Despite the strong evidence that many falls are preventable [1], there has been a failure to implement prevention evidence into routine clinical practice across the population of older people. Lack of uptake and adherence to effective fall prevention programmes is well documented. For example, reported participation rates are as low as 6% for balance-promoting activities among older people in Australia [2].

The vast amount of literature on the many risk factors for falls and the various intervention options can make interpretation and implementation of the evidence difficult. This chapter overviews the research findings presented in previous chapters to assist the reader to integrate this information and use it to guide their own research and/or practice. It concludes with a brief review of select research issues that need to be addressed in the future.

In this chapter, we have brought together the findings from published studies cited in Chapters 1 to 14 that have addressed fall risk in older people. We have rated the major socio-demographic, physiological, psychological, health, and environmental factors that have been posited as important fall risk factors according to the strength of the published evidence associating that factor with falls, using the following four-level rating system:

In this chapter, we examine the epidemiology of falls in older people. We review the major studies that have described the incidence of falls, the locations where falls occur, and falls sequelae. We also examine the costs required to treat and manage fall-related injuries. Before addressing these issues, however, it is helpful to briefly discuss three important methodological considerations that are relevant to all research studies of falls in older people: how falls are defined, how falls are counted, and what constitutes an older person.

Daily life requires humans to undertake tasks in a range of environmental settings. Falls occur due to a mismatch between an individual’s physiological function, environmental demands and the individual’s behaviour. Many of the physiological impairments that increase the risk of falls (as outlined in Part 1 of this book) can be improved with structured exercise interventions. Poor balance control and impaired muscle strength particularly increase the risk of falling but are amenable to change with exercise [1, 2]. Exercise may also prevent falls by enabling practise of safe negotiation of the environment and a greater awareness of one’s abilities in different situations.

Medications have long been implicated as an iatrogenic cause of falls and fractures, with a number of epidemiological and prospective cohort studies providing support for a link between medications and falls. This chapter will discuss the pharmacology of ageing and the potential physiological mechanisms by which medications may impact on postural stability. Specific drug classes will be highlighted where there is evidence to support a causal link between drug use and falls, and the concept of optimization of prescribing will be explored.

Drugs and ageing

Ageing is not a clearly defined single entity but more the result of a combination of anatomical, biochemical and physiological changes that occur with time. There are alterations to the physiological reserve capacity of the human body that can lead to marked haemodynamic and biochemical compromise even with the mildest of external stressor, e.g. a urinary tract infection.

The ageing process can be associated with an alteration of the body's ability to absorb, metabolize, distribute and excrete drugs (pharmacokinetics) as well as an alteration of the drug effect at its intended target site (pharmacodynamics). Changes with age are seen in body composition, with a reduction in total body water and lean body mass and a relative increase in body fat, which impact on the pharmacokinetics of a given drug. Advancing age can also be associated with an increase in the number of disease processes, which can impact on the body's ability to deal with and respond to drugs.

As discussed in Chapter 1, falls result from the interaction between intrinsic risk factors (i.e. those pertaining to the individual, such as poor vision and reduced strength) and extrinsic risk factors (i.e. those relating to environmental hazards). The interface between the individual and their environment is also important, and can be modified by a range of physical assistive devices, which are used by at least one-quarter of older people. Devices to be addressed in this chapter include footwear, foot orthoses, walking aids, other physical assistive devices, spectacles, hip protectors, aids to prevent ‘long lies’ and restraints. The potential impact of each of these devices on falls and/or fall injury is discussed.

Footwear

Footwear has an important role in protecting the foot from extremes of temperature, moisture and mechanical trauma. However, since the development and widespread popularity of fashion footwear in the 1600s, the functional aspect of footwear has largely been supplanted by cosmetic requirements. In both males and females of all ages, shoe selection is primarily based on aesthetic considerations, many of which are incompatible with optimal function of the lower extremity. This is of particular importance in older people, as certain types of footwear, by modifying the interface between the sole of the foot and the ground, may have a significantly detrimental impact on postural stability and possibly predispose to falls.

Unfortunately, evidence to support the suggestion that certain types of shoes increase the risk of falls is meagre.

As indicated in Chapter 10, exercise is a key intervention strategy for preventing falls in older people. Many diverse forms of exercise have been used in trials, ranging from highly prescribed resistance training regimes and laboratory-based balance training to unstructured general exercise programmes. In addition to studying the efficacy of exercise programmes on falls, many studies have also assessed the effectiveness of such programmes on a range of physical outcome measures, including strength, balance and gait. These studies elucidate the mechanisms by which exercise may prevent falls. Although falls are relatively common, most older individuals do not fall very frequently. Thus, large studies with long follow-up periods are required to detect the effects of exercise on fall rates. In contrast, the effects of exercise on risk factors for falls can be detected with smaller studies. Thus, complementary information can be gleaned from the analysis of studies with falls risk factors as outcome measures. Indeed, Liu-Ambrose and colleagues found that the risk of falling, as measured on the Physiological Profile Assessment tool (PPA, described in Chapter 16), could be reduced by around 50% by resistance or agility training.

This chapter describes the major forms of exercise that have been used in studies of older people, and summarizes the evidence for the effectiveness of each form on falls risk factors such as balance, strength and functional abilities. Additional considerations, including exercise setting selection, target population selection, and factors affecting adoption and adherence, are then explored.

Many of the risk factors and prevention strategies outlined in previous chapters are also relevant to falls among hospital patients, and residents of hostels and nursing homes. This chapter discusses risk factors for falling which seem to be particularly important within hospitals and residential aged care facilities. There have been many programmes developed which aim to reduce falls in institutional settings and a number of these have now been evaluated in randomized controlled trials (RCTs). This chapter outlines the results of trials conducted to date and discusses programme features likely to be important for preventing falls in institutional settings.

Incidence and risk factors

Hospitals

Falls among inpatients are a key issue for hospitals. Falls in hospitals increase morbidity, prolong hospital stays, and strain the resources of the healthcare system, family and community. Up to one-quarter of people fall during their time in a rehabilitation hospital or ward. These figures are even higher for particular diagnoses. Up to 40 % of stroke patients fall while in a rehabilitation unit.

Many falls in hospitals occur around patients' bedside and ward area, with up to 43 % of falls occurring from (or near) patients' beds. Peak periods for patient falls coincide with peak periods of patient activity. A number of studies have found falls to be associated with getting in and out of beds and chairs, walking, and toileting.