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Fall Prevention for a Person with Dementia in the Ruby State Who Has Monocular Vision

When your loved one is in the Ruby state—high-energy, restless, and driven to move—and also has monocular vision, the risk of falling multiplies. Their brain is working against gravity with only one eye providing depth perception, making missteps and collisions more likely. This article gives you concrete, step-by-step ways to reduce that risk, from adjusting the environment to using specific phrases that redirect their energy safely. You are not alone in this; small changes can make a big difference.

Key points

  • The Ruby state (high energy) combined with monocular vision (poor depth perception) creates a high fall risk. Prevention is key.
  • Remove all clutter and area rugs from walkways. Use bright, even lighting to eliminate shadows, especially in the evening.
  • Use a shower chair for any task that involves closing the eyes, like washing hair or face.
  • Keep frequently used items within arm's reach to reduce the need to walk around.
  • Use redirection phrases to channel their restless energy into seated or slow-moving activities.
  • Ensure they wear non-slip shoes or socks with grips. Avoid bare feet or socks on hard floors.
  • Stand up slowly and drink enough water throughout the day to prevent dizziness from blood pressure changes.
  • Talk to their clinician about medications, vision aids, and physical therapy to further reduce fall risk.

Why the Ruby State and Monocular Vision Together Create a High Fall Risk

The Ruby state is characterized by high energy, restlessness, and a strong drive to move or do things. Your person may pace, try to help, or seem unable to settle. This is not willful behavior; it is a symptom of their dementia. Their brain is telling them to keep going, even when their body is tired or their balance is off. When you add monocular vision—seeing with only one eye—the brain loses a key tool for judging distance, depth, and the position of objects in space. This combination means they are more likely to misjudge a step, bump into furniture, or lose their balance while moving quickly.

How Sundowning and Evening Shadows Increase the Danger

Many people with dementia experience sundowning, a state of increased confusion and agitation that often begins in the late afternoon or early evening. Shadows from the setting sun can look like holes, steps, or moving objects to a person with monocular vision. Their brain may interpret a shadow on the floor as a drop-off, causing them to freeze, step back, or try to avoid it—and that sudden movement can lead to a fall. The Ruby state can make this worse because they are already in motion and less able to pause and re-evaluate. Keeping the environment well-lit and reducing shadows is a critical prevention strategy.

The Role of Dehydration and Blood Pressure Changes

Dehydration is a common cause of falls in people with dementia. When the body is low on fluids, blood pressure can drop when standing up, causing lightheadedness or dizziness. This is especially dangerous for someone who is already moving quickly in a Ruby state. They may not recognize the warning signs or be able to communicate them. Monocular vision adds another layer: if they feel dizzy, their depth perception is already compromised, making it even harder to steady themselves. Ensuring they drink enough water throughout the day and stand up slowly can prevent many falls.

General caregiving information, not medical advice. Check medications and major care changes with your clinician.

Step-by-step

  1. Remove all clutter from main walkways, especially items at ankle height like cords, shoes, or low furniture legs. Walk through every room your person uses and look at the floor from their eye level (about 4 feet off the ground). If you see anything that could cause a trip, move it or mark it with bright tape.

  2. Install bright, even lighting in every room they use, especially in hallways and the bathroom. Use nightlights in the bathroom and along the path from the bedroom to the toilet. For evening hours, close blinds or curtains to reduce shadows from the setting sun, and turn on all overhead lights to create a consistent, shadow-free environment.

  3. Place a shower chair or bench in the tub or shower. Encourage your person to sit down whenever they close their eyes to wash their face or hair. Say, 'Let's sit down so you can relax while you wash. I'll hand you the soap.' This prevents the loss of balance that happens when vision is temporarily blocked.

  4. Keep frequently used items—remote control, water glass, reading glasses, phone—within arm's reach of their favorite chair or bed. This reduces the need to get up and walk across the room for something they might forget they were looking for. Place these items on a small table or in a caddy attached to the chair.

  5. Use a white noise machine or soft music in the late afternoon to reduce sudden noises that might startle them. Startling can cause a quick, unbalanced movement. Keep the volume low and consistent. This also helps calm the Ruby state by reducing environmental triggers.

  6. Provide well-fitting, non-slip shoes with closed backs and good traction. Avoid slippers, socks on hard floors, or backless shoes. If they resist wearing shoes, try a pair of non-slip socks with rubber grips on the bottom. Say, 'These will help you feel steady on your feet.'

  7. Create a consistent daily routine that includes morning exposure to natural light. Within 10-15 minutes of waking, open the curtains or sit outside for a few minutes. This helps reset their circadian rhythm and reduces the intensity of sundowning later in the day, which in turn lowers fall risk.

  8. Encourage them to stand up slowly from sitting or lying down. Count to 10 before they take their first step. You can model this by saying, 'Let's take our time. I'll count to three, and then we'll stand up together.' This helps prevent orthostatic hypotension (blood pressure drop) that can cause dizziness and falls.

What not to do

  • Do not grab or pull them suddenly if they start to fall. This can cause injury to both of you and may make them more agitated. Instead, lower them gently to the floor by supporting their back and guiding them down. Call for help if needed.

  • Do not leave area rugs on the floor, even if they are secured with tape. The edge can still catch a foot. Remove all area rugs from rooms they use. If you need a rug for comfort, choose a low-pile carpet that is wall-to-wall or use a large, flat mat that is taped down on all sides.

  • Do not assume they can see obstacles just because you can. With monocular vision, depth perception is impaired. Place brightly colored tape on the edge of steps, the threshold of doorways, and the front edge of furniture like coffee tables. This gives their brain a visual cue to slow down.

  • Do not let them walk in the dark, even for a moment. Install motion-sensor nightlights in every room and hallway. If they get up at night, the light will come on automatically. This is especially important for bathroom trips, which are a common time for falls.

  • Do not try to reason with them during a Ruby state episode. Their brain is not processing logic well. Instead of saying, 'You need to sit down or you'll fall,' use a redirection phrase like, 'Let's go see what's in the kitchen. I need your help with something.' This channels their energy into a safer activity.

Practical tools

  • The 'Within Reach' Caddy

    A small basket or caddy attached to the arm of their favorite chair or placed on a side table. Fill it with the remote, a water bottle, their glasses, and a small snack. This reduces the need to get up and walk across the room for items they use often. Check it daily and restock.

  • Non-Slip Socks with Grips

    Socks with rubber dots or strips on the bottom. Buy several pairs so they are always clean and available. If they refuse shoes, these are a good alternative. Look for ones with a wide, non-binding top so they are comfortable. Wash them in a mesh bag to keep the grips intact.

  • Shower Chair or Bench

    A plastic or aluminum chair that fits inside the tub or shower. Place it so they can sit while washing. Say, 'This chair is for you to sit on while you wash your hair. It's much easier.' Make sure it has rubber feet to prevent slipping. Test it yourself first to ensure stability.

  • Bright Tape for Visual Cues

    Use brightly colored tape (like neon yellow or orange) to mark the edges of steps, door thresholds, and the front edge of furniture. Apply it in a straight line. This provides a visual warning for someone with monocular vision who may not see the depth change. Replace tape when it wears.

  • Motion-Sensor Nightlights

    Plug-in nightlights that turn on automatically when they detect movement. Place one in the hallway, one in the bathroom, and one in the bedroom. Choose ones with a warm, soft light to avoid startling them. Test them weekly to ensure they work.

  • Redirection Script for Ruby State

    A short list of phrases to use when they are restless and moving quickly. Examples: 'I need your help folding these towels.' 'Let's go look at the bird feeder together.' 'Can you show me how to do this puzzle?' These phrases redirect their energy into a purposeful, seated or slow-moving activity.

Discuss with your clinician

Ask the doctor if any of their current medications could be causing dizziness or increasing fall risk. Some blood pressure meds, sedatives, or antidepressants can affect balance.

Ask about a referral to physical therapy for balance and strength training. A PT can also recommend the right type of walker or cane and teach you both how to use it safely.

Ask about a vision evaluation to see if their monocular vision can be improved with glasses or other aids. Even small improvements can help with depth perception.

Ask about a home safety evaluation by an occupational therapist. They can recommend specific grab bar placements, bed heights, and other modifications tailored to your home.

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