The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis

Prevalence, risk factors and disability associated with fall-related injury in older adults in low- and middle-incomecountries: results from the WHO Study on global AGEing and adult health (SAGE)

BACKGROUND

In 2010 falls were responsible for approximately 80 % of disability stemming from unintentional injuries excluding traffic accidents in adults 50 years and over. Falls are becoming a major public health problem in low- and middle-income countries (LMICs) where populations are ageing rapidly.

METHODS

Nationally representative standardized data collected from adults aged 50 years and over participating in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 1 in China, Ghana, India, Mexico, the Russian Federation and South Africa are analysed. The aims are to identify the prevalence of, and risk factors for, past-year fall-related injury and to assess associations between fall-related injury and disability. Regression methods are used to identify risk factors and association between fall-related injury and disability. Disability was measured using the WHO Disability Assessment Schedule Version 2.0 (WHODAS 2.0).

RESULTS

The prevalence of past-year fall-related injuries ranged from 6.6 % in India to 1.0 % in South Africa and was 4.0 % across the pooled countries. The proportion of all past-year injuries that were fall-related ranged from 73.3 % in the Russian Federation to 44.4 % in Ghana. Across the six countries this was 65.7 %. In the multivariable logistic regression, the odds of past-year fall-related injury were significantly higher for: women (OR: 1.27; 95 % CI: 0.99,1.62); respondents who lived in rural areas (OR: 1.36; 95 % CI: 1.06,1.75); those with depression (OR: 1.43; 95 % CI: 1.01,2.02); respondents who reported severe or extreme problems sleeping (OR: 1.54; 95 % CI: 1.15,2.08); and those who reported two or more (compared with no) chronic conditions (OR: 2.15; 95 % CI: 1.45,3.19). Poor cognition was also a significant risk factor for fall-related injury. The association between fall-related injury and the WHODAS measure of disability was highly significant (P<0.0001) with some attenuation after adjusting for confounders. Reporting two or more chronic conditions (compared with none) was significantly associated with disability (P<0.0001).

CONCLUSIONS

The findings provide a platform for improving understanding of risk factors for falls in older adults in this group of LMICs. Clinicians and public health professionals in these countries must be made aware of the extent of this problem and the need to implement policies to reduce the risk of falls in older adults.

Using entropy measures to characterize human locomotion

Entropy measures have been widely used to quantify the complexity of theoretical and experimental dynamical systems. In this paper, the value of using entropy measures to characterize human locomotion is demonstrated based on their construct validity, predictive validity in a simple model of human walking and convergent validity in an experimental study. Results show that four of the five considered entropy measures increase meaningfully with the increased probability of falling in a simple passive bipedal walker model. The same four entropy measures also experienced statistically significant increases in response to increasing age and gait impairment caused by cognitive interference in an experimental study. Of the considered entropy measures, the proposed quantized dynamical entropy (QDE) and quantization-based approximation of sample entropy (QASE) offered the best combination of sensitivity to changes in gait dynamics and computational efficiency. Based on these results, entropy appears to be a viable candidate for assessing the stability of human locomotion.

Low FAB score as a predictor of future falling in patients with Parkinson's disease: a 2.5-year prospective study

Falling is one of the most disabling features of Parkinson's disease (PD). Many cross-sectional studies, case-control studies, and prospective studies have attempted to identify risk factors or predictors of falls, but consistent results are yet to be obtained because of the various factors involved. We prospectively studied patients with various severities of PD to identify risk factors for future falls during 2.5 years of follow-up. We registered 95 patients with PD, and 83 patients were included in data analysis. A total of 23 variables were evaluated by multivariate logistic regression analysis. Thirty-one patients (37%) had a previous history of falling, and 26 patients (30%) experienced their first fall. The prevalence of falls at 2.5 years was 62% (52 of 83 patients). Frontal Assessment Battery (FAB) score (OR 1.393, p = 0.005, 95% CI 1.104-1.759) and history of fall present (OR 0.142, p = 0.002, 95% CI 0.042-0.48) were related to falling on multiple logistic regression analysis. The following variables differed significantly between patients with first falls and those without falling: levodopa equivalent dose (p = 0.023), UPDRS part I (p = 0.006), SF-8 (p = 0.017), and FAB (p = 0.026). Calculation of the FAB score may be useful for predicting the risk of future falls in patients with various severities of PD. Our results suggest that a low FAB score combined with a history of falling within the past 6 months carries an increased risk of future falls.

Effectiveness of exercise programs to reduce falls in older people with dementia living in the community: a systematic review and meta-analysis

Objective

The objective of this systematic review and meta-analysis is to evaluate the effectiveness of exercise programs to reduce falls in older people with dementia who are living in the community.

Method

Peer-reviewed articles (randomized controlled trials [RCTs] and quasi-experimental trials) published in English between January 2000 and February 2014, retrieved from six electronic databases – Medline (ProQuest), CINAHL, PubMed, PsycInfo, EMBASE and Scopus – according to predefined inclusion criteria were included. Where possible, results were pooled and meta-analysis was conducted.

Results

Four articles (three RCT and one single-group pre- and post-test pilot study) were included. The study quality of the three RCTs was high; however, measurement outcomes, interventions, and follow-up time periods differed across studies. On completion of the intervention period, the mean number of falls was lower in the exercise group compared to the control group (mean difference [MD] [95% confidence interval {CI}] =−1.06 [−1.67 to −0.46] falls). Importantly, the exercise intervention reduced the risk of being a faller by 32% (risk ratio [95% CI] =0.68 [0.55–0.85]). Only two other outcomes were reported in two or more of the studies (step test and physiological profile assessment). No between-group differences were observed in the results of the step test (number of steps) (MD [95% CI] =0.51 [−1.77 to 2.78]) or the physiological profile assessment (MD [95% CI] =−0.10 [−0.62 to 0.42]).

Conclusion

Findings from this review suggest that an exercise program may potentially assist in preventing falls of older people with dementia living in the community. However, further research is needed with studies using larger sample sizes, standardized measurement outcomes, and longer follow-up periods, to inform evidence-based recommendations.

Falls and fallers in traumatic brain injury (TBI) rehabilitation settings: an integrative review

PURPOSE

To critically appraise the research literature on the nature of falls and fallers in traumatic brain injury (TBI) rehabilitation settings.

METHOD

An integrative review of the literature using thematic analysis was undertaken. Papers identified via a systematic search strategy were independently appraised by two reviewers. A data extraction instrument was developed to record results and to aid identification of themes in the literature. Critical Appraisal Skills Programme instruments were utilised to conduct a methodological critique of the papers included.

RESULTS

Thirteen studies were identified as having between 4% and 100% TBI patients in their study cohorts. From these papers, up to 71% of falls took place in a patient's bedroom occurring in peaks and troughs over a 24-h period. With some divergent results, nine themes were identified describing faller characteristics including: (1) functional mobility impairments; (2) dizziness; (3) bladder and bowel dysfunction; (4) certain medications and number of medications prescribed; (5) executive functioning; (6) patient age; (7) fear of falling; (8) coma length following TBI; and (9) Functional Independence Measure (FIM™) total score, subscale scores and particular individual items.

CONCLUSIONS

Being a multifactorial phenomenon, falls are a complex clinical issue. Despite the heterogeneity of diagnosis related groups (DRGs) in the included studies, TBI patients were identified as a high falls risk patient population in several studies. Implications for Rehabilitation Due to multisystem impairments, falls in the traumatic brain injury (TBI) rehabilitation context are a multifactorial and significant clinical issue. When interpreting and generalising results from research into falls, clinicians need to be mindful that falls and faller characteristics may be dependent on study setting and patient population. There is need for context specific research into faller characteristics following a TBI; particularly in relation to post-traumatic amnesia.

Efficacy and Feasibility of Functional Upper Extremity Task-Specific Training for Older Adults With and Without Cognitive Impairment

BACKGROUND

Although functional task-specific training is a viable approach for upper extremity neurorehabilitation, its appropriateness for older populations is unclear. If task-specific training is to be prescribed to older adults, it must be efficacious and feasible, even in patients with cognitive decline due to advancing age.

OBJECTIVE

This cross-sectional study tested the efficacy and feasibility of upper extremity task-specific training in older adults, including those with lower cognitive scores.

METHODS

Fifty older adults (age 65-89 years) without any confounding neuromuscular impairment were randomly assigned to a training group or no-training group. The training group completed 3 days (dosage = 2250 repetitions) of a functional upper extremity motor task (simulated feeding) with their nondominant hand; the no-training group completed no form of training at all. Both groups' task performance (measured as trial time) was tested at pre- and posttest, and the training group was retested 1 month later. Efficacy was determined by rate, amount, and retention of training-related improvement, and compared across levels of cognitive status. Feasibility was determined by participants' tolerance of the prescribed training dose.

RESULTS

The training group was able to complete the training dose without adverse responses and showed a significant rate, amount, and retention of improvement compared with the no-training group. Cognitive status did not alter results, although participants with lower scores on the Montreal Cognitive Assessment were slower overall.

CONCLUSIONS

Task-specific training may be appropriate for improving upper extremity function in older adults, yet future work in older patients with specific neurological conditions is needed.

Exposure-Based CBT for Older Adults After Fall Injury: Description of a Manualized, Time-Limited Intervention for Anxiety

Fall accidents among older adults can be devastating events that, in addition to their physical consequences, lead to disabling anxiety warranting the attention of mental health practitioners. This article presents "Back on My Feet," an exposure-based cognitive-behavioral therapy (CBT) protocol that is designed for older adults with posttraumatic stress disorder (PTSD), subthreshold PTSD, or fear of falling resulting from a traumatic fall. The protocol can be integrated into care once patients have been discharged from hospital or rehabilitation settings back to the community. Following a brief description of its development, the article presents a detailed account of the protocol, including patient evaluation and the components of the eight home-based sessions. The protocol addresses core symptoms of avoidance, physiological arousal/anxiety, and maladaptive thought patterns. Because older patients face different coping challenges from younger patients (for whom the majority of evidence-based CBT interventions have been developed), the discussion ends with limitations and special considerations for working with older, injured patients. The article offers a blueprint for mental health practitioners to address the needs of patients who may present with fall-related anxiety in primary care and other medical settings. Readers who wish to develop their expertise further can consult the online appendices, which include a clinician manual and patient workbook, as well as guidance on additional resources.

Does a Wii-based exercise program enhance balance control of independently functioning older adults? A systematic review

Background

Exercise programs that challenge an individual’s balance have been shown to reduce the risk of falls among older adults. Virtual reality computer-based technology that provides the user with opportunities to interact with virtual objects is used extensively for entertainment. There is a growing interest in the potential of virtual reality-based interventions for balance training in older adults. This work comprises a systematic review of the literature to determine the effects of intervention programs utilizing the Nintendo Wii console on balance control and functional performance in independently functioning older adults.

Methods

Studies were obtained by searching the following databases: PubMed, CINAHL, PEDro, EMBASE, SPORTdiscus, and Google Scholar, followed by a hand search of bibliographic references of the included studies. Included were randomized controlled trials written in English in which Nintendo Wii Fit was used to enhance standing balance performance in older adults and compared with an alternative exercise treatment, placebo, or no treatment.

Results

Seven relevant studies were retrieved. The four studies examining the effect of Wii-based exercise compared with no exercise reported positive effects on at least one outcome measure related to balance performance in older adults. Studies comparing Wii-based training with alternative exercise programs generally indicated that the balance improvements achieved by Wii-based training are comparable with those achieved by other exercise programs.

Conclusion

The review indicates that Wii-based exercise programs may serve as an alternative to more conventional forms of exercise aimed at improving balance control. However, due to the great variability between studies in terms of the intervention protocols and outcome measures, as well as methodological limitations, definitive recommendations as to optimal treatment protocols and the potential of such an intervention as a safe and effective home-based treatment cannot be made at this point.

Exposure to anticholinergic and sedative drugs, risk of falls, and mortality: an elderly inpatient, multicenter cohort

This study aimed to assess whether exposure to anticholinergic and sedative medications and its evolution was associated with increased risk of in-hospital falls and all-cause mortality. Furthermore, results were compared with 2 definitions of drug burden index (DBI) against the outcomes.This observational, multicentric, and longitudinal study was conducted among patients aged 65 years or older, in 3 geriatric hospitals, in Francheville, Lyon, and Villeurbanne, France (duration of follow-up, 11.6 months). The exposure to anticholinergic and sedative medications was quantified using a DBI, at admission and at the end of observation for 337 patients. The evolution of exposure was the absolute difference between the index at admission and at the end of observation. The outcomes were in-hospital falls and all-cause mortality.Overall, 5.9% of patients experienced a fall. The risk of fall was nearly 3-fold in patients whose DBI increased during hospital stay compared to those with stable or decreased DBI (hazard ratio, 2.9 [1.14-7.12]; P = 0.03), after adjustment for comorbidities.The overall proportion of mortality was 6.5%. The evolution of DBI during hospital stay was not related to the risk of mortality (hazard ratio, 1.9 [0.8-4.4]; P = 0.14). Results were similar with the 2 definitions of DBI.Increased exposure to anticholinergic and sedative medications during hospital stay is associated with a higher risk of in-hospital falls but not with mortality. The DBI could be implemented in hospital, to guide prescription and reduce anticholinergic and sedative drug exposure.

Depressive symptoms are independently associated with recurrent falls in community-dwelling older adults

BACKGROUND

Falls and depression are two major public health problems that affect millions of older people each year. Several factors associated with falls are also related to depressive symptoms such as medical conditions, sleep quality, use of medications, cognitive functioning, and physical capacities. To date, studies that investigated the association between falls and depressive symptoms did not control for all these shared factors. The current study addresses this issue by examining the relationship between falls and depression symptoms after controlling for several confounders.

METHODS

Eighty-two community-dwelling older adults were enrolled in this study. The Geriatric Depression Scale (GDS-30) was used to evaluate the presence of depressive symptoms, and the following question was used to assess falls: "Did you fall in the last 12 months, and if so, how many times?"

RESULTS

Univariate analyses indicated that the number of falls was significantly correlated with gender (women), fractures, asthma, physical inactivity, presence of depressive symptoms, complaints about quality of sleep, use of antidepressant drugs, and low functional capacities. Multivariate analyses revealed that depressive symptoms were significantly and independently linked to recurrent falls after controlling for confounders.

CONCLUSIONS

Results of the present study highlight the importance of assessing depressive symptoms during a fall risk assessment.

Supporting dementia patients in hospital environments: health-related risks, needs and dedicated structures for patient care

The diagnostics and treatment of dementia are progressively gaining importance for European neurologists. Our hospital structures are poorly prepared for patients suffering from dementia. As a consequence of cognitive and physical deficits, dementia patients have an increased risk for serious complications and poor outcomes in hospital environments. In this review, the specific needs of dementia patients are outlined, describing how geriatricians, neurologists and psychiatrists may contribute to better patient care, e.g. with consultation or liaison services, geriatric wards, dedicated dementia wards or memory clinics in interaction with nurses, occupational therapists, physiotherapists, speech therapists, psychologists and social workers. Due to their multifaceted needs, dementia patients can most successfully be supported in clinical environments that closely integrate specialized inpatient, outpatient and primary care offers.

Relationships between balance and cognition in patients with subjective cognitive impairment, mild cognitive impairment, and Alzheimer disease

BACKGROUND

Balance impairments are common in patients with Alzheimer disease (AD), but which aspects of balance are affected, at which stage of cognitive impairment, and their associations with cognitive domains remain unexplored.

OBJECTIVES

The aims of this study were: (1) to explore differences in balance abilities among patients with subjective cognitive impairment (SCI) or mild cognitive impairment (MCI), mild AD, and moderate AD and (2) to examine the relationship between the various aspects of balance and cognitive domains.

DESIGN

This was a cross-sectional study.

METHODS

Home-dwelling patients with SCI or MCI (n=33), mild AD (n=99), and moderate AD (n=38) participated in this study. The Balance Evaluation Systems Test (BESTest), comprising 6 subscales-"Biomechanical Constraints," "Stability Limits/Verticality," "Anticipatory Postural Adjustments," "Postural Responses," "Sensory Orientation," and "Stability in Gait"-was used to assess balance. Cognitive domains were assessed using the following measures: Mini-Mental Status Examination, Word-List Learning Test from the Consortium to Establish a Registry for Alzheimer's Disease (CERAD), Verbal Fluency Test, Clock Drawing Test, and Trail Making Test, parts A and B (TMT-A and TMT-B, respectively). Two-way between-group analyses of variance, adjusted for age, were used to analyze differences among the groups. Multiple linear regression analysis was used to explore the associations between balance and cognition.

RESULTS

Differences were found between the groups on all BESTest subscales; the moderate AD group had the worst scores. The TMT-B (measuring executive function) was associated with all of the BESTest subscales after controlling for demographic factors.

LIMITATIONS

The cross-sectional design hampered interpretation of the development of balance impairments.

CONCLUSIONS

The study findings indicate that all aspects of balance control deteriorate with increasing severity of cognitive impairment and that executive function plays an important role in balance control. Physical therapists should pay attention to these findings both in clinical practice and in future research.

Fear of falling and falls in older adults with mild cognitive impairment and Alzheimer's disease

Cognitive impairment and fear of falling are risk factors for falls in older adults. Recurrent falls are more prevalent in older adults with cognitive impairment. We examined the number of previous falls, self-reported fear of falling, and the Falls Efficacy Scale-International (FES-I) in 104 older adults [26 with mild Alzheimer's disease (AD), 42 with mild cognitive impairment (MCI) and 36 cognitively healthy]. Older adults with AD and MCI had a higher number of falls (1.1 ± 1.2 and 1.5 ± 1.5, respectively) compared to the control group (0.3 ± 0.5, P < .001). Older adults with MCI more often reported fear of falling (74%) than patients with AD (31%) (P ≤ .002) and scored higher on the FES-I (29.7 and 23.8, respectively, P ≤ .01). The prevalence of falls in older adults with MCI and AD is higher than in subjects cognitively healthy. Older adults with MCI and AD differ in terms of reported fear of falling and falls self-efficacy.

Interventions to reduce the number of falls among older adults with/without cognitive impairment: an exploratory meta-analysis

OBJECTIVE

This exploratory meta-analysis aimed to examine and compare the effective interventions to prevent falls among institutionalized/non-institutionalized older adults without cognitive impairment with interventions to prevent falls for older adults with cognitive impairment.

DESIGN

A database search identified 111 trials published between January 1992 and August 2012 that evaluated fall-prevention interventions among institutionalized/non-institutionalized older adults with and without cognitive impairment as measured by valid cognition scales.

RESULTS

Exercise alone intervention was similar effective on reducing the numbers of falls among older adults without cognitive impairment regardless of setting (non-institutionalized: OR = 0.783, 95% confidence interval (CI) = 0.656-0.936; p = 0.007 institutionalized: OR = 0.799, 95% CI = 0.646-0.988, p = 0.038). Vitamin D/calcium supplementation had a positive effect on the reduction of numbers of falls among non-institutionalized older adults without cognitive impairment (OR = 0.789, 95% CI = 0.631-0.985, p = 0.036), as did home visits and environment modification (OR = 0.751, 95% CI = 0.565-0.998, p = 0.048). Exercise alone, exercise-related multiple interventions, and multifactorial interventions were associated with positive outcomes among both institutionalized and non-institutionalized older adults with cognitive impairment, but studies are limited.

CONCLUSIONS

Single exercise interventions can significantly reduce numbers of falls among older adults with and without cognitive impairment in institutional or non-institutional settings. Vitamin D and calcium supplementation, home visits, and environment modification can reduce the risk of falls among older adults in non-institutional settings. Exercise-related multiple interventions and multifactorial interventions may only be effective for preventing falls in older adults with cognitive impairment.

Reliability of the senior fitness test in community-dwelling older people with cognitive impairment

BACKGROUND AND PURPOSE

In older people with cognitive impairment, we require reliable and valid measures to assess physical fitness and to measure change, for example, as a result of an exercise intervention. The purpose of our study was to determine the relative and absolute test-retest reliability of the Senior Fitness Test (SFT) in older people with cognitive impairment.

METHODS

A test-retest reliability study was conducted for the Senior Fitness Test in older people with cognitive impairment. Participants were tested at two time points with a time interval of 24 hours to 1 week between tests. The Intraclass Correlation Coefficient model 3.1 (ICC, 3.1) with 95% confidence intervals (CIs) was used as a measure of relative reliability. The standard error of measurement and minimal detectable change (MDC) were used to measure absolute reliability.

RESULTS

The ICC reflected very high reliability (0.93-0.98) in all SFT items, indicating that there was no systematic error in the measurements. MDC values at the 90% CIs were calculated: chair stand test = 2.0 repetitions, armcurl test = 2.3 repetitions, chair sit and reach test = 6.0 cm, back scratch test = 4.6 cm, 2.45-m up-and-go test = 1.4 seconds and 6-minute walk test = 37.1 metres.

DISCUSSION

The SFT battery showed high to very high test-retest reliability and thus may be suitable for detecting changes in physical fitness and evaluating physical fitness in older people with cognitive impairment, both in research and for clinical purposes.

Differential diagnosis between 'unexplained' fall and syncopal fall: a difficult or impossible task

Falls may be accidental (because of slipping, tripping or environmental hazards) or 'unexplained', when there is no apparent cause. Syncope is a transient loss of consciousness (LOC) and, if it occurs when the person is in the upright position, may lead to a fall. The differential diagnosis between 'unexplained' fall and syncopal fall can be difficult, if not impossible, because many patients have retrograde amnesia after syncope, that is they do not remember their prodromal symptoms. Based on the results of many randomized studies, the international guidelines on falls suggest multifactorial assessment and multifactorial treatment. Unfortunately, however, the vast majority of studies have been carried out on a mixed population of patients who have suffered accidental and 'unexplained' falls. As 'unexplained' falls account for a minority of cases, we really do not know the efficacy of multifactorial treatment in patients with this type of fall. Very recent data seem to prove that many older patients with 'unexplained' falls are actually affected by reflex syncope with retrograde amnesia, as they experience LOC during tilt testing or carotid sinus massage. Although these data make an important contribution to our knowledge of the mechanism of 'unexplained' falls, the therapeutic problems remain largely unsolved.

Cognitive contributions to gait and falls: evidence and implications

Dementia and gait impairments often coexist in older adults and patients with neurodegenerative disease. Both conditions represent independent risk factors for falls. The relationship between cognitive function and gait has recently received increasing attention. Gait is no longer considered merely automated motor activity but rather an activity that requires executive function and attention as well as judgment of external and internal cues. In this review, we intend to: (1) summarize and synthesize the experimental, neuropsychological, and neuroimaging evidence that supports the role played by cognition in the control of gait; and (2) briefly discuss the implications deriving from the interplay between cognition and gait. In recent years, the dual task paradigm has been widely used as an experimental method to explore the interplay between gait and cognition. Several neuropsychological investigations have also demonstrated that walking relies on the use of several cognitive domains, including executive-attentional function, visuospatial abilities, and even memory resources. A number of morphological and functional neuroimaging studies have offered additional evidence supporting the relationship between gait and cognitive resources. Based on the findings from 3 lines of studies, it appears that a growing body of evidence indicates a pivotal role of cognition in gait control and fall prevention. The interplay between higher-order neural function and gait has a number of clinical implications, ranging from integrated assessment tools to possible innovative lines of interventions, including cognitive therapy for falls prevention on one hand and walking program for reducing dementia risk on the other.

Identifying balance and fall risk in community-dwelling older women: the effect of executive function on postural control

PURPOSE

The mechanisms linking cognition, balance function, and fall risk among older adults are not fully understood. An evaluation of the effect of cognition on balance tests commonly used in clinical practice to assess community-dwelling older adults could enhance the identification of at-risk individuals. The study aimed to determine (1) the association between cognition and clinical tests of balance and (2) the relationship between executive function (EF) and balance under single- and dual-task testing.

METHODS

Participants (24 women, mean age of 76.18 [SD 16.45] years) completed six clinical balance tests, four cognitive tests, and two measures of physical function.

RESULTS

Poor balance function was associated with poor performance on cognitive testing of EF. In addition, the association with EF was strongest under the dual-task timed up-and-go (TUG) test and the Fullerton Advanced Balance Scale. Measures of global cognition were associated only with the dual-task performance of the TUG. Postural sway measured with the Standing Balance Test, under single- or dual-task test conditions, was not associated with cognition.

CONCLUSIONS

Decreased EF was associated with worse performance on functional measures of balance. The relationship between EF and balance was more pronounced with dual-task testing using a complex cognitive task combined with the TUG.

Neuropsychological mechanisms of falls in older adults

Falls, a common cause of injury among older adults, have become increasingly prevalent. As the world's population ages, the increase in-and the prevalence of-falls among older people makes this a serious and compelling societal and healthcare issue. Physical weakness is a critical predictor in falling. While considerable research has examined this relationship, comprehensive reviews of neuropsychological predictors of falls have been lacking. In this paper, we examine and discuss current studies of the neuropsychological predictors of falls in older adults, as related to sporting and non-sporting contexts. By integrating the existing evidence, we propose that brain aging is an important precursor of the increased risk of falls in older adults. Brain aging disrupts the neural integrity of motor outputs and reduces neuropsychological abilities. Older adults may shift from unconscious movement control to more conscious or attentive motor control. Increased understanding of the causes of falls will afford opportunities to reduce their incidence, reduce consequent injuries, improve overall well-being and quality of life, and possibly to prolong life.

The profile of spinal injuries in the elderly population

This retrospective cross-sectional study sought to: describe the profile of the elderly population who suffered spinal injury (SI) between 2005 and 2010 in Porto Alegre (RS), Brazil; compare the trauma mechanism and type of SI prevalence in both sexes; and compare the trauma mechanism in the sample's age groups. To this end, medical records were reviewed for the following data: age, sex, main mechanisms of injury and spinal levels affected. Out of 1.320 records analyzed, 370 belonged to elderly subjects, 58.6% women (73.07±8.52 years) and 41.4% men (69.4±7.5 years). The most prevalent SI mechanisms were falls from own height (37.7%), height (24.3%) and unspecified (20.1%). The most affected vertebral levels were L1 (30.0%), T12 (16.2%) and L2 (11.9%). Only 26 (7%) individuals who had SI suffered a spinal cord lesion, with a higher prevalence of incomplete lesion (82.6%). No significant association was detected between the occurrence of SI and its type or sex. In the time and region investigated, the SI profile in the elderly can be described as: women over 70, who suffered a fall from their own height, injuring mainly the lumbar region. Elderly men and women were equally affected by SI without spinal cord lesion. Falls from height predominated in those aged 60-69, whereas falls from own height were commonest among those aged 70 and over.

Risk of accidental injuries amongst Parkinson disease patients

BACKGROUND AND PURPOSE

To investigate the spectrum and risks of accidental injuries (AIs) amongst Parkinson disease (PD) patients.

METHODS

The participants comprised PD patients aged 50 years and older who were initially diagnosed between 2000 and 2009, and a comparison group of non-PD patients. The incidence rates of accidental injury types amongst PD and non-PD patients were calculated; hazard ratios were calculated and adjusted for comorbidities, using 95% confidence intervals (CIs) of developing such outcomes in PD patients.

RESULTS

In total, 4046 PD patients and 16 184 non-PD patients were followed over time. The PD patients demonstrated the following incidence rates and hazard ratios in comparison to the control cohort for accidental injuries: all injuries, 19.78 per 100 person-years (100 PYs), adjusted hazard ratio (HR) 1.30 (95% CI 1.24-1.36); head injury, 2.95 per 100 PYs, HR 1.88 (95% CI 1.64-2.15); bone fracture and dislocation, 4.61 per 100 PYs, HR 1.39 (95% CI 1.25-1.54); burns, 0.66 per 100 PYs, HR 1.01 (95% CI 0.78-1.32); injury to spinal cord, plexus and nerves, 0.15 per 100 PYs, HR 1.25 (95% CI 0.72-2.17); superficial injuries and contusions, 11.41 per 100 PYs, HR 1.20 (95% CI 1.12-1.27). The injury risk for the 69-79 years age group in PD compared with controls of the same age (HR 1.38) was significantly higher compared with that of the 50-69 age groups in PD and controls (HR 1.16).

CONCLUSIONS

Parkinson disease patients demonstrate a significantly elevated risk of developing all accidental injury types except burn injuries and injuries to spinal cord, plexus and nerves, compared with age-matched controls. The risk increases as age increases.

Effects of mild and global cognitive impairment on the prevalence of fear of falling in community-dwelling older adults

OBJECTIVES

Few studies have reported the relationship between fear of falling (FoF) and mild and global cognitive impairment in community-dwelling older adults. We aimed to determine whether the status of cognitive impairment affects the prevalence of FoF in community-dwelling older adults.

STUDY DESIGN

Cross-sectional study among 4474 community-dwelling older adults who participated in the Obu Study of Health Promotion for the Elderly.

MAIN OUTCOME MEASURES

Participants underwent cognitive tests and were divided into three groups: cognitive healthy, mild cognitive impairment (MCI), and global cognitive impairment (GCI). FoF and related variables, such as fall history, physical function, and depression, were also investigated.

RESULTS

The prevalence of FoF was significantly different by group (p<0.001; healthy: 43.6%, MCI: 50.6%, GCI: 40.6%). Logistic regression analysis showed that GCI (odds ratio=0.63; 95% confidence interval=0.526-0.76) was independently associated with FoF, after controlling for confounding factors. Older adults with GCI showed the lowest prevalence of FoF, although they had the lowest physical function comparing with the other groups (p<0.001).

CONCLUSION

MCI and GCI in community-dwelling older adults affect the prevalence of FoF in a completely different manner. Further study is required to determine whether insensitivity to FoF with GCI increases the risk of falling in older adults.

Effect of music-based multitask training on cognition and mood in older adults

BACKGROUND

in a secondary analysis of a randomised controlled trial, we investigated whether 6 months of music-based multitask training had beneficial effects on cognitive functioning and mood in older adults.

METHODS

134 community-dwellers aged ≥65 years at increased risk for falling were randomly assigned to either an intervention group (n = 66) who attended once weekly 1-h supervised group classes of multitask exercises, executed to the rhythm of piano music, or a control group with delayed intervention (n = 68) who maintained usual lifestyle habits, for 6 months. A short neuropsychological test battery was administered by an intervention-blinded neuropsychologist at baseline and Month 6, including the mini-mental state examination (MMSE), the clock-drawing test, the frontal assessment battery (FAB) and the hospital anxiety (HADS-A) and depression scale.

RESULTS

intention-to-treat analysis showed an improvement in the sensitivity to interference subtest of the FAB (adjusted between-group mean difference (AMD), 0.12; 95% CI, 0.00 to 0.25; P = 0.047) and a reduction in anxiety level (HADS-A; AMD, -0.88; 95% CI, -1.73 to -0.05; P = 0.039) in intervention participants, as compared with the controls. Within-group analysis revealed an increase in MMSE score (P = 0.004) and a reduction in the number of participants with impaired global cognitive performance (i.e., MMSE score ≤23; P = 0.003) with intervention.

CONCLUSION

six months of once weekly music-based multitask training was associated with improved cognitive function and decreased anxiety in community-dwelling older adults, compared with non-exercising controls. Studies designed to further delineate whether training-induced changes in cognitive function could contribute to dual-task gait improvements and falls reduction, remain to be conducted.

Fatores associados a quedas e quedas recorrentes em idosos: estudo de base populacional

Objetivo: Identificar a prevalência e os fatores associados a quedas e quedas recorrentes em uma amostra de idosos que vivem na comunidade no município de Cuiabá-MT. Métodos: Estudo transversal, de base populacional, com idosos de 65 anos ou mais. Os domicílios foram arrolados por meio do sorteio de regiões censitárias, de acordo com a densidade populacional e o número de idosos em cada região. Foi utilizado um inquérito multidimensional contendo dados sociodemográficos, clínicos, psicológicos, de desempenho funcional e uma bateria de testes físicos. Resultados: A amostra foi composta por 391 participantes, com idade média (dp) de 72,4 (6,0) anos. Do total de participantes, 37,5% referiram ter caído no último ano e 16,5% relataram duas ou mais quedas. Cair foi associado a sintomas depressivos (OR=1,96; 95% IC 1,22-3,14, p=0,005); morar só (OR=2,83; 95% IC 1,57-5,12, p<0,001); baixa autoeficácia para quedas (OR=1,77; 95% IC 1,10-2,83, p=0,017); e artrite (OR= 2,10; 95% IC 1,34-3,29, p=0,001). Cair recorrentemente foi associado a: gênero feminino (OR=2,54; 95% IC 1,23-5,21, p=0,011); ter 80 anos e mais (OR=2,30; 95% IC 1,12-4,72, p=0,022); queixa de tontura (OR=1,91; 95% IC 1,04-3,49, p=0,035); morar só (OR=2,57; 95% IC 1,27-5,18, p=0,008); artrite (OR=1,94; 95% IC 1,07-3,51, p=0,027); e sintomas depressivos (OR=2,13 95% IC 1,17-3,88, p=0,013). Conclusão: Os fatores associados a quedas e quedas recorrentes modificáveis foram morar só, ter sintomas depressivos, baixa autoeficácia para quedas, tontura e artrite. Sugere-se que esses fatores sejam considerados em programas de prevenção de quedas nesta população.

Does progressive resistance and balance exercise reduce falls in residential aged care? Randomized controlled trial protocol for the SUNBEAM program

Introduction

Falls are common among older adults. It is reported that approximately 60% of residents of aged care facilities fall each year. This is a major cause of morbidity and mortality, and a significant burden for health care providers and the health system. Among community dwelling older adults, exercise appears to be an effective countermeasure, but data are limited and inconsistent among studies in residents of aged care communities. This trial has been designed to evaluate whether the SUNBEAM program (Strength and Balance Exercise in Aged Care) reduces falls in residents of aged care facilities.

Research question

Is the program more effective and cost-effective than usual care for the prevention of falls?

Design

Single-blinded, two group, cluster randomized trial.

Participants and setting

300 residents, living in 20 aged care facilities.

Intervention

Progressive resistance and balance training under the guidance of a physiotherapist for 6 months, then facility-guided maintenance training for 6 months.

Control

Usual care.

Measurements

Number of falls, number of fallers, quality of life, mobility, balance, fear of falling, cognitive well-being, resource use, and cost-effectiveness. Measurements will be taken at baseline, 6 months, and 12 months.

Analysis

The number of falls will be analyzed using a Poisson mixed model. A logistic mixed model will be used to analyze the number of residents who fall during the study period. Intention-to-treat analysis will be used.

Discussion

This study addresses a significant shortcoming in aged care research, and has potential to impact upon a substantial health care problem. Outcomes will be used to inform care providers, and guide health care policies.

[Physical and cognitive capabilities among persons aged 65-79 years in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1)]

In older age, physical and cognitive capabilities play an important role for independent living. For this reason, the German Health Interview and Examination Survey for Adults (DEGS1) included the Timed Up and Go test (TUG) and a chair-rise test, balance tests, a measurement of hand grip strength and the Digit Symbol Substitution Test (DSST) in order to representatively describe physical and cognitive performance of older people in Germany. Among 1,853 persons 65-79 years of age who came to the study centre more than 90 % participated in the performance tests. The average time needed to complete the TUG and chair-rise tests were 10.7 and 11.8 s, respectively. On average, participants reached 3.9 of a maximum of 5 points in the balance tests (FICSIT4 protocol). Mean maximum grip strength was 32.3 kg. The mean number of correctly assigned symbols in the DSST was 43.8. In all functional capacity areas tested, performance declined with increasing age. There were differences by sex in the chair-rise test, hand grip strength and DSST. The objective measurement of physical and cognitive capabilities in DEGS1 contributes to describe the health status of older people with implications for health promotion and prevention. An English full-text version of this article is available at SpringerLink as supplemental.

Preludes to brain failure: executive dysfunction and gait disturbances

The progressive and insidious gait and cognitive decline seen in older individuals without overt disease may result from a combination of age-dependent neuronal changes that are often exacerbated by vascular pathomechanisms. Emerging evidence suggests that slow gait and executive dysfunction are early phenomena in this decline and may further evolve to the development of falls and dementia. These early manifestations can be seen as "brain failure" and their co-occurrence suggests that they may share a common underlying mechanism. The authors argue that brain cortical control of motor and gait performance; and high complex cognitive functions such as executive function, share the same brain networks. Due to its particular watershed vascularization, these brain networks are highly susceptible to microvascular damage and the effects of vascular risk factors. A unified approach for evaluating and treating these two features of aging will close the gap in our understanding of cognitive-motor interactions and ultimately alter the pathways to disability. Besides the standard treatment for cognitive and mobility decline, the authors suggest that treating reversible vascular risk factors and hypertension, especially when they represent early manifestations of brain damage, has the potential to be a complementary method to prevent loss of mobility and cognitive decline in older adults.

Maximising functional recovery following hip fracture in frail seniors

This review discusses factors affecting recovery following hip fracture in frail older people as well as interventions associated with improved functional recovery. Prefracture function, cognitive status, co-morbidities, depression, nutrition and social support impact recovery and may interact to affect post-fracture outcome. There is mounting evidence that exercise is beneficial following hip fracture with higher-intensity/duration programmes showing more promising outcomes. Pharmacologic management for osteoporosis has benefits in preventing further fractures, and interest is growing in pharmacologic treatments for post-fracture loss of muscle mass and strength. A growing body of evidence suggests that sub-populations - those with cognitive impairment, residing in nursing homes or males - also benefit from rehabilitation after hip fracture. Optimal post-fracture care may entail the use of multiple interventions; however, more work is needed to determine optimal exercise components, duration and intensity as well as exploring the impact of multimodal interventions that combine exercise, pharmacology, nutrition and other interventions.

Does frailty predict increased risk of falls and fractures? A prospective population-based study

A frailty concept that includes psychological and cognitive markers was prospectively shown to be associated with increased risk of multiple falls and fractures among 1,509 community dwelling older adults, especially in those aged 75 and over. The predictive ability of frailty is not superior to falls history.

INTRODUCTION

The concept of frailty has been defined with or without psychological and cognitive markers. Falls are associated with multiple risk factors, including cognitive and mood disorders. The purpose of this study was to investigate the association of a comprehensive concept of frailty and its components with falls and fractures in community-dwelling older adults and to compare its predictive ability with having a history of falls.

METHODS

One thousand five hundred nine participants in the Longitudinal Aging Study Amsterdam aged ≥65 were assessed to determine fall history and the prevalence of nine frailty markers, including cognitive and psychological factors. The number of falls and time to second fall were prospectively registered for 1 year. Fractures were registered for 6 years.

RESULTS

Frailty was significantly associated with time to second fall: hazard ratio of 1.53 [95% confidence interval (CI), 1.07-2.18] and area under the receiver operating characteristic curve (AUC) of 0.58 (CI, 0.53-0.62). In participants aged ≥75, frailty was associated with ≥2 falls: odds ratio (OR) of 1.74 (CI, 1.19-2.55) and AUC of 0.62 (CI, 0.55-0.68). Frailty, adjusted for age and sex, was significantly associated with ≥2 fractures: OR of 3.67 (CI, 1.47-9.15). The AUCs for falls history (aged ≥75) ranged from 0.62 (CI, 0.58-0.67) for ≥1 falls to 0.67 (CI, 0.59-0.74) for ≥3 falls.

CONCLUSIONS

A concept of frailty including psychological and cognitive markers is associated with both multiple falls and fractures. However, frailty is not superior to falls history for the selection of old persons at increased risk of recurrent falls.

Poor balance and lower gray matter volume predict falls in older adults with mild cognitive impairment

Background

The risk of falling is associated with cognitive dysfunction. Older adults with mild cognitive impairment (MCI) exhibit an accelerated reduction of brain volume, and face an increased risk of falling. The current study examined the relationship between baseline physical performance, baseline gray matter volume and falls during a 12-month follow-up period among community-dwelling older adults with MCI.

Methods

Forty-two older adults with MCI (75.6 years, 43% women) underwent structural magnetic resonance imaging and baseline physical performance assessment, including knee-extension strength, one-legged standing time, and walking speed with normal pace. ‘Fallers’ were defined as people who had one or more falls during the 12-month follow-up period.

Results

Of the 42 participants, 26.2% (n = 11) experienced at least one fall during the 12-month follow-up period. Fallers exhibited slower walking speed and shorter one-legged standing time compared with non-fallers (both p < .01). One-legged standing time (sec) (standardized odds ratio [95% confidence interval]: 0.89 [0.81, 0.98], p = .02) was associated with a significantly lower rate of falls during the 12-month follow-up after adjusting for age, sex, body mass index, and history of falling in the past year at baseline. Voxel-based morphometry was used to examine differences in baseline gray matter volume between fallers and non-fallers, revealing that fallers exhibited a significantly greater reduction in the bilateral middle frontal gyrus and superior frontal gyrus.

Conclusions

Poor balance predicts falls over 12 months, and baseline lower gray matter densities in the middle frontal gyrus and superior frontal gyrus were associated with falls in older adults with MCI. Maintaining physical function, especially balance, and brain structural changes through many sorts of prevention strategies in the early stage of cognitive decline may contribute to decreasing the risk of falls in older adults with MCI.

Classification of falls in stroke rehabilitation – not all falls are the same

Objective:

To develop a practical taxonomy of falls and to determine whether these different fall groups have different outcomes.

Design:

Descriptive study examining patient characteristics at the time of each fall and iterative development of falls taxonomy.

Setting:

An inpatient stroke rehabilitation ward.

Methods:

All falls over 21 months were reviewed retrospectively. Case notes were reviewed and each patient’s level of functioning at the time of fall, together with admission profile and discharge outcomes, were collected. Outcomes for fallers (as opposed to falls) were compared using the predominant fall type.

Results:

There were 241 falls in 122 patients and most falls occurred around the bed (196 (81%) falls). Toileting-related falls occurred in 54 patients (22.4%). The taxonomy proposes seven main fall types. One fall type (‘I’m giving it a go’) appeared quite different and was associated with better functioning at time of fall and better outcomes. Other fall types were related to high dependency needs, visuospatial difficulties or delirium. Medication-related falls were uncommon in this cohort.

Conclusions:

The falls taxonomy developed showed four main types of falls with different, but overlapping, patient characteristics at time of fall with different outcomes. Different fall-prevention strategies may be required for each group.

Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study

Background

Although lower urinary tract symptoms have been associated with falls, few studies have been undertaken to understand this relationship in vulnerable community dwelling older adults. The purpose of this study was to describe the relationship over time of falls risk and lower urinary tract symptoms among community based older women receiving home support services.

Methods

A prospective cohort study which took place in an urban setting in western Canada. Participants were 100 older women receiving home care or residing in assisted living with home support services and were followed for six months. Demographic characteristics were collected at baseline, with the Timed Up and Go (TUG), International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms (ICIQ-FLUTS), and self-report of falls collected at baseline, 3 and 6 months. Descriptive statistics were used to summarize demographic data. Differences between the three visits were analyzed using the Friedman test with post hoc analysis and associations between variables by the Spearman Rank-Order Correlation Coefficient.

Results

One hundred women initially enrolled; 88 and 75 remained at three months and six months. Mean age = 84.3 years; 91% reported at least one urinary symptom at baseline and 35% reported falling in the six months prior to enrollment; 15.9% reported falling between the baseline and three months and 14.6% between three and six months. Mean TUG scores at each time point indicated falls risk (27.21, 29.18 and 27.76 seconds). Significant correlations between TUG and ICIQ-FLUTS (r ₌ 0.33, p < .001; r ₌ 0.39, p < .001) as well as TUG and overactive bladder scores (r ₌ 0.25, p = .005; r ₌ 0.28, p < .008) were found at baseline and three months, but not six months.

Conclusions

The association of lower urinary tract symptoms and falls risk in this group of vulnerable community dwelling older women at baseline and three months has potential clinical relevance. Lack of correlation at six months may be due loss of less robust participants, illuminating the difficulty in following frailer groups over time. Further studies are needed to understand the contribution of urinary symptoms to falls risk, and clinicians should incorporate continence assessment within falls risk assessment.

Effects of a multimodal exercise program in pedal dexterity and balance: study with Portuguese older adults of different contexts

This study investigated the effects of a multimodal exercise program (MEP) on pedal dexterity and balance in two groups of older adult participants (65–92 years of age) from a psychiatric hospital center (HC), a residential care home (RCH), and a daily living center (DLC). The experimental group (EG) trained three times per week for 12 months, and the control group (CG) maintained their normal activities. The Mini-Mental State Examination and the Modified Baecke Questionnaire, as well as the Pedal Dexterity and the Tinetti tests, were applied to all subjects before and after the experimental protocol. Furthermore, the foot preference was controlled using the Lateral Preference Questionnaire proposed by Coren [10]. In the EG, the results from the Pedal Dexterity test showed that both males and females from the RCH and DLC improved their performances after the MEP. In the HC, the males slightly decreased their performance with both feet, contrarily to females. Both males and females from the CG decreased their pedal dexterity performance, namely, with the non-preferred foot. Concerning the Tinetti test, the EG of both males and females from the HC, the RCH (males were better than females regarding the gender factor), and the DLC improved their balance after the MEP. In the CG, no significant effects or interactions were found for any of the context groups.

Risk factors for falls among older adults: a review of the literature

Falls are one of the major causes of mortality and morbidity in older adults. Every year, an estimated 30-40% of patients over the age of 65 will fall at least once. Falls lead to moderate to severe injuries, fear of falling, loss of independence and death in a third of those patients. The direct costs alone from fall related injuries are a staggering 0.1% of all healthcare expenditures in the United States and up to 1.5% of healthcare costs in European countries. This figure does not include the indirect costs of loss of income both to the patient and caregiver, the intangible losses of mobility, confidence, and functional independence. Numerous studies have attempted to define the risk factors for falls in older adults. The present review provides a brief summary and update of the relevant literature, summarizing demographic and modifiable risk factors. The major risk factors identified are impaired balance and gait, polypharmacy, and history of previous falls. Other risk factors include advancing age, female gender, visual impairments, cognitive decline especially attention and executive dysfunction, and environmental factors. Recommendations for the clinician to manage falls in older patients are also summarized.

Cognitive function modifies the effect of physiological function on the risk of multiple falls--a population-based study

BACKGROUND

There is a poor understanding of the interplay between cognitive and physiological functions in leading to falls. We hypothesized that poorer physiological function would modify the effect of poorer cognitive function on increased risk of falling in older people.

METHODS

A range of cognitive (executive function/attention, memory, processing speed, and visuospatial ability) and physiological functions (vision, proprioception, sway, leg strength, reaction time) were measured using standardized tests in 386 randomly selected adults aged 60-86. Incident falls were recorded over 12 months. Log-multinomial regression was used to model the relationships and test for interactions between cognition and physiological function in explaining the risk of single or multiple falls.

RESULTS

Overall, 94 people (24.4%) had a single fall, and 78 (20.2%) had multiple falls. No significant associations were observed between cognitive function and the risk of single falls. The risk of multiple falls was increased with poorer function in Stroop dot time (RR = 1.03, 95% CI [1.01, 1.05], p = .002) and Stroop word time (RR = 1.02 [1.01, 1.03], p = .001) and reduced with better function in Category Fluency (RR = 0.94 [0.91, 0.98], p = .001) and visuospatial function (RR = 0.95 [0.92, 0.98], p < .001). These associations were amplified by the presence of greater body sway, less ambulatory physical activity, slower reaction time and gait speed, weaker muscle strength, and poorer visual contrast (p for interactions <.05).

CONCLUSIONS

Preventing falls due to physiological impairments in community-dwelling older people may need to be tailored based on cognitive impairment, a key factor in their inability to compensate for physical decline.

Prevalence and Determinants of Falls among Older Adults in Ecuador: An Analysis of the SABE I Survey

The present study based on a nationally representative sample of older adults living in the Andes mountains and coastal region of the country indicates that 34.7% of older adults had fallen in the previous year in Ecuador. Among fallers, 30.6% reported a fall-related injury. The prevalence of falls was higher in women and among older adults residing in the rural Andes mountains. In the multivariate model, women, subjects with cognitive impairment, those reporting urinary incontinence, and those being physically active during the previous year were variables found independently associated with increased risk of falling among older adults in Ecuador. Moreover, a gradual and linear increase in the prevalence of falls was seen as the number of risk factors increased. Falls represent a major public health problem among older adults in Ecuador. The present findings may assist public health authorities to implement programs of awareness and fall prevention among older adults at higher risk of falls.

V-TIME: a treadmill training program augmented by virtual reality to decrease fall risk in older adults: study design of a randomized controlled trial

BACKGROUND

Recent work has demonstrated that fall risk can be attributed to cognitive as well as motor deficits. Indeed, everyday walking in complex environments utilizes executive function, dual tasking, planning and scanning, all while walking forward. Pilot studies suggest that a multi-modal intervention that combines treadmill training to target motor function and a virtual reality obstacle course to address the cognitive components of fall risk may be used to successfully address the motor-cognitive interactions that are fundamental for fall risk reduction. The proposed randomized controlled trial will evaluate the effects of treadmill training augmented with virtual reality on fall risk.

METHODS/DESIGN

Three hundred older adults with a history of falls will be recruited to participate in this study. This will include older adults (n=100), patients with mild cognitive impairment (n=100), and patients with Parkinson's disease (n=100). These three sub-groups will be recruited in order to evaluate the effects of the intervention in people with a range of motor and cognitive deficits. Subjects will be randomly assigned to the intervention group (treadmill training with virtual reality) or to the active-control group (treadmill training without virtual reality). Each person will participate in a training program set in an outpatient setting 3 times per week for 6 weeks. Assessments will take place before, after, and 1 month and 6 months after the completion of the training. A falls calendar will be kept by each participant for 6 months after completing the training to assess fall incidence (i.e., the number of falls, multiple falls and falls rate). In addition, we will measure gait under usual and dual task conditions, balance, community mobility, health related quality of life, user satisfaction and cognitive function.

DISCUSSION

This randomized controlled trial will demonstrate the extent to which an intervention that combines treadmill training augmented by virtual reality reduces fall risk, improves mobility and enhances cognitive function in a diverse group of older adults. In addition, the comparison to an active control group that undergoes treadmill training without virtual reality will provide evidence as to the added value of addressing motor cognitive interactions as an integrated unit.

TRIAL REGISTRATION

(NIH)-NCT01732653.

Limited health literacy and decline in executive function in older adults

Limited health literacy is associated with worse executive function, but the association between limited health literacy and decline in executive function has not been established because of a lack of longitudinal studies. The authors aimed to examine this association by studying a prospective cohort in the setting of a randomized controlled trial to promote walking in older adults. Participants were community-dwelling older adults (65 years of age or older) who scored 2 or more on the Mini-Cog, without depression (score of less than 15 on the 9-item Patient Health Questionnaire), and who completed baseline and 12-month evaluations (n = 226). Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Executive function measured at baseline and 12 months using the Trail Making Test (TMT), Controlled Oral Word Association Test, and Category Fluency. The associations between health literacy and 12-month decline in each test of executive function were modeled using multivariate linear regression. Health literacy was found to be limited in 37% of participants. Limited health literacy was associated with reduced performance on all 3 executive function tests. In fully adjusted models, limited health literacy was associated with greater 12-month decline in performance on the TMT than higher health literacy (p = .01). In conclusion, older adults with limited health literacy are at risk for more rapid decline in scores on the TMT, a measure of executive function.

Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in eastern France

OBJECTIVE

To estimate: (1) the association between executive function (EF) impairment and falls; and (2) the association of EF impairment on tests of physical function used in the evaluation of fall risk.

DESIGN

Cross-sectional study.

SETTING

Thirteen health examination centres in Eastern France.

PARTICIPANTS

Four thousand four hundred and eighty one community-dwelling older adults without dementia aged 65 to 97 years (mean age 71.8±5.4, women 47.6%).

MEASUREMENTS

Participants underwent a comprehensive medical assessment that included evaluations of EF using the Clock Drawing Test and of physical performance using the Timed Up and Go Test (TUG). Analysis used multivariable modified Poisson regression to evaluate the association between impaired EF and each of the fall outcomes (any fall, recurrent falls, fall-related injuries). Multivariable linear regression was used to evaluate the association between EF impairment and performance on the TUG and grip strength.

RESULTS

EF impairment, assessed using the clock drawing test, was present in 24.9% of participants. EF impairment was independently associated with an increased risk of any fall (RR=1.13, 95% CI (1.03, 1.25)) and major soft tissue fall-related injury (RR= 2.42, 95% CI (1.47, 4.00)). Additionally, EF impairment was associated with worse performance on the TUG (p<0.0001).

CONCLUSIONS

EF impairment among older adults without dementia was highly prevalent and was independently associated with an increased risk for falls, fall-related injuries and with decreased physical function. The use of the Clock Drawing Test is an easy to administer measure of EF that can be used routinely in comprehensive fall risk evaluations.

Gait and cognition: a complementary approach to understanding brain function and the risk of falling

Until recently, clinicians and researchers have performed gait assessments and cognitive assessments separately when evaluating older adults, but increasing evidence from clinical practice, epidemiological studies, and clinical trials shows that gait and cognition are interrelated in older adults. Quantifiable alterations in gait in older adults are associated with falls, dementia, and disability. At the same time, emerging evidence indicates that early disturbances in cognitive processes such as attention, executive function, and working memory are associated with slower gait and gait instability during single- and dual-task testing and that these cognitive disturbances assist in the prediction of future mobility loss, falls, and progression to dementia. This article reviews the importance of the interrelationship between gait and cognition in aging and presents evidence that gait assessments can provide a window into the understanding of cognitive function and dysfunction and fall risk in older people in clinical practice. To this end, the benefits of dual-task gait assessments (e.g., walking while performing an attention-demanding task) as a marker of fall risk are summarized. A potential complementary approach for reducing the risk of falls by improving certain aspects of cognition through nonpharmacological and pharmacological treatments is also presented. Untangling the relationship between early gait disturbances and early cognitive changes may be helpful in identifying older adults at risk of experiencing mobility decline, falls, and progression to dementia.