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

Background - Falls in Dementia

0

10

20

30

40

50

60

70

Fallers Multiple fallers

Pe

rce

nt

fall

eac

h y

ear

Cognitively intact Cogntively impaired

Risk Factors for Falls in Dementia

Limited evidence in this population

Grading System

*** good evidence as a risk factor for falls, multiple studies have reported as a risk factor, consistent findings

** some evidence as a risk factor for falls, a few studies have reported as a risk factor, generally consistent findings

* limited evidence as a risk factor for falls, one study or conflicting evidence as a fall risk factor

- Little or no evidence of association

ns not studied

Risk Factor Association Psychosocial and Demographic Factors

Advanced age *

Male gender *

History of falls ***

Walks with an aid **

Inactivity *

ADL limitations ***

Living alone ns

Medical Factors

Dementia duration *

Dementia severity **

Parkinson’s disease/Parkinsonism **

Arthritis/Musculoskeletal complaint **

Symptomatic orthostatic hypotension *

Peripheral neuropathy *

Autonomic neuropathy *

Cardiac arrhythmia *

Cataracts *

Impaired vision *

Risk Factor Association

Medication Factors

Psychoactive medications **

Antidepressants **

Cardiovascular medications *

NSAIDs -

Polypharmacy **

Balance and Mobility Factors

Impaired stability when standing ***

Impaired stability when leaning and reaching *

Impaired gait and mobility ***

Risk Factor Association Sensory and Neuromuscular Factors

Poor visual contrast sensitivity -

Muscle weakness *

Slow reaction time *

Impaired proprioception -

Neuropsychological Factors

Wandering / behavioural factors **

Attention and orientation *

Impaired executive function **

Poor memory *

Depression/depressive symptoms **

Anxiety *

Fear of falling *

Environmental Factors

Home hazards -

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 CaFRiS

Nursing home 6/12 Whitney 2012

Fall Prevention in Dementia

Setting Study Intervention Fall

outcome

Re

sid

en

tial

Car

e

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

Fall Prevention in Dementia

Setting Study Intervention Fall

Outcome

Ho

spit

al Stenvall

2007, 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

Summary

• More research is needed – Growing evidence for risk factors

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

– Exercise offers potential to modify risk factors

• Pragmatic approach

Osteoporosis management

Rationalise medication

Vitamin D

Exercise Intervention Considerations

• Experience

• Environment

• Instruction

• Supervision

• Achievable

• Sustainable

• Progressive

• Fun

• Co-morbidities

Acknowledgements

Supervisors

A/Prof Jacqueline Close

Prof Stephen Lord

Dr Kim Delbaere

Falls and Balance Research Group

Falls and Injury Prevention Group

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. 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., 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.

CaHFRiS