Falls are, unfortunately, common among the elderly—regardless of whether they’re at home or in a healthcare facility. Many healthcare providers are faced with litigation related to elderly patients falling and injuring themselves, but familiarity with why falls happen can help providers prevent them from occurring, or document what contributed to the event.

It is estimated that more than one third of older adult admissions to nursing homes are related to falls and instability. Add dementia to the mix, and the risk of falls increases due to impaired gait, visual perception, judgment, and decreased safety awareness. Despite being a common occurrence no matter the location, falls are also a frequent trigger event for claims and litigation. In assessing falls among patients with dementia—and separating those that are caused by neglect from those that are truly accidental—it is crucial to understand the underlying issues that make falls and related injuries so common among this demographic.

Five Factors That Contribute to an Increased Risk of Falling

Age-Related Mobility: Many people become less active as they age, leading to loss of the muscle strength needed for balance and unassisted mobility. This problem can be compounded for dementia patients if the area of the brain damaged by dementia controls coordination and balance. In these cases, the risk of falls increases dramatically.

Gait: Fall risk is also impacted by gait, and the disease process of some common ailments can affect walking style. For example, arthritis may cause one to take small, slow steps to avoid pain. In dementia, gait issues may be even more pronounced. For example, some dementia patients may walk slowly, but sway side to side with small, shuffling steps to try to keep their balance. Others, particularly those with poor judgment, may take regular steps but at an increased rate of speed, which causes increased instability. Dementia patients also commonly forget to use walking aids, such as canes or walkers, leading to an even greater risk of falls.

Vision: Depending on the area of the brain affected by dementia, vision may be affected. When it is, the dementia patient may not see items in their path or in their periphery. They might trip over items on the ground, or lose balance by bumping into an unseen object.

Environment: Further, dementia patients might misinterpret their environment and fail to recognize unsafe situations, including loose rugs, uneven surfaces, and slippery surfaces. They may choose inappropriate footwear. Confused and agitated patients may get up during the night without sufficient light; if they cannot remember the location of light switches or lamps and are unfamiliar with their environment due to confusion, this can increase their risk of falling.

Medications: Finally, medications used by dementia patients can cause additional confusion. Some may also cause stiffness and rigidity, which increases the difficulty in getting up from a chair or with walking in general, creating gait and balance issues. Among the medications that could exacerbate confusion or cause balance problems are drugs for overactive bladder, allergies, vertigo, and nausea; certain antipsychotic medications; and certain drugs for nerve pain or depression. People with dementia are also more likely than other patients to fall when taking sedatives or tranquilizers. Additionally, blood pressure medications can occasionally cause blood pressure to drop when the patient stands, thus causing balance problems.

Nine Tips for Reducing the Risk of Falling

Even with recommended safety measures in place, falls cannot be completely prevented. Alarms can alert staff that a dementia patient is getting up without assistance, but if no one is in immediate proximity, the patient could fall before anyone can reach them. Additionally, prolonged restraints will weaken the patient and predispose them even further to falls; for this reason, they are discouraged from being used. However, several proactive measures can be taken to reduce fall risks:

1. Provide therapy and exercise programs that can help dementia patients maintain strength while they are still ambulatory.
2. Conduct gait evaluations to identify problems that can be addressed in therapy.
3. Encourage patients to undergo annual eye exams to determine vision problems and get proper treatment, such as corrective lenses or cataract surgery that may better enable dementia patients to identify their surroundings.
4. Ensure that the facility is adequately lighted to help dementia patients more safely navigate their environment.
5. Provide all patients and residents with safe and stable footwear.
6. Remove tripping hazards such as throw rugs, extension cords, and clutter from walking pathways.
7. Recognize what sorts of objects may pose a fall risk, such as pets for patients living in a more residential environment.
8. When possible, avoid medications that have been linked to increased falls.
9. When possible, place grab bars in showers, bathtubs, and near toilets. These are sturdy and can be grasped when patients feel themselves losing balance. Towel racks are not sturdy enough for such use.

Strategies to Encourage the Use Mobility Aids

One of the most obvious interventions to reduce fall risks—the use of rolling walkers, canes, and Merry Walkers when ambulation is increasingly difficult—is also one of the most difficult to execute. Many dementia patients are likely to forget to use their mobility aids. Therefore, it is crucial for healthcare staff to take consistent measures to encourage their use.

For patients who can still read and comprehend, the use of written notes or other visual reminders can be very useful. For patients who cannot read or comprehend written communication, verbal reminders are necessary. Caregivers should use clear instructions, one short sentence at a time, focus on the present, and observe the patient’s response to ensure that they have been understood. In any communication with dementia patients, positive approach, tone, and enforcement are keys to reducing resistance and gaining compliance.

Very often, dementia patients may simply not recognize that they need their mobility devices at all, because they may not recognize their own debility or the risks involved in not using the aids. When this occurs, caregivers should use sensitivity in finding ways to encourage their use. For instance, the caregiver might help the patient recall someone meaningful in his or her life who suffered a fall as an example of why mobility aids are necessary.

The issue of fall risk in dementia is complicated, like many issues in elder care. Not only does the disorder itself increase risk, but gaining patient compliance is often negatively impacted as well, which further increases risk. When a fall occurs, it is important to consider and document all the mitigating factors, because—as every provider knows—every fall is unintended and every injury is unfortunate, but not every fall is a symptom of neglect, especially in the presence of dementia.