The vast majority (75%) of falls among community-dwelling older persons are not reported to a health care professional [1]. When falls are reported, 68% are to general practitioners (GPs) and 16% to emergency department clinicians. Older people may present with falls, risk factors for falling, or complications of a fall. Risk factors for falls include a history of a fall [2], dementia [3], stroke [4] and Parkinson’s disease [5], and use of falls-risk-increasing drugs (FRIDs) [6–12]. Complications of falls may present as fractures, soft tissue injury, fear of falling and loss of independence [13, 14].

Habitual upright walking is a characteristically human trait that provides a challenging set of physiological challenges. When standing erect, two-thirds of the body’s mass is located two-thirds of body height from the ground, precariously balanced on two narrow legs with the only direct contact with the ground provided by the feet [1]. Such a structure challenges the basic principles of mechanical engineering and requires a highly developed postural control system to ensure that the body remains upright. However, in order to progress forwards, it is necessary to repeatedly initiate a forward fall and then ‘re-capture’ this momentum by the appropriate placement of the leading limb. The potential for a loss of balance when performing an apparently simple task such as walking is considerable. It is therefore not surprising that between 50 and 70% of falls in older people occur when walking [2–4]. The aim of this chapter is to provide an overview of the literature pertaining to gait patterns in older people and their relationship to falls. Specifically, this chapter will address gait characteristics during level walking, when distracted by secondary tasks, when stepping over, avoiding, and approaching obstacles, during turning, stair walking, and the ability to respond to trips and slips.

Originally discussed in early clinical reports (e.g. [1]), the relationship between psychological factors and falls is now well supported in the literature. Specifically, fear of falling, balance confidence or fall efficacy (i.e. belief in ability to maintain one’s balance),1 and depression are well-established predictors of falls and determinants of fall risk (e.g. [4,5]). Anxiety also appears to play a role in the determination of balance performance and gait parameters [6]. These psychological variables, which can also be the consequence of or be changed by a fall, can lead to activity avoidance in an effort to prevent future injuries [7]. In this chapter, psychological risk and consequences of falls and interventions designed to address them are discussed.

Many studies have now shown that both physical and cognitive factors are important in fall risk. In accordance with the common-cause theory of cognitive ageing, which states that age-related declines in cognitive, sensory, and motor functioning are attributed to a common neurobiological mechanism, there is evidence of shared variance between sensorimotor and cognitive age-related changes. Indeed, cognitive, sensory, and motor inter-relationships strengthen with age [1]. It is, therefore, of little surprise that parameters of the postural control system are influenced by the cognitive demand of a task, particularly in older people. Undertaking daily tasks, such as maintaining upright posture and safely navigating complex environments, requires adequate sensory perception, cognitive integration, and subsequent motor adjustments [2], with increased cognitive processing required with aging [3]. Furthermore, many daily activities require the handling of two or more simultaneous tasks, such as walking while talking, carrying a basket with laundry while navigating the stairs, or crossing a busy road safely [4]. Older people appear not to be able to process multiple tasks as quickly and/or as well as younger adults and such impairments have been linked to falls in older people [5]. Figure 18.1 displays a hypothetical model of how the sensory, cognitive, and motor domains are inter-linked and how these factors and interactions might contribute to falls.

Falls and fall-related injuries among older adults represent a substantial health burden. Approximately 30% of older adults experience at least one fall each year, and half of these individuals fall recurrently [1, 2]. Fall-related non-fatal injuries are associated with increased morbidity, decreased functioning, and increased health care resource utilization [3, 4]. Fall-related injuries such as fracture account for 10-15% of emergency department presentations of those aged 65 years and older [5, 6]. With the number of adults aged 65 and older expected to increase to 1 in 5 by 2050, the economic burden imposed by falls is expected to increase proportionally [7].

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.

In relation to falls in older people, the focus on the environment is often restricted to the individual’s immediate home surroundings [1]. However, the environment can be conceptualized on three levels: the individual’s immediate home surroundings, which is the home and adjoining grounds, the wider community or local neighbourhood, and the country, including the social, cultural, and political context of the society in which the person lives, including accessibility, potential hazards relating to public facilities, government policy on environmental design, housing standards, public transport, neighbourhood conditions, and social networks [2]. Within each of these levels, the environment comprises social and physical elements [3]. In this chapter, the environment in relation to falls is defined as ‘the context within which the occupational performance of the person takes place. It influences behaviour and in turn is influenced by the behaviour of the person’ [4, p17]. This inclusive definition is used because there have been promising study findings suggesting that fall prevention interventions are effective in the wider community [5–8]. Further, there is debate about whether research should separately address falls in the home environment and those in the wider community, because hazards and risk factor profiles of people who fall in these environments differ [9–11].

Postural stability can be defined as the ability of an individual to maintain the position of the body, or more specifically, its centre of mass, within specific boundaries of space, referred to as stability limits. Stability limits are boundaries in which the body can maintain its position without changing the base of support [1]. This definition of postural stability is useful as it highlights the need to discuss stability in the context of a particular task or activity. For example, the stability limit of normal relaxed standing is the area bounded by the two feet on the ground, whereas the stability limit of unipedal stance is reduced to the area covered by the single foot in contact with the ground. Due to this reduction in the size of the stability limit, unipedal stance is an inherently more challenging task requiring greater postural control.

The early landmark trials which showed that multi-factorial interventions were effective in preventing falls included assessments of medical risk factors for falls which were then used to guide interventions. As discussed in Chapter 20, the identification of medical risk factors can inform which of a suite of possible multi-factorial interventions a patient should receive. The maintenance of the postural stability is a complex task involving many physiological systems (Chapters 2–5). Sensory input from visual and vestibular pathways, muscle spindles, and joint proprioceptors is channelled centrally to the brain where it is rapidly processed to produce appropriate and co-ordinated motor responses [1]. The key components of this process are represented in Figure 10.1, whilst Table 10.1 lists some of the diseases which can impact on these systems to increase an individual’s risk of falling.

As outlined in earlier chapters, falls in older people result from the interaction between intrinsic, or physiological risk factors (such as visual impairment, muscle weakness, and slowed reaction time), and extrinsic, or environmental risk factors (such as slippery surfaces, cracked footpaths, or loose floor rugs). Because the foot is the only direct source of contact with the supporting surface when undertaking weightbearing activities, it represents an important interface between intrinsic and extrinsic falls risk factors. This interface is further modified by footwear, which can affect balance in either a beneficial or detrimental manner. As such, foot problems and footwear have a significant influence on risk of falling in older people. This chapter provides an overview of the contribution of foot problems and footwear to falls in older people, and the role of podiatry in preventing falls. The use of footwear and foot orthoses as interventions is further addressed in Chapter 22.

Medications have long been implicated as an iatrogenic cause of falls and fractures, with several prospective cohort studies providing support for a link between medications and falls. This chapter discusses the pharmacology of ageing and the potential physiological mechanisms by which medications may impair postural stability. Specific drug classes strongly associated with falls are highlighted and the role of optimization prescribing in relation to polypharmacy is explored.

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.

Step training can be defined as training of single or multiple volitional or reactive steps in an upright (standing or walking) position in response to an environmental challenge. For example, stepping onto a target, avoiding an obstacle, or responding to a postural perturbation large enough to require reconfiguration of the base of support [1]. Volitional step training uses stepping targets or distractors (no-go zones), whereas reactive step training exposes participants to repeated mechanical perturbations that displace body segments and induce unplanned stepping responses. Reactive step training is also referred to as ‘perturbation training’ [2], ‘reactive balance training’ [3], or ‘perturbation-based balance training’ [4].

Dementia is a progressive clinical syndrome characterized by neurocognitive domain impairment(s) (i.e. complex attention, executive function, learning and memory, language, perceptual-motor, and social cognition), with or without significant behavioural disturbances, resulting in impairments in activities of daily living [1]. Further, these signs and symptoms cannot be better explained by another medical condition and should not be solely present during delirium [1].

As indicated in Chapter 4, there is good evidence that important visual functions including poor contrast sensitivity, deficient depth perception, and visual field loss increase the risk of falls and fall-related fractures in older people. Some visual impairments are amenable to intervention by surgery or refractive correction, and accordingly several randomized controlled trials have investigated visual interventions as a fall prevention strategy. This chapter provides summaries of these trial findings as well as a complementary study that evaluated the roles of exercise and home safety programmes for older people with visual impairment.