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Noticing Barriers Below The Knee

Although there can be a number musculoskeletal and sensory factors that may cause an older person to trip or stumble, the presence of Alzheimer’s disease greatly increases the risk.  A loss of depth perception and an inattention to things below knee level are common visu0-spatial deficits seen in Alzheimer’s disease.  Add in a little glaucoma, macular degeneration, and  a cataract or two, and the risk of tripping over the leg of a chair rises sharply.

This issue usually presents itself somewhere between the early and middle stages (4.0 on the Allen Cognitive Scale).

Part of our jobs as physical and occupational therapists is to mitigate the risk of falls.  When working with someone with dementia, traditional approaches are not always effective.   I cannot tell someone with Alzheimer’s disease to watch out for the leg of the table and expect them to remember the warning the next time they walk by.  I have to train someone with Alzheimer’s disease to learn the motor pattern of safe mobility through each specific room.  Repetition and training to locate the barriers will reinforce your cues.  The trick is to draw their attention toward the hazard over and over again.

Using procedural learning techniques, it is possible to train people with Alzheimer’s to visually locate tripping hazards.  Learning to locate and navigate around hard to see hazards requires repetition in a consistent environment.

I do this using Post It notes.



There is much to be said about the versatility of the Post It note.  But for teaching people with dementia to automatically know where the tripping hazards are, Post Its are a great training tool.  By marking each barrier below the knee with a bright tag, I can train someone with Alzheimer’s disease to purposely scan the room and try to find each piece of paper.  I don’t remove them, though.  We sometimes walk around the room counting the papers, drawing the visual attention of the person down to a level below the knee.



Although I would much prefer to remove area rugs like these from the home, sometimes that does not occur.  At least we can draw attention to the edges with bright markings and train the body to step carefully over the end of the rug.

I usually recommend leaving the papers on the low barriers for at least a month, with the recommendation for the caregivers to reinforce the location of each Post It and the barrier beneath it each time they walk by it.  Like most things in the environment, the awareness of the Post It note will fade into the ordinary.  Changing the color of the notes may promote a new awareness for a period of time.  Numbering the papers and making a “scavenger hunt” activity is another way to reinforce visual awareness.


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