Part 2 of 3 — A physiotherapist’s perspective for residential aged care management.
A behavioural label documents that an event occurred — not why. That distinction is where most falls programs stall.
In the first article in this series, I set out the epidemiological case that a clinically significant proportion of falls in residents with dementia are attributable to unmet need, not physical frailty alone. This instalment addresses a pattern I encounter routinely in otherwise well-run facilities: treating the behaviour as the diagnosis, rather than as a presenting symptom.
“Wandering.” “Agitation.” “Resisting care.” “Non-compliant with the care plan.” These terms appear in progress notes daily across the sector. They function as documentation. They do not function as clinical assessment. And left as the endpoint of the reasoning process, they will not move your facility’s falls indicators — because a behavioural label identifies that an event occurred, not why.
The scale of the problem you’re documenting
This isn’t a marginal issue. Behavioural and psychological symptoms of dementia (BPSD) affect up to 90% of people living with dementia over the course of their illness, and approximately 53% of residents in Australian residential aged care are living with dementia. Under the Australian National Aged Care Classification (AN-ACC) funding model, behaviour and cognition are assessed as distinct, direct cost drivers of care — meaning nearly one in two of your residents is likely to present with behavioural symptoms that are both clinically significant and financially material to your organisation, whether or not they are currently being investigated as such.
The clinical reasoning gap
When a resident with dementia repeatedly attempts to mobilise unassisted, the default operational response is often environmental or restrictive: relocation closer to the nurses’ station, a pressure-sensitive alarm mat, increased supervision rounds. These aren’t incorrect interventions — but they manage the falls risk as a logistics problem rather than a clinical one. If the underlying need — pain, boredom, loneliness, the urge to toilet — remains unidentified and unaddressed, the behaviour typically re-emerges in a different form, at a different time, or via a route the sensor doesn’t detect.
This is where a structured clinical reasoning process earns its place in your governance framework. The one I apply most consistently is the DICE framework — Describe, Investigate, Create, Evaluate — developed by an interdisciplinary US expert consensus panel specifically for the assessment and management of BPSD.
- Describe the behaviour and its context with clinical specificity — not “agitated in the afternoon,” but the precise antecedent, setting and sequence of events.
- Investigate contributors across three domains: the resident (pain, acute illness, sensory change), the caregiver (approach, communication, routine), and the environment (noise, lighting, unfamiliarity).
- Create a tailored, non-pharmacological response based on the investigation findings — not a standardised default.
- Evaluate the response against a defined outcome measure, and revise if the target isn’t met.
Applied to a falls review, DICE provides a repeatable, auditable process for interrogating what unmet need might explain the resident’s movement — before a restrictive or purely environmental response is documented as the intervention.
Structured assessment as the clinical prerequisite
DICE performs best when applied against a genuine needs baseline, not triggered reactively after each incident. The instrument I recommend to every clinical team for this baseline is the Camberwell Assessment of Need for the Elderly (CANE) — a comprehensive, person-centred needs assessment covering environmental, physical, psychological and social domains, validated for use with older people including those with dementia. Its clinical strength is structural: it captures the resident’s own perspective where possible, the family carer’s view, and the professional’s assessment concurrently, and defines a “need” formally as a problem paired with an appropriate intervention.
Validation studies of CANE in long-term care populations report an overall staff–resident rating agreement of 86.2%. Agreement falls substantially in specific domains, however — to 65.3% for company, 75.7% for memory, and 70.5% for both eyesight/hearing/communication and psychological distress. These are precisely the domains most likely to present as falls-related behaviour if they remain unassessed, and the data indicates staff are least confident assessing them without a structured tool.
Structured behavioural observation instruments, such as the Cohen-Mansfield Agitation Inventory, add a further layer of clinical rigour: they allow staff to quantify the frequency, pattern and antecedents of behaviours that frequently precede a fall — restlessness, pacing, repetitive vocalisation — converting anecdotal shift-note entries into longitudinal data your clinical governance committee can act on.
This is a compliance and funding obligation, not a discretionary enhancement
If you are assessing the return on investment of this level of clinical structure, it is worth noting that it is not optional in the way it may once have felt.
Under the strengthened Aged Care Quality Standards, effective from 1 November 2025, Standard 5 (Clinical Care) requires clinical care to be person-centred, evidence-based and responsive to each resident’s changing needs — explicitly including residents with cognitive impairment, across 35 discrete actions. The Commission’s guidance directs providers to implement person-centred, evidence-based falls prevention practice and to conduct a structured post-fall review. For a resident living with dementia, that review cannot satisfy the intent of Standard 5 unless it considers what unmet need may have contributed to the fall.
The AN-ACC funding instrument, which replaced the Aged Care Funding Instrument in October 2022 and became the sole funding model from 1 November 2025, adds a second, concrete obligation. AN-ACC allocates funding according to the resident attributes that most drive the cost of care — frailty, mobility, cognition, behaviour and technical nursing needs — with cognition and behaviour assessed through dedicated components of the tool. A resident’s unaddressed behavioural symptoms are therefore not solely a quality-of-care matter; they are a funding-relevant clinical attribute your organisation is already obligated to assess and document accurately. A facility that treats behavioural change as noise rather than clinical signal is forgoing both a falls prevention opportunity and an accurate resourcing outcome.
Implementation, in practice
Operationalising this doesn’t require a parallel system. It requires:
- CANE, or an equivalent validated tool, built into admission assessment and a scheduled review cycle — not triggered only by crisis.
- DICE applied as the standard clinical reasoning process for every fall or clinically significant behavioural change, not an occasional escalation pathway.
- The outcome of each intervention recorded against the specific need identified, not solely against the fall count, so the process is genuinely auditable and improves over successive review cycles.
Documenting the behaviour is where the paperwork stops. Identifying the need is where falls prevention actually begins. In the final article in this series, I turn to what should happen once the need is identified — and why a standardised group activity calendar is rarely a sufficient clinical response for your highest-risk residents.
Sources
Sources referenced include the strengthened Aged Care Quality Standards (effective November 2025) and Aged Care Quality and Safety Commission guidance, the Australian National Aged Care Classification (AN-ACC) casemix and funding literature (Eagar et al.; Wesson et al.), the Camberwell Assessment of Need for the Elderly (CANE) validation literature, and the DICE framework for BPSD management (Kales, Gitlin and Lyketsos).
This article is general information for operational planning purposes and does not replace individual clinical assessment or facility-specific policy review.
