Managing falls in older patients with cognitive...
Transcript of Managing falls in older patients with cognitive...
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.