Managing falls in older patients with cognitive impairment. Morag Taylor

Transcription

1 Managing falls in older patients with cognitive impairment Morag Taylor

2 1. Background 2. Risk factors 3. Fall risk assessment 4. Interventions

3 Background - Dementia people 1 million people million people 115 million people

4 Percent fall each year Background - Falls in Dementia Fallers Cognitively intact Multiple fallers Cogntively impaired

5 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

6 Risk Factor 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 * Association

7 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 ***

8 Risk Factor Sensory and Neuromuscular Factors Association 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 -

9 Fall Risk Assessment in Dementia Tool Population tested Followup 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

10 Residential Care Fall Prevention in Dementia Setting Study Intervention Fall outcome Jensen 2003, RCT, n=170, MMSE <19, n=171 MMSE 19 Shaw 2003, RCT n=274 Rapp 2008, RCT n=148 Neyens 2009, RCT n=518 Multifactorial Multifactorial designed for community Multifactorial Multifactorial

11 Community Hospital Fall Prevention in Dementia Setting Study Intervention Stenvall 2007, RCT, n=64 Haines 2011, RCT n=300 Shaw 2003, RCT n=274 Geriatric unit specialising in geriatric orthopaedic management post NOF Patient education: materials +/- physio Multifactorial Fall Outcome Zieschang 2013, RCT n=91 Progressive resistance and functional training

12 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

13 Exercise Intervention Considerations Experience Environment Instruction Supervision Achievable Sustainable Progressive Fun Co-morbidities

14 Acknowledgements Supervisors A/Prof Jacqueline Close Prof Stephen Lord Dr Kim Delbaere Falls and Balance Research Group Falls and Injury Prevention Group

15 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, 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, 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, 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, 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, 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, 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, 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, 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, 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, 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, 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,

16 CaHFRiS