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Falls in the elderly

What's new

The American Physical Therapy Association (APTA) has published a new guideline for physical therapy management of fall risk in community-dwelling older adults. Multicomponent exercise is the key intervention and should include progressive, challenging balance training, with additional options such as Tai Chi. Balance training should incorporate volitional step training and/or gait adaptability training, and may also include reactive perturbation training. Resistance training alone is not recommended. .

Background

Overview

Definition
Falls in the elderly is an accidental event due to loss of center of gravity and imbalance that results in an increased risk of traumatic injuries and hospitalizations.
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Pathophysiology
Falls in the elderly can be caused due to intrinsic (sight disorders, hearing disorders, balance deficit, alterations in CNS, musculoskeletal alterations; neurological, cardiovascular, endocrine, psychiatric, and iatrogenic pathologies) and extrinsic (environmental factors such as obstacles, inadequate footwear) predisposing factors. Recurrent falls may suggest elder abuse or neglect.
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Disease course
Clinical manifestations of falls in the elderly include pain, bruising, lacerations, fractures (mostly upper extremity and hip fractures), and intracranial bleeding in severe cases. Falls in the elderly increase the risk of hospitalizations and morbidity.
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Prognosis and risk of recurrence
Falls-related mortality in adults with 65, 75, and 85 years of age is 50 per 100,000, 150 per 100,000 and 5,252 per 100,000 individuals, respectively.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of falls in the elderly are prepared by our editorial team based on guidelines from the American Physical Therapy Association (APTA 2025), the American Academy of Family Physicians (AAFP 2024), the Osteoporosis Canada (OC 2023), the World Falls Guidelines (WFG 2022), the American College of Obstetricians and Gynecologists (ACOG 2021), the ...
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Screening and diagnosis

Indications for screening
As per AAFP 2024 guidelines:
Use the CDC's Stopping Elderly Accidents, Deaths, and Injuries questionnaire to screen older adults for fall risk.
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Obtain further evaluation, including the Timed Up and Go, 30-Second Chair Stand, and 4-Stage Balance tests, to evaluate for gait, strength, and balance abnormalities if there is an affirmative response to any of the three Stopping Elderly Accidents, Deaths, and Injuries questions.
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Classification and risk stratification

Risk prediction, general principles: as per WFG 2022 guidelines, obtain multiprofessional, multifactorial assessment in community-dwelling older adults identified to be at high risk of falling, to guide tailored interventions.
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  • Risk prediction (screening for environmental hazards)

  • Risk prediction (cardiovascular assessment)

  • Risk prediction (assessment of gait and balance)

  • Risk prediction (assessment of dizziness)

  • Risk prediction (assessment of vision and hearing)

  • Risk prediction (assessment of urinary symptoms)

  • Risk prediction (assessment of pain)

  • Risk prediction (assessment of mental health)

  • Risk prediction (assessment of nutritional status)

Diagnostic investigations

Clinical history: as per WFG 2022 guidelines, ask older adults presenting with a fall or related injury about the details of the event and its consequences, previous falls, transient loss of consciousness, or dizziness, and any preexisting impairment of mobility or concerns about falling causing limitation of usual activities.
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  • Diagnostic imaging

Medical management

Management of cardiovascular issues
As per WFG 2022 guidelines:
Manage orthostatic hypotension as a component of a multidomain intervention.
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Offer the same intervention for cardiovascular disorders identified during assessment for risk of falls as for similar conditions associated with syncope, in addition to other interventions based on the multifactorial falls risk assessment.
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  • Management of vestibular issues

  • Management of impaired vision

  • Management of pain

  • Management of patient concerns

Inpatient care

Inpatient assessment: as per WFG 2022 guidelines, obtain a multifactorial falls risk assessment in all hospitalized patients aged > 65 years. Do not use scored falls risk screening tools in hospitals for multifactorial falls risk assessment in older adults.
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  • Inpatient prevention strategies

Specific circumstances

Patients in care homes: as per WFG 2022 guidelines, do not obtain fall risk screening to identify care home residents at risk for falls since all residents should be deemed at high risk of falls.
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  • Patients with Parkinson's disease

  • Patients with hip fracture

Patient education

General counseling
As per APTA 2025 guidelines:
Provide tailored education combined with individualized exercise intervention for older adults. Ensure the tailored education includes specific actions to address identified risk factors, such as home hazards and strength and balance impairments, and include referral to appropriate providers for risk factors outside the scope of physical therapy practice.
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Do not provide education alone to older adults to reduce the risk and/or rate of falls.
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Preventative measures

General principles: as per WFG 2022 guidelines, incorporate the individual's values and preferences in the care plan developed to prevent falls and related injuries.
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include both the individual's and their caregivers' perspectives when creating fall prevention care plans for older adults with cognitive impairment.
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  • Environmental modifications

  • Exercise interventions

  • Multifactorial interventions

  • Hip protectors

  • Vestibular rehabilitation

  • Vitamin D/calcium supplementation

  • Medication review