Mobility, balance and coordination – falls prevention

Clinical guidelines

• Australian Commission on Safety and Quality in Health Care: Preventing falls and harm from falls in older people 
• The Royal Australian College of General Practitioners (RACGP): Exercises for falls prevention, in Handbook of non-drug interventions (HANDI) 

Tools

• Falls Risk for Older People – Community setting (FROP-Com) guidelines 
• Kimberley Indigenous Cognitive Assessment (KICA) 

Background

Optimising mobility and preventing falls is important for all older people. For older Aboriginal and Torres Strait Islander people, having capacity to engage in cultural practices and connections to Country is important for socioemotional, spiritual and physical wellbeing. In a study on healthy ageing, an Elder from Ulladulla said, ‘[Culture] helps me do my Aboriginal talks, I do a lot of walking there. It’s good, it keeps us mobile, keeps us fit, keeps your body going’.¹⁰ Older adults who require a mobility aid or wheelchair should be supported to continue their important roles within their families and communities. By asking older adults about falls, opportunity is created for discussion about mobility concerns, dizziness/vertigo, fear of falling and any episodes of collapse that may have occurred. In this way, risk factors may be addressed to prevent falls, fractures and other injuries. 

The World Health Organization definition of a fall is ‘an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. Falls, trips and slips can occur on one level or from a height’.⁵ In older age, sarcopenia (loss of muscle mass and strength), bone fragility and poor balance contribute to an increased risk of morbidity and mortality. Falls are more likely during periods of illness and hospitalisation, particularly in the context of delirium.⁵ For people aged over 65 years, falls constitute 70% of all injury hospitalisations and 7% of injury deaths.¹ In 2019–20 there were 133,000 hospitalisations for falls in Australia, half of which included a fracture.¹ The risk of falls increases with age, and falls accounted for 41% of hospitalisations for people aged 85 years and over.¹ An increased mortality rate was seen for people hospitalised after a fall living in areas with the most socioeconomic disadvantage.¹ For Aboriginal and Torres Strait Islander people, the age-standardised rate of hospitalisation associated with falls was 3602 per 100,000 which is 1.2-fold the rate among non-Indigenous Australians.¹ This pattern was seen across all age groups, except for those aged 85 years and over.¹

Falls can be mechanical, and can also be precipitated by a loss of consciousness. Syncope is defined as ‘a transient loss of consciousness due to cerebral hypoperfusion, characterised by a rapid onset, short duration and spontaneous recovery’.¹¹ Neurally mediated (reflex) syncope includes vasovagal episodes, situational and carotid sinus syndrome.¹¹ Orthostatic hypotension (when blood pressure drops significantly on standing) can result in a syncopal event. Orthostatic hypotension is common in older people and is often caused by medications (selective serotonin reuptake inhibitors [SSRIs], serotonin–noradrenaline reuptake inhibitors [SNRIs], tricyclic antidepressants, calcium channel blockers and benzodiazepines).¹² Other causes of orthostatic hypotension include neurodegenerative conditions, diabetes and HIV neuropathy. Age-related changes, immobility, deconditioning, arterial stiffness and frailty can affect the autonomic response to standing.¹² Syncope can also be caused by cardiac conditions, including structural heart disease (eg aortic stenosis) and cardiac arrhythmia. Thorough history taking and an electrocardiogram (ECG) are important in the risk stratification process. Cardiac imaging is indicated if there is suspected (eg abnormal ECG) or known heart disease.¹¹ 

Individuals may not view themselves as at risk of a fall. If a fall occurs, the tendency is for it to be attributed to external factors (eg uneven flooring, trip hazards) or inattention. In reality, the aetiology of falls is usually multifactorial with environmental, behavioural, biological and socioeconomic risk factors present.^1,5 For all fall-related presentations to hospitals in Australia in 2019–20, half the falls occurred at home. The most common locations of a fall at home were outdoor areas and the bathroom.¹ Therefore, the adequacy and suitability of housing contribute directly to falls risk, particularly bathroom areas.

When older adults are living in multigenerational or large households, physical spaces can become crowded with environmental hazards. Housing is a key priority in the National Aboriginal and Torres Strait Islander health plan 2021–31.¹³ The use of mobility aids, ill-fitting or soft-soled shoes, lighting, uneven flooring and steps, inaccessibility of bathroom/shower/toilet and the presence of pets should be explored as contributing to falls risk.² 

Falls can result in injuries requiring hospitalisation. Many fractures sustained from a fall are regarded as minimal trauma fractures and may be evidence of bone fragility or osteoporosis. In the Australian Institute of Health and Welfare report Falls in older Australians 2019–20, the most frequent injuries requiring hospital admission involved the head (29%), hip and thigh (20%), abdomen, lower back and pelvis (9.5%), knee and lower leg (9.4%) and forearm (9.1%).¹ This report did not include data from individuals not admitted to hospital, thereby underestimating less serious hand and wrist injuries, skin tears and soft tissue injuries. 

Falling and fall-related injuries may have socioemotional impacts, including loss of confidence leading to a fear of falling, decreased mobility and reduced independence and social engagement. This theme was identified in a qualitative study of older Aboriginal and Torres Strait Islander people’s perspectives about fall prevention.¹⁴ An older participant in that study said, ‘I think falls shake your confidence. So regardless of whether it’s a minor fall, a major fall or whatever, it can affect your mental attitude to things’.¹⁴ 

Researchers have sought to identify risk factors associated with falls in Aboriginal and Torres Strait Islander communities. In a study based in the Kimberley region of Western Australia, the risk factors identified were the number of medications, poor eyesight, environmental hazards, the need for assistance with activities of daily living and unsteady mobilisation.¹⁵ A subsequent study in which 336 participants from five Aboriginal communities in New South Wales were interviewed found that the primary risk factors for falls included taking three or more medications, the presence of macular degeneration, moderate/severe depression, stroke, the inability to do own housework, female sex, osteoarthritis and/or inflammatory arthritis and the inability to do own shopping.¹⁶ In a systematic review of fall-related injury in indigenous populations worldwide, factors associated with falls included impaired mobility, stroke, epilepsy, head injury, hearing impairment, urinary incontinence and excessive alcohol consumption.¹⁷ 

Improving mobilisation and functional capacity, and optimising vision and hearing, are evidence-based interventions to prevent falls.^2,3,6 Access to vision and hearing services is important to ameliorate falls risk for Aboriginal and Torres Strait Islander people. Polypharmacy is consistently identified as a risk factor for falls.^4,5,15,17 Polypharmacy increases the risk of drug interactions, medication errors and side effects. Given that multimorbidity is often associated with polypharmacy, medication review and rationalisation is particularly pertinent for Aboriginal and Torres Strait Islander people. 

In addition, higher risk of falls is associated with:

• a previous fall and accompanying injury
• multiple (more than two) falls in the previous 12 months
• known frailty
• an inability to get up after the fall without help for at least an hour
• witnessed or suspected transient loss of consciousness.⁶

The following policy documents have informed the recommendations in this guide:

• Preventing falls and harm from falls in older people²
• RACGP Guidelines for preventive activities in general practice⁴
• international guidelines for falls prevention and management for older adults.⁶

Screening for a history of falls

People do not always volunteer a history about having fallen, so the clinician needs to ask about falls and whether the person is worried about falling.⁶ Furthermore, individuals should also be asked about any loss of consciousness, dizziness or gait/balance difficulties as part of this risk assessment.⁶ For Aboriginal and Torres Strait Islander people, asking about falls from the age of 50 years, at least once per year, is recommended. People who are at higher risk of falls, for example after stroke or acquired brain injury, should be asked about falls at any age. This can be included in comprehensive health assessments such as annual health checks (MBS Item 715). A mobility screening tool, such as the timed up and go or the sit-to-stand tests, may be used.² Gait speed is the most sensitive indicator of falls risk, with a cut-off value of <0.8 m/s; however, a cut-off value of >15 seconds in the timed up and go test is an acceptable alternative.⁶

Comprehensive, multidisciplinary falls risk assessment

Multidisciplinary falls risk assessment is associated with reduced harm from falls in community and other care settings.^2,6,15,17 Referral to a specialised falls clinic is recommended for people at high risk of falls.⁶ Unexplained or recurrent falls or collapse should be investigated for the underlying cause, such as cardiac or neurological aetiologies.^6,11

The screening and assessment of the key contributing factors presented in Box 3 are recommended in primary care and/or multidisciplinary falls clinics, where resources permit.^4,6

The FROP-Com with the cognitive assessment domain of the KICA was found to identify falls risk most effectively¹⁵ (see Useful resources).

A home assessment provided by an occupational therapist to determine behavioural and environmental hazards is recommended, particularly for those at high risk of falls.^5,6 A Cochrane review confirmed that fall hazard reduction, particularly in people with an increased risk of falls, was associated with a 26% reduced risk of falls (rate ratio [RR] 0.74; 95% confidence interval [CI] 0.61–0.91).⁷

Behavioural interventions

Exercise has been shown to reduce both the risk of falls and the rate of falling. The key therapeutic targets are ‘muscle strength and power in the lower legs, reaction time and balance’.³

In a Cochrane review of the effects of exercise interventions on preventing falls, the exercise interventions aiming to reduce falls compared with exercise ‘not thought to reduce falls’ resulted in a 23% decrease in the rate of falls.⁸ In subgroup analysis, balance and functional training were most effective in preventing falls. Different types of exercise, notably balance, functional and resistance exercises, probably reduced falls (34% reduction; moderate certainty evidence) and Tai Chi may also reduce falls (19% reduction; low certainty evidence).⁸ The integration of walking programs for falls intervention is not specifically supported by the literature. This may be because of increased exposure to risk when walking or time taken away from balance training. If balance training is prioritised and adequate safety mechanisms are in place, walking can be added to the program for adults with adequate functional capacity.³

Exercise and Sports Science Australia outlined the recommended exercise program for falls prevention in a 2011 position paper, which was centred on balance. Exercises should be:

…conducted while standing in which the participants aim to (a) stand with their feet closer together or on one leg (b) minimise use of their hands to assist balance and (c) practice controlled movements of the body’s centre of mass.³

Dual-task training may improve functional mobility because falls can occur when a person is attempting a secondary activity.³ Referral to an exercise physiologist or physiotherapist, where local services are available, is recommended, particularly for people with frailty and at high risk of falls.³

The Ironbark program, adapted for Aboriginal and Torres Strait Islander people from the home-based Otago exercise program, incorporated leg muscle strengthening, balance retraining and education. Yarning circles were used as a culturally appropriate way of offering and receiving knowledge about falls prevention.¹⁸ The Ironbark Program was subsequently locally adapted and run in Western Australia with facilitation by participating Elders and improvements in gait speed, lower limb strength and functional mobility at 12 months were observed.¹⁹

Vitamin D supplementation has an uncertain role in falls prevention. Although postulated that it may improve muscle strength and reduce falls, the literature regarding the benefits of vitamin D supplementation is inconsistent.²⁰ In a 2020 meta-analysis of randomised controlled trials, vitamin D reduced falls risk compared with placebo (RR 0.948; 95% CI 0.914–0.984; P=0.004).²¹ However, the Study To Understand Fall Reduction and vitamin D in You (STURDY) trial examined the effect of vitamin D supplementation on physical function (gait speed, timed up and go, grip strength and short physical performance battery) in older adults at increased risk of falls and with low vitamin D.²² The principal finding of that study was of no consistent benefit or harm of vitamin D supplementation.²² Despite the lack of consistent evidence of benefit, the World Health Organization recommends vitamin D supplements in the context of vitamin D insufficiency.⁵

There is strong consensus that medication should be regularly reviewed and rationalised.^4,6,11 Medications that are no longer required or are potentially harmful should be stopped, especially medications that are sedating or psychoactive.^2,5 Medications associated with falls include antihypertensives, sedating antihistamines, SSRIs and SNRIs, tricyclic antidepressants, opioids, anti-arrhythmics, nitrates and hypoglycaemic medications.² Polypharmacy is particularly seen in people with chronic kidney disease due to the pattern of comorbidity (hypertension, ischaemic heart disease, diabetes and thyroid disorders).²³ Dose adjustment and the cessation of nephrotoxic medications are also required.²³ There are tools available to support deprescribing, including the Screening Tool of Older People’s Prescription (STOPP) and Screening Tool to Alert to Right Treatment (START).²⁴ A formal medication review by a pharmacist may be facilitated by a home medication review (MBS Items 900 and 903).