Managing falls in older patients with cognitive impairment

Managing falls in older patients with cognitive impairment

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
300 000 people
2012
1 million people
2050
36 million people
115 million people
Falls and consequences
2 fold increase in
population > 65yrs by
2050
Background - Falls in Dementia
70
• Fractures 2-3 x more
common
• More centrally acting
drug use
• More gait
abnormalities
• More likely to be
placed in residential
care
Percent fall each year
60
50
40
30
20
10
0
Intact
Multiple (2+)
Impaired
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
Yes†
Yes
No
Inconsistent findings
Reduced physical activity
Environmental hazards
Domain and risk factor
Impaired
Intact
Cerebrovascular disease
Yes
Yes
Parkinson’s disease/parkinsonism
Yes
Yes
Not studied
Not studied
Inconsistent findings
Inconsistent findings
Syncope
Not studied
Not studied
Vestibular dysfunction
Not studied
Not studied
Cataracts
Yes†
Yes
Glaucoma
Not studied
Not studied
Age-related macular degeneration
Not studied
Yes
Arthritis
Yes†
Yes
Urinary incontinence
No*
Yes
Not studied
Not studied
Medical conditions
Cerebellar disorders
Orthostatic hypotension
Eye disease
Peripheral vascular disease
Domain and risk factor
Impaired
Intact
Depression
Yes†
Yes
Anxiety
Yes
Not studied
Fear of falling
Yes†
Yes
Polypharmacy
Yes
Yes
Centrally acting medications
Yes
Yes
Inconsistent findings*
Yes
Yes*
Yes
Antipsychotics
Inconsistent findings
Yes
Dementia drugs
No
n/a
Analgesics
No*
Inconsistent findings
Yes†
Inconsistent findings
Psychological disorders
Medication use
Sedatives/hypnotics
Antidepressants
Cardiovascular medications
Domain and risk factor
Impaired
Intact
Sensorimotor performance, balance and gait
Strength
Inconsistent findings
Yes
No
Yes
Yes†
Inconsistent findings
No
Yes
Not studied
Yes
Yes†
Yes
Not studied
Not studied
Yes
Yes
Simple
Yes
Yes
Dual task
Yes†
Yes
Vision
Peripheral sensation
Proprioception
Tactile sensitivity
Reaction time
The vestibular system
Postural stability and balance
Gait
Domain and risk factor
Impaired
Intact
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
No*
No
Cognitive factors
Global
Language
Fall risk assessment in dementia
Tool
Population
tested
Follow- Author/more
info
up
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
6/12
Whitney 2012
Whitney 2012
Four-item nursing home Nursing home
tool or seven-item
CaHFRiS
Physiological Profile Assessment (PPA)
Melbourne Edge Test
Proprioception
Simple Reaction Time
2.5
Knee Extension Strength
Fall Risk Score: predicts recurrent falls
with 75% accuracy (Lord et al., 2003)
Postural Sway
xx
x
x
x
x
x
c
x
x
x
c
x
x
Error Score = 28
Coordinated Stability
c
x
CaHFRiS
(Whitney 2012, n=254, 89% cog imp)
Whitney 2012 – n=110, all with
cognitive impairment
Fall Prevention in Dementia
Community
Hospital
Setting
Study
Intervention
Stenvall
2007/2012,
RCT, n=64
Geriatric unit specialising
in geriatric orthopaedic
management post NOF
Haines
2011, RCT
n=300
Patient education:
materials +/- physio
Shaw
2003, RCT
n=274
Multifactorial
Zieschang
2013, RCT
n=91
Progressive resistance and
functional training
Fall
Outcome
Residential Care
Setting
Study
Intervention
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
Fall
outcome
So what can we do?
Implications for fall prevention
Input
Central processing
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.