuity using Snellen chart.1
  • Neurologic:1,14
    • Mental status (e.g., Short Portable Mental Status, Mini Mental Status Examination), cranial nerve function
    • Motor (especially lower extremities)
    • Sensation (proprioception/vibration)
    • Reflexes (e.g., hyperreflexia)
    • Cerebellar function
    • Balance
    • Gait/Station observational analysis
    • Romberg test
  • Musculoskeletal: Lower and upper extremity joint range of motion, feet, and footwear evaluation1,14

Functional assessment

Functional evaluation: Many functional performance-based tests are available. However, there is no conclusive evidence supporting one test over another.6,17

Timed Up & Go (TUG)18

  • Patient attempts to rise from chair, walk 3 meters and then return.
  • The Timed Up & Go version times this same task performance
    • <10 sec – independent
    • <20 secs – independent with transfers, stairs, and outdoors
    • 20-29 sec – variable balance, gait speed, functional capacity
    • ≥30 secs – needs help with chair, toilet transfer & stairs,
  • Pros: simple, quick, and inexpensive to perform. Assessment includes some functional task data
  • Cons: There is limited change sensitivity data6,19

Tinetti Balance & Gait Index20

  • Functional performance test with a 9-item balance scale (max. score = 16); and a 7-item gait scale (max. score = 12).
    • Balance tasks include sitting & standing balance with eyes both open and closed, sitting & arising from chair, and performing a 360-degree turn.
    • Gait test assesses initiation, step symmetry, length and height, foot clearance, trunk sway, path and stance.
  • Pros: Simple and widely used. Assessment does include some functional tasks.
  • Cons: Subjective scoring.19

Berg Balance Scale (BBS)21

  • Consists of 14 items assessing ability to stand and maintain standing despite internally produced perturbations. Items are scored on 0 (unable) to 4 (safely done) scale (max. score = 56)
    • In elderly, score >45 indicates a low fall risk.
    • Change of 8 points indicates a genuine function change for ADL dependent older people.
  • Good inter- and intra-rater reliability
  • Pros: Easy, quick (10-15 min.) to administer. This test is familiar to and is typically performed by most physical therapists.
  • Cons: Low validity and sensitivity for non-ambulatory stroke patients.19

Direct observation of the patient’s independence with basic Activities of Daily Living (ADL), including use of gait aids/assistive equipment.14 Assess perceived functional ability and fear of falling.14 If warranted, assess for depression (Geriatric Depression Scale).

Laboratory studies

  • Complete Blood Count (CBC) to evaluate anemia, leukocytosis, platelet abnormalities.
  • Basic Metabolic Panel to evaluate electrolytes and renal function.
  • Albumin for nutritional status.
  • Glucose and HgbA1c for evaluation of diabetes.
  • Thyroid Stimulating Hormone (TSH), Vitamin B12 and D levels for thyroid and vitamin status.
  • Urinalysis, if suspicion of urinary tract infection.
  • Check for toxicity of medications, such as digoxin or anticonvulsants.


A DEXA scan may be performed to evaluate bone mineral density, if warranted.

Other imaging may be performed as necessary to evaluate abnormalities/deficits noted by history, physical examination, and/or laboratory testing.

Supplemental assessment tools

One-Leg Stance (OLS) Test: Ask patient to stand unassisted on one limb of their choice; record stance time from when foot leaves floor until it touches again

  • Stance >30 sec indicates very low fall risk; stance <5 sec is good predictor of injurious fall in elderly persons.
  • Good inter-rater reliability but limited evidence for reliable change over time measurement.
  • Pros: very simple and quick
  • Cons: accurate but nonspecific as prolonged OLS not a functional activity19

Sharpened (modified) Romberg Test: Measures static standing balance by assessing the length of time the patient can stand heel-to-toe with arms across chest and eyes closed for 60 seconds over a series of 4 trials.

  • Perfect score is 240 seconds.
  • Pros: easy, and inexpensive to administer; timing adds objectivity
  • Cons: non-specific for a particular problem, pathway or system; no functional information19

Functional Reach (FR): Ask patient to stand parallel to a wall-mounted yardstick with arms held at 90 degrees of flexion. The patient is instructed to reach forward maximally without taking a step. The distance change from start position is the patient’s functional reach.

  • Reach ≤ 6 inches predicts a fall.
  • Pros: Simple, inexpensive to administer. There are established reliability and validity data. This test is also sensitive to change over time.
  • Cons: This test yields limited functional information.19

Elderly fall screening test: sensitivity 93%, specificity 78%. Dynamic Gait Index: sensitivity 85%, specificity 38%. Morse Falls Risk Assessment (acute care or acute rehabilitation setting): predicts likelihood that a patient will fall based off six variables – history of falls, secondary diagnoses, ambulatory aids, intravenous therapy, gait and mental status; quick and easy to score. Long-term care minimum dataset (LTCMDS) for all aspects of care in Nursing Home settings: captures falls and injury histories at regular intervals in the resident’s day.

Early predictions of outcomes

Primary sequelae of falls include injuries and post-fall anxiety. There is a four-fold greater fracture rate with falls in stroke patients than in the general population.

Multifactorial risk assessment and a multifactorial intervention focused on identified deficits and risk factors are effective in reducing falls. However, few studies have shown benefits for fall prevention programs on quality of life.


Indoor environmental hazards, including broken furniture or lamps, flooring issues, and other tripping hazards inside the home, may be an important indicator for an elevated risk of falls as older adults spend most of their time inside the home. Older women tend to fall more indoors, and older men fall more outdoors. Evaluation, identification and removal of environmental hazards in the home should be done by trained individuals and is recommended to help prevent falls, although study results are mixed.6,14 A recent randomized clinical trial found no evidence that an occupational therapist-delivered home assessment and modification reduced falls in community-dwelling people aged 65 years and over compared with usual care.22 However, a recent systematic review found that home/environmental interventions can be effective in reducing the number of individuals who fall and the frequency of falls in community-dwelling people aged 65 and over. The literature suggests that using slip-resistant flooring, adequate lightning, appropriate furniture, and an adequate and convenient layout2,23 may be the most helpful modifications.24 Also, one study suggests the importance of a gender-specific environmental context of older adults and evidence regarding a differential effect of environmental factors on falls for women and men, which could potentially be used for environmental and gender specific educational interventions to prevent falls.23

Social role and social support system

The older person’s living situation and social support may significantly impact their fall risk. Supportive, attentive family, friends, neighbors and/or caregivers may assist in reducing falls.

However, this may result in significant caregiver burden if 24-hour supervision and/or assistance with ambulation, ADLs, shopping, housekeeping, and financial oversight are required. Telecommunication alarm devices can facilitate safety.

Professional issues

State legislatures have been establishing protocols and programs to address falls by providing funding, setting up task forces, and enacting laws to protect seniors. Between 2015 and 2022, twenty-three states have had proposed or passed legislation related to or establishing fall prevention programs and the reporting of falls; these include AK, AZ, CA, CO, CT, DC, HI, IL, IA, MA, MI, MN, NV, NJ, NM, NY, PA, TX, UT, VA, WA, WV, and WI.25

Rehabilitation Management and Treatments

Available or current treatment guidelines

Initial management entails a multifactorial intervention to address specific contributing risk factors or impairments customized to an individual patient’s multifactorial risk assessment. A sound general management strategy should be to fix things that are identified and fixable, help the person to compensate for, substitute for, or avoid non-fixable conditions or factors

Interventions include the following:

  • Medications: Eliminate, or reduce the dose of high-risk medications especially psychotropic medications (e.g., sedative hypnotics, anxiolytics, antidepressants, antipsychotics)1,6,9 Management of contributing neuromuscular and musculoskeletal problems
  • Exercise: Initiate a personalized exercise program including strength, balance, gait and coordination training6,9,26 Formal therapy may be needed for home exercise program to address aforementioned exercises, transfer and function training, and training with a gait aid. Exercise programs reduce injury and non-injury fall rate by 15-50% with better outcomes in higher intensity exercise programs1,27
  • Correct vision impairments (e.g., cataract removal). Advise patients to not wear multifocal lenses while walking1,9
  • Correct cardiovascular problems (e.g., postural hypotension, abnormal rate/rhythm)14
  • Calcium and Vitamin D supplementation1,6,9
  • Address foot/footwear problems. Older persons should be advised to wear shoes with low heels and high surface contact area6,9
  • Home/environmental hazard evaluation and modification as needed.
  • Patient/caregiver education/information regarding falls/falls prevention

Comprehensive (physical behavioral, environmental) interventions targeting multiple risk factors in high-risk individuals significantly reduces falls. Single exercise alone, health education alone, or single exercise+health education is less effective1

At different disease stages

  • New onset/acute: If risk factors for future falls identified, schedule follow-up to re-evaluate patient, complete medication review. May need to initial multi-factorial treatment intervention, if necessary.
  • Subacute
    • Scheduled follow-up should be arranged as needed to re-evaluate the patient for compliance with the treatment interventions and to assess for recurrent falls. Medication review should be completed again.
    • Treatment of other complicating conditions (e.g., incontinence, depression, osteoporosis) may be initiated.
    • The older person needs to be reassessed for falls with any change in medical condition.
    • Home safety evaluation can be done by home health agencies and occupational therapists.
  • Chronic/stable
    • Scheduled, or as needed, follow-up, to re-evaluate for fall risk, repeat multifactorial risk assessment and revise the multifactorial treatment intervention, if necessary.

Patient & family education

Detailed explanations in simple language (i.e., appropriate to patient’s/caregiver’s cognitive level) should be provided to the patient/caregiver regarding the older person’s risk assessment and the plan for fall prevention.

Written educational/informational materials with instructions for improved safety at home and in the community should be provided, as well as information about helplines for emergencies.14

Emerging/unique interventions

Clinically important effects of interventions for study may include the number of people sustaining falls, rates of falls, number of fall-related injuries, and quality of life (physical, psychologic, social and environmental domains) after the intervention. Measuring falls prospectively over 12 months with regular follow-up/ diaries is the gold standard for data collection in community-based trials. Randomized controlled trials of multifactorial interventions in at-risk patients can give high-quality evidence. This needs to include review of medications, exercise programs incorporating balance training of sufficient duration and frequency, and educational interventions.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

All older persons should be asked at least once per year if they have fallen, and/or queried with the above noted falls screening questions. The American Geriatrics Society (AGS)/British Geriatrics Society (BGS) clinical algorithm should then be instituted, depending upon the patient responses.9,14

Individually prescribed and group exercises that include balance and gait training and strengthening can reduce risk of falling and reduce fractures but is less effective in people at higher risk of falling.

Multifactorial interventions integrating assessment with individualized intervention, usually involving a multidisciplinary team, are effective in reducing rate of falls but not risk of falling.

Home safety interventions reduce rate of falls and risk of falling, especially when delivered by an occupational therapist.

Implementation of a falls screening program could be challenging and would be suitable for a PIP project. Similarly, compliance with the multifactorial intervention program (e.g., gait/balance exercise program, medication modifications, home modifications) may be problematic, and coordination with the patient’s primary care provider may be difficult; these issues may be potential PIP projects as well.

Cutting Edge/ Emerging and Unique Concepts and Practice

As more hospital systems adopt electronic medical records, better coordination of care and communication between physicians and caregivers should become much easier; research into epidemiology and efficacy of falls prevention interventions can be undertaken.

Also, adverse drug interactions can be avoided through automatic messages to ordering physicians. Social marketing campaigns regarding fall prevention might be delivered to the at-risk population through mail or the internet to change practices and attitudes.

Emerging technology has the potential to assist patients and clinicians in understanding more about the occurrence and mechanisms involved in falls, enhancing intervention efforts, and identifying and monitoring falls. There is a growing body of literature describing the development and use of wearable sensors (accelerometers) and radar technology that can measure movement, detect falls, and monitor physiological and environmental parameters.28,29 This can lead to better understanding of factors related to the fall, which can in turn lead to prevention. Other technology applications, such as the use of exercise gaming devices (Microsoft Kinnect,® Nintendo Wii Fit®) or the use of virtual reality devices have been used to successfully enhance balance training in persons who fall or who are at risk for falling.26,30,31 In the future, existing computerized gait analysis and recognition systems will combine with embedded or wearable sensors in “smart homes” to detect near-falls or falls and will trigger appropriate responses or alarms.29

Gaps in the Evidence-Based Knowledge

Commonly used Fall Risk Assessment Tools (FRAT) have varying validity and reliability. Poor standardization of data collection and analysis have made interpretation challenging and thus it is difficult to determine trends. Public health initiatives to reduce falls are necessary to translate the positive evidence that exists towards developing more effective fall prevention strategies.

Research targeting health professionals is needed to increase clinician awareness and for implementation of clinical practice guidelines and effective interventions to decrease falls. Improved communication and collaboration are needed between referring clinicians and community service providers, who can develop and deploy ongoing community-based fall-prevention activity programs.32 More studies exploring methods for increasing acceptance and adherence to effective falls prevention programs by older people and measurement of outcomes are also needed.33

The impact of management programs for risk factors, such as cognitive impairment and urinary incontinence needs additional investigation. Better standardization of research methods needs to be adopted in future studies.

Economic evaluations should be conducted alongside randomized controlled trials to establish the cost-effectiveness of each intervention being tested. Measuring health related quality of life as an outcome, defining the perspective and timeframe for costs, collecting data on healthcare use, costing healthcare resources, calculating cost-effectiveness ratios (if the intervention is effective in reducing falls), and evaluating uncertainty is needed. Guidelines for carrying out and reporting economic evaluations in falls prevention trials have recently been published.


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  33. Thilo FJS, Hürlimann B, Hahn S, Bilger S, Schols JMGA, Halfens RJG. Involvement of older people in the development of fall detection systems: a scoping review. BMC Geriatr [Internet]. 2016;16(1):42. Available from: http://dx.doi.org/10.1186/s12877-016-0216-3

Original Version of the Topic

J. George Thomas, MD. Fall Prevention in the Elderly. 11/14/2011.

Previous Revision(s) of the Topic

Kevin M Means, MD, Lindsay E Mohney, DO. Fall Prevention in the Elderly. 7/18/2017.

Author Disclosure

Kevin M Means, MD
Nothing to Disclose

Lindsay Mohney, DO
Nothing to Disclose