Caring for Dementia

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Understanding and Preventing falls

Falls can significantly threaten the well-being of elderly individuals (with or without dementia). As we age, falls carry much more severe physical and mental consequences. Older individuals with cognitive impairments are at extremely high risk for falls, which is why fall prevention is essential. Examining fall prevention for dementia involves assessing cognitive impairment, motor skills and balance, environmental impacts, and clothing choices/accessories.

Causes for Falls

1. Cognitive Impairment:

Cognitive impairment can increase the risk of falls for those with dementia, this can have a detrimental effect on various aspects of daily functioning. As cognition declines, functions controlling the mind, including spatial awareness, judgment, altered perception, sensory impairment, disorientation, sleep disturbances, and behavioural symptoms, become compromised. Below we explore some possible ways cognitive impairment can affect falls for people with dementia.

• Spatial Awareness and Judgment:
  Cognitive decline can impair spatial awareness, introducing challenges in accurately perceiving surroundings. Spatial awareness can affect judging distances, navigating obstacles, and impacts the risk of falls. Examples of ways impaired spatial awareness can contribute to falls include: difficulties in gauging doorway widths or misjudging the proximity of furniture or objects.

• Altered Perception:
  Those with altered perception may misinterpret objects and people in their environment, this can include the tendency to perceive things inaccurately and potentially overlook hazards. Examples of altered perception are instances where a rug or a shadow on the floor could be misinterpreted as a hole, or perceiving a coat rack as a person. This disruption in visual processing increases misjudgments of surroundings, contributing to higher fall risks.

• Sensory Impairment:
  Impaired vision and hearing present additional challenges to maintaining balance and preventing falls. With impaired vision, individuals may struggle to recognize obstacles such as uneven surfaces or changes in elevation. With impaired hearing, individuals may experience a distortion in their equilibrium, disrupting balance.

• Disorientation:
  Disorientation can lead to unintended wandering and increased exposure to environmental hazards. For instance, disoriented individuals might unintentionally head towards an area with potential fall risks, such as stairs or unsuitable environments.

• Behavioural Symptoms:
  Behavioural symptoms like restlessness and physical aggression can introduce additional fall hazards. Restlessness may lead individuals to pace or move abruptly, increasing the risk of tripping over objects or losing balance. Physical aggression, if directed towards caregivers or others, may result in sudden movements, leading to accidental falls.

• Sleep Disturbances:
  Individuals experiencing sleep disturbances may encounter difficulties maintaining alertness during waking hours, contributing to slips and stumbles. Additionally, poor sleep on cognitive function may lead to slower reaction times and diminished coordination, further increasing the risk of falls.

2. Physical Aspects impacting falls:

As dementia advances, its possible that physical challenges could arise, limiting mobility and potentially increasing the risk of falls. Below we explore a few examples that relate to physical well-being and the prevention of falls.

• Deterioration in Motor Skills and Balance:
  As dementia advances, individuals commonly experience a decline in motor skills and balance. This physical deterioration makes them more susceptible to maintaining balance or tripping. For example, impaired motor skills may lead to challenges in lifting the feet properly while walking, increasing the likelihood of catching on uneven surfaces or obstacles.

• Apraxia and Impaired Movement:
  Apraxia, a neurological condition that can develop in dementia, contributes to diminishing motor skills and movement. This condition disrupts the ability to plan and execute purposeful movements, impacting activities like walking and maintaining balance. For instance, individuals with apraxia might struggle to coordinate their steps or have difficulty adjusting their balance.

• Lack of Physical Activity:
  A sedentary lifestyle can result in muscle weakness and diminished overall fitness, affecting balance and stability. Basic functions like walking, range of motion, endurance, flexibility and maintaining balance become more challenging.

• Muscle Stiffness:
  Muscle stiffness can elevate the risk of falls in individuals with dementia by limiting free movement and safe navigation. For instance, stiffness in the arms may impede one’s ability to use handrails or grab onto surfaces for support, compromising stability and increasing the likelihood of falls.

3. Clothing AND ACCESSORIES

• Footwear:
  Ill-fitting shoes, high heels, or slippery soles can compromise stability and increase the risk of falls. Encouraging supportive, well-fitted shoes with non-slip soles is crucial.
• Loose Clothing:
  Long, loose garments like skirts or baggy pants may pose a tripping hazard. Recommending well-fitted clothing that doesn’t drag on the ground can help reduce the risk of falls.
• Accessories:
  Long scarves, dangling jewelry, or accessories that may catch on objects can create a risk of entanglement and increase potential for falls. Suggesting shorter or well-secured accessories can minimize this risk.
• Slippers and Socks:
  Wearing socks or slippers without adequate traction can lead to slips on smooth surfaces. Non-slip footwear or mobility socks can enhance stability.
• Walking Aids:
  Improper use or adjustment of walking aids such as canes or walkers may contribute to falls. Ensuring these devices are correctly fitted and regularly maintained is essential.

4. Medical Reasons for Falls

There are certain medical conditions or ailments that would increase our susceptibility of falls, especially in those with dementia. Below we explore some possible causes for falls related to medical conditions.

• Hypotension:
  Sudden drops in blood pressure upon standing or walking can result in dizziness or fainting.
• Medication Side Effects:
  Certain medications, especially those with side effects such as dizziness or drowsiness, can compromise physical stability and contribute to falls.
• Vascular Dementia:
  Strokes and TIA’s common in Vascular Dementia can cause a person to lose consciousness.
• Poor Nutrition/Hydration:
  Inadequate nutrition and dehydration can lead to weakness, dizziness, and reduced overall physical function.
• Incontinence Issues:
  Managing incontinence can involve frequent trips to the bathroom, increasing likelihood due to frequency.
• Neurological Disorders:
  Conditions like Parkinson’s disease, Lewy Body Dementia or tremors can impact balance, coordination, and mobility.
• Heart Conditions:
  Cardiovascular issues, such as irregular heartbeats or heart diseases, may affect blood circulation.
• Vertigo or Inner Ear Disorders:
  Disorders affecting the inner ear, leading to vertigo or imbalance, can significantly increase the risk of falls.

5. environment

• Poor Lighting:
  Insufficient or inadequate lighting can increase potential hazards, making it difficult for individuals to identify obstacles or changes in elevation.
• Uneven Flooring:
  Irregular or uneven surfaces, such as loose rugs, uneven floorboards, or thresholds, pose a tripping hazard and contribute to falls, especially for individuals with mobility challenges. (Hint: Patterns on the carpet can look like an uneven floor or steps)
• Cluttered Spaces:
  Clutter and obstacles in walkways can impede safe movement and increase the risk of falls. Items like loose cables, scattered belongings, or furniture can pose significant hazards.
• Slippery Surfaces:
  Wet or slippery floors, particularly in bathrooms or kitchens, can lead to slips and falls.
• Lack of Handrails or Grab Bars:
  Absence of handrails or grab bars in areas like staircases and bathrooms reduces support for balance and stability.
• Bed is too high/too low
  When individuals get up in the morning, or even in the middle of the night it’s important that they’re safe in the process. If someone is frequent to climbing out of bed and cannot mobilize, they may have their bed closer to the ground with mats nearby. Whereas, a person who is really tall would be at a high risk for falls if their bed was too low, encouraging them to work extra hard to try and stand. It’s important to assess each individual and find the height that they can maneuver in and out of bed with as much independence as possible.

Risks Associated with Falls

• Physical Injuries:
  Falls can result in fractures, sprains, broken bones, or more severe injuries, particularly for the elderly. Individuals with dementia may have difficulty communicating pain or discomfort, leading to delayed medical attention.
• Psychological Impact:
  Falls can have a psychological impact, causing fear and anxiety in those with dementia. This fear may lead to reduced physical activity, isolation and even depression, contributing to the decline in muscle strength and coordination.
• Decreased Independence:
  Each fall may limit their independence, as individuals may become fearful to move on their own, and caregivers may become more cautious about allowing the person to move freely. This loss in autonomy can negatively impact the individual’s quality of life, leading to further complications.
• Financial Strain
  Falls can cause significant medical expenses such as costs associated with hospital stays, rehabilitation, mobility devices, ongoing care, or environmental modifications to the living space.
• Long-Term Care
  A fall can cause an individual to require care that only a facility can manage. Equipment such as lifts and mechanical beds may not be feasible in a home care setting, the inability to attain such equipment would possibly mean placement into a long-term care facility.

Preventive Strategies

1. Environmental AND CLOTHING Modifications:

• Remove Hazards:
  Identify and eliminate tripping hazards such as loose rugs, clutter, or uneven flooring. Secure electrical cords along the baseboards. For items that are regularly on the ground (pet food and water) try to find bowls that are brightly coloured to grab the persons attention. It’s important to keep pathways clear to encourage safer movement.
• Non-Slip Flooring:
  Use non-slip mats or rugs in areas prone to moisture, like bathrooms and kitchens. Use a thin, high contrast coloured mat if you must use a rug, to ensure it is visible to the person with dementia.
• Proper Lighting:
  Ensure adequate lighting in all areas, especially at night. Well-lit spaces can help individuals with dementia better perceive their surroundings and reduce the risk of missteps. Adequate lighting can also prevent increased disorientation.
• Proper footwear and fitted clothing
  Ensure all clothing properly fits, be mindful of loose fabric that can catch on objects, or robes, and dresses they could trip over. Footwear should be light and form fitting with arch and heel support. Slip on or Velcro shoes are ideal, but confirm that the foot does not move around, and that the heel does not come out of the shoe when lifting the foot.
• Mobility (Grip) socks
  Utilize socks with grips on the bottom to stabilize the individual and to prevent from slipping. These types of socks are especially helpful for those who have short and rigid steps, or might shake as they walk.

2. Assistive Devices:

• Mobility Aids:
  Introduce appropriate mobility aids, such as canes or walkers, to provide additional support. Ensure that these devices are in good condition and are used correctly. A proper assessment from the physiotherapist will ensure each gait aid is appropriate for the person.
• Grab Bars:
  Although it’s best to have an occupational therapist assess your home for grab bars, you may install grab bars for showers, toilet area and areas they may need to step-up to (i.e. a wide platform at the bottom of the stairs)
• Raised toilet seats and commodes:
  If regular trips to the bathroom is a concern for falls, you could utilize a portable toilet or a commode. This will prevent the person from having to navigate their surroundings frequently. Raised toilet seats will assist the person to prevent them from bending too far down.

3. Regular Exercise Programs:

• Strength and Balance Exercises:
  Implement regular exercise routines focusing on muscle strength and balance. Utilize range of motion activities to reduce muscle stiffness and joint pain. Encourage repetitive exercises to increase endurance. These can help improve overall physical condition and reduce the likelihood of falls.
• Physical Therapy:
  Enlist the support of physical therapists who specialize in working with individuals with dementia. Tailored exercise programs can address specific needs and challenges.

4. Medication Management:

• Review Medications:
  Regularly review and assess medications with healthcare professionals to identify potential side effects or interactions that may contribute to dizziness or instability.
• Timely Adjustments:
  Speak with your doctor about adjusting times for medications that can cause balance or drowsiness. If possible, give these types of medications when a person is routinely sitting down or inactive.

Conclusion

Addressing the risks of falls for people with dementia requires an assessment of the whole person, combining environmental modifications, assistive devices, exercise programs, medication management, clothing and footwear decisions. By using preventive strategies, caregivers, facility staff and family members can create a safer and more supportive environment.