Falls are the leading cause of injury in people with dementia, and they happen at roughly twice the rate seen in older adults without cognitive impairment. The good news is that most falls are preventable through a combination of environmental changes, physical activity, medication reviews, and daily routine adjustments. Prevention works best as a layered approach, where no single strategy eliminates the risk but several together make a significant difference.
Why Dementia Increases Fall Risk
Dementia doesn’t just affect memory. It changes the way the brain processes balance, spatial awareness, and movement planning. People with dementia show measurable declines in standing balance, including greater postural sway and less ability to lean in a controlled way without losing stability. In more advanced stages, gait changes become pronounced: shorter stride length, slower walking speed, and more variability in the timing between steps. Each of these makes a stumble more likely and recovery from a stumble harder.
Visual perception also deteriorates. Research using simple drawing tests found that people with dementia who struggled to copy intersecting shapes had a higher fall risk, likely because the same brain changes that impair visual processing also make it harder to judge distances, detect edges, or navigate around furniture. White matter damage visible on brain scans, particularly near the brain’s fluid-filled chambers, has been linked to an eightfold increase in the odds of falling. These aren’t problems that willpower or “being more careful” can fix. They require changes to the person’s environment, routine, and physical conditioning.
Make the Home Safer
Environmental modifications are the most immediate thing you can do. Start with the areas where falls happen most: bathrooms, bedrooms, and stairs.
- Grab bars: Install them next to the toilet and inside the shower or tub. These should be wall-mounted and weight-bearing, not suction-cup models.
- Lighting: Replace dim bulbs with high-intensity LED lights, especially in hallways and bathrooms. Motion-sensor lights are particularly useful for nighttime trips to the bathroom, since a person with dementia may not remember to flip a switch.
- Flooring: Remove loose rugs or secure them with non-slip backing. Apply non-slip mats in the bathroom and consider non-slip flooring in areas that get wet. Avoid high-gloss floors, which can look wet or slippery to someone with impaired depth perception.
- Clutter: Keep walkways completely clear. Cords, shoes, pet bowls, and low furniture are all trip hazards that a person with dementia may not notice or may not be able to step around quickly enough.
Contrast matters, too. A white toilet in a white bathroom is hard to see for someone with visual processing problems. Using contrasting colors for key surfaces (a dark toilet seat, colored tape on stair edges) helps the brain identify where things are.
Review Medications Regularly
Several drug classes commonly prescribed to people with dementia directly increase fall risk. Antipsychotics, antidepressants, and benzodiazepines (sleep and anxiety medications) are collectively known as fall-risk-increasing drugs. Antipsychotics like risperidone and quetiapine can cause blood pressure to drop suddenly when standing, a condition called orthostatic hypotension. Benzodiazepines slow nerve signaling throughout the brain, impairing reaction time and coordination.
Prescribing guidelines already recommend limiting benzodiazepines and antipsychotics in dementia patients because of this well-documented risk. If your family member is taking any of these medications, ask their doctor whether the dose can be reduced or the drug replaced with something less likely to cause dizziness or sedation. Even over-the-counter antihistamines and sleep aids can contribute. A comprehensive medication review, ideally by a pharmacist working with the prescribing doctor, is one of the highest-impact steps you can take.
Build Strength and Balance With Exercise
Physical therapy and structured exercise programs reduce falls even in people with moderate dementia. The Otago Exercise Program, originally designed for older adults, has been adapted for people living with dementia in care facilities. The adapted version involves one-hour group sessions of strength, balance, and walking exercises, performed three times per week for six months in small groups of five to seven people. The exercises are simple: leg raises, standing on one foot with support, sit-to-stand repetitions, and supervised walking.
You don’t need a formal program to get started. A physical therapist can design a home routine that targets the specific deficits your family member has. The key is consistency. Even 15 to 20 minutes of guided balance and leg-strengthening exercises several days a week builds the muscular reserves that help someone recover when they stumble. The sit-to-stand test is a useful benchmark: if a person can’t stand up from a chair five times in 15 seconds, their lower body strength is below the threshold associated with increased fall risk.
Choose the Right Footwear
What someone wears on their feet matters more than most caregivers realize. Evidence-based recommendations for older adults point to shoes with wide soles, low heels, moderately firm materials, and high collars (the part that wraps around the ankle). Treaded rubber outsoles reduce slipping. Secure fastening, whether Velcro straps or laces, keeps the shoe from shifting during movement. Rigid, cupped insoles improve dynamic balance during walking.
Slippers are one of the worst options. They’re loose, flat-soled, and offer no ankle support. If the person with dementia resists wearing shoes indoors, look for slipper-style shoes that have non-slip rubber soles and a back that cups the heel. Going barefoot or wearing only socks on hard floors is equally risky.
Stay Hydrated on a Schedule
Orthostatic hypotension, the sudden drop in blood pressure when standing up, is a major and underrecognized contributor to falls in people with dementia. It causes lightheadedness, blurred vision, and momentary disorientation, all of which are worse in someone whose brain is already struggling to maintain balance. Dehydration makes orthostatic hypotension significantly more likely because low fluid volume means less blood returning to the heart when gravity pulls it downward.
A recent study found that scheduled water intake (drinking at regular, planned intervals throughout the day) was associated with 89% lower odds of mild cognitive impairment in people with orthostatic hypotension, compared to no significant benefit from unscheduled or irregular drinking. Drinking 350 to 500 milliliters of water can produce a short-term increase in blood pressure, helping stabilize circulation. For a person with dementia who may forget to drink, offering water at set times (with meals, mid-morning, mid-afternoon, and before bed) is a simple intervention with real protective value.
Manage Sundowning and Restlessness
Many people with dementia become agitated, confused, and restless in the late afternoon and evening, a pattern called sundowning. This is a high-risk window for falls because the person may pace, wander, or try to get up repeatedly without awareness of their surroundings. Fatigue makes it worse, so avoiding long late-day naps and overly packed schedules helps.
The National Institute on Aging recommends several practical strategies: stick to a predictable daily routine for meals, bathing, and activities. Get natural sunlight exposure earlier in the day, either outdoors or near a window. Avoid caffeine and alcohol in the afternoon and evening. When restlessness starts, try redirecting attention with a familiar activity like folding laundry, listening to music, or looking through a photo album. Keeping the home calm and well-lit during the transition from daylight to evening can reduce the confusion that triggers unsafe movement.
Assess Fall Risk Early and Often
Fall prevention works best when you know how high the risk actually is. A modified version of the CDC’s STEADI screening algorithm uses three simple questions: Has the person fallen in the past year? Are they worried about falling? Do they feel unsafe standing or walking? A “yes” to any of these triggers further assessment, including a tandem stance test (standing heel-to-toe for 10 seconds) and a sit-to-stand test (five repetitions in 15 seconds). Failing either of these places someone in a moderate-to-high risk category.
For people with dementia, these assessments should happen regularly because abilities can decline quickly over months. A person who was steady on their feet in January may not be in June. If your family member uses a mobility aid like a walker or cane, keep in mind that using one is itself associated with increased fall risk in people with dementia. This doesn’t mean the aid should be removed. It means the person likely needs closer supervision and possibly a reassessment of whether the current aid is the right fit.