Understanding Risk of Falls in People With Cognitive Impairment Living in Residential Care

The Ability of Physical Performance Measures to Identify Fall Risk in Older Adults Living With Dementia: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine whether physical performance measures commonly used in clinical settings can discriminate fallers from nonfallers and predict falls in older adults with dementia.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Older adults with dementia residing in the community, hospitals, and residential care facilities.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL, SPORTDiscus, the Cochrane Library, and the PEDro databases were searched from inception until December 27, 2023 (PROSPERO registration number: CRD42022303670). Retrospective or prospective studies that evaluated the associations between physical performance measures and falls in older adults with dementia were included. A random effects model was used to calculate the standardized mean difference (SMD) and 95% CI for each physical performance measure between fallers and nonfallers. Sensitivity analyses were conducted on the longitudinal studies to determine the ability of physical performance measures to predict future falls.

RESULTS

Twenty-eight studies were included in this review (n = 3542). The 5-time chair stand test [SMD = 0.23 (0.01, 0.45)], the Berg Balance Scale [SMD = -0.52 (-0.87, -0.17)], postural sway when standing on the floor [SMD = 0.25 (0.07, 0.43)] and on a foam surface [SMD = 0.45 (0.25, 0.66)], and the Short Physical Performance Battery total score [SMD = -0.46 (-0.66, -0.27)] could discriminate fallers from nonfallers. Sensitivity analyses showed that gait speed could predict future falls in longitudinal cohort studies [SMD = -0.29 (-0.49, -0.08)]. Subgroup analyses showed that gait speed [SMD = -0.21 (-0.38, -0.05)] and the Timed Up and Go test [SMD = 0.54 (0.16, 0.92)] could identify fallers staying in residential care facilities or hospitals.

CONCLUSIONS AND IMPLICATIONS

The 5-time chair stand test, the Berg Balance Scale, postural sway when standing on the floor and a foam surface, and the Short Physical Performance Battery can be used to predict falls in older adults with dementia. Gait speed and the Timed Up and Go test can be used to predict falls in institutionalized older adults with dementia. Clinicians are recommended to use these physical performance measures to assess fall risk in older adults with dementia.

Comparison of the relationship between cognitive function and future falls in Chinese community-dwelling older adults with and without diabetes mellitus

OBJECTIVE

The aim of this study was to determine whether cognitive function is associated with future falls in older patients with diabetes mellitus (DM) compared with those without DM. Cognitive function was divided into several domains to further analyze.

METHODS

A total of 678 individuals met the inclusion criteria and comprised the final study population. The mean age was 74.35 ± 5.35 years, and 58.9% of the participants were female (n = 400). At the baseline, cognitive function was measured by the Mini Mental State Examination (MMSE), and DM diagnoses were determined by medical records. The self-reported any falls data were obtained via face-to-face questioning at the 1-year follow-up.

RESULTS

At baseline, 15.6% of participants (n = 106) were diagnosed with DM. According to whether they had any falls during 1-year follow-up, there was a significant difference between the two group in fasting plasma glucose (p = 0.012) and DM (p = 0.036) at baseline. Among the older adults with DM, those who had experienced any falls had poorer cognitive function (p = 0.014). After adjusting for various covariates, we found that MMSE (95% CI 0.790-0.991, p = 0.034), orientation to place (95% CI 0.307-0.911, p = 0.022) and registration (95% CI 0.162-0.768, p = 0.009) were significantly associated with falls in the follow-up.

CONCLUSION

Our study found that in patients with DM, cognitive function is related to future falls. Not only overall cognitive function, but also orientation to place and registration were all associated with future falls in older adults with DM. When completing the fall risk assessment of elderly patients with DM, clinicians should give more attention to the testing of cognitive function.

Association between mild cognitive impairment and falls among Chinese older adults: the mediating roles of balance capacity and depressive symptoms

BACKGROUND

This study aimed to examine the association between mild cognitive impairment (MCI) and the follow-up risk of falls among Chinese older adults, exploring the mediating roles of balance capacity and depressive symptoms in the association between MCI and falls.

METHODS

A total of 5482 adults aged 60 years and above from waves 2015 and 2018 of the China Health and Retirement Longitudinal Study were included for analysis. Cognition was assessed by a global cognition score, which included three tests: episodic memory, figure drawing and Telephone Interview of Cognitive Status. Depressive symptoms were assessed with the Centre for Epidemiological Studies Depression Scale. Logistic regression models were used to estimate the association between MCI and falls. Mediation analysis was employed to explore the potential mediating roles of balance capacity and depressive symptoms in the association between MCI and falls.

RESULTS

MCI was significantly associated with the risk of falls (OR 1.259, 95% CI 1.080 to 1.467). Balance capacity and depressive symptoms played parallel mediating roles in the association between MCI and falls, and the mediating effects were 0.004 (95% CI 0.003 to 0.024) and 0.010 (95% CI 0.004 to 0.016), respectively.

CONCLUSIONS

It is necessary to screen for and recognise MCI in order to prevent falls among older adults. More efforts should be made to improve balance capacity and relieve depressive symptoms to reduce the risk of falls among older adults with MCI.

Development of an effective clustering algorithm for older fallers

Falls are common and often lead to serious physical and psychological consequences for older persons. The occurrence of falls are usually attributed to the interaction between multiple risk factors. The clinical evaluation of falls risks is time-consuming as a result, hence limiting its availability. The purpose of this study was, therefore, to develop a clustering-based algorithm to determine falls risk. Data from the Malaysian Elders Longitudinal Research (MELoR), comprising 1411 subjects aged ≥55 years, were utilized. The proposed algorithm was developed through the stages of: data pre-processing, feature identification and extraction with either t-Distributed Stochastic Neighbour Embedding (t-SNE) or principal component analysis (PCA)), clustering (K-means clustering, Hierarchical clustering, and Fuzzy C-means clustering) and characteristics interpretation with statistical analysis. A total of 1279 subjects and 9 variables were selected for clustering after the data pre-possessing stage. Using feature extraction with the t-SNE and the K-means clustering algorithm, subjects were clustered into low, intermediate A, intermediate B and high fall risk groups which corresponded with fall occurrence of 13%, 19%, 21% and 31% respectively. Slower gait, poorer balance, weaker muscle strength, presence of cardiovascular disorder, poorer cognitive performance, and advancing age were the key variables identified. The proposed fall risk clustering algorithm grouped the subjects according to features. Such a tool could serve as a case identification or clinical decision support tool for clinical practice to enhance access to falls prevention efforts.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

Depression is common within the first year of relocation to residential care/assisted living (RC/AL). Yet, few studies investigate the relationship between depression and relocation factors that might help identify at-risk residents, such as previous location. This study analyzed cross-sectional resident data (n = 2651) from the National Survey of Residential Care Facilities to test: (1) group differences between residents relocating from acute/post-acute facilities (e.g., hospital, rehabilitation facility) and community-based residences, and (2) the relationship between previous location and depression within the first year of relocation. The 921 (35%) residents relocating directly from acute/post-acute facilities were more likely to have depression (p < .001) and poorer outcomes on select health and psychosocial variables. After controlling for covariates, relocating directly from an acute/post-acute facility significantly related to depression (OR = 1.22). Findings highlight opportunities to improve routine screening and transitional care for this subpopulation of RC/AL residents at heightened risk for depression.

Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens

Purpose of review

The management of hypertension in frail older adults remains controversial, as these patients are underrepresented in clinical trials and practice guidelines. Overtreatment may cause harm while undertreatment may lead to greater risk of cardiovascular events. Our research aims to examine this controversy and provide guidance regarding deprescribing decisions in frail older adults.

Results

Current evidence suggests that there may be minimal cardiovascular benefit and significant harm of antihypertensive medication in the frail older adult population. A minority of hypertension guidelines provide sufficient recommendations for frail older adults, and there are limited tools available to guide clinical decision-making.

Conclusion

Randomized controlled trials and well-designed observational studies are needed to confirm the benefit-to-harm relationship of antihypertensive medication in frail older adults. Decision tools that comprehensively address antihypertensive deprescribing would be advantageous to help clinicians with hypertension management in this population. Clinicians should engage in shared decision-making with the patient and family to ensure that decisions regarding antihypertensive deprescribing best meet the needs of all involved.

Association Between Cognitive Status and Falls With and Without Injury During a Skilled Nursing Facility Short Stay

OBJECTIVES

To examine the relationship between cognitive status and falls with and without injury among older adults during the first 18 days of a skilled nursing facility (SNF) and determine if this association is mediated by limitations in activities of daily living (ADL) and impaired balance.

DESIGN

Cohort study of Medicare fee-for-service beneficiaries admitted to an SNF between October 1, 2016, and September 31, 2017.

SETTINGS AND PARTICIPANTS

815,927 short-stay nursing home residents admitted to an SNF within 3 days of hospital discharge.

METHODS

Cognitive status at SNF admission was classified as intact, mild, moderate, or severe impairment. Residents were classified as having no falls, a fall without injury, and a fall with a minor or major injury. We used ordinal logistic regression to model the association between cognitive status and falls adjusting for resident and facility characteristics. A causal mediation analysis was used to test for the mediating effects of ADL limitations and impaired balance on the association between cognitive status and falls with an injury.

RESULTS

Mild, moderate, and severe cognitive impairment were associated with 1.72 (95% CI: 1.68-1.75), 2.72 (95% CI: 2.66-2.78), and 2.61 (95% CI: 2.48-2.75) higher odds of being in a higher fall severity category, respectively, compared to being cognitively unimpaired. Greater ADL limitations and impaired balance were significantly associated with falls, but each mediated the association between cognitive status and falls by less than 2%.

CONCLUSIONS AND IMPLICATIONS

Older adults with cognitive impairment are more likely to experience a fall during an SNF stay. ADL limitations and impaired balance are risk factors for falls but may not contribute to the increased fall risk for SNF residents with cognitive impairment. Continued research is needed to better understand the risk factors for falls among SNF residents with cognitive impairment.

The effect of physical and social isolation due to the COVID-19 pandemic on the incidence of hip fractures among senior citizens

This study aimed to explore the effects of the lockdown due to the coronavirus disease 2019 pandemic on the incidence and characteristics of hip fracture in older adults. Data from the three-month lockdown period and the corresponding period in the previous year were obtained from the computerized medical records of a large acute-care hospital. No significant differences were observed in the absolute and relative numbers of hip fractures. There were no significant differences in terms of socio-demographic and clinical characteristics, which are considered risk factors for falls. Similarly, there was no difference in the length of time between admission and surgery and the mean length of hospital stay. Compared to the previous year, there was a significantly higher incidence of hip fractures in older adults living alone during the lockdown. Health policy should provide social support and monitoring of healthcare, particularly to older adults living alone.

Effect of Dementia on Outcomes After Surgically Treated Hip Fracture in Older Adults

BACKGROUND

Hip fractures are associated with increased mortality and functional limitations. However, the effect that dementia has on these outcomes in individuals in aged care settings after fracture is not well established. This study examined the association of dementia with post-hip fracture mortality, permanent residential aged care entry, transition care use, and change in activities of daily living (ADL) needs.

METHODS

A retrospective cohort study using data from the Registry of Senior Australians (2003-2015) was conducted. Individuals with a hip fracture while receiving aged care services were included. Associations of dementia with mortality, risks of transition and permanent care use, and ADL needs progression were estimated using multivariable Cox, Fine-Gray, and logistic regression methods, respectively.

RESULTS

Of 4771 individuals evaluated, 76% were women, the median age was 86 years (IQR 82-90), and 71% already lived in permanent residential aged care at the time of fracture. Within two years of their hip fracture, 50.4% (95% CI 48.9%-51.8%) of individuals died, 16.2% (95% CI 14.2%-18.2%) entered a transition care program, 59.1% (95% CI 56.5%-61.7%) entered permanent residential aged care, and 32% had greater ADL needs. Dementia was associated with higher risk of two-year mortality (HR = 1.19, 95% CI 1.09-1.30), 90-day entry into permanent care (sHR = 1.96, 95% CI 1.60-2.38), and increased likelihood of ADL limitations (OR = 1.36, 95% CI 1.00-1.85). Minor differences were seen in transition care use by dementia status.

CONCLUSION

Dementia is a strong risk factor for mortality after hip fractures in individuals in aged care settings and associated with a high risk of entry into permanent care.

LEVEL OF EVIDENCE

Prognostic level III.

Applying the RE-AIM implementation framework to evaluate fall prevention interventions in community dwelling adults with cognitive impairment: a review and secondary analysis

BACKGROUND

Cognitive impairment (CI) is a risk factor for falls due to environmental or living settings, balance, gait and vision impairments, as well as medications. While previous systematic reviews have focused on the effectiveness of fall prevention programs in adults with cognitive impairment, very limited information is available on their implementation. This review examines what aspects of fall prevention interventions for community-dwelling adults with CI have been reported using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to support successful implementation.

METHODS

We examined the included studies from our systematic review, which searched 7 databases for primary and secondary fall prevention interventions involving community-dwelling adults ≥50 years with mild to moderate CI. Reviewers screened citations and extracted data for study characteristics and the 5 dimensions (62 criteria) of the RE-AIM framework.

RESULTS

Twelve randomized or clinical controlled trials (RCTs/CCTs) consisting of 8 exercise interventions, 3 multifactorial interventions, and 1 medication treatment were included in the review. Only 4 of 62 criteria were reported by all 12 included studies and 29 criteria were not reported by any of the studies. Five of the included studies reported on 20 or more of the 62 possible RE-AIM criteria and 3 of these studies self-identified as "feasibility" studies. While Reach was the best-reported construct by the included studies, followed by Effectiveness and Implementation, the criteria within the Adoption and Maintenance constructs were rarely mentioned by these studies. In general, there was also wide variation in how each of the criteria were reported on by study authors.

CONCLUSION

Based on the reporting of RE-AIM components in this review, we are unable to make connections to successful intervention components and thus practice-based recommendations for fall prevention in those with CI. The lack of detail regarding implementation approaches greatly limits the interpretation and comparisons across studies to fully inform future research efforts.

A mixed methods systematic review of informal caregivers' experiences of fall risk among community-dwelling elders with dementia

Evidence on effective fall prevention strategies for community-dwelling elders with dementia is limited, although these elders are at high risk of falling. Informal caregivers may play an essential role in managing fall risk for elders with dementia. Thus, understanding caregiver's experiences is critically important. This systematic review aims to (a) identify caregivers' perceptual, emotional and behavioural responses to fall risk in elders with dementia and (b) examine the outcomes and effects of caregiver behavioural responses. A mixed methods systematic review of 10 databases (PubMed, PsycINFO, CINAHL, Social Service Abstracts, Social Work Abstracts, EMBASE, Web of Science, Scopus, Cochrane Library and TRIP Medical Database) was conducted. We searched English language, peer-review articles (January 1, 1985-March 20, 2020) that met the predefined inclusion/exclusion criteria. Study quality was assessed using the Mixed Methods Appraisal Tool. Data were analysed using thematic synthesis techniques. Twenty-nine studies were included. Six analytic themes were generated concerning caregivers' perceptual, emotional and behavioural responses: (a) fear of the negative health consequences of falls; (b) limited insights into factors contributing to falls; (c) varying expectations of managing fall risk; (d) multi-level efforts; (e) struggling with responsibilities; and (f) inaction and withdrawal. The findings about the outcomes and effects of caregivers' behaviours were synthesised into three analytic themes: (a) multi-faceted outcomes; (b) uncertain and inconsistent evidence; and (c) unclear associations. The study generated new insights in understanding caregivers' responses of fall risk among community-dwelling elders with dementia and identified significant gaps in examining the impact of caregivers' responses and what shapes these responses. Investment in understanding caregivers' perspectives will inform future interventions and policies to reduce negative outcomes for elders, caregivers and care systems.

Prevalence/potential risk factors for motoric cognitive risk and its relationship to falls in elderly Chinese people: a cross-sectional study

BACKGROUND AND PURPOSE

Motoric cognitive risk syndrome (MCR) is characterized by slow walking speed and subjective memory complaints (SMCs). This study investigated the prevalence and potential risk factors of MCR and its association with falls in Chinese community-dwelling older adults.

METHODS

The analysis was based on data from the Rugao Longevity and Aging Study (RuLAS). MCR was defined as the presence of both SMCs and slow walking speed in participants free of major neurocognitive disorders. SMCs were determined according to a positive answer to the question 'Do you feel you have more problems with memory than most?' in the 15-item Geriatric Depression Scale. Slow walking speed was defined as one standard deviation or more below the mean value for patients' age and sex. Data on falls were derived from a standardized questionnaire.

RESULTS

The prevalence of SMCs, slow walking speed and MCR in the RuLAS cohort (N = 1592) was 51.9%, 15.6% and 8.3%, respectively. After adjusting for other covariates, an occupation of farming (odds ratio [OR] 2.358, 95% confidence interval [CI] 1.007-5.521, p = 0.048), history of cerebrovascular disease (OR 2.215, 95% CI 1.032-4.752, p = 0.041) and hospitalization (OR 2.008, 95% CI 1.120-3.602, p = 0.019) were risk factors for MCR. Binary logistic regression analysis indicated that the risk of falls was increased by MCR (OR 1.547, 95% CI 1.009-2.371), SMC (OR 1.308, 95% CI 1.003-1.707) and slow walking speed (OR 1.442, 95% CI 1.030-2.017).

CONCLUSIONS

Early identification of potential risk factors of MCR can prevent the occurrence of adverse health events such as falls in the elderly.

Frailty, with or without Cognitive Impairment, is a Strong Predictor of Recurrent Falls in a US Population-Representative Sample of Older Adults

BACKGROUND

Physical frailty and cognitive impairment have been separately associated with falls. The purpose of the study is to examine the associations of physical frailty and cognitive impairment separately and jointly with incident recurrent falls among older adults.

METHODS

The analysis included 6000 older adults in community or non-nursing home residential care settings who were ≥65 years and participated in the National Health Aging Trends Study (NHATS). Frailty was assessed using the physical frailty phenotype; cognitive impairment was defined by bottom quintile of clock drawing test or immediate and delayed 10-word recall, or self/proxy-report of diagnosis of dementia, or AD8 score≥ 2. The marginal means/rates models were used to analyze the associations of frailty (by the physical frailty phenotype) and cognitive impairment with recurrent falls over 6 years follow-up (2012-2017).

RESULTS

Of the 6000 older adults, 1,787 (29.8%) had cognitive impairment only, 334 (5.6%) had frailty only, 615 (10.3%) had both, and 3,264 (54.4%) had neither. After adjusting for age, sex, race, education, living alone, obesity, disease burden, and mobility disability, those with frailty (with or without cognitive impairment) at baseline had higher rates of recurrent falls than those without cognitive impairment and frailty (frailty only: Rate ratio (RR)=1.31, 95% confidence interval (CI)=1.18-1.44; both: RR=1.28, 95% CI=1.17-1.40). The association was marginally significant for those with cognitive impairment only (RR=1.07, 95% CI=1.00-1.13).

CONCLUSIONS

Frailty and cognitive impairment were independently associated with recurrent falls in non-institutionalized older adults. There was a lack of synergistic effect between frailty and cognitive impairment.

Application of Machine Learning Methods in Nursing Home Research

Background: A machine learning (ML) system is able to construct algorithms to continue improving predictions and generate automated knowledge through data-driven predictors or decisions. Objective: The purpose of this study was to compare six ML methods (random forest (RF), logistics regression, linear support vector machine (SVM), polynomial SVM, radial SVM, and sigmoid SVM) of predicting falls in nursing homes (NHs). Methods: We applied three representative six-ML algorithms to the preprocessed dataset to develop a prediction model (N = 60). We used an accuracy measure to evaluate prediction models. Results: RF was the most accurate model (0.883), followed by the logistic regression model, SVM linear, and polynomial SVM (0.867). Conclusions: RF was a powerful algorithm to discern predictors of falls in NHs. For effective fall management, researchers should consider organizational characteristics as well as personal factors. Recommendations for Future Research: To confirm the superiority of ML in NH research, future studies are required to discern additional potential factors using newly introduced ML methods.

Neuropsychiatric Symptoms as Predictors of Falls in Long-Term Care Residents With Cognitive Impairment

OBJECTIVES

Falls and neuropsychiatric symptoms (NPS) are common among long-term care residents with cognitive impairment. Despite the high prevalence of falls and NPS, little is known about their association. The aim of our study was to explore how NPS, particularly the severity of NPS and specific NPS subgroups, are associated with falls and how psychotropics modify this association.

DESIGN

Longitudinal cohort study.

SETTING AND PARTICIPANTS

In total, 532 long-term care residents aged 65 years or older in Helsinki, Finland.

METHODS

NPS were measured with Neuropsychiatric Inventory (NPI) at baseline. Participants were grouped into 3 groups: no significant NPS (NPI points 0‒3), low NPS burden (NPI 4‒12), and high NPS burden (NPI >12). The number of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment.

RESULTS

Altogether, 606 falls occurred during the follow-up year. The falls led to 121 injuries, 42 hospitalizations, and 20 fractures. Falls and injuries increased significantly with NPS burden (P < .001): 330 falls in the high NPS group (n = 184), 188 falls in the low NPS group (n = 181), and 88 falls in the no significant NPS group (n = 167). The risk of falling showed a curvilinear association with NPI total score. Of NPS subgroups, psychosis and hyperactivity were associated with a higher incidence rate ratio of falls, whereas apathy had a protective association even after adjustment for age, sex, and mobility. Affective symptoms were not associated with falls. Psychotropics did not modify the association between NPS burden and falls.

CONCLUSIONS AND IMPLICATIONS

The results of this study show that NPS, especially NPS severity, may predict falls and fall-related negative consequences. Severity of NPS should be taken into account when assessing fall risk in long-term care residents with cognitive impairment.

Review of Gait, Cognition, and Fall Risks with Implications for Fall Prevention in Older Adults with Dementia

BACKGROUND

Older people with cognitive impairment are at increased risk of falls; however, fall prevention strategies have limited success in this population. The aim of this paper is to review the literature to inform a theoretical framework for fall prevention in older adults with dementia.

SUMMARY

A narrative review was conducted on fall risk factors in people with cognitive impairment, the relationship between cognition and gait, and their joint impact on the risk of falls. This was used to develop a theoretical framework for fall prevention for people with dementia. Executive function and motor function are closely related as they share neuroanatomy. This close relationship has been confirmed by observational studies including neuroimaging and intervention studies. Executive function is the cognitive domain most commonly associated with gait dysfunction. Attention, sensory integration, and motor planning are the sub-domains of executive function associated with risk of falls through gait dysfunction, whereas cognitive flexibility, judgement, and inhibitory control affect risk of falls through risk-taking behaviour. Key Messages: Gait, cognition, and falls are closely related. The comorbidity and interaction between gait abnormality and cognitive impairment may underpin the high prevalence of falls in older adults with dementia. Gait assessment and cognitive assessment, particularly executive function, should be integrated in fall risk screening. Assessment results should be interpreted and utilised using a multidisciplinary approach; specific strategies such as customised gait training and behavioural modulation should be considered as part of falls prevention for people with dementia.

Evaluating Mobility in Advanced Dementia: A Scoping Review and Feasibility Analysis

BACKGROUND AND OBJECTIVES

Mobility decline is a symptom of advanced dementia that affects function, safety, caregiving, and quality of life. Monitoring mobility status is essential for initiating timely and targeted interventions aimed at preventing excess disability in people with dementia (PWD). The physical, cognitive, and behavioral symptoms of dementia however, present unique challenges for mobility assessment. The goals of this review were to (a) identify and describe measures of mobility used for PWD and (b) assess measures' feasibility for use in people with advanced dementia; a group whose degree of cognitive impairment results in severe functional deficits.

RESEARCH DESIGN AND METHODS

Electronic searches of Medline, Embase, CINAHL, and PsychInfo databases were conducted using keywords related to dementia, mobility, measurement, and validation. Descriptive characteristics were extracted and measures coded for mobility components. Tools were also evaluated for feasibility of use in advanced dementia and those deemed feasible, screened for psychometric strength.

RESULTS

Thirty-eight measures were included and 68% of these tools were performance-based. Elements of mobility evaluated were walking (53% of measures), postural transitions (42%), standing (40%), mobility-related behavioral/psychological symptoms (24%), transfers (10%), bed mobility (5%), and wheeled mobility (3%). 36% of studies included people with advanced dementia. Only 18% of tools received high scores for feasibility.

DISCUSSION AND IMPLICATIONS

Existing measures provide only partial information regarding mobility and few target elements that become relevant as dementia progresses. Most measures are not feasible for people with advanced dementia, and the psychometric evaluation of these measures is limited. Further research is needed to develop a comprehensive, dementia-specific, mobility assessment tool.

Key factors for the assessment of mobility in advanced dementia: A consensus approach

INTRODUCTION

Loss of mobility is common in advanced dementia and has important negative consequences related to fall risk, loss of independence, and lack of participation in meaningful activities. The causes of decline are multifactorial, including disease-specific changes in motor function, behavior, and cognition. To optimize clinical management of mobility, there is a need to better characterize capacity for safe and independent mobility. This study aimed to identify key factors that impact on mobility in dementia.

METHODS

Expert input was gathered using a modified Delphi consensus approach. The primary criterion for participation was specialist knowledge in mobility or dementia, either as a clinician or a researcher. Participants rated elements of mobility for importance and feasibility of assessment in advanced dementia and prioritized items for inclusion in a mobility staging tool. Descriptive statistics and qualitative content analysis were used to summarize responses.

RESULTS

Thirty-six experts completed the first survey with an 80% retention rate over three rounds. One-third of 61 items reached consensus for being both important and feasible to assess, representing five categories of elements. Items reaching agreement for a staging tool included walking, parkinsonism, gait, impulsivity, fall history, agitation, transfers, and posture control.

DISCUSSION

This study highlights the need for a multidimensional, dementia-specific approach to mobility assessment. Results have implications for development of assessment methods and management guidelines to support the clinical care of mobility impairment in people with dementia.

Falls Prevention Process in Assisted Living Communities

Falls are a significant issue for older adults, and many older adults who once received care in nursing homes now reside in assisted living communities (ALCs). ALC staff needs to address resident falls prevention; however, federal or state requirements or oversight are limited. This research explores falls prevention in Wisconsin ALCs in the context of the Kotter Change Model to identify strategies and inform efforts to establish a more consistent, proactive falls prevention process for ALCs. A mixed methods approach demonstrated inconsistency and variability in the use of falls risk assessments and prevention programs, which led to the development of standardized, proactive falls prevention process flowcharts. This process, as delineated, provides ALCs with an approach to organize a comprehensive falls reduction strategy. Findings highlight the importance of educating staff regarding assessments, resident motivation, falls prevention programs, and feedback, all key components of the falls prevention process.

Can clinical and physical-functional factors predict falls in cognitively impaired older adults?

Abstract Objective: to investigate the frequency of falls and clinical and physical-functional factors associated with falls, and the accuracy of such factors to identify the risk of falling in cognitively impaired older adults. Method: a cross-sectional study with cognitively impaired older adults was carried out using the Mini-Mental State Examination. The dependent variable was a history of falls in the previous six months. The independent variables were self-reported mental confusion, hearing and visual impairment, physical fatigue, muscle weakness, dizziness, body imbalance, insecurity when walking, diagnosed depression, hospitalizations, continuous use medications (form from study used), muscle mass (calf circumference) and handgrip strength (dynamometry), functional capacity (Pfeffer) and mobility (SAM-Br). Descriptive statistics were applied. The groups were compared using the Mann Whitney U test, the risk factors were identified by univariate and multivariate logistic regression, and the area under the ROC curve (AUC) was calculated for the associated factors. Results: 216 cognitively impaired older adults were included in the analysis, 41.7% of whom were fallers. Multivariate regression analyzes indicated that complaints of visual impairment (OR=2.8; p=0.015) and body imbalance (OR=2.7; p=0.004), and greater medication use (OR=1.1; p=0.038) were associated with a history of falls. The AUC found poor accuracy for quantity of medications as a screening tool for fallers (AUC=0.6 [0.5; 0.7]; p=0.028). Conclusion: cognitively impaired older adults had a high frequency of falls. Complaints of visual impairment, body imbalance and polypharmacy were predictors of falls. The early assessment of these factors can contribute to the identification of cognitively-impaired older adults at risk of falling in clinical practice and research.

Polypharmacy in Assisted Living and Impact on Clinical Outcomes

OBJECTIVE

The purpose of this study was to describe medication use and polypharmacy in assisted living settings. We hypothesized that: 1) age, gender, race, setting, multi-morbidity, and cognitive status would influence polypharmacy; and 2) polypharmacy would be associated with falls, emergency room visits, and hospitalizations.

DESIGN

This was a descriptive study using data from a larger study testing the Dissemination and Implementation of Function Focused Care for Assisted Living (FFC-AL-EIT).

SETTING

Participants were recruited from 26 assisted living settings.

PARTICIPANTS

A total of 242 individuals for cohort 1 consented and completed baseline data collection.

INTERVENTIONS

Data were obtained from participant medical records, observations, and input from staff.

MAIN OUTCOME MEASURE(S)

Age, gender, race, ethnicity, comorbidities, cognitive status, medications, falls, emergency room visits, hospitalizations, function based on the Barthel Index and physical activity using the MotionWatch 8.

RESULTS

Participants had a mean age of 86.86 (standard deviation [SD] = 7.0), the majority were women (n = 179, 74%) and white (n = 233, 96%), with five (SD = 2) diagnoses. The mean number of drugs was seven (SD = 3.56), and 51% were exposed to polypharmacy. The mean Barthel Index score was 63.06 (SD = 20.20), and they engaged in 111,353 (SD = 87,262) counts of activity daily. Fifty-eight residents fell at least once (24%), 22 were sent to the hospital (9%), and 32 (13%) to the emergency room. Neither hypothesis was supported.

CONCLUSION

Continued research is needed to explore the factors that influence polypharmacy. Identification of these factors will help guide deprescribing so that medication management does not harm older adults physically or cause unnecessary financial burden.

Differences Between Moderate to Severely Cognitively Impaired Fallers Versus Nonfallers in Nursing Homes

INTRODUCTION

The purpose of this study was to test differences in psychotropic medication, function, physical activity, agitation, resistiveness to care, comorbidities, and depression among moderate to severely cognitively impaired nursing home residents who were fallers versus nonfallers.

METHODS

This was a secondary data analysis using baseline data from a randomized controlled trial testing the Function and Behavior Focused Care intervention across 12 nursing homes. The sample included 336 older adults, the majority of whom were female and white.

RESULTS

There was a significant difference in the total number of comorbidities, agitation, the total number of psychotropic medications, depressive symptoms, and physical activity between those who fell and those who did not fall (Pillai-Bartlett trace = 4.91; P < .001).

DISCUSSION

Findings support prior work except with regard to medication use, cognition, and function. Due to inconsistent findings, additional research is recommended particularly with regard to the use of specific drug groups and medications.

Withdrawal of antihypertensive therapy in people with dementia: feasibility study

BACKGROUND

This study explored the feasibility of a randomised controlled withdrawal trial of antihypertensive medication in normotensive people with dementia. Feasibility aspects included response, recruitment, exclusion and drop-out rates, suitability of outcome measures, acceptability of study procedures and an indicative economic evaluation for a randomised controlled trial.

METHODS

A cohort study attempting the withdrawal of antihypertensive drugs where appropriate and a feasibility study of home-based blood pressure monitoring, in people with dementia treated for hypertension, was undertaken. Interviews with participants and carers and an indicative economic evaluation were also undertaken.

RESULTS

Three hundred and sixty-two primary care practices in the East Midlands were contacted of which only 41 (11% (95%CI 8-15%)) agreed to support the study. These 41 practices posted 940 letters to potential participants. Thirty participants were enrolled in the cohort study of whom 9 were eligible for the antihypertensive withdrawal programme, 20 participated in a home blood pressure monitoring sub-group analysis and 12 took part in an interview study. Twenty-two of those enrolled in the cohort study were followed up at 6 months. The withdrawal programme was acceptable to participants and general practitioners (GPs). The study procedures including assessments and home blood pressure monitoring were acceptable to the participants and their carers. The economic evaluation was not possible.

CONCLUSION

A withdrawal trial of antihypertensive medication in normotensive people with dementia may not be feasible in the UK because of low recruitment rates.

Dementia

Dementia is a syndrome seen most commonly in older people and characterized by a decline in cognitive performance which impacts on the person's ability to function. There are approximately 47 million people worldwide with dementia and there are 10 million new cases every year. It is a major cause of disability and dependence and impacts on the physical, psychologic, and social well-being of families and carers. Alzheimer's disease is the most common form of dementia. Gait and balance impairments are common in people with dementia and contribute to the significantly elevated risk of falls. Older people with dementia are at increased risk of injury, institutionalization, hospitalization, morbidity, and death after a fall. There is preliminary evidence, predominantly from relatively small studies, that falls and disability can be prevented in this population. However, more good-quality research is needed, both to provide some certainty around the existing evidence base as well as to explore alternate approaches to prevention, including combined cognitive-motor training and cognitive pharmacotherapy.

Circumstances of Falls With Fractured Femur in Residents of Australian Nursing Homes: An Analysis of Falls Reports

OBJECTIVE

This study aimed to explore the circumstances and characteristics of falls with fractured femur reported in nursing homes.

METHOD

Mixed methods were used. There were reports on 401 eligible falls from 88 residential care facilities in the Hunter region of Australia. A falls report form was developed for the study and was completed by nursing staff. Information was collected about the circumstances of falls with fractured femur and resident data. Descriptive and qualitative analyses were used.

RESULTS

Falls with fractured neck of femur were associated with being ambulant, having dementia, increasing age, and a high falls risk assessment. Themes from the falls report data were resident-related factors, organizational or environmental issues, and activities at the time of the fall.

DISCUSSION

Falls in residential care settings are very complex and difficult to prevent. Attention should be given to the needs of recently admitted residents and management of the facility environment.

Feasibility and efficacy of a multi-factorial intervention to prevent falls in older adults with cognitive impairment living in residential care (ProF-Cog). A feasibility and pilot cluster randomised controlled trial

BACKGROUND

Falls are common in people with dementia living in residential care. The ProF-Cog intervention was developed to address fall risk factors specific to this population. The aim of this study was to evaluate the safety, acceptability, and feasibility of the intervention and provide an estimate of its efficacy.

METHODS

This was a cluster randomised controlled pilot study undertaken in care homes in London, UK. All permanent residents living in participating homes who were not terminally ill were invited to participate. The intervention included an assessment of falls risk factors followed by a tailored intervention which could include dementia care mapping, comprehensive geriatric assessment, occupational therapy input and twice-weekly exercise for 6 months as required to target identified risk factors. The control group received usual care without a falls risk assessment. Standing balance was the primary outcome. This and other outcome measures were collected at baseline and after 6 months. Falls were recorded for this period using incident reports. Changes were analysed using multi-level modelling. Adherence to the interventions, adverse events and trial feasibility were recorded.

RESULTS

Nine care homes enrolled in the study with a total 191 participants (51% of those eligible); five homes allocated to the intervention with 103 participants, and four homes to the usual care control group with 88 participants. The intervention was safe with only one reported fall whilst undertaking exercise. Adherence to agreed recommendations on activity and the environment was modest (21 and 45% respectively) and to exercise was poor (41%). Balance scores (score range 0-49) analysed on 100 participants decreased by a mean of 3.9 in the control and 5.1 in the intervention groups, a non-significant difference (p = 0.9). In other measures, both groups declined equally and there was no difference in falls rates (IRR = 1.59 95%, CI 0.67-3.76).

CONCLUSION

The intervention was safe but not clinically effective. Poor adherence suggests it was not an acceptable or feasible intervention.

TRIAL REGISTRATION

ISRCTN00695885 . Registered 26th March 2013.

Risk Factors Associated with Falls in Older Adults with Dementia: A Systematic Review

Purpose: People with dementia fall more often than cognitively healthy older adults, but their risk factors are not well understood. A review is needed to determine a fall risk profile for this population. The objective was to critically evaluate the literature and identify the factors associated with fall risk in older adults with dementia. Methods: Articles published between January 1988 and October 2014 in EMBASE, PubMed, PsycINFO, and CINAHL were searched. Inclusion criteria were participants aged 55 years or older with dementia or cognitive impairment, prospective cohort design, detailed fall definition, falls as the primary outcome, and multi-variable regression analysis. Two authors independently reviewed and extracted data on study characteristics, quality assessment, and outcomes. Adjusted risk estimates were extracted from the articles. Results: A total of 17 studies met the inclusion criteria. Risk factors were categorized into demographic, balance, gait, vision, functional status, medications, psychosocial, severity of dementia, and other. Risk factors varied with living setting and were not consistent across all studies within a setting. Conclusion: Falls in older adults with dementia are associated with multiple intrinsic and extrinsic risk factors, some shared with older adults in general and others unique to the disease. Risk factors vary between community- and institution-dwelling samples of adults with dementia or cognitive impairment.

An Occupational Therapy intervention for residents with stroke-related disabilities in UK Care Homes (OTCH): cluster randomised controlled trial with economic evaluation

BACKGROUND

Care home residents with stroke-related disabilities have significant activity limitations. Phase II trial results suggested a potential benefit of occupational therapy (OT) in maintaining residents' capacity to engage in functional activity.

OBJECTIVE

To evaluate the clinical effectiveness and cost-effectiveness of a targeted course of OT in maintaining functional activity and reducing further health risks from inactivity for UK care home residents living with stroke-related disabilities.

DESIGN

Pragmatic, parallel-group, cluster randomised controlled trial with economic evaluation. Cluster randomisation occurred at the care-home level. Homes were stratified according to trial administrative centre and type of care provided (nursing or residential), and they were randomised 1 : 1 to either the intervention or the control arm.

SETTING

The setting was 228 care homes which were local to 11 trial administrative centres across England and Wales.

PARTICIPANTS

Care home residents with a history of stroke or transient ischaemic attack, including residents with communication and cognitive impairments, not receiving end-of-life care.

INTERVENTION

Personalised 3-month course of OT delivered by qualified therapists. Care workers participated in training workshops to support personal activities of daily living. The control condition consisted of usual care for residents.

MAIN OUTCOME MEASURES

Outcome data were collected by a blinded assessor. The primary outcome at the participant level was the Barthel Index of Activities of Daily Living (BI) score at 3 months. The secondary outcomes included BI scores at 6 and 12 months post randomisation, and the Rivermead Mobility Index, Geriatric Depression Scale-15 and European Quality of Life-5 Dimensions, three levels, questionnaire scores at all time points. Economic evaluation examined the incremental cost per quality-adjusted life-year (QALY) gain. Costs were estimated from the perspective of the NHS and Personal Social Services.

RESULTS

Overall, 568 residents from 114 care homes were allocated to the intervention arm and 474 residents from another 114 care homes were allocated to the control arm, giving a total of 1042 participants. Randomisation occurred between May 2010 and March 2012. The mean age of participants was 82.9 years, and 665 (64%) were female. No adverse events attributable to the intervention were recorded. Of the 1042 participants, 870 (83%) were included in the analysis of the primary outcome (intervention, n = 479; control, n = 391). The primary outcome showed no significant differences between groups. The adjusted mean difference in the BI score between groups was 0.19 points higher in the intervention arm [95% confidence interval (CI) -0.33 to 0.70, p = 0.48; adjusted intracluster correlation coefficient 0.09]. Secondary outcome measures showed no significant differences at all time points. Mean incremental cost of the Occupational Therapy intervention for residents with stroke living in UK Care Homes intervention was £438.78 (95% CI -£3360.89 to £1238.46) and the incremental QALY gain was 0.009 (95% CI -0.030 to 0.048).

LIMITATIONS

A large proportion of participants with very severe activity-based limitations and cognitive impairment may have limited capacity to engage in therapy.

CONCLUSION

A 3-month individualised course of OT showed no benefit in maintaining functional activity in an older care home population with stroke-related disabilities.

FUTURE WORK

There is an urgent need to reduce health-related complications caused by inactivity and to provide an enabling built environment within care homes.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00757750.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 15. See the Health Technology Assessment programme website for further project information.

Influence of cognitive impairment on fall risk among elderly nursing home residents

BACKGROUND

Information relating the severity of cognitive decline to the fall risk in institutionalized older adults is still scarce. This study aims to identify potential fall risk factors (medications, behavior, motor function, and neuropsychological disturbances) depending on the severity of cognitive impairment in nursing home residents.

METHODS

A total of 1,167 nursing home residents (mean age 81.44 ± 8.26 years; 66.4% women) participated in the study. According to the MEC, (the Spanish version of the Mini-Mental State Examination) three levels of cognitive impairment were established: mild (20-24) "MCI", moderate (14-19) "MOCI", and severe (≤14) "SCI". Scores above 24 points indicated the absence cognitive impairment (NCI). Information regarding fall history and fall risk during the previous year was collected using standardized questionnaires and tests.

RESULTS

Sixty falls (34%) were registered among NCI participants and 417 (43%) among people with cognitive impairment (MCI: 35%; MOCI: 40%; SCI: 50%). A different fall risk model was observed for MCI, MOCI, SCI, and NCI patients. The results imply that the higher the level of cognitive impairment, the greater the number of falls (F1,481 = 113.852; Sig = 0.015), although the level of significance was not maintained when MOCI and SCI participants were compared. Depression, neuropsychiatric disturbances, autonomy constraints in daily life activity performance, and low functional mobility were factors closely associated with fall risk.

CONCLUSION

This study provides evidence indicating that fall risk factors do not hold a direct correlation with the level of cognitive impairment among elderly nursing home care residents.

The Cognitive Daisy - A novel method for recognising the cognitive status of older adults in residential care: Innovative Practice

The Cognitive Daisy is an innovative assessment system created to provide healthcare staff with an instant snapshot of the cognitive status of older adults in residential care. The Cognitive Daisy comprises a flower head consisting of 15 colour coded petals depicting information about: visual-spatial perception, comprehension, communication, memory and attention. This study confirmed the practicality of the Cognitive Daisy protocol for assessing cognition in a sample of 33 older adults living in residential care and endorsed the use of the Cognitive Daisy as a tool for recognising the cognitive status of care home residents.

Hip Fracture in People with Erectile Dysfunction: A Nationwide Population-Based Cohort Study

The aims of this study were to investigate the risk of hip fracture and contributing factors in patients with erectile dysfunction(ED). This population-based study was performed using the Taiwan National Health Insurance Research Database. The analysis included4636 patients aged ≥ 40 years who had been diagnosed with ED (International Classification of Diseases, Ninth Revision, Clinical Modification codes 302.72, 607.84) during 1996–2010. The control group included 18,544 randomly selected age-matched patients without ED (1:4 ratio). The association between ED and hip fracture risk was estimated using a Cox proportional hazard regression model. During the follow-up period, 59 (1.27%) patients in the ED group and 140 (0.75%) patients in the non-ED group developed hip fracture. After adjusting for covariates, the overall incidence of hip fracture was 3.74-times higher in the ED group than in the non-ED group (2.03 vs. 0.50 per 1000 person-years, respectively). The difference in the overall incidence of hip fracture was largest during the 3-year follow-up period (hazard ratio = 7.85; 95% confidence interval = 2.94–20.96; P <0.0001). To the best of our knowledge, this nationwide population-based study is the first to investigate the relationship between ED and subsequent hip fracture in an Asian population. The results showed that ED patients had a higher risk of developing hip fracture. Patients with ED, particularly those aged 40–59 years, should undergo bone mineral density examinations as early as possible and should take measures to reduce the risk of falls.

[Interventions based on exercise and physical environment for preventing falls in cognitively impaired older people living in long-term care facilities: A systematic review and meta-analysis]

This systematic review aims to report the effectiveness of interventions based on exercise and/or physical environment for reducing falls in cognitively impaired older adults living in long-term care facilities. In July 2014, a literature search was conducted using main databases and specialised sources. Randomised controlled trials assessing the effectiveness of fall prevention interventions, which used exercise or physical environment among elderly people with cognitive impairment living in long-term care facilities, were selected. Two independent reviewers checked the eligibility of the studies, and evaluated their methodological quality. If it was adequate, data were gathered. Fourteen studies with 3,539 participants using exercise and/or physical environment by a single or combined approach were included. The data gathered from studies that used both interventions showed a significant reduction in fall rate. Further research is needed to demonstrate the effectiveness of those interventions for preventing falls in the elderly with cognitive impairment living in long-term care establishments.

Assessing the quality of a non-randomized pragmatic trial for primary prevention of falls among older adults

Current approaches to falls prevention mostly rely on secondary and tertiary prevention and target individuals at high risk of falls. An alternative is primary prevention, in which all seniors are screened, referred as appropriate, and educated regarding falls risk. Little information is available on research designs that allow investigation of this approach in the setting of aging services delivery, where randomization may not be possible. Healthy Steps for Older Adults, a statewide program of the Pennsylvania (PA) Department of Aging, involves a combination of education about falls and screening for balance problems, with referral to personal physicians and home safety assessments. We developed a non-randomized statewide trial, Falls Free PA, to assess its effectiveness in reducing falls incidence over 12 months. We recruited 814 seniors who completed the program (503 first-time participants, 311 people repeating the program) and 1,020 who did not participate in the program, from the same sites. We assessed the quality of this non-randomized design by examining recruitment, follow-up across study groups, and comparability at baseline. Of older adults approached in senior centers, 90.5 % (n = 2,219) signed informed consent, and 1,834 (82.4 %) completed baseline assessments and were eligible for follow-up. Attrition in the three groups over 12 months was low and non-differential (<10 % for withdrawal and <2 % for other loss to follow-up). Median follow-up, which involved standardized monthly assessment of falls, was 10 months in all study groups. At baseline, the groups did not differ in measures of health or falls risk factors. Comparable status at baseline, recruitment from common sites, and similar experience with retention suggest that the non-randomized design will be effective for assessment of this approach to primary prevention of falls.

Use of fall risk increasing drugs in residents of retirement villages: a pilot study of long term care and retirement home residents in Ontario, Canada

BACKGROUND

Falls continue to be a problem for older people in long-term care (LTC) and retirement home (RH) settings and are associated with significant morbidity and health care use. Fall-risk increasing drugs (FRIDs) are known to increase fall risk and represent modifiable risk factors. There are limited data regarding the use of FRIDs in contemporary LTC and RH settings, and it has not been well documented to what extent medication regimens are reviewed and modified for those who have sustained falls. The objective of this study is to characterize medication related fall risk factors in LTC and RH residents and on-going use of medications known to increase fall risk.

METHODS

Retrospective chart review of residents aged >65 who sustained one or more falls living in LTC or RH settings.

RESULTS

105 residents who fell one or more times during 2009-2010 were identified with a mean age of 89 years, a mean of nine scheduled medications and seven diagnoses, and 83% were women. Residents in LTC were ostensibly at higher risk for falls relative to those in RH settings as suggested by higher proportion of residents with multiple falls, multiple comorbidities, comorbidities that increase fall risk and visual impairment. Post fall injuries were sustained by 42% of residents, and residents in RH sustained more injuries relative to LTC residents (47 vs 34%). Use of FRIDs such as benzodiazepines, antipsychotic, antidepressant and various antihypertensive drugs was common in the present sample. No medication regimen changes were noted in the 6-month post fall period.

CONCLUSIONS

The present study documented common use FRIDs by LTC and RH residents with multiple falls. These potentially modifiable falls risk factors are not being adequately addressed in contemporary practice, demonstrating that there is much room for improvement with regards to the safe and appropriate use of medications in LTC and RH residents.

Motor and Visuospatial Attention and Motor Planning After Stroke: Considerations for the Rehabilitation of Standing Balance and Gait

Attention and planning can be altered by stroke, which can influence motor performance. Although the influence of these factors on recovery from stroke has been explored for the upper extremity (UE), their impact on balance and gait are unknown. This perspective article presents evidence that altered motor and visuospatial attention influence motor planning of voluntary goal-directed movements poststroke, potentially affecting balance and gait. Additionally, specific strategies for rehabilitation of balance and gait poststroke in the presence of these factors are discussed. Visuospatial attention selects relevant sensory information and supports the preparation of responses to this information. Motor attentional impairments may produce difficulty with selecting appropriate motor feedback, potentially contributing to falls. An original theoretical model is presented for a network of brain regions supporting motor and visuospatial attention, as well as motor planning of voluntary movements. Stroke may influence this functional network both locally and distally, interfering with input or output of the anatomical or functional regions involved and affecting voluntary movements. Although there is limited research directly examining leg function, evidence suggests alterations in motor and visuospatial attention influence motor planning and have a direct impact on performance of gait and balance. This model warrants testing comparing healthy adults with individuals with stroke.

The Falls In Care Home study: a feasibility randomized controlled trial of the use of a risk assessment and decision support tool to prevent falls in care homes

Objective:

To explore the feasibility of implementing and evaluating the Guide to Action Care Home fall prevention intervention.

Design:

Two-centre, cluster feasibility randomized controlled trial and process evaluation.

Setting:

Purposive sample of six diverse old age/learning disability, long stay care homes in Nottinghamshire, UK.

Subjects:

Residents aged over 50 years, who had fallen at least once in the past year, not bed-bound, hoist-dependent or terminally ill.

Interventions:

Intervention homes (n = 3) received Guide to Action Care Home fall prevention intervention training and support. Control homes (n = 3) received usual care.

Outcomes:

Recruitment, attrition, baseline and six-month outcome completion, contamination and intervention fidelity, compliance, tolerability, acceptance and impact.

Results:

A total of 81 of 145 (56%) care homes expressed participatory interest. Six of 22 letter respondent homes (27%) participated. The expected resident recruitment target was achieved by 76% (52/68). Ten (19%) residents did not complete follow-up (seven died, three moved). In intervention homes 36/114 (32%) staff attended training. Two of three (75%) care homes received protocol compliant training. Staff valued the training, but advised greater management involvement to improve intervention implementation. Fall risks were assessed, actioned and recorded in care records. Of 115 recorded falls, 533/570 (93%) of details were complete. Six-month resident fall rates were 1.9 and 4.0 per year for intervention and control homes, respectively.

Conclusions:

The Guide to Action Care Home is implementable under trial conditions. Recruitment and follow-up rates indicate that a definitive trial can be completed. Falls (primary outcome) can be ascertained reliably from care records.

“I’ve Fallen and I Can’t Get Up,” a Basic Primer for Caregivers to Understand Falls in Persons With Dementia, Alzheimer’s Disease, and Cognitive Impairment

This article seeks to demystify the complexity of what constitutes dementia, Alzheimer’s disease, and cognitive impairment as it relates to identifying the basic contexts of these diseases in relationship with falls and fall prevention. It further will identify the new changes in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) that replaces the term dementia and provides the new diagnostic framework for major and mild neurocognitive functioning. This article additionally provides some practical strategies for caregivers to equip themselves to understand some of the difficulties and challenges that they face when dealing with loved ones or patients who become afflicted by these diseases.

Factors related to the high fall rate in long-term care residents with dementia

BACKGROUND

Falls in long-term care residents with dementia represent a costly but unresolved safety issue. The aim of the present study was to (1) determine the incidence of falls, fall-related injuries and fall circumstances, and (2) identify the relationship between patient characteristics and fall rate in long-term care residents with dementia.

METHODS

Twenty long-term care residents with dementia (80 ± 11 years; 60% male) participated. Falls were recorded on a standardized form, concerning fall injuries, time and place of fall and if the fall was witnessed. Patient characteristics (66 variables) were extracted from medical records and classified into the domains: demographics, activities of daily living, mobility, cognition and behavior, vision and hearing, medical conditions and medication use. We used partial least squares (PLS) regression to determine the relationship between patient characteristics and fall rate.

RESULTS

A total of 115 falls (5.1 ± 6.7 falls/person/year) occurred over 19 months, with 85% of the residents experiencing a fall, 29% of falls had serious consequences and 28% was witnessed. A combination of impaired mobility, indicators of disinhibited behavior, diabetes, and use of analgesics, beta blockers and psycholeptics were associated with higher fall rates. In contrast, immobility, heart failure, and the inability to communicate were associated with lower fall rates.

CONCLUSIONS

Falls are frequent and mostly unwitnessed events in long-term care residents with dementia, highlighting the need for more effective and individualized fall prevention. Our analytical approach determined the relationship between a high fall rate and cognitive impairment, related to disinhibited behavior, in combination with mobility disability and fall-risk-increasing-drugs (FRIDs).

Psychiatric disorders, psychotropic medication use and falls among women: an observational study

BACKGROUND

Psychotropic agents known to cause sedation are associated with an increased risk of falls, but the role of psychiatric illness as an independent risk factor for falls is not clear. Thus, this study aimed to investigate the association between psychiatric disorders, psychotropic medication use and falls risk.

METHODS

This study examined data collected from 1062 women aged 20-93 yr (median 50 yr) participating in the Geelong Osteoporosis Study, a large, ongoing, population-based study. Depressive and anxiety disorders for the preceding 12-month period were ascertained by clinical interview. Current medication use and falls history were self-reported. Participants were classified as fallers if they had fallen to the ground at least twice during the same 12-month period. Anthropometry, demographic, medical and lifestyle factors were determined. Logistic regression was used to test the associations, after adjusting for potential confounders.

RESULTS

Fifty-six women (5.3%) were classified as fallers. Those meeting criteria for depression within the past 12 months had a 2.4-fold increased odds of falling (unadjusted OR = 2.4, 95% CI 1.2-4.5). Adjustment for age and mobility strengthened the relationship (adjusted OR = 2.7, 95% CI 1.4-5.2) between depression and falling, with results remaining unchanged following further adjustment for psychotropic medication use (adjusted OR = 2.7, 95% CI 1.3-5.6). In contrast, past (prior to 12-month) depression were not associated with falls. No association was observed between anxiety and falls risk. Falling was associated with psychotropic medication use (unadjusted OR = 2.8, 95% CI 1.5-5.2), as well as antidepressant (unadjusted OR = 2.4, 95% CI 1.2-4.8) and benzodiazepine use (unadjusted OR = 3.4, 95% CI 1.6-7.3); associations remained unchanged following adjustment for potential confounders.

CONCLUSION

The likelihood of falls was increased among those with depression within the past 12 months, independent of psychotropic medication use and other recognised confounders, suggesting an independent effect of depression on falls risk. Psychotropic drug use was also confirmed as an independent risk factor for falls, but anxiety disorders were not. Further research into the underlying mechanisms is warranted.

An occupational therapy intervention for residents with stroke related disabilities in UK care homes (OTCH): cluster randomised controlled trial

OBJECTIVE

To evaluate the clinical efficacy of an established programme of occupational therapy in maintaining functional activity and reducing further health risks from inactivity in care home residents living with stroke sequelae.

DESIGN

Pragmatic, parallel group, cluster randomised controlled trial.

SETTING

228 care homes (>10 beds each), both with and without the provision of nursing care, local to 11 trial administrative centres across the United Kingdom.

PARTICIPANTS

1042 care home residents with a history of stroke or transient ischaemic attack, including those with language and cognitive impairments, not receiving end of life care. 114 homes (n=568 residents, 64% from homes providing nursing care) were allocated to the intervention arm and 114 homes (n=474 residents, 65% from homes providing nursing care) to standard care (control arm). Participating care homes were randomised between May 2010 and March 2012.

INTERVENTION

Targeted three month programme of occupational therapy, delivered by qualified occupational therapists and assistants, involving patient centred goal setting, education of care home staff, and adaptations to the environment.

MAIN OUTCOME MEASURES

Primary outcome at the participant level: scores on the Barthel index of activities of daily living at three months post-randomisation. Secondary outcome measures at the participant level: Barthel index scores at six and 12 months post-randomisation, and scores on the Rivermead mobility index, geriatric depression scale-15, and EuroQol EQ-5D-3L questionnaire, at all time points.

RESULTS

64% of the participants were women and 93% were white, with a mean age of 82.9 years. Baseline characteristics were similar between groups for all measures, personal characteristics, and diagnostic tests. Overall, 2538 occupational therapy visits were made to 498 participants in the intervention arm (mean 5.1 visits per participant). No adverse events attributable to the intervention were recorded. 162 (11%) died before the primary outcome time point, and 313 (30%) died over the 12 months of the trial. The primary outcome measure did not differ significantly between the treatment arms. The adjusted mean difference in Barthel index score at three months was 0.19 points higher in the intervention arm (95% confidence interval -0.33 to 0.70, P=0.48). Secondary outcome measures also showed no significant differences at all time points.

CONCLUSIONS

This large phase III study provided no evidence of benefit for the provision of a routine occupational therapy service, including staff training, for care home residents living with stroke related disabilities. The established three month individualised course of occupational therapy targeting stroke related disabilities did not have an impact on measures of functional activity, mobility, mood, or health related quality of life, at all observational time points. Providing and targeting ameliorative care in this clinically complex population requires alternative strategies.Trial registration Current Controlled Trials ISRCTN00757750.