๐ Key Information Summary
- Falls are a major geriatric syndrome affecting approximately 30% of community-dwelling Australians aged โฅ65 years each year, rising to 50% in those aged โฅ80 years; they are the leading cause of injury-related hospitalisation and death in older Australians.
- Multifactorial risk assessment is the cornerstone of falls prevention โ always evaluate gait, balance, muscle strength, vision, cognition, medications, continence, orthostatic hypotension, footwear and home environment.
- Gait and balance examination should include the Timed Up and Go (TUG) test, 30-Second Chair Stand, 4-Stage Balance Test, and observation of walking speed and stride variability.
- A TUG time โฅ12 seconds identifies increased falls risk; values โฅ14 seconds indicate high risk and warrant specialist referral or comprehensive geriatric assessment.
- Medication review is essential โ psychotropics (benzodiazepines, antipsychotics, SSRIs), opioids, anticholinergics, antihypertensives and polypharmacy (โฅ4 medications) independently increase falls risk.
- Orthostatic hypotension must be assessed with lying-to-standing blood pressure (โฅ20 mmHg systolic or โฅ10 mmHg diastolic drop within 3 minutes of standing is diagnostic).
- Exercise is the single most effective falls prevention intervention โ supervised balance training โฅ3 times per week reduces falls by 23โ40%; Tai Chi, Otago Exercise Programme and group-based strength-and-balance programmes have the strongest evidence.
- Vitamin D supplementation (800โ1000 IU/day cholecalciferol) should be considered for older adults who are housebound, institutionalised or have documented deficiency, as it may reduce falls in residential care settings.
- Home hazard modification by an occupational therapist reduces falls by approximately 20%, particularly when targeted to those at high risk with a history of falls.
- Falls in hospital and residential aged care require structured risk screening on admission and ongoing reassessment; multi-component inpatient programmes reduce falls by 20โ30%.
- Aboriginal and Torres Strait Islander older adults experience higher rates of falls and fall-related injury with lower access to preventive services โ culturally safe, community-based programmes are essential.
- Fracture risk must be considered in every faller โ assess for osteoporosis (FRAX/DXA), ensure adequate calcium and vitamin D, and consider bisphosphonate therapy where indicated.
- Post-fall assessment should include cardiac evaluation (carotid sinus hypersensitivity, arrhythmia screen) and head-CT if head injury or anticoagulant use, even in the absence of obvious trauma.
Introduction & Australian Epidemiology
Falls are a major geriatric syndrome and the leading cause of injury-related morbidity, mortality and residential aged-care admission in older Australians. They commonly arise from interacting intrinsic factors โ including gait impairment, muscle weakness, cognitive decline, sensory deficits and medication effects โ and extrinsic risks such as environmental hazards, ill-fitting footwear and acute illness. The dynamic interplay between an individual's physiological reserve and their activity level, environment and exposure to precipitating factors determines whether a fall occurs.
According to the Australian Institute of Health and Welfare (AIHW), falls accounted for over 250,000 hospitalisations in 2021โ22, with the age-standardised rate increasing by approximately 3% per year over the past decade. In 2022, falls were the underlying cause of death in approximately 5,400 Australians, making them the leading cause of injury-related death nationally. The direct healthcare cost of falls exceeds .3 billion annually when hospital, emergency department, rehabilitation and aged-care costs are included.
Community-dwelling Australians aged โฅ65 years experience a falls incidence of approximately 0.6โ1.0 falls per person-year; this rises to 1.5 falls per person-year in residential aged care. Approximately 10โ15% of falls result in serious injury including hip fracture, other fractures, head injury or joint dislocation. Hip fractures are particularly devastating โ with 30-day mortality of 5โ10% and 12-month mortality approaching 25โ30% โ and are a major driver of loss of independence and long-term residential care admission.
One fall is a strong predictor of future falls. An older person who has fallen once has a 2-fold increased risk of falling again within 12 months. A history of โฅ2 falls or a fall presenting to the emergency department should trigger a comprehensive multifactorial assessment, not simply reassurance.
Key risk factors for falls in Australian older adults include:
- Intrinsic: Age โฅ80 years, female sex (for hip fracture), previous falls, gait and balance impairment, muscle weakness (quadriceps), visual impairment, cognitive impairment or dementia, depression, urinary incontinence, orthostatic hypotension, neuropathy (peripheral or autonomic), Parkinson's disease, osteoarthritis, and stroke sequelae.
- Extrinsic / Environmental: Loose rugs, poor lighting, wet or uneven surfaces, absence of handrails, clutter, inappropriate footwear (slippers, thongs), and inadequate assistive devices.
- Medication-related: Polypharmacy (โฅ4 medications), psychotropic agents, opioids, antihypertensives (particularly when recently initiated or dose-changed), and anticholinergic burden.
- Situational: Rushing to the toilet (urgency incontinence), postprandial hypotension, nocturia, and unfamiliar environments.
Falls Risk Assessment
A comprehensive, multifactorial falls risk assessment is recommended for all older adults who present with a fall, report recurrent falls or demonstrate gait and balance impairment. The assessment should be performed by the general practitioner in primary care, with referral to a geriatrician, physiotherapist or falls clinic as indicated. The Royal Australian College of General Practitioners (RACGP) and the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommend a structured approach aligned with the 45+ Health Check and annual over-75 assessments.
When to Screen
- All adults aged โฅ65 years should be asked about falls at least annually.
- Any presentation with a fall (including unwitnessed falls or "found on floor") requires a systematic assessment.
- Patients reporting loss of balance, near-falls ("stumbles") or fear of falling should be assessed even without a reported fall.
- Reassessment at every change in functional status, after hospitalisation, on medication change, or on transition to residential aged care.
Components of the Multifactorial Assessment
| Domain | Assessment | Red Flags / Action Thresholds |
|---|---|---|
| Fall history | Circumstances, frequency, injury, lying time, witness accounts | โฅ2 falls in 12 months; unexplained falls; loss of consciousness preceding fall |
| Gait, balance & mobility | TUG, 30-Second Chair Stand, 4-Stage Balance Test, Tinetti, DGI | TUG โฅ12 s; Chair Stand <5 reps; unable to hold tandem stance 10 s |
| Muscle strength | Hand-held dynamometry; 30-Second Chair Stand; quadriceps testing | Chair Stand <5 reps; grip strength below age-sex norms |
| Vision | Visual acuity (Snellen chart), visual fields, cataract screening | VA worse than 6/12; visual field defect; diplopia |
| Cognition | MMSE, MoCA, GP assessment of cognitive tool (GPCOG) | Impaired executive function or attention increasing fall risk; delirium screen |
| Medications | Medication count, high-risk drug classes, anticholinergic burden, recent changes | โฅ4 medications; psychotropics; opioids; anticholinergic burden scale score โฅ3 |
| Orthostatic hypotension | Lying and standing BP at 1 and 3 minutes; symptoms on standing | โฅ20/10 mmHg drop or symptomatic |
| Continence | Bladder diary, urgency, nocturia episodes, pad use | โฅ2 nocturia episodes; urgency incontinence; rushing to toilet |
| Feet & footwear | Foot inspection, proprioception, appropriate shoe assessment | Peripheral neuropathy; ill-fitting shoes; walking in socks or barefoot |
| Home environment | OT home assessment; hazards checklist; assistive device evaluation | Loose rugs, poor lighting, no grab rails, steep stairs, wet areas |
| Fear of falling | Falls Efficacy ScaleโInternational (FES-I) | High FES-I score; activity restriction due to fear |
| Nutrition | MNA-SF, weight, albumin, vitamin D level | BMI <22; unintentional weight loss; 25(OH)D <50 nmol/L |
Screening Tools in Primary Care
For rapid screening in time-limited consultations, the following approach is recommended:
1
Ask about falls
"Have you fallen in the past 12 months? Are you worried about falling?" If yes to either, proceed to step 2.
2
Perform TUG test
Timed Up and Go โ patient rises from armchair, walks 3 m, turns, walks back, sits. Normal <10 s; borderline 10โ12 s; abnormal โฅ12 s.
3
Check orthostatic BP
Measure lying (5 min rest) and standing BP at 1 and 3 minutes. Document symptoms.
4
Review medications
Count medications. Identify high-risk drugs. Consider deprescribing where safe.
5
Refer for comprehensive assessment
Physiotherapy for balance and strength, occupational therapy for home assessment, falls clinic or geriatrician if complex or recurrent falls.
Gait and Balance Examination
Gait and balance assessment is the single most informative component of the falls evaluation. Abnormalities in gait โ including reduced speed, widened base, shortened stride, increased variability and asymmetric arm swing โ are independent predictors of falls, disability, cognitive decline and mortality in older adults. In Australian primary care, gait assessment can be performed rapidly with simple validated tools requiring minimal equipment.
Systematic Approach to Gait Observation
Observe the patient walking at their comfortable pace for at least 10 metres in a well-lit corridor. Note the following features:
- Initiation: Hesitancy or freezing at start suggests Parkinson's disease, normal pressure hydrocephalus or frontal lobe pathology.
- Speed: Normal gait speed in healthy older adults is 1.0โ1.3 m/s. Speed <0.8 m/s is associated with increased falls risk, disability and mortality; <0.6 m/s indicates severe mobility impairment.
- Stride length and symmetry: Shortened stride suggests deconditioning, fear, arthritis, or neurodegeneration. Asymmetry suggests stroke, unilateral joint disease or pain.
- Base width: Widened base (>10 cm heel-to-heel) indicates cerebellar disease, vestibular loss or proprioceptive deficit.
- Cadence and rhythm: Irregular cadence or festination suggests Parkinson's disease. Steppage gait suggests foot drop (peroneal neuropathy, L5 radiculopathy, peripheral neuropathy).
- Arm swing: Reduced unilateral arm swing suggests Parkinson's disease. Bilateral reduction may be deconditioning or Parkinsonism.
- Trunk stability and posture: Lateral trunk lean, kyphosis, and inability to maintain upright posture during turning increase falls risk.
- Turning: Multi-step turns (>3 steps) or instability during turning are predictive of falls. The "Turn 180ยฐ" test is a simple screen.
Validated Assessment Tools
| Tool | What It Measures | Cut-off / Scoring | Setting |
|---|---|---|---|
| Timed Up and Go (TUG) | Functional mobility โ sit to stand, walk 3 m, turn, return | <10 s = normal; 10โ12 s = borderline; โฅ12 s = increased risk; โฅ14 s = high risk | Primary care, ward, clinic |
| 30-Second Chair Stand | Lower limb strength and endurance | Age-sex norms; <5 repetitions = high risk for falls | Primary care, community |
| 4-Stage Balance Test | Static balance โ parallel stance, semi-tandem, tandem, single leg | Unable to hold tandem stance โฅ10 s = increased falls risk | Primary care, community |
| Tinetti POMA | Gait (12 items) and balance (9 items); total /28 | <19 = high falls risk; 19โ24 = moderate risk | Clinic, inpatient, research |
| Dynamic Gait Index (DGI) | Dynamic balance during functional tasks (8 items, /24) | <19/24 = increased falls risk | Physiotherapy, falls clinic |
| Functional Reach Test | Limits of stability โ forward reach distance | <25 cm = high risk; <15 cm = very high risk | Primary care, clinic |
| 10-Metre Walk Test | Gait speed at comfortable and fast pace | <0.8 m/s (comfortable) = falls and disability risk | Primary care, rehab |
| DGI abbreviated / GaitSpeed | Quick screen โ "6th vital sign" | Age โฅ65 with gait speed <1.0 m/s warrants further assessment | Any setting |
Gait Patterns and Clinical Correlation
| Gait Pattern | Features | Suggests |
|---|---|---|
| Antalgic | Shortened stance phase on affected side, pain-limited | Osteoarthritis (hip/knee), fracture, peripheral vascular disease |
| Shuffling / Festinating | Short shuffling steps, stooped posture, reduced arm swing, acceleration | Parkinson's disease, Parkinsonism |
| Steppage / High-stepping | Exaggerated hip and knee flexion to clear foot; foot slaps ground | Foot drop โ peroneal neuropathy, L5 radiculopathy, peripheral neuropathy |
| Ataxic / Wide-based | Wide base, irregular, lurching, difficulty with tandem walking | Cerebellar disease, alcohol, posterior fossa pathology |
| Waddling | Lateral trunk lean, Trendelenburg sign, pelvic drop | Hip abductor weakness โ myopathy, hip osteoarthritis, lumbar stenosis |
| Senile / Cautious | Wide base, short stride, arms forward for balance, slow speed | Deconditioning, fear of falling, multi-sensory deficit |
| Magnetic / Apraxic | Feet seem "glued" to floor, difficulty lifting feet, poor initiation | Normal pressure hydrocephalus, frontal lobe disease, bilateral MCA stroke |
| Hemiplegic | Circumduction of affected leg, stiff arm, unilateral pattern | Stroke, intracranial pathology |
Gait speed as the "6th vital sign": Measuring comfortable gait speed over 4โ6 metres is a simple, rapid and highly informative functional test. Speed <0.8 m/s in an older adult predicts falls, disability, hospitalisation and mortality. It can be incorporated into routine clinical encounters with no special equipment โ only a measured corridor and a stopwatch.
Vestibular and Proprioceptive Assessment
- Romberg test: Eyes-open then eyes-closed on firm surface. Loss of balance with eyes closed suggests proprioceptive or vestibular deficit. Duration <30 s is abnormal.
- Untersberger (Fukuda) stepping test: Patient marches on the spot with eyes closed for 50 steps. Rotation >30ยฐ or lateral displacement >1 m suggests unilateral vestibular lesion.
- Head impulse test: Assess vestibulo-ocular reflex. Corrective saccade indicates peripheral vestibular deficit. Refer for formal vestibular assessment if positive.
- Sensory Organization Test: Formal posturography (available at specialist balance centres) can differentiate sensory vs motor contributions to balance impairment.
Medication and Orthostatic Review
Medications are one of the most modifiable risk factors for falls in older Australians. Polypharmacy โ commonly defined as โฅ4 regular medications โ and specific drug classes independently increase falls risk through mechanisms including sedation, orthostatic hypotension, impaired cognition, blurred vision, muscle weakness and prolongation of reaction time. A structured medication review should be performed for every older person who falls or is at risk of falling.
High-Risk Medication Classes
| Drug Class | Mechanism of Falls Risk | Relative Risk | Action |
|---|---|---|---|
| Benzodiazepines | Sedation, impaired coordination, cognitive impairment | OR 1.5โ2.0 | Gradual taper and cease; if essential, short-acting agents only (oxazepam) |
| SSRIs / SNRIs | Orthostatic hypotension, sedation, hyponatraemia, serotonin effects on balance | OR 1.5โ1.7 | Review indication; consider dose reduction or switching; monitor sodium |
| Antipsychotics | Sedation, extrapyramidal effects, orthostatic hypotension, QTc prolongation | OR 1.5โ2.0 | Deprescribe if prescribed for behavioural symptoms of dementia; seek specialist advice |
| Opioids | Sedation, dizziness, constipation-related urgency, myoclonus | OR 1.5โ2.0 | Minimise dose; use paracetamol and non-pharmacological strategies first; review regularly |
| Antihypertensives | Orthostatic hypotension, excessive blood pressure lowering | OR 1.2โ1.4 | Review BP targets in elderly (150/90 acceptable for โฅ80 yrs); avoid aggressive titration |
| Diuretics | Dehydration, electrolyte disturbance, nocturia, urgency | OR 1.2โ1.4 | Review indication; monitor electrolytes; consider timing to reduce nocturia |
| Anticholinergics | Sedation, blurred vision, cognitive impairment, urinary retention | OR 1.2โ1.5 | Calculate anticholinergic burden score; deprescribe agents with high burden |
| Anticonvulsants | Sedation, ataxia, cognitive impairment, osteomalacia | OR 1.5โ1.9 | Minimise dose; review indication for gabapentinoids; monitor vitamin D |
| Hypnotics (Z-drugs) | Sedation, nocturnal confusion, impaired nocturnal coordination | OR 1.5โ2.0 | Deprescribe; use sleep hygiene strategies; short course only if essential |
Central nervous system (CNS) polypharmacy โ the concurrent use of โฅ3 CNS-active medications (benzodiazepines, opioids, antidepressants, antipsychotics, anticonvulsants) โ confers a particularly high falls risk (OR 2.5โ3.5). This combination is increasingly common in residential aged care and warrants urgent medication review.
Orthostatic Hypotension
Orthostatic hypotension (OH) is defined as a sustained reduction in systolic blood pressure โฅ20 mmHg or diastolic blood pressure โฅ10 mmHg within 3 minutes of standing from a supine position. It affects 15โ30% of community-dwelling older adults and up to 50% of those in residential aged care. OH is an independent risk factor for falls, syncope, fractures, cardiovascular events and mortality.
Measurement Technique
- Patient rests supine for โฅ5 minutes (ideally 10 minutes) in a quiet room.
- Record supine BP (average of 2 readings), heart rate, and any symptoms.
- Patient stands (with assistance if needed). Record standing BP and HR at 1 minute and 3 minutes.
- Document symptoms: dizziness, lightheadedness, visual blurring, weakness, palpitations, neck/shoulder "coat-hanger" pain.
- A positive result = โฅ20/10 mmHg drop OR symptoms on standing.
Causes and Contributing Factors
Medication Causes
- Antihypertensives (all classes)
- Diuretics
- Alpha-blockers (tamsulosin, prazosin)
- Nitrates
- Tricyclic antidepressants
- Antipsychotics (especially clozapine, quetiapine)
- Levodopa / dopamine agonists
- Sildenafil and PDE-5 inhibitors
Non-Medication Causes
- Dehydration / hypovolaemia
- Autonomic neuropathy (diabetes, Parkinson's, amyloidosis)
- Adrenal insufficiency
- Anaemia
- Prolonged bed rest / deconditioning
- Venous insufficiency / varicosities
- Postprandial hypotension
- Age-related baroreflex decline
Management of Orthostatic Hypotension
Midodrine
Gutronยฎ ยท Alpha-1 adrenergic agonist
Adult dose
2.5โ5 mg PO TDS (morning, midday, late afternoon); max 10 mg TDS; avoid dosing after 6 PM
Renal adjustment
No specific adjustment; use with caution in renal impairment
Key considerations
Monitor supine BP; contraindicated in supine hypertension (>180/110); avoid in urinary retention and severe cardiac disease
PBS status
Authority Required
Fludrocortisone
Florinefยฎ ยท Mineralocorticoid
Adult dose
50โ200 mcg PO daily (start 50 mcg, titrate over 1โ2 weeks)
Renal adjustment
Use with caution; monitor potassium and fluid balance closely
Key considerations
May worsen supine hypertension; monitor for oedema, hypokalaemia, headache; avoid in heart failure
PBS status
PBS General Benefit
Non-Pharmacological Measures for Orthostatic Hypotension
- Slow positional changes โ sit at edge of bed for 2 minutes before standing; stand for 2 minutes before walking.
- Adequate hydration โ aim for 1.5โ2.5 L/day fluid intake (adjusted for cardiac/renal status).
- Increase salt intake to 6โ10 g NaCl/day if no contraindication (heart failure, hypertension, renal disease).
- Compression stockings (thigh-high, 20โ30 mmHg) โ effective but compliance is often poor; abdominal compression garments may be better tolerated.
- Physical counter-maneuvers: leg crossing, squatting, muscle tensing before standing.
- Head-of-bed elevation 10โ15ยฐ to reduce supine hypertension and nocturnal pressure natriuresis.
- Avoid triggers: hot environments, large meals, alcohol, prolonged standing, straining at stool.
- Review and adjust medication timing โ give antihypertensives at night rather than morning where safe to do so.
Deprescribing Principles
Deprescribing should be a structured, patient-centred process using shared decision-making. The following approach is recommended:
1
Comprehensive medication reconciliation
Review all medications including OTC, supplements, and complementary medicines. Use the PBS My Health Record medicines list and community pharmacy records.
2
Identify high-risk and potentially inappropriate medications
Apply STOPP/START criteria (v2), Beers Criteria, and anticholinergic burden scale (Anticholinergic Cognitive Burden Scale).
3
Prioritise and plan tapering
Taper one medication at a time. Start with the highest-risk agent. Allow 2โ4 weeks between dose reductions. Use dose-reduction schedules (e.g., benzodiazepine taper over 8โ12 weeks).
4
Monitor and follow up
Review within 2โ4 weeks of each change. Monitor for withdrawal effects, disease recurrence, and functional improvement. Document goals and outcome.
Prevention, Exercise and Rehabilitation
Falls prevention requires a multifaceted approach targeting the individual risk factors identified during assessment. Systematic reviews and meta-analyses (including the 2019 Cochrane review by Sherrington et al.) have established that exercise โ particularly programmes emphasising balance training โ reduces the rate of falls by 23% in community-dwelling older adults and up to 34% in those with Parkinson's disease. When combined with medication review, home modification and vision correction, the cumulative effect is greater.
Evidence-Based Exercise Programmes
Community
Group Strength & Balance Classes
Tai Chi, gentle exercise groups, and community strength-and-balance classes. Minimum 2 sessions/week (ideally 3). Focus on challenging balance (reducing base of support, moving centre of mass, single-leg standing, stepping exercises).
Setting: community centre, council-run programmes, local PCYC
Individual
Otago Exercise Programme
Home-based individually prescribed programme of progressive strength (ankle dorsiflexors, knee extensors, hip abductors/extensors) and balance exercises. 5ร/week with 5 physiotherapy visits over 12 months. Falls reduction of 35% in those aged โฅ80. Available through Australian physiotherapy services.
Setting: home-based; prescribed by physiotherapist; funded via Medicare (EPC items 10950โ10970)
Specialist
Falls Prevention Clinic / Geriatrician-Led Programme
Comprehensive multidisciplinary assessment with physiotherapy, OT, geriatrician, pharmacy. Indicated for recurrent falls, complex comorbidities, falls with injury, or failure of community programmes. Includes neurophysiology, vestibular rehab, cardiac investigation.
Setting: hospital outpatient; referral via GP or emergency department
Exercise Prescription Principles
- Balance training must be the core component โ static balance (standing with reduced support) and dynamic balance (walking with direction changes, obstacles, dual-tasking). The exercise must challenge balance to be effective.
- Progressive resistance training โ targeting lower limb extensors, ankle dorsiflexors and hip abductors. Use body weight, resistance bands or weights. Aim for 2โ3 sets of 8โ12 repetitions at moderate intensity (RPE 5โ6/10).
- Frequency: Minimum 2 hours per week of balance and strength training; optimal 3โ5 sessions per week. "More is better" โ dose-response relationship is well established.
- Intensity: The balance challenge must be sufficient to cause some instability (within safe limits). Simply walking or standing is not sufficient โ exercises must be performed near the limits of stability.
- Duration: Benefits are maintained only while exercising continues. Programmes should be lifelong or at minimum ongoing. Encourage transition from supervised to self-directed exercise.
- Adherence: Intrinsic motivation, enjoyment, social engagement and perceived benefit are the strongest predictors of adherence. Group programmes tend to have better long-term adherence than home programmes.
Tai Chi has Level I evidence for falls prevention, with a meta-analytic falls rate reduction of approximately 20%. It improves balance, strength, proprioception, reaction time and fear of falling. Multiple Australian community programmes are available through local councils and community health services.
Home Hazard Modification
Occupational therapy-delivered home hazard assessment and modification is an evidence-based intervention, particularly effective when targeted to those at high risk (history of โฅ1 fall, recent hospital discharge). The OT assesses and addresses environmental hazards and prescribes assistive devices.
| Hazard | Modification | Priority |
|---|---|---|
| Loose rugs, mats, cords | Remove or secure with non-slip backing/tape | High |
| Poor lighting (especially hallways, stairs, bathrooms) | Install night lights, sensor lights, increase wattage, improve switch access | High |
| Wet/slippery bathroom surfaces | Non-slip mat in shower/bath; grab rails at shower, toilet and bath; consider shower chair | High |
| Stairs without handrails | Install handrails on both sides; ensure stair nosings are visible; non-slip treads | High |
| Clutter, furniture obstructing pathways | Clear pathways; rearrange furniture; remove low objects | Medium |
| Inadequate outdoor lighting | Sensor lights at entries; improve garden path surfaces | Medium |
| Steep or uneven steps/paths | Ramp installation; handrails; path repair; consider alternative entry route | Medium |
Assistive Devices
- Walking aids: Walking sticks (single-point or quad stick), rollator frames, and walking frames should be individually assessed and fitted by a physiotherapist. An incorrectly fitted or inappropriate walking aid can increase falls risk. Review regularly.
- Hip protectors: Evidence for hip protectors is mixed. May be considered for high-risk individuals in residential aged care (where compliance can be supported), but are not recommended as a primary prevention strategy.
- Personal alarm systems: Wearable alarms or medical alert devices can reduce lying time after a fall. Recommended for those living alone with recurrent falls risk. Available through community support services and Commonwealth Home Support Programme (CHSP).
- Footwear assessment: Recommend firm, low-heeled shoes with non-slip soles and secure fastening (lace-up or Velcro). Avoid thongs, loose slippers, high heels and walking in socks or barefoot on hard surfaces.
Vision Correction
- Annual optometry review for all older adults at risk of falls (Medicare-funded for โฅ65 years).
- Cataract surgery reduces falls by approximately 34% โ refer for cataract assessment when visual impairment contributes to falls risk.
- Multifocal and progressive lenses may increase falls risk due to peripheral distortion โ consider single-vision distance glasses for outdoor walking and bifocals only for indoor use.
- Avoid new multifocal prescription when hospitalised or in unfamiliar environments.
Vitamin D Supplementation
Cholecalciferol (Vitamin Dโ)
Ostelinยฎ, various generic ยท Vitamin supplement
Indication
Housebound older adults, residential aged care residents, documented 25(OH)D <50 nmol/L
Dose for falls prevention
800โ1000 IU (20โ25 mcg) PO daily; loading dose of 50,000 IU weekly ร 6โ10 weeks if severely deficient (<25 nmol/L), then maintenance
Renal adjustment
CKD Stage 4โ5: use calcitriol or alfacalcidol under nephrology guidance; monitor calcium and phosphate
Key considerations
May reduce falls in residential aged care (Level I evidence); effect in community-dwelling adults with adequate vitamin D is minimal. Combine with calcium if osteoporosis co-exists.
PBS status
Not PBS (OTC supplement)
Cardiac and Syncope Evaluation
For unexplained falls, recurrent falls or falls with features suggesting loss of consciousness, cardiac evaluation is essential:
- 12-lead ECG โ assess for arrhythmia, conduction disease, QTc prolongation, ischaemic changes.
- Carotid sinus massage (under continuous cardiac monitoring) โ carotid sinus hypersensitivity causes up to 35% of unexplained falls in older adults; diagnosis requires โฅ3 second asystole or โฅ50 mmHg systolic drop. Refer to cardiology for consideration of dual-chamber pacemaker if symptomatic.
- Holter monitor / event recorder / implantable loop recorder โ for suspected arrhythmic syncope or unexplained falls with negative initial workup.
- Echocardiography โ if structural heart disease suspected (murmur, heart failure signs, ECG abnormalities).
- Active standing test / tilt table test โ for suspected vasovagal syncope or autonomic dysfunction causing unexplained falls.
In-hospital falls prevention: All Australian hospitals must have a falls prevention programme as part of NSQHS Standards (Standard 5). Interventions include admission risk screening (STRATIFY or FRAT), bed/chair alarms, low beds, non-slip footwear, supervised mobilisation, medication review and toileting programmes. Inpatient falls prevention reduces falls by 20โ30%.
Post-Fall Management Algorithm
1
Immediate assessment
Assess for injury (fracture, head injury, soft tissue). Check for anticoagulant use โ if on warfarin/DOAC with head strike, CT head regardless of symptoms. Assess for loss of consciousness. Check neurological status.
2
Investigate cause
Detailed history of circumstances. Orthostatic BP. ECG. Bloods (FBC, UEC, glucose, calcium, vitamin D, TSH, B12). Medication review. Cognitive screen if not already assessed.
3
Multifactorial intervention
Address modifiable risks: exercise programme, medication adjustment, vision/footwear/home modification, orthostatic management, continence treatment, vitamin D, fracture risk assessment.
4
Follow-up and monitoring
GP review at 2โ4 weeks. Physiotherapy/OT within 1โ2 weeks. Reassess in 3 months. Ongoing annual falls risk review. Consider referral to falls clinic if recurrent or complex.
Fracture Risk Assessment
Every older person who falls should have their fracture risk assessed. Falls and osteoporosis are independent but synergistic risk factors for fracture. Assessment and management includes:
- FRAX (Fracture Risk Assessment Tool) โ 10-year probability of major osteoporotic fracture and hip fracture. Australian-specific thresholds for DXA referral and treatment initiation apply.
- DXA (Dual-energy X-ray Absorptiometry) โ indicated when FRAX suggests high risk, or when a minimal-trauma fracture has occurred (MBS item 12320).
- Calcium and vitamin D adequacy โ ensure dietary calcium โฅ1300 mg/day (supplement if dietary intake insufficient) and 25(OH)D โฅ50 nmol/L.
- Anti-osteoporosis therapy โ bisphosphonates (alendronate, risedronate), denosumab, or teriparatide as indicated per PBS criteria. For patients with minimal-trauma fracture presenting via ED, the Australian Fracture Liaison Service model recommends initiating treatment before discharge or at 6-week follow-up.
Special Populations
Elderly (โฅ80 years)
Falls incidence: 50% per year; multiple falls in 15โ20%.
Key considerations: Sarcopenia, frailty, multi-morbidity, polypharmacy and sensory decline are highly prevalent. Comprehensive geriatric assessment is strongly recommended.
BP targets: Relaxed targets (systolic 140โ150 mmHg) are appropriate if falls and orthostatic symptoms are present. Avoid over-treatment of hypertension.
Cognitive considerations: Patients with dementia have 2โ3ร the falls risk. Supervised exercise and environmental modification are critical. Ensure wandering risks are assessed (e.g., door alarms in residential care).
Residential aged care: Over 50% of residents fall annually. Structured falls programmes with physiotherapy, vitamin D, medication review, hip protectors (where acceptable), and bed/low-height interventions are recommended.
Paediatrics
Not applicable for this topic: Falls in children are developmentally normal and differ fundamentally from geriatric falls in aetiology and management.
Exception โ childhood falls as cause of injury: Paediatric falls (playground, home) are the leading cause of childhood injury presentations to Australian EDs. Prevention focuses on environmental safety (window guards, playground surfacing, supervision).
Renal Impairment
Increased risk: CKD stages 3bโ5 independently increases falls risk through anaemia, electrolyte disturbance (hypokalaemia, hypomagnesaemia), acidosis, uraemic neuropathy, bone-mineral disorder and polypharmacy.
Vitamin D: CKD stages 4โ5 require active vitamin D metabolites (calcitriol or alfacalcidol) rather than cholecalciferol; use under nephrology guidance. Monitor calcium and phosphate closely.
Antihypertensives: Dialysis patients experience intradialytic hypotension โ review antihypertensives in the context of dialysis schedules; avoid pre-dialysis dosing.
Drug dose adjustments: Renal drug clearance alterations increase side-effect risk for many falls-related medications (gabapentin, opioids, lithium, digoxin). Refer to renal drug dosing guidelines.
Hepatic Impairment
Increased risk: Hepatic encephalopathy, coagulopathy (increased bleeding risk post-fall), muscle wasting (sarcopenia of cirrhosis), and altered drug metabolism.
Benzodiazepines: Avoid or use with extreme caution โ prolonged half-life, increased sedation. If essential for alcohol withdrawal management, use short-acting agents and monitor closely.
Fracture risk: Osteoporosis is common in chronic liver disease (particularly cholestatic and alcohol-related). Ensure DXA assessment and appropriate anti-osteoporosis treatment.
Paracetamol: Safe at โค2 g/day in compensated cirrhosis; avoid exceeding recommended doses. NSAIDs are contraindicated.
Immunocompromised
Increased risk: Immunosuppressant medications (corticosteroids, tacrolimus, cyclosporine) contribute to falls through myopathy, neuropathy, glucose disturbance and osteoporosis.
Corticosteroid-induced osteoporosis: Prolonged prednisolone โฅ7.5 mg/day for โฅ3 months increases fracture risk independently of falls. DXA and bisphosphonate initiation per PBS criteria (alendronate 70 mg weekly or risedronate 35 mg weekly; PBS General Benefit for steroid-induced osteoporosis).
Infection risk: Fracture-related immobility increases risk of hospital-acquired infections (pneumonia, UTI, pressure injuries) in immunocompromised patients.
Pregnancy
Not applicable for the primary target population: This article focuses on geriatric falls (age โฅ65 years).
Note: Falls in pregnancy relate to altered centre of gravity, laxity of ligaments and are managed differently. Refer to obstetric guidelines.
Aboriginal and Torres Strait Islander Health
๐ References
- 1. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019;1(1):CD012424.
- 2. Australian Institute of Health and Welfare (AIHW). Falls in older Australians 2019โ20: hospitalisations and deaths among people aged 65 and over. AIHW; 2023.
- 3. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am Geriatr Soc. 2011;59(1):148โ157.
- 4. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th ed. Melbourne: RACGP; 2016 (updated 2018). Chapter 11: Falls prevention in older people.
- 5. Australian Commission on Safety and Quality in Health Care (ACSQHC). Safety and Quality Improvement Guide Standard 5: Comprehensive Care โ Preventing Falls and Harm from Falls. Sydney: ACSQHC; 2021.
- 6. O'Mahony D, O'Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213โ218.
- 7. Thomas S, Mackintosh S, Halbert J. Does the 'Otago exercise programme' reduce mortality and falls in older adults?: a systematic review and meta-analysis. Age Ageing. 2010;39(6):681โ687.
- 8. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;(9):CD007146.
- 9. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69โ72.
- 10. Australian Institute of Health and Welfare (AIHW). The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. AIHW; 2023.
- 11. National Health and Medical Research Council (NHMRC). Australian guidelines to reduce health risks from drinking alcohol. Canberra: NHMRC; 2020. [Relevant for alcohol-related falls risk.]
- 12. Hosseini SR, Cumming RG, Kheirkhah F, et al. The association between polypharmacy and falls in older adults: a systematic review and meta-analysis. Drugs Aging. 2024;41(1):21โ35.
- 13. Lord SR, Sherrington C, Menz HB, Close JCT. Falls in older people: risk factors and strategies for prevention. 3rd ed. Cambridge: Cambridge University Press; 2021.
- 14. Logan PA, Armstrong S, Birtles T, et al. Occupational therapy home assessment and modification for older adults at risk of falls: a systematic review and meta-analysis. Age Ageing. 2023;52(8):afad147.
- 15. Royal Australian and New Zealand College of Psychiatrists (RANZCP). Practice guideline for deprescribing benzodiazepines and Z-drugs. Melbourne: RANZCP; 2023.