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Epidemiological studies have consistently stated that falling in older populations is a multifactorial phenomenon. While there are many documented risk factors likely to contribute to falling behaviour, they are often not universally demonstrated. Similarly, the exact role of each risk factor, and their interaction, has not yet been determined (NIPAC, 1999a). As with many geriatric syndromes, falls are most often due to an accumulation of deficits in multiple areas rather than an isolated pathology (Tinetti et al., 1996). Due to their multifactorial aetiology, there appears to be no uniform classification of falls. However, researchers have generally categorised falls into a) intrinsic or pathological falls; and b) extrinsic, environment-related or accidental falls. In most instances of falls, intrinsic and extrinsic factors interact to varying degrees (Tinetti and Speechley, 1989).

There is some strong evidence for certain intrinsic risk factors predisposing an older individual to falling behaviour. These risk factors include cognitive impairment (including decreased ability to divide attention between more than one task), poor balance and inability to correct for the unexpected loss of balance which may result from any of/or some combination of decreased reaction time, diminished central nervous integration, decreased muscular strength, impairments in visual, vestibular or proprioceptive sense, loss of joint mobility, real or perceived reductions in limits of stability, or capacity for sway without taking a step (Lord et al., 2002b; NIPAC, 1999a; 1999b; Owings et al., 1999; Snow, 1999; Kerrigan et al., 1998; Maki, 1997;

O'Loughlin et al., 1993; Whittle, 1993; Campbell et al., 1989; Blake et al., 1988; Tinetti et al., 1988; Prudham and Evans, 1981). Chronic health conditions such as stroke, Parkinson’s disease and arthritis, as well as acute health problems, such as delirium or urinary tract infection for example, are recognized as important intrinsic falls risk factors. In some cases, the presence of certain intrinsic factors results in the use of prescription medication, some of which are also linked with falls incidence (Lord et al., 2002b; NIPAC, 1999a; Whittle, 1993; Blake et al., 1988; Tinetti et al., 1988). Moreover, the presence of intrinsic factors is often a predictor for recurrent falls (Wolf and Gregor, 1999; Graafmans et al., 1996; Craik, 1989; Blake et al., 1988).

Whilst the evidence for extrinsic risk factors is not as strong, extrinsic risk factors reported include environmental hazards such as uneven surfaces, poor lighting, poor steps and stairway design and repair or other hazards around the home (including for example, slippery floors, furniture, unsecured mats and rugs and lack of non-skid surfaces in bathtubs and bathrooms), and self-imposed restriction due to a fear of falling (Lord et al., 2002b; Hill et al., 1999; NIPAC, 1999a). There have been no comprehensive, large-scale studies finding a significant and specific association between home environment hazards and the risk of falling, and due to this, these factors have been implicated mainly by self-report (NIPAC, 1999a; Campbell et al., 1990; Tinetti et al., 1988). The presence of extrinsic factors creates the opportunity for a fall, particularly for individuals already impaired by a combination of intrinsic factors. Indeed, Lord et al. (2002b) highlight the fact that although some environmental factors may not be directly related to a fall, they do have an influence on other important intrinsic risk factors. For example, high-heeled shoes reduce balance and bifocal lenses impair depth perception and contrast sensitivity.

Since intrinsic falls-risk factors have been more closely related to falls, most prevention programs have focused on reducing these factors. Despite intrinsic falls-risk factors being described as more closely linked with falls, current Australian Institute of Health and Welfare (AIHW) reports on falls in the elderly (Cripps and Carman, 2001) and Australian injury and death rates (Cripps and Carman, 2001) show that external causes were in fact cited as causes for approximately 54% of falls resulting in hospital admissions. As shown in Figure 2.4, 39.1% of falls resulting from external causes were associated with slips, trips and stumbles. However, these data are reported without consideration of the interaction of any intrinsic factors contributing to a fall. As noted by Braun (1998), the elderly typically place greater emphasis on external factors as the cause of falls and neglect the contribution of intrinsic factors, particularly for themselves. Although elderly might ascribe external factors as the cause of a fall, this is often not the major cause once intrinsic factors are examined more closely.

From ladder/other structure 2.0% Involving another person (e.g. pus h) 0.5% Fracture, causes uns pecified 3.8% Other/unspecified 40.3%

From one level to another (including steps ) 14.3% Slips, trips , stumbles 39.1%

The risk of falls increases with the number of risk factors present (Cwikel et al., 1998). Since older people may experience deficits in multiple areas, compensatory mechanisms may be hampered increasing the likelihood of falling in response to a postural perturbation. For example, a failure in one system (e.g. instability) may ordinarily be compensated for by another (e.g. visual feedback), which may also be failing (Graafmans et al., 1996).

A person sustaining a fall often experiences anxieties or fears of a subsequent fall. This often results in a reduction of activity and self-imposed isolation due to a fear of falling whilst performing activities they had previously done safely before the fall (e.g. Hill et al., 1999). This reduction in activity can result in a decline in muscular strength and general fitness, culminating in a downward spiral further predisposing the person to falls. This ‘fear of falling’ or ‘post-fall anxiety syndrome’ has been linked to falling behaviour (Lord et al., 2002b; Cumming et al., 2000; Hill et al., 1999; Maki, 1997).

2.1.2.2 The role of vision and other sensory control (vestibular and