Better Health While Aging

Practical information for aging health & family caregivers

Why Older People Fall & How to Reduce Fall Risk

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senior man falling downWhy do aging adults fall? To be honest, people don’t usually ask me this.

Instead, they want to know things like “How do I keep my mother from falling?” or “What should I do? My grandfather’s been falling.”

After all, falls are a scary thing. Most people know that falls are dangerous for older adults.

The Center for Disease Control (CDC) reports that one in five falls causes a serious injury such as a broken bone or head injury. Fear of falling can also seriously affect an aging adult’s quality of life and sadly, can keep a person from being active and thriving.

So, many older adults and family caregivers are interested in fall prevention because the risks are so great. (According to Google, “balance exercises for seniors” is a popular search query; I do like balance exercises in aging, especially when combined with strength training and other exercises.)

And the good news is that although it’s not possible to prevent all falls, it almost always IS possible to take actions that will reduce the chance of a bad fall.

And it’s easier to take action once we understand more about why an older person has fallen.

If you want to learn more, you’re in the right place. In this article, I’ll cover:

  • How understanding why aging adults fall can help you keep an older parent — or yourself — safer,
  • Why personalized fall prevention plans work better than relying on general fall prevention tips,
  • The four-step process I use to help older adults prevent falls,
  • A practical example showing you how to use these steps to avoid falls yourself.

First, understand why older people fall

There are many reasons that aging adults fall. Most older people will be falling due to their own unique combination of reasons.

So how, exactly, should YOU go about reducing fall risk?

Now, you can — and should — try to implement the general tips that are often listed in most fall prevention resources: exercise, medication review with the doctor, vision checks, and home safety reviews. 

But if you really want to help an older loved one avoid falls, I recommend you learn to better understand why he or she, in particular, might fall.

Why? Because when you understand the specific reasons an older person may be falling, you’ll then be able to:

  • Identify which fall prevention strategies are most likely to help the person you worry about,
  • Recognize risky situations, and take steps to avoid them,
  • Know which medical conditions — and which medications — to ask your doctors to look into,
  • Understand what may have caused a specific fall, which can help you avoid future falls.

In other words, learning why older people fall means that you’ll be able to figure out why YOUR older relative is likely to fall — and take steps to help them.

Why personalized fall prevention works better than general fall prevention

Once you understand the particular factors contributing to your older loved one’s risk, it will be easier to focus on the fall prevention strategies that are most relevant to your situation. In other words, you’ll be able to personalize your approach to fall prevention.

Personalizing fall prevention is critical. You don’t want your mom to start by spending a lot of time on tai chi or some form of balance exercise for seniors, if her current major risk for falls might be that her blood pressure medications are too strong, or her eyesight is terrible.

Also, don’t assume that most doctors will identify and manage the most important risk factors for falls. In my experience, busy doctors often miss opportunities to reduce fall risk, unless a family is proactive in asking for the right kind of help.

Now that we’ve covered how understanding falls can help you, let’s talk about falls. First, I’ll explain why any fall happens. Then I’ll share my framework for understanding why a particular older person might fall.

Why a fall happens

Why does a fall happen? Fundamentally, no matter who you are and what age you are, here’s why:

Challenge to balance or strength > Ability to stay upright”

In other words, we fall when we experience some kind of event that challenges our balance or strength. If this event overwhelms our ability to remain upright, down we go.

When we’re young and healthy, we tend to have lots of ability to stay upright. So if we stumble, we can often catch ourselves and recover before we fall. But of course, a big enough knock off-balance will send even a 20-year-old sprawling. And if that 20-year-old happens to be tipsy, it will take even less of a trigger to provoke a fall.

Illness or weakness is another situation that will reduce anyone’s ability to stay upright. (This is why people of all ages are prone to fall in the hospital.) But of course, older adults often have many other things going on which affect their ability to stay on their feet.

4 Steps to Reduce Fall Risk

Falls in older people are almost always “multifactorial.” This means there are usually several factors that are contributing to a fall, or to a person’s fall risk.

It can be hard to try to address every single factor. And some, such as slower reflexes, may be impossible to reverse.

Still, it’s often useful to go through them and try to spot a few that are either easy to fix, or potentially offer a big reduction in fall risk.

As a geriatrician, here’s what I do:

  1. Create a list of factors contributing to an individual older person’s fall risk.
  2. Identify risk factors and triggers related to recent or recurrent falls.
  3. Identify the factors that are easiest to modify or change. This is partly about the factor itself, and partly about what’s feasible for my patient to try to change. (Stairs can be a risk, but changing houses can be tricky.)
  4. Implement practical strategies to address modifiable fall risk factors. 

3 types of fall risk factors you should consider

I also find it helpful to think of the factors as belonging to one of three categories:

  • Health-based risks. This includes things like balance problems, weakness, chronic illnesses, vision problems, and medication side-effects. They are specific to an individual person.
  • Environmental risks. These are things like home hazards (e.g. loose throw rugs), outside hazards (e.g. icy sidewalks), or risky footwear (e.g. high heels). This category can also include improper use of a walker, cane, or other assistive device.
  • Triggers: These are the sudden or occasional events that cause a challenge to balance or strength.  They can be things like a strong dog pulling on a leash, or even health-related events like a moment of low blood sugar (hypoglycemia) in a person with diabetes.

Now, you will probably find it hard to make a list of all these factors on your own. The health-based factors, in particular, tend to be closely related to medical problems. So they can be hard to properly sort out unless you’ve learned a lot about medicine.

Still, I encourage older adults and family caregivers to learn to think about fall risk factors, since this can help people get better at asking their doctors the right questions.

It’s also a good idea to ask lots of questions after a fall. You can learn more about what to ask here: 8 Things to Have the Doctor Check After an Aging Person Falls.

Example: Why is Mr. Jones falling?

Let’s consider an example together, to illustrate how you can put this understanding to work.

Mr. Jones is 82 years old. He lives at home with his wife, and takes a daily walk in his neighborhood. He has had diabetes for a long time, and has chronic numbness in his feet.  He is on medication for diabetes, high blood pressure, and also uses Tylenol PM.

His daughter Wendy subscribes to a newsletter about elder care, and she recently read the CDC’s fact sheet on how important fall prevention is. Her father has had a few falls, which has made Wendy concerned. She would like to keep her father from falling.

What should Wendy do? As I mentioned earlier, the usual recommendations to lower fall risk are a good place to start. So Wendy could encourage her father to remain physically active and do balance exercises, and she might want to take a closer look at the house to remove common trip hazards.

She might also want to help him get evaluated for vision problems and for low leg strength, since these are common fall risk factors among people Mr. Jones’ age. Furthermore, diabetes can cause or worsen vision problems.

But if Wendy wants to personalize the fall prevention plan, she should also consider asking the doctor to help make a list of Mr. Jones’ health-based risk factors.

In Mr. Jones’ case, some additional factors that jump out at me are:

  • Chronic numbness in feet. This is a common problem in people who have had diabetes for a long time, and it can definitely affect how easily people stay on their feet.
    • It’s good to be aware of this risk, however, this problem usually can’t be cured or reversed.
  • Diabetes. Some people with diabetes are prone to episodes of low blood sugar (hypoglycemia), especially if they take insulin or other drugs to actively lower blood sugar.
    • Wendy could ask her father if he ever has low blood sugar episodes, which could trigger a fall. If he does, she should make sure this is addressed with the doctor.
    • It is often appropriate to relax blood sugar control as people become older and frailer. This is because as people age, tight control brings fewer benefits but more risks.
  • Blood pressure medication. This could increase fall risk, especially if Mr. Jones’ blood pressure is often below 120/80.
  • Tylenol PM. Any over-the-counter medication labeled “PM” contains a sedative, usually in the form of an antihistamine such as diphenhydramine (brand name Benadryl). Older adults are often sensitive to these drugs, which can worsen balance or even thinking.
    • Wendy should help her father review his medications. She should focus on spotting sedatives or any other medications with strong “anticholinergic” effects, such as a medication for overactive bladder. (For a link to a good list of anticholinergic drugs to avoid, see this post.) All sedating or anticholinergic drugs increase fall risk, but doctors may forget to avoid or minimize them unless a family specifically requests this.

You may have noticed that in this example, I’ve particularly focused on medications.

That’s for three key reasons:

  • Medications are among the most common causes of increased fall risk in older people.
  • Medications are often a fixable risk factor, when it comes to falls in older adults.
  • Medication-based risks are often missed by busy regular doctors. Family caregivers can make a big difference by being proactive in this area.

If you’re concerned that you or your older relative might be on medications that are increasing your fall risk, see this article: 10 Types of Medications to Review if You’re Concerned About Falling.

You can also learn more about how to prevent injuries from a fall here: 3 Ways to Prevent Injury From a Fall (Plus 3 Ways That Don’t Work as Well as You’d Think)

Take the next step: create a personalized fall prevention plan

Remember, older adults usually fall because a) multiple risk factors make them vulnerable to falling, and b) a stumble or moment of weakness triggers the actual fall.

Most fall risk factors are health-based, and are related to chronic medical conditions or medications. And then some fall risk factors are environmental, and involve the home or outside environment.

You can definitely reduce fall risk by encouraging strength and balance exercises, and by optimizing the home environment. (Learn more about good strength and balance exercises here: Videos Illustrating Otago Exercises for Fall Prevention.)

But you’ll be most effective in preventing falls if you can get your doctors to help you understand your loved one’s personal fall risk factors.

This way, you’ll be able to develop a more personalized fall prevention plan…one that targets the risks and vulnerabilities most relevant to your situation.

[This article was last updated by Dr. Kernisan in March 2024.]

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Comments

  1. I’m 90 years and in good heath. I go for short walk almost every day, weather permitting.

    I think I now know why many elderly people fall when moving about. It’s because they are looking straight ahead. They need to be taught to look down to see where their feet are about to go next.

    That’s particularly true when walking down stairs. Don’t look straight ahead, look at the next few steps.

    Try it out for yourself. If you agree, tell your elderly relatives and friends.

    • Wonderful that you are doing well at age 90 and walking every day. Thanks for sharing what’s been working for you.

    • Yes we were all taught to look straight ahead keep our shoulders straight etc. I’m 66 and have had two falls one had stitches. These falls happened because I was walking around outside in low light with my head straight up looking forward On uneven ground. I have to teach myself to look down. It sounds like a easy thing to pursue but it is most difficult. A training of a lifetime it’s almost impossible I don’t know how I’m going to remind myself to look down.

      • I use a pair of walking sticks when taking a walk. Remember to go forward with the stick opposite the leg/foot going forward (to avoid setting the stick down on your foot!). The sticks actually make you look down and forward a bit more while walking, and they also help you keep better balance while walking. It takes some practice, but once you get used to walking sticks, you’ll love using them.

    • Prozac is an antidepressant and Byetta is a diabetes drug. Both these types of medications are associated with increased fall risk, so they should be used judiciously. I explain medications in more depth here:
      10 Types of Medications to Review if You’re Concerned About Falling

      As far as I know, the research on estrogen maintaining balance or otherwise preventing falls is inconclusive. Estrogen does help maintain bone strength, and so people taking estrogen do have a reduced risk of fractures if they fall. But estrogen therapy is also associated with an increased risk of cardiovascular events, blood clots, breast cancer, and more. So…I would not recommend taking estrogen just to reduce fall risk or fall injury risk, and if you are already on it, I would say the main benefit is probably reduced risk of fracture if you fall.

  3. At 65 and 2 hip fractures I seem to be starting on this trip we call geriactric and all the things you will need to know to make life some what normal. I have read all the comments written and sometimes am overwhelmed at all the problems and concerns I need to have. Since I am just starting on this journey I have a lot to think about as well as doing my best to find the correct way to handle the issues I seem to have at this point in my life. Thank you for your support and ways to look at problems in a solving frame of mind. Also…where do I find a geriactric doctor?

    • Yes, unfortunately there can be a lot to do and research and keep track of, to optimize health as one ages. I can certainly see how it would be overwhelming, especially at the beginning, where the more you learn, the more you realize you need to learn.

      But, if you give yourself some time and pace yourself, you can probably find a reasonable balance in which you spend some time overseeing your health (you’ll need it, in order to make the best of life as you get older) without being too consumed by the details and every little thing you possible could do. (It’s just not possible to do every single little thing that might be good for one’s health.)

      A good primary care provider or team can make a big difference. I have suggestions on finding geriatrics care here:
      How to find geriatric care — or a medication review — near you

      Also, if you’ve had falls or hip fractures, you might find some useful information here:
      3 Ways to Prevent Injury From a Fall (Plus 2 Ways That Don’t Work as Well as You’d Think)

      Good luck!

  4. I’m only 69 but I think I’m more apt to trip over a tripping hazard than I was when I was younger. I don’t have any of the conditions you mentioned. I have fairly low blood pressure and take fludrocortisone to raise it, but none of my trips related to fainting. My vision is still quite good, but I’m wondering if I simply fail to lift my foot high enough or whether my feet sometimes droop or whether depth perception worsens with age even with good vision. (I had cataract replacement surgery when I was in my 50’s so my eyes don’t change much.) Or perhaps I multitask (thinking about something else while walking) even more poorly than I did when I was younger. Do any of those explanations make sense? I obviously can’t distinguishing between the causes because if I were aware of the cause at the time I would not fall.

    • Yes, people do become worse at multitasking as they age.

      If you have not yet talked to your doctor about your falls, I would recommend you do so. Your doctor can do a neurological exam to see if there’s anything obviously amiss with your reflexes or the way you are moving. I would also recommend a physical therapy evaluation.

      We don’t always uncover specific causes for falls when we investigate, but it’s important to check. The explanations you are considering for yourself are plausible. Improving your balance and lower leg strength through certain exercises might help. Good luck!

    • I am 65 and work full time. I go to the gym three to four times a week. Yet I’ve had two falls one very recently. I’m in good health without no medication.

      • Sorry to hear of your recent falls. I would recommend a comprehensive evaluation to assess why you might be falling. There is often more than one issue putting an older person at risk for falls. Your health provider can also discuss your gym routine and whether adding different types of exercises might help. Good luck!

  5. i fall often. i am 59 years old not so old right but i have pretty bad numbness neuropathy in my feet. i think this causes alot of my tripping. i’m not as active as i used to be because i’m afraid to do much walking because of trippping. it seems to be a vicious circle. what should i do. i try to not have risk factors like high heels or rugs. what else can i do. i drive w/ hand controls on my car because i can’t feel the brakes so its pretty bad……i just feel and really hurt both knees badly on hard tile floor ;-(

    • I’m very sorry to hear of your difficulties. It’s not very common for people to have such severe neuropathy, or to have so many falls at your age.

      I would certainly recommend you work closely with clinicians to make sure your neuropathy has been carefully evaluated and that everything is being done to try to improve it.

      Otherwise, it’s still quite possible that you would benefit from the fall prevention strategies that I cover in this article and in other articles on this site: have your medications carefully checked and avoid those associated with falls, get a physical therapy assessment, find out if you’d benefit from physical therapy or a structured exercise program to improve leg strength and balance, make sure your vision has been checked, make sure you’ve done everything possible to make your home safe, etc.
      Try these articles if you haven’t already seen them:
      10 Types of Medication to Review if You’re Concerned About Falling
      Otago & Proven Exercises for Fall Prevention

      If you are extremely unsteady, you might also ask the doctor or the physical therapist to discuss the possibility of a mobility aid.
      Good luck!

  6. I am 86 years old and in good health except for a pacemaker implanted 3 years ago. No problems there.
    I drive, travel. Shop, everything. I fell Wednesday when simply stepping up a curb and fell again last night in my home while walking slowly on a carpet. I am checking all of my prescriptions and will notify my doctor (who was a pharmacist prior to becoming a doctor) tomorrow. Your information is very helpful. Thank you.

    • So sorry to hear of your recent falls, I hope you were not injured.

      Checking your prescriptions is a good idea; I have just published an article that provides more detail on which medications to re-assess: 10 Types of Medications to Review if You’re Concerned About Falling.

      However, I would also encourage you to work with your doctor on checking for other problems that might be causing falls, or increasing your vulnerability to falls. This article lists some things that doctors can check: 8 Things to Have the Doctor Check After an Aging Person Falls.

      Last but not least, if you’re concerned about falls, it’s often a good idea to make sure you have been appropriately screened for osteoporosis, and offered treatment if you do have significant osteoporosis.

      Good luck and take care!

  7. There is a new invention called Hip to Hope which is designed to help geriatrics with falling and breaking their hips. It acts as a way to prevent damage once the person is falling.
    “Once Hip-Hope’s multi-sensor detection system senses an impending collision with a ground surface, two large airbags are deployed instantly from each side of the belt to cushion the hips, and a connected smartphone app sends an automatic alert message to predetermined recipients.”
    You can read more about it here:
    https://www.israel21c.org/hip-hope-cushions-falls-to-prevent-fractures-in-elderly/

    • Yes, I have come across similar innovations. If an older adult is willing to wear such a device then it might reduce hip fractures. But historically older adults have been reluctant to wear such protective equipment.

      There are other ways to reduce fractures and injuries in the event of a fall. These include detecting and treating osteoporosis, and also providing older adults with a mechanism to get help in case they fall and can’t get up.

  8. Thx for the great information. I recently read an article in our local newspaper which talked about falling. The physio who was quoted said there is a lot of information on fall prevention but not much on how to fall safely. Because falls do happen. I’m studying up on that as I’ve had a few falls and hope to avoid future injuries.

    • I’m not aware of much high-quality research on helping older adults “fall safely.” It would be difficult to design a study of such an educational intervention. But if you come across any good information on this topic, let us know!

      • I was taught how to fall when I was in sports for high school football and wrestling.

        • Yes, it’s not uncommon for people to be taught a certain way to fall when they are learning certain sports. However, as far as I know, no one has successfully proven that one can reduce falls by teaching older adults how to fall.

          Increasing leg strength and balance through specific exercises has been proven to reduce falls, and such exercises are also associated with reduced injury from falls.

          • Being ”taught to fall”..one tends to be young and fit when one is taught this..but imagine teaching a very unfit still elderly person to fall- they’d not have the confidence or muscle control to let fly with grace..
            Possibly Yoga done from 50’s onwards might help, but older people are not likely to want to practice falling, even with crash-mats.
            The drug element is very interesting.[painkillers, blood pressure meds]
            My lovely 92 yr old neighbour has had yet another bad fall..she was too disorientated to even press her medic alert button- her carer who pops in once a day has no key could not get in ..none of us have keys, which is crazy- only someone aged 85 down the road has a set..neighbour says ”I’ll let you in”
            But in a case of a fall, of course she cannot get to the door.
            Her daughter lives about 45 mins drive away.

            I heard today that our lovely neighbour ”won’t make it”..she was found very dehydrated.
            If I’d had a key, I’d willingly have checked up on her..goodness knows how long she was left lying there..I didn’t hear anything.
            Older people need neighbours to have keys..there was ”bother’ about no keys when neighb broke leg a few years ago..plus she fell after that- while on the phone and the company she was on the phone to called an ambulance [well done Panasonic]
            Blood pressure meds I think in her case don’t help.
            🙁

          • Thanks for sharing these thoughts and your neighbor’s story.

            Good point re the key! If I ever get around to writing more articles on safety, I’ll have to remember to address this point. One good option is for the older adult (or family) to place an extra key in a lockbox outside. Trusted people can be given the code to the lockbox, and then can open the door if needed during an emergency.

            It’s also important for older adults to have a plan for calling for help, or at least scheduling daily check-ins with others. I address this and some related issues in this article:
            3 Ways to Prevent Injury From a Fall (Plus 2 Ways That Don’t Work as Well as You’d Think)

          • My sister with Parkinson’s D. in her 70’s was taught by PTs both in NYC & OH how to fall to avoid serious injuries. I did see her use this maneuver on 2 different occasions. Sadly, cognitive problems prevent use these days.

          • I have read some articles about how to fall “safely”, as well as how to get up after a fall. Here’s one example:https://www.health.harvard.edu/staying-healthy/how-to-fall-without-injury#:~:text=Fall%20sideways%2C%20if%20possible.%20Aim%20toward%20open%20areas,Swing%20your%20arms%20sideways%20to%20direct%20your%20fall.. And you’re correct that Physical therapists and Occupational therapists can give very valuable advice about falls.

            Most of the time we try to prevent falls, but there are some skills that are helpful in the event one does take a tumble.

  9. My mom’s neuro checked her b12 level and found it to be very low. She was put on 1000 mcg sublingual b12 and it has made a remarkabke difference in her balance! A simple fix for a serious issue in her case. I was amazed to read what bad symptoms a b12 deficiency could cause in the elderly. I had no idea!

      • I am having too many falls, and weakness in mornings. and I notice to my right are backwards when standing. my Doctor did blood work last week. hoping he can find something that will work. I have gone through much therapy . but this has started more. thanks for the post.

        • Recurrent falls are tough. It is often possible to identify several contributing factors and work to reduce them, but it can take some effort. Good luck!

  10. Could Blood Thinners (Xarelto) taken daily have an effect on frequent falls at 82 Years?

    • Blood thinners sometimes cause anemia (low red blood cell count), because they can make people prone to have small — or occasionally bigger — bleeds in their stomach or bowels. Anemia can cause people to feel weak or dizzy, and can increase fall risk.

      Blood thinners also increase the risk of injury — such as bleeding in or around the brain — in the event of a bad fall. The risk of bleeding AFTER a fall is the main reason clinicians sometimes hesitate to prescibe or continue blood thinners in an older adult who is at high risk for falls.

      Otherwise, I don’t particularly think of blood thinners as being among the medications that increase the risk of falling. But of course, it’s always possible for an individual to have an unusual reaction to a medication.

      If you are concerned about this medication, I would encourage you to discuss it with the prescribing doctor and/or your pharmacist.

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