Professor Jacqueline CT Close

Neuroscience Research Australia

Prince of Wales Clinical School

University of New South Wales

Assessment and management of dementia in relation to falls risk: Tools and tips for

community, hospital and residential care

Why is it important

Annual falls incidence is 70-80%.

Fractures are up to 3x commoner in people with dementia.

Psychotropic drug use more common in people with

dementia.

26% of admissions to hospital for people with dementia are

fall related.

When admitted to hospital, people with dementia have

poorer outcomes including adverse events.

What do we need to know?

Is this person cognitively impaired (screen).

What domains of cognition seem to be affected most.

How is it impacting on function.

How will the identified impairments impact of potential

choice of intervention/s.

How will the impairments impact on how I deliver the

intervention.

Is dementia subtype important in relation to falls assessment and management

Allan LM, Ballard CG, Rowan EN, Kenny RA (2009) Incidence and

Prediction of Falls in Dementia: A Prospective Study in Older People.

PLoS ONE 4(5): e5521. doi:10.1371/journal.pone.0005521

Be clear as to why you are testing – it should determine the choice of test

Screening

Assessment of undiagnosed cognitive decline

Assessment with a view to tailoring falls prevention approach

How will the information gathered affect your management

Testing

Tests

AMTS

MMSE / sMMSE

MOCA

RUDAS

ACE-III

MMSE (Folstein 1975)

Affected by level of education, age & language

Low reliability

Too many easy items

Wrongly used as a unidimensional tool

Wrongly used to diagnose dementia

Wrongly(?) used to justify prescription of cholinesterase

inhibitors

MMSE / SMMSE

The ability to plan, organise, sequence tasks, problem solve etc.

Simple clinical examples

Clock drawing

Verbal fluency – letter, animals, supermarket

Alternating hand sequence

Luria’s three step

Trails A and B

Executive Function

MMSE 25 ACE-R 77

MMSE 28 ACE-R 74 MMSE 28 ACE-R 78 MMSE 26 ACE-R 72

Verbal Fluency

Assessing cognition though gait assessment

Assessing cognition though gait assessment

Higher level gait disorder

Apraxia - Inability to perform a skilled or learned act that

cannot be explained by an elementary motor or sensory deficit

or language comprehension disorder.

Initiation of gait

Posture

Velocity (m/s)

Cadence (steps/min)

Armswing

Heel strike

Turning / freezing

Foot clearance

Step length (cm)

Step length variability

Stride length variability

Impact of dual tasking

Assessment of gait

Overall falls risk score 1.88

66 year old woman with multiple falls MMSE 24/30 and knee pain

Painful knee but predominantly falling backwards

Upright posture and gait apraxia

Complex processing speed - slowed.

Acquisition of new visual information - impaired

Visuospatial skills - variable

Problem solving skills - poor

Orientation, attention, working memory and verbal memory

skills remain preserved

Cognitive Assessment

How did the assessment help

Explained functional decline which was being attributed to

knee OA

Provided clarity as to indication for TKR

Prepared clinical team in advance of admission for TKR

Realistic goals for rehabilitation and discharge planning

Future planning

Intervention

If the mechanism by which the intervention has it’s effect is understood and not felt to affected by the presence of

cognitive impairment / dementia then it is reasonable to extrapolate data from trials undertaken in cognitively intact

populations

Example. Treatment of osteoporosis

Extrapolation from existing trials

Intervention - Community Rate of falls Risk of falling

Multicomponent group exercise (16, 22) RaR 0.71 (0.63-0.82) RR 0.85 (0.76-0.96)

Multicomponent home exercise (7, 6) RaR 0.68 (0.58-0.8) RR 0.78 (0.64-0.94)

Tai Chi (5, 6) RaR 0.72 (0.52-1.0) RR 0.71 (0.57-0.87)

Multifactorial interventions (19, 34) RaR 0.76 (0.67-0.86) RR 0.93(0.86-1.02)

Vitamin D (7, 13) RaR 1.00 (0.9-1.11) RR 0.96 (0.89-1.03)

OT intervention (6, 7) RaR 0.81 (0.68-0.97) RR 0.88 (0.8-0.96)

Vision intervention (1) RaR 1.57 (1.19-2.06) RR 1.54 (1.24-1.91)

Cataract extraction (1) RaR 0.66 0.45-0.95 -

Bifocal / multifocal glasses (1) RaR 0.92 (0.73-1.17) RR 0.97 (0.85-1.11)

Psychotropic withdrawal (1) RaR 0.34 0.16-0.73

Pharmacy detailing - RR 0.61 (0.41-0.91)

Pacemakers (3) RaR 0.73 0.57-0.93

Podiatry for painful feet (1) RaR 0.64 0.45-0.91

Anti-slip shoe (1) RaR 0.420.22-0.78 -

Increase knowledge/educate /CBT (2,6)

FOCIS - Prospective risk factor study. n=174

Recruitment

Re Assessment Measures

Baseline Measures &

Randomisation

Monthly Falls Calendars

INTERVENTION 26 weeks

Exercise Program

i-FOCIS Pilot 2

Intervention - Hospitals Rate of falls Risk of falls

General hospital setting

Trained nurse targeting individual fall risk factors (1)

_ RR 0.29 (0.11-0.74)

Multifactorial interventions (4, 3) RaR 0.69 (0.49-0.96) RR 0.71 (0.46-1.09)

Orthogeriatric MoC (1, 1) RaR 0.38 (0.19-0.74) RR 0.41 (0.20-0.83)

Subacute setting

Exercise (1, 2) RaR 0.54 (0.16-1.81) RR 0.36 (0.14-0.93)

Carpet flooring (1) RaR 14.73 (1.88-115.35)

RR 8.33 (0.95-73.97)

Hospital

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Number of sedatives dispensed per month - POWH

Antipsychotic use - POWH

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POW Med & Surg: mg Haloperidol / mth

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POW Med & Surg mg Olanzapine / mth

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POW Med & Surg mg Risperidone/ mth

Intervention - RACFs Rate of falls Risk of falling

Exercise (8,8) RaR 1.03 (0.81-1.31) RR 1.07 (0.94-1.23)

Vitamin D (5,6) RaR 0.63 (0.46-0.86) RR 0.99 (0.90-1.08)

Multifactorial interventions (7,7) RaR 0.78 (0.59-1.04) RR 0.89 (0.77-1.02)

Post hoc analysis suggests that people in intermediate care facilities may

benefit from exercise but in high level care the risk may be increased

How will the presence of cognitive impairment impact on how I deliver

my intervention/s

Identifies underlying cognitive processes – focuses on preserved cognitive abilities

Helps tailor content and instruction process

Helps educate carers re

expectations for behaviour

Functional cognition

Assessment of Functional Cognition

The Future

THE i-FOCIS Overview

• RCT

• 360 subjects

• Diagnosis of cognitive impairment

• Community dwelling

• Carer – 3.5hrs+/ week contact

THE i-FOCIS Overview

• Can a professionally prescribed, carer assisted exercise and home hazard reduction program reduce falls in people with dementia

– Rate of falls (control 1.8 falls/yr – 30% reduction, mean follow-up 11 months)

– Number of fallers

• Secondary aims – function, QoL, uptake and adherence, cost and cost-effectiveness

Acknowledgements

Morag Taylor

Stephen Lord

Cathie Sherrington

Kim Delbaere

Jacki Wesson

Lindy Clemson

Henry Brodaty

Laura Gitlin

Stef Mikolaizak

Barbara Toson

James Scandol