What is the most effective way to prevent falls in older people?

The strongest single intervention for falls prevention is progressive strength and balance exercise — programmes like the Otago Exercise Programme reduce falls by approximately 35% in community-dwelling older adults, and Tai Chi reduces them by 20 to 30%. Exercise works by building muscle strength, improving balance and reaction time, and increasing confidence. The key is that the programme must be genuinely challenging to your balance (not just walking), sustained for at least six months, and performed at least three hours per week. Physiotherapists and exercise physiologists can prescribe and supervise tailored programmes, which are available under the GPCCMP allied health items in Australian general practice.

Which medications increase the risk of falling?

Several common medication classes significantly increase falls risk, particularly in older adults. Benzodiazepines and Z-drugs (such as temazepam and zopiclone) cause sedation, impaired balance, and slowed reaction time — they are among the most important targets for deprescribing. Opioids cause sedation and postural hypotension. Anticholinergic drugs — including some older antihistamines, bladder medications, and antidepressants — impair cognition and balance. Antipsychotics increase sedation, extrapyramidal symptoms, and postural hypotension. Antihypertensives, particularly when newly started or recently dose-escalated, cause postural hypotension. A Home Medicines Review conducted by a pharmacist in your home is the most systematic way to identify and address medication-related fall risk.

What is the Otago Exercise Programme?

The Otago Exercise Programme is a home-based strength and balance exercise programme developed in New Zealand and validated in multiple randomised controlled trials. It consists of a set of leg-strengthening exercises and progressively challenging balance exercises — including standing on one leg, tandem walking, and stair practice — combined with walking. It is individually prescribed and supervised by a physiotherapist, then done independently at home three times a week. The programme reduces falls by approximately 35% in community-dwelling older adults and is particularly effective in people aged 80 and over and those with a previous fall. It is deliverable under GPCCMP allied health referral to physiotherapy.

I take warfarin and my GP says not to worry about falls — is that right?

This is actually supported by evidence, with an important nuance. Research — including modelling by Donzé et al in the BMJ — suggests a person with atrial fibrillation on warfarin would need to fall approximately 295 times per year for the bleeding risk to outweigh the stroke-prevention benefit. Current Australian and international guidance is clear: fall risk alone is not a contraindication to anticoagulation for appropriate indications. However, for someone on anticoagulation who does fall and hits their head, the rules change: a CT scan of the brain is recommended regardless of symptoms, because bleeding in the brain can be delayed on anticoagulants. The right approach is to prevent the falls, not stop the anticoagulant.

When should I see a specialist for falls?

A GP can manage most falls assessments, but some situations warrant specialist input. Referral to a Falls and Balance Clinic (geriatrician-led) is appropriate for recurrent or unexplained falls despite standard intervention, or when multiple complex medical conditions make the assessment more than a standard consultation can address. Cardiology input is needed when falls are accompanied by palpitations, chest pain, syncope, or an abnormal ECG — cardiac arrhythmia or structural disease may be the cause. A neurologist is helpful for suspected Parkinson's disease, normal-pressure hydrocephalus (the triad of gait problems, cognitive decline, and urinary incontinence), peripheral neuropathy, or first seizure. Vestibular physiotherapy is the definitive treatment for BPPV.

Falls in older adults

Falls in older adults: multifactorial prevention in Australian general practice

By Dr HB Lo, FACRRM Reviewed 5 June 2026 10 min read

About 30% of community-dwelling adults aged 65 and over fall each year; 50% of residential aged care residents fall annually. Falls drive hip fractures, head injuries, and the post-fall syndrome — fear, restricted activity, and deconditioning.

The strongest predictor of a future fall is a previous fall. The most effective approach is multifactorial: progressive strength and balance exercise (Otago Programme, Tai Chi), medication deprescribing, occupational therapist home assessment, and vision optimisation.

Vitamin D supplements help only if the person is genuinely deficient — blanket supplementation of replete older adults is not recommended.

Falls in older Australians represent one of general practice’s most consequential prevention opportunities. About 30% of community-dwelling adults aged 65 and over fall at least once per year, rising to approximately 50% of residents in aged care facilities, according to the Australian Commission on Safety and Quality in Health Care (ACSQHC). Falls cause hip fractures, head injuries, lacerations, and the post-fall syndrome — fear of falling, activity restriction, deconditioning, and progressive loss of independence — as well as driving significant healthcare costs and a substantial proportion of injury-related hospitalisations and deaths in older Australians.

The single biggest predictor of a future fall is a previous fall — a history of at least one fall in the past twelve months places a person at approximately 50% risk of a further fall within that period. Risk is inherently multifactorial, which is why piecemeal approaches (vitamin D alone, or a home hazard checklist alone) have limited effect, and why the World Falls Guidelines 2022 (Montero-Odasso, Age and Ageing) — the current international reference standard — endorse comprehensive multifactorial assessment and intervention.

A. Core clinical — the AU general-practice framework

Screening for falls risk

The RACGP Aged Care Clinical Guide (Silver Book) and the 75+ Health Assessment item 705 both mandate falls screening at every annual health assessment for older adults. The CDC STEADI 3-question screen is a practical tool: “Have you fallen in the past year?”, “Do you feel unsteady when standing or walking?”, “Are you worried about falling?” — a “yes” to any one triggers a full multifactorial assessment.

Risk factor assessment

Intrinsic risk factors:

Prior falls — the strongest predictor
Gait and balance impairment — Timed Up and Go (TUG) ≥12 seconds suggests increased risk
Muscle weakness and sarcopenia — sit-to-stand 30-second count below age norms
Cognitive impairment — dementia increases falls risk two to three-fold (see our dementia article)
Peripheral neuropathy — particularly diabetic (see our peripheral neuropathy article)
Visual impairment — cataracts, macular degeneration, refractive error, paradoxically: multifocal lenses worn outdoors increase falls
Postural hypotension — drop ≥20 mmHg systolic or ≥10 mmHg diastolic on standing within three minutes
Vertigo and BPPV — responsible for a significant proportion of falls
Urinary urgency and nocturia — rushing to the toilet is a common fall mechanism at night

High-risk medications — polypharmacy (≥4 medications) is an independent risk factor. The most important culprits:

Benzodiazepines and Z-drugs (temazepam, zopiclone, zolpidem) — sedation, ataxia, prolonged reaction time; on SafeScript/RTPM
Opioids — sedation, postural hypotension, confusion
Anticholinergic drugs — older tricyclics, oxybutynin, diphenhydramine, promethazine; impair cognition and balance
Antipsychotics — sedation, extrapyramidal effects, postural hypotension; particularly hazardous in dementia
Antihypertensives — especially when newly initiated or recently dose-escalated
Sulfonylureas and insulin — hypoglycaemia, particularly at night

Environmental factors: loose rugs, poor lighting, bathroom slip hazards, stairs without rails, inappropriate footwear (slippers, slip-on sandals, high heels), outdated walking aid sizing.

Examination

Lying and standing blood pressure — supine, then standing at one, three, and five minutes; a drop ≥20 mmHg systolic or ≥10 mmHg diastolic at any time point diagnoses postural hypotension
Timed Up and Go (TUG) — ask the patient to rise from a chair, walk three metres, turn, walk back, and sit — time in seconds; ≥12 seconds suggests clinically meaningful impaired mobility
Neurological examination — tone (parkinsonism, spasticity), power, reflexes, vibration and proprioception at toes, heel-shin and finger-nose coordination
Cognitive screen — MoCA or MMSE
Visual acuity — Snellen chart; ask about multifocal lens use outdoors
Feet and footwear — calluses, deformity, neuropathy, shoe stability and fit

Targeted investigations

Not a blanket battery — choose based on clinical findings:

FBC, UEC (electrolytes, renal function), calcium, glucose or HbA1c, TSH, vitamin B12, 25-OH vitamin D, LFTs — reversible metabolic contributors
ECG — AF, bradyarrhythmia, long QT, heart block
Holter or event monitor — if palpitations or unexplained loss of consciousness accompanying falls
CT brain (non-contrast) — post-fall with head injury if: on anticoagulant or antiplatelet agent, GCS under 15, focal neurological signs, amnesia, persistent headache or vomiting; lower threshold in dementia and prior stroke
DXA — if fragility fracture occurred or significant osteoporosis risk factors present (see osteoporosis post)

B. Evidence appraisal — the multifactorial prevention bundle

Exercise — the single most effective intervention

Progressive strength and balance exercise has the strongest and most consistent evidence base for falls prevention in community-dwelling older adults. The Cochrane 2019 systematic review (Sherrington et al.) confirms exercise reduces both the rate of falls and the number of people who fall.

Otago Exercise Programme — reduces falls by approximately 35% in community-dwelling older adults; home-based; physiotherapist-supervised initially; most effective in those aged ≥80 and those with a prior fall
Tai Chi — 20 to 30% fall reduction in community-dwelling older adults; group-based; additionally benefits cognition, mood, and social connection
Falls Management Exercise (FaME) — group plus home programme; similar efficacy

The important prescription specifics per the World Falls Guidelines 2022: at least three hours per week of moderate-to-challenging balance training, sustained for at least six months. Balance must be genuinely challenged — walking alone is insufficient for falls prevention.

Vitamin D — only if deficient

The USPSTF 2018 evidence review (JAMA) found that routine vitamin D supplementation in non-institutionalised community-dwelling older adults with adequate vitamin D levels does not reduce falls. Importantly, annual high-dose bolus vitamin D injections (e.g., 500,000 IU) actually increased falls in some trials. The correct approach: measure 25-OH vitamin D; if below 50 nmol/L, supplement with 1000 to 2000 IU daily. Do not give blanket vitamin D to all older adults for falls prevention.

Medication review and deprescribing

Reducing the number and burden of high-risk medications is one of the most impactful and modifiable interventions. The Home Medicines Review (HMR), rebatable under MBS item 900, provides systematic domiciliary pharmacist review and is gold-standard for identifying and actioning medication-related fall risk. Targets: benzodiazepines and Z-drugs (gradual taper — cold cessation risks withdrawal seizures), anticholinergics, opioids, antipsychotics, reassessment of antihypertensive intensity.

Occupational therapist home assessment

An OT home assessment — deliverable under GPCCMP allied health referral — identifies and modifies specific environmental hazards: grab rails in bathroom, non-slip mats, lighting improvements, doorway clearances, removal of loose rugs. The Cochrane environmental interventions review (2023) confirms this is particularly effective in people with a prior fall and those with significant functional impairment.

Vision and hearing

Annual ophthalmology or optometry review; cataract surgery where indicated. Advise against wearing multifocal or bifocal glasses for outdoor activities — the changed visual field at ground level increases falls risk outdoors; single-vision distance glasses are preferable for walking outdoors.

Hearing aids have a modest signal for falls reduction through improved spatial awareness and may reduce the cognitive effort of hearing that competes with postural attention.

C. Post-fall workup — what every fall warrants

Every fall deserves a structured review, however trivial it seems:

Mechanism — witnessed mechanical (tripped on rug), presyncope (lightheadedness before fall), true syncope (loss of consciousness and tone), vertigo (BPPV — sudden onset with head movement), confusion (delirium, hypoglycaemia), or unexplained
Injury screen — head, hip, wrist (Colles fracture), vertebral pain; check for bruising, lacerations
CT head threshold — any fall with head contact in a patient on anticoagulant or antiplatelet drugs, GCS below 15, focal signs, amnesia, or persistent symptoms warrants CT; lower threshold in dementia, alcohol use, prior stroke
“Long lie” (on the floor for more than one hour) — check for rhabdomyolysis (creatine kinase, UEC), pressure injury, dehydration, hypothermia

Every injurious fall or second fall within twelve months is a trigger for a full multifactorial assessment and intervention plan.

D. Australian operations

MBS access points:

75+ Health Assessment: item 705 — annual; includes mandatory falls, cognition, and medication review; the cornerstone of falls prevention in general practice
GPCCMP preparation 965 and review 967 — falls with any chronic condition (osteoporosis, diabetes, heart failure, dementia) qualifies; plan should include exercise referral, OT home assessment, HMR, bone health, continence, and advance care planning
Allied health under GPCCMP: items 10950 to 10970 — five services per calendar year shared across physiotherapy, occupational therapy, exercise physiology, podiatry, and dietetics
Home Medicines Review: item 900 — pharmacist domiciliary medication review; highest-yield falls-related deprescribing tool
ATSI Health Assessment: item 715 — applicable at any age; ATSI Australians may have earlier-onset falls risk
CT brain: item 56001 — post-fall head injury when indicated
DXA bone densitometry: item 12306 — post fragility fracture or specified risk factors

PBS items: Vitamin D (cholecalciferol) general schedule and OTC. Bisphosphonates (alendronate, risedronate) and zoledronic acid — Authority Required (Streamlined) for osteoporosis. Denosumab — Authority Required; note cessation rebound risk (see osteoporosis article). Fludrocortisone and compression stockings for postural hypotension.

My Aged Care (myagedcare.gov.au): Regional Assessment Service (RAS) for Commonwealth Home Support Programme (low need); ACAT (Aged Care Assessment Team) for home care packages, residential aged care, or transition care post-fracture. Home modifications (grab rails, ramps, stair lifts) funded through the Commonwealth Home Support Programme.

DVA: Gold Card holders receive funded falls-related allied health, home modifications, and residential care. White Card for service-related conditions.

Driving review post-fall — falls are a trigger for fitness-to-drive assessment under Austroads Assessing Fitness to Drive 2022. A single mechanical fall does not automatically mean cessation; assess cognition, vision, neurological and cardiac fitness, and refer for OT driver assessment when uncertain. Mandatory reporting applies in the Northern Territory and South Australia; ethical reporting framework applies in other states. Document the assessment and discussion clearly.

E. Special populations

People with dementia — falls risk is two to three times higher; supervision needs increase with cognitive decline. Environmental safety modifications (removing hazards, securing furniture, sensor mats, bathroom grab rails) are particularly important. Exercise remains beneficial; physiotherapy can adapt Otago for cognitive impairment.

Residential aged care residents — approximately 50% fall annually. Hip protectors (padded garments over the greater trochanter) have Cochrane evidence (2014) for modest fracture reduction in highest-risk residents; adherence is limited by comfort and dressing difficulty. Multifactorial programmes in aged care have strong trial support but implementation quality varies significantly.

Falls and anticoagulation in AF — this is a common clinical dilemma. The evidence is clear: falls risk alone is not a contraindication to anticoagulation for atrial fibrillation. Donzé et al. (BMJ 2012) modelled that a patient would need to fall approximately 295 times per year for the intracerebral haemorrhage risk to outweigh stroke prevention benefit. The correct approach: prevent the falls with the multifactorial bundle, and use a DOAC (particularly apixaban) over warfarin given more predictable pharmacokinetics. Document shared decision-making about the risk-benefit discussion.

Elder abuse — falls may occasionally be a presentation of physical abuse. Injury patterns inconsistent with the described mechanism, delayed presentation, multiple falls without a plausible explanation, or signs of neglect warrant sensitive inquiry and mandatory reporting per state frameworks. Compass (compass.info) provides guidance.

When to escalate

Refer to a Falls and Balance Clinic (geriatrician-led) or geriatric assessment service for:

Recurrent falls (two or more in twelve months) despite standard general practice intervention
Complex multimorbidity making comprehensive assessment difficult in a standard consultation
Post-hip fracture requiring comprehensive geriatric rehabilitation

Refer to cardiology when:

Falls with palpitations, chest pain, exertion, or syncope with cardiac features
ECG showing arrhythmia, severe bradycardia, or long QT

Refer to neurology when:

Parkinsonism features (rigidity, tremor, festinating gait)
Normal-pressure hydrocephalus triad (gait, cognition, incontinence)
First seizure or epileptic features
Severe peripheral neuropathy without clear aetiology

What this article is and is not

This is general health information drawn from the RACGP Silver Book, ACSQHC guidelines, World Falls Guidelines 2022, eTG, and AMH. It is not personal medical advice. Individual falls assessment and management plans are developed with your own GP and treating team.

For Australian consumer resources: HealthDirect — Falls in older people, Better Health Channel — Falls prevention, My Aged Care, Stay On Your Feet.

Sources cited

Frequently asked questions

What is the most effective way to prevent falls in older people?

The strongest single intervention for falls prevention is progressive strength and balance exercise — programmes like the Otago Exercise Programme reduce falls by approximately 35% in community-dwelling older adults, and Tai Chi reduces them by 20 to 30%. Exercise works by building muscle strength, improving balance and reaction time, and increasing confidence. The key is that the programme must be genuinely challenging to your balance (not just walking), sustained for at least six months, and performed at least three hours per week. Physiotherapists and exercise physiologists can prescribe and supervise tailored programmes, which are available under the GPCCMP allied health items in Australian general practice.
Which medications increase the risk of falling?

Several common medication classes significantly increase falls risk, particularly in older adults. Benzodiazepines and Z-drugs (such as temazepam and zopiclone) cause sedation, impaired balance, and slowed reaction time — they are among the most important targets for deprescribing. Opioids cause sedation and postural hypotension. Anticholinergic drugs — including some older antihistamines, bladder medications, and antidepressants — impair cognition and balance. Antipsychotics increase sedation, extrapyramidal symptoms, and postural hypotension. Antihypertensives, particularly when newly started or recently dose-escalated, cause postural hypotension. A Home Medicines Review conducted by a pharmacist in your home is the most systematic way to identify and address medication-related fall risk.
Do I need vitamin D supplements to prevent falls?

Only if you are genuinely vitamin D deficient — a blood level below 50 nmol/L. Supplementing with 1000 to 2000 IU of vitamin D daily is appropriate for people with measured deficiency, as it supports muscle function and bone health. However, the USPSTF reviewed the evidence in 2018 and found that routine vitamin D supplementation in non-institutionalised older adults with adequate vitamin D levels does not reduce falls, and importantly, annual high-dose bolus vitamin D injections actually increase falls in some studies. The lesson is: test first, then supplement only if deficient — and avoid very high intermittent doses.
What is the Otago Exercise Programme?

The Otago Exercise Programme is a home-based strength and balance exercise programme developed in New Zealand and validated in multiple randomised controlled trials. It consists of a set of leg-strengthening exercises and progressively challenging balance exercises — including standing on one leg, tandem walking, and stair practice — combined with walking. It is individually prescribed and supervised by a physiotherapist, then done independently at home three times a week. The programme reduces falls by approximately 35% in community-dwelling older adults and is particularly effective in people aged 80 and over and those with a previous fall. It is deliverable under GPCCMP allied health referral to physiotherapy.
I take warfarin and my GP says not to worry about falls — is that right?

This is actually supported by evidence, with an important nuance. Research — including modelling by Donzé et al in the BMJ — suggests a person with atrial fibrillation on warfarin would need to fall approximately 295 times per year for the bleeding risk to outweigh the stroke-prevention benefit. Current Australian and international guidance is clear: fall risk alone is not a contraindication to anticoagulation for appropriate indications. However, for someone on anticoagulation who does fall and hits their head, the rules change: a CT scan of the brain is recommended regardless of symptoms, because bleeding in the brain can be delayed on anticoagulants. The right approach is to prevent the falls, not stop the anticoagulant.
When should I see a specialist for falls?

A GP can manage most falls assessments, but some situations warrant specialist input. Referral to a Falls and Balance Clinic (geriatrician-led) is appropriate for recurrent or unexplained falls despite standard intervention, or when multiple complex medical conditions make the assessment more than a standard consultation can address. Cardiology input is needed when falls are accompanied by palpitations, chest pain, syncope, or an abnormal ECG — cardiac arrhythmia or structural disease may be the cause. A neurologist is helpful for suspected Parkinson's disease, normal-pressure hydrocephalus (the triad of gait problems, cognitive decline, and urinary incontinence), peripheral neuropathy, or first seizure. Vestibular physiotherapy is the definitive treatment for BPPV.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.