Risk factors and strategies for prevention
Stephen R. Lord
Prince of Wales Medical Research Institute, Sydney
Prince of Wales Medical Research Institute, Sydney
Hylton B. Menz
Prince of Wales Medical Research Institute, Sydney
The Pitt Building, Trumpington Street, Cambridge, United Kingdom
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© Cambridge Un
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Library of Congress Cataloguing-in-Publication Data
Lord, Stephen R., 1957–
Falls in older people : risk factors and strategies for prevention / by Stephen R. Lord,
Catherine Sherrington, Hylton B. Menz.
ISBN 0–521–58964–9 (pb)
1. Falls (Accidents) in old age–Risk factors. 2. Falls (Accidents) in old
age–Prevention. I. Sherrington, Catherine. II. Menz, Hylton B. III. Title.
RC952.5 L67 2000
ISBN 0 521 58964 9 paperback
Every eﬀort has been made in preparing this book to provide accurate and up-to-date
information which is in accord with accepted standards and practice at the time of publication.
Nevertheless, the authors, editors and publisher can make no warranties that the information
contained herein is totally free from error, not least because clinical standards are constantly
ing through research and regulation. The authors, editors and publisher therefore
disclaim all liability for direct or consequential damages resulting from the use of material
contained in this book. Readers are strongly advised to pay careful attention to information
provided by the manufacturer of any drugs or equipment that they plan to use.
Part I Risk factors for falls
1 Epidemiology of falls and fall-related injuries 3
2 Postural stability and falls 17
3 Sensory and neuromuscular risk factors for falls 40
4 Medical risk factors for falls 55
5 Medications as risk factors for falls 82
6 Environmental risk factors for falls 96
7 The relative importance of falls risk factors: an evidence-based summary 107
Part II Strategies for prevention
Overview: Falls prevention 119
8 Exercise interventions to prevent falls 121
9 Modifying the environment to prevent falls 146
10 The role of footwear in falls prevention 154
11 Assistive devices 166
12 Prevention of falls in hospitals and residential aged care facilities 180
13 The medical management of older people at risk of falls 190
14 Modifying medication use to prevent falls 206
15 Targeted falls prevention strategies 215
16 A physiological profile approach for falls prevention 221
Part III Research issues in falls prevention
17 Falls in older people: future directions for research 239
Epidemiology of falls and fall-related injuries
In this chapter, we examine the epidemiology of falls in older people. We review the
major studies that have described the incidence of falls, the locations where falls
occur and falls sequelae. We also examine the costs and services required to treat
and manage falls injuries. Before looking at the above, however, it is helpful to
discuss brieﬂy two important methodological considerations that are pertinent to
all research studies of falls in older people. First, how falls are deﬁned, and second,
how falls are counted.
The definition of a fall
In 1987 the Kellogg International Working Group on the prevention of falls in the
elderly deﬁned a fall as ‘unintentionally coming to the ground or some lower level
and other than as a consequence of sustaining a violent blow, loss of consciousness,
sudden onset of paralysis as in stroke or an epileptic seizure’ . Since then, many
researchers have used this or very similar deﬁnitions of a fall. Depending on the
focus of study, however, some researchers have used a broader deﬁnition of falls to
include those that occur as a result of dizziness and syncope. The Kellogg deﬁnition
is appropriate for studies aimed at identifying factors that impair sensorimotor
function and balance control, whereas the broader deﬁnition is appropriate for
studies that also address cardiovascular causes of falls such as postural hypotension
and transient ischaemic attacks.
Although falls are often referred to as accidents, it has been shown statistically
that falls incidence diﬀers signiﬁcantly from a Poisson distribution . This implies
that causal processes are involved in falls and that they are not merely random
The earliest published studies on falls were retrospective in design in that they asked
subjects whether and/or how many times they fell in a past period – usually 12
months. This approach has limitations because subjects have only limited accuracy
in remembering falls over such a long period . More recent studies have used
prospective designs, in which subjects are followed up for a period, again usually
12 months, to determine more accurately the incidence of falling. Not surprisingly,
these studies have usually reported higher rates of falling. In community studies,
the only feasible method of ascertaining falls is by self-report and a number of
methods have been used to record falls in prospective follow-up periods. These
include monthly or bi-monthly mail-out questionnaires [4, 5], weekly  or
monthly falls calendars , and monthly telephone interviews .
Each method has advantages and disadvantages in terms of accuracy, cost and
researcher time commitment. Calendars have an advantage in that subjects are
requested to indicate daily whether or not they have fallen. However, speciﬁc details
about the circumstances of any falls cannot be ascertained until the diary is
returned at the end of the month. Monthly questionnaires have an advantage in
that all relevant details can be gained from a single form. A sample of a monthly
questionnaire is shown in Figure 1.1. Telephone interviews gain the same informa-
tion as mail-out questionnaires, but may require many calls to contact active older
people. However, even with the most rigorous reporting methodology, it is quite
likely that falls are underreported and that circumstances surrounding falls are
sometimes incomplete or inaccurate. After a fall, older people are often shocked
and distressed and may not remember the predisposing factors that led to the fall.
Denial is also a factor in underreporting, as it is common for older people to lay the
blame on external factors for their fall, and not count it as a ‘true’ one. Simply for-
getting falls leads to further underreporting, especially in those with cognitive
In institutional settings, the use of falls record books maintained by nursing staﬀ
can provide an ancillary method for improving the accuracy of recording falls. In
a study of intermediate care (hostel) residents in Sydney, we found that systematic
recording of falls by nurses increased the number of falls reported by 32% .
The incidence of falls in older people
In 1977, Exton-Smith examined the incidence of falls in 963 people over the age of
65 years. He found that in women, the proportion who fell increased with age from
about 30% in the 65–69 year age group to over 50% in those over the age of 85 years.
In men, the proportion who fell increased from 13% in the 65–69 year age group
to levels of approximately 30% in those aged 80 years and over .
Retrospective community studies undertaken since Exton-Smith’s work have
reported similar ﬁndings: that about 30% of older persons experience one or more
4 Epidemiology of falls
5 Incidence of falls in older people
Fig. 1.1. Example of a monthly falls questionnaire.
falls per year [10–12]. For example, Campbell et al.  analysed a stratiﬁed
population sample of 533 subjects aged 65 years and over and found that 33% expe-
rienced one or more falls in the past year. Blake et al.  reported a similar inci-
dence (35%) in their study of 1042 subjects aged 65 years and over. In a large study
of 2793 subjects aged 65 years and over, Prudham and Evans  estimated an
annual incidence for accidental falls of 28%, a ﬁgure identical to that found in the
Dubbo osteoporosis epidemiology study of 1762 older people aged 60 years and
More recent prospective studies undertaken in community settings have found
slightly higher falls incidence rates. In the Randwick falls and fractures study con-
ducted in Australia, we found that 39% of 341 community-dwelling women
reported one or more falls in a 1-year follow-up period . In a large study of 761
subjects aged 70 years and over undertaken in New Zealand, Campbell et al. 
found that 40% of 465 women and 28% of 296 men fell at least once in the study
period of 1 year, an overall incidence rate of 35%.
In the USA, Tinetti et al.  found an incidence rate of one or more falls of 32%
in 336 subjects aged 75 years and over. Similar rates have been reported in Canada
by O’Loughlin et al.  in a 48-week prospective study of a random sample of 409
community-dwelling people aged 65+ years (29%), and in Finland by Luukinen et
al.  in 833 community-dwelling people aged 70+ years from ﬁve rural districts
(30%). Falling rates also increase beyond the age of 65 years. Figure 1.2 shows the
proportion of women who took part in the Randwick falls and fractures study 
who reported falling, once, twice, or three or more times in a 12-month period.
The prospective studies that have reported the incidence of multiple or recurrent
falls are also in good agreement. The reported rates from ﬁve studies for two or
more falls in follow-up year average 15% and range from 11% to 21%. The three
studies that report data for three or more falls all report an incidence of 8%.
Residents of long-term care institutions
Studies on the prevalence of falls have also been conducted in institutions, where
the reported frequency of falling is considerably higher than among those living in
their own homes. For example, Luukinen et al.  estimate that among people
aged 70 and over in Finland, the rate of falling in the institutionalized population
is three times higher than that among those living independently in the commu-
The prospective studies conducted in nursing homes have found 12-month falls
incidence rates ranging from 30% to 56%. In an early study, Fernie et al. 
studied 205 nursing home residents for 12 months and found 30% of the men and
42% of the women had one or more falls. More recently, two studies have reported
higher falls incidence rates in institutionalized older people. Lipsitz et al.  found
6 Epidemiology of falls
that 40% of 901 ambulatory nursing home residents fell two or more times in
6 months and Yip and Cumming  found that 56% of 126 nursing home resi-
dents fell at least once in a year.
Two other studies have calculated falls incidence rates across a number of
nursing homes. Rubenstein et al.  summarized the ﬁndings from ﬁve published
and two unpublished studies on the incidence of falls in long-term care institu-
tions. They calculated that the incidence rate ranged between 60% to 290% per bed,
with a mean fall incidence rate of 170% or 1.7 falls per person per year. Thapa et al.
 conducted a 12-month prospective study in 12 nursing homes involving 1228
residents. They reported that during the 1003 person-years of follow-up, 548 resi-
dents suﬀered 1585 falls.
Falling rates are also high in residents living in intermediate (hostel) care institu-
tions and retirement villages. We found a yearly falls incidence rate for one or more
falls of 52%, and for two or more falls of 39% in a hostel population of older people
. Tinetti et al.  also found a high incidence of falling in 79 persons admitted
consecutively to intermediate care facilities: 32% fell two or more times in a 3-
month period. In the one study that has been conducted in a retirement village to
date, Liu et al.  found that 61% of 96 subjects fell over a 12-month period.
7 Incidence of falls in older people
Fig. 1.2. Proportion of older women who took part in the Randwick Falls and Fractures Study who
reported falling, once, twice or three or more times in a 12-month period. Diagram
adapted from: Lord SR, Ward JA, Williams P, Anstey KJ. An epidemiological study of falls in
older community-dwelling women: the Randwick falls and fractures study. Australian
Journal of Public Health 1993;17(3):240–5.
Older people who have suﬀered a fall are at increased risk of falling again. In a
prospective study of 325 community-dwelling persons who had fallen in the pre-
vious year, Nevitt et al.  found that 57% experienced at least one fall in a 12-
month follow-up period and 31% had two or more falls. Not surprisingly, falling
is also more prevalent in frailer older people than vigorous ones, in those who have
diﬃculties undertaking activities of daily living, and in those with particular
medical conditions that aﬀect posture, balance and gait. Northridge et al. 
reported that when community-dwelling persons were classiﬁed as either frail or
vigorous, frailer people were more than twice as likely to fall as vigorous people.
Similarly, Speechley and Tinetti  reported 52% of a frail group fell in a 1-year
prospective period compared with only 17% of a vigorous group.
With regard to medical conditions, Mahoney et al.  found that 14% of older
patients fell in the ﬁrst month after discharge from hospital following a medical
illness. Falling rates are also increased in those with stroke and Parkinson’s disease.
Forster and Young  found that 73% of elderly stroke patients fell within 6
months after hospital discharge. Koller et al.  and Paulson et al.  report
falling yearly incidence rates of 38% and 53% respectively in elderly people with
idiopathic Parkinson’s disease. Kroller et al.  also noted that very frequent
falling was a problem in this group, with 13% reporting falling more than once a
week. Falls incidence is also high in older people following lower limb amputation.
Kulkarni  found that 58% of people with a unilateral amputation had at least
one fall within a 12-month period before their survey.
Increased falls incidence is also evident in persons with cognitive impairments
and other neurological conditions, arthritis and diabetes, although few studies have
reported speciﬁc falls incidence rates in these groups. In one study that examined
falls incidence in persons with Alzheimer’s disease, only 17% were reported to fall
within a prospective period of 3 years . This would appear to be an under-
estimate, as cognitive impairment has been found to be an independent risk factor
for falling in many subsequent prospective studies (see Chapter 4).
In independent older community-dwelling people, about 50% of falls occur within
their homes and immediate home surroundings (Figure 1.3) [16, 33]. Most falls
occur on level surfaces within commonly used rooms such as the bedroom, living-
room and kitchen. Comparatively few falls occur in the bathroom, on stairs or from
ladders and stools. While a proportion of falls involve a hazard such as a loose rug
or a slippery ﬂoor, many do not involve obvious environmental hazards . The
remaining falls occur in public places and other people’s homes. Commonly
8 Epidemiology of falls
reported environmental factors involved in falls in public places include pavement
cracks and misalignments, gutters, steps, construction works, uneven ground and
The location of falls is related to age, sex and frailty. In community-dwelling
older women, we found that the number of falls occurring outside the home
decreased with age, with a corresponding increase in the number of falls occurring
inside the home on a level surface (Figure 1.4) . Campbell et al.  found that
fewer men than women fell inside the home (44% versus 65%) and more men fell
in the garden (25% versus 11%). Also as would be expected, frailer groups with
limited mobility suﬀer most falls within the home. These ﬁndings indicate that the
occurrence of falls is strongly related to exposure, that is, they occur in situations
where older people are undertaking their usual daily activities. Furthermore, most
falls occur during periods of maximum activity in the morning or afternoon, and
only about 20% occur between 9 p.m. and 7 a.m. .
Consequences of falls
Falls are the leading cause of injury-related hospitalization in persons aged 65 years
and over, and account for 4% of all hospital admissions in this age group . In
Australia we found that hospital admissions resulting from falls are uncommon in
young adulthood but with advancing age, the incidence of fall-related admissions
increases at an exponential rate. Beyond 40 years, the admission rate due to falls
increases consistently by 4.5% per year for men (doubling every 15.7 years) and by
7.9% per year for women (doubling every 9.1 years)  (Figure 1.5). In those aged
9 Consequences of falls
Fig. 1.3. Location of falls. 56% of falls occur outside the home (in the garden, street, footpath or
shops), with the remainder (44%) occurring at various locations in the home. Adapted
from: Lord SR, Ward JA, Williams P, Anstey KJ. Physiological factors associated with falls in
older community-dwelling women. Australian Journal of Public Health 1993;17(3):240–5.
outside the home
shower / bath
getting out of bed
chair / ladder
85 years and over, the levels have reached 4% per annum in men and 7% per annum
in women. Falls also account for 40% of injury-related deaths, and 1% of total
deaths in this age group .
Depending on the population under study, between 22% and 60% of older
people suﬀer injuries from falls, 10–15% suﬀer serious injuries, 2–6% suﬀer frac-
tures and 0.2–1.5% suﬀer hip fractures. The most commonly self-reported injuries
include superﬁcial cuts and abrasions, bruises and sprains. The most common
injuries that require hospitalization comprise femoral neck fractures, other frac-
tures of the leg, fractures of radius, ulna and other bones in the arm and fractures
of the neck and trunk [1, 26, 35].
In terms of morbidity and mortality, the most serious of these fall-related
injuries is fracture of the hip. Elderly people recover slowly from hip fractures and
are vulnerable to postoperative complications. In many cases, hip fractures result
in death and of those who survive, many never regain complete mobility. Marottoli
et al.  analysed the outcomes of 120 patients from a cohort study who suﬀered
a hip fracture over a 6-year period. They found that before their fractures, 86%
could dress independently, 75% could walk independently and 63% could climb a
ﬂight of stairs. Six months after their injuries, these percentages had fallen to 49%,
15% and 8%, respectively.
Another consequence of falling is the ‘long lie’, i.e. remaining on the ground
or ﬂoor for more than an hour after a fall. The long lie is a marker of weakness,
illness and social isolation and is associated with high mortality rates among the
10 Epidemiology of falls
Fig. 1.4. Indoor falls location according to age. Adapted from: Lord SR
, Ward JA, Williams P, Anstey
KJ. An epidemiological study of falls in older community-dwelling women: the Randwick
falls and fractures study. Australian Journal of Public Health 1993;17(3):240–5.
chair / ladder
getting out of
shower / bath
0 5 10 15 20 25 30 35 40
% of all falls
11 Consequences of falls
Fig. 1.5. Hospital admissions for falls according to age and gender. Adapted from: Lord SR. Falls in
the elderly: admissions, bed use, outcome and projections. Medical Journal of Australia
elderly. Time spent on the ﬂoor is associated with fear of falling, muscle damage,
pneumonia, pressure sores, dehydration and hypothermia [6, 38, 39]. Wild et al.
 found that half of those who lie on the ﬂoor for an hour or longer die within
6 months, even if there is no direct injury from the fall. Vellas  suggests that
long lies are not uncommon. He found that more than 20% of patients admitted
to hospital because of a fall had been on the ground for an hour or more. Such a
ﬁgure could be expected as Tinetti et al.  found that up to 47% of non-injured
fallers are unable to get up oﬀ the ﬂoor without assistance.
Falls can result in restriction of activity and fear of falling, reduced quality of life
and independence. Even falls that do not result in physical injuries can result in the
‘post-fall syndrome’; a loss of conﬁdence, hesitancy, tentativeness, with resultant
loss of mobility and independence. It has been found that after falling, 48% of older
people report a fear of falling and 25% report curtailing activities [6, 43]. Tinetti et
al.  have also found that 15% of nonfallers also report avoiding activities due
to a fear of falling.
Finally, falls can also lead to disability and decreased mobility which o
in increased dependency on others and hence an increased probability of being
admitted to an institution. Falls are commonly cited as a contributing reason for an
older person requiring admission to a nursing home [42, 44].
The cost of falls
As indicated above, falls in older people are common and can lead to numerous dis-
abling conditions, extensive hospital stays and death. It is not at all surprising, then,
that falls constitute a signiﬁcant health care cost. Fall-related costs can include the
direct costs, which include doctor visits, acute hospital and nursing home care, out-
patient clinics, rehabilitation stays, diagnostic tests, medications, home care, home
modiﬁcations, equipment and institutional care. Indirect costs include carer and
patient morbidity and mortality costs. The literature on the total cost of falls is
scarce, however, as there are many diﬃculties and limitations involved in estimat-
ing the economic cost of any disease or condition. Problems exist because cost data
are only estimates, and many costs are only relevant to the country in which they
are incurred. Furthermore, because of inﬂation and other economic and health
care factors, costs are outdated soon after they are published.
A number of researchers have estimated the hospital costs of an injurious fall in
absolute terms and as a proportion of health budgets [35, 45–49]. In a detailed
report to the US Congress in 1989, Rice and MacKenzie  calculated that in 1985,
nearly $10 billion of the $158 billion or 6% of the lifetime economic cost of injury
in the United States was attributable to falls in older people. Furthermore, falls
account for 70% of all injury-related costs in elderly people. The cost per injured
12 Epidemiology of falls
person in 1985 was $4226, which was nearly double that of the average cost per
injured person for all age groups. Englander et al.  updated the costs of falls as
presented by Rice and MacKenzie  from 1985 US dollars to 1994 US dollars.
They projected the cost of falls in 1994 to total $20.2 billion, with a cost per injured
person being $7399. The authors further extrapolated these ﬁgures to the year 2020
and estimated the cost of falls injuries at $32.4 billion.
Despite the disparate methodologies of falls ascertainment used in the above
studies, the incidence rates reported are remarkably similar. Approximately one
third of older people living in the community fall at least once a year, with many
suﬀering multiple falls. Falling rates are higher in older women (40%) than in older
men (28%) and continue to increase with age above 65 years. The incidence of falls
is increased in people living in retirement villages, hostels and nursing homes, in
those who have fallen in the past year and in those with particular medical condi-
tions that aﬀect posture, balance and gait. In community-dwelling older people,
about 50% of falls occur within their homes and 50% in public places. Falls
account for 4% of hospital admissions, 40% of injury-related deaths and 1% of
total deaths in persons aged 65 years
and over. The major injuries that result from
falls include fractures of the wrist, neck, trunk and hip. Falls can also result
ability, restriction of activity and fear of falling, which can reduce quality of life and
independence and contribute to an older person being admitted to a nursing home.
Finally, as many fall-related injuries require medical treatment including hospital-
ization, falls constitute a condition requiring considerable health care expenditure.
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16 Epidemiology of falls