July 07, 2021
Granted, falling may not be a “behavior” per se – but it often occurs as results of behavior, and it can offer valuable clues as to unmet needs in a person with dementia.
People with dementia tend to fall more often – and receive more serious injuries – than cognitively healthy older adults.
Although many fall risk factors are related to other underlying conditions – not necessarily the dementia itself – changes in cognition can increase and complicate the chances of falling.
Dementia can affect a person’s ability to accurately judge the safety of a situation, realize or remember their limitations, and recognize or communicate their needs.
Perhaps they are falling as a result of restlessness (which can be caused by pain, constipation or other sources of discomfort).
They may be falling because they are malnourished or dehydrated (because they’re forgetting to eat and drink, or because of swallowing difficulties or oral pain).
They might be exhausted due to insomnia (stemming from anxiety, distressing delusions or depression.)
By looking at each fall as a message – a piece of a puzzle – we can identify needs that we may have otherwise overlooked. We’ll have to dig a little to get to the root of the problem, but when we do, we can respond meaningfully and effectively. By addressing unmet needs, we can reduce the likelihood of another fall – and we can often improve their mood, functioning, and quality of life in the process.
It’s important to take every fall seriously. After all, the only difference between a non-injury fall and a serious, life-changing one is a random bit of luck. Even near-falls should be taken as red flags and precious opportunities to enact interventions that can potentially prevent a future catastrophe.
We should do as much as we can to prevent falls in the first place with a fall risk evaluation. Then, after every fall that may occur, it’s important to review the circumstances to determine what may have led up to it – and what we can do to reduce the chances it will happen again.
There are several fall risk evaluation forms available online for use in different circumstances. These can help identify where the risks lie so we can come up with plans to minimize them.
We should endeavor to address each risk identified. Some risk factors are pretty straightforward to address. Tripping hazards, worn out shoes or a lack of supportive equipment can be corrected.
However, other risk factors are trickier to figure out. Even if the risk factor can’t be changed – such as a history of falling – there are often interventions that can be identified. Brainstorming with a partner or team can be helpful in developing a plan. Some of the fall risk evaluation forms provide some ideas for interventions.
Take a look at ABC Dementia’s Fall Risk Factors and Sample Interventions Table for some ideas.
When a person with dementia in our care does fall, it’s important to look at the circumstances surrounding the event. It’s very helpful to do this with a partner or a team, if possible, so we can benefit from various points of view.
It’s also great practice to keep a record of falls and circumstances so that over time we can identify patterns that can reveal extremely helpful clues as to the nature of the cause of the fall.
It’s easy to look at a fall and see the surface-level reason that they fell.
Example: Maria fell because she was trying to get out of her wheelchair without the brakes on.
Unfortunately, unless we dig a little deeper, we’re likely to miss the true cause at the root of the problem. Experts recommend that we ask ourselves “Why” at least five times to uncover the root cause.
Why did Maria fall?
- She was trying to get out of the wheelchair and the brakes were off.
Why was she trying to get out of the wheelchair?
- She needed to use the bathroom.
Why did she need to use the bathroom?
- She hadn’t been to the bathroom in several hours.
Why were the brakes off on her wheelchair?
- She didn’t remember to engage them.
Why didn’t she remember to engage them?
- She’s been becoming more forgetful lately.
Why has she been more forgetful lately?
- She hasn’t been sleeping well.
Why hasn’t she been sleeping well?
- She tosses and turns and seems restless.
Why is she restless?
- Her back has been hurting more.
Why is her back hurting more?
- It’s been hurting more since she stopped taking her pain medication.
Why has she stopped taking her pain medication?
- She said it gives her a stomach ache and declines to take it.
When we ask a number of questions to dig down into the root of the issue, we can see that there are a couple potential interventions worth trying. We can create or update her toileting schedule, and make a point to help her to the toilet more often. We can also follow up on the problem with her back pain (and probably investigate her stomach ache further – does it hurt only after taking this medication, or other times as well? Is she taking the med with food?) We can bring the pain and stomach concerns to her doctor’s attention. Once resolved, she should be able to sleep better, which may in turn allow her to think and function at her fullest again.
Without the full investigation, and following the “why’s” to the root of the problem, we wouldn’t have had the information we needed to stop the falls. We would probably be stuck trying in vain to remind her not to get up, and believing there was nothing further that could be done. Maria would have likely continued to hurt, miss sleep, and fall until something was bad enough to change the course of this pattern – perhaps a fall with fracture or hospitalization.
By paying attention to the underlying message her non-injury fall was communicating, we were able to reduce the chance of it recurring, as well as address her unmet needs of pain relief and sleep.
It can be a lot easier to ace the process of the five “whys” in a fictional example than in real life. We have to find the right questions – which can take a little practice in and of itself. We then have to make our best guesses at the answers, and we often are left having to test out our theories to see if we were right.
It’s very helpful, if not downright essential, to have a number of people contribute to the process of brainstorming and root cause analysis. Engage various staff from different shifts. If you’re at home without caregiving help, talk to the doctor, social worker, therapist, day program staff, friends, family members, or anyone else you can find for your care support team.
Keep a running log of falls, the circumstances surrounding them, and interventions tried so far to uncover patterns which can shed light on the matter.
Tracking falls and their circumstances can provide clues as to what may be contributing to falls in the first place, and therefore what we can do to reduce the chances of recurrence.
Make a note of the date, time and location of the fall. Be detailed regarding the location, for example:
“Foot of the bed”
“Near sink in bathroom”
“In front of the recliner in the living room”
It’s not always obvious which circumstances are relevant, but we can do our best to gauge this.
“She was trying to get out of a wheelchair without engaging the brakes” is a basic circumstance. It can help to add more detail if possible. “She was napping in her wheelchair, and hadn’t been to the bathroom in three hours” provides a little more to work with as far as identifying patterns later on.
For example, if we notice she’s napping in her wheelchair frequently, or at a particular time of day, we can start to anticipate the need. We can help her to bed for a nap as part of her daily routine. If we notice she’s rushing to the restroom, we can help her get there routinely, before it becomes urgent.
Helpful details to note can include:
- What was their mood?
- Any new medications? When were medications last given?
- When were they last to the toilet?
- When was their last bowel movement?
- Type and location of injury, if any
- Type of footwear
- What did the person say happened?
- What did the first people who responded to the fall think might help?
Making a note of dates and details of interventions can help track which may be making an impact.
See ABC Dementia’s Fall Risk Factors and Sample Interventions table for an assortment of suggested interventions for various common fall risk factors. In the meantime, read up on a few of the top contributors to falls in people with dementia: footwear, rushing to the restroom and untreated pain.
In 2019, a team of Dutch doctors and scientists set out to discover what constitutes proper footwear for older adults. By systematically reviewing 57 separate studies on the subject they came up with some compelling evidence that shows that wearing the proper footwear is incredibly important to reducing fall risk in seniors. What’s more, proper footwear powerfully impacts pain levels in the feet, legs and back – and actually has been shown to increase social functioning and overall quality of life!
- Wide, firm outsoles for a wide base of support
- Little to no heel (if present, it should be broad and less than one inch in height)
- Enclosed heel back
- Supportive insoles
Supportive insoles reduce the risk of falling by improving balance, gait and postural stability. Postural stability also reduces misalignment, which results in pain and discomfort. Supportive insoles also reduce energy exertion, which can reduce fatigue, improve activity tolerance and promote healthy physical activity levels.
- Lack of non-slip tread, or tread that has worn out
- Floppy slippers or sandals, or those that are loose, worn out or easy to stumble over
- Backless shoes or slippers
- Heavy shoes, which can be hard to walk in, and contribute to fatigue and stumbling
- Poorly fitting shoes
Amazingly, up to 83% of seniors are wearing the wrong size shoe! This is due in part to the fact that our feet change over time. Older feet lose fat and muscle in their feet, and tend to change in length and width. In addition, many change shape with various medical conditions, including vascular disease, diabetes and rheumatoid arthritis. When seniors wear the same shoes for many years – or buy shoes based on their perceived size without actually measuring their feet – they often end up in shoes that don’t fit well.
Shoes that are too small lead to foot pain, while shoes that are too large adversely affect balance.
Generally speaking athletic shoes with a wide base of support and adjustable velcro closures are the safest option. (Watch out for shoes with extra-large soles and excessive traction, which may “stick” to carpet, actually increasing their risk for stumbling, especially if the person has a tendency to drag or shuffle their feet.)
The Dutch study also found that walking barefoot increases the risk for falling, not only because of the potential for slipping, but also because it affects our posture and balance. Non-slip socks may be better than nothing, but they can’t compete with a well-fitting, supportive, closed-back pair of slippers!
Creating a toileting schedule can make a big difference in restroom-related falls because they can reduce the need to rush. Bathrooms can be dangerous places, with their hard, potentially slippery surfaces. When someone is in a rush they may be more likely to slip on a bit of water or powder on the floor, or skip safety steps, like putting on shoes.
Rushing to the restroom is common first thing in the morning, or when it’s been a while since the last visit. Urinary urgency can also result from diuretic medication, such as Lasix (furosemide) or certain blood pressure medications. People also tend to feel desperate to get to the toilet when they have had laxative medication or have loose stools for other reasons.
Toileting schedules are individualized plans to assist someone to the restroom on a schedule based on their unique needs. “Assistance to the restroom” may mean anything from gentle reminders to complete care.
Pay attention to the person’s patterns when it comes to using the bathroom and customize the schedule to those needs. For example, a simple schedule reflective of times that people commonly use the restroom could be as follows:
- Upon rising
- After breakfast
- Before lunch
- After lunch
- Before dinner
- After dinner
- Before bed
Add to or adjust this to their unique needs.
It’s a good idea to let people sleep throughout the night to the extent possible when they have dementia, as interrupted sleep can severely impact their ability to function.
Briefs designed for overnight use can keep skin dry for up to 8 hours (although they do need to be changed for bowel incontinence).
If we notice that someone is getting up on their own to use the bathroom in the night, or is rushing to the restroom in the morning, we should plan to assist them just prior to that time. For example, if someone routinely gets up around midnight and 5:00 a.m., we may want to wake them up around 11:30 and 04:30.
Pain is terribly under-recognized and under-treated in people with dementia, in part because they often have trouble communicating, or even recognizing it themselves. However, this doesn’t mean that they aren’t affected by it! Pain is at the core of a surprising amount of behavioral challenges, negative moods, and functional decline.
One of the reasons that pain can be hard to identify in someone with dementia is that they often won’t mention it, and may even deny it outright when asked. In many cases, it’s more effective to gauge their non-verbal signs of pain using a pain assessment tool designed for detecting pain in people with advanced dementia, such as the PAINAD.
Some key signs of potential pain in someone with dementia include:
- Distressed pacing
- Tense or rigid body posture
- Fists clenched
- Striking out
- Pulling or pushing someone away
- Grimacing, frowning or appearing sad or frightened
- Repeatedly calling out in distress
- Negative or disapproving speech (including muttering, whining, grumbling, swearing, complaining, sarcasm, caustic tone)
- Moaning or groaning
- Labored breathing
Pain can cause restlessness because it can be hard to stay in one position when we hurt. It can compel us to keep moving beyond the point of fatigue. Our muscles tire and our cognition fades further.
Pain frequently interferes with both sleep and appetite. Without sleep we’re exhausted, often fumbling about or making poor decisions. Without eating properly our bodies lose strength. We grow weaker, more frail, and more prone to falling.
Pain can cause our bodies to become rigid, and keep us from being active. We lose strength and flexibility. The deconditioning increases our fall risk in and of itself, and also puts us at higher risk for depression, sleep disturbance and continuing a vicious cycle.
Painful knees and backs can give out, resulting in falls. Painful feet and legs can alter our gait, affecting our balance, and putting us at risk for falling directly, as well as for developing more pain which just adds to the problem.
When pain is suspected but not confirmed, an analgesic pain medication trial, such as is outlined at GeriatricPain.org can be helpful.
It used to be that restraining someone for “their own good” was common practice. Sometimes, people still wonder if it wouldn’t be better to seatbelt someone to a chair or raise rails on a bed to keep them from falling out.
However, physical restraints have been shown to lead to a number of serious problems, including:
- Decreased circulation
- Cardiovascular stress
- Muscle atrophy
- Pressure ulcers
- Functional decline
- Social isolation
- Reduced appetite
- Behavioral changes
- Resistance to care or treatment
- Psychiatric problems
- Serious injuries
In the case of bed rails, there is a substantial risk of entrapment, as well as a heightened risk of serious injuries from falls as the person with dementia crawls over the rail to escape from bed.
These outcomes are very often much worse in the big picture than the fall themselves. Studies show that with an appropriate approach, restraint is rarely necessary. It just takes a bit of determination, some knowledge of best practices and some familiarity with the individual’s routines, preferences and idiosyncrasies to find an answer that works.
Anticipating their needs – and recognizing behavior as communication of these needs – is key to finding a safe solution to the challenge.
Any unmet need can make dementia symptoms worse. Pain, fear or anxiety resulting from a fall can interfere with sleep, appetite, cognition and overall functioning.
They can also lead to secondary effects which can further worsen the situation. For example, if medications are needed to control pain it can come with side effects. If dehydration occurs due reduced fluid intake resulting from changes in appetite or mobility it can also affect cognition, strength and functioning.
If we’re attentive – and a little lucky – we can identify and meet any needs as early as possible in the process to prevent complications from becoming bigger problems or permanent functional decline.
Like most problems in dementia care, we want to be as proactive as possible in solving them, and we aim to prevent them whenever possible!