Older adult (aged 65+) falls are a growing public health issue in the United States. Older adults reported 36 million falls and 8 million fall-related injuries in 2018 (Moreland et al., 2020). Falls are the leading cause of unintentional injury deaths for older adults, resulting in about 41,000 deaths annually (Centers for Disease Control and Prevention & National Center for Health Statistics., 2024a). Age-adjusted death rates for unintentional falls have increased 35% between 2013 and 2022 (Centers for Disease Control and Prevention & National Center for Health Statistics., 2024a, 2024b).

Modifiable risk factors associated with falls include gait and balance impairments, lower extremity muscle weakness, adverse drug effects, polypharmacy, vitamin D deficiency, visual impairment, foot problems, improper footwear, and home hazards (Ambrose et al., 2013; Rubenstein & Josephson, 2006). Evidence-based clinical and community fall prevention strategies like exercise and physical therapy to improve strength and balance (Guirguis-Blake et al., 2018; Sherrington et al., 2019), medication management to stop, switch, or reduce the dose of medication that increase fall risk, vitamin D supplementation, cataract surgery to improve vision, reducing foot deformities, and working with an occupational therapist to remove home hazards (e.g., throw rugs, clutter) (Cumming et al., 1999; Gillespie et al., 2012; Karlsson et al., 2013; Stevens & Burns, 2015) are effective in reducing fall risks (Gillespie et al., 2012; Stevens & Burns, 2015).

Of the 1063 older adults who completed the survey, 45% (542) were male and 55% (521) were female; 67% were 65–74 years old, while 29% were 75–84 years old and 5% were aged 85 and older. A quarter (25%) of older adults strongly disagreed and 60% disagreed that that there is nothing that can be done to prevent falls (Table 1). About one fifth (20%) of adults reported falling once in the past year and almost 10% reported falling two or more times. About half (53%) were at risk of falling based on STEADI’s 3-Key Fall Risk Screening Questions (Centers for Disease Control and Prevention, 2019a; Eckstrom et al., 2017); one third (33%) had spoken to a healthcare provider about their risk of falling.

The frequency distribution across the SOC varied by type of fall prevention strategy (overall fall prevention, medications, and strength/balance) (Figure 1). For overall fall prevention, 61% of older adults were in the action stage. For medication management, 39% of adults were in the pre-contemplation stage and 45% in the contemplation stage. For strength/balance, older adults were mostly in the preparation stage (29%) or action stage (29%).

Most older adults in overall fall prevention Change stages reported doing at least one activity to prevent falls (92%), with 79% reporting participation in at least one evidence-based strategy (Supplemental Figure 2). Older adults most frequently reported that they “took more care” to prevent falls (e.g., slowing down) (69%), a limited evidence strategy, followed by the evidence-based strategies of vitamin D supplements (39%), strength/balance training (34%), and vision testing (33%). Only 29% of older adults in a medication management Change stage reported changing medications (data not shown). About 65% of older adults in a strength/balance Change stage reported doing at least one evidence-based strength and balance activity: strength and balance training (53%), physical therapy (19%), or group exercises (19%) (data not shown).

In adjusted models, believing falls are preventable and having talked to healthcare provider about falls increased the likelihood that older adults were in a Change stage for overall fall prevention versus a Pre-change stage. Those who believed that falls can be prevented were 40% more likely (aRR: 1.4; 95% CI: 1.1–1.7) (Table 2), and those who talked to a healthcare provider were 30% more likely (aRR: 1.3; 95% CI: 1.2–1.4) to be in an overall fall prevention Change stage after adjusting for other variables. Older adults who talked to a healthcare provider were over twice as likely (aRR: 2.2; 95% CI:1.4–3.5) to be in a medication management Change stage after adjusting for other variables. Those at risk of a fall (aRR: 0.8; 95% CI: 0.7, 0.9) were 20% less likely to be in a strength/balance Change stage while those who talked to a healthcare provider (aRR: 1.3; 95% CI: 1.1–1.5) and those who believed falls were preventable (aRR: 1.3; 95% CI: 1.0, 1.6) were 30% more likely to be in strength/balance Change stages after adjusting for other variables.

The purpose of this study was to determine older adults’ readiness to change behaviors using the SOC model. Due to limited results, the five SOC stages were combined into three stages (Pre-contemplation, Pre-change, and Change) and those in Change were compared to those in Pre-change. For strength/balance behavior, 43% of subjects reported being in one of the Change stages (action (29%) or maintenance (14%)) and almost two-thirds (65%) reported doing a strength/balance activity. The Strategies to Reduce Injuries and Develop Confidence (STRIDE) study, a large national fall prevention trial, found that over 90% of those at risk of sustaining fall injuries had strength, gait, and balance problems (Bhasin et al., 2020) and that this was the most common fall risk factor. Although our study did not assess for risk factors, findings from the STRIDE study suggest that strength and balance problems was a likely risk factor for most participants.

Our study revealed a disconnect where older adults in a Change stage reported doing strength/balance exercise activities but about one-third did not select any exercise activities when asked what they were doing to prevent this. Some may engage in an appropriate activity that they reported as “Other”; however, the percentage reporting “other” did not make up the difference. Social desirability, participants providing the answers they believe researchers are looking for, may be another explanation. One study of middle-aged women found that social desirability was associated with over reporting physical activity (Swann et al., 2005).

Henry et al. (2024) found that about 83% of older adult participants believed strength/balance exercises help older people prevent falls. Despite this, less than half in this study are in a Change stage for strength/balance exercises and only two-thirds of those in a Change stage report doing them. Some barriers to strength/balance training participation include not believing or having the knowledge that exercise is effective at reducing fall risks; not remembering or knowing how to do prescribed exercises (Britten et al., 2017; Hill, 2014; Jagnoor et al., 2014; Powell-Cope et al., 2014); existing health or mobility problems; lack of time, (Britten et al., 2017; Hutton et al., 2009; Powell-Cope et al., 2014; Sandlund et al., 2018), financial or physical access to programs, and transportation (Britten et al., 2017; Powell-Cope et al., 2014; Robins et al., 2016). Identifying barriers to strength/balance exercises enables healthcare providers to help their patients move towards maintenance of a specific activity. Healthcare providers are well-positioned to reassure older adults that the activity is appropriate (Stevens et al., 2018) and can use the CDC resource (Helping My Older Patients Reduce Their Risk of Falling (CDC.gov) to move their patients towards a strength/balance Change stage.

For medication management most older adults were in the precontemplation and contemplation stages. These results are supported by the STRIDE study findings (Bhasin et al., 2020) where only 29% of older adults prioritized and agreed to address identified medications potentially linked to increased fall risk compared to other identified risk factors like poor gait and balance (91%) and vision problems (68%). There are many reasons why older adults are less likely to take action to change medications to prevent falls: not knowing side effects can increase fall risk (NSW, 2010), reluctance to allow a primary care provider to change medication prescribed by a specialist (Gillespie et al., 2018), prioritizing the management of chronic conditions that medications with increased fall risk are treating (Gillespie et al., 2018), and a fear of side effects from stopping, switching, or changing medications (Martin et al., 2018; Martin & Tannenbaum, 2017; Reeve et al., 2016). While this study did not measure which subjects used fall-risk-increasing-drugs (FRID), many were likely at increased fall risk due to medication side effects. In a study of 9,228 older adult veterans who screened positive for a fall, 75% were prescribed at least one FRID and three-fourths were on two or more medications associated with increased fall risk (Elias et al., 2020). Another study found that the percent of older adults prescribed at least one FRID increased from 57% in 1999 to 94% in 2017 (Shaver et al., 2021). Collectively, this emphasizes the need to educate and encourage older adults to consider taking action to stop, switch, or reduce FRID when medically indicated.

A second goal of this study was to explore evidence-based strategies that older adults in Change stages take to reduce falls. While 92% of older adults in a Change stage for overall fall prevention considered themselves to be taking action to prevent falls, the most common activity was taking care or slowing down. There is no evidence that this is effective at reducing falls. Slowing down may have a negative effect, where restricting activity leads to reduced muscle strength that in turn increases fall risk (Stevens et al., 2018). Older adults may not participate in evidence-based exercise programs for fear it may increase fall risk (Clemson et al., 2012; Kim et al., 2014; Lord et al., 2003; Siegrist et al., 2016). Moreover, the low proportions of older adults in Change stages for medication management (29%) and strength/balance (65%) that reported doing corresponding evidence-based activities, suggest that being in a Change stage is not indicative of using evidence-based strategies. These outcomes are noteworthy as they suggest older adults may have a false perception of taking appropriate action and highlights the importance of educating patients on evidence-based fall prevention interventions.

The final goal of this study was to determine factors related to older adults taking action to reduce falls. Those who believed falls are preventable and talked to a healthcare provider about falling were significantly more likely to be in Change stages for overall fall prevention. Similarly, those who talked to a healthcare provider were about twice as likely to be in medication management Change stages compared to those who had not talked to a provider. These results support previous studies that demonstrate the positive impact providers can have in getting older adults to adopt fall prevention measures (Galazzi et al., 2016; Kohn et al., 2016; Martin & Tannenbaum, 2017; Robins et al., 2016; Sandlund et al., 2018). For those not in Change stages, education, especially from a healthcare provider is critical. Finally, medication management advice given by healthcare providers is particularly important. A study that looked at the beliefs and attitudes of older adults regarding deprescribing (medication management) found they were more willing to deprescribe if they discussed it with their provider, knew the rationale behind deprescribing, and were told what to expect during the process (Reeve et al., 2016).

Using the SOC Model (Prochaska & Velicer, 1997; Stevens & Phelan, 2013) provided insight regarding older adults’ behaviors and readiness to adopt fall prevention strategies. The finding that most older adults are in Change stages, except for medication management, informs healthcare providers on the need to increase awareness of medication management as a strategy for fall prevention. The finding that the leading strategy was one with limited evidence highlights the importance of patient education.

Healthcare providers play an important role in older adult fall prevention. While older adults saw falls as potentially preventable, and considered themselves in Change stages for prevention, only about one-third had discussed falls with their healthcare providers. Others may not be aware of appropriate strategies needed to reduce their fall risk. Healthcare providers can use CDC’s STEADI fall prevention initiative to screen older adults for fall risk, identify modifiable risk factors, and intervene to reduce risk by recommending effective strategies. STEADI contains tools for assessing modifiable risk factors along with recommendations for evidence-based strategies to decrease identified fall risks (CDC, nd; Lee, 2017; Stevens & Phelan, 2013). This includes several resources to assist providers with managing and reducing medication use, including their SAFE (Screen, Assess, Formulate, and Educate) medication review framework, which guides providers on how to conduct a medication review (Centers for Disease Control and Prevention, 2017b) and STEADI-Rx which is designed to improve collaboration between pharmacists and healthcare providers (Centers for Disease Control and Prevention, 2019b). Other important resources used to manage medications include the AGS Beers Criteria which outlines medication classes considered inappropriate for geriatric use (American Geriatrics Society Beers Panel, 2019) and Deprescribing.org, a website dedicated to providing deprescribing resources to patients and providers. Providers can also refer to the AGS response to the World Falls Guidelines, which includes recommendations for fall risk assessments and prevention pathways (Eckstrom et al., 2024).