Why 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:
- Create a list of factors contributing to an individual older person’s fall risk.
- Identify risk factors and triggers related to recent or recurrent falls.
- 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.)
- 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.
- Wendy may want to take steps to make sure her father isn’t being over-treated for high blood pressure.
- 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.]
Lori D'Amico says
Hello Dr.
I am not sure if you will see this since apparently this article is a bit older. I thought I’d try however.
My mom will be 79 in December. She is a lung cancer survivor (2011 diagnosis and surgery to remove lobe of left lung) and a long term smoker. She also has high blood pressure, diagnosed as borderline diabetic (no insulin needed), mild COPD, and has a deadened thyroid, taking thyroid medication for that. She was fairly active (worked, social activities on occasion, bowling, dancing, raising 3 kids etc) in her younger years but has been sedentary for quite some time now due to health issues.
She has been complaining for a while of pain in her lower back and hips. She said if she bends over or lifts her leg, it eases slightly but I am noticing increasing limitations in her mobility. She tires and feels weak easily. She walks perhaps 10 to 15 feet recently and is either in so much pain she has to stop for a bit or, is slightly short of breath. She has begun to have a lot of falls over the past few months–perhaps 6 or so in the past 2 to 3 months. She also around that time began bleeding easily–even a little tiny scratch could cause bleeding that might last half a day or so. She has woken with her pajama leg bloody if she picks at a dry piece of skin in the middle of the night for instance. Her doc finally sent her to a hematologist (she is also seeing a dermatologist due to a sudden case of eczema that developed about a year or so ago) and her hematologist says she has a clotting factor disorder. Then she began losing bowel control (she has irritable bowel syndrome but never lost control as frequently as recently) from time to time.
She fell yesterday going into her doctors office–they sent her next door to the hospital. She scraped the top layers of skin off from wrist to elbow and the hospital cleaned it, bandaged her up, sent her home. She was hospitalized early in June for the weakness, severe dehydration (despite drinking plenty of water. She is also on Lasix) and they said she had an acute kidney injury and they said there was some internal bleeding. However the care was not up to par and they tried to do a colonoscopy and endoscopy but she had a mild heart attack for the first time and went into Afib on the table. They aborted the procedure. She later had the endo done and that was fine.
She is weak, today it is in the 80’s here and she is running a fever. The falls concern me as does the other issues. I feel we are going to lose her if they don’t find out what is wrong. What can I do to help? Who do I send her to?
Leslie Kernisan, MD MPH says
Hello, I do review comments all my articles regardless of how old they are, but usually only once a week and last week I was out of town. I’m sorry to hear of your mother’s situation. Honestly, it sounds medically quite complicated and like there is more than garden-variety fall risk factors going on. I hope there’s been some progress in understanding what is going on. She does sound like she’s accumulated a lot of chronic pain and illnesses, and now is getting worse from something. I hope her doctors are able to figure it out soon. Good luck!
Cindy says
My dad is 86, has had triple by pass surgery, has COPD, a pacemaker & stage 4 lung cancer. In the past year his balance has gotten so bad he as fallen 5 times in the house, once landing him in the hospital. Yesterday he fell walking out of church and wound up with several cuts, which do not head due to the blood thinners. His right shoulder is almost nonfunctional due to (what i think is) a blown rotator cuff. To top all this off, he refuses to use any walking aids, no cane, no walker, nadda. Is there anything you can think of to help stabilize him?
Leslie Kernisan, MD MPH says
Well, in principle he needs to be evaluated to help figure out what is contributing to his falls, and then his health providers and he could decide what’s feasible to modify and improve. There might be chronic problems contributing but given his cancer and blood thinners, a new problem (such as a low red blood cell count) is also quite possible.
But before spending a lot of time trying to modify his fall risk factors, you may also want to talk to his health providers about his overall prognosis and the bigger picture of his health care. Especially if he has stage 4 lung cancer, does he want to spend whatever time he has left doing exercises to improve his strength or balance? Especially if time may be limited, it is important to focus your energies on helping him in ways that he welcomes, and otherwise on focusing on your relationship with him.
Fall prevention is important, but has to be taken in the context of a person’s overall health, what’s feasible, and what’s in line with the older person’s goals and priorities. Good luck!
Debbie Reddick says
My almost 98 year old mother in law is living with us. She has fallen backwards twice in the last week. I witnessed one fall and it happened so quickly that I couldn’t even catch her. She said she doesn’t have any dizziness and no forewarning. I am having her eyes tested and also have an appt with her PCP to check her meds. Anything else I should be checking? She does use a walker but that doesn’t seem to help when she falls backwards. Thank you in advance for any help.
Leslie Kernisan, MD MPH says
Sorry to hear of her falls. I cover what I recommend checking in this article:
8 Things to Have the Doctor Check After an Aging Person Falls
For her, I would especially recommend checking her blood pressure sitting and standing, and making sure her labs have been checked recently (to confirm that she doesn’t have anemia or any other medical abnormality that would make her much more prone to falls). Otherwise, almost everyone her age suffers from poor balance (usually for a variety of reasons) and low leg strength is also common. Exercises can help, although it usually takes some work to set up a routine that the older person will stick with (and that actually improves strength and balance). Good luck!
Michael Schaeffer says
Are there signs that an elderly person is act risk of falling that can be monitored from a fitbit type device?
Change heart rate, blood pressure, balance for example.
Leslie Kernisan, MD MPH says
In general, I don’t find currently available wearables to be particularly useful for identifying fall risk. The main risk factor is having had a fall or being afraid of falling. Otherwise a wearable is not going to be as useful as a decent clinical evaluation for fall risk factors. For certain specific fall risk triggers, it’s possible that a wearable could help detect them. But in most older adults, falls are multi-factorial and to effectively reduce the risk requires an individualized multi-component intervention. Most older adults also require some form of balance or strength exercises. Providing them with the correct exercises and the support to consistently do them is a much bigger barrier than “detecting they are at risk for falls.”
Tom says
Regarding a neighbors locked doors, do not hesitate to call 911. Fire/Rescue trucks carry crowbars that will bust open any door. I fainted and fell . . . Was able to call 911 when I became conscious. Fire Dept broke in. Prob saved my life.
Leslie Kernisan, MD MPH says
Thanks for sharing this tip. Glad the emergency services were able to reach you during your time of need.
It can also be a good idea to have a lockbox (let a few trusted family members or friends know how to access it), so that family can enter and check in if it seems necessary (e.g., no one has heard from you for a few days) but it’s not obviously a 911 emergency.
Ann Sulistija says
Hi I am 56 years old and have a history of falling when I’m walking outdoors. I had a ASD closure in 2004 and was diagnosed with a hole in my heart/heart valve and had surgery to repair it. So lately with my falls and busting up my knees pretty badly I need to know why I fall so much. Going to dr in morning and see if they can check my heart but what other health concerns should I be looking for. I have type 2 diabetes on methformin , depression, on bp meds.
Leslie Kernisan, MD MPH says
Sorry to hear of your recent falls, that must be scary.
It’s hard to summarize what should be looked for in just a few sentences. We do have lots of articles on the site and then the Fall Prevention Mini-Course does explain it all in more detail and walks you through a workbook, to help identify issues to ask your doctors about.
Otherwise, most of what is in our mini-course is covered on the CDC STEADi site. The good stuff is all in the recommendations for clinicians; they are available to the public but of course the tone is more technical. Good luck!
Taylor Bishop says
Thanks for this advice for preventing falls. It’s nice to know that you should try to first list some factors that could contribute to someone’s fall risk. It sounds important to first know what could be considered a fall risk especially if it can help you identify areas where someone might fall.
Christie says
My 69 year old mother has had three falls in the past year, two while traveling, and one in our house.
All three falls had an environmental risk factor present: the first involved a broken entryway platform at a convenient store; the second happened at the top of an escalator; the third involved a throw rug. She also has potential risk factors in many areas: vision (cataracts/bi-focals), medications (post-MI maintenance drugs started in 2007, psych drugs started in 2012), absent strength (no exercise routine, started work-at-home 2016 so even less daily walking, recent foot surgery to straighten a claw toe but no PT after), and chronic health conditions (daytime sleepiness from apnea, depression, anxiety, non-MI angina). The most recent changes were a new bp medication that produced headaches, but they treated the headaches with more medication; the foot surgery and non-weight bearing period; and an increase in daytime sleepiness that was treated successfully with melatonin at night.
She trusts her doctor’s judgment with medications and has been hesitant to ask for changes unless the side effects are black and white. My dad said that when she fell the first two times, she didn’t even put out her hands to catch herself. Is this the result of slowed reflexes? Does the “not putting her hands out to catch herself” help to narrow down the possible contributing factors?
Also, after the first fall, my mom has been anxious about falling again. Even though she has a lot of possible risk factors, it seems that lack of strength plus the broken step could have been sufficient to have caused the first fall. Is it possible for anxiety or distraction to cause falls? I mean, I’ve noticed that when I’m not paying attention to what I’m doing, I can run into things. I usually catch myself though because I have good reflexes.
Finally, do you have any specific exercise or low-impact strength training programs that you recommend? I found one for lupus that seems simple enough (https://resources.lupus.org/entry/low-impact-exercise-routine-for-lupus). She is hesitant to do more involved exercises because they can be complicated, or because she says that she avoids getting down on the floor because she struggles to get up easily. Thank you.
Leslie Kernisan, MD MPH says
Falls are usually due to multiple risk factors/contributors, plus a triggering event.
You have already done a good job identifying several contributing factors, so the question is which can be modified. A comprehensive falls evaluation might also uncover some additional factors or causes that you haven’t identified; occasionally there is some kind of neurological or cardiac issue playing a role.
Exercise would be helpful, it will improve her ability to recover from losing her balance and also is associated with less risk of injury when people do fall.
The National Council on Aging maintains a good page listing proven fall prevention programs here:
Evidence-Based Falls Prevention Programs
I especially like the Otago program and Tai Chi, but what is most important is to find something that your mother is willing/able to do several times a week.
Most people have difficulty motivating to do a program on their own, plus they might be doing the exercises incorrectly. So being in a group or in physical therapy is a good idea.
I would not recommend a program (such as the lupus one) that isn’t specifically designed for older adults and fall prevention. For instance, squats and deep lunges can be very difficult for older adults to do safely and effectively. Hope this helps and good luck!
Rebecca Hunter says
In the case of someone who is wanting and/or needing strength and balance exercises to help maintain abilities and confidence for as long as possible to help reduce falls, how would you recommend this could be done without assistance? Are there any products or plans you might be able to recommend?
Generally, what is your opinion on ‘progressive resistive training’ on the lower body to reduce the instance of falls? What do you think are the difficulties that surround this area with the elderly?
Leslie Kernisan, MD MPH says
By progressive resistive training, I assume you mean resistance exercises that are “progressed” so that they become more challenging over time; this is often done by adding some weights to the ankle.
Such exercises have a good track record in fall prevention, especially if they are combined with exercises that specifically challenge and improve balance. The Otago program combines such strength and balance exercises, and is proven to reduce falls in vulnerable older adults:
Videos Illustrating Otago Exercises for Fall Prevention.
Tai Chi has also been shown to help reduce falls.
The difficulty is that such programs require people to practice the exercises three times weekly. Strength exercises are also safer and more effective when a physical therapist or other qualified person is available to select appropriate starter exercises, train the older person in doing the exercises, and also step up the resistance or difficulty of the exercises when it’s appropriate.
I am not aware of any completely “do it yourself” programs that have been proven to reduce falls, plus doing a program on one’s own would require more motivation and discipline than many people can maintain on their own. So generally I recommend doing a program via a live class or with a physical therapist.
Tony Brandon says
Hi, for the past couple of months I have started falling out of bed on a very regular basis, sometimes up three times in one night, it is now quite painful. For the past year I have been suffering with acute pain down my right-hand side, from my neck into my shoulder and through my arm, as though my muscles and inside my bones are on fire. One morning I woke up blind in one eye. I have had steroid injections, electric shock tests, nerve tests to no avail. My hip is also loosening after fifteen years which also causes pain. I currently take co-codamol to control the pain. I am also taking Astor statin (20mg) Venlafaxine (150mg) Felopadine (5mg) Losartan (100mg) Oxazepam to help me sleep and daily aspirin. I also have a history of fairly severe depression. I already see my Dr far more than I should but any ideas or clues in my description above? Thanks Tony
Leslie Kernisan, MD MPH says
Sorry to hear of your recent falls. Honestly, your situation sounds more complicated than most, so good that you are working closely with your doctor. Regarding falling out of bed more frequently, I wonder if you have been able to get any other information on how you are sleeping and are you otherwise moving more than before while asleep? Perhaps evaluating and treating your sleep might help with the falls during the night.
Otherwise, oxazepam is a benzodiazepine and is associated with increased risk of falls. However, if you have significant anxiety or sleep issues, it can be hard to eliminate this type of medication.
Good luck!