Falls are among the most common and clinically significant adverse events in older adults and are increasingly recognized as a geriatric syndrome rather than isolated accidental injuries. They arise from complex interactions between biological ageing, frailty, sarcopenia, impaired mobility, cognitive dysfunction, sensory deficits, polypharmacy, cardiovascular Current international guidelines support a multifactorial and person-centred approach to fall prevention. The World Guidelines for Falls Prevention and Management for Older Adults recommend risk stratification, comprehensive assessment, and individualized multidomain interventions (3,4). NICE Guideline NG249 emphasizes prevention not only of falls but also of injury, disability, dependency, and mortality (5). The CDC STEADI programme provides a practical Screen–Assess–Intervene model incorporating mobility testing, orthostatic blood pressure measurement, medication review, vision assessment, and home-safety evaluation (6). However, most existing tools assess frailty, sarcopenia, cognition, medications, environmental hazards, and functional impairment separately, limiting comprehensive multidimensional risk evaluation.

A precision-based approach may improve prevention by identifying dominant fall-risk phenotypes. Frailty-dominant individuals may require comprehensive geriatric assessment and nutritional rehabilitation, sarcopenia-related falls may respond to resistance and balance training, medication-related falls require structured deprescribing, orthostatic falls need cardiovascular evaluation and hydration optimization, and environmentally mediated falls require targeted home modification.

Emerging evidence also highlights climate vulnerability and digital health as important determinants of fall prevention. Heat exposure can aggravate dehydration, orthostatic hypotension, fatigue, and medication intolerance, particularly among frail older adults receiving diuretics, psychotropic drugs, or anticholinergic medications (7). Age-related impairment of thermoregulation further increases susceptibility during extreme heat events (8). Wearable sensors, smart-home technologies, electronic health records, and artificial intelligence may support continuous mobility monitoring and early fall detection, although they should complement rather than replace comprehensive clinical assessment (9).

Accordingly, this review synthesizes evidence on established and emerging determinants of falls, including frailty, sarcopenia, polypharmacy, cognition, sensory dysfunction, orthostatic instability, environmental hazards, climate vulnerability, and digital health. It proposes the PRECISION-Falls framework (Precision Risk Evaluation for Climate-sensitive, Integrated, Sarcopenia-informed, Individualized Older-adult Fall Screening) as a conceptual multidimensional model for future fall-risk prediction and phenotype-based prevention. Importantly, this framework is not yet a validated clinical score and requires systematic item selection, Delphi consensus, psychometric evaluation, and prospective validation before clinical implementation.

Evidence Acquisition and Review Strategy

This review was conducted as a state-of-the-art narrative review to develop a conceptual framework for a future multidimensional fall-risk assessment model. The objectives were to synthesize current evidence on falls in older adults and identify clinically measurable variables for future risk prediction.

A structured literature search was performed using PubMed/MEDLINE, Google Scholar, international guideline repositories, and professional society resources. Priority was given to international guidelines, consensus statements, systematic reviews, meta-analyses, validated assessment tools, and methodological publications, including the World Guidelines for Falls Prevention and Management, CDC STEADI, NICE, STOPPFall, and consensus statements on frailty and sarcopenia (3,5,9,10).

The search focused on two objectives: evaluating falls as a multidimensional geriatric syndrome and identifying measurable candidate variables for future score development. Search terms included falls, frailty, sarcopenia, cognition, dual-task gait, fall-risk-increasing drugs, orthostatic hypotension, sensory impairment, environmental hazards, climate vulnerability, digital health, wearable technologies, artificial intelligence, and fall prediction.

Evidence was synthesized into ten clinically relevant domains: fall history; frailty; sarcopenia and mobility; polypharmacy; cognition; sensory function; orthostatic and hydration status; environmental hazards; climate vulnerability; and social or digital monitoring. Landmark studies were retained for established concepts, while recent literature was prioritized for emerging areas such as climate change, digital health, and implementation in low-resource settings.

Methodological quality was guided by the SANRA framework for narrative reviews (11). Although this was not a systematic review, PRISMA 2020 principles informed transparent reporting of the search strategy (12), while Joanna Briggs Institute critical appraisal principles were considered during evidence evaluation (13). The proposed PRECISION-Falls Score should therefore be regarded as a conceptual research framework, not a validated clinical instrument.

Falls as a Geriatric Syndrome

Falls in older adults are increasingly recognized as a geriatric syndrome resulting from the interaction of multiple physiological, functional, cognitive, environmental, and social factors rather than a single disease. Like frailty and delirium, falls reflect accumulated vulnerability and often indicate underlying multisystem impairment rather than isolated accidental events.

Unlike younger adults, falls in older individuals usually occur in the presence of frailty, sarcopenia, impaired balance, sensory deficits, cognitive impairment, orthostatic hypotension, medication effects, dehydration, or environmental hazards. Therefore, labelling a fall as merely mechanical may overlook important modifiable risk factors requiring comprehensive assessment.

The World Guidelines for Falls Prevention and Management recommend routine fall-risk screening, multifactorial assessment, and individualized multidomain interventions for high-risk older adults (3,4). Rubenstein similarly described falls as multifactorial events associated with increased morbidity, mortality, institutionalization, and healthcare utilization, with many contributing factors being identifiable and modifiable (14).

Falls commonly occur when acute triggers such as illness, medication changes, dehydration, heat exposure, or nocturnal toileting interact with underlying vulnerabilities including frailty, sarcopenia, cognitive decline, visual impairment, or poor social support. Effective assessment should therefore identify both the immediate trigger and the underlying vulnerability profile.

Fall outcomes also vary according to individual resilience. Frailty, osteoporosis, anticoagulant use, delayed rescue, and limited rehabilitation influence not only fall occurrence but also injury severity and functional decline. Accordingly, NICE NG249 emphasizes preventing injury, disability, loss of independence, and mortality in addition to reducing falls (5).

Recognizing falls as a geriatric syndrome supports phenotype-based prevention, in which interventions are tailored to dominant risk profiles such as frailty, sarcopenia, polypharmacy, cognitive impairment, orthostatic instability, environmental hazards, and climate vulnerability. This concept underpins the PRECISION-Falls framework, which integrates biological, functional, pharmacological, environmental, and social domains for future fall-risk prediction.

Epidemiology and Clinical Burden of Falls in Older Adults

Falls are a major global public health problem and a leading cause of injury, disability, and mortality among older adults. Beyond the immediate event, they contribute to fractures, head injuries, fear of falling, functional decline, hospitalization, institutionalization, loss of independence, and substantial socioeconomic burden.

According to the World Health Organization, approximately 684,000 fatal falls occur annually, making falls the second leading cause of unintentional injury-related deaths worldwide. More than 80% of these deaths occur in low- and middle-income countries, while 37.3 million falls require medical attention each year (1). The Global Burden of Disease Study 2021 reported a 174.08% increase in fall-related deaths among adults aged ≥65 years between 1990 and 2021, reaching 555,539 deaths globally; although women experience more falls, mortality is generally higher among men (15).

In the United States, the CDC estimates that more than 14 million older adults, or one in four adults aged ≥65 years, fall annually (2). In 2021, 38,742 fall-related deaths were reported, and approximately 37% of falls resulted in injuries requiring medical care or activity restriction (16).

The burden of falls increases with ageing because frailty, sarcopenia, multimorbidity, polypharmacy, impaired balance, cognitive decline, and environmental hazards frequently coexist. Falls are associated not only with fractures and traumatic brain injury but also with fear of falling, reduced mobility, social isolation, caregiver dependence, increased healthcare utilization, and mortality (14).

Because fall risk changes after acute illness, hospitalization, medication modification, dehydration, or environmental change, assessment should be continuous rather than episodic. This is especially relevant in low- and middle-income countries, where limited rehabilitation services, environmental hazards, and climate-related stressors may further increase vulnerability. These trends support the need for multidimensional risk-assessment models that identify both fall probability and modifiable determinants of injury.

Existing Fall-Risk Assessment Tools and the Role of Frailty

Fall-risk assessment has evolved from subjective clinical judgement to structured screening, functional testing, and multifactorial evaluation. Since many older adults do not spontaneously report falls or fear of falling, standardized assessment is essential for identifying individuals requiring targeted intervention. However, most existing tools evaluate selected risk components and do not fully integrate the domains required for precision-based prevention.

The CDC STEADI programme remains one of the most widely used clinical frameworks, following a Screen–Assess–Intervene approach that incorporates fall history, gait and balance assessment, muscle strength, orthostatic blood pressure, medication review, vision, footwear, and home-safety evaluation (17). The Stay Independent Questionnaire identifies individuals at increased risk using patient-reported factors, with a score of ≥4 indicating elevated fall risk (18). Performance-based tests such as the Timed Up and Go test, 30-Second Chair Stand Test, and Four-Stage Balance Test provide objective assessment of mobility and balance but do not adequately capture cognition, frailty, medication effects, or environmental influences (19).

The World Guidelines for Falls Prevention and Management and NICE NG249 recommend comprehensive multidomain assessment incorporating fall history, gait, balance, strength, cognition, medications, vision, cardiovascular status, orthostatic hypotension, functional ability, and environmental hazards (3-5). Despite these advances, current tools give limited attention to frailty, sarcopenia, polypharmacy, cognitive-motor impairment, climate vulnerability, delayed rescue, and digital monitoring, limiting their ability to support phenotype-based prevention.

Frailty represents the biological foundation of fall risk. Unlike chronological age, frailty reflects reduced physiological reserve and explains why individuals of similar age differ markedly in mobility, resilience, and recovery. The Fried Frailty Phenotype defines frailty using five criteria—weight loss, exhaustion, weakness, slow gait, and low physical activity—while the Clinical Frailty Scale provides a practical global assessment of functional vulnerability (20,21). Meta-analytic evidence confirms frailty as an independent predictor of falls (22).

Frailty contributes to falls through weakness, impaired gait, reduced endurance, malnutrition, and diminished physiological reserve, while also increasing the risk of fractures, hospitalization, functional decline, and loss of independence after a fall. Importantly, frailty is dynamic and potentially reversible through resistance exercise, nutritional optimization, medication review, and comprehensive rehabilitation.

Because frailty interacts with sarcopenia, polypharmacy, cognitive impairment, orthostatic hypotension, environmental hazards, and climate-related stress, it should be considered a central component of multidimensional fall-risk assessment. Building on existing tools, the PRECISION-Falls framework integrates frailty with biological, functional, pharmacological, environmental, and social determinants to support future phenotype-based fall-risk prediction.

Sarcopenia, Mobility and Balance

Sarcopenia is a major contributor to falls, characterized by progressive loss of muscle strength, muscle mass, and physical performance, leading to impaired mobility, balance, and recovery from postural perturbations. As a potentially reversible condition, it represents one of the most measurable and modifiable domains of fall risk.

The EWGSOP2 defines low muscle strength as the primary indicator of probable sarcopenia, confirmed by reduced muscle quantity, with poor physical performance indicating severe sarcopenia (10). Recommended cut-offs include grip strength <27 kg in men and <16 kg in women, chair-stand time >15 seconds, gait speed ≤0.8 m/s, and SPPB ≤8, providing objective and reproducible measures for routine practice.

The SARC-F questionnaire is a practical screening tool, with a score ≥4 indicating probable sarcopenia; however, objective measures such as grip strength, gait speed, and chair-stand performance improve diagnostic accuracy (23). A systematic review and meta-analysis confirmed that sarcopenia significantly increases the risk of both falls and fractures (24).

Mobility assessment complements sarcopenia evaluation because most falls occur during standing, turning, stair climbing, or walking. The Short Physical Performance Battery provides a validated measure of lower-extremity function (25), while gait speed and the Timed Up and Go test assess mobility, balance, and transfers. A TUG time ≥12 seconds indicates increased fall risk but should be interpreted alongside frailty, cognition, medication use, orthostatic status, and environmental factors (19).

Although closely related, frailty and sarcopenia are distinct. Frailty reflects global physiological vulnerability, whereas sarcopenia specifically affects muscle function. Consequently, sarcopenia-related fall risk may respond particularly well to progressive resistance exercise, balance training, nutritional optimization, and management of underlying medical conditions.

For the proposed PRECISION-Falls framework, candidate variables include SARC-F score, grip strength, chair-stand performance, gait speed, SPPB, TUG, inability to rise without arm support, and walking-aid use. These measures are clinically feasible and evidence-based but require prospective validation before incorporation into a predictive scoring system.

Overall, sarcopenia, impaired mobility, and balance dysfunction are highly actionable determinants of fall risk and should form core components of multidimensional fall-risk assessment and precision-based prevention.

Polypharmacy and Fall-Risk-Increasing Drugs

Medication-related factors are among the most modifiable determinants of falls in older adults. Although polypharmacy is common because of multimorbidity, medication type is often more important than medication number, as a few high-risk drugs may increase fall risk more than multiple well-tolerated medications.

Fall-risk-increasing drugs (FRIDs) include benzodiazepines, sedatives, antidepressants, antipsychotics, opioids, antiepileptics, antihypertensives, diuretics, α-blockers, anticholinergics, and hypoglycaemia-inducing medications. These drugs impair cognition, balance, gait, postural stability, or blood pressure regulation, particularly in frail or sarcopenic older adults.

The World Guidelines for Falls Prevention and Management recommend structured medication review as part of routine fall-risk assessment (3). Similarly, the STOPPFall consensus and European position paper identify major FRID classes and provide deprescribing guidance, emphasizing drug class, indication, dose, interactions, cumulative burden, and recent medication changes rather than medication count alone (9,27).

Medication-related risk is amplified by frailty, dehydration, acute illness, and heat exposure. Falls may occur after medication initiation, dose escalation, or therapeutic modification, highlighting the need to review both current treatment and recent prescribing changes. Heat-related dehydration may further increase adverse effects of diuretics, anticholinergic agents, psychotropic medications, and ACE inhibitor/ARB–diuretic combinations (7).

Within the PRECISION-Falls framework, medication assessment should include FRID exposure, psychotropic and anticholinergic burden, opioid or antiepileptic use, antihypertensive or diuretic therapy associated with postural symptoms, hypoglycaemia-risk medications, recent medication changes, and heat-sensitive drug combinations. These variables are clinically measurable, modifiable, and suitable for future validation.

Overall, structured medication review and individualized deprescribing are essential components of precision-based fall prevention and should complement biological, functional, and environmental risk assessment.

Cognition, Dual-Task Gait and Neurogeriatric Fall Risk

Falls are not solely musculoskeletal events but also reflect impaired cognitive-motor integration. Safe mobility requires attention, executive function, visuospatial ability, judgement, reaction time, and environmental awareness. As cognitive reserve declines, walking becomes increasingly attention-dependent, making cognitive impairment and dual-task dysfunction important determinants of fall risk.

Many falls occur during multitasking, such as walking while talking, carrying objects, turning, or negotiating obstacles. Impaired executive function reduces the ability to adapt gait to changing environments, and systematic review evidence shows that executive dysfunction and poor dual-task performance are associated with increased fall risk (28).

Dual-task gait assessment, in which walking is combined with a cognitive task, can reveal cognitive-motor deficits not detected during routine gait assessment. Reduced gait speed, increased gait variability, or instability during dual-task testing reflects impaired brain–body integration. Montero-Odasso et al. demonstrated the relationship between gait, cognition, and fall risk, while Ramírez et al. identified dual-task gait as a promising marker of early cognitive impairment (29,30).

Cognitive impairment increases fall risk through impaired judgement, attention, visuospatial dysfunction, delirium, dementia-related wandering, and poor adherence to assistive devices. Depression and fear of falling may further contribute to gait instability and reduced physical activity (31). Caregiver reports are particularly valuable because cognitively impaired individuals may underreport falls or provide unreliable histories.

Although the Timed Up and Go test assesses functional mobility, dual-task gait or cognitive TUG may improve detection of subtle cognitive-motor impairment (19). Accordingly, the World Guidelines recommend cognition as an essential component of multifactorial fall-risk assessment (3).

Within the PRECISION-Falls framework, the cognitive domain includes cognitive impairment, delirium, caregiver-reported unsafe judgement, dual-task gait impairment, wandering, fear of falling, and depression-related psychomotor slowing. Basic assessment may rely on history and caregiver reports, while advanced versions may incorporate dual-task gait measures or wearable-derived cognitive parameters.

Overall, integrating cognition and dual-task gait into multidimensional fall-risk assessment provides a more comprehensive approach to identifying high-risk older adults and supports individualized prevention beyond traditional physical performance testing.

Sensory, Vestibular, Vision and Foot-Related Risk

Balance depends on the integrated function of visual, vestibular, somatosensory, and musculoskeletal systems. Impairment of one or more of these systems reduces postural stability and increases fall risk, making sensory function a key component of multidimensional fall-risk assessment.

Visual impairment limits obstacle detection, depth perception, and environmental navigation. Cataract, glaucoma, macular degeneration, refractive errors, and poor lighting are recognized risk factors. The CDC recommends regular eye examinations, vision correction, and environmental modification to reduce falls (32). Recent evidence also confirms that distance and near vision impairment, as well as glaucoma, independently increase fall risk (33).

Dizziness and vestibular dysfunction may result from vestibular disorders, orthostatic hypotension, medications, neurological disease, or dehydration. A systematic review involving more than 100,000 older adults found that dizziness significantly increased the risk of future and recurrent falls, supporting vestibular, cardiovascular, neurological, and medication assessment (34).

Peripheral neuropathy, foot pain, deformity, arthritis, and inappropriate footwear impair gait and balance by reducing plantar sensation and altering foot mechanics. Properly fitted, slip-resistant footwear may improve stability and reduce fall risk (35).

These deficits often interact with environmental hazards such as poor lighting, uneven surfaces, or slippery floors. The World Falls Guidelines and CDC STEADI therefore recommend assessment of vision, dizziness, feet, footwear, gait, balance, and home hazards as part of comprehensive fall-risk evaluation (3,6).

Within the PRECISION-Falls framework, this domain includes vision impairment, dizziness or vertigo, peripheral neuropathy, reduced plantar sensation, foot disorders, unsafe footwear, recurrent tripping, and poor-lighting-related falls. These factors are identifiable and potentially modifiable through vision care, vestibular rehabilitation, foot management, footwear optimization, and environmental modification.

Overall, sensory and foot-related impairments are common, clinically detectable, and modifiable determinants of falls and should form an integral component of multidimensional fall-risk assessment.

Orthostatic, Cardiovascular and Hydration-Related Falls

Falls in older adults should not be assumed to be purely mechanical, as many result from orthostatic hypotension, cardiovascular instability, dehydration, medication effects, syncope, or acute illness. These mechanisms are common, clinically measurable, and often reversible, making them important targets for fall prevention.

Orthostatic hypotension is defined as a sustained fall in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg within three minutes of standing and is an important contributor to falls (36). Age-related autonomic dysfunction, frailty, diabetes, Parkinsonism, dehydration, antihypertensive therapy, and acute illness may impair postural blood pressure regulation, leading to dizziness, presyncope, or collapse. Orthostatic hypotension is also associated with fractures, cognitive decline, and mortality (37).

The CDC STEADI programme recommends routine orthostatic blood pressure measurement during fall-risk assessment because it is simple, inexpensive, and guides interventions such as hydration and medication review (6,17). However, delayed or intermittent orthostatic hypotension may be missed by a single measurement. The STURDY trial showed that both immediate and delayed orthostatic hypotension predict future falls, supporting repeated assessment when clinically indicated (38).

Other reversible causes, including syncope, cardiac arrhythmias, dehydration, hypoglycaemia, and medication-related hypotension, should be considered in older adults with unexplained or recurrent falls. Heat exposure further increases risk by aggravating dehydration and medication intolerance, particularly among individuals receiving diuretics, anticholinergic agents, psychotropic medications, or ACE inhibitor/ARB–diuretic combinations (7).

Within the PRECISION-Falls framework, this domain includes orthostatic hypotension, postural dizziness, syncope, dehydration, poor fluid intake, acute illness, nocturia, heat exposure, hypoglycaemia-related symptoms, and medication-associated postural instability. These factors support targeted interventions such as hydration optimization, medication adjustment, gradual postural changes, management of reversible conditions, and cardiovascular evaluation (39).

Overall, orthostatic, cardiovascular, and hydration-related factors are common, measurable, and modifiable contributors to falls and should form a core component of multidimensional fall-risk assessment.

Climate Vulnerability and Heat-Sensitive Falls

Climate vulnerability is an emerging contributor to fall risk in older adults. Heat exposure may exacerbate dehydration, fatigue, orthostatic hypotension, cognitive impairment, medication intolerance, and reduced physical performance, thereby amplifying existing vulnerabilities rather than acting as an isolated cause of falls. Age-related impairment of thermoregulation further increases susceptibility to heat-related instability (8).

Medication use substantially modifies heat-related risk. The CDC identifies diuretics, anticholinergic agents, psychotropic medications, and ACE inhibitor/ARB–diuretic combinations as drugs that may impair hydration, blood pressure regulation, and thermoregulation (7). Older adults receiving these medications have a higher risk of heat-related hospitalization (40), while anticholinergic medications and some β-blockers may further impair heat tolerance (42).

Population-based evidence also links ambient temperature with fall-related outcomes. A nationwide study from China involving 860,724 fall-related deaths showed that both high and low temperatures increased fall-related mortality, with stronger effects during extreme heat (41). Thus, heat acts as a risk amplifier, particularly among frail, sarcopenic, dehydrated, cognitively impaired, or polymedicated older adults.

Within the PRECISION-Falls framework, climate vulnerability includes recent heat exposure, dehydration, poor ventilation, heat-related dizziness or confusion, heat-sensitive medications, and living alone during extreme heat. Preventive strategies include adequate hydration, seasonal medication review, cooling measures, avoidance of peak heat exposure, caregiver education, and monitoring during heatwaves.

Overall, climate vulnerability is a potentially modifiable determinant of falls and should be incorporated into future multidimensional fall-risk assessment and precision-prevention models, particularly in hot-climate and low-resource settings.

Environmental and Home-Safety Determinants of Falls

Falls result from the interaction between individual vulnerability and environmental hazards. Older adults with frailty, sarcopenia, visual impairment, dizziness, neuropathy, or medication-related instability are especially susceptible to poor lighting, slippery floors, loose rugs, unsafe stairs, bathroom hazards, and inappropriate footwear. As these factors are largely modifiable, environmental assessment is a cornerstone of fall prevention.

Because many falls occur at home, hazards in bathrooms, bedrooms, corridors, kitchens, and stairways require particular attention. Wet floors, clutter, inadequate lighting, unstable furniture, low toilet seats, and absent grab bars can substantially increase fall risk but are often correctable through simple home modifications.

The World Guidelines, NICE NG249, and CDC STEADI recommend routine home-hazard assessment as part of comprehensive fall-risk evaluation (3,5,6). Supporting this, a Cochrane review showed that targeted home modifications reduced fall rates by 26% and were particularly beneficial among high-risk individuals (43). Similar findings were reported in a recent meta-analysis of individualized home-hazard interventions (44).

Environmental hazards should be interpreted in relation to functional status. Poor lighting, nocturnal toileting, slippery surfaces, inappropriate footwear, and unsafe stairs become more hazardous when combined with frailty, orthostatic hypotension, cognitive impairment, or visual deficits. Appropriate walking-aid use and caregiver involvement may further improve home safety, particularly in community and low-resource settings (45).

Within the PRECISION-Falls framework, this domain includes poor lighting, bathroom hazards, slippery floors, clutter, unsafe stairs, absence of grab bars, inappropriate footwear, unsafe transfers, walking-aid problems, outdoor hazards, and delayed rescue due to living alone. These variables are inexpensive to assess, modifiable, and directly linked to preventive interventions.

Overall, environmental modification and home-safety assessment are practical strategies for reducing falls and should be integrated with intrinsic risk assessment in multidimensional fall-prevention programmes.

Digital Health, Wearables and AI-Enabled Fall Prevention

Digital health is an emerging component of fall prevention because falls are often intermittent, context-dependent, and unwitnessed. Wearable sensors, smartphones, smart-home systems, electronic health records, and artificial intelligence can support continuous monitoring of mobility and changing fall risk, but should complement rather than replace comprehensive geriatric assessment.

Digital applications include fall detection, risk prediction, and prevention support. Wearable sensors can monitor gait speed, step count, cadence, gait variability, turning, and physical activity, providing objective markers of mobility decline. A systematic review confirmed their utility for fall-risk assessment in community-dwelling older adults (46). Smartwatches, pendant alarms, and smart-home systems may also facilitate rapid assistance after falls, reducing complications associated with prolonged immobilization.

Artificial intelligence may enhance fall prediction by integrating clinical, medication, frailty, and electronic health record data. Recent studies demonstrate the feasibility of predicting one-year fall risk using machine-learning models, although external validation remains necessary (47,48). Systematic reviews also support the potential of digital technologies for fall detection and prediction but highlight heterogeneity in current evidence (9). Future AI models should follow TRIPOD+AI reporting standards to ensure transparency and reproducibility (49).

Despite these advances, implementation is limited by cost, infrastructure, privacy concerns, digital literacy, internet access, and algorithmic bias. Therefore, digital health should strengthen rather than replace evidence-based clinical assessment (50).

Within the PRECISION-Falls framework, digital technologies are considered an optional extension. The basic model relies on clinical history, examination, medication review, and functional assessment, whereas advanced versions may incorporate wearable-derived mobility metrics, smart-home monitoring, electronic health record-based prediction, and AI-assisted risk stratification.

Overall, digital health, wearable technologies, and AI have potential to improve fall detection, risk prediction, and personalized prevention. However, rigorous validation, usability testing, privacy safeguards, and equitable access remain essential before routine clinical implementation.

PRECISION-Falls Score Domains and Precision Prevention Pathway

The proposed PRECISION-Falls framework provides a preliminary candidate item pool for future multidimensional fall-risk score development. It is intended as a conceptual research framework, not a validated clinical instrument, and requires Delphi consensus, feasibility testing, reliability assessment, and prospective validation before clinical use.

The framework has two objectives: to estimate the probability of future falls and fall-related harm, and to identify dominant modifiable risk phenotypes for individualized prevention. Candidate variables are organized into ten domains: fall history; frailty; sarcopenia, mobility and balance; polypharmacy and FRIDs; cognition and dual-task function; sensory, vestibular, vision and foot-related factors; orthostatic, cardiovascular and hydration-related factors; environmental hazards; climate vulnerability; and social or digital monitoring. Representative variables include recurrent falls, frailty severity, grip strength, gait speed, TUG, SPPB, psychotropic medication use, anticholinergic burden, dual-task impairment, orthostatic hypotension, visual impairment, unsafe footwear, poor home lighting, dehydration, heat exposure, living alone, delayed rescue, and caregiver support. Final item selection and weighting should be determined through prospective validation rather than expert opinion alone.

A major strength of the framework is its phenotype-based prevention pathway, in which each risk domain guides targeted intervention. Frailty-dominant phenotypes require comprehensive geriatric assessment, nutrition, rehabilitation, and caregiver support; sarcopenia-dominant phenotypes require resistance and balance training, physiotherapy, and protein optimization; medication-dominant phenotypes require FRID review and deprescribing; and orthostatic or cardiovascular phenotypes require hydration optimization, medication adjustment, and cardiovascular evaluation. Cognitive phenotypes benefit from caregiver-supported mobility, cognitive-motor training, and delirium prevention, while sensory and environmental phenotypes require vision care, footwear optimization, vestibular rehabilitation, and home modification. Climate-vulnerable individuals may need hydration, seasonal medication review, cooling strategies, and monitoring during heat exposure, whereas socially vulnerable older adults may benefit from caregiver planning, emergency alert systems, and wearable monitoring.

This approach is supported by evidence showing that multifactorial assessment, supervised resistance and balance exercise, Tai Chi, medication optimization, and home-hazard modification are effective fall-prevention strategies (3,51-53). Because fall risk changes after illness, hospitalization, medication modification, cognitive decline, or environmental exposure, reassessment should be dynamic rather than episodic. By linking multidimensional risk assessment with phenotype-specific interventions, the PRECISION-Falls framework provides a practical foundation for future individualized fall-risk prediction and precision prevention.

Research Gaps and Future Directions

Key Research Gaps

Several gaps remain in current fall-risk assessment. Existing models usually assess individual domains but do not integrate frailty, sarcopenia, cognition, medications, orthostatic risk, environmental factors, climate vulnerability, and delayed rescue into a single validated framework. Current approaches also identify high-risk individuals but rarely define the dominant mechanism needed to guide targeted intervention.

Further validation is required to determine the predictive contribution of clinical measures such as TUG, gait speed, grip strength, SPPB, orthostatic blood pressure, FRID burden, and home hazards. Emerging domains, including climate vulnerability, heat–medication interactions, delayed rescue, and digital monitoring, remain underrepresented in existing tools. Evidence is also limited in low-resource settings, where practical and low-cost models suitable for primary care and community-based care are needed. In addition, wearable and AI-based prediction models require real-world evaluation of accuracy, usability, privacy, equity, and cost-effectiveness.

Future Directions

Future research should develop and refine the PRECISION-Falls Score using Delphi consensus, structured item selection, and expert review. Feasibility, reliability, and acceptability should be evaluated across diverse clinical and community settings. Prospective and external validation should use standardized outcomes, including any fall, recurrent falls, injurious falls, hospitalization, long lie, fear of falling, and functional decline.

Prediction models should follow TRIPOD+AI reporting standards where applicable (49), and measurement properties should be evaluated using COSMIN methodology (54). Future studies should also determine whether PRECISION-Falls-guided interventions improve outcomes compared with usual care. Overall, the principal research gap is not the identification of fall-risk factors, but the absence of a validated, multidomain, intervention-linked prediction model.

Development and Validation Roadmap for the PRECISION-Falls Score

The PRECISION-Falls framework requires rigorous development before clinical implementation. The proposed pathway includes: defining the target population, intended outcomes, and candidate multidomain variables; selecting evidence-based items through multidisciplinary Delphi consensus; pilot testing feasibility, acceptability, administration time, and usability; assessing inter-rater reliability, test–retest reliability, content validity, construct validity, and predictive validity using COSMIN principles (54); developing an additive, weighted, or probability-based scoring algorithm; and prospectively validating the model across diverse healthcare settings using TRIPOD+AI recommendations where appropriate (49).

After validation, clinical implementation should assess workflow integration, cost-effectiveness, calibration, discrimination, decision-curve analysis, and net clinical benefit. Periodic recalibration will be required as new evidence, digital technologies, and climate-related factors emerge.

Potential clinical versions may include a basic version based on history, medication review, simple mobility assessment, orthostatic symptoms, and home-safety evaluation; an enhanced version adding frailty assessment, grip strength, gait speed, SPPB, and orthostatic blood pressure; and a digital version incorporating wearable sensors, electronic health records, AI-assisted prediction, smart-home monitoring, and climate-linked alerts. This staged approach would allow PRECISION-Falls to remain practical for routine care while supporting advanced precision-based assessment where resources permit.

This figure outlines the proposed staged pathway for developing the PRECISION-Falls Score, including conceptual framework development, item selection, Delphi consensus, pilot testing, reliability assessment, validation, model development, external validation, and clinical implementation. The framework is intended as a conceptual roadmap for future multidimensional fall-risk prediction and requires prospective validation before clinical use.

Table 1. Proposed Domains for the PRECISION-Falls Framework

Abbreviations: ADL, Activities of Daily Living; CFS, Clinical Frailty Scale; CGA, Comprehensive Geriatric Assessment; EHR, Electronic Health Record; FRIDs, Fall-Risk-Increasing Drugs; MCI, Mild Cognitive Impairment; OH, Orthostatic Hypotension; SARC-F, Strength, Assistance with walking, Rise from chair, Climb stairs and Falls questionnaire; SPPB, Short Physical Performance Battery; TUG, Timed Up and Go.

Table 2. Basic Clinical Checklist for Low-Resource PRECISION-Falls Screening

Abbreviations: ADL, Activities of Daily Living; BP, Blood Pressure; CGA, Comprehensive Geriatric Assessment; FRIDs, Fall-Risk-Increasing Drugs.

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