Falls-proofing a home: the changes that actually reduce fractures

Roughly a third of adults over sixty-five fall each year, and about half of those over eighty. Most falls happen at home, doing ordinary things — walking across a room, getting out of bed, reaching for something on a high shelf.

The intuitive response is to remove hazards, and that response is correct with an important qualification. The Cochrane review of home safety assessment and modification found it reduces falls — but the effect is concentrated in people at high risk of falling, particularly those with visual impairment or a history of falls, and is small or absent in lower-risk populations.

The other qualification is who does it. Interventions delivered by occupational therapists work considerably better than those delivered by others or by a leaflet, most likely because the assessment is functional rather than generic — watching how a person actually moves through their own home, rather than ticking off a list of items.

The changes with the best evidence

Lighting. The single most under-rated item. Older eyes need substantially more light — often two to three times as much as at forty — and adapt more slowly between light levels. Night-time falls on the way to the bathroom are common and preventable.

Motion-activated night lights on the route from bed to toilet. Two-way switches at the top and bottom of stairs. Brighter bulbs generally, and consistent lighting levels to reduce the adaptation problem. A light within reach of the bed.

Stairs. Handrails on both sides, extending beyond the top and bottom step. Contrasting tape or paint on the edge of the top and bottom step, which matters because depth perception declines and stairs of uniform colour become genuinely ambiguous. Clear the stairs of anything stored on them.

Bathroom. Grab rails by the toilet and in the shower — properly fixed into structure, not suction-cup rails, which fail. A non-slip mat. A shower seat. A raised toilet seat if standing from low is difficult. Bathrooms combine wet surfaces, hard fixtures, low seats and a hurried occupant.

Floors. Remove or secure loose rugs, particularly at thresholds. Fix curling carpet edges. Route cables around rooms rather than across them. Clear the habitual walking paths.

Footwear, which is not part of the house but should be

Indoor footwear is a substantial and easily fixed contributor. Backless slippers, worn-out soles and walking in socks on hard floors all increase risk. The evidence supports well-fitting shoes with a firm, thin, non-slip sole, a low heel, and a fastening that holds the foot.

Thin soles improve proprioception, which is why very cushioned soles are not obviously better despite feeling safer.

What the house cannot fix

This is where home modification is oversold. A meaningful share of falls have causes that no amount of grab rails will address.

Medication. Sedatives, antidepressants, antihypertensives causing postural drops, and polypharmacy generally. A medication review is at least as effective as anything structural.

Postural hypotension. Worth measuring — lying and standing blood pressure — and often correctable.

Vision. Cataracts, out-of-date prescriptions, and varifocals. Varifocals distort the ground when looking down, and there is trial evidence that single-vision distance glasses reduce outdoor falls in people who go out regularly.

Vitamin D deficiency, where correction reduces falls in deficient individuals — though supplementing in replete people does not, and high intermittent doses increase falls.

Foot problems. Painful feet, bunions, long toenails and reduced sensation all alter gait. Podiatry is under-used.

Fear of falling, which produces a cautious, shuffling gait that is itself less stable.

And strength and balance, which remain the intervention with the largest effect and the one the house cannot supply. Exercise programmes that challenge balance reduce falls by roughly a quarter. No handrail does that.

Getting the assessment

In most health systems an occupational therapy home assessment can be requested through a GP, and after any fall resulting in a healthcare contact it should be offered as a matter of course. It frequently is not, and asking is usually all that is required.

Falls clinics exist in many areas and bring together medication review, blood pressure assessment, vision, strength and balance testing, and home assessment in one place. They are the appropriate referral after a second fall, or a first fall with injury.

The plan for after a fall

Two things worth arranging before they are needed. Learn a technique for getting up from the floor using furniture — an occupational therapist can teach the backward-chaining method in one session. And consider a personal alarm, which removes the long lie from the range of possible outcomes.

These are unwelcome purchases. They are also the difference between an embarrassing hour and a hospital admission, and the people who set them up are almost never the ones who regret it.