Managing falls in older patients with cognitive impairment

Morag Taylor

1. Background

2. Risk factors

3. Fall risk assessment

4. Interventions

Background - Dementia

2012 2050

2012 2050

115 million people

300 000 people 1 million people

36 million people

2 fold increase in population > 65yrs by

2050

Falls and consequences

Background - Falls in Dementia

• Fractures 2-3 x more common

• More centrally acting drug use

• More gait abnormalities

• More likely to be placed in residential care

0

10

20

30

40

50

60

70

Intact Impaired

Pe

rce

nt

fall

eac

h y

ear

Multiple (2+) Faller (1+)

Domain and risk factor Impaired Intact

Sociodemographic and environmental

Age Inconsistent findings Yes

Female gender Inconsistent findings Yes

White race Not studied Yes

Lives alone No† Yes

Previous falls Yes Yes

Mobility aid use Yes Yes

ADL impairment Inconsistent findings Yes

Reduced physical activity Yes† Yes

Environmental hazards No Inconsistent findings

Domain and risk factor Impaired Intact

Medical conditions

Cerebrovascular disease Yes Yes

Parkinson’s disease/parkinsonism Yes Yes

Cerebellar disorders Not studied Not studied

Orthostatic hypotension Inconsistent findings Inconsistent findings

Syncope Not studied Not studied

Vestibular dysfunction Not studied Not studied

Eye disease

Cataracts Yes† Yes

Glaucoma Not studied Not studied

Age-related macular degeneration Not studied Yes

Arthritis Yes† Yes

Urinary incontinence No* Yes

Peripheral vascular disease Not studied Not studied

Domain and risk factor Impaired Intact

Psychological disorders

Depression Yes† Yes

Anxiety Yes Not studied

Fear of falling Yes† Yes

Medication use

Polypharmacy Yes Yes

Centrally acting medications Yes Yes

Sedatives/hypnotics Inconsistent findings* Yes

Antidepressants Yes* Yes

Antipsychotics Inconsistent findings Yes

Dementia drugs No n/a

Analgesics No* Inconsistent findings

Cardiovascular medications Yes† Inconsistent findings

Domain and risk factor Impaired Intact

Sensorimotor performance, balance and gait

Strength Inconsistent findings Yes

Vision No Yes

Peripheral sensation Yes† Inconsistent findings

Proprioception No Yes

Tactile sensitivity Not studied Yes

Reaction time Yes† Yes

The vestibular system Not studied Not studied

Postural stability and balance Yes Yes

Gait

Simple Yes Yes

Dual task Yes† Yes

Domain and risk factor Impaired Intact

Cognitive factors

Global Inconsistent findings Inconsistent findings

Executive function and attention Yes Yes

Processing speed Yes† Inconsistent findings

Memory Inconsistent findings No

Visuospatial ability Inconsistent findings Inconsistent findings

Language No* No

Fall risk assessment in dementia

Tool Population tested

Follow-up

Author/more info

Physiological Profile Assessment

Community Nursing home

12/12 6/12

Taylor 2012

Whitney 2012

Performance Oriented Mobility Assessment

Community Nursing home

12/12 3/12

Allan 2009

Sterke 2010

Four-item nursing home tool or seven-item CaHFRiS

Nursing home 6/12 Whitney 2012 Whitney 2012

Physiological Profile Assessment (PPA)

2.5

Melbourne Edge Test Proprioception Simple Reaction Time

Knee Extension Strength Postural Sway Fall Risk Score: predicts recurrent falls

with 75% accuracy (Lord et al., 2003)

x

x x

x x

x

x x x

x

c

c c

Error Score = 28

x

x

x

Coordinated Stability

CaHFRiS (Whitney 2012, n=254, 89% cog imp)

Whitney 2012 – n=110, all with cognitive impairment

Fall Prevention in Dementia

Setting Study Intervention Fall

Outcome

Ho

spit

al Stenvall

2007/2012, RCT, n=64

Geriatric unit specialising in geriatric orthopaedic management post NOF

Haines 2011, RCT n=300

Patient education: materials +/- physio

Co

mm

un

ity Shaw

2003, RCT n=274

Multifactorial

Zieschang 2013, RCT n=91

Progressive resistance and functional training

Setting Study Intervention Fall

outcome R

esi

de

nti

al C

are

Jensen 2003, RCT, n=170, MMSE <19, n=171 MMSE ≥ 19

Multifactorial

Shaw 2003, RCT n=274

Multifactorial designed for community

Rapp 2008, RCT n=148

Multifactorial

Neyens 2009, RCT n=518

Multifactorial

Kovacs 2013, RCT N=86

Exercise

So what can we do?

Implications for fall prevention

Central processing Input Response

Implications for fall prevention

• Pragmatic approach – consider interventions not affected by degenerative processes associated with dementia

– Osteoporosis management – Vit D +/- calcium, bisphosphonates

– Medication rationalisation

– Cataract extraction

– ? Single lens glasses

Possible Interventions

• ? Exercise

• ? Cognitive training

• ? Gait retraining

• ? Dual task training

• ? Multifactorial

• ? Dementia drugs 100, 93, 86, 79, 72, 65, 58, 51

Summary

• More research is needed

• Growing evidence for risk factors

• Limited evidence for fall prevention, particularly in the hospital and community setting

• Exercise has potential to improve multiple risk factors

Exercise Intervention Considerations

• Experience

• Environment

• Instruction

• Supervision

• Achievable

• Sustainable

• Progressive

• Fun

• Co-morbidities

Acknowledgements

A/Prof Jacqueline Close

Prof Stephen Lord

Dr Kim Delbaere

References

Allan, L. M., Ballard, C. G., Rowan, E. N. and Kenny, R. A. (2009). Incidence and prediction of falls in dementia: a prospective study in older people. PLoS ONE, 4, e5521.

Haines, T. P., et al. (2011). Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Archives of internal medicine, 171, 516-524.

Jensen, J., Nyberg, L., Gustafson, Y. and Lundin-Olsson, L. (2003). Fall and injury prevention in residential care--effects in residents with higher and lower levels of cognition. J Am Geriatr Soc, 51, 627-635.

Kovacs, E., Sztruhar Jonasne, I., Karoczi, C. K., Korpos, A. and Gondos, T. (2013). Effects of a multimodal exercise program on balance, functional mobility and fall risk in older adults with cognitive impairment: a randomized controlled single-blind study. Eur J Phys Rehabil Med.

Neyens, J. C., et al. (2009). A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomised controlled trial (RCT). Age and Ageing, 38, 194-199.

Rapp, K., Sarah, E. L., Gisela, B., Ranjit, L., Ulrich, L. and Clemens, B. (2008). Prevention of Falls in Nursing Homes: Subgroup Analyses of a Randomized Fall Prevention Trial. Journal of the American Geriatrics Society, 56, 1092-1097.

Shaw, F. E., et al. (2003). Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ: British Medical Journal, 326, 73-75.

Stenvall, M., et al. (2007). A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 18, 167-175.

Sterke, C. S., Huisman, S. L., van Beeck, E. F., Looman, C. W. and van der Cammen, T. J. (2010). Is the Tinetti Performance Oriented Mobility Assessment (POMA) a feasible and valid predictor of short-term fall risk in nursing home residents with dementia? Int Psychogeriatr, 22, 254-263.

Taylor, M. E., Delbaere, K., Close, J. C. T. and Lord, S. R. (2012a). Managing falls in older patients with cognitive impairment. Aging Health, 8, 573-588.

Taylor, M. E., Delbaere, K., Lord, S. R., Mikolaizak, A. S., Brodaty, H. and Close, J. C. T. (IN PRESS). Neuropsychological, Physical, and Functional Mobility Measures Associated With Falls in Cognitivley Impaired Older People. Journals of Gerontology - Series A Biological Sciences and Medical Sciences.

Taylor, M. E., Lord, S. R., Delbaere, K., Mikolaizak, A. S. and Close, J. C. T. (2012b). Physiological Fall Risk Factors in Cognitively Impaired Older People: A One-Year Prospective Study. Dementia and Geriatric Cognitive Disorders, 34, 181-189.

Whitney, J., Close, J. C., Jackson, S. H. and Lord, S. R. (2012a). Understanding risk of falls in people with cognitive impairment living in residential care. J Am Med Dir Assoc, 13, 535-540.

Whitney, J., Close, J. C., Lord, S. R. and Jackson, S. H. (2012b). Identification of high risk fallers among older people living in residential care facilities: A simple screen based on easily collectable measures. Archives of Gerontology and Geriatrics, 55, 690-695.

Zieschang, T., Schwenk, M., Oster, P. and Hauer, K. (2013). Sustainability of Motor Training Effects in Older People with Dementia. Journal of Alzheimer's Disease, 34, 191-202.