Twice the Risk: Falls and Hip Fractures Among People With Dementia

People living with dementia fall more often than other older people, and are hurt more often when they do. The World Falls Guidelines, drawn up by 96 experts from 39 countries, state that dementia and mild cognitive impairment double the risk of falls and fall-related injuries, including hip fractures^[1]. After a hip fracture, people with dementia are more likely to die within a year: in Sweden, 39% died within a year of surgery, against 20% of people without dementia^[2].

A fall can change a life with dementia overnight. A broken hip means surgery, an unfamiliar ward, often delirium, and a long and uncertain recovery; for some people it is the point at which living at home ends. For families, and for care staff across whole homes, the worry about the next fall can be constant. This article sets out what registers, cohort studies, audits and guidelines from several countries show about how often people with dementia fall, what follows a hip fracture, and where services fall short.

People with dementia fall about twice as often as other older people

Falls are common in later life for everyone. The World Falls Guidelines report that falls occur in 30% of adults aged over 65 each year^[1], and the World Health Organization estimates that 684,000 people die from falls worldwide each year, and the greatest number of fatal falls are among adults over 60^[3]. Over 80% of those deaths are in low- and middle-income countries^[3].

Against that background, dementia stands out. In Australia’s Concord Health and Aging in Men Project, which followed 1,705 men aged 70 to 97 living in the community for an average of six years, the 93 men with dementia at the start had 2.26 times the rate of falls of men with normal cognition, after adjustment for other factors^[4]. A 2024 meta-analysis of 31 studies covering 4,654 older adults with Alzheimer’s disease put the pooled share who fall in a year at 44.27%, with an average of 1.30 falls per person per year; 42.08% were recurrent fallers^[5]. The review had no comparison group, so it shows how often falls happen, not how much higher the risk is.

How cognition is measured matters. An earlier meta-analysis of 27 studies linked impaired global cognition in community-dwelling older people to 2.13 times the odds of serious fall injury, while in institutions a dementia diagnosis was associated with any fall but not serious injury^[6].

Hip fractures are two to three times as common after a dementia diagnosis

In South Korea, a national health insurance cohort followed people newly diagnosed with dementia between 2003 and 2007, each matched by age and sex with five people without dementia, up to 2015. Over the 12-year follow-up, 10.66% of people with dementia had a hip fracture, against 4.53% of those without; dementia was independently associated with 2.84 times the hazard of hip fracture^[7]. The raised risk was highest within two years of diagnosis^[7].

In Finland, a register study of all community-dwelling people with a verified diagnosis of Alzheimer’s disease at the end of 2005, each matched with a person without it (56,186 people in all), found a hazard ratio of 2.57 for a new hip fracture over the following four years, after adjusting for health status and medicines^[8]. The extra risk was larger in men than women and shrank with age, but people with Alzheimer’s disease had a higher risk regardless of sex or age^[8]. In the Australian men’s cohort, dementia was linked to hip fractures but not other fracture types^[4].

These studies use different measures in different countries and years, so the figures are not directly comparable. What they share is direction: dementia goes with more falls and more hip fractures. That is association, not proof that dementia alone causes each fall.

Hospitals and care homes are where the risk is highest, and the gaps most visible

The World Falls Guidelines note that falls are more frequent among older adults living in care homes or during a hospital stay, and that delirium, cognitive impairment and dementia are independent risk factors for falls in hospitals, residential aged care and at home^[1]. In a secondary analysis of three national prevalence surveys in German hospitals (9,246 patients aged 65 or over in 37 hospitals), 12.9% of cognitively impaired patients had fallen in the previous two weeks, against 4.2% of those without cognitive impairment; after adjustment, cognitive impairment carried 2.1 times the odds of a fall^[9].

England and Wales audit inpatient falls that cause a hip fracture or other serious injury. In 2025, the National Audit of Inpatient Falls recorded 4,191 such cases from 169 trusts and 7 health boards, and estimates it captured just under 90% of expected inpatient hip fractures; hip fracture was the most common single injury, at 35%^[10]. The audit does not report dementia status, but it does report delirium, which the World Falls Guidelines list alongside dementia as a risk factor for falls^[1]. A delirium screen had been recorded before the fall in only 45% of cases, and the audit notes that delirium screening has continued to decline; where a 4AT score was recorded, 38% scored 4 or more, indicating delirium^[10]. Only 39% of people received pain relief within 30 minutes of the injurious fall^[10]. For more on delirium and emergency care, see our study on emergency admissions and delirium.

In care homes, falls can be very frequent and are often unseen. A small Dutch study of 20 long-term care residents with dementia recorded 5.1 falls per person per year over 19 months; 85% of residents fell, and only 28% of falls were witnessed^[11]. It is too small to generalise from, but fits the World Falls Guidelines’ advice that all care home residents should be considered at high risk of falls, without the need for screening^[1]. For more on care home settings, see dementia and care homes.

In Sweden, people with dementia were about twice as likely to die in the year after a hip fracture

A Cochrane review notes that over 40% of people with hip fracture have dementia or cognitive impairment^[12]. Recorded diagnoses give lower figures, partly because many people are undiagnosed: 22% of hip fracture patients aged 65 and over in Sweden had a dementia diagnosis before the fracture^[2], and 13.4% in a Korean national cohort aged 60 and over^[13].

Sweden’s linked national registers give the clearest picture of what follows. Among 111,353 people aged 65 and over who had hip fracture surgery between 2010 and 2018, deaths were roughly twice as common in people with dementia at every point measured: 13% against 6% within 30 days, 27% against 12% within four months, and 39% against 20% within a year^[2].

Other countries show the same direction, though the size of the gap depends on what is adjusted for. In Korea, after adjustment, people with dementia had 1.23 times the hazard of death in the year after hip fracture surgery^[13]. In the US Health and Retirement Study (2008–2018), predicted one-year mortality after hip fracture was 35.4% for people with dementia against 24% for people without; and while function stabilised for people without dementia after the fracture, it kept declining for people with dementia^[14].

Much of the difference may reflect frailty rather than dementia itself. A Swedish study of 121,305 hip fracture patients found that once measures of frailty, such as being able to walk alone outdoors and living in an institution, were included, dementia added little to predicting who would die^[15]. The higher death rate is not a fixed property of a diagnosis, but a signal of who needs the most skilled care.

Hip fracture care is less equal than it should be

There are signs that people with cognitive impairment receive slower and less complete care after a hip fracture. A review of 382 hip fracture admissions at one English hospital in 2024–25, using National Hip Fracture Database data, compared patients with dementia, suspected cognitive decline or delirium with cognitively unimpaired patients. Those with cognitive impairment waited longer for surgery (a median of 35.3 hours against 29.8), were less often mobilised early (81.6% against 89.9%), and were far less likely to return home (52.7% against 84.4%); 35.3% were discharged to residential care, against 7.5%^[16]. Agitation was often noted as a barrier to early mobilisation^[16]. This is one hospital and the figures are unadjusted, but services can check for the same pattern in their own data.

Evidence on how to do better is surprisingly thin. A 2020 Cochrane review of enhanced rehabilitation and care after hip fracture found seven trials (555 participants), and none of the interventions had been designed specifically for people with dementia; the data came from subgroups of larger trials^[12]. There was low-certainty evidence that enhanced in-hospital care may reduce postoperative delirium, and that geriatrician-led care may shorten hospital stays by about four days compared with orthopaedic-led care^[12]. For wider evidence on hospital stays, see dementia and hospital admissions.

Falls prevention for people with dementia rests on too few, too small trials

Exercise is the backbone of most falls prevention, but for people with dementia the trial evidence is fewer and weaker than it should be. A 2023 systematic review found 12 randomised trials of exercise among 1,827 people with a medical diagnosis of dementia. Exercise reduced falls in two; the other ten found no clear effect, and no trial was powered to detect a change in falls. The authors concluded there was insufficient evidence that exercise reduces falls, recurrent falls or injurious falls in people with dementia^[17].

An individual-patient analysis of seven trials (1,314 participants) found that 34.4% of people who exercised had at least one fall, against 41.3% of controls. One method of analysis found exercise reduced the odds of falling (odds ratio 0.75); another found no effect on any outcome^[18]. A broader review of 72 studies on falls in people with dementia found only 15 tested an intervention, and concluded there was insufficient evidence to endorse any intervention in any setting^[19].

Some trials are encouraging. In Australia’s Sunbeam trial in 16 long-term care homes, a subgroup analysis of 148 residents with mild to moderate cognitive impairment or dementia found that progressive strength and balance training reduced the rate of falls by 50% and injurious falls by 44%, with no serious adverse events^[20]. On balance, the World Falls Guidelines make a strong recommendation (GRADE 1B) that people living in the community with mild cognitive impairment or mild to moderate dementia be offered exercise to prevent falls, while noting that exercise has proved more effective in the community than in residential care^[1]. They also recommend that falls prevention plans include both the older person’s and their caregiver’s perspectives, which improves adherence and outcomes^[1].

What the evidence asks of us

The figures point in one direction: people living with dementia carry roughly double the risk of falls and hip fractures, worse outcomes after a fracture, and the weakest evidence base for prevention. The gap lies in services and research, not in the person. The evidence suggests several things for services, commissioners, funders and policymakers.

• Treat dementia as a falls risk from the point of diagnosis. In Korea, the extra risk of hip fracture was highest in the first two years after diagnosis^[7]. Post-diagnostic support is a natural place for falls risk assessment; see post-diagnostic support.
• Make exercise programmes accessible to people with dementia. The World Falls Guidelines strongly recommend exercise for people in the community with mild cognitive impairment or mild to moderate dementia, with closer supervision where impairment is greater, and with carers involved in planning^[1].
• Hold hospitals and care homes to the guidelines. The guidelines recommend against physical restraints to prevent falls in care homes, find no robust evidence for bed and chair alarms in hospitals, and say that when delirium, dementia and cognitive impairment are managed well, falls are less frequent^[1]. In England and Wales, fewer than half of people who had an injurious fall in hospital had a recorded delirium screen beforehand^[10].
• Audit hip fracture care by cognitive status. Where one hospital looked, people with cognitive impairment waited longer for surgery and were mobilised less often^[16]. National registries can report these measures routinely, so that unequal care becomes visible.
• Fund trials designed for people with dementia. No exercise trial in one major review was powered to detect an effect on falls^[17], and no hip fracture rehabilitation model in the Cochrane review was designed for people with dementia^[12]. Funders can change that, including in low- and middle-income countries, where most fall deaths occur^[3].

Language: this piece uses person-first language ("people living with dementia", "people with dementia"), as most dementia organisations and people with lived experience prefer, and uses clinical terms such as "Alzheimer's disease" or "mild cognitive impairment" only where a study, dataset or diagnosis refers to that specific condition.

Why we're publishing this

Falls are often treated as an unavoidable part of dementia, and a broken hip as the moment when things simply get worse. The evidence does not support that resignation. It shows a risk that can be named from diagnosis, care after a fracture that is not always equal, and a research base that has not yet been built around people living with dementia. We publish this so that dementia organisations, carers’ groups and campaigners can make that case with sourced figures from several countries. It sits within our Dementia & Health research library.

How to read this data

• Different measures. Studies report rate ratios, odds ratios, hazard ratios and simple percentages. They are not interchangeable; we name the measure each time.
• Diagnosed versus present. Register studies count people with a recorded dementia diagnosis; many people with dementia are undiagnosed, so registers likely understate how many hip fracture patients have dementia. The German hospital study measured cognitive impairment rather than diagnosed dementia, and the English hospital study grouped dementia with delirium and suspected cognitive decline.
• Association, not cause. Cohort and register studies show that dementia goes with more falls and worse outcomes; they cannot show that dementia alone causes them. The Swedish frailty study shows how much overlaps with frailty.
• Crude versus adjusted. The Swedish mortality figures are unadjusted; the Korean hazard ratio is adjusted and smaller.
• Countries and years. Figures come from Australia, Finland, Germany, the Netherlands, South Korea, Sweden, the UK and the US, over periods from 2002 to 2025. They are not directly comparable, and most evidence comes from high-income countries, even though most fall deaths occur in low- and middle-income countries.
• Abstracts. Most peer-reviewed figures were checked against abstracts; the guidelines and the audit were read in full.

Use this data

Free to cite with attribution to Understanding Aging. Charities, carers' groups, campaigners and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Important: This article summarises published research and statistics for general information. It is not medical, care or financial advice and cannot be used to diagnose, treat or predict anything about an individual. If you have concerns about your own or someone else's memory or health, please speak to a GP or another qualified health professional.

Sources

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