Falls are among the most serious and frequent adverse events affecting the elderly population worldwide. According to the World Health Organization (WHO), falls are the second leading cause of accidental or unintentional injury deaths globally, with adults over 65 years accounting for the majority of fall-related morbidity and mortality; approximately 37.3 million falls severe enough to require medical attention occur annually, and 646,000 individuals die from falls each year.[1]

Falls in the elderly represent a major public health concern involving a complex interplay of intrinsic factors — age-related physiological changes, chronic disease, and polypharmacy — and extrinsic environmental hazards.[1] Tinetti et al. found that approximately one-third of community-dwelling adults over 65 years fall at least once annually, with half experiencing recurrent falls, and that the consequences extend beyond physical injury to psychological effects such as fear of falling and further functional decline.[2]

In India, the ageing population is growing rapidly, with over 140 million individuals currently aged 60 years and above. This demographic shift has led to a rising burden of fall-related injuries, disability, prolonged hospitalisation, and significant healthcare costs. Falls in older adults frequently result in fractures (particularly hip, wrist, and vertebral fractures), head injuries, and serious psychological consequences such as fear of falling, loss of confidence, and reduced independence.[2] Despite the high prevalence and serious consequences of falls, awareness regarding fall-prevention strategies remains inadequate among both elderly individuals and their caregivers. A study from a tertiary hospital in South India found that only 38% of geriatric patients had adequate awareness about fall-prevention strategies, underscoring the need for structured health-education programmes to bridge this knowledge gap.[3] Many older patients and their families remain unaware of intrinsic risk factors (such as muscle weakness, balance impairment, visual deficits, and cognitive decline) and extrinsic risk factors (such as slippery floors, poor lighting, loose rugs, and inappropriate footwear) that contribute to falls.

Health literacy and awareness play a crucial role in fall prevention. Polypharmacy (use of four or more medications) is one of the most significant modifiable risk factors for falls: psychotropic drugs, antihypertensives, and diuretics have each been shown to significantly increase fall risk in older adults, yet medication-related fall-risk awareness remains low among elderly patients.[4] Balance and strength-training exercise programmes have been shown to reduce fall rates by up to 23% in community-dwelling older adults, though adherence depends heavily on patient awareness and motivation.[5] Taken together, evidence-based strategies — including targeted education, home-hazard modification, exercise programmes, and regular medication review — can meaningfully reduce fall incidence, but their effectiveness depends on adequate patient and caregiver awareness.

At a tertiary care hospital such as the Mandya Institute of Medical Sciences (MIMS), a large number of elderly patients attend the outpatient and inpatient departments for various chronic illnesses and are at heightened risk of falls due to comorbidities, polypharmacy, and reduced mobility. A prospective study at a geriatric clinic found that patients with higher education and a previous history of falls were more likely to have adequate fall-prevention knowledge, and recommended routine fall-risk assessment and patient education during outpatient visits.[6] However, no study has evaluated the level of awareness of fall prevention among the geriatric population in this region. This study therefore aimed to describe the level of awareness of fall prevention among the geriatric population attending a tertiary care hospital in Mandya, and to identify knowledge gaps regarding intrinsic and extrinsic risk factors, prevention measures, and healthcare resources among the participants. Thus, the results of this study would provide recommendations for targeted educational interventions to improve patient safety and quality of life among elderly patients attending this tertiary care centre.

Study design: Descriptive cross-sectional study. Study period: Three months. Sampling technique: Consecutive sampling. Sample size: 157. Study set-up: Department of Orthopaedics (outpatient and inpatient services), Mandya Institute of Medical Sciences (MIMS), Mandya — a tertiary care hospital. Selection criteria: Inclusion criteria - 1) Age 60 years and above, attending the outpatient or inpatient departments of MIMS, Mandya. 2) Ambulatory (able to walk independently or with minimal assistance). 3) Willing to give informed consent to participate in the study. Exclusion criteria - 1) Severe cognitive impairment (e.g., advanced dementia) precluding comprehension of the questionnaire. 2) Completely bedridden or non-ambulatory patients. 3) Patients with acute medical emergencies in an unstable condition. Institutional ethics committee approval was obtained before starting the research project, and written informed consent was obtained from every participant. All eligible geriatric patients attending MIMS, Mandya were enrolled consecutively. A structured, interviewer-administered questionnaire was administered by the investigator in the patient's preferred language (Kannada/English). The questionnaire used in this study was designed after review of existing literature, including the WHO fact sheet on falls,[1] the work of Tinetti et al. on risk factors for falls among community-dwelling older adults,[2] and the AGS/BGS Clinical Practice Guideline on the prevention of falls in older persons.[8] The proforma consisted of socio-demographic data, a history section documenting previous falls, a section on comorbidities and current medications, and an 18-item, interviewer-administered awareness questionnaire covering three domains — awareness of fall risk factors (8 items), awareness of fall-prevention measures (7 items), and awareness of healthcare resources for fall prevention (3 items) — each item scored 1 for a correct response and 0 for an incorrect or “don't know” response, giving a maximum possible total score of 18. After collection, data were entered in Microsoft Excel and analysed using IBM SPSS Statistics version 30.0. Descriptive statistics (percentages for categorical variables such as awareness items, sex, and education; mean and standard deviation for continuous variables such as age) were computed, and the chi-square test was used to assess the association of adequate awareness (total score ≥70%) with age group, sex, education, and history of previous falls. A p-value <0.05 was considered statistically significant.

A total of 157 patients aged 60 years and above were enrolled consecutively over the study period. The mean age was 71.6 ± 9.5 years; 66.9% (n=105) were male and 33.1% (n=52) were female. Socio-demographic and clinical characteristics of the study population are summarised in Table 1.

Table 1: Socio-demographic and Clinical Profile of Study Participants (N = 157)

Figure 1: Age group distribution of study participants

Figure 2: Sex distribution of study participants

A history of at least one fall in the preceding year was reported by 77.8% (119/153) of participants, reflecting the case-mix of an orthopaedic department in which many patients present following a fall-related injury. Comorbidity data were captured for only 6 participants and could not be meaningfully analysed; polypharmacy (≥4 medications) was present in 57.6% of the 66 participants for whom medication data were recorded.

Figure 3: History of fall in the preceding one year

Figure 4: Polypharmacy status among participants with medication data (n = 66)

Overall fall-prevention awareness scores are summarised in Table 2. Among the 151 participants with a recorded score, the mean total awareness score was 10.79 ± 3.45 out of 18 (59.9%), and only 34.4% (52/151) met the pre-defined threshold for adequate awareness (≥70%); the remaining 65.6% (99/151) had inadequate awareness

Table 2: Overall Fall-Prevention Awareness Score (n = 151 with recorded score)

Figure 5: Overall fall-prevention awareness level

Domain-wise scores, available for the 157 participants whose item-level (question-by-question) responses were fully transcribed from the proforma, are shown in Table 3. Awareness was highest for prevention measures (53.1%), closely followed by risk factors (51.8%), and markedly lower for healthcare resources (41.8%).

Table 3: Domain-wise Fall-Prevention Awareness Scores (n = 57)

Figure 6: Domain-wise fall-prevention awareness scores

Within this subset, the weakest individual items were awareness of dedicated fall-prevention programmes or clinics (12.3% correct), awareness that physiotherapy can improve balance and reduce fall risk (17.5%), and awareness that a doctor can formally assess fall risk (19.3%) — all three belonging to the healthcare-resources domain.

Figure 7: Weakest individual awareness items (healthcare resources domain)

On chi-square testing for association with adequate awareness (Table 4), a borderline trend toward lower awareness was seen with increasing age and with illiteracy or no formal education, while sex and prior fall history showed no significant association.

Table 4: Association Between Adequate Awareness and Selected Variables

Figure 8: Mean awareness score by age group, education status, and fall history

This study aimed to describe the level of awareness of fall prevention, and to identify domain-specific knowledge gaps, among elderly patients attending a tertiary care orthopaedic department in Mandya. This descriptive cross-sectional study enrolled 157 elderly patients (mean age 71.6 ± 9.5 years; 66.9% male) attending the orthopaedic outpatient and inpatient services of MIMS, Mandya. Notably, 77.8% of participants reported a fall in the preceding year — substantially higher than the roughly one-third annual fall incidence reported in community-dwelling older adults by Tinetti et al.[2] This is best explained by the sampling frame itself: patients recruited from an orthopaedic department are inherently enriched for those who have already sustained a fall-related injury, rather than representing the general geriatric population. This referral bias should be kept in mind when generalising the awareness findings outward. More broadly, our findings are consistent with the well-established epidemiological framework for falls in older people, in which a complex interplay of risk factors and preventive strategies determines outcomes.[7] The mean total awareness score was 10.79 ± 3.45 out of 18 (59.9%), and only 34.4% of participants met the pre-defined threshold for adequate awareness (≥70%). This is broadly consistent with — if slightly lower than — the 38% adequate-awareness figure reported by Ramesh et al. in a South Indian tertiary care geriatric population,[3] reinforcing that inadequate fall-prevention awareness is a recurring finding across Indian tertiary care settings rather than an isolated observation at this centre. The domain-wise breakdown (available for the 157 participants with fully transcribed item-level data) revealed an uneven knowledge profile. Awareness of intrinsic and extrinsic risk factors (51.8%) and of basic prevention measures (53.1%) was moderate, but awareness of available healthcare resources — that a doctor can formally assess fall risk, that physiotherapy improves balance, or that dedicated fall-prevention clinics exist — was strikingly low at 41.8%. This pattern suggests the deficit is not primarily about recognising danger but about knowing where to seek help — a distinction with direct implications for intervention design: generic risk-factor education is unlikely to close this particular gap, whereas structured referral pathways and clinician-initiated counselling, as recommended in the AGS/BGS guideline,[8] target it directly. Associations with awareness followed expected directions but did not reach conventional significance, likely reflecting reduced power from missing covariate data. Awareness declined with advancing age (mean score 11.66 in the 60–69 group vs. 9.50 in the 80+ group; χ²=5.95, p=0.051) and was lower among illiterate or no-formal-education participants (mean 7.45 vs. 10.31; χ²=2.92, p=0.087) — both consistent with Kumar et al.’s finding that education level correlates with fall-prevention knowledge.[6] Sex showed no meaningful association (p=0.483). Counter-intuitively, participants with a prior fall history scored higher, not lower, than those without one (11.28 vs. 9.00; p=0.233) — plausibly explained by post-fall clinical counselling raising awareness after the event, rather than low awareness causing the fall; the cross-sectional design cannot distinguish these directions of effect. Beyond the design’s inherent inability to establish causality, several data-completeness issues should be acknowledged. Comorbidity variables were captured for only 6 of 157 records and could not be meaningfully analysed; education was recorded for 91 (58.0%); and item-level awareness responses were available for only 57 (36.3%), meaning the domain-wise results rest on a considerably smaller and potentially non-representative subset of the full cohort. Single-centre, orthopaedic-department-only recruitment also limits generalisability to the wider community-dwelling elderly population, who likely have a lower baseline fall burden and possibly different awareness levels than this hospital-based, fall-enriched sample. These findings carry practical implications. Rather than relying on generic risk-factor education alone, healthcare providers — including orthopaedic surgeons, physicians, nursing staff, and physiotherapists — could meaningfully close the largest identified gap by routinely informing elderly patients, at every encounter, that formal fall-risk assessment, physiotherapy, and dedicated fall-prevention services are available and how to access them.

Among 157 elderly patients attending a tertiary care orthopaedic department in Mandya, awareness of fall prevention was inadequate in nearly two-thirds (65.6%), with a mean awareness score of just under 60%. While patients had moderate awareness of fall risk factors and basic preventive measures, awareness of available healthcare resources for fall prevention — clinical risk assessment, physiotherapy, and dedicated fall-prevention services — was markedly poor, identifying this as the single most actionable gap. Awareness trended lower with increasing age and lower educational attainment, though these associations were only borderline significant in this sample. Given that over three-quarters of participants had already experienced a fall, these findings support incorporating structured, resource-focused fall-prevention education and routine fall-risk screening into every geriatric encounter in the orthopaedic OPD/IPD setting, rather than relying on patients’ spontaneous awareness of when and where to seek help.

Data availability statement

The data supporting the findings of this study are available from the corresponding author on reasonable request.

Author contribution

Mohith Rajeek K: conceptualisation, data collection, data analysis, and drafting of the manuscript. Shamanth KS: study design and supervision, critical revision of the manuscript, and final approval of the version to be published. Amogh SR: literature review, data interpretation, and review of the manuscript.

Financial support and sponsorship

Self

Conflicts of interest

There are no conflicts of interest.

Acknowledgement

The authors thank the Department of Orthopaedics and the Institutional Ethics Committee, Mandya Institute of Medical Sciences, Mandya, for their support, and gratefully acknowledge all the elderly patients who voluntarily participated in this study.

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