On a warm night, Jeanette Walker, 79, turned off the TV and went to check whether her pot plants needed water. As she bent down to touch the soil, her body weight kept moving forward. Oh crumbs, she thought, I’m going to fall now. She crashed into an ornamental table, ricocheted into another. Crikey, I’m heading towards the TV, was her last thought before she hit the floor with a thud.

This was Walker’s 15th fall since turning 70. She moved in a kind of bum shuffle to the couch to hoist herself up, and noticed the loungeroom littered with upturned pots, loose soil and glass from a chipped table. She felt bruises forming on her head and elbow. Still, she breathed a sigh of relief – if she had fallen the other way she could have gone through a window. “It’s always, I could have, I could have,” she tells us a few weeks after the incident.

There have been times when Walker hasn’t been so lucky. One fall led to her being hospitalised with a delayed concussion, another left her with broken toes. The tumbles have happened in her backyard, when walking her dogs or while carrying shopping bags on the way out of a supermarket. There’s little warning. “I never have a dizzy turn. I never think I’m going to keel over here. It’s always just walking along and tripping into a stick or something.”

The likelihood of falling grows, and consequences worsen, as we age. Every year in Australia, one in three people older than 65 has a fall. But it’s when you get to 80 or older that the risks increase by 50 per cent compared with those aged 65 to 69. Falls land about 238,000 people of all ages in hospitals each year, for an average of five days; some 6378 people died from injuries related to a fall in 2021-22. “It’s been under the radar and not as sexy as trauma,” says Dr Ronald Leong, deputy head of aged care at Melbourne’s Alfred Health. “But it’s a much bigger problem than [road] trauma-related accidents.”

Yet falling is not always inevitable. And, contrary to popular ideas, falls are not necessarily a fast-track to aged care. So how do we fall? When can falls lead to decline and even death for older people? What are the ways to prevent them?

How do we manage to stay upright in the first place?

Ever since humans began walking on two legs, about 6 million years ago, the risk of falling has been a fact of every step we take. “It’s inherently unstable,” says Stephen Lord, a world-leading falls expert at Neuroscience Research Australia (NeuRA). “As we walk, every step is described as a controlled fall. And so we have to continually put in effort just to maintain our balance as we take a step. So we throw the leg forward, we regain balance. We throw the other leg forward, we regain balance.”

‘It needs all of these inputs – both sensory inputs and then the strength side – to co-ordinate it all. That’s been the great puzzle.’

Simply standing still takes balance. Buckingham Palace’s Grenadier Guards appear to stand like statues, yet Lord has observed them make slight involuntary movements over their ankles because of a process called postural sway. The body does this to keep its centre of mass, a point around our waistlines, over our feet. So, what is balance? “It’s really just how well we can control the position and movement of our centre of mass,” says Lord. “And that’s while we do our everyday activities, like just stand, step, walk, turn – you’re walking around with this moving column and it has to be quite tight.”

Balance is partly to do with strength, too. Having strong muscles, particularly in the legs, helps us support and control the body to keep it upright. Says Lord: “Balance is just so different to something like fracture risk or a bone-density score, where there’s just one measure. For us, it’s such a complex system. And you know, it needs all of these inputs – both sensory inputs and then the strength side – to co-ordinate it all. That’s been the great puzzle.”

Why do people fall?

Jeanette Walker has undergone an MRI and blood tests to try to determine why she has fallen so often, but the tests have offered no clues. “I don’t get up out of a chair and think, oh, I’m dizzy, I’m going to fall over. I’m fine in that respect. And there’s not tingling in my feet or anything to warn me,” she says. “I suppose I’d call it – not clumsy, because it’s not clumsy – it’s just a fact of getting older, which gives me the irrites but never mind, you can’t help that.”

Common falls are trips and slips. In 2022-23, 41,472 people wound up in hospital because they tripped, 21,846 slipped and 11,076 stumbled. The experts we spoke with listed culprits such as wet surfaces, inclines and uneven paving, pets, lack of lighting, unsupportive footwear such as slippers, cords, garden hoses and crumpled rugs. Another 15,845 people fell down stairs.

But internal changes matter too. Balance, much like fitness, appears to peak in our 20s and worsen from our mid-40s. “Every body system goes through changes, not just the ones that relate to falling,” says Lord. “But the crucial ones for falls are neuromuscular and sensory.”

These systems include eyesight, which is like a radar that scans for obstacles and helps us observe distances. (Typically, when scientists ask people to close their eyes, their postural sway increases by about 30 per cent.) The inner ear plays a part too – tiny hairs in each ear canal that detect movements in fluid, telling the brain about the body’s position. Proprioception, information sent from joints and muscles, is another input that helps our brain sense where our body is in space (one test for this is to close your eyes and try to touch your nose). Information also comes through feeling our own weight, and the surfaces we’re walking on, through our feet.

One of the most common times people fall is when they get up in the night to go to the toilet.

All this information travels through our body and brain via our central nervous system, which also shows changes as we age. One measure is our reaction time: how fast we can process information and correct our balance. “If reaction time and response is slow, there’s less integration going on and people are also just less able to react in time if they lose balance, or if they’re knocked off balance,” says Lord. “This can happen as people transfer from a chair to standing up or turning around. They sometimes just trip over their own legs. You make an incorrect step and that puts you off balance and then you don’t recover. That becomes more common in frailer people.”

One of the most common times people fall is when they get up in the night to go to the toilet. Dim lighting or none at all are often blamed but Alfred Health geriatrician Ronald Leong says lower blood pressure influenced by dehydration can be a factor, too. “If you look at the 24-hour period, it’s often the longest period of time where you haven’t had much to drink from the night before to the day after.”

Medications that can cause drowsiness such as antidepressants, anti-anxiety agents and sleeping tablets can double the risks of falls, says Lord. Depression itself is also a risk factor as it can decrease central nervous system functioning and coincide with physical deconditioning.

Fear of falling has been shown to triple the risk of falling. “Concerns about falling are actually more common than falls themselves. It isn’t just a response to past tumbles. It’s a major risk in its own right,” says Kim Delbaere, a senior falls researcher at NeuRA. “We’ve seen people walking so hesitantly because of the concerns, but ironically that kind of behaviour can make them more unstable. You can try this as well: if you walk at your normal pace, you’re actually more stable than when you’re walking slow.” The fear of falling can lead people to avoid activities, and therefore they exercise the muscles involved in balance less. Says Leong: “It becomes a vicious circle.”

Are falls a slippery slope to death?

Fall, stumble or misstep, Stephen Lord has come to the conclusion that losing our feet comes with an awkwardness. “It’s an indication of weakness, of failure. There’s no dignity in it. So, if you fall over in a public place and you’re down on the footpath, people try to spring up as fast as possible,” he says. “It probably starts in the schoolyard where your friends may even laugh at you when you fall over. It’s just, it doesn’t matter in the school yard – you just pick yourself up and get going. As people get older and more likely to get injured, it becomes a serious, important thing.”

Not only does our balance decrease over the years but our risk of breaks and fractures becomes greater as our bones weaken. A fall can be a part of a trajectory into aged care but this is not always the case. Figures are difficult to come by but Lord studied people over 70 presenting at a Sydney hospital after a fall and followed their journey for a month after discharge. He found 9.5 per cent of patients became first-time residents of long-term care facilities.

At the Alfred, geriatrician Ronald Leong says patients might stay in hospital for about a month after a fall. During their time in rehab, it becomes clear whether they will regain the mobility they had before the fall. “As you become frailer, at one point it may not be reversible completely, in which case you might reach a critical threshold where you’re no longer safe at home,” says Leong. Patients’ personal circumstances are also part of the picture: whether they still have a partner, or a carer who can drop in more than once a day. “If they can’t be supported, there’s still an element of, well, we maybe will risk it because they want to go, but sometimes people say, ‘Look, this is too risky.’” If a decision can’t be made while they’re in hospital, some people will go into transition care, which provides more time for them to regain functional independence.

The most common serious injuries from falls are to the head and neck, closely followed by hip fractures, which account for a quarter of hospital stays, and shoulder injuries (just over a fifth). Much more common are grazes, bruises and wrist injuries, which don’t lead to hospital but are no fun all the same.

At first blush, one of the starkest statistics surrounding falls is that a quarter of adults aged 69 or older who fracture their hip die within a year. But often it’s not so much that the fall leads to death as that it can be a harbinger that someone is becoming more fragile. “What we do find is that people who have heart failure start to become increasingly frail and consequently have a fall,” says Ronald Leong at the Alfred.

‘It can be complications from the fracture, complications from the surgery, things that can happen post-surgery – people can have a deep-vein thrombosis, for example.’

One NSW study of hip fractures found deaths occur in about 6 per cent of cases within 30 days, but the biggest factor in these deaths was the presence of chronic diseases, what medicos call co-morbidities. “They don’t have just a fracture, of course,” says Leong. “Or if that’s all they have, it can be complications from the fracture, complications from the surgery, things that can happen post-surgery – people can have a deep-vein thrombosis, for example.” At any age, people will lose condition if they’re stuck in bed for a long time, but in old age the drop-off in function is fast and can make a person more susceptible to an infection such as pneumonia. Comedian Barry Humphries, best known for his character Dame Edna Everage, died in 2023 at the age of 89 from complications from hip surgery after falling two months earlier.

What can you do if you’re about to fall?

At NeuRA’s lab in Sydney, Stephen Lord has a “trip and slip walkway” to help people with limited balance – suffering from, say, Parkinson’s or multiple sclerosis – test their recovery skills and learn how not to fall. (The actor Michael J. Fox, who suffers from Parkinson’s, once said, “Every step is now like a frigging math problem, so I take it slow.” ) One of our reporters recently tried the walkway, which uses a harness secured to the ceiling. She strode along the path that a researcher had “booby trapped” so a tile would slide from under her and trip her. On most trials, she regained her balance quickly after striking the hazard. However, in a few trials, she deliberately fell, and a monitor showed more than 30 per cent of her body weight went into her support harness – a point people can’t recover from.

‘That’s the worst possible way to fall – to fall stiffly, fall to the side, just with no plan.’

Key to avoiding any fall is our ability to take a reactive step – a reflex that requires mental and physical training. If, for example, someone were to gently push us in the back, most of us would take a step forward to stop ourselves toppling over. Lord has found that over four sessions on the walkway, people with balance difficulties showed a 40 per cent improvement in their reaction. “The idea is, once they learn that in the lab, that will transfer to everyday life.” He’s also observed many people who don’t react at all to a trip. “That’s the worst possible way to fall – to fall stiffly, fall to the side, just with no plan.”

Lord has also trialled people playing the 1990s arcade games Dance Dance Revolution and Tetris on a step mat to train accurate stepping and better decision-making. “If we want to stop people from falling, let’s do these types of activities that are directly related to fall avoidance.”

When it comes to the moment of falling, martial arts have a trove of advice, albeit not always practical for everyone. People could use their arms to absorb some of the impact and then rotate other points of the body to bear their weight too. Or, if they are moving at a brisk walking pace, they can roll and use the momentum to protect themselves. Says Lord: “Preliminary research shows you can do this in younger people, and you can do this to some degree in older people as well. But the risk, of course, is you don’t want to hurt people during the training.”

Tai chi grandmaster Gary Khor was a research adviser for falls prevention to the NSW government in 2000. Today, he’s 77 and has had two knee replacements and several falls, “when somebody knocked into me, or I was shopping at the supermarket and there was water on the floor”. He teaches that stopping a fall is like learning defensive driving. “If at any time we lean in any direction, your weight falls outside your base and that means you’re already inclined to fall,” he says. “There’s no way to prevent every fall, so the strategy is to break the fall.”

Khor has a solution for when we fall forward or to the side: tuck your tailbone under yourself to re-calibrate your centre of mass. He narrows it down to three movements. Spread the legs, tuck the bottom in and brace the legs. He says if people brace and have enough leg strength, they give themselves a better chance of stopping the fall. “You brace, pressing against the ground with your legs,” he says. “People need to practise these three moves, but at the same time learn to strengthen the legs.” What if you fall backwards, though? “Now that’s a problem,” says Khor. “It’s much more difficult to throw the legs back. Even then, even if you can slide your leg forward when you’re falling back, or drop onto your back leg, you can drop your body weight down to your legs.”

How do you prevent falls in the first place?

Jeanette Walker is working on ways to stop another fall, above all because she wants to stay in the home she’s lived in for half a century. “I’m staying here forever,” she says. “That’s why I try desperately to look after myself physically and mentally.” Since her most recent fall, she’s been attending a six-week exercise program. The sessions go for an hour and she does weights, steps over mini-hurdles, walks between cones and holds an object while trying to balance. “The one I just dread is standing on a firm, foamy cushiony thing. It’s OK standing on it, but then you shut your eyes and I get the wobbles, and I can’t do that,” she says.

Exercise with a balance component is the No.1 way to prevent falls, reducing the risk by up to 40 per cent in older people, studies show. The key ingredients in these exercises are balance control, functional strength, co-ordination and reaction time. The federal government recommends that people 65 or older do at least 30 minutes of moderate physical activity on most days. But when it comes to fall prevention, two hours of balance-specific training a week is key.

To be effective, a program needs to be tailored to the person, says senior physiotherapist Stephanie Ng at Eastern Health’s falls and balance clinic in Melbourne. “The most helpful thing would probably be someone practising getting on and off the floor. That’s the main factor,” she says. Weaknesses in our glutes and poor flexibility make it harder for people to get up with age. “Even if you manage to find a chair to push off from, if your arms are quite weak you won’t be able to push yourself up.” Lower and upper body strength training is therefore crucial as we age.

Ng will prescribe tasks people can do at home. She might get people to stand on one leg, or if that’s not possible to stand with one foot behind the other. She might also get them to close their eyes, or to stand on pillows to create uneven surfaces. “But most people can’t do that.” Digital solutions are also emerging to help older adults build balance at home. One such program, StandingTall, is a research-backed app that guides users through progressive balance exercises without needing supervision.

‘When you want to take evasive action, you want your body to react faster, so you train this body-mind connection.’

The key to any balance exercise is that it safely pushes people to the threshold of their balance. In other words, they feel slightly unbalanced. Says Ng: “It’s finding that fine line so that you know they’re not unsafe when they’re practising at home, but at the same time, it’s challenging them enough so that their brain can adapt and help with their balance reaction.” Tai chi, a 17th-century martial art, also shows promising results, says Kim Delbaere at NeuRA. “It’s kind of moving slowly towards the edges of your base of support – to really challenge your balance right out. And that kind of thing is good for falls prevention.” (Some 300 million people around the world practise tai chi.)

Gary Khor says tai chi both tests strength and trains us to relax and understand our centre of mass. “If you exhale and relax more, your body weight is on your leg muscles. So you’re loading your body weight onto your legs. That’s the same as resistance training in the gym, but you’re using your body weight instead.” Tai chi also gives people more awareness of their own body in motion. “You’re aware of your body, how it feels, the muscles, the pain, everything in there,” Khor says. “When you want to take evasive action, you want your body to react faster, so you train this body-mind connection.”

Tweaking your house can help, too. People aged between 65 and 74 are much more likely to fall outdoors, whereas over 74, falls become more likely in the home. Clearing trip hazards – securing carpets and mats, removing clutter and loose cords – are relatively easy solutions, and minor renovations such as shower and toilet grab rails, non-slip mats (especially in bathrooms), and sensor lighting for those late-night toilet visits can help avoid calamity.

Diana Olsberg, 83, has lived in her apartment near the sea in Sydney for 50 years and is hoping to keep it that way. As an adjunct associate professor at UNSW, she has researched the social impacts of ageing. “You want to remain independent as long as you can. Preventing a fall is a very important issue in terms of you maintaining that independence.” She does two exercise classes a week and one hydrotherapy session. She has installed a small lift to ensure she doesn’t need to navigate the stairs, where the injuries from a fall could be severe. “It’s a real ‘beam me up, Scotty’ lift. It fits in the well of the stairs. And here I am still in my flat.”

‘I was very fortunate, I didn’t do any damage to myself at all. But it really alerted me very much to the fact that I have to be very careful.’

Olsberg’s partner died seven years ago and her adult children live interstate. “So I’m totally alone, and a lot of people are totally alone. The number of older people living alone is increasing. We’re living longer but more at risk.” She had a fall three years ago in her loungeroom. She wasn’t injured but wasn’t able to get back up without wriggling to the next room to use a chair. “I was very fortunate, I didn’t do any damage to myself at all. But it really alerted me very much to the fact that I have to be very careful.” She now has a plan in case she falls: she carries her phone at all times, and has a device she can wear around her neck that she can use to alert neighbours if she needs help and pinpoint her location using GPS (several smartwatches also have options to alert emergency contacts if the wearer has fallen).

For Jeanette Walker, the most important thing is spending time in her garden – full of crepe myrtles and native shrubs. She has installed posts in the garden beds to help her steady herself as she works out there. She also walks her two kelpies, and never leaves the house without a hiking pole, which she prefers to a walking stick as it makes her stand upright. “I have excellent neighbours, I have an excellent family, I’m out and about,” she says of life at 79. “But it is limiting, I’m always afraid of falling over.”

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