Of all the things that happen in this illness, a fall is the one most likely to end life at home. Not because of the fall itself — because of what follows it. A fracture, a hospital admission, a delirium that arrives in the ward and never fully lifts, three weeks of lying still that takes away the strength to stand. Families who were coping on Monday are having a placement conversation by the end of the month.
So this is the letter I would most like you to read before you need it.
Dementia roughly doubles the risk — and not for the reason most people assume
People assume it is frailty. Frailty is part of it, but the bigger contributors are specific to the illness.
The disease changes walking itself. Gait becomes shorter, wider, more hesitant, particularly in Lewy body and vascular dementia, and in the later stages of Alzheimer’s. This happens long before anyone would call the person unsteady.
The eyes work; the interpreting doesn’t. Visuospatial impairment means depth, edges and contrast are misread. A dark bathmat on a light floor can read as a hole to step over. A patterned carpet can read as uneven ground. Where a stair edge stops and the floor begins becomes genuinely ambiguous.
Judgement goes before ability does. They stand and set off without the walker — not because they forgot they own one, but because the part of thinking that pauses to check has been eroded. This is why “just remind him to use it” fails.
And they are up at night. Night-time wandering, the bathroom trip at 3 a.m. in the dark, the late-afternoon restlessness described in sundowning — the hours when they are most likely to be walking are the hours when they are least safe.
The causes families never think to check
This is the part worth your attention, because most fall advice online stops at removing rugs. Rugs matter. These matter more.
The medication list. This is the single highest-yield thing to look at, and almost nobody raises it. Sedatives, sleeping tablets, benzodiazepines, opioids, and antipsychotics prescribed to manage behaviour all increase falls. So do drugs with anticholinergic effects, which accumulate quietly across a list — some bladder medications, some antidepressants, some antihistamines — each individually reasonable, together a problem. The question to ask is not “is this drug necessary?” but “given that he is falling, can anything on this list be reduced or stopped?”
Blood pressure that drops on standing. If they go lightheaded getting up, or the falls happen shortly after rising from a chair or the bed, that pattern is worth measuring. Blood pressure taken lying and then standing is a simple test, and blood pressure medication that was right five years ago is often too much now. A reading taken sitting in a clinic can look perfectly fine while the standing pressure is not.
Vitamin D. Someone who is largely indoors, eats poorly, and rarely gets sun is very likely to be deficient, and correcting it is routine practice in older adults at risk of falls and fracture. It is one of the few things on this list that is cheap, low-risk and easy. Ask about it specifically.
Eyes and feet. An out-of-date prescription, an unoperated cataract, or bifocals worn on stairs all cause falls. So do long toenails, numb feet, and slippers with no back — the single most common footwear in every house I visit, and among the worst.
Something acutely wrong. A person who suddenly starts falling this week, having been steady last week, may have an infection, pain, or a delirium brewing. Sudden change is a different problem from gradual decline, and it has its own rules — they are in when to call the doctor and when to go.
What actually helps at home
Light the night route. The path from bed to toilet, lit automatically. Motion-sensor plug-in lights are the highest-value few pounds you will spend, because the 3 a.m. trip in the dark is where a large share of falls happen.
Use contrast, not decoration. A toilet seat in a colour that stands out against the floor. A stair edge marked in tape that contrasts. A plain plate on a plain placemat. If they can see where a thing begins and ends, they place themselves correctly. Busy patterns do the opposite.
Take away the traps. Loose mats, trailing cables, the low coffee table nobody sees, the dog. Grab rails in the bathroom, which is the highest-risk room in the house.
Raise what they get up from. A chair or bed that is too low takes strength they no longer have. Firmer and higher is safer.
Shoes indoors, not slippers. Something enclosed, flat, with a back and a grippy sole.
And stop hurrying them. Most falls I hear about happened while somebody was being rushed — to the car, to the table, to the phone. Speed is the risk factor nobody lists.
What to ask at the next appointment
Bring the dates. “He’s been a bit unsteady” produces reassurance; “four falls since May, two in the last fortnight, all within an hour of getting up” produces a plan. Then ask for:
- A medication review specifically for falls risk — using that phrase
- Blood pressure lying and standing
- Vitamin D, and whether supplementation is appropriate
- A vision check, and hearing while you are at it
- Referral to physiotherapy or occupational therapy for strength, balance and a home assessment — this is the intervention with the best evidence behind it, and it is chronically under-requested
- A conversation about bone health, because the fall that matters is the one that breaks something
The hour after a fall
Do not rush to lift them. Get down to their level first and look before you move anything.
Go now, even if they seem fine, if: they hit their head and take a blood thinner — bleeding can declare itself hours or days later, and “he seemed alright afterwards” is exactly the history that precedes it. Also: they cannot bear weight, one leg looks shorter or turned outward, there is severe pain, there is a head injury with drowsiness or vomiting, or they are newly confused in a way that is not their normal.
If none of that applies, help them up slowly — onto hands and knees, then to a chair — and watch them over the next day for pain, bruising or a change in walking. Then write it down: date, time, where, what they were doing, what they had eaten, what they had taken. That log is what turns the next appointment into something useful.
And if they were on the floor for a long time before you found them, say so out loud to whoever assesses them. A long lie has consequences of its own, and it is easy to leave out of the story.
The permission slip
They will fall anyway. Some falls are not preventable, and a person who never falls is usually a person who has stopped moving — which carries its own costs, and comes for their strength and their dignity both.
You are not failing when it happens. What you can do is remove the causes nobody looked for, light the route to the bathroom, and keep the log that makes the next appointment count. That is not nothing. In this illness it is most of what the evidence has to offer.