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Falls and Dementia

Original Editor - Ahmet Begde

Top Contributors - Ahmet Begde, Lucinda hampton, Tolulope Adeniji, Kim Jackson and Vidya Acharya  

Introduction

Having Dementia -A greater risk for Falls

Dementia dramatically increases fall risk, with 80% of patients falling annually - significantly higher than the general older adult population. The underlying mechanisms include impaired obstacle clearance, compromised balance during dual tasks, spatial navigation difficulties, and progressive mobility decline. With dementia cases projected to triple from 50 million to 150 million by 2050, and rising fall-related injuries, hospitalizations, and deaths, physiotherapists face an expanding clinical challenge. This epidemic demands evidence-based, multifactorial interventions targeting balance training, environmental modifications, and functional mobility preservation. Understanding these specific fall mechanisms in dementia enables physiotherapists to develop targeted prevention strategies that address cognitive-motor interactions rather than treating balance deficits in isolation..[1] [2]

Alzheimer’s disease (AD) is the most common cause of dementia in older individuals, affecting approximately 10%–30% of older adults All types of dementia (eg Alzheimer's disease, dementia with Lewy bodies, dementia in Parkinson's disease, fronto-temporal dementia, vascular dementia) increase risk of falls[3]. Falls cause an increases the risk of hospitalisation [4].

Falls Risk Factors: Dementia

Age remains the primary fall risk factor, with older adults facing the highest rates of fall-related death and serious injury due to age-related decline and poorly adapted environments. Remarkably, falls precede dementia development - pre-dementia falls increase subsequent dementia risk, particularly multiple falls after age 60, suggesting a bidirectional relationship.

People with dementia face additional challenges: impaired visuospatial processing, compromised sensory integration, deteriorated motor planning, anxiety, and polypharmacy effects. For physiotherapists, this means standard fall prevention requires modification - interventions must address cognitive-motor interactions, simplify movement tasks, and account for progressive neurological changes. Understanding these dementia-specific risk factors enables targeted strategies that go beyond traditional balance training to address the complex interplay between cognition and movement control.[5]. [6][7].

Mobility Risks: Dementia, which is characterised by cognitive and executive decline, prevents smooth walking and causes mobility problems [8]. Previous imaging, observational, and interventional studies have revealed a close and critical relationship between gait and balance [6][9].

Walking, which is a high-level, complex and controlled body movement, takes place along the neural pathway formed by the cortical, subcortical, spinal and peripheral [10]. Compared to cognitively healthy elderly individuals, PwD have a gait characterised by decreased gait velocity, cadence and stance time, and increased stride and swing time (the severity of this difference depending on the type and stage of dementia )[11].

  1. The cortico-cortical and cortico-subcortical connections defects in PwD cause problems in the highest sensorimotor functions leading to higher-level gait disorders [6].
  2. Perception and resolution of the relationship between the person and the environment with the integration of information coming from the sensorimotor system are very important for postural stability and the continuation of walking [12].
  3. Studies have shown that sensory input, visuospatial function, and motor planning, which are important in this integration, may be impaired in individuals with dementia [13][14].

Fall Prevention Strategies in People with Dementia

Ensure clear paths and good lighting

Fall risk can be reduced in PwD using different strategies. Studies have shown that modifying the external factors/environment that create the risk of falling can be effective and prevention is possible[15]. Attention must be given to the patient (keeping in good health, limitation in sedative treatment) and on his environment (lighting, obstacles on the ground, stress levels).[16]

Examples include

  1. Adequate lighting, using obvious contrasting colours,
  2. Cleared/safe pathways
  3. Easy-to-reach in visible places items needed
  4. Modified noise levels (can be effective to eliminate the effects of the affected sensorial impulse caused by dementia) [17].
  5. Assistive technologies/devices, education, and encouraging the participation of PwD in fall prevention programs can be other effective strategies [18].

Inconclusive Results: In addition to these, although some studies report that interventions such as vitamin D, hip protectors, medications, brisk walking, and cognitive behavioural group may have positive effects in reducing the risk of falls in people with cognitive impairment, such applications are not recommended to prevent falls because the results are inconclusive [18].

Exercise: One of the most effective fall prevention strategies for people with dementia is exercise (see the video below) [18][19]. Studies have shown that especially strengthening and balance training can reduce the fall rate by improving mobility [20]. It was also stated that exercises such as functional, cognitive-motor, and tai-chi could be effective in reducing falls [18]. However, there is not yet high-quality solid evidence showing the type and intensity of the most effective exercise in preventing falls in people with dementia [18].

According trending evidence, multicomponent exercise regimens, which include strength, balance, and cognitive-motor training, should be undertaken at least 2-3 times per week, at a moderate level that is both safe and demanding.[21] [22] Each session should last 30-60 minutes, for a minimum of 120 minutes per week. Exercises should emphasise functional strength, balance activities, dual-task walking, and Tai Chi, all of which have been demonstrated to increase mobility and cognition. Programs should be individualised and maintained for at least 6 months, with carers and therapists participating to support adherence and safety.

Overview of systematic reviews reported that multicomponent exercise training, including cognitive and physical exercises, may be more effective than other types of exercise in reducing fall rate by improving walking, balance, and cognitive functions [19][23]. Considering the cognitive impairment that significantly increases the risk of falling in individuals with dementia, combining different strategies/exercises may have more positive results in improving physical and cognitive outcomes.

Recent research also emphasizes the importance of individualized exercise programs tailored to the specific needs and abilities of people with dementia[24]. Customizing exercise routines based on individual assessments can enhance safety and effectiveness, as it addresses the unique physical and cognitive challenges each person faces. Moreover, incorporating caregiver involvement and ensuring a supportive environment can further enhance the benefits of exercise interventions, making them more accessible and sustainable for individuals with dementia [25].

Viewing

Watch these 2 videos on falls reduction strategies and exercises to reduce falls risk.

Resources

References

  1. ↑ Kumar S, Cruz F, Yates Z, Amin Q, Awan MU, Lee P, Kumar S, Elkbuli A. Falls among older adults: An exploration of trends, clinical outcomes, predisposing risk factors, and intervention strategies. The American Journal of Surgery. 2025 Apr 30:116385.Available: https://www.sciencedirect.com/science/article/abs/pii/S0002961025002077(accessed 9.10.2025)
  2. ↑ Simpkins C, Khalili SM, Yang F. Meta-Analysis-Based Comparison of Annual Fall Risk between Older Adults with Alzheimer’s Disease and Mild Cognitive Impairment. Advances in geriatric medicine and research. 2024;6(1). BibTeXEndNoteRefManRefWorks Available:https://pmc.ncbi.nlm.nih.gov/articles/PMC11081206/#S5 (accessed 29.12.2024)
  3. ↑ Petersen JD, Siersma VD, Christensen RD, Storsveen MM, Nielsen CT, Waldorff FB. The risk of fall accidents for home dwellers with dementia—A register-and population-based case-control study. Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring. 2018 Jan 1;10:421-8.
  4. ↑ Mitchell R, Draper B, Harvey L, Wadolowski M, Brodaty H, Close J. Comparison of hospitalised trends, treatment cost and health outcomes of fall-related hip fracture for people aged≥ 65 years living in residential aged care and the community. Osteoporosis international. 2019 Feb;30(2):311-21.
  5. ↑ Wang Z, Wang Q, Fu C, et al. The fall-dementia connection: Synergistic effects of falls with genetic and health risk factors. Journal of Alzheimer’s Disease. 2025;105(3):990-999.Available:https://journals.sagepub.com/doi/10.1177/13872877251333799 (accessed 9.10.2025)
  6. ↑ 6.0 6.1 6.2 Zhang W, Low LF, Schwenk M, Mills N, Gwynn JD, Clemson L. Review of gait, cognition, and fall risks with implications for fall prevention in older adults with dementia. Dementia and geriatric cognitive disorders. 2019;48(1-2):17-29.
  7. ↑ Fernando E, Fraser M, Hendriksen J, Kim CH, Muir-Hunter SW. Risk factors associated with falls in older adults with dementia: a systematic review. Physiotherapy Canada. 2017;69(2):161-70.
  8. ↑ Mehdizadeh S, Sabo A, Ng KD, Mansfield A, Flint AJ, Taati B, Iaboni A. Predicting short-term risk of falls in a high-risk group with dementia. Journal of the American Medical Directors Association. 2021 Mar 1;22(3):689-95.
  9. ↑ Li KZ, Bherer L, Mirelman A, Maidan I, Hausdorff JM. Cognitive involvement in balance, gait and dual-tasking in aging: a focused review from a neuroscience of aging perspective. Frontiers in neurology. 2018 Oct 29;9:913.
  10. ↑ Thompson PD, Nutt JG. Gait disorders. Bradley's Neurology in Clinical Practice E-Book. 2021 Mar 23;334.
  11. ↑ De Cock AM, Fransen E, Perkisas S, Verhoeven V, Beauchet O, Vandewoude M, Remmen R. Comprehensive quantitative spatiotemporal gait analysis identifies gait characteristics for early dementia subtyping in community dwelling older adults. Frontiers in neurology. 2019 Apr 5;10:313.
  12. ↑ Hobert MA, Meyer SI, Hasmann SE, Metzger FG, Suenkel U, Eschweiler GW, Berg D, Maetzler W. Gait is associated with cognitive flexibility: a dual-tasking study in healthy older people. Frontiers in aging neuroscience. 2017 May 24;9:154.
  13. ↑ Dawes P, Wolski L, Himmelsbach I, Regan J, Leroi I. Interventions for hearing and vision impairment to improve outcomes for people with dementia: a scoping review. International psychogeriatrics. 2019 Feb;31(2):203-21.
  14. ↑ Panza F, Lozupone M, Sardone R, Battista P, Piccininni M, Dibello V, La Montagna M, Stallone R, Venezia P, Liguori A, Giannelli G. Sensorial frailty: age-related hearing loss and the risk of cognitive impairment and dementia in later life. Therapeutic Advances in Chronic Disease. 2019 Jul;10:2040622318811000.
  15. ↑ Zucchella C, Sinforiani E, Tamburin S, Federico A, Mantovani E, Bernini S, Casale R, Bartolo M. The multidisciplinary approach to Alzheimer's disease and dementia. A narrative review of non-pharmacological treatment. Frontiers in neurology. 2018 Dec 13;9:1058.
  16. ↑ Strubel D, Jacquot JM, Martin-Hunyadi C. Dementia and falls. InAnnales de readaptation et de medecine physique: revue scientifique de la Societe francaise de reeducation fonctionnelle de readaptation et de medecine physique 2001 Feb 1 (Vol. 44, No. 1, pp. 4-12). Available:https://pubmed.ncbi.nlm.nih.gov/11587649/ (accessed 14.11.2022)
  17. ↑ Carnemolla P, Bridge C. A scoping review of home modification interventions–Mapping the evidence base. Indoor and Built Environment. 2020 Mar;29(3):299-310.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 Peek K, Bryant J, Carey M, Dodd N, Freund M, Lawson S, Meyer C. Reducing falls among people living with dementia: A systematic review. Dementia. 2020 Jul;19(5):1621-40.
  19. ↑ 19.0 19.1 Begde A, Jain M, Hogervorst E, Wilcockson T. Does physical exercise improve the capacity for independent living in people with dementia or mild cognitive impairment: an overview of systematic reviews and meta-analyses. Aging & Mental Health. 2021 Dec 15:1-1.
  20. ↑ Lam FM, Huang MZ, Liao LR, Chung RC, Kwok TC, Pang MY. Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review. Journal of physiotherapy. 2018 Jan 1;64(1):4-15.
  21. ↑ Yan J, Li X, Guo X, Lin Y, Wang S, Cao Y, Lin H, Dai Y, Ding Y, Liu W. Effect of multicomponent exercise on cognition, physical function and activities of daily life in older adults with dementia or mild cognitive impairment: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2023 Dec 1;104(12):2092-108.
  22. ↑ Cordes T, Bischoff LL, Schoene D, Schott N, Voelcker-Rehage C, Meixner C, Appelles LM, Bebenek M, Berwinkel A, Hildebrand C, Jöllenbeck T. A multicomponent exercise intervention to improve physical functioning, cognition and psychosocial well-being in elderly nursing home residents: a study protocol of a randomized controlled trial in the PROCARE (prevention and occupational health in long-term care) project. BMC geriatrics. 2019 Dec;19:1-1.
  23. ↑ McDermott O, Charlesworth G, Hogervorst E, Stoner C, Moniz-Cook E, Spector A, Csipke E, Orrell M. Psychosocial interventions for people with dementia: a synthesis of systematic reviews. Aging & mental health. 2019 Apr 3;23(4):393-403.
  24. ↑ Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S. Exercise programs for people with dementia. Cochrane database of systematic reviews. 2015(4).
  25. ↑ Thinnes A, Padilla R. Effect of educational and supportive strategies on the ability of caregivers of people with dementia to maintain participation in that role. The American journal of occupational therapy. 2011 Sep 1;65(5):541-9.
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