[Dementia and falls]

Association Between Acetylcholinesterase Inhibitors and Osteoporotic Fractures in Older Persons With Alzheimer's Disease

OBJECTIVE

To identify the association between the use of acetylcholinesterase inhibitors (AChEIs) and risk of osteoporotic fractures in older persons with Alzheimer's disease (AD).

DESIGN, SETTING, AND PARTICIPANTS

A nested case-control study was conducted using the Korean National Health Insurance Service-National Elderly Cohort database. Patients with AD who were newly diagnosed with osteoporotic fractures were identified as cases. Up to 3 controls were matched with cases according to age, sex, and duration of follow-up.

METHODS

Participants were considered as exposed to AChEIs if they had been prescribed at least 1 AChEI during a period of 2 years before the index date. A conditional logistic regression was performed to estimate the adjusted odds ratios with 95% confidence intervals for the association between the use of AChEIs and osteoporotic fractures in patients with AD. We also examined the impact of dose, duration of treatment, and timing of exposure on the estimates of the association between the use of AChEIs and risk of osteoporotic fractures.

RESULTS

The study cohort comprised 45,006 patients diagnosed with AD, of which 9470 patients, including 2385 cases and 7085 controls, were available for the study. The mean ages (standard deviations) were 78.6 (6.9) years in the cases and 80.0 (6.9) years in the controls. Adjusted odds ratios for the association between the use of AChEIs and osteoporotic fractures in patients with AD was 1.18 (95% confidence interval 1.07-1.31).

CONCLUSIONS AND IMPLICATIONS

Our data indicated that the use of AChEIs was not associated with a reduced risk of osteoporotic fractures in patients with AD; in contrast, their use was associated with a mild increased risk of osteoporotic fractures. Thus, clinicians should consider the possibility of AChEIs-associated fractures among older persons with AD. Findings of this study will support shared decision making among prescribers, patients, and caregivers.

Analysis of the risk and risk factors for injury in people with and without dementia: a 14-year, retrospective, matched cohort study

BACKGROUND

Most previous studies on dementia and injuries have focused on a particular type of injury, and few studies have investigated overall injury in people with dementia. In this study, we investigated the risk factors and risk of overall injury, including the diagnosis, cause, and intentionality of injury, in people with and without dementia in Taiwan.

METHODS

We collected relevant data between 2000 and 2013 from the National Health Insurance Research Database (NHIRD). Overall, 455,630 cases, consisting of 91,126 people with dementia and 364,504 people without dementia, were included in this study and we performed subgroup analysis. A multivariate Cox proportional hazards regression analysis was used to determine the risk of injuries.

RESULTS

The 14-year follow-up data showed that people with dementia had a higher risk of injury-related hospitalization than did people without dementia (19.92% vs 18.86%, hazard ratio (HR) = 1.070, p < 0.001). Regarding the cause of injury, people with dementia were more likely to be hospitalized due to suffocation (HR = 2.301, p < 0.001), accidental drug poisoning (HR = 1.485, p < 0.001), or falls (HR = 1.076, p < 0.001), and were less likely to be hospitalized due to suicide or self-inflicted injury (HR = 0.670, p < 0.001) or a traffic accident (HR = 0.510, p < 0.001) than were people without dementia. Subgroup analysis showed that people with dementia with any of the three subtypes of dementia were at a higher risk of homicide or abuse than were people without dementia (vascular dementia, HR = 2.079, p < 0.001; Alzheimer's disease, HR = 1.156, p < 0.001; other dementia, HR = 1.421, p < 0.001). The risk factors for overall injury included dementia diagnosis, female gender, age 65-74 years, and seeking medical attention for an injury within the past year.

CONCLUSION

People with dementia are at a higher risk of injury-related hospitalization than people without dementia. The results of this study provide a reference for preventing suffocation, drug poisoning, and falls in people with dementia. In addition, government agencies should pay attention to and intervene in cases of abuse suffered by people with dementia.

Dementia and osteoporosis in a geriatric population: Is there a common link?

AIM

To determine the existence of a common pathological link between dementia and osteoporosis through reviewing the current evidence base.

METHODS

This paper reviews the current literature on osteoporosis and dementia in order to ascertain evidence of a common predisposing aetiology. A literature search of Ovid MED-LINE (1950 to June 2016) was conducted. The keywords “osteoporosis”, “osteoporotic fracture”, “dementia” and “Alzheimer’s disease” (AD) were used to determine the theoretical links with the most significant evidence base behind them. The key links were found to be vitamins D and K, calcium, thyroid disease, statins, alcohol and sex steroids. These subjects were then searched in combination with the previous terms and the resulting papers manually examined. Theoretical, in vitro and in vivo research were all used to inform this review which focuses on the most well developed theoretical common causes for dementia (predominantly Alzheimer’s type) and osteoporosis.

RESULTS

Dementia and osteoporosis are multifaceted disease processes with similar epidemiology and a marked increase in prevalence in elderly populations. The existence of a common link between the two has been suggested despite a lack of clear pathological overlap in our current understanding. Research to date has tended to be fragmented and relatively weak in nature with multiple confounding factors reflecting the difficulties of in vivo experimentation in the population of interest. Despite exploration of various possible mechanisms in search for a link between the two pathologies, this paper found that it is possible that these associations are coincidental due to the nature of the evidence available. One finding in this review is that prior investigation into common aetiologies has found raised amyloid beta peptide levels in osteoporotic bone tissue, with a hypothesis that amyloid beta disorders are systemic disorders resulting in differing tissue manifestations. However, our findings were that the most compelling evidence of a common yet independent aetiology lies in the APOE4 allele, which is a well-established risk for AD but also carries an independent association with fracture risk. The mechanism behind this is thought to be the reduced plasma vitamin K levels in individuals exhibiting the APOE4 allele which may be amplified by the nutritional deficiencies associated with dementia, which are known to include vitamins K and D. The vitamin theory postulates that malnutrition and reduced exposure to sunlight in patients with AD leads to vitamin deficiencies.

CONCLUSION

Robust evidence remains to be produced regarding potential links and regarding the exact aetiology of these diseases and remains relevant given the burden of dementia and osteoporosis in our ageing population. Future research into amyloid beta, APOE4 and vitamins K and D as the most promising aetiological links should be welcomed.

Acetylcholinesterase inhibitors and the risk of hip fracture in Alzheimer's disease patients: a case-control study

Recent studies have reported the presence of acetylcholine (ACh) receptor subtypes in bone tissue, and have demonstrated that inhibition of the ACh receptors has negative effects on bone mass and fracture healing capacity. However, little is known about the potential clinical effects that increased ACh signaling might have on bone. Accordingly, this study was designed to determine whether the use of acetylcholinesterase inhibitors (AChEIs), a group of drugs that stimulate ACh receptors and are used to treat Alzheimer's disease (AD), is associated with a decreased risk of hip fracture in AD patients. To accomplish this objective, a case-control analysis was performed using the AD population, aged above 75 years, based in the local health area of the Carlos Haya Hospital, in Malaga, Spain. The cases were 80 AD patients that suffered a hip fracture between January 2004 and December 2008. The controls were 2178 AD patients without hip fracture followed at our health care area during the same period of time. Compared with patients who did not use AChEIs, the hip fracture adjusted odds ratio (OR) for users of AChEIs was 0.42 (95% confidence interval [CI], 0.24-0.72), for users of rivastigmine was 0.22 (95% CI, 0.10-0.45), and for users of donepezil was 0.39 (95% CI, 0.19-0.76). Data were adjusted for the following parameters: body mass index, fall risk, smoking habits, cognition, dependence, degree of AD, comorbidity score, treatment with selective serotonin reuptake inhibitors, age, and gender. Our data suggests that use of AChEIs donepezil and rivastigmine is associated with a reduced risk of fractures in AD patients. Many elderly patients with AD disease who are at risk of developing osteoporosis may potentially benefit from therapy with the AChEIs donepezil and rivastigmine.

Environmental interventions and the design of homes for older adults with dementia: an overview

In Western societies, the vast majority of people with dementia live at home and wish to remain doing so for as long as possible. Aging in place can be facilitated through a variety of environmental interventions, including home modifications. This article provides an overview of existing design principles and design goals, and environmental interventions implemented at home, based on literature study and additional focus group sessions. There is a multitude of design principles, design goals, and environmental interventions available to assist with activities of daily living and functions, although few systematic studies have been conducted on the efficacy of these goals and interventions. The own home seems to be a largely ignored territory in research and government policies, which implies that many problems concerning aging in place and environmental interventions for dementia are not adequately dealt with.

Rôle du Neurocom Balance Master® dans l'évaluation des troubles de l'équilibre et du risque de chute chez le sujet âgé

INTRODUCTION

Falls in elderly people is currently a health service problem because of the multiple consequences. Numerous teams have been interested in predicting the risk of falling with clinical and instrumental tests. Our study investigated instrumental evaluation by use of the Neurocom Balance Master in the global assessment of gait problems and risk of falling in elderly people.

PATIENTS AND METHODS

Transverse study concerning 60 subjects older than 65 years distributed in 2 groups of 30 subjects each according to the existence or not of falling incidents during the past year. Evaluation by the Balance Master involved the following items: 1) the modified Clinical Test for the Sensory Interaction on Balance (CTSIB), which estimates balance by measuring the speed of oscillation of the center of pressure (CP) with open then closed eyes and firm then mossy ground; 2) support monopodal 5" to the left then to the right, eyes open then closed in moderated speeds of oscillation of the CP; 3) passage from standing to sitting, in moderated speeds of oscillation of the CP; 4) limits of stability: the possibilities of moving the CP towards a predetermined target without moving the feet in moderated time and speed; 5) study of the step: determine length and width of the step as well as speed; 6) most about-turn: measure of speed of oscillation of the CP during the right then left about-turn; 7) clearing: the force of the impact and the oscillations of the CP during the clearing of an obstacle 10 cm high to measure leverage.

RESULTS

The oscillation speed of the CP in the 2 groups during modified CTSIB, support monopodal 5", passage from standing to sitting, about-turn and clearing were significantly improved the group of the patients with falls (P < 0.05). The step, length and speed of these patients were significantly reduced, with no difference in width of the step between the 2 groups. In the evaluation of the limits of stability, only time necessary to reach the target was significantly increased in the group with falls. Finally, the indication of leverage and the force of impact on the ground measured by the test of clearing were more important in the group of fallers than in non-fallers.

CONCLUSION

The Neurocom Balance Master estimates not only postural balance, but also the vestibulary system and reproduces the physiological conditions of daily life. It has a certain role in the early assessment of gait problems and the risk of falling. This system also allows for rehabilitation of the impaired balance and offers a profit with the biofeedback.

Erhalt und Förderung der Selbstständigkeit bei Pflegeheimbewohnern

Auch bei bereits eingetretener Pflegebedürftigkeit sind Maßnahmen der Rehabilitation zur Vermeidung eines Fortschreitens der Erkrankung oder der Verschlimmerung einer Behinderung zu gewähren. Zeitlich begrenzte stationäre wie ambulante Rehabilitationsmaßnahmen nach SGB V sind bei Pflegeheimbewohnern jedoch oftmals nicht sinnvoll, zumal eine nachhaltige Wirkung meist nicht erzielt werden kann. Für Pflegeheimbewohner sind langfristig angelegte rehabilitative Maßnahmen vor dem Hintergrund einer aktivierenden Pflege angebracht. Das Forschungsprojekt “Rehabilitation im Altenpflegeheim” untersucht die Anwendbarkeit und Effektivität eines auf Grundlage bestehender Rehabilitations- und Aktivierungsmaßnahmen beruhenden rehabilitativen Interventionsansatzes bei einer Pflegeheimklientel. In diesem Übersichtsartikel werden vor dem Hintergrund der theoretischen Grundlagen einer aktivierend-rehabilitativen Pflege, die als Basis aller interventionistischer Bemühungen in der stationären Altenhilfe angesehen werden kann, existierende therapeutisch-rehabilitative Ansätze für Pflegeheimbewohner dargestellt und anhand der vorliegenden Literatur diskutiert.

Évaluation posturale à domicile chez la personne âgée : comparaison chuteurs–non chuteurs

OBJECTIVES

To determine the main clinical and posturographic factors correlated with falls in elderly individuals and to specify the role of static posturography in this appraisal.

MATERIALS AND METHODS

The study involved 38 people living in an residential center who were autonomously ambulatory and had a Mini Mental Test score> or =24. Fallers (N = 15) had fallen within 1 month, and nonfallers (N = 23) had not fallen for at least a year. Assessment consisted of a series of questions, a complete clinical appraisal, specific independently validated tests, and static posturographic analysis different parameters of the stabilogram with the eyes first open and then closed, all carried out in the center.

RESULTS

From the clinical standpoint, spinal pathologic features and the scores on the Functional Reach Test were significantly different between the fallers and nonfallers. In static posturography, fallers' equilibrium was more precarious than that of nonfallers with eyes are closed: significant differences were observed in surface, X length and overall fast Fourier transform score. The comparison between results with open and closed eyes showed that the fallers had a pronounced tendency to retropulsion in the absence of visual participation: a significant difference as regards overall length, Y length, minimum Y and FFT Y (0.5-2 Hz).

CONCLUSIONS

To complement a satisfactorily conducted clinical examination, static posturography allows for rapid assessment of equilibrium and posture in elderly patients who fall? Performed at the place where an individual resides, this appraisal constitutes an original and pragmatic element. As an evaluation strategy, it can reveal nonnegligible information within the framework of an appraisal of such, and thereby allows for adjustment of the rehabilitation or compensatory strategy.