Falls in Older Adults — Identifying Causes, Reducing Risk

In geriatric medicine, we call this the geriatric cascade. A first fall that ends without serious injury is, medically speaking, a blessing. It is the only moment when the chain of events can still be broken. Studies clearly show that anyone who has fallen once is three times more likely to fall again within the next twelve months.

The typical sequence of untreated fall risk is predictable: from a fall to a fracture, from a fracture to immobility in old age, from immobility to muscle loss and the risk of delirium, and from loss of function to the need for long-term care. One-year mortality following a femoral neck fracture ranges between 20 and 30 percent, depending on the study. Among those over 90 years of age who underwent total hip replacement (THR), it reached 26.5 percent in the SOG study.

At my own hospital, the Main-Kinzig-Kliniken Schlüchtern, the number of hip fractures has nearly doubled within six years—from 109 cases in 2019 to 217 cases in 2025. That represents a 99.1 percent increase over a period in which the aging of our catchment area’s population has not grown nearly as rapidly. Demographic aging does not explain everything. A significant portion of the increase is attributable to preventable falls.

→ We explain exactly what happens medically after a hip fracture—and why care is interdisciplinary—in our article on geriatric traumatology and in the article on femoral neck fractures in older adults.

The most common misconception when dealing with falls among older adults is the search for a single trigger—the loose rug, the wrong shoes, the dark staircase. In reality, a fall among seniors is almost always multifactorial. The following ten causes are most commonly overlooked in clinical practice:

1. Medications—the invisible prime suspect

Benzodiazepines (lorazepam, diazepam, oxazepam), Z-drugs (zolpidem, zopiclone), tricyclic antidepressants (amitriptyline), potent anticholinergic agents, opioids, aggressively dosed antihypertensives, diuretics, and certain SSRIs measurably increase the risk of falls. The PRISCUS list and the FORTA classification evaluate these medications in terms of their suitability for older adults. In my clinical practice, I regularly see patients for whom discontinuing even a single medication makes the difference between repeated falls and maintaining a stable gait.

2. Orthostatic Hypotension

When standing up from a lying or sitting position, blood pressure drops more sharply than the body can compensate for. The result: dizziness, blackouts, and falls. Delayed orthostatic hypotension is particularly insidious, as it sets in only after 30 to 60 seconds—just when the patient is already on their way to the bathroom.

3. Sarcopenia and Muscle Weakness

Between the ages of 50 and 80, a person loses an average of 30 to 40 percent of their muscle mass without targeted training. Anyone who can no longer stand up from a low chair without using their arms for support is showing this typical warning sign. The Chair Rise Test measures this objectively.

→ You can find more information about gradual muscle loss and what helps counteract it in our article on sarcopenia in older adults.

4. Dizziness and Vestibular Disorders

Benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness in older adults and, at the same time, the easiest to treat—through simple positional maneuvers. It is not uncommon for patients to be treated with anti-vertigo medications for months when a two-minute Epley maneuver would resolve the problem.

5. Polyneuropathy and sensory disturbances

This is particularly common in older adults with long-standing diabetes mellitus: The feet have reduced sensation on the ground, surefootedness decreases, and balance is increasingly compensated for visually—which fails in poorly lit rooms.

6. Visual Impairments

Cataracts, macular degeneration, glaucoma, and even eyeglasses that haven’t been updated in years impair depth perception and contrast sensitivity. A new pair of glasses can measurably reduce the risk of falls—provided that adjusting to progressive lenses does not end up being counterproductive.

7. Cognitive Impairment and Delirium

Dementia in older adults doubles the risk of falls. Acute delirium—often triggered by infections, dehydration, or medications—can turn a stable person into someone at high risk of falling within a matter of hours.

→ We explain what delirium is, how to recognize it, and why it is often overlooked in our article on delirium prevention.

8. Pain and Osteoarthritis

Knee and hip pain caused by osteoarthritis in older adults leads to a cautious, shortened gait, impaired balance, and reduced step force. Pain management is therefore also fall prevention—though with the caveat that certain pain medications themselves can increase the risk of falls.

9. Home Environment

Loose rugs, missing grab bars in the bathroom, low toilet seats, no night light, steep stairs without handrails, slippery bathtubs, and unsuitable slippers—the classic list of hazards that family members can usually identify during a one-hour walk-through.

10. Fear of Falling

This may sound paradoxical, but it is well documented clinically: Anyone who has fallen once often moves more cautiously, less frequently, and more hesitantly—and as a result, loses even more muscle strength and balance. The result is a self-fulfilling cycle. In geriatrics, this syndrome is called “Fear of Falling” or post-fall syndrome and is one of the most commonly overlooked psychological factors.

???? If a family member begins to move less or sit more often after a fall—interpret this as a warning sign, not as sensible caution. This avoidance behavior increases the risk of another fall.

If I could share just one sentence today, it would be this: The most common cause of falls among older adults is not a tripping hazard in the living room. It’s the pill organizer on the kitchen table.

Polypharmacy in older adults—taking five or more medications at the same time—affects more than 40 percent of people over 65 in Germany. Every additional medication disproportionately increases the risk of drug interactions and side effects. And not every medication that was appropriate ten years ago is still appropriate today.

A case study from my clinic

An 81-year-old female patient was admitted to our hospital due to repeated falls and increasing confusion. Her initial medication regimen included 19 different drugs—heart medications, blood pressure medications, stomach protectants, sleep aids, a benzodiazepine, an SSRI, an opioid patch for back pain, and four different dietary supplements. Each one had been justified at some point. Taken together, they caused what we refer to as pharmacogenic delirium with a risk of falls.

After a systematic medication review based on PRISCUS and FORTA criteria, we reduced her regimen over three weeks to six medications that were truly indicated. The patient went home walking upright, lucid, and without a cane. This is not an exception, but rather the norm for us. At our clinic, we achieve average reductions of 30 to 50 percent in the number of medications for patients undergoing geriatric medication reduction—almost always without compromising their health.

???? The most important question you, as a family member, should ask the primary care physician or geriatrician is: “Which of these medications really needs to be continued today—and which ones were last deemed appropriate several years ago and have never been reviewed?”

→ For more details on the topic of too many medications and how to systematically reduce them: Polypharmacy in Older Adults and Deprescribing—Understanding the PRISCUS List.

A geriatrician does not replace the family doctor, orthopedist, cardiologist, or neurologist. Geriatrics is the specialty that determines which of these perspectives takes priority in each individual case—and that systematically identifies what the individual specialties overlook because they view the patient through their respective “organ-specific lenses.”

The tool used for this is called the Comprehensive Geriatric Assessment (CGA)—a structured assessment procedure that evaluates five dimensions over the course of one or more sessions: medical status, functional status, cognitive status, and emotional and social status. Four test procedures are particularly well-established for fall risk assessment:

• Timed Up and Go (TUG): The patient stands up from a chair, walks three meters, turns around, and sits back down. A time under 10 seconds is normal; over 13.5 seconds indicates a significant risk of falling.
• Tinetti Test (POMA): A 28-point scale for balance and gait. A score below 19 indicates a high risk of falling.
• Chair Rise Test: Standing up from a chair five times without using the arms for support. If it takes longer than 15 seconds, sarcopenia is suspected.
• Medication review according to PRISCUS/FORTA: Systematic review of each individual medication, including its indication, alternatives, and options for discontinuation.

→ We describe the full scope of the assessment, including all seven dimensions, in our article on geriatric assessment.

The good news to conclude: Fall prevention works. The comprehensive Cochrane review by Gillespie and colleagues, which included more than 150 individual studies, reaches a clear conclusion: Multifactorial interventions—programs that address multiple risk factors simultaneously—reduce the fall rate among older adults living at home by an average of 23 percent.

What Has Been Proven to Work

• Group-based exercise programs focusing on strength and balance (Otago Program, Tai Chi)—up to a 40 percent reduction in falls
• Individualized physical therapy program following a geriatric assessment
• Systematic medication review with discontinuation or dose adjustment of high-risk medications—more on this: deprescribing
• Treatment of orthostatic hypotension (adjustment of antihypertensive medications, compression stockings, fluid intake)
• Cataract surgery when indicated — up to a 30 percent reduction in falls in the operated eye
• Vitamin D supplementation in cases of confirmed deficiency (not routinely administered to everyone) — also relevant in the context of osteoporosis in older adults
• Home modifications: grab bars in the bathroom, lighting along the path to the toilet, non-slip mats, flat, closed-toe shoes
• Hip protectors for institutionalized high-risk patients

What’s Less Effective Than You Might Think

Vitamin D supplementation without a confirmed deficiency offers no preventive benefit and, in high-dose studies, even increases the risk of falls. Home modifications alone, without exercise, are less effective than combined programs. The effect of a single measure is limited—the benefit arises from a structured combination of measures, and that is precisely the domain of the geriatric treatment approach.

→ You can find concrete, action-oriented steps for fall prevention in your own environment in the article of the same name.

The following situations are specific occasions to supplement primary care with a geriatric second opinion—not as a replacement, but as a complement:

• First fall, even without a serious injury
• More than one fall in twelve months
• Five or more long-term medications (polypharmacy)
• Newly developed unsteadiness while walking, even if subtle
• Unexplained episodes of weakness, drowsiness, or dizziness
• Increasing forgetfulness combined with changes in movement—a possible sign of mild cognitive impairment (MCI)
• Before scheduled surgeries (preoperative geriatric assessment) — more on this: Surgical risk in older adults
• After a hospital stay with new functional loss — early geriatric rehabilitation can help here

The most common mistake I see is waiting too long. An evaluation after the first fall is far more effective than the same evaluation after the third fall resulting in a hip fracture. A fall with no consequences is not a reason to relax—it’s a warning sign.

→ If you’d like to know how your physical capacity is assessed before a planned surgical procedure, you’ll find all the information in the article on Surgical Risk in Older Adults.