About one in three people aged 65 or over will fall each year, rising to one in two by age 80 to 85—contributing to the idea that falls are inevitable as you get older.

But “nothing could be more wrong, because many falls are preventable,” says Professor Kim Delbaere, Discipline Lead of Physiotherapy at the University of New South Wales and a Senior Principal Research Scientist and Director of Innovation and Translation at the Falls, Balance and Injury Research Centre, Neuroscience Research Australia.

Until recently, a lack of up-to-date clinical practice guidelines has made it difficult to prescribe evidence-based prevention strategies, but last year, the Australian Commission on Safety and Quality in Health Care released guidance based on international recommendations for managing falls in older adults, Professor Delbaere explains.

These provide a consistent approach to falls prevention in various settings, including the community.

Falls risk screening

Falls aetiology is complex, involving “a culmination of different risk factors that all come together,” Professor Delbaere says. Many of them, such as declining balance, vision and reaction time, are associated with ageing—but can also be effectively managed.

To identify people at increased risk of falling, she recommends asking three questions:

• Have you had a fall in the past year?
• Do you feel unsteady when walking?
• Are you worried about falling?

A “Yes” to any of these should prompt further assessment of risk.

She also recommends running a simple gait speed test such as the 4-metre walk test or a timed up and go (TUG), where you ask the patient to stand from a chair, walk three metres, turn around, walk back and sit down again. This is a good way to observe a patient’s functional mobility, with cutoff points associated with an increased risk of falling.

Asking patients to stand on one leg is a quick way to assess balance, she adds. “They should be able to stand on one leg for 10 seconds. Your risk of falling is drastically increased if you can’t do five seconds.”

While falls prevention is a priority for patients over the age of 65, balance starts to decline from around age 40. Preventative strategies should be implemented sooner rather than later, and definitely before a first fall—although it’s never too late to start, she stresses.

Targeted balance training is crucial

Balance training, ideally from about the age of 50, but definitely from the age of 65, is key to prevention. To be effective, it needs to be challenging—but not so challenging that it’s unsafe, Professor Delbaere emphasises. Balance exercises therefore need to be individualised.

For example, one person may find it challenging to practise standing on one leg while brushing their teeth, but another might need to start by standing with one foot in front of the other.

Training must be adapted as the patient improves. For example, patients could begin with static activities and progress to tasks that involve movement, reaching or changes in direction.

The recommended minimum dose is two hours per week, which can be achieved through short sessions embedded in daily routines—such as while waiting for the kettle to boil or hanging clothes on the line, Professor Delbaere says.

Some patients may enjoy group-based programs like Tai Chi or yoga, while others will prefer to train at home. Digital and telehealth options may suit patients in regional areas with limited access to services.

Programs should be maintained for at least six months, and ongoing practice is needed to sustain the benefits, she explains.

The guidelines advise that falls prevention exercise programs should be designed and delivered by appropriately qualified health professionals (e.g. physiotherapist or exercise physiologist).

Motivating patients with balance training

It’s often helpful to frame exercise as a way to maintain independence and quality of life rather than around falls prevention, Professor Delbaere suggests.

“A lot of people really want to keep their lifestyle for as long as possible, being able to travel, play with the grandkids, go to social gatherings and just being independent and enjoying life,” she says.

“And we actually need our balance—we need to be able to walk around and mobilise freely—to do all those things.”

What about strength training?

While it can improve bone and muscle health, “strength exercise alone does not make a difference” to falls risk, Professor Delbaere says.

“And it’s the same for walking. There’s actually been an important study that showed a walking program increased falling. But that’s not saying it’s not good for you. It just says that if you prescribe walking for a person, but their balance is not quite right, you might actually expose them to risk,” she says.

“It’s very important to understand the nuance and make sure that the person has the balance to do the activity that you’re recommending.”

Mitigating risk at home

A lot of falls happen at home, and many potential hazards can be modified, Professor Delbaere says.

The guidelines recommend that older people living in the community who are at increased risk of falls should have a home safety assessment, and suggest organising an occupational therapy referral to assess whether any environmental modifications or equipment are needed.

In some cases, simple measures—like removing trip hazards and ensuring adequate lighting for night-time bathroom visits—can be enough to lower risk, Professor Delbaere says.

Health checks

At-risk patients should see their GP every six to 12 months for a review of health risk factors associated with falls, Professor Delbaere advises – noting polypharmacy is a priority. “Patients on four or more medications, and particularly those taking psychotropic drugs, antihypertensives or diuretics, face significantly increased risk, and medication review or deprescribing can reduce it rapidly.”

“Vitamin D deficiency is common in older adults and associated with muscle weakness, falls and injury; testing and supplementation where indicated is straightforward and effective,” she adds.

“Orthostatic hypotension is worth checking, particularly in patients on antihypertensives or with a history of dizziness or near-falls. Vision should also be on the checklist; cataracts and other age-related conditions are treatable, and even moving patients to single lens glasses can reduce risk.”

Breaking the fear cycle

Fear of falling is clinically significant and can affect anyone—not just people who’ve already had a fall. “Maybe someone they’ve known had a really nasty fall or they feel unstable and they’re worried about the consequences if they fall,” Professor Delbaere says.

“It’s actually more common than falls itself,” she says, noting fear of falling leads patients to restrict their activity. Over time, reduced activity leads to deconditioning and increased frailty, further raising the risk of falls.

“So it becomes this self-fulfilling prophecy almost,” she says, stressing that preventative strategies can help break this cycle.

Key takeaways

• Opportunistic screening from age 65 using three simple questions can help identify patients at increased risk of falls
• Balance training is essential; strength and walking alone do not reduce falls risk
• Balance begins to decline from midlife, making early intervention crucial
• Exercises must be challenging, progressive and performed regularly, aiming for around two hours per week
• Regular review of health factors, including medications and vision, along with attention to the home environment, are also key to prevention
• Fear of falling can increase risk and should be managed by focusing on prevention

Helpful resources

Australian Commission on Safety and Quality in Health Care | Falls prevention guidelines

The international clinical geriatrics journal | World guidelines for falls prevention and management for older adults: a global initiative

Falls prevention app | StandingTall

Falls Prevention Alliance Australia

NSW Fall Prevention and Healthy Ageing Network