How to prevent falls in patients with dementia?

Preventing Falls in Patients with Dementia

Implement a personalized multimodal intervention that prioritizes medication review (especially psychotropic reduction), balance and strength training exercises, management of orthostatic hypotension and cardiovascular disorders, and treatment of depression—these are the evidence-based interventions that reduce fall rates and improve outcomes in dementia patients. 1

Risk Assessment

Conduct a thorough fall risk assessment that includes:

• History of falls in the preceding 12 months (increases fall risk 2.5-fold in dementia) 2
• Current medications, particularly psychotropic drugs 1
• Symptomatic orthostatic hypotension (doubles fall risk) 2
• Depression screening using a short, simple tool 1
• Gait and balance evaluation using validated assessment tools 1
• Autonomic symptoms assessment 2
• Visual and hearing impairment screening 1
• Environmental hazards and use of walking aids 1

Patients with dementia experience nearly 8 times more falls than cognitively intact older adults, with Lewy body disorders carrying the highest risk (3.3-fold increased hazard). 2

Core Interventions That Reduce Falls

1. Medication Review and Reduction (Highest Priority)

Review and modify all medications, with particular attention to:

• Psychotropic medications (benzodiazepines, antipsychotics, antidepressants, anticholinergics) 1
• Patients taking 4 or more medications 1
• Opioids 1

Psychotropic medications show consistent association with falls across all settings, and medication reduction was a prominent component of effective fall-reducing interventions in multifactorial studies. 1 Use STOPP/START or Beers criteria to identify potentially inappropriate medications. 1

2. Exercise and Physical Activity Programs

Prescribe long-term exercise programs that include:

• Balance training as a core component 1, 3
• Strength training for lower extremities 1
• Aerobic exercise 1
• Gait and stability training 1

Exercise interventions reduce falls by 23% (655 vs 850 falls per 1000 patient-years), with balance and functional exercises showing the strongest evidence. 3 Higher levels of physical activity are protective (17% risk reduction per activity point). 2

3. Cardiovascular and Autonomic Management

Assess and treat:

• Symptomatic orthostatic hypotension (measure postural blood pressure and pulse) 1, 2
• Cardiac arrhythmias 1
• Autonomic symptoms (each point increase on autonomic symptom scale increases fall risk by 5.5%) 2

Management of postural hypotension was part of effective interventions in multiple Class I studies. 1

4. Depression and Mood Disorder Treatment

Screen and treat depression systematically:

• Use a short, simple depression screening tool 1
• Each point increase on Cornell depression score increases fall risk by 5.3% 2
• Treatment improves physical function and quality of life 1

5. Sensory Impairment Correction

Address vision and hearing deficits:

• Refer for cataract surgery when indicated (reduces falls by 32%) 3
• Optimize hearing aids and visual correction 1, 4
• Visual impairments are linked to cognitive decline, social isolation, and poor rehabilitation outcomes 1

6. Environmental Modifications (For High-Risk Patients Only)

Implement home safety assessment with facilitated modifications for patients at high risk:

• Home assessment by occupational therapy with direct intervention and referrals 1
• Remove hazards, improve lighting, ensure appropriate footwear 4
• Environmental interventions reduce falls by 39% in high-risk groups (number needed to treat = 4) 5

Critical caveat: Home environmental modification alone without other interventions shows equivocal or no benefit. 1 Advice alone about fall risk factors without implementation measures is ineffective. 1

What Does NOT Work (Avoid These Approaches)

• Advice alone without measures to implement recommended changes 1
• Self-management programs without professional intervention 1
• Environmental modifications alone without comprehensive assessment 1
• Staff education programs alone in acute hospital settings 1

Implementation Algorithm

Step 1: Immediate medication review—reduce total medications if ≥4 drugs, discontinue or minimize psychotropic medications 1

Step 2: Targeted medical assessment focusing on orthostatic hypotension, cardiovascular disorders, depression, and sensory impairment 1, 2

Step 3: Physical therapy referral for balance training, gait training, and strength exercises 1, 3

Step 4: For high-risk patients (history of falls, Lewy body disorders, symptomatic orthostatic hypotension), add facilitated home assessment with occupational therapy 1, 5

Step 5: Ongoing monitoring and sustained compliance with interventions (required for effectiveness) 1

Special Considerations for Dementia

Patients with Lewy body disorders (DLB, PDD) have 3.3 times higher fall risk than other dementia types and require particularly aggressive intervention. 2 The combination of cognitive impairment and frailty creates higher fall risk than either condition alone, necessitating comprehensive multimodal approaches rather than single interventions. 1