This study provides long-missing objective evidence of the cause and circumstances of falls in elderly adults, and shows new avenues for prevention of fall injury in long-term care. Our results show that incorrect weight shifting was the most common cause of falls, and that three major classes of activities—walking, sitting down, and standing—were the most common precipitants of falls. Our findings emphasise the need to target each of these activities in fall risk assessment and prevention strategies. Several validated clinical instruments incorporate such a multitask approach, including the timed up-and-go test,16
short physical performance battery,17
and Berg balance scale.18
However, residents of long-term care facilities are often unable to complete these measures because of mobility problems or cognitive impairment, showing the need to develop instruments for assessment of mobility and balance that are more applicable to this population.
Our results also show that many falls in long-term care result from sudden external perturbations to balance. Tripping was the second most common cause of falls, and hit or bump was the sixth most common. Clinical assessments of fall risk rarely include external perturbations, and most laboratory-based studies simulate slips, which we showed account for only 3% of falls. Our results show the need to develop and incorporate safe methods to simulate trips and bumps19,20
into routine clinical examinations—a new direction in assessment.
Our results also have implications for environmental modifications and the design of assistive devices for the long-term care setting. We showed that 25% of trips occurred due to the foot being caught on a chair or table leg, suggesting the need for improved staff awareness of this hazard, and improvements in environmental planning and furniture design. 21% of falls occurred during transferring, suggesting the need for exercises to enhance muscle strength, and improved assistive devices that provide adequate body support (eg, locking of wheels) when moving to and from chairs. Furthermore, although at least 74% of residents were classified as habitual users of assistive devices, only 21% of falls occurred while using an assistive device, showing the high risk of transferring to and from, or neglecting to use the device. Most of the falls we captured happened mid-afternoon, agreeing with findings reported by Rapp and colleagues21
from the analysis of more than 70 000 falls (including both public and private areas) from residents of nursing homes in Germany.
Our results also inform the design of wearable sensor systems for provision of information about movement quality during daily activities, and for automatic detection of falls in elderly people—a rapidly developing discipline.6,14,22
In particular, our results identify the most common sequence of events, including activities leading to falls, and subsequent causes of imbalance, that should be considered in designing and testing of fall detection algorithms appropriate for the long-term care population.
Our results differ substantially from existing scientific literature of self-reported mechanisms of falls in community-dwelling elderly adults (panel). When compared with our findings, Nevitt and Cummings9
reported that community-dwelling seniors were more likely to fall during walking, and less likely to fall during standing and transferring. Participants in Overstall and colleagues’7
study were more likely than those in ours to fall because of tripping, and less likely to fall because of incorrect weight shifting. We recorded results similar to these previous studies in the proportion of falls attributable to collapse or loss of consciousness (ranging between 6% and 12%). For residents of assisted living facilities, Topper and colleagues10
reported a sub stantially higher proportion of falls (54% vs
24%) attributable to base-of-support perturbations (trips, stumbles, or slips), and a much lower percentage (32% vs
52%) attributable to centre-of-mass perturbations (self-induced displacements or externally-applied pushes or collisions) than those which we identified.
These differences are probably partly attributable to the relatively higher prevalence of cognitive and physical impairment in the long-term care population we studied than in community-dwelling elderly people, with corresponding differences in fall mechanisms.25–27
Typically, the rate of falls in long-term care is two to three times higher than the rate recorded in the community,4
and fall prevention strategies that are effective with community-dwelling elderly people have not worked in the long-term care setting.28
These differences might also relate to differences in the locations of falls. We included only falls in common areas, whereas previous studies of self-reported falls have included falls in bedrooms and bathrooms, which present a different environmental and situational context, in need of further investigation. Conversely, the differences between our results and those reported previously might be attributable to errors in self-reported fall circumstances. Accurately recalling the circumstances of a fall is a challenging task even for young adults,29–31
and fallers might tend to rationalise falls as having an external, unavoidable cause, to avoid the perception of vulnerability.
We are aware of only one previous study with video recordings of real-life falls in elderly adults, undertaken by Holliday and colleagues,24
who analysed the activities associated with 25 falls by 17 individuals captured on video in a long-term care facility in the Toronto (ON, Canada) area. Our results are in general agreement, although we recorded a slightly smaller percentage of falls while walking (49% vs
68%), and a higher proportion of falls while standing (24% vs
12%) and sitting down or lowering (12% vs
Our study had important limitations. In analysis of video data, the team often faced challenges related to frame rate and camera resolution, distance between faller and camera, and occlusion of body parts from view. However, we recorded strong inter-rater and intra-rater reliability for our outcomes. We were also limited, because of the nature of our video footage, in identification of the contribution to falls of factors relating to the built environment such as lighting, and situational factors, such as changes from usual behaviour or secondary attention tasks (eg, talking). We did not examine the association between fall mechanisms and medical status of participants, because of the small number of participants who provided permission to access medical records and subsequently fell (41), and large number of established risk factors to consider. We did not measure (and were unable to incorporate in a risk analysis) the amount of time spent doing the various activities associated with falls. Nor did we acquire or analyse footage of near falls (imbalance episodes followed by successful balance recovery). We did not distinguish true episodes of syncope from, for example, collapse due to fatigue. An important question is whether the participants captured on video falling in common areas were representative of all fallers in the long-term care facilities that we studied. The demographics of individuals who fell between January and June, 2010, and had a fall captured on video were much the same as those who fell but were not captured on video. We stress that our results summarise the situational context of falls in common areas of the long-term care environment.
In summary, through video capture and analysis of real-life falls of elderly people in long-term care facilities, we show that the most common causes of falls are incorrect weight shifting and tripping, and the most common activities leading to falls are forward walking, standing quietly, and sitting down. Our approach avoids the usual trade-off in falls research between the high control but artificiality of the laboratory environment, and the questionable accuracy of individuals in recalling the circumstances of real-life falls, and our results provide insight into the causes and activities leading to falls in long-term care.