A single fall can shatter not just bones, but also one’s confidence, independence, and dignity, often marking the beginning of a decline in quality of life; a structured, multi-disciplinary orthogeriatric service plays a vital role in optimising care for elderly patients, particularly those at risk of falls or recovering from fractures
Meenakshi was an active senior citizen who enjoyed her morning walks and led a busy, independent life. One morning, the 76-year-old, after finishing her daily prayers, got up to head to the kitchen. Unaware that the granite floor had just been mopped, she slipped and fell.
A single fall can shatter not just bones, but also one’s confidence, independence, and dignity, often marking the beginning of a decline in quality of life. Meenakshi sustained a hip fracture and a head injury. She was confined to bed for several months. Her busy son and daughter could not take care of her themselves, owing to their tight work schedules and so, they had to hire help. Meenakshi stopped going out for walks and to all the usual places she used to go to with her friends. She stopped cooking her grandson’s favourite dishes. Once cheerful and energetic, she became quiet, dejected and lonely.
This is not an isolated incident but reflects a reality in Indian homes. It highlights the need to address the causes and risks of falls among the elderly in India’s rapidly ageing society.
Magnitude of problem
Globally, 28-35% of individuals aged 65 and over, experience a fall each year, and this number rises to over 40% among those aged 70 and above. Of these, up to 30% suffer from fractures, trauma and soft tissue injuries. In India, falls affect 30% to 50% of adults over 60 years.
The situation is particularly concerning due tolow awarenessand delayed treatment, often caused bylimited access to care. Falls are one of the prime reasons for hospital admissions among the elderly. Most require a hospital stay of 10 days or more, and months of home rehabilitation. This can be avoided with education and increased awareness about fall prevention.
Falls are a heavy burden on the individual as they lead to long hospital stays, followed by rehabilitation, causing a significant financial burden. A fall also directly impacts hospitals, especially government hospitals, as they are already understaffed and struggle to give specialised geriatric care in general wards. Preventing falls is not just a health imperative but an economic necessity.
Elderly at risk
Elderly people are at risk due to a number of factors. These include:
Age-related body changes: It is natural for elders to experience declining vision and hearing, as well as weakened muscles and stiffening joints, leading to unsteady gaits. A misstep in such a situation will most likely lead to a fall.
Chronic illnesses: Conditions such as arthritis cause joint pain and stiffness. Osteoporosis weakens the bone to the extent that a simple fall can lead to a serious fracture. Parkinson’s Disease affects movement control, causing tremors. A stroke can lead to poor coordination and imbalance. Dementia impairs judgement and spatial awareness. Diabetes causes numbing and tingling in the feet, affecting balance. Vestibular disorders too, can cause imbalance.
Medications: Sedatives, antihistamines, drugs for vertigo/nausea and anti-depressants can cause drowsiness, poor reaction time and poor coordination.
Psychological factors: Depression in some elders causes inattentiveness, lack of focus and poor coordination, all of which increase fall risk.
Environmental hazards: Poor lighting, slippery floors, steep stairs and objects lying around are the most common external causes of falls in elders.
An elder who has suffered a fall should not only receive physical treatment, but also counselling and emotional reassurance. The fear of falling again restricts their movement and decreases their confidence. Let’s go back to Meenakshi: after her bad fall, she first lost her confidence and independence. Her dependency on family members and hired help increased. The guilt associated with this dependency resulted in social withdrawal, which in turn led to depression and anxiety. A mere fall had turned an active and cheerful senior citizen into someone battling emotional grief.
Now that we understand the serious consequences of a fall, it is important to take proactive measures towards prevention. Regular fall screenings are essential to identify individuals who are at risk, and to implement timely interventions.
Public places should also try adopting elder-friendly designs, such as ramps, smooth pavements and railing to prevent falls. File photograph used for representational purposes only
Need for assessment
A comprehensive review of chronic diseases and past fall incidents is necessary. A thorough and detailed examination of all the drugs taken by the individual, with an assessment of side effects, especially those that induce dizziness and low blood pressure needs to be undertaken.
Check for high-risk medications: Identify drugs known to increase fall risk, such as sedatives (e.g., benzodiazepines, sleeping pills); antidepressants (tricyclics, SSRIs); antipsychotics; antihypertensives (especially when causing postural hypotension); diuretics (can cause dehydration or electrolyte imbalance) and opioids or strong painkillers
Review polypharmacy: Taking more than four medications increases the risk of falls. Check for: duplicate therapies; drug–drug interactions; inappropriate combinations.
Assess dosage and timing: High doses increase side effects. The timing (e.g., night doses of sedatives) of medications can affect balance during night-time bathroom trips.
Check for postural hypotension: Assess if the patient feels dizzy or lightheaded when standing up and review and adjust blood pressure medications accordingly.
Functional Assessments
Different tests can be done to evaluate the elderly.
Timed Up and Go Test (TUG)
Why: Screening for imbalance and gait disturbances
How it is done: The elderly person is asked to get up from a chair, walk three metres (10 feet), turn around, walk back and sit on the chair. The patient wears regular footwear and if needed, can use a walking aid.
Results: >12 seconds: increased risk of falls
If the screening test turns out positive, a detailed assessment should be done, which can be either a short physical performance battery or a Performance Oriented Mobility Assessment.
Muscle strength testing: Different groups of muscles are tested, such as the thighs, calves, hip and arms. The doctor asks the patient to push or pull against resistance and grades the strength.
0: No muscle contraction
1: Flicker of contraction, but no movement
2: Movement possible, but not against gravity.
3: Movement possible against gravity, but not resistance.
4: Movement possible against some resistance
5: Normal strength
Cognitive assessment: Cognitive screening is a simple evaluation used by doctors to check a senior’s thinking abilities, including memory, attention, problem-solving, and judgement. These mental skills are essential to safely navigate daily activities and avoid hazards that could lead to falls.
Doctors may also use quick, standardised tools such as:
Mini-Mental State Examination (MMSE): Assesses memory, language, and orientation.
Montreal Cognitive Assessment (MoCA): Screens for mild cognitive impairment.
Clock Drawing Test: Evaluates executive function and spatial skills
Trail Making Test: Assesses attention and task-switching ability
Eye and ear assessments: Hearing loss and reduced vision are natural consequences of ageing. Poor vision is directly responsible for falls, and inner ear imbalances can cause dizziness and unsteady gait. Both these impairments should be regularly assessed.
An effective way to prevent falls in the elderly is by improving balance, strength, flexibility, and body awareness. File photograph used for representational purposes only
Prevention strategies
At home, here are some safety tips to prevent falls in the elderly:
Flooring: Avoid slippery flooring — granite and marble in homes — as well as staircases. These surfaces increase the risk of falls.
Bathrooms: Wet bathrooms are a major hazard. Instead of bucket/mug bathing, encourage the use of a shower cubicle. Soapy water on the floor is dangerous. Avoid sitting on a stool and leaning over to pick up a fallen soap bar – this could cause the stool to topple over. Install grab bars near toilet seats, inside the shower cubicle, and near the wash basin. Use anti-skid mats in bathrooms. Climbing into a bathtub is highly risky for elders and should be avoided. Bathroom door mats should be firm and not slide easily.
Furnishings: Carpets and rugs on the floor should be avoided, especially if the elderly person uses walking aids. Too much furniture, as well as clutter such as stools and toys lying around, increases the risk of falls.
Lighting: Bright lighting in all parts of the house is very important. Motion sensor lighting helps in corridors as well as bathrooms, especially when the senior citizen gets up several times in the night. Steps and raised flooring should be marked brightly with tape or paint. Replace broken floor tiles and loose floorboards promptly to avoid falls.
Posture: Reaching for things out of reach is a fall hazard. Elderly people should never climb onto a stool to reach high shelves in the kitchen or elsewhere. Sitting on the floor and getting up suddenly can cause dizziness and a fall.
Footwear: Always wear footwear that fits well and never use ones with worn-out soles.
Exercise regimens that could help prevent falls include:
Standing on one leg: This exercise strengthens the legs and core. Practicing it regularly helps elders improve balance and prevents falls.
Tandem walking: This involves walking in a straight line, placing the heel of one foot directly in front of the toes of the other foot, as if walking on a tightrope. This improves coordination and balance.
Tai Chi: A gentle martial art that improves balance and prevents falls by strengthening muscles and mind-body awareness.
Yoga: An effective way to prevent falls in the elderly is by improving balance, strength, flexibility, and body awareness. It also reduces anxiety and fear of falling, helping seniors move more confidently and steadily in their daily lives. Recommended poses include: the tree pose (vrikshasana), the warrior pose (virabhadrasana), and the chair pose (utkatasana).
Resistance training: Thisinvolves using weights, resistance bands, or body weight to strengthen muscles, especially in the legs and core, which are vital for stability. For older adults, regular resistance training improves balance, posture, and the ability to recover from a stumble, significantly reducing the risk of falls.
Mobility aids: The use of walking aids like walking sticks enhances an elderly person’s independence. Lightweight options are available in the market and seniors should be encouraged to use them without any hesitation. Similarly, walkers come in different types. A standard walker is the four-legged one which needs to be lifted and used. Front-wheeled walkers help with smoother movement and a wheeled walker with brakes and a seat is ideal for people who need to rest between walks.
Going out on walks to parks or visiting places of worship can help in maintaining good physical and mental health for the elderly. But these may be unexplored territories for elders or may not be as familiar as their homes, and this can greatly increase the risk of falls. Making sure that they have proper walking aids and a caregiver accompanying them during these walks can ensure the elders’ safety while they enjoy quality time.
Public places should also try adopting elder-friendly designs, such as ramps, smooth pavements and railings. Adequate lighting should be the norm.
Comprehensive geriatric care
A structured, multi-disciplinary orthogeriatric service plays a vital role in optimising care for elderly patients, particularly those at risk of falls or recovering from fractures. By integrating the expertise of geriatricians, orthopaedic surgeons, physiotherapists, pharmacists, and nursing staff, such services ensure comprehensive assessment, timely intervention, and coordinated rehabilitation.
This collaborative approach not only improves patient outcomes and functional independence but also significantly reduces hospital readmissions and complications. In a multi-specialty hospital setting, it underscores the value of patient-centred, holistic care tailored to the unique needs of the ageing population.
Key services ideally include:
A clinicfocused on screening, assessing fall risk, and implementing prevention strategies.
An osteoporosis clinic dedicated to managing bone health and preventing fractures.
A dementia clinic addressing cognitive issues that may contribute to fall risk.
Surgical intervention and early mobilisation providing timely fracture treatment to minimise immobilisation; postoperative ICU care and pain management ensuring optimal recovery and comfort; a return to home or a familiar environment prioritising patient comfort and continuity of care and restoration of pre-fall mobility through individualised rehabilitation programs tailored to each patient’s needs are other vital aspects of a comprehensive geriatric care model.
(Dr. Aravindan Selvaraj is an orthopaedic surgeon and the co-founder and executive director of Kauvery Hospital, Chennai. draravindan@kauveryhealthcare.com)
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