Recent advances in technology allow for remote fall detection and risk assessment in the home environment. Technology has the potential to contribute to the prevention of falls, and associated physical and psychological trauma, and thereby improve the lives of older people. The aim of this chapter is to provide a comprehensive overview of the fields of remote fall detection and risk assessment with a focus on wearable technology and its clinical utility.

As outlined in previous chapters, falls are not random events and are associated with multiple risk factors. Fall risk increases in line with the cumulative effect of impairments, making a multi-factorial risk assessment important. A risk assessment should include tests with proven validity and reliability in the relevant setting and population, and linked to appropriate, evidence-based interventions to reduce fall risk. This chapter discusses the relevance and role of fall risk screening and assessment and provides information about validated tools that can be used to measure fall risk in the community, hospitals, and residential aged care.

Generating a comprehensive body of high-quality evidence that demonstrates the problem of falls, identifies causal mechanisms and risk factors, and determines effective interventions for reducing falls is critical for establishing a strong foundation on which to reduce the global burden of falls. While the establishment of such an evidence base is absolutely necessary, this alone will not have an impact on incidence of falls. Assumptions should not be made about the diffusion of fall prevention evidence into clinical practices and health systems [1]. There is growing recognition that most efforts to date attempting to incorporate health research into health care practices and policies are grossly ineffective, and thereby, inefficient [2, 3]. The challenges of moving health evidence into care practices and decision-making are not unique to fall prevention. In fact, published reports have estimated that there is a 17-year time lag between established health evidence reaching clinical practice [3].

This chapter reviews prevention from a different perspective. Instead of preventing the fall, this chapter examines fall injury prevention, a complementary approach that has a history of many decades. This approach has comprised two strategies. The first pertains to padding, or ‘protecting’ the hip or other body parts, including the head, while the second pertains to modifying the surface onto which the person falls to reduce fall impact. The main contrast between these approaches is that the use of body part protectors requires a commitment from the wearer or carers, whereas compliant flooring is a passive device requiring no such commitment or action.

Ageing is associated with a wide range of changes in the brain, including grey and white matter atrophy, as well as markers of small vessel disease such as white matter hyperintensities, microbleeds, and infarcts. Furthermore, beta-amyloid plaques and tau (the hallmarks of Alzheimer’s disease) are evident in the brain years before symptoms of dementia appear. A brain free of disease, with intact grey and white matter, is essential for the fast and efficient operation of the neural networks during daily life activities, and therefore also in reducing the risk of falling.

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].

In biomechanical terms, balance control is the maintenance of the body’s centre of mass (COM: the point around which the body’s mass is equally distributed) within the limits of the base of support (BOS: the area circumscribed by parts of the body that are in contact with a support surface) in the horizontal plane. Simply put, the vertical line of gravity acting through the COM (also termed the centre of gravity), must remain within the BOS for a body to remain in postural equilibrium. Falling is the loss of balance control, i.e. when the vertical projection of the COM moves beyond the BOS. Without a successful balance-correcting response or external intervention to arrest the falling state and regain postural equilibrium, a fall (to the ground or some other lower level) will result. Biomechanical investigations have sought to understand falling by characterizing balance control while standing, walking, during postural transitions, and following unexpected perturbations. These studies complement epidemiological and physiological investigations of fall risk. Findings can help to inform the development of intervention strategies and in turn, biomechanical investigations can enable the evaluation of their effects.

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 approximately one in seven people aged over 65 years [1]. Devices to be addressed in this chapter include footwear, orthoses, walking aids, wearable technology, and physical restraints. The demonstrated and potential impact of each of these approaches on falls is discussed.

Chapter 2 outlined how human balance is dependent on the interactions of multiple sensory, motor, and integrative systems. This chapter focuses on age-related changes in key sensory and motor systems involved in balance control, and the associations between impairments in these systems and falls in older people. Specific topics of review include vision, somatosensory and vestibular acuity, and muscle strength, power, and endurance.

The chapter synthesizes the current knowledge about falls, fall-related injuries, and fall prevention among residents of nursing homes, residential care, and assisted living. These groups are from here on referred to as residents of long-term care (LTC) facilities. Evidence on the efficacy and effectiveness of fall prevention measures is cross-linked to the findings of systematic reviews, meta-analyses, and the most recent Cochrane review published in 2018 [1]. Evidence based on controlled studies is not available for all relevant questions. Therefore, scientific evidence is augmented by recommendations based on observational data and the authors’ two decades of experience with large-scale implementation projects on fall prevention in German LTC facilities. The type of institutional care, and the qualification and cooperation of the staff differ significantly between countries and different care systems. In addition, resident case mix and care culture can differ considerably across countries. This should always be kept in mind. In order to update the knowledge, we performed a narrative literature search including study registries and databases. For the update, 46 either registered or published studies from 2010 onwards were considered.

Falls are one of the most frequent adverse events that occur in hospitals [1, 2]. Fall rates range from 3.4 to 11 falls per 1000 bed days in acute and rehabilitation wards [3–6]. These rates translate to significant numbers of patients falling during a hospital stay; for example, in England there were over 250,000 falls in hospitals 2015/2016 [1], and it is estimated that nearly one million patients fall in US hospitals each year [2]. For these patients, a hospital admission intended to improve health may result in serious injuries and even death.

There is compelling evidence that a range of risk factors contribute to falls in later life. A natural extension is to think that intervening on multiple risk factors as opposed to a single risk factor for falling might result in a greater reduction in falls. However, the evidence base suggests that interventions that target multiple risk factors are difficult to implement in practice and that the effect varies substantially across populations and practice settings. Multiple risk factor intervention is complex and requires greater commitment from participants and health care professionals than single-component interventions, and costs more to deliver.

Fear of falling refers to ongoing concerns about falls which can compromise an individual’s quality of life. ‘Fear of falling’ is often used as an umbrella term to include both cognitive constructs, like balance confidence and fall-related self-efficacy, and affect-based constructs, like concern or worry about falling [1]. Fear of falling can be an adaptive and justified response for people who are frail, preventing them from taking part in risky activities [2]. However, approximately one-third of community-dwelling older people experience high levels of fear of falling, which has been associated with restriction in physical and social activities with consequent negative impacts on quality of life [3]. Fear of falling is multi-dimensional in nature. Physical (poor balance and muscle weakness), psychological (unrealistic appraisals of one’s ability to avoid falls) and behavioural factors (reduced outdoor and social activities) can interact and contribute to a vicious cycle of fear of falling and activity avoidance [2].

As indicated in Chapter 12, the homes of many older people have environmental hazards [1–3] and the majority of these are amenable to modification. This chapter outlines environmental assessment, adaptations, and strategies to prevent falls and reviews the literature for interventions delivered individually or as part of multi-faceted programmes. It discusses the breadth and quality of assessments available; potential enablers and challenges to hazard removal and design strategies for minimizing older people’s risk of falling at home and in public places. Fall prevention strategies involving the provision of new glasses and assistive devices are presented in Chapters 21 and 22 respectively.

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: