Falls and dementia: Epidemiology and interventions

Professor Keith Hill, Head, School of Physiotherapy and Exercise Science, email [email protected]

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

Overview

Main focus of presentation: community setting Falls prevention for older people

 Magnitude of the problem  Risk factors  Evidence of effective interventions

Fall prevention for people with dementia

 Magnitude of the problem  Risk factors  Evidence of effective interventions  Falls prevention and injury prevention

Dementia

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% Alzheimer’s Society (UK)

The importance of dementia and falls

  Alzheimer’s disease (m ost 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 FALLS 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 Ageing populations

Falls in clinical groups

100 80 60

???

40 20 0 older people people with stroke people with Parkinson's disease people with polio people with dementia Lord et al, 1993; Forster & Young, 1995; Hill, 1998; Hill & Stinson, 2004

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

Falls in 12 months (prospective)

• Alzheimers disease – 47% • Vascular dementia – 47% • Dementia with Lewy Bodies – 77% • Parkinson’s disease dementia – 90% Allan et al, 2009

Why the increased falls risk in people with dementia?



aspects of the neurological condition



unrecognised falls risk factors



other

Falls are multi factorial

Health Problems (incl balance dysfunction) Ageing Intrinsic factors

Behavioral factors

Medications eg.

psychoactive meds Environment Activity related risks Extrinsic factors

Number of risk factors

30 20 10 0 80 70 60 50 40 0 1 2 3 Number of risk factors

NB: Modifiable vs non-modifiable risk factors

4+

Tinetti et al, 1988

Identifying who is at risk of falls…

Factors commonly associated with fallers:

 previous falls  lower extremity weakness  arthritis (hips / knees)  gait / balance disorders  cognitive disorders (depression / dementia / poor judgement...)  visual disorders  postural hypotension  bladder dysfunction (frequency / urgency / nocturia / incontinence...)  medications (psychotropics/ sedatives / hypnotics / antihypertensives...)  Others (stroke, PD)

Falls risk assessment tools to classify risk

Tideiksaar, 1995

Risk factors for falls for people with dementia * Shaw et al 2003 (Geriatrics & Ageing)

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 Some reliability research with people with cognitive impairment http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html

The FROP-Com

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

criteria:

• approaches to support client uptake in recommended interventions

cognitive

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

Other interventions ??????

Safe footwear Eyesight review Change gait aid Treat postural hypotension Treat incontinence

Summary of what works: falls prevention interventions in the community setting for people with dementia (randomised controlled trials)

Unsuccessful RCT – results (??some trends)

Shaw et al, 2003 - RCT

Recently published meta-analysis: Exercise vs usual care for fallers versus non-fallers – participants with dementia (community)

Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Burton E et al, e-pub ahead of publication, Clinical Interventions in Aging

Some learnings from successful RCTs in cognitively intact older people

Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J

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) Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J

Exercise and falls prevention: what we know…

54 RCTs (all settings, though most in community) Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J

Sherrington

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

Appropriate exercise prescription Horses for courses

Very frail/ High falls risk Tai chi for arthritis – Sun style CONTINUUM OF FRAILTY 24 form Beijing style – Yang style Healthy older people Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Otago Exercise Program “Otago Plus” – incl VHI kit

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

Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J

Spink M et al

,, .BMJ. 2011 Jun 16;342:

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 Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J

Haran M et al

,, .BMJ. 2010 May 25;340:c2265

Medication review

Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J  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.

Home safety modifications

 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 Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J

Cumming R et al, 1999 JAGS

; 1397-402

Importance of home safety for people with dementia: Community setting

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 2 nd 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

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 Injury minimisation Other best practice options     Appropriate footwear / glasses Correct use of walking aid Manage orthostatic hypotension Manage incontinence    Hip protectors Vitamin D / calcium Anti-resorptive medication

Summary



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