Falls are one of the leading causes of hospitalisation and death in Australia, accounting for more than 248,000 cases of injury hospitalisation in 2023–24 and almost 6700 fatalities in 2022–23. 

Overall, fall injuries are estimated to have cost the health system over $5 billion in 2023–24 (AIHW 2025). 

But for older Australians, falls are far more common than in younger populations – Australians aged 65 years and over were almost 12 times more likely to be hospitalised due to a fall than those aged 25–44 years – and come with a significant risk of injury. 

One in three Australians over the age of 65 experience at least one fall annually, with 50 per cent of falls happening at home and one in five at an aged care facility (Falls Prevention Alliance Australia 2025). 

The primary cause of falls is tripping, slipping and stumbling. 

‘One of the issues is that older people have a higher risk of falling while they’re just doing everyday activities, getting out of bed to go to the toilet or hanging out the washing,’ says Professor Cathy Said APAM, professor of physiotherapy at Western Health and the University of Melbourne. 

‘If someone is a bit frail already and they fall over, they might start to restrict their activity, which will put them at further risk of falls. 

‘The risk of injuries like fractures is much higher as people get older and the impact that can have on someone’s function is also greater. 

‘There is also a higher chance that someone who is older and more frail will end up in hospital.’ 

Risk factors for falls 

Prof Cathie Sherrington says many factors play a role in falls risk.

There are several factors that increase the risk of falls in older people, including a decline in physiological functions like balance, strength, vision, proprioception and reaction time. 

Cognitive function, mental health, medical conditions and medications can also play a role. 

‘Falls risk is the interaction of the person, their behaviour and the environment,’ says Professor Cathie Sherrington FACP, whose research group at the Institute for Musculoskeletal Health at the University of Sydney, Sydney and South Western Sydney Local Health Districts, has long focused on the role of exercise in preventing falls in older people. 

‘If we’re rushing about, we’re a bit unsteady, we’re wearing high heels or we’re walking on a slippery surface, that’s the behavioural aspect. 

‘There are also environmental triggers like tripping over a tree root. 

‘It’s all related because maybe we could prevent that by walking a bit more slowly and looking ahead to see where the tree root was… and if our balance and strength were better, then we could avoid a fall in that situation.’ 

Balance is a major factor in falls and the focus of most exercise-based interventions for falls prevention. 

‘Our balance starts deteriorating from around the age of 40 to 45. 

‘It’s a highly complex system, relying on multiple sensory inputs that the brain processes to help you maintain your balance, often while doing multiple tasks at once,’ says Professor Kim Delbaere, discipline lead for physiotherapy in the University of New South Wales School of Health Sciences and director of innovation and translation at the Neuroscience Research Australia Falls, Balance and Injury Research Centre. 

Kim explains that while our brains can compensate for decreasing balance, once we hit the age of 60 to 65, it becomes more challenging. 

‘From around 65 onwards, we see a sharp increase in falls and fall-related injuries. 

‘One in three people aged 65 and over fall once a year. 

‘Half of them will fall again in the same year and about a quarter will suffer an injury that requires medical attention. 

‘The consequences become most serious when injury occurs. 

‘As we get older, our bones get more brittle, our skin gets thinner and the impact of the fall will be bigger. 

‘It can be life-changing because older people don’t always have the strength and stamina to recover and bounce back from a fracture.’ 

An older person’s fear of falling can also increase their risk. 

‘Sometimes people who are afraid of falling change the way they walk. 

‘Their steps may become shorter and more variable and they may widen their stance, which can make their walking less steady,’ Kim says. 

Kim’s research has shown that high levels of concern about falling are consistently associated with activity restriction and physical decline – factors that can increase someone’s risk of falling over time. 

The evidence clearly shows that one critical thing people can do as they get older to reduce their risk of falling is to stay physically active (Sherrington et al 2019). 

This is where physiotherapy comes in – physiotherapists are extremely well placed to help people increase their physical activity to recommended levels and, as they get older, to work specifically on balance and strength to maintain mobility. 

World and national guidelines 

In 2022, World guidelines for falls prevention and management for older adults was published by the World Falls Guidelines Task Force in the journal Age and Ageing (Montero-Odasso et al 2022) and in 2025, the Australian Commission on Safety and Quality in Health Care published an update to its national guidelines for falls – Preventing falls and harm from falls in older people: best practice guidelines aka the national Falls Guidelines (ACSQHC 2025). 

Along with several other Australian physiotherapy researchers, Cathie, Kim and Cathy were all involved in the development of the World Falls Guidelines and Cathie and Kim were both part of the team that updated the national guidelines, while Cathy was a member of the team that reviewed the updates. 

The World Falls Guidelines are a comprehensive set of recommendations including a falls risk stratification approach, assessment across multiple domains, management and intervention recommendations and an algorithm for assessment and treatment. 

They also cover the provision of education to all older adults on falls prevention and physical activity. 

Considerations for specific settings (hospital, residential care and the community) and clinical populations and for low- and middle-income countries are included. 

A comprehensive modified GRADE approach was used to assess research evidence so that the strength and quality of each recommendation could be determined. 

The national Falls Guidelines, which have been aligned to the World Falls Guidelines, include recommendations for the three different settings – hospitals, residential aged care and community-dwelling groups. 

The biggest change in the national Falls Guidelines, since they were initially published in 2009, is that there is a lot more evidence now to back up exercise as a key preventive measure against falls. 

‘Recommendations have been strengthened. 

‘In particular, for residential care there is evidence that ongoing exercise as a single intervention can prevent falls, whereas that wasn’t a recommendation previously,’ says Cathie Sherrington. 

Assessing and managing falls risk 

Prof Cathy Said says physiotherapists can easily screen patients to identify their risk of falls.

Assessment of falls risk and exercise prescription for healthy aging and falls prevention are roles that physiotherapists should embrace with their clients and not just once their client reaches 65. 

‘As primary contact practitioners and experts in gait and balance assessment, we can do a quick screening test of someone’s walking to see whether they should have a more in-depth assessment,’ says Cathy Said. 

‘It’s not like something magic happens when you turn 65 and your balance suddenly deteriorates. 

‘We know that changes happen early on. 

‘We should be thinking about how we can incorporate some exercises that challenge our strength and balance so that we’re setting ourselves up to age well.’ 

Assessment for falls risk may be triggered by an older person having a fall or it can be included as part of a routine visit to a physiotherapist or GP. 

Other triggers include identification of a medical condition or medication that can cause falls. 

A good starting point is the ‘three key questions’ approach suggested in World Guidelines for falls prevention and management for older adults (Montero-Odasso et al 2022), which asks (a) have you fallen in the past year, (b) do you feel unsteady when standing or walking and (c) do you have worries about falling? 

A typical assessment will include a review of a patient’s medical history and medications; physical function tests including balance and gait assessments such as gait speed, the timed up-and-go and sit-to-stand tests; and, if necessary, cognitive and other tests. 

This approach allows people to be categorised into low, intermediate and high risk. 

The Australian fall prevention guidelines use the history of falls to classify people into three groups. 

Physiotherapists can help all three risk groups, especially when it comes to exercise, which is a crucial part of falls prevention. 

Exercise – in particular, balance and functional training – has been shown to reduce the number of falls by almost 25 per cent in people aged 60+ years living in the community (Sherrington et al 2019). 

‘For people who aren’t necessarily falling or have had infrequent falls (less than once per year), physios play an important role in prescribing and encouraging community and home exercise that maintains balance and functional strength,’ says Cathie Sherrington. 

‘That can include treating any conditions that might interfere with exercise – whether that’s musculoskeletal, respiratory or pelvic health.’ 

For the middle group – people who have had at least one fall in the past year and whose gait and/or balance is impaired – physiotherapists can prescribe an exercise program to improve gait and balance and provide education on falls prevention. 

And for the high-risk group, which includes people who have had two or more falls in 12 months resulting in injury as well as those with known frailty and other coexisting conditions that can affect their risk of falls, physiotherapists can deliver tailored exercise programs as part of a multidisciplinary approach that might include vision and cognitive assessments, review of medications and assessment of the home environment. 

It’s in the intermediate risk group that Kim sees the biggest opportunity for physiotherapists to make a difference. 

‘We can improve their balance and build up their physiological reserve so they don’t end up in that high-risk group so soon,’ she says. 

‘We have known for decades that targeted balance and functional exercise is the single most effective intervention for preventing falls and that’s across conditions and across ages. 

‘If you want to invest in one strategy, exercise is the one to back to prevent falls.’ 

The World Health Organization’s Guidelines on physical activity and sedentary behaviour says that people over the age of 65 should include physical activities for balance and coordination and to strengthen muscles, prevent falls and improve health (World Health Organization 2021). 

Kim is a strong advocate for using digital health to get – and keep – people moving. 

Her team at Neuroscience Research Australia has developed a simple-to-use app called StandingTall, a personalised, home-based exercise app designed to improve balance and mobility. 

The program was co-designed with older people to ensure it meets their needs. 

Clinical trials looking at adherence and implementation show that even after two years, 52 per cent of participants were still using the app for two hours a week and that falls and falls injuries were significantly reduced, with some cohorts – similar to the intermediate-risk group described earlier – experiencing injury reductions by as much as 42 per cent.

‘We use the principles of habit formation to motivate people because no-one likes to set goals. 

‘We help people build exercise habits into their routine. 

‘We focus on consistency by saying, two hours a week is what we want you to do and it doesn’t matter to us how you do it – it can be 10 minutes twice a day or two one-hour sessions a week; what matters is that it becomes part of everyday life,’ Kim says. 

Other current research programs in Australia for falls prevention include the Move Together: Reduce Falls program developed by Cathy Said and her team to address the needs of culturally and linguistically diverse communities and the TopUp telehealth program developed by Dr Rik Dawson (the APA’s current president) with Cathie Sherrington at the Institute for Musculoskeletal Health to deliver tailored exercise programs to older people living at home and in residential aged care facilities. 

And in Western Australia and Victoria, Anne-Marie Hill and her team are looking at ways to improve falls prevention in the hospital setting and beyond. 

Better advocacy for falls prevention 

Prof Kim Delbaere is keen to use digital health approaches to encourage older people to exercise.

For all the research showing that exercise and physical activity are key components of falls prevention programs, the role of physiotherapy is still under-recognised when it comes to funding and care, both from the consumer perspective and within the healthcare system. 

As Cathie Sherrington points out, funding models in Australia don’t necessarily support the role of physiotherapists – for example, falls are not eligible for chronic care support through Medicare and even if they were, five allied health appointments would not be adequate. 

Some people can afford to see a physiotherapist regularly to take part in exercise classes targeting balance and mobility, while some may not even be aware that they can do things to prevent falls as they age until they have had a fall that results in injury. 

The need for an Australia-wide strategy is underscored by each state having a different approach to falls prevention. 

Cathie, Cathy and Kim are all leaders of the Falls Prevention Alliance Australia, which was launched in 2025 to advocate for policy change to reduce fall-related injuries in older Australians. 

The organisation, which includes the APA as one of its members, is calling for a national action plan, a mass media campaign to raise awareness of falls prevention and the role of exercise, and better funding of evidence-based services. 

Cathy Said notes that funding is not the only barrier to implementation of the national Falls Guidelines. 

‘We certainly need the resources to support people but I also think we need to be working with the community to better understand how we can support them to be more active and to take up some of the other interventions that we know reduce falls. 

‘And we need to make sure we’ve got a workforce with the skills to deliver these services and programs.’ 

She has two key messages for physiotherapists about falls and older patients. 

‘The first is that falls are preventable but many people don’t know they’re preventable. 

‘Physios need to be strong advocates with their patients, encouraging them and checking in with them: “Have you had any falls? Do you know how to reduce your risk of falls?” 

‘That’s something that every physio can be doing,’ Cathy says. 

‘The second message for physios is to spread the word that exercise is the one thing every person can do to reduce their risk of falls. 

‘It doesn’t matter how old you are or what sort of health conditions you’ve got. 

‘People need to be doing exercises that challenge their balance as well as functional strength training exercises. 

‘Physios can play a key role in making sure people hear that message but also in supporting people with health conditions to do exercises that are appropriate for them.’ 

Quick links: 

• References
• Listen to our podcast on falls prevention and exercise, recorded at APASC25