When Mary Wasser-man's husband, Albert, was diagnosed at age 81 with Lewy body dementia along with Parkinson's disease in 2020, she worried about keeping him safe at their home in San Diego. Three years later, in April 2023, he had to be moved to a skilled nursing facility when his health and behavior deteriorated.
While Wasserman has been happy with her husband's overall care, a new concern has cropped up: frequent falls. For a while, he experienced two to three a week, usually when he got out of bed early in the morning or late at night. “His dementia made him combative, and he refused to use the wheelchair or any other safety precautions the staff offered,” she says. “He has tremors in his arms and hands and what they call a ‘Lewy lean,’ the tendency to lean sideways from the right side of his waist.” It was a constant struggle.
Finally, Wasserman was able to convince her husband to use a standing walker as a compromise. He's also on an antidepressant, which has made him less combative and more open to staff assistance. But Wasserman continues to worry. “I'm just thankful he never had a serious injury like a hip fracture or a concussion,” she says. “But it's always a nagging worry that I'm going to get another call from the care facility letting me know that he's fallen again.”
Falls are the main cause of injury among people 65 and older. Every year, more than 14 million—or one in four older adults—experience a fall, according to the U.S. Centers for Disease Control and Prevention (CDC). And the risk is even higher for people with dementia, according to a study published in Alzheimer's & Dementia in January 2023. “People who are cognitively impaired are more likely to fall because they have difficulty processing information in their environment,” says Joe Verghese, MD, FAAN, chair of the neurology department at the Renaissance School of Medicine at Stony Brook University in New York. “If multiple things are going on around them, they stop paying attention to how they walk.”
New research also suggests that falls themselves can raise dementia risk. A study published in JAMA Network Open Geriatrics in September 2024 of more than 2 million older adults found that more than 10 percent of people who fell were subsequently diagnosed with dementia. In addition, compared with other types of injury, falls were associated with a 21 percent increased risk for a future dementia diagnosis.
“Falling is a marker of aging, and aging itself is the biggest predictor of whether someone gets dementia,” says Frederick Marshall, MD, FAAN, chief of the geriatric neurology division at the University of Rochester School of Medicine and Dentistry in New York. It may be that in the early stages of dementia, people begin to develop subtle gait changes that predispose them to falls. In addition, “a lot of dementia goes undocumented and undiagnosed,” he says. “If you fall and end up in the hospital with a hip fracture, you'll be seeing doctors more frequently, and it's more likely your dementia will get picked up.”
A fall can be minor, resulting in barely a bruise, or life-threatening, resulting in hospitalization. In the United States, up to 30 percent of older adults who fall sustain serious injuries such as hip fractures or head trauma, according to the World Health Organization. The CDC reports that each year, about 1 million older Americans are hospitalized for falls, with nearly a third of them being admitted for hip fractures.
Risk Factors
Lower-body weakness, cognitive impairment, problems with balance, poor hearing or vision, and certain medications all can increase the risk of falling, says Barbara Resnick, PhD, RN, an endowed chair in gerontology at the University of Maryland in Baltimore. Blood pressure medications are particularly worrisome. “When you stand up, your blood pressure automatically goes down, and if it goes too low, you can get dizzy,” says Dr. Resnick. Antianxiety drugs like diazepam (Valium), overactive-bladder medications like oxybutynin (Ditropan), and antidepressants such as amitriptyline (Elavil) also raise the risk, as can over-the-counter products that contain the antihistamine diphenhydramine (Benadryl).
Hearing and vision problems more than triple the risk of a fall, according to a 2022 study published in BMC Geriatrics.
Once older adults fall, they're much more likely to fall again. In 2020, Geriatric Orthopaedic Surgery & Rehabilitation published a study of 199 older adults who had been hospitalized for falls. About a quarter of them had a second fall within a year.
“When older adults fall, they often change their behavior. They develop a fear of falling and are less active and more socially isolated,” says Dr. Verghese. Since their brains are less stimulated, it may accelerate the development of dementia, he adds.
Nine Ways to Play It Safe
Exercise
Physical activity is one of the best ways to prevent falls, says Joe Verghese, MD, FAAN, chair of the neurology department at the Renaissance School of Medicine at Stony Brook University in New York. People with physical limitations or mobility problems should ask their neurologists for referrals to physical therapists, who can customize exercise programs that include strength training and balance, Dr. Verghese suggests. A Cochrane Review published in 2019 of more than 100 studies found that older adults who worked on gait, balance, and muscle strength reduced their risk of falls by about 24 percent. Resistance and strength training also increases gait speed and improves balance, which was closely associated with a reduced risk of falling in older adults, according to a study published in Clinical Interventions in Aging in 2017.
Fall-Proof Your Home
Remove anything you can trip over, such as extension cords, papers, books, and other clutter, from stairs or places where you walk frequently. Install grab bars next to and inside the tub and next to the toilet. Use nonslip mats in the bathtub and shower. Improve home lighting, including adding night-lights so it's easier to move around safely in the middle of the night, says Frederick Marshall, MD, FAAN, chief of the geriatric neurology division at the University of Rochester School of Medicine and Dentistry in New York. Add handrails and lights to all staircases. Consider having a home safety evaluation in which a nurse or physical therapist visits the home and assesses it for fall risks. It's covered under Medicare Part B if it's ordered by your physician, says Dr. Marshall. A bill known as the SAFE Act was recently introduced in the U.S. House of Representatives to add risk assessments and prevention services for falls into annual wellness visits and initial preventive physical exams under Medicare.
Review Your Medication
A 2023 study published in BMC Geriatrics found that certain classes of drugs, such as muscle relaxants, medications for Parkinson's disease, epilepsy drugs, antipsychotics, and opioids, were associated with the highest risk of injuries related to falls. Primary care providers or pharmacists can go over your list of drugs with you every year, says Barbara Resnick, PhD, RN, an endowed chair in gerontology at the University of Maryland in Baltimore, who adds that the review is usually covered by Medicare.
Address Your Footwear
The National Institute on Aging recommends nonskid, rubber-soled, low-heeled shoes. Don't pad around the house barefoot, in socks, or in slippers, either. Doing so has been shown to more than double the risk of falls.
Modify Activities
If the weather is bad, stay inside, advises Dr. Resnick. You don't want to slip or fall. See if you can get groceries and prescriptions delivered or have a family member or friend pick them up. If you do venture out, use an ice-melt product to clear icy areas by your front door and walkways.
Assess Hearing and Vision
Even small changes in sight or hearing may increase the risk of a fall, says Dr. Marshall. Stay current on eye doctor appointments, and get your hearing checked every few years. If you need glasses or hearing aids, wear them.
Use Assistive Devices
If your neurologist recommends a cane or walker, use one, as it can help prevent falls, says Dr. Marshall. A physical or occupational therapist also can recommend devices and show you how to use them safely.
Be Frank with Your Doctor
If you fall, let your physician know right away, even if you weren't injured. The same is true if you begin to feel unsteady on your feet. “The sooner we know, the faster we can get you a home safety assessment and refer you to therapists to improve your walking and balance skills,” says Dr. Verghese. “We don't want to get to the point where you have a fall and then become terrified to move.”
Get Screened
Older adults who fall and end up in emergency departments or admitted to hospitals should have cognitive screenings, says Dr. Verghese. “They may have mild cognitive impairment that's gone undiagnosed,” he says. “The sooner we can catch that, the better.”
