Why does my parent with Parkinson's keep falling?

The first time my father fell, I thought it was just bad luck. The second time, I worried. By the fifth, sixth, seventh time, I was terrified — and desperate to understand why it kept happening.

If you're in that same place right now, watching a parent with Parkinson's disease fall repeatedly, I want you to know: it's not carelessness, it's not stubbornness, and it's not something they can simply "be more careful" about. Falls in Parkinson's are caused by real, measurable changes in the brain and body — specifically, the progressive loss of dopamine-producing neurons in a brain region called the substantia nigra.

It's not just "being unsteady"

When most people think about falling, they imagine tripping over something. But falls in Parkinson's disease (and related conditions grouped under the term parkinsonism) are fundamentally different. They come from the inside — from neurodegeneration disrupting the basal ganglia, the brain circuitry responsible for initiating and controlling movement, maintaining posture, and processing sensory feedback.

Here's what's actually going on:

Their automatic balance reflexes are impaired

Healthy people constantly make tiny, unconscious adjustments to stay upright. Your brain integrates signals from three systems — proprioception (body position sense), the vestibular system (inner ear balance), and vision — and sends corrective motor commands in milliseconds. In Parkinson's, dopamine depletion in the basal ganglia disrupts this sensorimotor integration, so these automatic postural reflexes become slow, small, or absent entirely.

When your parent stumbles, their body simply can't correct fast enough. The compensatory step they take is too small, too slow, or doesn't come at all. This is called postural instability, and it's one of the four cardinal motor features of Parkinson's (alongside bradykinesia, rigidity, and resting tremor). You may also notice retropulsion — a tendency to topple backwards — which is especially dangerous because we can't see what's behind us.

Their feet literally freeze to the floor

Freezing of gait (FOG) is one of the most frightening symptoms for both the person experiencing it and the people watching. Their feet suddenly feel glued to the ground, but their upper body keeps moving forward. The result is a fall. Researchers believe FOG involves a breakdown in communication between the basal ganglia, the supplementary motor area, and the pedunculopontine nucleus (PPN) — brain regions that coordinate the automatic rhythm of walking.

Freezing accounts for 61% of all falls in Parkinson's disease. It becomes more common as the disease progresses and as levodopa (the primary dopamine-replacement medication) begins to lose its consistent effect. FOG is triggered by specific situations:

• Walking through doorways or narrow spaces
• Turning around, especially in tight spaces
• Approaching a chair or destination
• Feeling rushed, stressed, or anxious
• When medication wears off ("off" periods)

Their blood pressure drops when they stand up

Orthostatic hypotension (OH) affects 30-58% of people with Parkinson's. It's a direct consequence of autonomic dysfunction — the disease damages the nerves that regulate involuntary functions like blood pressure, heart rate, and digestion. Specifically, the noradrenergic neurons that help blood vessels constrict when you stand are depleted. When your parent stands up, their blood pressure drops suddenly, causing dizziness, lightheadedness, blurred vision, and sometimes syncope (fainting).

Certain PD medications can worsen this. Dopamine agonists like pramipexole (Mirapex) and ropinirole (Requip), as well as levodopa/carbidopa (Sinemet), can lower blood pressure as a side effect. This is why your parent might seem fine sitting down but becomes unsteady the moment they stand. The fix seems simple — stand up slowly, in stages — but PD also impairs their ability to judge how quickly they're moving. If OH is severe, the neurologist may prescribe fludrocortisone, midodrine, or droxidopa (Northera) to raise blood pressure.

Their brain can't handle walking and thinking at the same time

For most of us, walking is automatic — controlled by the basal ganglia without conscious thought. We can walk and talk, carry groceries, look at our phone. In Parkinson's, dopamine depletion forces walking to shift from automatic (basal ganglia) to voluntary control (the prefrontal cortex and frontal lobe). Walking now requires conscious effort and competes for the same limited executive function resources used for thinking, planning, and attention.

When your parent tries to walk and do anything else — talk to you, carry a cup of tea, think about where they're going — their gait deteriorates. Steps get shorter, shuffling increases, and falls become much more likely. Researchers call this dual-task interference, and it's one of the reasons people with PD are told to "do one thing at a time."

Their steps are getting smaller without them realising

One of the cruelest aspects of Parkinson's is that the brain loses its ability to accurately judge movement size — a deficit in proprioceptive scaling. Your parent may think they're taking normal steps, but they're actually shuffling with a shortened stride length. This is called hypokinesia (reduced movement amplitude), a direct consequence of bradykinesia (slowness of movement). You may also see festination — involuntary small, rapid, accelerating steps that look like they're chasing their own centre of gravity. This is why telling someone to "take bigger steps" sometimes actually works — they need to consciously override what the depleted basal ganglia is telling them feels normal.

Why it gets worse over time

Falls in Parkinson's tend to increase as the disease progresses, for several compounding reasons:

• Disease progression — as neurodegeneration continues and more dopaminergic neurons are lost, all motor symptoms worsen. On the Hoehn and Yahr scale, postural instability typically appears at stage 3 (of 5)
• Levodopa wearing-off — over years of treatment, the "on"/"off" fluctuations with levodopa/carbidopa become more pronounced and less predictable. During "off" periods, dopamine levels drop and motor symptoms surge, dramatically increasing fall risk
• Dyskinesias — prolonged levodopa use can cause involuntary writhing or jerking movements (levodopa-induced dyskinesias), which also destabilise balance
• Fear of falling leads to less activity, which causes muscle weakness and deconditioning, which causes more falls — a vicious cycle
• Cognitive changes — many people develop mild cognitive impairment or Parkinson's disease dementia, reducing the executive function needed to compensate for motor deficits

What you can actually do about it

Understanding why your parent falls is important, but what you really want to know is: how do I help?

Get a physical therapy referral

This is the single most impactful step. A physical therapist experienced with Parkinson's can assess your parent's specific fall risks and create a targeted exercise programme. Supervised exercise reduces falls by approximately 35% (Cochrane Review, 2022). Ask specifically about LSVT BIG therapy, which exploits neuroplasticity — the brain's ability to form new pathways — to retrain larger, more confident movements that counteract bradykinesia.

Talk to their neurologist about falls

Falls are a medical symptom that should be actively managed, not just accepted. Their neurologist can optimise the levodopa/carbidopa (Sinemet) dosing schedule, adjust dopamine agonist timing, add a COMT inhibitor like entacapone (Comtan) or an MAO-B inhibitor like rasagiline (Azilect) to smooth out "off" periods, check for orthostatic hypotension, and refer to appropriate specialists. For advanced PD with severe motor fluctuations, deep brain stimulation (DBS) of the subthalamic nucleus may be discussed. Report every fall, even minor ones — it helps your neurologist understand whether the current medication regimen is working.

Make the home safer

Remove loose rugs, improve lighting, install grab bars in the bathroom, and clear walking paths. These changes sound simple, but they prevent a significant number of falls. An occupational therapist can do a professional home safety evaluation.

Learn to be a fall-prevention partner

• Don't rush them — time pressure triggers freezing
• Don't grab their arm if they're unsteady (this can cause both of you to fall)
• Do use verbal cues: "big steps," "heel first," counting together
• Do help them plan movements before standing or turning
• Keep a fall diary to identify patterns and triggers

Encourage movement, not rest

This is counterintuitive but critical. The more your parent moves — safely, with appropriate support — the stronger and more stable they'll be. Research suggests that vigorous exercise may have neuroprotective effects, potentially slowing dopaminergic neurodegeneration. Tai chi, dance classes for PD, Nordic walking, and even boxing programmes have all shown measurable benefits for gait velocity, stride length, balance confidence, and UPDRS motor scores (the standardised clinical scale for tracking Parkinson's symptoms).

You're not alone in this

Watching a parent fall is one of the hardest parts of this disease. The helplessness, the worry, the constant vigilance — it takes a toll on you too.

But know this: falls in Parkinson's are not inevitable, and they're not your fault. With the right support, the right environment, and the right information, you can meaningfully reduce how often your parent falls and how severe those falls are.

Start with one thing today. Call the neurologist, schedule a PT appointment, or remove that rug in the hallway. Every small action counts.