Falls in Older Adults

by Sue Coppola
August 2009

“A fall is a major event in the life of an older person,” wrote John Morley in the Journal of Gerontology. It can be a life changing event for a person and a family, and is now a significant public health concern. Young people fall but are much less likely to be injured, and according to the Centers for Disease Control and Prevention (CDC), falls for older adults are the most common cause of injury deaths, nonfatal injuries and hospital admissions for trauma.

In about 30% of cases, falls cause bruises, fractures (often of the hip, wrist or spine), or head traumas. The financial price is compelling, with the current cost of a fall injury averaging about $20,000. Moreover, the estimated annual cost for falls in the U.S. are expected to exceed $50,000,000,000 by 2020. These injuries can lead to a cascade of secondary problems including pneumonia and debility from which they never fully recover. The personal costs of falls or fear of falling are immeasurable. Some adults become depressed, socially isolated and weak from inactivity. Others recover from falls and become adept at preventing future falls.

Risk — There are multiple ways of thinking about risk. One is the chance of falling, another is the consequences of a fall. In the US, people over age 65 have a 30%-50% incidence of falling, and that risk increases with each passing decade. People living in nursing homes have an even greater risk for falling. Certain conditions such as Parkinson’s disease, low vision, stroke, and dementia put a person at greater risk for falls. Increases in a person’s cumulative number of heath conditions and number of prescription medications also may contribute to the risk. This cumulative effect is partly because the human body is designed for compensation. For example, if we are unable to see, we use our other senses to know whether we are standing upright or leaning. Yet if our other sensory systems are not working properly, it is difficult to maintain an upright position. Thus if someone has poor vision and sensory loss in their feet, balance can be difficult.

Health conditions are only part of the picture. Two people may have the same list of medications and health conditions, yet one falls while the other does not. Frequent falls are considered a “geriatric syndrome”, they are not a single health condition but a confluence of factors that create a pattern of risk. Characteristics of the person, such as impulsivity, distractibility and risk taking behavior, contribute to falls risk.

The nature of a person’s lifestyle and daily occupations influence whether or how a fall might occur. Older adults who play high-risk sports or climb ladders, for example, have different kinds of falls than others who may lose their balance when attempting to stand up from the edge of the bed. Multitasking is a hallmark of the modern life, and it is a habit that everyone knows carries risk. If there were one mantra for a person who does not want to fall it is “do one thing at a time”.

The environment plays a key role in falls. In the community, uneven terrain, stairs without handrails, or a lack of strategically located seating create barriers to participation for people at risk for falls. Home modifications, such as grab bars, railings and raised seats, are helpful to prevent falls when those features are tailored to the user and the person habitually uses those supports. Keeping pathways free of clutter is an obvious but recalcitrant problem for people with low vision or unstable gait.

Walking devices, such as canes and walkers, can liberate a person to walk more safely without fear of falling. However, those devices need to fit the person and be used properly to prevent risk of falling. For some, overuse of power mobility devices can contribute to debilitation. A strong sense of identity and persistence are virtues that can make a person less willing to make these changes. Adaptability is a virtue that works better in this situation.

Prevention — When approaching falls prevention, the person who is at risk needs to be at the center of the plan. That person does not want to fall. Offering information and making a plan together is essential, even when the person has mild cognitive problems. If the person has severe cognitive problems, of course they will need a more active role by others. Restraints to keep someone from standing up from a bed or chair are not good practice, and they are humiliating. The person will still attempt to get up and therefore is at greater risk for injury because of the restraint, regardless of whether the restraint is a physical device or a medication to sedate the person. For people with cognitive problems it is better to engage the person in a safe activity than restrain them and expect them to sit still.

Falls prevention brings up many ethical issues because the person may wish to take more risk than others can cope with. Value for personal autonomy can be pitted against a desire to protect the person. Such conflicts sets the stage for underreporting of falls by a person who fears that they will be “put in a nursing home” or lose other freedoms once labeled as a person who falls. Long term care facilities, while obligated to report all falls may underreport to prevent citations, fines or legal repercussions. As a community we must accept that falls exist and that they are a problem that we need to work together to solve.

It takes a village — There are many professionals with expertise in falls prevention, and a person who falls or has fear of falling may need them all. As an occupational therapist, my focus is to keep the person participating in life using strategies that reduce falls risk. Pacing oneself, using a cart to transport items, or adding handrails in key locations are examples of strategies and modifications. The natural way a person moves and lives life is key to what new habits or supports one should recommend.

Physical therapists are experts on mobility. They have individual and group sessions to improve balance, mobility, and strength, and can recommend footwear, exercise, canes and walkers. Physicians, nurses, pharmacists who practice with older adults are essential to optimize health and weigh benefits and risks of medications and supplements. Nutritionists are too often overlooked in their role to optimize nourishment and hydration to prevent falls. These professionals are trained in depth on particular areas, but everyday common sense about, water, rest, food, and activity goes a long way.

ABCs of Fall Prevention
Sue Coppola proposes the ABC’s of falling: Active But Careful. Be Active — Use it or lose it!

  • Do routine activity whenever it’s safe: laundry, housework, walking to the mailbox, taking walks, sports, enjoying a hobby. Paid or volunteer work can keep you fit. Limit TV to less than two hours per day. Manage weight to reduce strain on your joints when you move.
  • Be with people; go out to meals or other activities on a regular basis.
  • Use medicine, good footwear and other strategies to minimize pain so it is comfortable to move.
  • Exercise classes particularly those tailored to balance, including Tai Chi are beneficial. If that’s not your style, join a club that will involve activity (birding, religious, crafts, etc.).
  • Eat well, drink plenty, and rest when you need it.
  • If you fear falling, you can do something about it. Talk with your healthcare providers.

Be Careful — "Common sense is genius dressed in working clothes." Ralph Waldo Emerson

  • Do one thing at a time, so you can pay attention to your movement.
  • Be open to assistive devices like a cane if it can keep you safe and active.
  • Ask for a review of your medicines to minimize fall risk and to discuss medication to strengthen your bones to prevent fractures.
  • Modify your home for good lighting throughout and install supports like handrails at any risk area.
  • Plan what you do, avoiding rushing, quick movements. Think “It can wait.”
  • Weigh risks of activities like shaky ladders. Get help.
  • Consider an alerting system so you can get help if you fall.
  • If you do fall, tell someone so that you can be monitored for late effects that can be dangerous.

A fall is a major event in the life of an older person. Considering the consequences of a fall, older adults who have fear of falling, are actually being reasonable. The problem is that when fear of falling causes curtailment of activity, then the risk and consequences of falls is even greater. There are many ways to reduce risk and consequences of falls, especially when a person is ‘active but careful’.


Sue Coppola, MS, OTR/L, BCG, FAOTA is Associate Professor and Fieldwork Coordinator in the Division of Occupational Science at the University of North Carolina at Chapel Hill. She served as Chair of the Board Certification in Gerontology Panel for the American Occupational Therapy Association (AOTA), and is first editor for the AOTA(2008) text: “Strategies to Advance Gerontology Excellence: Promoting Best Practice in Occupational Therapy.” For videos of Sue Copola on falls prevention, go to unchealthcare.org/site/newsroom/falls20923 and unchealthcare.org/site/newsroom/falls10923

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