Risk for Falls Plan of Care
Immediate Assessment Requirements
For an elderly patient with dementia and impaired mobility, implement a comprehensive multifactorial fall risk assessment immediately, as this patient meets high-risk criteria requiring multicomponent interventions. 1, 2
History and Screening Components
Document fall history specifics: exact number of falls in past 12 months, circumstances of each fall (location, time spent on ground), presence of loss of consciousness, near-syncope symptoms, orthostatic symptoms, and any injuries sustained 2, 3
Assess gait and balance using the Timed Up and Go test: completion time >12 seconds indicates high fall risk and mandates intervention; healthy adults over 60 complete this in <10 seconds 2, 4, 5
Measure orthostatic blood pressure: check for postural hypotension as a major modifiable risk factor 2, 3
Evaluate cognitive function: use Mini-Cog or Memory Impairment Screen, as executive function deficits significantly increase fall risk in dementia patients 1, 2
Screen for depression: use PHQ-2, as late-life depression contributes to falls 2
Assess vision formally: conduct visual acuity testing, as visual impairment is a modifiable fall risk factor 2, 3
Medication Management
Conduct an immediate comprehensive medication review focusing on fall risk-increasing drugs. 1, 2, 3
Target high-risk medications for deprescribing: psychotropic medications (antipsychotics, sedative/hypnotics), antihypertensives (vasodilators, diuretics), vestibular suppressants, and anticholinergic agents 1, 2, 3
Address polypharmacy: multiple medications significantly increase fall risk and require systematic review 2, 3
Avoid specific antidepressants in dementia: do not use tricyclics due to anticholinergic burden; avoid fluoxetine due to long half-life; prefer venlafaxine, vortioxetine, or mirtazapine if antidepressants are needed 1
Physical Exercise Interventions
Prescribe supervised balance training exercises 3 or more days per week combined with strength training twice weekly. 2, 3, 4
Refer immediately to physical therapy: for gait training, balance assessment, and supervised exercise program implementation 2, 3
Include specific exercise components: aerobic training, strength training, balance and stability training tailored to individual deficits 1, 2
Consider tai chi programs: as balance-focused exercise to reduce fall risk 2
Evaluate and prescribe assistive devices: properly fitted cane or walker as indicated, with mandatory training on correct use to prevent the device itself from becoming a fall hazard 2, 5
Environmental Modifications
Arrange occupational therapy home assessment with direct intervention for environmental hazard removal. 2, 3
Remove specific hazards: eliminate loose rugs and floor clutter, ensure adequate lighting throughout the home, install grab bars in bathroom 2, 3
Recommend proper footwear: prescribe properly fitting non-skid footwear 2
Address environmental conditions: evaluate use of walking aids, assess for sensory deficits affecting navigation 1
Nutritional and Supplementation Interventions
Prescribe vitamin D supplementation at 800 IU daily to reduce fall risk. 2, 3, 4
Assess nutritional status: evaluate for nutritional deficits that contribute to muscle weakness and fall risk 1
Screen for osteoporosis: conduct DEXA scan to assess fracture risk, as dementia patients with falls are at high risk for fractures 2, 3
Dementia-Specific Considerations
Modify fall prevention interventions to accommodate cognitive deficits, communication limitations, and behavioral problems. 6, 7
Activate implicit memory systems: focus on repetitive functional activities that utilize preserved memory systems in dementia 6
Use decision-making tools: implement discussion tools that facilitate collaboration between patient, caregivers, and healthcare professionals to increase uptake of acceptable interventions 7
Prioritize commonly identified risks in dementia: address impaired balance/mobility (92% prevalence), polypharmacy (60%), and incontinence (56%) as these are most frequently rated high-risk factors 7
Provide caregiver education: implement functional maintenance programs with specific instruction on communication strategies preserved in dementia 6
Social and Psychological Interventions
Screen for loneliness and social isolation using the 3-item UCLA Loneliness Scale or open-ended questions. 1
Refer to social assistance programs: connect patient and family to local support groups, community centers, and social engagement opportunities 1
Address mood disorders: implement interventions targeting depression through physical activity, nutrition optimization, social engagement, and cognitive stimulation 1
Follow-Up and Monitoring Protocol
Schedule reassessment at regular intervals with ongoing multifactorial intervention adjustments. 2, 3
Confirm therapy appointments: verify physical therapy and occupational therapy sessions are scheduled and attended 2
Monitor for fall recurrence: this patient population is at high risk for repeated falls requiring vigilant monitoring 2, 3
Reassess gait stability: repeat Timed Up and Go test to track improvement 2
Continue medication review: ongoing evaluation and adjustment of fall risk-increasing drugs 2, 3
Maintain environmental modifications: ensure home safety interventions remain in place and effective 2, 3
Critical Implementation Pitfalls to Avoid
Do not rely on screening alone without implementing targeted interventions: assessment without intervention is ineffective 3
Do not address single risk factors in isolation: falls in dementia require multicomponent interventions addressing multiple domains simultaneously 1, 3
Do not discharge without gait assessment and intervention plan: ensure mobility evaluation and exercise prescription before care transition 3
Do not prescribe assistive devices without proper training: devices become fall hazards if patients are not trained in correct use 2, 5