Falls and Frailty in Dementia: Prevention, Post-Fall Response and Safe Mobility Support

January 22, 2026

Falls risk in dementia is rarely “just unsteadiness”. It is shaped by frailty, medicines, continence urgency, distress, environment, fatigue and how staff respond in the moment. Services focused on Medicines, Frailty, Falls & Safety need to evidence a practical falls operating model that works across different Dementia Service Models. The goal is not to remove all risk, but to reduce avoidable harm while enabling movement, purpose and independence.

Why dementia increases falls risk

Dementia affects gait, perception and judgement. People may misinterpret patterns on floors, struggle with depth perception, forget they need mobility aids, or stand quickly without recognising dizziness. Falls also cluster around predictable triggers:

Toileting urgency and rushing
Night-time disorientation and poor lighting
Fatigue and “end of day” sundowning patterns
Orthostatic hypotension, dehydration or infection-related delirium
Sedating medication effects and polypharmacy

A credible falls approach in dementia balances prevention, enablement and rapid learning when incidents occur.

Commissioning and inspection focus

Commissioner expectation: a measurable falls prevention model

Commissioners typically want more than a generic risk assessment. They look for an end-to-end model that includes:

Initial multifactorial assessment (mobility, vision, continence, medicines, environment, cognition)
Named actions, owners and review dates in support plans
Evidence of partnership working (GP, OT, physio, falls service) and timely referrals
Service-level oversight: trend analysis, repeat fall reviews, and learning actions

Regulator / Inspector expectation: safe systems and person-centred enablement

Inspectors will test whether staff can explain the person’s specific falls risks and what they do differently day to day to manage them. They will also look for proportionality: over-restrictive responses (e.g., unnecessary bedrails, limiting walking) can create harm and reduce quality of life. Documentation must show reasoning, consent/capacity considerations, and ongoing review.

Prevention in practice: what actually reduces falls

High-performing dementia services use layered controls rather than a single intervention:

Mobility coaching: consistent prompts (“stand, pause, steady, step”), correct aid positioning, and supervised transfers when the person is tired or distressed
Environment: clutter-free routes, stable chairs, clear contrast for toilet doors, and predictable furniture layouts
Routines: planned toileting, hydration prompts, and fatigue management (rest breaks before peak activity times)
Medicines optimisation: monitoring dizziness/sedation patterns and escalating for review
Footwear and equipment: safe shoes, well-fitted walking aids, and OT-led adaptations

The key is consistency: if different staff do different things, the person’s risk increases.

Operational example 1: Toileting urgency driving repeat falls

Context: A resident with early-to-mid dementia falls twice in one week rushing to the bathroom in the late afternoon. They are embarrassed about continence and often refuse help.

Support approach: The team introduces a planned toileting routine linked to the person’s usual patterns, while maintaining dignity and privacy. They review hydration timing and reduce bladder irritants where clinically appropriate, escalating to GP if symptoms suggest infection.

Day-to-day delivery detail: Staff use discreet prompts (“shall we pop to the bathroom before tea?”), ensure the route is clear, and use consistent language and pace. A sensor light is fitted for evening hours. Staff offer support with clothing fastenings to reduce time pressure and rushing. The plan includes what to do if the person declines: step back, re-offer in 10 minutes, and monitor cues (fidgeting, pacing, checking doors).

How effectiveness is evidenced: Falls reduce to zero over four weeks. Continence incidents reduce, and staff notes show improved cooperation with prompts. The service records the change in the falls log and reviews the support plan monthly to ensure it stays aligned as cognition changes.

Post-fall response: the part services often under-do

A post-fall response must be clinically safe and operationally disciplined. A robust protocol includes:

Immediate checks: pain, head injury signs, skin tears, limb shortening, capacity to weight-bear
Decision-making: when to call 999, when to request urgent clinical review, and when to observe
Observation schedule after unwitnessed falls or head impact (with clear triggers to escalate)
Family notification and documentation of what was said and agreed
Same-day learning: what changed, what was the trigger, what can be altered immediately

The learning loop is essential: a fall is rarely “random” when you map the preceding hour.

Operational example 2: Night-time disorientation and unsafe transfers

Context: In supported living, a tenant gets up at night believing they need to “go to work”. They attempt to transfer without their walking frame and fall near the hallway.

Support approach: The team combines environmental adjustments with gentle reorientation and safe transfer support. They also explore sleep pattern and possible pain or urinary urgency contributing to night waking, escalating to GP if concerns persist.

Day-to-day delivery detail: Staff ensure the frame is positioned consistently and visible. A low-glare night light is installed. The overnight staff use a scripted, reassuring approach (“You’re safe at home, it’s night-time; let’s get comfortable”), offer the toilet with support, and guide the person back to bed without confrontation. A “night routine” plan is added that specifies what to do if the person insists on leaving the flat (de-escalation steps, when to call the on-call manager, and safeguarding considerations if risks escalate).

How effectiveness is evidenced: The number of unsafe night transfers reduces, and incident data shows improved response consistency across staff. Supervision notes confirm staff confidence in the script and protocol. A follow-up review identifies that night waking increased when constipation worsened; once addressed, waking frequency decreased further.

Frailty and positive risk-taking: enabling movement safely

A frailty-informed approach recognises that reduced activity increases weakness, which increases falls risk. Services should therefore support safe movement rather than discourage it. Practical enablement includes:

Short, supported walks at predictable times (after meals, mid-morning)
Chair-based strength work integrated into daily routines (standing practice with supervision, sit-to-stand coaching)
Meaningful reasons to move (gardening, laundry routines, familiar tasks)
Monitoring fatigue and adjusting expectations on “bad days”

Operational example 3: Balancing independence with supervision after a hospital discharge

Context: A person returns from hospital after a fall-related admission. They are deconditioned and weaker, but strongly values independence and becomes distressed if “hovered over”.

Support approach: The service agrees a graded enablement plan with the person and family, aligned to OT/physio guidance. The plan focuses on dignity: support is framed as “coaching” rather than “control”.

Day-to-day delivery detail: Staff support transfers using a consistent cue sequence (“feet back, nose over toes, stand, pause, step”) and position themselves for safety without crowding. They set up the environment before movement (chair height, clear path, frame within reach). A daily mobility note records what the person managed, what support was needed, and any dizziness, pain or breathlessness. Staff escalate promptly if new symptoms emerge (e.g., sudden confusion suggesting infection or delirium).

How effectiveness is evidenced: Over six weeks, the person progresses from supervised transfers to prompt-only support in familiar areas. Falls do not recur, and the service can demonstrate measured enablement: increased walking distance, improved confidence, reduced distress, and consistent documentation supporting clinical review if needed.

Service-level governance that holds up under scrutiny

Falls governance is not just individual risk plans; it is how the service manages trends. A credible model includes:

Weekly review of incidents with “repeat fall” flags and immediate action planning
Monthly analysis: time of day patterns, location hotspots, staffing factors, and recurring triggers (toileting, fatigue, distress)
Joint working: evidence of OT/physio involvement and timely adaptations
Learning actions tracked to completion (e.g., lighting upgrades, furniture changes, refresher coaching)

Where restrictions are considered (e.g., sensor mats, increased supervision), documentation should show capacity considerations, least restrictive reasoning, and planned review—so enablement remains the default.

What “good” looks like in dementia falls support

Good dementia falls and frailty support is visible in everyday practice: consistent prompts, safer environments, predictable routines, and staff who can explain the “why” behind actions. Post-fall response is structured and learning-led, not reactive. Most importantly, services protect independence by enabling movement safely rather than removing it—meeting both commissioner expectations and inspection standards in a way that families can trust.