Professor Keith Hill, Head, School of Physiotherapy and Exercise Science, email Keith.Hill@Curtin.edu.au

Gippsland Forum: Falls prevention for people with dementia (Sept 2014)

Falls and dementia: Epidemiology and interventions

Main focus of presentation: community setting

Falls prevention for older peopleMagnitude of the problemRisk factorsEvidence of effective interventions

Fall prevention for people with dementiaMagnitude of the problemRisk factorsEvidence of effective interventions

Falls prevention and injury prevention

Overview

What is dementia: “a set of symptoms that may include memory loss

and difficulties with thinking, problem-solving or language. Dementia is

caused when the brain is damaged by diseases, such as Alzheimer's

disease or a series of strokes. Dementia is progressive disorder…”

Different types of dementia• Alzheimer's disease (AD): 62%• Vascular dementia (VaD): 17%• Mixed dementia (AD and VaD): 10%• Dementia with Lewy bodies: 4%• Fronto-temporal dementia: 2%• Parkinson's dementia: 2%• Other dementias: 3%

Dementia

Alzheimer’s Society (UK)

Alzheimer’s disease (most common form of dementia)

Progressive degenerative disorder

Currently leading cause of disability in Australia

Incidence of new cases in Australia projected to increase from:

69000 new cases in 2009, to

385000 new cases in 2050 (Access Economics 2009)

Falls One in three older people fall each year

10% of falls cause serious injury

Leading cause of injury related hospitalisations among older

people in Australia (78600 fall related hospitalisations 2008-9)

(AIHW 2012)

10% of bed days for older people attributable to falls (AIHW

2012)

Direct costs to the health care system in Australia was

$648million in 2007-8

The importance of dementia and falls

FALLS

Dem

entia

Ageing populations

0

20

40

60

80

100

older people people withstroke

people withParkinson's

disease

people withpolio

people withdementia

Lord et al, 1993; Forster & Young, 1995; Hill, 1998; Hill & Stinson, 2004Lord et al, 1993; Forster & Young, 1995; Hill, 1998; Hill & Stinson, 2004

???

Falls in clinical groups

Survival curve (time to first fall) - community sample – Out-patient clinic

Allan et al, 2009

Falls in 12 months (prospective)• Alzheimers disease – 47%• Vascular dementia – 47%• Dementia with Lewy

Bodies – 77%• Parkinson’s disease

dementia – 90%

aspects of the neurological condition

unrecognised falls risk factors

other

Why the increased falls risk in people with dementia?

Intrinsic factors

Extrinsic factors

Medications

HealthProblems (incl

balance dysfunction)

Ageing

Environment

Activityrelatedrisks

eg.psychoactive meds

Behavioralfactors

Falls are multi factorial

0

10

20

30

40

50

60

70

80

0 1 2 3 4+

Number of risk factors

Perc

en

tag

e w

ho

fell

Tinetti et al, 1988NB: Modifiable vs non-modifiable risk factors

Number of risk factors

Factors commonly associated with fallers:previous falls lower extremity weaknessarthritis (hips / knees)gait / balance disorderscognitive disorders (depression / dementia / poor

judgement...)visual disorderspostural hypotensionbladder dysfunction (frequency / urgency / nocturia /

incontinence...)medications (psychotropics/ sedatives / hypnotics /

antihypertensives...) Others (stroke, PD)

Falls risk assessment tools to classify risk

Tideiksaar, 1995

Identifying who is at risk of falls…

Shaw et al 2003 (Geriatrics & Ageing)

*

Risk factors for falls for people with dementia

The importance of reporting falls or near falls

• One of the strongest risk factors for future falls

• Only 25% of older people report a fall to a Doctor or health professional

• accept falls as inevitable part of ageing

• concern of consequences of reporting a fall

• Better chance of successful interventions

• Avoid development of secondary

complications such as loss of confidence

and reduced activity

Falls risk assessment tools – examples:

Physiological Profile Assessment – PPA (FallScreen) http://www.neura.edu.au/fbrg

Quickscreen http://www.neura.edu.au/research/

facilities/falls-and-balance-research-group/quickscreen

Falls risk for older People – Community

version (FROP-Com) National Ageing Research Institute

Identifying falls risk

Some reliability research with people with

cognitive impairment

http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html

The FROP-Com

COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants)

What works in falls prevention for older people in the community setting

There is good research (at least one randomised trial) evidence that a number of single interventions can reduce falls / injuries:

• exercise (home exercise; tai chi, group exercise)• cataract extraction / change multifocal glasses to 2 sets of glasses• psychotropic medication withdrawal / medication review• home visits by Occupational Therapists• improved post hospital discharge follow-up• approaches to support client uptake in recommended interventions• vitamin D and calcium supplementation (in low vit D cases)• cardiac pacemaker for carotid sinus hypersensitivity• foot exercise, footwear and orthoses

multiple interventions based on a falls risk assessment have also been shown to be effective (including in high falls risk groups, eg older fallers presenting to ED)

Common exclusion criteria:

cognitive impairment

Safe footwear

Treat posturalhypotension

Eyesight review

Treat incontinence

Change gait aid

Other interventions ??????

Summary of what works: falls prevention interventions in the community setting for

people with dementia (randomised controlled trials)

Shaw et al, 2003 - RCT

Unsuccessful RCT – results (??some trends)

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Recently published meta-analysis:Exercise vs usual care for fallers versus non-fallers –

participants with dementia (community)

Burton E et al, e-pub ahead of publication, Clinical Interventions in Aging

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Some learnings from successful RCTs in cognitively intact older people

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Evidence of what works in exercise in falls prevention

Group exercise programs

Home exercise programs (often prescribed by a physiotherapist

Tai Chi- (note: different types of Tai Chi may have different effects)

Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011)

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Exercise and falls prevention: what we know…

22Sherrington C, et al. NSW Public Health Bull. 2011 Jun;22(3-4):78-83

54 RCTs (all settings, though most in community)

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Appropriate exercise prescription - Horses for courses

Very frail/High falls risk

Healthy older people

CONTINUUM OF FRAILTY

Tai chi for arthritis – Sun style 24 form Beijing style – Yang style

Otago Exercise Program “Otago Plus” – incl VHI kit

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Exercise interventions (recent study)

Sample with disabling foot pain and increased falls risk

Intervention=foot & ankle exercise, footwear subsidy, and orthoses provision

Intervention group had 36% fewer falls, p<0.05

Spink M et al,, .BMJ. 2011 Jun 16;342:

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Vision - Single vs multi focal lens glasses

Sample=regular wearers of multi-focal glasses

Intervention=provision of single lens glasses for walking and outdoor activities

8% (non significant) reduction in falls in intervention group

Significant reduction in outdoor falls in those with regular outdoor activity

Haran M et al,, .BMJ. 2010 May 25;340:c2265

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Medication review Sample=older patients of 20 general practitioners

Intervention=education (academic detailing, provision of prescribing information, medication risk assessment, medication review, financial incentives)

Intervention group had improved medication use at 4 mths, and reduced risk of having a fall or injury at 12 mths (p<0.05)

Pit S et al, Med J Aust, 2007 ;187(1):23-30.

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Cumming R et al, 1999 JAGS; 1397-402

Sample= 530 older people discharged from hospital

Intervention=home visit by OT targeted at reducing home hazards

Significant reduction in falls in home modification group

50% of home modifications remained in place 12 months later

Improved outcomes with higher adherence

Home safety modifications

42% of a community sample with mild-moderate dementia

fall at least once each year (9% fallers suffered leg #)

Most common falls related hazards in homes: included: low chairs (57%), absence of grab rails (toilet – 48%), loose rugs (48%), missing 2nd bannister on steps (38%) and absent night lights (28%)

Horikawa et al 2005 (124 out-patients with diagnosis of probable AD); Lowery et al, 2000

Importance of home safety for people with dementia: Community setting

Best practice falls prevention with dementia

Evidence from community setting Falls risk assessment Exercise (balance focus) Cataract surgery Environmental modification Behaviour change Medication review Vitamin D Hip protectors

Other best practice options Appropriate footwear / glasses Correct use of walking aid Manage orthostatic hypotension Manage incontinence

Injury minimisation Hip protectors Vitamin D / calcium Anti-resorptive medication

Dementia is an independent risk factor for falls

Despite good evidence of many single and multifaceted falls prevention programs being effective for older people without cognitive impairment, there is very little

research demonstrating effectiveness for people with

dementia

Need to identify and manage existing falls risk factors of people with dementia

Promising research results using exercise for people with

mild to moderate dementia

Summary