In geriatric medicine we call this the geriatric cascade. A first fall that ends harmlessly is, medically speaking, a gift. It is the only moment in which the chain can still be interrupted. Studies show clearly: 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 the fall to the fracture, from the fracture to immobilization in old age, from immobilization to muscle loss and the risk of delirium, from loss of function to the need for care. The one-year mortality after a femoral neck fracture lies, depending on the study, between 20 and 30 percent. Among those over 90 years of age after hip joint replacement, it reached 26.5 percent in the SOG study.
In my own clinic, the Main-Kinzig-Kliniken Schlüchtern, the number of hip fractures has almost doubled within six years — from 109 cases in 2019 to 217 cases in 2025. That is an increase of 99.1 percent over a period in which the age structure of our catchment area has not grown anywhere near as strongly. Demographic aging does not explain everything. A considerable part of the increase is due to avoidable falls.
→ What exactly happens medically after a hip fracture — and why care is provided in an interdisciplinary way — we explain in the article on geriatric traumatology and in the article on the femoral neck fracture in old age.
The most frequent misjudgement in dealing with falls in older people is the search for a single trigger — the loose rug, the wrong shoes, the dark staircase. In truth, a fall in seniors is almost always multifactorial. The following ten causes are the ones most frequently overlooked in practice:
1. Medications — the invisible main suspect
Benzodiazepines (lorazepam, diazepam, oxazepam), Z-drugs (zolpidem, zopiclone), tricyclic antidepressants (amitriptyline), strongly anticholinergic substances, opioids, aggressively dosed antihypertensives, diuretics and certain SSRIs measurably increase the risk of falling. The PRISCUS list and the FORTA classification evaluate these medicines with regard to their suitability for older people. In my clinical work I regularly see patients in whom even discontinuing a single preparation makes the difference between repeated falling and a steady stance.
2. Orthostatic hypotension
When standing up from lying or sitting, blood pressure drops more sharply than the body can counter-regulate. The result: dizziness, blackness before the eyes, a fall. Particularly treacherous is delayed orthostatic hypotension, which only sets in after 30 to 60 seconds — precisely 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 without targeted training loses on average 30 to 40 percent of their muscle mass. Anyone who can no longer rise from a low chair without supporting themselves with their arms is showing the typical warning sign. The chair-rise test measures it objectively.
→ More on the insidious loss of muscle and what helps against it can be found in our article on sarcopenia in old age.
4. Dizziness and vestibular disorders
Benign positional vertigo (BPPV) is the most common cause of dizziness in old age and at the same time the most easily treatable — through simple positioning maneuvers. Not infrequently, months are spent treating with antivertiginous drugs when two minutes of the Epley maneuver would solve the problem.
5. Polyneuropathy and sensory disorders
Especially in long-standing diabetes mellitus in old age: the feet feel the ground less well, surefootedness decreases, balance is increasingly compensated visually — which fails in poorly lit rooms.
6. Visual impairments
Cataract, macular degeneration, glaucoma and even a pair of glasses not updated for years worsen depth perception and contrast vision. New glasses can measurably reduce the risk of falling — provided that getting used to varifocal lenses does not turn out to be counterproductive instead.
7. Cognitive impairment and delirium
Dementia in old age doubles the risk of falling. An acute delirium — often triggered by infections, dehydration or medications — can turn a stable person into one at severe risk of falling within hours.
→ What delirium is, how to recognize it and why it is often overlooked, we explain in the article on delirium prevention.
8. Pain and osteoarthritis
Knee and hip pain due to osteoarthritis in old age leads to a cautious, shortened gait, shifted balance and reduced stepping power. Pain therapy is therefore also fall prevention — albeit with the caveat that certain painkillers themselves promote falls.
9. Living environment
Poorly secured rugs, missing grab rails in the bathroom, low toilet seats, missing night lights, steep stairs without a banister, slippery bathtubs and unsuitable slippers — the classic repertoire that relatives can usually identify with a one-hour walk-through.
10. Fear of falling
This sounds paradoxical, but is clinically well documented: anyone who has fallen once often moves more cautiously, less, more hesitantly — and thereby loses further 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 frequently overlooked psychological components.
???? If a relative begins to move less or sit more often after a fall — regard this as a warning sign, not as reasonable caution. The avoidance behavior increases the risk of the next fall.
If I were only allowed to pass on one sentence today, it would be this: the most common cause of falls in older people is not the tripping hazard in the living room. It is the pill sorting box on the kitchen table.
Polypharmacy in old age — the simultaneous intake of five or more medications — affects more than 40 percent of those over 65 in Germany. Each additional medication increases the risk of interactions and side effects disproportionately. And not every medication that was right ten years ago still makes sense today.
A case example from my clinic
An 81-year-old patient was admitted to us with repeated falls and increasing confusion. The admission medication comprised 19 preparations — heart medications, blood pressure reducers, stomach protection, a sleeping aid, a benzodiazepine, an SSRI, an opioid patch for back pain, plus four different dietary supplements. Every single one had been justified at some point. In sum, they produced what we call pharmacogenic delirium with a risk of falling.
After a systematic medication review according to PRISCUS and FORTA criteria, we reduced over three weeks to six genuinely indicated medications. The patient went home upright, clear-headed and without a walking stick. This is not an exception, but our standard case. In our clinic we achieve average savings of 30 to 50 percent of preparations in patients with geriatric medication reduction — almost always without the state of health suffering.
???? The most important question that you as a relative should ask the family doctor or the geriatrician: “Which of these medications really has to be continued today — and which was last classified as appropriate several years ago and never reviewed?”
→ In detail on the topic of too many medications and how to reduce them systematically: polypharmacy in old age and deprescribing — understanding the PRISCUS list.
A geriatrician does not replace the family doctor, the orthopedist, the cardiologist or the neurologist. They are the speciality that decides which of these perspectives is given which priority in the individual case — and that systematically clarifies what the individual specialities do not see because they look through their respective organ window.
The tool for this is called the Comprehensive Geriatric Assessment (CGA) — a structured examination procedure that, within one to several sessions, captures five dimensions: medical status, functional status, cognitive status, emotional and social status. For the clarification of falls, four test procedures are particularly well established:
- Timed Up and Go (TUG): The patient stands up from a chair, walks three meters, turns around and sits down. Under 10 seconds is unremarkable, over 13.5 seconds means a significant risk of falling.
- Tinetti test (POMA): 28-point scale for balance and gait pattern. Under 19 points: high risk of falling.
- Chair-rise test: Standing up from a chair five times without arm support. Longer than 15 seconds: suspected sarcopenia.
- Medication review according to PRISCUS/FORTA: Systematic review of every single substance with its indication, alternatives and options for discontinuation.
→ We describe the entire spectrum of the assessment with all seven dimensions in the article on the geriatric assessment.
The good news at the end: fall prevention works. The comprehensive Cochrane review by Gillespie and colleagues with more than 150 individual studies comes to a clear result: multifactorial interventions — programs that tackle several risk factors at the same time — reduce the fall rate in older people living at home by an average of 23 percent.
What demonstrably works
- Group-based exercise programs with a focus on strength and balance (Otago program, Tai Chi) — fall reduction up to 40 percent
- Individual physiotherapy program after a geriatric assessment
- Systematic medication review with discontinuation or dose adjustment of risk medications — more on this: deprescribing
- Treatment of orthostatic hypotension (adjustment of antihypertensives, compression stockings, fluid intake)
- Cataract surgery when indicated — fall reduction up to 30 percent in the operated eye
- Vitamin D substitution in case of proven deficiency (not routinely in everyone) — also relevant in connection with osteoporosis in old age
- Home adaptation: grab rails in the bathroom, lighting on the way to the toilet, non-slip mats, flat closed shoes
- Hip protectors in institutionalised high-risk patients
What works less than one thinks
Giving vitamin D without a proven deficiency brings no preventive benefit and in high-dose studies even increases the risk of falling. Isolated home adaptation without training is less effective than combined programs. The effect of a single measure is limited — the effect arises through the structured combination, and that is precisely the domain of the geriatric treatment approach.
→ Concrete, action-oriented steps for fall prevention in your own environment can be found in the article of the same name.
The following situations are concrete occasions to supplement family-doctor care with a geriatric second perspective — not as a replacement, but as a complement:
- First fall, even without serious injury
- More than one fall in twelve months
- Five or more long-term medications (polypharmacy)
- Newly occurring gait unsteadiness, even if subtle
- Unexplained phases of weakness, light-headedness, dizziness
- Increasing forgetfulness in combination with a change in movement — a possible sign of a mild cognitive impairment (MCI)
- Before planned operations (preoperative geriatric assessment) — more on this: surgical risk in old age
- After a hospital stay with a new loss of function — here the geriatric early rehabilitation helps
The most common mistake I see is: waiting too long. A clarification after the first fall is many times more effective than the same clarification after the third fall with a hip fracture. A fall without consequences is not reassurance — it is an appointment.
→ Anyone who, before a planned surgical procedure, wants to know how resilience is assessed will find all the information in the article on surgical risk in old age.
Is a fall in old age always a reason to go to the doctor?
Yes. Even if the fall apparently remained without consequences, the cause should be clarified — especially in older people. Studies show that the risk of a further fall increases threefold after the first event. The first fall is the diagnostic window of opportunity, before it comes to a fracture. A visit to the family doctor, ideally with a referral to the geriatric outpatient clinic, is the right step.
Which medications increase the risk of falling the most?
Benzodiazepines and Z-drugs (sleeping and sedative medications), tricyclic antidepressants, strongly anticholinergic substances, opioids, aggressively dosed antihypertensives and diuretics are the main groups. The PRISCUS list and the FORTA classification offer structured overviews of this. Important: never discontinue medications on your own — always under medical supervision. More on the systematic reduction of medications: deprescribing.
Does vitamin D help to prevent falls?
Only in case of a proven vitamin D deficiency. With a sufficient level, substitution brings no preventive benefit; in high-dose studies an increased risk of falling was even seen. The decision should be based on a blood level, not on blanket prophylaxis.
What is the difference between a geriatrician and a family doctor?
The family doctor looks after the patient continuously and knows the individual medical history best. The geriatrician is a specialist in geriatrics and geriatric medicine and brings in an additional, structured perspective: the Comprehensive Geriatric Assessment. They are not a replacement, but a complement — typically for specific questions such as fall clarification, medication review, preoperative assessment or after a clinic stay.
Can falls be prevented completely?
No — and no one should make that promise. But structured programs demonstrably reduce the fall rate by 20 to 40 percent, and the severity of the consequences of falls can be markedly reduced. The goal is not freedom from falls at any price, but rather the longest possible preservation of independence and quality of life — in the sense of a comprehensive fall prevention strategy.
