Merck Manual

Please confirm that you are a health care professional

honeypot link

Approaching the Staggering Problem of Falls in Older Adults—Commentary

09/21/15 Laurence Z. Rubenstein, MD, MPH, University of Oklahoma College of Medicine|University of California, Los Angeles;

In July 2015, the National Council on Aging released a plan to reduce the growing number of falls and injuries related to falls among older adults. This 2015 Falls Free National Action Plan reports on key action items from an April 2015 Falls Prevention Summit, an event sponsored by the White House Conference on Aging. The National Action Plan, the CDC’s STEADI materials for health care providers, and the Merck Manual chapter on Falls in the Elderly provide useful tools to help health care providers identify patients at risk for falls and offer suggestions providers can give patients to help them decrease the risk of falls. 

The National Council on Aging has designated the first day of fall, September 23, as Falls Prevention Awareness Day. Falls are one of the most serious clinical problems facing older adults. They cause substantial morbidity, mortality, and premature nursing home placement. Unintentional injuries are the fifth leading cause of death in older adults, and falls comprise two thirds of these deaths. In the US, about three fourths of deaths due to falls occur in the 13% of the population aged 65 and older, making injurious falls a true geriatric syndrome. At least a third of older persons living at home will fall each year, and about 1 in 40 will be hospitalized. Of those hospitalized after a fall, nearly half will die within a year. Repeated falls and instability are common precipitators of nursing home admission. And within long-term care institutions, fall rates are even higher, averaging almost 2 falls per patient year.

The problem of falls in older persons is more than simply their high incidence, since young children and athletes fall more frequently than all but the frailest elderly groups. Rather it is a combination of a high incidence of falling together with a high susceptibility to injury, due to a high prevalence of clinical diseases (eg, osteoporosis) and age-related physiological changes (eg, slowed protective reflexes) that make even a relatively mild fall particularly dangerous. In addition, recovery from fall injury is often slow in older persons, further increasing risk for subsequent falls through deconditioning. Another complication is the post-fall syndrome, in which an individual down-regulates activity in a perhaps over-cautious fear of falling; this in turn further contributes to deconditioning, weakness, abnormal gait, and in the long run can further increase risk of falls. The financial costs of falls are immense as well: by 2020 the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion (in 2007 dollars).1  

Yet there is good news too. The U.S. Public Health Service has estimated that two thirds of deaths due to falls are potentially preventable, based on analysis of causes and circumstances of serious falls. In the past two decades there have been over 220 randomized clinical trials published that focus on methods for fall prevention, and many promising techniques have been documented and confirmed in meta-analyses.2-4 Effective approaches include

  • Multidimensional risk factor assessment tied to targeted interventions
  • Exercise programs (including balance, strength, and endurance training)
  • Environmental assessment and modification
Programs combining all of these approaches seem to have had the strongest effects. Moreover, most of these fall prevention interventions offer other benefits as well, such as improved strength, endurance, and quality of life. 

Consideration of important fall risk factors can help the clinician identify patients most at risk of falls and guide in reducing risk. The clinical practice guidelines on fall prevention and treatment of the American and British Geriatrics Societies recommend that a fall-risk assessment should be an integral part of primary healthcare for older persons, and that the intensity of the assessment should vary with the target population.5 Low-risk community-dwelling older persons should be asked at least once a year about fall occurrence and circumstances. High-risk populations should undergo a comprehensive assessment. The most important high risk factors are multiple falls in the past year, muscle weakness, problems with gait and balance, need for medical attention because of a fall, and residence in a nursing home. Other risk factors include visual deficits, arthritis, functional impairment, depression, cognitive impairments, psychoactive medications, and polypharmacy. Once risk factors are determined, specific and effective therapy can be instituted. 

In summary, falls are common and often devastating to the elderly population, and systematic attention to fall prevention is a vital part of comprehensive care of the older adult. A number of important risk factors, such as for example, weakness, gait/balance impairment, functional and cognitive deficits, psychotropic medications, and polypharmacy, will identify people who are most likely to fall and therefore who most need prevention interventions. Substantial research has confirmed the clear effectiveness of fall prevention measures, including fall risk assessments tied to interventions, exercise programs, environmental inspection and modification, and combined interventions. The future looks bright in this area, as in so many areas of geriatrics. 


1. Costs of Falls among Older Adults. Accessed August 28, 2015.

2. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012 Sep 12;9:CD007146. doi: 10.1002/14651858.CD007146.pub3.

3. Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012 Dec 12;12:CD005465. doi: 10.1002/14651858.CD005465.pub3. 

4. Howe TE, Rochester L, et al. Exercise for improving balance in older adults. Cochrane Database Syst Rev 2007: CD004963. PMID 17943831.

5. Kenny RA, Rubenstein LZ, Tinetti ME, et al. AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. J Am Geriatr Soc 59(1):148–157, 2011.

See Dr. Rubenstein's discussion of Falls in the Elderly in the Merck Manual.