Roughly one in three adults over 65 falls each year, and the proportion rises with age and frailty. Falls are a leading cause of injury-related disability and death in older people, and many of the patients who arrive on a PM&R service with a hip fracture, a subdural haematoma or a vertebral compression fracture began their journey with a fall at home.
Even falls without injury carry consequences. Fear of falling leads to self-imposed activity restriction, which leads to deconditioning and weakness, which leads to more falls — a downward spiral that is entirely familiar to anyone who works in geriatric rehabilitation.
A fall is best understood as a symptom: the visible end-point of several interacting problems in gait, balance, strength, vision, cognition, cardiovascular regulation, medication and environment. Because every one of those components is something the physiatrist assesses routinely, PM&R is ideally placed to lead falls assessment and prevention.
The World Guidelines for Falls Prevention and Management for Older Adults (Montero-Odasso et al., Age and Ageing, 2022) provide a practical, globally applicable structure. They recommend opportunistic case-finding — asking about falls whenever an older adult has contact with a health professional — followed by risk stratification into low, intermediate and high risk.
A “yes” to any of these warrants further evaluation.
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Risk Level
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Recommended Response
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Low
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Education on fall prevention; encourage regular exercise for general health and bone health; reassess annually
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Intermediate
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Targeted exercise programme emphasising balance and strength; reassess in 6–12 months
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High
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Multifactorial falls risk assessment followed by individualised, multidomain intervention; close follow-up
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The multifactorial assessment for high-risk patients is where the physiatrist’s training is most valuable.
Establish the circumstances: time of day, activity, footwear, lighting, whether there was a prodrome (dizziness, palpitations, vertigo), whether the patient tripped or the legs “gave way”, and how long they remained on the floor. A fall on getting up at night to urinate points to a different set of causes than a fall while crossing a busy road.
Fall-risk-increasing drugs (FRIDs) are among the most modifiable risk factors. Look specifically for:
Deprescribing should be planned with the patient’s treating physician and tapered where appropriate.
Screen for cognitive impairment (Mini-Cog or MoCA) and depression. Urinary urgency and nocturia drive night-time trips to the toilet — a classic fall scenario.
Cataract, uncorrected refractive error and the use of multifocal glasses while walking all increase fall risk. Cataract surgery for the first eye has been shown to reduce falls.
Every faller should have fracture risk assessed. Use FRAX where applicable and arrange DXA where it will change management. A fall in an osteoporotic patient is a fracture waiting to happen.
Indian homes present specific hazards: wet bathroom floors, Indian-style toilets requiring a deep squat, raised door thresholds, loose rugs and floor mats, poor lighting on stairways, and floor-level seating and sleeping. Where a home visit is not feasible, photographs or a video call taken by a family member are a practical substitute.
Fear of falling is common, disabling and treatable. It can be measured with the Falls Efficacy Scale–International (FES-I). Graded exposure through exercise, education, and — where appropriate — cognitive-behavioural strategies help restore confidence. The physiatrist should explicitly address fear as part of the rehabilitation goals rather than treating it as a side issue.
As the Consultant and Incharge of the NeuroRehabilitation and Musculoskeletal & Sports Rehab Units at Kauvery hospitals Bangalore & Hosur, I lead and empower a diverse team of specialists—including physiotherapists, occupational therapists, speech & swallow therapists, and clinical psychologists, Rehabilitation Nurses—to provide patient-centered care and achieve outstanding results.
