In Singapore, about one in three older people aged 60 and above have fallen more than once.

Falls are common occurrences in both the young and old, however, falls are especially concerning for the elderly, in whom falls can lead to serious injuries or even death. 

For individuals with high risk for falling, or history of recurrent falls, a fall assessment should be done to identify the possible reasons contributing to the fall.

These reasons may range from a multitude of underlying medical conditions (affecting any system in the body from head to toe), to environmental factors such as uneven surfaces, steps/kerbs, slippery floor, and poor lighting. 

It is therefore important to identify the contributory factors in order to guide treatment and advice to reduce the risk of further falls.

Treatment may be in the form of:

• Optimisation of the underlying medical condition, 

• Prescription of suitable walking aids, 

• Having adequate supervision, 

• Adjustments to the environment, or a

• Combination of the above

Have questions about fall risk assessment and prevention? Don’t miss this chance to ask our specialist now! This Q&A is ]for a limited time only.

Useful articles for you:

Caregiver Tips: Ways to Prevent Falls in the Elderly

10 Safety Tips to Prevent Falls at Home

About Dr Charmaine Tan

Dr Charmaine Tan is an Associate Consultant at the Post-Acute & Continuing Care Department of Outram Community Hospital (part of SingHealth Community Hospitals).

She graduated from NUS Yong Loo Lin School of Medicine, then underwent Family Medicine training in Singhealth. She completed her Masters of Medicine (Family Medicine) in 2019, and Fellowship in Family Medicine in 2023.

In her current role at Outram Community Hospital (OCH), Dr Charmaine works with a multi-disciplinary team to provide holistic care to inpatients to optimise them before their transition back to the community.

Questions and answers on preventing falls 

1. Question by Cynthia

Dear Dr Tan,

My neighbour had a fall just before Chinese New Year. And since then she has fear of falling and so she would not want to walk unnecessarily.

Another neighbour would not want to use a walking stick even though she is weak as she felt ashamed to use one. I gave her a walking stick but she prefers to just stay home.

I know that physical movement is important in keeping muscles strong and preventing future falls, so please let me know how I can encourage them to move more.

Answer by Dr Charmaine Tan

Dear Cynthia, your neighbours are lucky to have you looking out for them!

Indeed, physical movement is so important in maintaining function and reducing fall risks. However, there are often barriers to doing so, such as those that you brought up above, like fear of falling, concerns about appearance, or perhaps uncertainty on what and how to perform these exercises in a safe manner.

Every behavior change begins with small steps. A suggestion would be to encourage them to enroll in a Day Rehabilitation Centre (DRC) near their home where they can undergo supervised exercise 1-2 times a week in a group setting. This will help to kickstart their journey to learning exercises in a safe environment. Subsidies for DRCs are available if needed, subject to means testing, and can be applied via medical social workers (MSW) in the polyclinic or hospital. MSWs can also help with applying for transport or escort services, if required.

2. Question by Pat

Dear Dr Tan,

Regarding this topic on preventing falls by the elderly, I’m wondering if there is a class available for them to learn how to fall safely?

I read that it’s all about muscle memory and teaching our elderly how to break their fall to prevent life-threatening injuries may be one of the safeguard.

Answer by Dr Charmaine Tan

Dear Pat, thank you for your question.

A very important component to fall prevention is to first identify what is causing the elderly to be at risk of falls, and address those causes directly. I would highly recommend elderly who are at risk of falls or have fallen before to get a fall assessment done to evaluate for any reversible causes.

As you mentioned, there are courses on falling safely. Such courses, if incorporating elements of repeated physical practice, can be a good and fun way to introduce components of strength and stability/ balance training, in addition to conventional exercises. While such skills can come in handy, falls often occur very quickly, hence there may be limits to how effective tips on breaking falls might be.

As such, the strongest evidence is still for fall risk assessment, addressing the risk directly by removing contributory factors if any (this could come in the form of visual/hearing aids, home modification, medication changes, etc), using walking aids or supervision (subject to therapist assessment and recommendation), as well as embarking on an exercise regime with a mix of balance and resistance training catered to the elderly at hand.

3. Question by KK Wong

Dear Dr Tan,

I am delighted to learn of the opportunity for seniors like me to seeking your advice on our fall risks.

I am 68 and have no mobility issue. Prior to my accident, I did walking exercise and static exercises often and considered myself physically able than many people in my age group.

However, last month when I was holidaying in Japan, I slipped and fractured my right ankle when I was walking down a slope as I was distracted with something else. The diagnosis is lateral malleolus fracture. I am in the beginning of the 7th week since the accident. I am now able to walk at a slightly slower speed than normal. I still need to go to the orthopaedic doctor for a 2nd review.

May I know does this injury increase my fall risk in future, after I recovered? Are there any specific movements or activities I should avoid so as to minimise the risk of injuring the ankle again or increase my fall risk in general?

Thank you in advance for your kind advice.

Answer by Dr Charmaine Tan

Dear KK Wong, I am sorry to hear of your accident. It is good to hear that you are now able to walk and are on the way to recovery. It is also good that you are keeping active despite the injury, as this is important in maintaining your mobility and strength in your unaffected joints, and maintaining your stamina. You can continue with exercises involving your upper limbs and core, as well as low-impact activities that are tolerable for your right ankle.

With regards to your ankle, it is likely to be stiffer and weaker than before your injury, even after the fracture has fully healed. This is a normal and common occurrence. Hence, this stiffness and weakness of your ankle may increase your fall risk. In order to mitigate this, it would be advisable to undergo a period of dedicated physiotherapy to regain strength, balance, and range of motion of your ankle, so that the risk of future ankle injuries or falls will not be increased due to your ankle injury.

Wishing you a speedy recovery.

4. Question by Jenny

Hi Doctor,

I tend to trip and when I fall I can't seems to stop it. Is there something I can do to avoid injuring myself badly during a fall?

Answer by Dr Charmaine Tan

Dear Jenny, tripping often occurs suddenly and may at times inevitably result in a fall. What can increase your chances of being able to stop your fall is balance training (e.g. standing with feet together, tandem stance, single-leg stance) and strength training of your buttocks and thigh muscles (e.g squats, sit to stand), which increases the chances of you being able to stabilize yourself after tripping, and thereby prevent falling.

5. Question by Coleman

Hi Dr,

I woke up one morning 3 weeks ago and lost consciousness momentarily. As a result, I fell and hit my head and ended up with a few stitches. I think I rose too quickly when I got up.

Some friends shared with me that they had similar experience when they got up of bed too quickly in the morning. Is this symptom common? Is there something that I should be concerned about?

Answer by Dr Charmaine Tan

Dear Coleman, sorry to hear about this.

What you described sounds like what we call postural hypotension, where there is a drop in blood pressure when one goes from lying to sitting or standing. This is commonly experienced after a prolonged period of lying down, and can be exacerbated by dehydration, certain medications (e.g. blood pressure medications, certain prostate medications), or underlying medical conditions (e.g. poor heart function).

Generally in mild cases, adequate oral hydration and precautions (e.g. getting up slowly, sitting and doing calf pumps first before getting up, stabilisation in standing before walking) will be sufficient. 

However, if this occurs frequently, or if it impairs your ability to stand and walk due to recurrent dizziness, please see a doctor for the relevant assessment and treatment as severe postural hypotension can be dangerous, putting you at risk for falls and fainting.

Meanwhile, you can monitor your blood pressure at home with a blood pressure machine that utilises a cuff around your arm. You may take and record your blood pressure as well as heart rate in:

• Lying position
  

• After 1 minute of sitting, and 

• After 1-3 minutes of standing. 

This information will help your doctor assess the severity of your condition during your medical visit.

6. Question by David

Dear Dr,

Thank you for your time to answer the question. My question is when we do fall and hit our head on the ground what signs must we have to see a doctor or check in to A&E to get an MRI or head scan to check we don’t have concussion or blood clog? Thank you.

Answer by Dr Charmaine Tan

Dear David, thank you for your question.

Red flags that would necessitate immediate medical attention at the A&E following a head injury would include a new onset of any of the following symptoms: headache, dizziness, vomiting, loss of memory, loss of strength or sensation in face/limbs, slurred speech, large bruise/swelling at the scalp where the head may have hit the floor or an object.

Other things to consider would be if the person with head injury is an elderly on blood thinners, as such individuals can have a bleed much more easily in the brain following a low trauma fall, as compared to younger individuals who are not on blood thinners. This is because the brain volume shrinks as we grow older, hence it is easier for the blood vessels to break even during a mild head injury.

7. Question by Abdul Rahman

Dear Dr,

I was told by the physiotherapists that my legs and hips need strengthening in order to avoid falls. Am I on the right path to undergo the strengthening programme? Thank you.

Answer by Dr Charmaine Tan

Dear Abdul Rahman. Yes, strengthening of your legs and hips is key to avoiding falls, alongside balance training! Do continue to persist with your exercises and aim to progress (i.e get stronger, able to do more reps/sets/weight, increase difficulty) so that you will continue to get stronger 😊

8. Question by Winnie

Dear Dr,

My question is: It is very common for seniors to have “3 highs”: high Bp, high cholesterol, high sugar level. Doctors always treat high cholesterol with statins. Many people taking statins ended up with damaged muscles and fatigue, which are common causes of a senior's fall.

How should the doctors manage and educate the patients on the effects of the medication? Thank you.

Answer by Dr Charmaine Tan

Dear Winnie, thank you for your question.

What you are describing is a potential side effect of statins, called statin induced myopathy, whereby there may be a varying degree of muscle damage due to statin intake. Fortunately, most people tolerate statins very well with no side effect. For those with some degree of myopathy, the majority are mild with some muscle aches, but do not cause weakness nor contribute to fall risk.

Risk factors that increase the risk of statin induced myopathy include: older age (>80 years old), lower BMI (body mass index), female gender, other diseases (e.g. kidney / liver disease), drug interactions, vigorous exercise, alcohol, and genetic factors. For such patients, statins may be started at lower doses, then gradually increased as tolerated, with appropriate monitoring.

As with any medication, the risks versus benefits of the medication should be balanced, and customised to the patient at hand. Patients are encouraged to follow the recommended prescriptions from their doctors.

9. Question by Edna

Dear Dr,

May I know what exercises are good for a strong ankle as I hope to strengthen my ankle so I can walk more steadily and save any falls? Thank you.

Answer by Dr Charmaine Tan

Dear Edna,

You can do some ankle strengthening exercises such as slow eccentric calf raises (can start with both feet together, then progress to 1 foot at a time) on a step or raised surface. You can also add on ankle stability exercises such as tandem balance and single leg balance.

I would strongly encourage you to also consider strengthening your knee (thigh muscles) and hip (buttock muscles) as that would improve your stability too. Exercises such as step ups, sit to stand, and seated knee extensions will help. Do seek advice from a physiotherapist if more guidance or customised treatment is required.

An unsteady gait can be due to many other factors besides a weak ankle. You may wish to consult a doctor for further assessment.

10. Question by Jasmine

Hi Dr Charmaine,

I have a tendency to sway sideways and this put me at risk of falling if I am not mindful of the situation. Please advise what can be done to prevent this?

Answer by Dr Charmaine Tan

Dear Jasmine,

Thank you for your question. It would be advisable to first see a doctor to assess if your tendency to sway sideways is related to any underlying medical issue that may be affecting your balance, strength, or sensation.

Thereafter, you can engage in exercises to improve your balance (e.g. standing with feet together, tandem stance, single-leg stance) as well as strength training of your buttock and leg muscles to better stabilize yourself.

11. Question by Jasmine

Dear Doctor,

I had a fall a month ago I stepped on the road kerb I slipped and fell.

Went to A&E, took x-rays they told me to ice it. I was told there were no fractures. The swelling is on my right ankle and left foot was quite bad. I had to use a wheelchair for 2 weeks as I could not walk. I used Acustop for anti-inflammatory. It has help me with the swelling. I wish to know how long can I used this Acustop any side effects esp? For people with kidney disease?

Please note my creatinine serum reading is 57.

After a month there is still some pain on my left foot near the metatarsal.

Another x-rays was done I found out there is a crack a small fracture. The doctor said it will take 3 months to recover.

I would like to know can I walk everyday? I’m tired easily slight pain on my left foot. Is there any exercise I can do to strengthen my leg?

I hope to hear from u. Thank you.

Answer by Dr Charmaine Tan

Dear Tina, sorry to hear about your accident.

Keeping active is important to prevent further deconditioning of the rest of your body, and low impact activities such as walking and strengthening exercises are appropriate. However, what exercise is allowed and how much weight you can put on the fracture site depends on the severity of fracture as well as the healing progress. Do follow the advice given by the doctor regarding the weightbearing status while doing your exercises so as to not jeopardize the healing process.

Swelling is normal and expected after an injury and will improve over time. You can elevate your affected foot when resting to reduce the swelling. Topical analgesia like Acustop/Ketoprofen may be with other agents like Paracetamol for pain control if needed.

Ref: H24