Dementia and falls

What you need to know about falls risk in people with dementia

Falls are a major reason why many older people lose independence and mobility, and people with dementia have twice the risk of falling compared to people without dementia.

Falls can result in fractures to limbs (arms/legs) and/or head injury, and people with dementia are three times more likely to sustain a hip fracture that may require surgical intervention and the potential complications of delirium, immobility (Tinetti et al., 1988).

Once a person has fallen, the chance of falling again doubles. Therefore, preventing falls in people with dementia is an important aspect of their care.

Across North America, every 11 seconds, one person, age 65 years or older, is treated for a fall in the emergency department. This means, on average, 7,855 older people fall daily, and of those falls, 20 per cent cause serious injury, even death.

The risk of falls associated with dementia in the older person, may be caused by four main factors:

• Physical changes
• Cognitive changes
• Environmental
• Medications

Physical Changes

• Weaker bones, decreased strength, muscle loss due to aging process
• Decreased energy due to inactivity and/or pre-existing health condition e.g. arthritis
• Loss of flexibility in joints, increased pain/stiffness especially hips and ankles
• Impaired balance reactions due to slower brain processing
• Dementia is associated with impairment of cardiovascular reflexes that help maintain blood pressure (BP) when standing
• People with Lewy body dementia and Parkinson’s dementia are at an increased risk of falling due to significant gait changes
• People with frontal lobe vascular lesions are at high risk of falling due to impulsivity
• From the middle to advanced stage of dementia, there is a noted decline in strength, balance and walking ability  

Cognitive Changes

• Impulsivity
• Poor judgment e.g. walking on an icy path
• Cognitive impairment affects the capacity to judge depth and distance between objects e.g. sit down in gaps between chairs
• Misprocessing of information e.g. black rug on white floor  
• Sensory changes (see article Dementia and the Five Senses)

Environment

Most falls leading to serious injury and/or death, occur at home or in the garden. The most common areas are:

• Stairs
• Bathroom
• Kitchen
• Bedroom
• Garden

Hazards:

• Poor lighting
• Hoarding/clutter
• Badly placed furniture, power cords, loose carpeting, curled edges of rugs
• Ill fitting clothing, inappropriate footwear
• Chairs which tip over, step stools
• Rugs that slide, unstable hand rails
• Wet floors, spillage
• Uneven paving, loose gravel
• Ice/wet leaves on pathway
• Family pet
• Items placed out of reach

Medications

Many common medications have side effects that are associated with an increase in falls risk.

Therefore, it is very important to have your doctor and/or pharmacist review all possible side effects and medication interactions when taking any new medications. Important tips include:

• Do not mix medication with alcohol. People who consumed more than five drinks daily, or seven weekly, are seven times more likely to have fallen in the past year and six times more likely to forget their medications (Wilner, 2013)
• Do not stop taking a medication without telling you doctor
• Talk to your pharmacist/doctor before taking herbal or over the counter medication

Psychoactives:

A recent study of 20,852 older people in Germany identified anti-depressants, sedatives and hypnotics as major contributors to an increase in falls risk (Wilner, 2013). These medications cause drowsiness, worsen confusion and affect brain function:

• Benzodiazepines: Ativan, Valium usually prescribed to help with anxiety and sleep
• Non-benzodiazepines: Ambien, Lunesta (sedative hypnotics)
• Antipsychotics: Risperdal, Seroquel, Zyprexa, Haldol are usually prescribed for difficult behaviors e.g. aggression
• Anticonvulsants: Neurontin is a seizure medication (epilepsy) often used to treat nerve pain
• Mood Stabilizers: Depakote is sometimes used to manage antisocial behaviours in dementia
• Antidepressants: Zoloft, Effexor, Celexa are used to treat depression with anxiety. Trazadone is usually given as a sleep aid
• Opioids: Codeine, Morphine, Fentanyl used to treat pain; side effects include drowsiness and confusion

Anti-cholinergics:

This group comprises many drugs that can be prescribed or purchased over the counter. Anticholinergics should be used with great caution as they have many side effects including drowsiness, poor coordination, confusion, double or blurred vision, agitation, irritability and hallucinations.  

• Tricyclic antidepressants: Elavil, Pamelor
• Overactive bladder medications: Ditropan, Detrol
• Vertigo/nausea medications: Antivert, Dramamine
• Anti-itch medications: Vistaril
• Muscle Relaxants: Flexaril
• Antihistamines: Benadryl, cold/sinus medications, and pain relievers e.g. Nyquil, Tylenol PM

Medications that affect blood pressure:

These are drugs that can cause a sudden drop in BP or worsen an already low BP. Low BP can make someone weak, faint, and/or dizzy which increases falls risk.

Antihypertensives: Atenolol, Norvasc used to treat high blood pressure
Alpha-blockers: Flomax, Cardura which help men with an enlarged prostate urinate

 Medications that lower blood sugar:

The aim of taking a drug to manage diabetes is to lower the blood sugar. However, if the blood sugar falls too low (hypoglycemia) it can cause dizziness and confusion which can increase a person’s risk of falling.

Sometimes, the person with dementia may not know how he/she fell, or may fall when no one else is around. To help determine what may have happened, some caregivers have found it is helpful to ask these simple questions:

• What was the person doing?
• Getting out of chair
• Where did the fall occur?
• In kitchen
• How did it happen?
• Chair too light and fell back

This article is written by or on behalf of an outsourced columnist and does not necessarily reflect the views of Castanet.