Why this matters more than almost anything else

Falls are the leading cause of injury-related hospitalisation in older Australians, and a fractured hip is one of the sharpest turning points in an older person's life. A large proportion of people never return to their previous level of independence afterwards.

Falls are also not an inevitable part of ageing, which is the belief that does the most damage. Most falls have identifiable, modifiable causes.

What frailty actually is

Frailty is not simply being old or thin. It is a recognised clinical state of reduced physiological reserve - less capacity to bounce back from a stressor such as an infection, a fall or an operation. It is usually identified by a combination of unintentional weight loss, exhaustion, weakness, slow walking speed and low activity.

The important point is that frailty is not one-directional. It responds to resistance exercise, adequate protein, treating underlying conditions and reducing unnecessary medication. It is worth naming and treating rather than accepting.

Why people fall

Almost never one reason. Usually several stacking up:

  • Muscle weakness and deconditioning, especially in the legs. Two weeks in hospital can undo years of strength.
  • Balance and gait problems, including from stroke, Parkinson's or neuropathy.
  • Medication - sedatives, sleeping tablets, some antidepressants and blood pressure medicines all increase risk. Polypharmacy is a major and correctable contributor.
  • Blood pressure dropping on standing, causing a moment of light-headedness on rising.
  • Vision - uncorrected changes, cataracts, and multifocal glasses on stairs.
  • Feet and footwear - pain, deformity, neuropathy, and worn or backless shoes and slippers.
  • The home - loose rugs, poor lighting, no rail on the steps, cords, a bathroom with nothing safe to hold.
  • Fear of falling, which causes people to move less, lose more strength, and become more likely to fall. This loop is very common and very reversible.

If someone has fallen once, act. A first fall is the strongest predictor of a second. Ask the GP for a falls assessment and a medication review. Do not wait for the second one to make the point.

What actually reduces falls

The evidence here is unusually clear:

  • Strength and balance exercise, done regularly and progressed over time. This is the single most effective intervention, and low-intensity walking alone is not enough.
  • Medication review - deliberately reducing or stopping medicines that increase risk.
  • Home hazard assessment and modification, most effective when done by an occupational therapist for someone at higher risk.
  • Vision correction and appropriate glasses use.
  • Foot care and footwear - properly fitting, supportive, enclosed shoes with a firm sole.
  • Vitamin D and calcium where deficient, and assessment for osteoporosis so that a fall does not become a fracture.

Where aged care fits

  • Occupational therapy for a proper home assessment, rails, equipment and bathroom safety. Under Support at Home, equipment and home modifications are funded separately through the Assistive Technology and Home Modifications scheme, so they do not consume your quarterly budget - see our guide to budgets.
  • Podiatry for foot pain, nail and skin care, and footwear advice.
  • Allied health assistance to keep a strength and balance program going between clinical appointments, which is the part that determines whether it works.
  • Registered nurse clinical care to coordinate a medication review with the GP.
  • Home maintenance, gardening and cleaning so that nobody is climbing on chairs, carrying baskets up steps or scrubbing a wet floor.
  • Personal care and supervision during showering, where a disproportionate number of falls happen.

The conversation nobody wants to have

Older people frequently hide falls, because they know where the conversation leads. If you suspect falls are happening and not being mentioned, look for the evidence rather than asking directly - unexplained bruising, furniture moved to create handholds, avoiding certain rooms, or sleeping downstairs. Approaching it as "how do we keep you here safely" rather than "you are not safe here" tends to get further.

General information only, not clinical advice. Ask a GP for a falls risk assessment and medication review. My Aged Care: 1800 200 422.