professor keith hill, head, school of physiotherapy and exercise science, email...
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Professor Keith Hill, Head, School of Physiotherapy and Exercise Science, email Keith.Hill@Curtin.edu.au
Gippsland Forum: Falls prevention for people with dementia (Sept 2014)
Falls and dementia: Epidemiology and interventions
Main focus of presentation: community setting
Falls prevention for older peopleMagnitude of the problemRisk factorsEvidence of effective interventions
Fall prevention for people with dementiaMagnitude of the problemRisk factorsEvidence of effective interventions
Falls prevention and injury prevention
Overview
What is dementia: “a set of symptoms that may include memory loss
and difficulties with thinking, problem-solving or language. Dementia is
caused when the brain is damaged by diseases, such as Alzheimer's
disease or a series of strokes. Dementia is progressive disorder…”
Different types of dementia• Alzheimer's disease (AD): 62%• Vascular dementia (VaD): 17%• Mixed dementia (AD and VaD): 10%• Dementia with Lewy bodies: 4%• Fronto-temporal dementia: 2%• Parkinson's dementia: 2%• Other dementias: 3%
Dementia
Alzheimer’s Society (UK)
Alzheimer’s disease (most common form of dementia)
Progressive degenerative disorder
Currently leading cause of disability in Australia
Incidence of new cases in Australia projected to increase from:
69000 new cases in 2009, to
385000 new cases in 2050 (Access Economics 2009)
Falls One in three older people fall each year
10% of falls cause serious injury
Leading cause of injury related hospitalisations among older
people in Australia (78600 fall related hospitalisations 2008-9)
(AIHW 2012)
10% of bed days for older people attributable to falls (AIHW
2012)
Direct costs to the health care system in Australia was
$648million in 2007-8
The importance of dementia and falls
FALLS
Dem
entia
Ageing populations
0
20
40
60
80
100
older people people withstroke
people withParkinson's
disease
people withpolio
people withdementia
Lord et al, 1993; Forster & Young, 1995; Hill, 1998; Hill & Stinson, 2004Lord et al, 1993; Forster & Young, 1995; Hill, 1998; Hill & Stinson, 2004
???
Falls in clinical groups
Survival curve (time to first fall) - community sample – Out-patient clinic
Allan et al, 2009
Falls in 12 months (prospective)• Alzheimers disease – 47%• Vascular dementia – 47%• Dementia with Lewy
Bodies – 77%• Parkinson’s disease
dementia – 90%
aspects of the neurological condition
unrecognised falls risk factors
other
Why the increased falls risk in people with dementia?
Intrinsic factors
Extrinsic factors
Medications
HealthProblems (incl
balance dysfunction)
Ageing
Environment
Activityrelatedrisks
eg.psychoactive meds
Behavioralfactors
Falls are multi factorial
0
10
20
30
40
50
60
70
80
0 1 2 3 4+
Number of risk factors
Perc
en
tag
e w
ho
fell
Tinetti et al, 1988NB: Modifiable vs non-modifiable risk factors
Number of risk factors
Factors commonly associated with fallers:previous falls lower extremity weaknessarthritis (hips / knees)gait / balance disorderscognitive disorders (depression / dementia / poor
judgement...)visual disorderspostural hypotensionbladder dysfunction (frequency / urgency / nocturia /
incontinence...)medications (psychotropics/ sedatives / hypnotics /
antihypertensives...) Others (stroke, PD)
Falls risk assessment tools to classify risk
Tideiksaar, 1995
Identifying who is at risk of falls…
Shaw et al 2003 (Geriatrics & Ageing)
*
Risk factors for falls for people with dementia
The importance of reporting falls or near falls
• One of the strongest risk factors for future falls
• Only 25% of older people report a fall to a Doctor or health professional
• accept falls as inevitable part of ageing
• concern of consequences of reporting a fall
• Better chance of successful interventions
• Avoid development of secondary
complications such as loss of confidence
and reduced activity
Falls risk assessment tools – examples:
Physiological Profile Assessment – PPA (FallScreen) http://www.neura.edu.au/fbrg
Quickscreen http://www.neura.edu.au/research/
facilities/falls-and-balance-research-group/quickscreen
Falls risk for older People – Community
version (FROP-Com) National Ageing Research Institute
Identifying falls risk
Some reliability research with people with
cognitive impairment
http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html
The FROP-Com
COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants)
What works in falls prevention for older people in the community setting
There is good research (at least one randomised trial) evidence that a number of single interventions can reduce falls / injuries:
• exercise (home exercise; tai chi, group exercise)• cataract extraction / change multifocal glasses to 2 sets of glasses• psychotropic medication withdrawal / medication review• home visits by Occupational Therapists• improved post hospital discharge follow-up• approaches to support client uptake in recommended interventions• vitamin D and calcium supplementation (in low vit D cases)• cardiac pacemaker for carotid sinus hypersensitivity• foot exercise, footwear and orthoses
multiple interventions based on a falls risk assessment have also been shown to be effective (including in high falls risk groups, eg older fallers presenting to ED)
Common exclusion criteria:
cognitive impairment
Safe footwear
Treat posturalhypotension
Eyesight review
Treat incontinence
Change gait aid
Other interventions ??????
Summary of what works: falls prevention interventions in the community setting for
people with dementia (randomised controlled trials)
Shaw et al, 2003 - RCT
Unsuccessful RCT – results (??some trends)
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Recently published meta-analysis:Exercise vs usual care for fallers versus non-fallers –
participants with dementia (community)
Burton E et al, e-pub ahead of publication, Clinical Interventions in Aging
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Some learnings from successful RCTs in cognitively intact older people
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Evidence of what works in exercise in falls prevention
Group exercise programs
Home exercise programs (often prescribed by a physiotherapist
Tai Chi- (note: different types of Tai Chi may have different effects)
Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011)
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Exercise and falls prevention: what we know…
22Sherrington C, et al. NSW Public Health Bull. 2011 Jun;22(3-4):78-83
54 RCTs (all settings, though most in community)
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Appropriate exercise prescription - Horses for courses
Very frail/High falls risk
Healthy older people
CONTINUUM OF FRAILTY
Tai chi for arthritis – Sun style 24 form Beijing style – Yang style
Otago Exercise Program “Otago Plus” – incl VHI kit
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Exercise interventions (recent study)
Sample with disabling foot pain and increased falls risk
Intervention=foot & ankle exercise, footwear subsidy, and orthoses provision
Intervention group had 36% fewer falls, p<0.05
Spink M et al,, .BMJ. 2011 Jun 16;342:
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Vision - Single vs multi focal lens glasses
Sample=regular wearers of multi-focal glasses
Intervention=provision of single lens glasses for walking and outdoor activities
8% (non significant) reduction in falls in intervention group
Significant reduction in outdoor falls in those with regular outdoor activity
Haran M et al,, .BMJ. 2010 May 25;340:c2265
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Medication review Sample=older patients of 20 general practitioners
Intervention=education (academic detailing, provision of prescribing information, medication risk assessment, medication review, financial incentives)
Intervention group had improved medication use at 4 mths, and reduced risk of having a fall or injury at 12 mths (p<0.05)
Pit S et al, Med J Aust, 2007 ;187(1):23-30.
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Cumming R et al, 1999 JAGS; 1397-402
Sample= 530 older people discharged from hospital
Intervention=home visit by OT targeted at reducing home hazards
Significant reduction in falls in home modification group
50% of home modifications remained in place 12 months later
Improved outcomes with higher adherence
Home safety modifications
42% of a community sample with mild-moderate dementia
fall at least once each year (9% fallers suffered leg #)
Most common falls related hazards in homes: included: low chairs (57%), absence of grab rails (toilet – 48%), loose rugs (48%), missing 2nd bannister on steps (38%) and absent night lights (28%)
Horikawa et al 2005 (124 out-patients with diagnosis of probable AD); Lowery et al, 2000
Importance of home safety for people with dementia: Community setting
Best practice falls prevention with dementia
Evidence from community setting Falls risk assessment Exercise (balance focus) Cataract surgery Environmental modification Behaviour change Medication review Vitamin D Hip protectors
Other best practice options Appropriate footwear / glasses Correct use of walking aid Manage orthostatic hypotension Manage incontinence
Injury minimisation Hip protectors Vitamin D / calcium Anti-resorptive medication
Dementia is an independent risk factor for falls
Despite good evidence of many single and multifaceted falls prevention programs being effective for older people without cognitive impairment, there is very little
research demonstrating effectiveness for people with
dementia
Need to identify and manage existing falls risk factors of people with dementia
Promising research results using exercise for people with
mild to moderate dementia
Summary
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