With falls not slowing down, it’s time to rethink how we prevent them

Falls among older adults remain a major and stubbornly persistent problem, even though the evidence on how to prevent them is strong. A new falls resilience framework offers a more complete way forward, helping people not just avoid falls but withstand and recover from them, and it puts you in an ideal position to lead.

Falls among older adults remain stubbornly common, and a recent Personal View in Lancet Healthy Longevity argues that traditional risk-factor prevention only tells half the story. Its falls resilience framework asks not just how to stop a fall but how to help people withstand, adapt to and recover from one, and it puts you at the centre of that shift.

Every year, between 25% and 40% of people aged 65 and older will experience a fall. Fall-related deaths have doubled over the past three decades, and falls now account for roughly 36 million years of healthy life lost worldwide. These numbers represent broken hips, lost independence and families forced to watch a parent or grandparent’s world get smaller.

And yet, despite decades of research, guidelines and public health campaigns, the authors point out an uncomfortable truth: “progress in reducing the global burden of falls among older adults has remained slow.” We have the evidence. We have the guidelines. So why isn’t the needle moving faster?

Traditional fall prevention has focused heavily on identifying risk factors and minimising exposure to them: strength training, balance work, medication reviews, home hazard removal. These strategies work, but they only tell half the story. The proposed falls resilience framework shifts the question from “how do we stop this person from falling?” to “how do we help this person withstand, adapt to and recover from the fall-related challenges they will inevitably face?” It maps the full continuum of a fall-related event:

• Resistance: the ability to maintain balance and avoid a fall in the first place
• Event-phase protection: how injury severity is reduced when a fall can’t be avoided
• Recovery: how someone regains function, mobility and confidence afterwards

This matters because two people with near-identical risk profiles can have completely different outcomes when a stressor hits. One recovers their balance and carries on, another suffers a serious injury and never fully regains their independence. Understanding why is where real prevention gains are hiding.

One of the clearest, most actionable threads running through the evidence is inactivity. Physical activity levels among older adults drop sharply with age, from around 20–30% inactivity through most of adulthood to 47% after age 74 and over 70% among those 85 and older. That decline in strength, endurance and balance is not an inevitable feature of ageing; much of the disability we associate with getting older is actually attributable to disease, deconditioning and negative beliefs about ageing itself, all of which are modifiable.

The evidence on exercise as an intervention is strong and consistent: strength and balance programmes, delivered at sufficient dose (guidelines point to around 50 hours total, split across 2–3 hours weekly, including genuinely challenging balance work), reduce both the rate of falls and the number of people who fall. Encouragingly, the people who are least active and least fit tend to see the fastest, most meaningful gains from even small increases in activity, which is a genuinely motivating starting point for any conversation with a patient. If you want to go deeper on programming and dose, the Fall Prevention Through Exercise course on Physiopedia Plus (Plus) works through it in detail.

Fall risk doesn’t live only in the gym or the clinic. It lives in hallways, bathrooms and kitchens. Environmental hazards like poor lighting, loose rugs, cluttered pathways and unsecured furniture are major contributors to falls. Compensatory strategies, such as task modification, environmental changes and appropriately chosen assistive devices, can dramatically reduce risk without requiring a person’s physical condition to change at all. Simple, practical adjustments (grab bars, better lighting, decluttered counters, properly fitted mobility aids) preserve something just as important as safety: a person’s autonomy, dignity and ability to keep doing the things that matter to them. The Fall Prevention Strategies and Home Modification course on Plus covers this side in practical depth.

Fall prevention is a team effort, and while no one person has all the answers, as physiotherapists and physical therapists this is an area where you’re well placed to lead.

1. Strength and balance. This is core physiotherapy territory: the very things that keep us upright. Personalised, progressive exercise builds a person’s ability to stay steady and recover quickly if they do trip.
2. Training for real-world challenges. It’s not just how strong someone is at rest but how they react when caught off guard. Reactive balance training lets people practise responding to real stumbles, turning resilience into a practical skill.
3. A bridge from prevention to recovery. Physiotherapy spans the whole journey, from building strength beforehand to rebuilding confidence and mobility afterwards, so a fall is treated as part of a larger health picture rather than a one-off accident.
4. Getting the dose right. Exercise that is too easy can lift confidence without building strength, which risks unsafe behaviour. Knowing how to monitor and progress movement keeps it safe, effective and challenging enough to make a real difference.
5. Collaboration. The best results come when everyone works together, so physical training can be shaped around a person’s daily life and home environment alongside occupational therapists, carers and families.

The falls resilience framework doesn’t replace risk-factor-based prevention. It complements it, offering a more complete, more personalised way of understanding why similar stressors lead to very different outcomes across different people. Progress has been slow not because we lack tools, but because we’ve often applied them too narrowly, too late or without enough attention to the person’s actual capacity to respond and recover. By combining appropriately dosed exercise with a resilience-informed lens, and working closely with the wider care team, you can move fall prevention toward something genuinely proactive and personalised.