Falls in cognitive impairment and dementia

Predictors of Non-Variceal Hemorrhage in a National Cohort of Patients With Chronic Liver Disease

Background

Non-variceal hemorrhage in patients with chronic liver disease (CLD) increases morbidity, mortality, and healthcare costs. There are limited data on risk factors for non-variceal hemorrhage in the CLD population. The aim of this study was to assess the predictive value of various clinical and laboratory parameters for non-variceal hemorrhage in CLD patients.

Methods

We conducted a retrospective cohort study of US veterans diagnosed with CLD between 2002 and 2018 within the Veterans Health Administration database. We derived candidate variables from existing risk prediction models for hemorrhage, risk calculators for severity of liver disease, Charlson index of prognostic comorbidities, and prior literature. We used a competing risk analysis to study the relationship between putative risk factors and incidence of non-variceal hemorrhage in patients with CLD.

Results

Of 15,183 CLD patients with no history of cancer or anticoagulation use, 674 experienced non-variceal hemorrhage within 1 year of CLD diagnosis. In multivariable analysis, 11 of the 26 candidate variables independently predicted non-variceal hemorrhage: race, international normalized ratio (INR) > 1.5, bilirubin ≥ 2 mg/dL, albumin ≤ 3.5 g/dL, anemia, alcohol abuse, antiplatelet therapy, chronic kidney disease, dementia, proton pump inhibitor prescription, and recent infection.

Conclusions

In this study of almost 15,000 veterans, risk factors for non-variceal bleeding within the first year after diagnosis of CLD included non-Caucasian race, laboratory parameters indicating severe liver disease and recent infection in addition to the risk factors for bleeding observed in a general non-CLD population.

Changing trends in maxillofacial injuries among paediatric, adult and elderly populations: A 22-year statistical analysis of 3424 patients in a tertiary care centre in Northwest Italy

BACKGROUND

This retrospective study analysed the epidemiology of maxillofacial trauma over 22 years to assess whether there have been significant changes in the causes and characteristics of fractures in paediatric, adult and elderly populations.

MATERIALS AND METHODS

The following data were collected: age, sex, injury cause and mechanism, fracture site, Facial Injury Severity Scale, associated injuries, time of injury, type of treatment and length of hospital stay. The patients were analysed by age group (children [≤16 years], adults [17-60 years] and elderly [>60 years]) and divided into two time groups (group 1: 2001-2011; group 2: 2012-2022) that were compared to each other. Statistical analyses were performed using SPSS software.

RESULTS

Between 01 January 2001 and 31 December 2022, 3535 patients (2690 males and 845 females, mean age 39.3 years) were admitted for facial fractures. The comparison of the two temporal periods showed a decrease in the prevalence of males (p = .02), in road traffic injuries (p < .001), and in fractures of the lower third of the face (p = .005); there were significant increases in the mean age (p < .001), prevalence of the elderly (p = .006) and in fall- and assault-related injuries (p < .001 and p = .03, respectively). Assault injuries increased only in the 17-60 age group (p = .02) while RTA-related fractures decreased in all age groups (p < .05 for all comparisons). Bicycle accidents increased significantly, with a parallel decrease in motor vehicle accidents (both p < .001). Fall-related fractures increased only in 17-60 and >60 age groups (p < .001 and p = .02, respectively).

CONCLUSIONS

This study shows significant changing trends in the epidemiology of maxillofacial trauma. While road traffic policies have been effective in the last years, preventive measures for falls in the elderly population and new legislative measures to prevent interpersonal violence should be advocated.

Relationship between cognitive function and phase angle measured with a bioelectrical impedance system

PURPOSE

The purpose of this study was to investigate the relationship between cognitive function and phase angle (PhA), an indicator of muscle quality.

METHODS

This cross-sectional study enrolled outpatients who visited a memory clinic at the Nagoya University hospital from January 2016 to June 2022. We enrolled 153 participants with body composition measurements. Inclusion criteria were a Mini-Mental State Examination score of 20-30 and a clinical diagnosis of Alzheimer's dementia (AD) or amnesic mild cognitive impairment (aMCI). The background characteristics of the participants were compared according to AD and aMCI. Next, linear regression analysis was performed with PhA as the objective variable. In addition, logistic regression analysis was performed for AD diagnosis.

RESULTS

PhA was lower in the AD group (P = 0.009). In linear regression analysis, PhA consistently decreased with worsening ADAS score. In logistic regression analysis, high PhA was associated with absence of AD. Gender-specific analyses showed these associations existed only in men.

CONCLUSIONS

Our study of patients with AD and aMCI found that PhA decreased with worsening of cognitive function. Compared with aMCI, AD was associated with significantly lower PhA. Our results strengthen the limited evidence in the literature showing that low muscle quality is associated with poor cognitive function.

Dementia, osteoporosis and fragility fractures: Intricate epidemiological relationships, plausible biological connections, and twisted clinical practices

Dementia, osteoporosis, and fragility fractures are chronic diseases, often co-existing in older adults. These conditions pose severe morbidity, long-term disability, and mortality, with relevant socioeconomic implications. While in the research arena, the discussion remains on whether dementia is the cause or the consequence of fragility fractures, healthcare professionals need a better understanding of the interplay between such conditions from epidemiological and physiological standpoints. With this review, we summarized the available literature surrounding the relationship between cognitive impairment, dementia, and both low bone mineral density (BMD) and fragility fractures. Given the strength of the bi-directional associations and their impact on the quality of life, we shed light on the biological connections between brain and bone systems, presenting the main mediators, including gut microbioma, and pathological pathways leading to the dysregulation of bone and brain metabolism. Ultimately, we synthesized the evidence about the impact of available pharmacological treatments for the prevention of fragility fractures on cognitive functions and individuals' outcomes when dementia coexists. Vice versa, the effects of symptomatic treatments for dementia on the risk of falls and fragility fractures are explored. Combining evidence alongside clinical practice, we discuss challenges and opportunities related to the management of older adults affected by cognitive impairment or dementia and at high risk for fragility fracture prevention, which leads to not only an improvement in patient health-related outcomes and survival but also a reduction in healthcare cost and socio-economic burden.

Mortality rate and its determinants among people with dementia receiving home healthcare: a nationwide cohort study

People with dementia (PwD) who receive home healthcare (HHC) may have distressing symptoms, complex care needs and high mortality rates. However, there are few studies investigating the determinants of mortality in HHC recipients. To identify end-of-life care needs and tailor individualized care goals, we aim to explore the mortality rate and its determinants among PwD receiving HHC. We conducted a retrospective cohort study using a Taiwanese national population database. People with new dementia diagnosis in 2007-2016 who received HHC were included. We calculated the accumulative mortality rate and applied Poisson regression model to estimate the risk of mortality for each variable (adjusted risk ratios, aRR) with a 95% confidence interval (CI). We included 95,831 PwD and 57,036 (59.5%) of them died during the follow-up period (30.5% died in the first-year). Among comorbidities, cirrhosis was associated with the highest mortality risks (aRR 1.65, 95% CI 1.49-1.83). Among HHC-related factors, higher visit frequency of HHC (> 2 versus ≦1 times/month, aRR 3.52, 95% CI 3.39-3.66) and higher level of resource utilization group (RUG, RUG 4 versus 1, aRR = 1.38, 95% CI 1.25-1.51) were risk factor of mortality risk. Meanwhile, HHC provided by physician and nurse was related to reduced mortality risk (aRR 0.79, 95% CI 0.77-0.81) compared to those provided by nurse only. Anticipatory care planning and timely end-of life care should be integrated in light of the high mortality rate among PwD receiving HHC. Determinants associated with increased mortality risk facilitate the identification of high risk group and tailoring the appropriate care goals. Trial registration number: ClinicalTrials.gov Identifier is NCT04250103 which has been registered on 31st January 2020.

Association Between Contrast Sensitivity and Physical Function in Cognitively Healthy Older Adults: The Brain Networks and Mobility Function Study

BACKGROUND

To evaluate whether contrast sensitivity is associated with lower extremity physical function in cognitively intact older adults.

METHODS

Cross-sectional analysis of the relationship of binocular and worse eye log contrast sensitivity (LCS) to expanded Short Physical Performance Battery (eSPPB) and its components (gait speed, narrow walking speed, chair stand pace, and balance) in 192 cognitively healthy older adults. The association of LCS with postural sway and gait was also tested with tasks that further challenged functional reserve.

RESULTS

Mean age was 76.4 years with 56% identifying as female and over 98.5% having good corrected visual acuity. Lower LCS was significantly associated with worse performance on the eSPPB, 4-M gait speed, narrow walking speed, and balance time in unadjusted and adjusted models. The relationship between worse eye LCS and larger postural sway was 3 times greater on a foam surface (beta 1.07, 95% CI [0.35, 1.80]) than a firm surface (beta 0.35, 95% CI [0.05, 0.65]), and both were robust to adjustment for confounders; similar findings were observed with binocular LCS. Lower binocular LCS had a greater decremental effect on gait velocity during the fast pace (beta -0.58, 95% CI [-0.90, -0.27]) than the usual pace (Beta -0.39 [-0.63, -0.15]) gait task.

CONCLUSIONS

These findings suggest that cognitively unimpaired older adults without significant visual acuity impairment can have subtle preclinical deficits in contrast sensitivity and physical function that could place them at risk of mobility and balance issues. Future studies should determine whether this subset of older adults may benefit from targeted intervention to prevent disability.

The 'Bermuda Triangle' of orthostatic hypotension, cognitive impairment and reduced mobility: prospective associations with falls and fractures in The Irish Longitudinal Study on Ageing

BACKGROUND

Orthostatic hypotension (OH), cognitive impairment (Cog) and mobility impairment (MI) frequently co-occur in older adults who fall. This study examines clustering of these three geriatric syndromes and ascertains their relationship with future falls/fractures in a large cohort of community-dwelling people ≥ 65 years during 8-year follow-up.

METHODS

OH was defined as an orthostatic drop ≥ 20 mmHg in systolic blood pressure (from seated to standing) and/or reporting orthostatic unsteadiness. CI was defined as Mini Mental State Examination ≤ 24 and/or self-reporting memory as fair/poor. MI was defined as Timed Up and Go ≥12 s. Logistic regression models, including three-way interactions, assessed the longitudinal association with future falls (explained and unexplained) and fractures.

RESULTS

Almost 10% (88/2,108) of participants had all three Bermuda syndromes. One-fifth of participants had an unexplained fall during follow-up, whereas 1/10 had a fracture. There was a graded relationship with incident unexplained falls and fracture as the number of Bermuda syndromes accumulated. In fully adjusted models, the cluster of OH, CI and MI was most strongly associated with unexplained falls (odds ratios (OR) 4.33 (2.59-7.24); P < 0.001) and incident fracture (OR 2.51 (1.26-4.98); P = 0.045). Other clusters significantly associated with unexplained falls included OH; CI and MI; MI and OH; CI and OH. No other clusters were associated with fracture.

DISCUSSION

The 'Bermuda Triangle' of OH, CI and MI was independently associated with future unexplained falls and fractures amongst community-dwelling older people. This simple risk identification scheme may represent an ideal target for multifaceted falls prevention strategies in community-dwelling older adults.

The Nebulous Association between Cognitive Impairment and Falls in Older Adults: A Systematic Review of the Literature

BACKGROUND

In older people, dementia is a well-established risk factor for falls. However, the association and the causal relationship between falls and the earlier stages of cognitive impairment remains unclear. The purpose of the study was to review the literature data on the association between falls and cognitive impairment, no dementia, including Mild Cognitive Impairment.

METHODS

According to PRISMA guidelines, we searched five electronic databases (EMBASE, Web of Science, Medline, CINAHL, and PsychINFO) for articles published between January 2011 and August 2022 on observational studies of older people with a cognitive assessment and/or cognitive impairment diagnosis and a recording of falls. Their quality was reviewed according to the STROBE checklist.

RESULTS

We selected 42 of the 4934 initially retrieved publications. In 24 retrospective studies, a statistically significant association between falls and cognitive status was found in only 15 of the 32 comparisons (47%). Of the 27 cross-sectional analyses in prospective studies, only eight (30%) were positive and significant. We counted four longitudinal analyses, half of which suggested a causal relationship between falls and cognitive impairment. The investigational methods varied markedly from one study to another.

CONCLUSION

It is still not clear whether falls are associated with cognitive impairment, no dementia. Data in favor of a causal relationship are scarce. Further studies are needed to clarify their relationship.

Examining the intersection of cognitive and physical function measures: Results from the brain networks and mobility (B-NET) study

Background and objectives

Although evidence exists that measures of mobility and cognition are correlated, it is not known to what extent they overlap, especially across various domains. This study aimed to investigate the intersection of 18 different objective cognitive and physical function measures from a sample of unimpaired adults aged 70 years and older.

Research design and methods

Canonical correlation analysis was utilized to explore the joint cross-sectional relationship between 13 cognitive and 6 physical function measures in the baseline visit of the Brain Networks and Mobility Function (B-NET) Study (n = 192).

Results

Mean age of participants was 76.4 years. Two synthetic functions were identified. Function 1 explained 26.3% of the shared variability between the cognition and physical function variables, whereas Function 2 explained 19.5%. Function 1 termed "cognitive and physical speed" related the expanded Short Physical Performance Battery (eSPPB), 400-m walk speed, and Dual Task gait speed measures of physical function to semantic fluency animals scores, Digit Symbol Coding (DSC), and Trail Making Test B. Function 2 termed "complex motor tasks and cognitive tasks" related the Force Plate Postural Sway Foam Task and Dual Task to the following cognitive variables: MoCA Adjusted Score, Verbal Fluency L words, Craft story immediate and delayed recall, and Trail Making Test B.

Discussion and implications

We identified groups of cognitive and physical functional abilities that were linked in cross-sectional analyses, which may suggest shared underlying neural network pathway(s) related to speed (Function 1) or complexity (Function 2).

Translational significance

Whether such neural processes decline before measurable functional losses or may be important targets for future interventions that aim to prevent disability also remains to be determined.

World Oral and Maxillofacial Trauma (WORMAT) project: A multicenter prospective analysis of epidemiology and patterns of maxillofacial trauma around the world

BACKGROUND/AIM

The World Oral Maxillofacial Trauma (WORMAT) project was performed to analyze the causes and characteristics of maxillofacial fractures managed in 14 maxillofacial surgery divisions over a 1-year period.

METHODS

The following data were collected: age, sex, cause and mechanism of maxillofacial fracture, alcohol and/or drug abuse at the time of trauma, fracture site, Facial Injury Severity Scale score (FISS), associated injury, day of trauma, timing and type of treatment, and length of hospitalization. Statistical analyses were performed using SPSS software.

RESULTS

Between 30 September 2019 and 4 October 2020, 2,387 patients (1,825 males and 562 females [ratio 3.2:1], 47.6% aged 20-39 years [mean age 37.2 years, median 33.0 years]) were hospitalised. The main cause of maxillofacial fracture was road traffic accidents (RTA), which were statistically associated with male adults as like as assault, sport, and work (p<0,05). Half of the fractures involved the middle third of the face, statistically associated with fall and assault (p<0.05). Trauma in multiple locations was significantly associated with longer hospital stay (p<0.05). The mean length of hospitalization was 3.9 days (95% Confidence Interval 3.7-4.2).

CONCLUSIONS

This prospective, multicenter epidemiological study confirmed that young adult males were the ones most commonly affected by maxillofacial fracture. RTAs and assaults are statistically associated with the adult population, while falls are associated with females and older population.

The Value of Cognitive and Physical Function Tests in Predicting Falls in Older Adults: A Prospective Study

Introduction

Previous studies suggested that physical and cognitive function can be indicators to assess the risk of falls in the elderly. Various tests are widely used in geriatric clinical studies as assessment tools of physical and cognitive function. However, large sample studies comparing the fall predictive value of these tests are still sparse. This study was conducted to investigate the value of cognitive and physical function tests in predicting the risk of subsequent falls in the elderly, with the overarching goal of providing more evidence on fall-risk assessment.

Methods

The current study was based on the data of respondents aged 60 and above from the China Health and Retirement Longitudinal Study (CHARLS). Data from the 2015 CHARLS national survey were used as the baseline data, and the fall data in 2018 were used as the follow-up data. Physical function tests included balance, walking speed, the five times sit-to-stand test (FTSST), and grip strength. The value of cognitive and physical function tests in predicting falls was evaluated by logistic regression analysis and receiver operating characteristic (ROC) curves.

Results

The incidence of falls among the 4,857 subjects included in this study was 20.86%. Results showed that cognition (OR = 0.83, 95% CI: 0.70–0.98), the FTSST (OR = 3.51, 95% CI: 1.66–7.46), and grip strength (OR = 1.02, 95% CI: 1.01–1.03) were independent predictors of falls in the full sample after adjusting for various confounders. Notably, the above tests showed better predictive value for falls for the oldest-old (≥ 80 years) subjects.

Conclusion

Overall, results showed that grip strength, the FTSST, and cognition tests are simple and practicable tools for identifying individuals at higher risk of falls in the community. Moreover, the fall predictive performance of physical and cognitive function tests was age-dependent, with a higher predictive value in older adults aged 80 and above.

The Association Between Cognitive Impairment and Subsequent Falls Among Older Adults: Evidence From the China Health and Retirement Longitudinal Study

Introduction

Previous studies have suggested that cognitive impairment is associated with falls in older adults. However, the consistency of results among different subgroups defined by multiple characteristics of the elderly has not yet been tested. Additionally, results are inconsistent regarding the effects of different cognitive domains on falls. Therefore, this study sought to use representative data from a nationwide study to better understand the longitudinal association between cognitive impairment and subsequent falls in older adults.

Methods

The current study was conducted based on the China Health and Retirement Longitudinal Study (CHARLS) data of respondents aged ≥60 years in 2015 and the fall data in 2018. The respondents were divided into subgroups according to different demographic characteristics. Multiple logistic regression analysis was conducted to adjust for various confounding factors and evaluate the association between cognitive impairment and falls.

Results

Of the 5,110 respondents included in this study, 1,093 (21.39%) had falls within the last 2 years. A significant association was found between cognitive impairment and subsequent falls (OR = 0.97, 95% CI 0.95–0.99, P = 0.001) after adjusting for all of the covariates related to falls. Analysis of different cognitive domains showed that orientation (OR = 0.94, 95% CI 0.90–0.99, P = 0.013) and memory (OR = 0.93, 95% CI 0.90–0.97, P = 0.001) were significantly associated with falls. In subgroup analysis, the ORs of people aged 60–74 years, male, with lower education level were 0.97 (95% CI 0.95–0.99, P = 0.008), 0.96 (95% CI 0.93–0.98, P = 0.001), and 0.97 (95% CI 0.95–0.99, P = 0.001), respectively, suggesting that the associations were also statistically significant in these subgroups. There was also a significant association both in urban (OR = 0.97, 95% CI 0.95–0.99, P = 0.001) and in rural residents (OR = 0.97, 95% CI 0.95–0.99, P = 0.003).

Conclusions

Our results suggest that the associations between cognition and falls vary depending on the different demographic characteristics of older adults. These findings may be useful for designing more accurate identification and intervention for the fall risk for specific high-risk groups.

Trajectories of physical functioning among US adults with cognitive impairment

BACKGROUND

physical functioning impairment is common among persons with cognitive impairment, but little is known about physical functioning trajectories across the US population or how trajectories may differ among persons with dementia and mild cognitive impairment (MCI).

OBJECTIVE

to examine trajectories of physical functioning among persons with MCI and dementia in the USA.

DESIGN

we used data from the National Health and Aging Trends study (NHATS) 2011-18. Physical functioning was assessed using the NHATS Expanded Short Physical Performance Battery.

PARTICIPANTS

the 661 individuals with MCI and 980 individuals with dementia were included in this study.

METHODS

we applied group-based trajectory models to identify latent groups and estimate their trajectories. Multinomial logistic regressions were applied to examine relationships between sociodemographic and health characteristics and trajectory group memberships.

RESULTS

both MCI- and dementia-specific trajectories differed at baseline levels and declined at varying rates across groups. Approximately, 78.43% of persons with MCI were in trajectories with a moderate rate of decline, with only 9.75% in a trajectory with good physical function and 11.82% with poor physical function without as much change over time. Among persons with dementia, approximately 81.4% experienced moderate or fast declines, and 18.52% with virtually no functional ability remained at this same low level. Worse physical functioning trajectories were found among persons who were females, Blacks, with at least four comorbidities, and among persons who had a low socioeconomic status.

CONCLUSIONS

persons with both dementia and MCI experienced steady declines in physical functioning. Socioeconomically disadvantaged groups have worse physical functioning trajectories.

A Night-Time Monitoring System (eNightLog) to Prevent Elderly Wandering in Hostels: A Three-Month Field Study

Older people are increasingly dependent on others to support their daily activities due to geriatric symptoms such as dementia. Some of them stay in long-term care facilities. Elderly people with night wandering behaviour may lose their way, leading to a significant risk of injuries. The eNightLog system was developed to monitor the night-time bedside activities of older people in order to help them cope with this issue. It comprises a 3D time-of-flight near-infrared sensor and an ultra-wideband sensor for detecting human presence and to determine postures without a video camera. A threshold-based algorithm was developed to classify different activities, such as leaving the bed. The system is able to send alarm messages to caregivers if an elderly user performs undesirable activities. In this study, 17 sets of eNightLog systems were installed in an elderly hostel with 17 beds in 9 bedrooms. During the three-month field test, 26 older people with different periods of stay were included in the study. The accuracy, sensitivity and specificity of detecting non-assisted bed-leaving events was 99.8%, 100%, and 99.6%, respectively. There were only three false alarms out of 2762 bed-exiting events. Our results demonstrated that the eNightLog system is sufficiently accurate to be applied in the hostel environment. Machine learning with instance segmentation and online learning will enable the system to be used for widely different environments and people, with improvements to be made in future studies.

The association of psychiatric and neurological comorbidities with outcomes in traumatic injury patients

INTRODUCTION

Mental illness is a well-known risk factor for injury and injury recidivism. The impact of pre-existing psychiatric illness on trauma outcomes, however, has received less attention. Our study examines the relationship of pre-existing psychiatric illness on trauma outcomes including length of stay, cost, and mortality.

METHODS

Patient data were obtained from the Healthcare Cost and Utilization Project's State Inpatient Database. All patients admitted for trauma in the Detroit metropolitan area from 1/1/2006 to 12/31/2014 were included. The relationship between individual psychiatric comorbidities (depression, psychosis, and other neurological disorders) and outcomes were evaluated with logistic regression (mortality) and generalized linear modeling (length of stay and cost).

RESULTS

Over 260,000 records were reviewed. Approximately one-third (29.9%) of patients had one or more psychiatric diagnoses. Patients with depression had longer hospital stays (RR = 1.12, p < 0.001) and higher costs (RR = 1.07, p < 0.001), but also lower mortality (OR = 0.69, p < 0.001). Patients with psychosis had longer stays (RR = 1.18, p < 0.001), higher costs (RR = 1.02, p = 0.002), and lower mortality (OR = 0.61, p < 0.001). Patients with other neurological comorbidities had higher mortality (OR = 1.23, p < 0.001), longer stays (RR = 1.29, p < 0.001), and higher costs (RR = 1.10, p < 0.001).

CONCLUSION

Patients with a psychiatric disorder required longer care and incurred greater costs, whereas mortality was higher for only those with a neurological disorder. Identifying patients' psychiatric comorbidities at the time of admission for trauma may help optimize treatment. Addressing these conditions may help reduce the cost of trauma care.

Exergame training-induced neuroplasticity and cognitive improvement in institutionalized older adults: A preliminary investigation

BACKGROUND

Prior research has reported cognitive improvements in elderly individuals when mental and physical exercise are practiced simultaneously, as in exergaming. However, the molecular mechanisms driving this beneficial response remain unclear. Moreover, there is robust evidence that regular exercise increases neurotrophic factors and promotes neuroplasticity, contributing to cognitive improvement. This research aimed to assess the impact of a 6-week Xbox 360 Kinect exergame protocol on cognitive function and brain-derived neurotrophic factor (BDNF) levels in institutionalized older individuals.

METHODS

Participants living in a long-term care facility were included. The intervention (Xbox 360 Kinect exergame protocol) was conducted individually and consisted of two sessions per week (40 min each) over 6 weeks. Participants' cognitive function (Montreal Cognitive Assessment, MoCA) was evaluated before and after the intervention. Blood samples (15 ml) were collected at the same time to measure BDNF levels.

RESULTS

Although there were no changes in total MoCA scores, exergame training improved the "language" domain and demonstrated a tendency toward an improvement in the "abstraction" and "memory/delayed recall" domains. Furthermore, BDNF levels were significantly increased after the intervention.

CONCLUSION

BDNF enhancement might mediate, at least in part, the cognitive changes induced by a 6-week Xbox 360 Kinect exergame protocol in institutionalized older adults.

Perturbation-based balance assessment: Examining reactive balance control in older adults with mild cognitive impairments

Background

Older adults with mild cognitive impairment (OAwMCI) present subtle balance and gait deficits along with subjective memory decline. Although these presentations might not affect activities of daily living (ADLs), they attribute to a two-folded increase in falls. While changes occurring in volitional balance control during ADLs have been extensively examined among OAwMCI, reactive balance control, required to recover from external perturbations, has received little attention. Therefore, this study examined reactive balance control in OAwMCI compared to their healthy counterparts.

Methods

Fifteen older adults with mild cognitive impairment (OAwMCI), fifteen cognitively intact older adults (CIOA) (>55 years), and fifteen young adults (18-30 years) were exposed to stance perturbations at three different intensities. Behavioral outcomes postural COM state stability, step length, step initiation, and step execution were computed.

Results

Postural COM state stability was the lowest in OAwMCI compared to CIOA and young adults, and it deteriorated at higher perturbation intensities (P < 0.001). Step length was the lowest among OAwMCI and was significantly different from young adults (P < 0.001) but not from CIOA. Unlike OAwMCI, CIOA and young adults increased their step length at higher perturbation intensities (P < 0.001). OAwMCI showed longer recovery step initiation times and shorter execution times compared to CIOA and young adults at higher perturbation intensities (P < 0.001).

Conclusion

OAwMCI exhibit exacerbated reactive instability and are unable to modulate their responses as the threat to balance control altered. Thus, they are at a significantly higher risk of falls than their healthy counterparts.

Association between Anti-Psychotic Drugs Use and Hip Fractures in Patients with Dementia: A Nationwide Population-Based Study

Background: People with dementia are a high-risk group for hip fractures. Although the increased risk of hip fractures associated with antipsychotic drugs (APD) is found in older populations, little is known about the risk for people with dementia living in Asia. We aimed to investigate the association between hip fractures and the characteristics of APD use in patients with dementia. Methods: A nested case-control analysis was conducted on a nationwide cohort in Taiwan. People with diagnoses of dementia during 2003–2012 were identified. Conditional logistic regression analysis was performed, and adjusted odds ratios (aORs) were calculated with a 95% confidence interval (CI) to estimate the risk of hip fractures. Results: APD use was associated with an increased risk of hip fractures in patients with dementia; current use or combined use of first and second generations of APDs had even higher risks. Regarding the duration of APD use, a U-shape curve of hip fracture risk was noted, and the risk peaked during 0–15 days and >215 days of exposure (aOR = 1.46, 95% CI 1.37–1.57; aOR = 1.47, 95% CI 1.37–1.58; respectively). Considering the doses of APDs, the hip fracture risk was significantly increased with all four levels of the cumulative doses and average daily doses and peaked in the group with the highest average daily dose. Conclusions: The findings suggest that caution must be taken when initiating APD use in patients with dementia, even in a small dose, and mixed types of APD prescriptions should be administered with care. Furthermore, frequent evaluation of the possibility of tapering or withdrawal of the medication is necessary, as the risk does not attenuate after long-term use.

Is Fall Risk Systematically Evaluated in Memory Clinics? A National Survey of Practice in France

BACKGROUND

Falls are a major health problem in older persons but are still under-diagnosed and challenging to prevent. Current guidelines do not target high-risk populations, especially people living with dementia. In France, people with neurocognitive disorders are mainly referred to memory clinics (MCs).

OBJECTIVE

We aimed to survey the routine practice of physicians working in MCs regarding fall risk assessment.

METHODS

We conducted a cross-sectional survey in France from January to May 2019 among physicians working in MCs, through an anonymous online questionnaire: twenty-seven questions about the physician's background and their practice of fall risk assessment, especially use of clinical and paraclinical tools. We compared the results according to the age and the specialty of the physician.

RESULTS

We obtained 171 responses with a majority of women (60%) and geriatricians (78%). All age classes and all French regions were represented. Most of respondents (98.8%) stated that they address gait and/or falls in outpatient clinic and 95.9%in day hospitals. When asked about how they assess fall risk, fall history (83%) and gait examination (68.4%) were the most widely used, while orthostatic hypotension (24%) and clinical standardized tests (25.7%) were less common. Among standardized tests, One-leg Balance, Timed Up and Go Test, and gait speed measurements were the most used. Geriatricians had more complete fall risk assessment than neurologists (e.g., 56%versus 13%for use of standardized tests, p < 0.0001).

CONCLUSION

Almost all physicians addressed the question of fall in MC, but practices are widely heterogeneous. Further investigations are needed to standardize fall risk assessment in MCs.

Fall-related cognition, motor function, functional ability, and depression measures in older adults with dementia

BACKGROUND

As the severity of dementia progresses over time, cognition and motor functions such as muscle strength, balance, and gait are disturbed, and they eventually increase the risk of fall in patients with dementia.

OBJECTIVE

To determine the relationship between the fall risk and cognition, motor function, functional ability, and depression in older adults with dementia.

METHODS

Seventy-four older adults diagnosed with dementia were recruited. Clinical measurements included the Fall Risk Scale by Huh (FSH), Korean version of the Mini-Mental State Examination (MMSE-K), hand grip strength (HGS), Tinetti Performance Oriented Mobility Assessment (POMA), 10-m walk test (10-MWT), Korean version of the Modified Barthel Index (MBI-K), and the Geriatric Depression Scale (GDS).

RESUTLS

The MMSE-K was significantly correlated with the FSH, HGS, and the MBI-K, and FSH was significantly correlated with all of the other outcome measures. In particular, the MMSE-K, HGS, POMA, and the MBI-K were negatively correlated with fall history among the FHS sub-items. Additionally, the MMSE sub-item, attention/concentration was associated with the FSH, HGS, POMA, and the MBI-K.

CONCLUSIONS

These findings suggest that falling is significantly related to impaired cognition, reduced muscle strength, impaired balance, gait, and activities of daily living abilities, and depression in older adults with dementia.

Special Report from the CDC Antidepressant subclass use and fall risk in community-dwelling older Americans

INTRODUCTION

Falls among older adults are a significant health concern affecting more than a quarter of older adults (age 65+). Certain fall risk factors, such as medication use, increase fall risk among older adults (age 65+).

AIM

The aim of this study is to examine the association between antidepressant-medication subclass use and self-reported falls in community-dwelling older adults.

METHODS

This analysis used the 2009-2013 Medicare Current Beneficiary Survey, a nationally representative panel survey. A total of 8,742 community-dwelling older adults, representing 40,639,884 older Medicare beneficiaries, were included. We compared self-reported falls and psychoactive medication use, including antidepressant subclasses. These data are controlled for demographic, functional, and health characteristics associated with increased fall risk. Descriptive analyses and multivariate logistic regression analyses were conducted using SAS 9.4 and Stata 15 software.

RESULTS

The most commonly used antidepressant subclass were selective serotonin reuptake inhibitors (SSRI) antidepressants (13.1%). After controlling for characteristics associated with increased fall risk (including depression and concurrent psychoactive medication use), the risk of falling among older adults increased by approximately 30% among those who used a SSRI or a serotonin-norepinephrine reuptake inhibitors (SNRI) compared to non-users. The adjusted risk ratio (aRR) for SSRI was 1.29 (95% CI = 1.13, 1.47) and for SNRI was 1.32 (95% CI = 1.07, 1.62).

CONCLUSION

SSRI and SNRI are associated with increased risk of falling after adjusting for important confounders. Medication use is a modifiable fall risk factor in older adults and can be targeted to reduce risk of falls. Practical Applications: Use of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors increased the risk of falling in older adults by approximately 30%, even after controlling for demographic, functional, and health characteristics, including depression. Health care providers can work towards reducing fall risk among their older patients by minimizing the use of certain medications when potential risks outweigh the benefits.

Night-Time Monitoring System (eNightLog) for Elderly Wandering Behavior

Wandering is a common behavioral disorder in the community-dwelling elderly. More than two-thirds of caregivers believe that wandering would cause falls. While physical restraint is a common measure to address wandering, it could trigger challenging behavior in approximately 80% of the elderly with dementia. This study aims to develop a virtual restraint using a night monitoring system (eNightLog) to provide a safe environment for the elderly and mitigate the caregiver burden. The eNightLog system consisted of remote sensors, including a near infra-red 3D time-of-flight sensor and ultrawideband sensors. An alarm system was controlled by customized software and algorithm based on the respiration rate and body posture of the elderly. The performance of the eNightLog system was evaluated in both single and double bed settings by comparing to that of a pressure mat and an infrared fence system, under simulated bed-exiting scenarios. The accuracy and precision for the three systems were 99.0%, 98.8%, 85.9% and 99.2%, 97.8%, 78.6%, respectively. With higher accuracy, precision, and a lower false alarm rate, eNightLog demonstrated its potential as an alternative to physical restraint to remedy the workload of the caregivers and the psychological impact of the elderly.

Lateralized Deficits in Motor, Sensory, and Olfactory Domains in Dementia

BACKGROUND

There exist functional deficits in motor, sensory, and olfactory abilities in dementias. Measures of these deficits have been discussed as potential clinical markers.

OBJECTIVE

We measured the deficit of motor, sensory, and olfactory functions on both the left and right body side, to study potential body lateralizations.

METHODS

This IRB-approved study (N = 84) performed left/right clinical tests of gross motor (dynamometer test), sensory (Von Frey test), and olfactory (peppermint oil test) ability. The Mini-Mental Status Exam was administered to determine level of dementia; medical and laboratory data were collected.

RESULTS

Sensory and olfactory deficits lateralized to the left side of the body, while motor deficits lateralized to the right side. We found clinical correlates of motor lateralization: female, depression, MMSE <15, and diabetes. While clinical correlates of sensory lateralization: use of psychotherapeutic agent, age ≥85, MMSE <15, and male. Lastly, clinical correlates of olfactory lateralization: age <85, number of medications >10, and male.

CONCLUSION

These lateralized deficits in body function can act as early clinical markers for improved diagnosis and treatment. Future research should identify correlates and corresponding therapies to strengthen at-risk areas.

Spatial-Temporal Parameters of Gait Associated With Alzheimer Disease: A Longitudinal Analysis

Alzheimer's disease (AD) is one of the biggest social and medical concerns in the aging world. A dual task of walking and talking is a particularly practical means to assess AD considering the cognitive and behavioral changes that characterize the disease. The purpose of the study was to assess the effect of the dual task of walking and talking on people with early stage AD under differing cognitive load levels of talking. Participants (9 women and 5 men, mean age (years) = 78.03, standard deviation [SD] = 12.06) with mild or moderate AD (mean Dementia Rating Scale 2 score = 88.14, SD = 7.07) completed 12 monthly walking sessions under no, low, or high cognitive load. They also completed the low and high cognitive load tasks while seated. Linear mixed-effects modeling revealed that values in the Functional Ambulation Profile, stride length, and velocity decreased as tasks became more complex and double support time increased at the same rate. The walking and seated conditions comparison indicated that participants' performance on both low and high cognitive tasks was poor when they were walking rather than seated. The results show that people with early stage AD exhibited gait impairments that increased over time and when completing tasks with greater cognitive load.

An intervention to improve outcomes of falls in dementia: the DIFRID mixed-methods feasibility study

BACKGROUND

Fall-related injuries are a significant cause of morbidity and mortality in people with dementia. There is presently little evidence to guide the management of such injuries, and yet there are potentially substantial benefits to be gained if the outcomes of these injuries could be improved. This study aimed to design an appropriate new health-care intervention for people with dementia following a fall and to assess the feasibility of its delivery in the UK NHS.

OBJECTIVES

To determine whether or not it is possible to design an intervention to improve outcomes of falls in dementia, to investigate the feasibility and acceptability of the DIFRID (Developing an Intervention for Fall related Injuries in Dementia) intervention and to investigate the feasibility of a future randomised controlled trial and the data collection tools needed to evaluate both the effectiveness and the cost-effectiveness of the DIFRID intervention.

DESIGN

This was a mixed-methods feasibility study. A systematic review (using Cochrane methodology) and realist review [using Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) methodology] explored the existing evidence base and developed programme theories. Searches were carried out in November 2015 (updated in January 2018) for effectiveness studies and in August 2016 for economic studies. A prospective observational study identified service use via participant diary completion. Qualitative methods (semistructured interviews, focus groups and observation) were used to explore current practice, stakeholder perspectives of the health and social care needs of people with dementia following a fall, ideas for intervention and barriers to and facilitators of change. Each of the resulting data sets informed intervention development via Delphi consensus methods. Finally, a single-arm feasibility study with embedded process evaluation was conducted.

SETTING

This study was set in the community.

PARTICIPANTS

The participants were (1) people with dementia presenting with falls necessitating health-care attention in each setting (primary care, the community and secondary care) at three sites and their carers, (2) professionals delivering the intervention, who were responsible for training and supervision and who were members of the intervention team, (3) professionals responsible for approaching and recruiting participants and (4) carers of participants with dementia.

INTERVENTIONS

This was a complex multidisciplinary therapy intervention. Physiotherapists, occupational therapists and support workers delivered up to 22 sessions of tailored activities in the home or local area of the person with dementia over a period of 12 weeks.

MAIN OUTCOME MEASURES

(1) Assessment of feasibility of study procedures; (2) assessment of the acceptability, feasibility and fidelity of intervention components; and (3) assessment of the suitability and acceptability of outcome measures for people with dementia and their carers (number of falls, quality of life, fear of falling, activities of daily living, goal-setting, health-care utilisation and carer burden).

RESULTS

A multidisciplinary intervention delivered in the homes of people with dementia was designed based on qualitative work, realist review and recommendations of the consensus panel. The intervention was delivered to 11 people with dementia. The study suggested that the intervention is both feasible and acceptable to stakeholders. A number of modifications were recommended to address some of the issues arising during feasibility testing. The measurement of outcome measures was successful.

CONCLUSIONS

The study has highlighted the feasibility of delivering a creative, tailored, individual approach to intervention for people with dementia following a fall. Although the intervention required greater investment of time than usual practice, many staff valued the opportunity to work more closely with people with dementia and their carers. We conclude that further research is now needed to refine this intervention in the context of a pilot randomised controlled trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41760734 and PROSPERO CRD42016029565.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 59. See the NIHR Journals Library website for further project information.

Specific Motor and Cognitive Performances Predict Falls during Ward-Based Geriatric Rehabilitation in Patients with Dementia

The aim of this study was to identify in-hospital fall risk factors specific for multimorbid hospitalized geriatric patients with dementia (PwD) during hospitalization. Geriatric inpatients during ward-based rehabilitation (n = 102; 79.4% females; 82.82 (6.19) years of age; 20.26 (5.53) days of stay) were included in a comprehensive fall risk assessment combining established clinical measures, comprehensive cognitive testing including detailed cognitive sub-performances, and various instrumented motor capacity measures as well as prospective fall registration. A combination of unpaired t-tests, Mann-Whitney-U tests, and Chi-square tests between patients with ("in-hospital fallers") and without an in-hospital fall ("in-hospital non-fallers"), univariate and multivariate regression analysis were used to explore the best set of independent correlates and to evaluate their predictive power. In-hospital fallers (n = 19; 18.63%) showed significantly lower verbal fluency and higher postural sway (p < 0.01 to 0.05). While established clinical measures failed in discriminative as well as predictive validity, specific cognitive sub-performances (verbal fluency, constructional praxis, p = 0.01 to 0.05) as well as specific instrumented balance parameters (sway area, sway path, and medio-lateral displacement, p < 0.01 to 0.03) significantly discriminated between fallers and non-fallers. Medio-lateral displacement and visuospatial ability were identified in multivariate regression as predictors of in-hospital falls and an index combining both variables yielded an accuracy of 85.1% for fall prediction. Results suggest that specific cognitive sub-performances and instrumented balance parameters show good discriminative validity and were specifically sensitive to predict falls during hospitalization in a multimorbid patient group with dementia and an overall high risk of falling. A sensitive clinical fall risk assessment strategy developed for this specific target group should include an index of selected balance parameters and specific variables of cognitive sub-performances.

Potentially inappropriate medication use and related hospital admissions in aged care residents: The impact of dementia

AIMS

To determine the prevalence of potentially inappropriate medication (PIM) use at hospital admission and discharge, and the contribution to hospital admission among residential aged care facility residents with and without dementia.

METHODS

We conducted a secondary analysis using data from a multihospital prospective cohort study involving consecutively admitted older adults, aged 75 years or older, who were taking 5 or more medications prior to hospital admission and discharged to a residential aged care facility in South Australia. PIM use was identified using the 2015 Screening Tool for Older Persons' Prescription and 2019 Beers criteria. An expert panel of clinicians with geriatric medicine expertise evaluated the contribution of PIM to hospital admission.

RESULTS

In total, 181 participants were included, the median age was 87.5 years and 54.7% were female. Ninety-one (50.3%) had a diagnosis of dementia. Participants with dementia had fewer PIMs, according to at least 1 of the 2 screening criteria, than those without dementia, at admission (dementia: 76 [83.5%] vs no dementia: 84 [93.3%], P = .04) and discharge (78 [85.7%] vs 83 [92.2%], P = .16). PIM use was causal or contributory to the admission in 28.1% of study participants (n = 45) who were taking at least 1 PIM at admission.

CONCLUSIONS

Over 80% of acutely admitted older adults took PIMs at hospital admission and discharge and for over a quarter of these people the admissions were attributable to PIM use. Hospitalisation presents an opportunity for comprehensive medication reviews, and targeted interventions that enhance such a process could reduce PIM use and related harm.

An Exploration of Equine-Assisted Therapy to Improve Balance, Functional Capacity, and Cognition in Older Adults With Alzheimer Disease

BACKGROUND AND PURPOSE

Alzheimer disease (AD) is a chronic, progressive dementia syndrome that features cognitive and behavioral symptoms, as well as physical and functional limitations that develop over the course of the disease. As an activity that involves physical and cognitive aspects, equine-assisted therapy (EAT) could be a useful therapeutic approach in conditions that involve physical and cognitive decline. However, to date, there are no reports of the use of this therapy in participants with AD. Within this context, the objective of this case series was to describe the effects of EAT on balance, functional capacity, and cognition in older adults diagnosed with AD.

METHODS

We enrolled 9 participants, of both sexes, with a mean age of 79.7 (7.8) years and a diagnosis of AD. The study intervention comprised 20 sessions of EAT. We evaluated participants at baseline and at the end of the intervention. Outcome measures were balance (force plate), functional capacity (Timed Up and Go test and 30-second chair stand test), and cognition (verbal fluency and Mini-Mental State Examination).

RESULTS

Comparison between the pre- and postintervention time points (Wilcoxon test) revealed significant improvements in balance (center of pressure in the anterior-posterior direction, P = .017) and functional capacity (Timed Up and Go test, P = .036, and 30-second chair stand test, P = .012).

CONCLUSION

These findings provide evidence of an association between EAT and improved balance and functional capacity in older adults with AD, with no significant impact on cognitive performance.

Falls and Cancer

Falls among older people are common and are associated with substantial morbidity, mortality and healthcare costs. Increasingly cancer is becoming a disease of older people and fall rates are higher in elders living with cancer. Cancer and its treatments potentiate important risk factors for falls, including muscle weakness, poor balance, proprioception, cognitive impairment and functional disability. Sarcopenia refers to the progressive deterioration in muscle strength, mass and quality with ageing. Chronic conditions and cancer amplify this decline and are associated with a greater negative effect on function. Age-related impairments of lower limb neurological function are commonly exacerbated by neurotoxic chemotherapy, resulting in gait and balance deficits. Postural instability and falls erode confidence and result in a negative cycle of diminishing activity levels, further deconditioning and a higher risk of further falls. Cancer-related fatigue, sleep and mood disturbances compound this progressive frailty, further worsening treatment tolerance and outcomes. Cognitive impairment is a potent risk factor for falling and is frequently associated with gait abnormalities. The well-recognised effects of cancer treatment on working memory, attention, processing speed and executive function are often apparent (when their presence is sought) before treatment and may be as much the result of the cancer itself as they are 'chemo brain'. Structured exercise programmes focusing on progressively challenging strength and balance training are of proven benefit in falls prevention. Regular aerobic exercise accrues additional benefits in improved cardiorespiratory resilience and concomitant positive effects on treatment tolerance. Increased activity levels positively influence cognition, mood and foster an improved sense of well-being. Simple, practicable clinic-based tests of physical functioning, cognition and neurological function can help to identify those at high risk of falls and functional decline. The use of such instruments can aid judicious treatment planning and identify those most likely to benefit from more detailed specialist comprehensive geriatric assessment.

[Physical restraint use in relation to falls risk in a nursing home]

BACKGROUNDS AND OBJECTIVES

The use of physical restraints (PR) is common in the care of the elderly. However, their efficacy and safety are not supported by scientific evidence. The aim of this study was to determine the role of PR in preventing falls.

MATERIALS AND METHODS

A retrospective cohort study design was used, in which each fall incident (n=575) was examined in the residents over 65 years of age who resided at the one nursing homes from February 2009 to September 2013. An analysis was made of the association between the use of PR and risk of falls using a multivariate logistic regression, adjusting for the characteristics of residents that were associated with the use of PR according to a bivariate analysis.

RESULTS

Risk factors for falls after accounting for PR use, include: risk of falling (Tinetti test) (OR 4.57; 95% CI 1.76-11.75); ability to walk (OR 6.40; 95% CI 2.78-14.74); hearing impairment (OR 2.12; 95% CI 1.05-4.29); and history of a previous fall (OR 17.81; 95% CI 8.83-35.93). The risk of falls was greater in restrained, ambulatory residents with cognitive impairment (OR 18.95; 95% CI 7.06-50.85). No differences were found in injuries between falls that occurred with and without PR.

CONCLUSIONS

Restraint use was not significantly associated with fewer falls and injuries. The risk of falls could increase in ambulatory residents with cognitive impairment. The study results suggest the need to consider whether restraints provide adequate protection against the risk of falls.

Equipping staff with the skills to maximise recovery of people with dementia after an injurious fall

Objectives: People with dementia are more likely to fall and less likely to recover well after a fall than cognitively intact older people. Little is known about how best to deliver services to this patient group. This paper explores the importance of compensating for cognitive impairment when working with people with dementia. Methods: Qualitative methods - interviews, focus groups and observation - were used to explore the views and experiences of people with dementia, family carers and professionals providing services to people with dementia following an injurious fall. A thematic, iterative analysis was undertaken in which emerging themes were identified from each individual dataset, prior to an integrative analysis. Results: A key theme across all datasets was the need to deliver services in ways that compensate for cognitive impairment, such as negotiating meaningful activities that can be embedded into the routines of people with dementia. Professionals varied in their ability to adapt their practice to meet the needs of people with dementia. Negative attitudes towards dementia, a lack of knowledge and understanding of dementia limited the ability of some professionals to work in person-centred ways. Conclusion: Improving outcomes for people with dementia following a fall requires the principles of person-centred care to be enacted by professionals with a generic role, as well as specialist staff. This requires additional training and support by specialist staff to address the wide variability in current practice.

Do replicable profiles of multimorbidity exist? Systematic review and synthesis

This systematic review aimed to synthesise multimorbidity profiling literature to identify replicable and clinically meaningful groupings of multimorbidity. We searched six electronic databases (Medline, EMBASE, PsycINFO, CINAHL, Scopus, and Web of Science) for articles reporting multimorbidity profiles. The identified profiles were synthesised with multidimensional scaling, stratified by type of statistical analysis used in the derivation of profiles. The 51 studies that met inclusion criteria reported results of 98 separate analyses of multimorbidity profiling, with a total of 407 multimorbidity profiles identified. The statistical techniques used to identify multimorbidity profiles were exploratory factor analysis, cluster analysis of diseases, cluster analysis of people, and latent class analysis. Reporting of methodological details of statistical methods was often incomplete. The discernible groupings of multimorbidity took the form of both discrete categories and continuous dimensions. Mental health conditions and cardio-metabolic conditions grouped along identifiable continua in the synthesised results of all four methods. Discrete groupings of chronic obstructive pulmonary disease with asthma, falls and fractures with sensory deficits and of Parkinson's disease and cognitive decline where partially replicable (identifiable in the results of more than one method), while clustering of musculoskeletal conditions and clustering of reproductive systems were each observed only in one statistical approach. The two most replicable multimorbidity profiles were mental health conditions and cardio-metabolic conditions. Further studies are needed to understand aetiology and evolution of these multimorbidity groupings. Guidelines for strengthening the reporting of multimorbidity profiling studies are proposed.

Service organisation for people with dementia after an injurious fall: challenges and opportunities

Introduction

people with dementia are more likely to fall and less likely to recover well after a fall than cognitively intact older people. Little is known about how best to deliver services to this patient group. This paper explored current service provision to help inform the development of a new intervention.

Methods

qualitative approaches were used to explore the views and experiences of people with dementia, family carers and professionals providing services to people with dementia following an injurious fall. These data were analysed using a thematic, iterative analysis.

Findings

while a wide range of services potentially relevant to people with dementia was identified, there were no dedicated services for people with dementia with fall-related injuries in our three geographical areas. Factors influencing service uptake included a lack of knowledge of local provision amongst professionals and underdeveloped information sharing systems. Some aspects of current service organisation were incompatible with the needs of people with dementia. These include an emphasis on time-limited interventions; lack of longer-term follow-up; and service delivery in environments that could be challenging for people with dementia.

Conclusions

care pathways for people with dementia who fall are fragmented and unclear. This is likely to preclude people with dementia from receiving all appropriate support and contribute to poor recovery following a fall. The findings highlight the need for new approaches to service organisation and delivery which address the specific needs of people with dementia who fall.

Oral health care for patients with Alzheimer's disease: An update

Alzheimer's disease and related disorders (ADRD) are among the age-associated chronic conditions that are most challenging to health care systems around the globe, as patients with dementia require full-time, intensive care for multiple years. Oral health care is negatively impacted by cognitive decline, and consequently poor oral health is common among people with ADRD. Poor oral health status is linked with many undesirable consequences for the well-being of people with ADRD, from excruciating local pain to life-threatening conditions, as aspiration pneumonia. In this paper, the authors provide an update on the most current concepts about Alzheimer's disease epidemiology, etiology, and management, current oral health care for patients with Alzheimer's disease, oral health promotion strategies for this population, as well as current research and future direction for improving oral health care for patients with Alzheimer's disease. It concludes that oral health care should be included in the patient's routine health care as early as possible in the progression of Alzheimer's disease for preventing rapid oral health deterioration. Establishing oral hygiene routines and providing dental treatment that is customized to the patients' individual needs and disease stage are important to achieve good oral health outcomes and prevent quality of life decline.

Developing an Intervention for Fall-Related Injuries in Dementia (DIFRID): an integrated, mixed-methods approach

BACKGROUND

Falls in people with dementia can result in a number of physical and psychosocial consequences. However, there is limited evidence to inform how best to deliver services to people with dementia following a fall. The aim of the DIFRID study was to determine the feasibility of developing and implementing a new intervention to improve outcomes for people with dementia with fall-related injuries; this encompasses both short-term recovery and reducing the likelihood of future falls. This paper details the development of the DIFRID intervention.

METHODS

The intervention was designed using an integrated, mixed-methods approach. This involved a realist synthesis of the literature and qualitative data gathered through interviews and focus groups with health and social care professionals (n = 81). An effectiveness review and further interviews and observation were also conducted and are reported elsewhere. A modified Delphi panel approach with 24 experts was then used to establish a consensus on how the findings should translate into a new intervention. After feedback from key stakeholders (n = 15) on the proposed model, the intervention was manualised and training developed.

RESULTS

We identified key components of a new intervention covering three broad areas: • Ensuring that the circumstances of rehabilitation are optimised for people with dementia • Compensating for the reduced ability of people with dementia to self-manage • Equipping the workforce with the necessary skills and information to care for this patient group Consensus was achieved on 54 of 69 statements over two rounds of the Delphi surveys. The statements were used to model the intervention and finalise the accompanying manual and protocol for a feasibility study. Stakeholder feedback was generally positive and the majority of suggested intervention components were approved. The proposed outcome was a 12-week complex multidisciplinary intervention primarily based at the patient's home.

CONCLUSIONS

A new intervention has been developed to improve outcomes for people with dementia following a fall requiring healthcare attention. The feasibility of this intervention is currently being tested.

TRIAL REGISTRATION

ISRCTN41760734 (16/11/2015).

Relationship between mobility and cognitive impairment in patients with Alzheimer's disease

OBJECTIVE

Alzheimer's disease (AD) is usually accompanied by impairments to mobility, performance of the basic activities of daily life (ADL), and progressive cognitive decline. We analyzed the relationship between cognitive performance and related cognitive subdomains and mobility.

PATIENTS AND METHODS

All AD patients of the recruited individuals were living in nursing homes; they underwent a blood analysis, cognitive examination by using the Mini-Mental State Examination, functional evaluation of independence in the ADLs with Barthel score and Katz index, and mobility assessment with the elderly mobility scale.

RESULTS

The mean sample age was 84 years and majority were women; more than 60% of the participants had severe cognitive impairment. Statistically significant relationships were found between the severity of cognitive impairment and functional capacity (p <  0.01) and their degree of mobility (p <  0.05). Among the different domains, memory impairment was not associated with impaired mobility or ability to perform the ADLs. Women had lower scores in the ADL and mobility assessments (p <  0.05) and an increased ratio of severe cognitive impairment (OR = 3.03 95% CI: [1.30, -7.05]) compared to men. Being overweight or obese and high blood levels of HDL cholesterol were directly (p <  0.05) and inversely (p <  0.01) associated with poor cognitive performance in individuals with mild to moderate cognitive dysfunction, respectively.

CONCLUSIONS

This study shows that better functional capacity and mobility are generally, but not exclusively, correlated with better cognitive function, depending on the severity of cognitive impairment. In contrast, lipid profile alterations might play a role in cognitive deficits in individuals with mild to moderate cognitive impairment who are overweight. Further longitudinal studies will be required to explore this possibility.

The Diagnostic and Prognostic Value of a Dual-Tasking Paradigm in a Memory Clinic

BACKGROUND

Daily living requires the ability to perform dual-tasking. As cognitive skills decrease in dementia, performing a cognitive and motor task simultaneously become increasingly challenging and subtle gait abnormalities may even be present in pre-dementia stages. Therefore, a dual-tasking paradigm, such as the Timed Up and Go-Dual Task (TUG-DT), may be useful in the diagnostic assessment of mild cognitive impairment (MCI).

OBJECTIVE

To investigate the diagnostic and prognostic ability of a dual-tasking paradigm in patients with MCI or mild Alzheimer's disease (AD) and to evaluate the association between the dual-tasking paradigm and cerebrospinal fluid (CSF) AD biomarkers.

METHODS

The study is a prospective cohort study conducted in a clinical setting in two memory clinics. Eighty-six patients were included (28 MCI, 17 AD, 41 healthy controls (HC)). The ability to perform dual-tasking was evaluated by the TUG-DT. Patients underwent a standardized diagnostic assessment and were evaluated to determine progression yearly.

RESULTS

ROC curve analysis illustrated a high discriminative ability of the dual-tasking paradigm in separating MCI patients from HC (AUC: 0.78, AUC: 0.82) and a moderate discriminative ability in separating MCI from AD (AUC: 0.73, AUC: 0.55). Performance discriminated clearly between all groups (p < 0.01). Logistic regression analyses revealed a low prognostic value of the dual-tasking paradigm for progression and rate of cognitive decline. A moderately strong correlation between the dual-tasking paradigm and CSF AD biomarkers was observed.

CONCLUSION

In our study, we found that patients with MCI and mild AD have increasing difficulties in dual-tasking compared to healthy elderly. Hence, the dual-tasking paradigm may be a potential complement in the diagnostic assessment in a typical clinical setting.

Is it feasible to deliver a complex intervention to improve the outcome of falls in people with dementia? A protocol for the DIFRID feasibility study

Background

People with dementia (PWD) experience ten times as many incident falls as people without dementia. Little is known about how best to deliver services to people with dementia following a fall. We used an integrated, mixed-methods approach to develop a new intervention which combines theory generated via a realist synthesis and data on current provision and pathways, gathered through a prospective observational study as well as qualitative interviews, focus groups and ethnographic observation. This intervention is to be tested in a feasibility study in the UK National Health Service.

Methods

People living with dementia in one of three geographical areas will be eligible for the study if they experience a fall requiring healthcare attention and have an informal carer. Potential participants will be identified by community services (primary care, paramedics, telecare), secondary care (ED, facilitated discharge services, rehabilitation outreach teams) and research case registers. Participants will receive a complex multidisciplinary intervention focused on their goals and interests for up to 12 weeks. The intervention will be delivered by occupational therapists, physiotherapists and rehabilitation support workers. Feasibility outcomes will include recruitment and retention, suitability and acceptability of outcome measures and acceptability, feasibility and fidelity of intervention components. PWD outcome measures will include number of falls, Montreal Cognitive Assessment (MOCA), European Quality of Life Instrument (EQ-5D-5L), Quality of Life–Alzheimer’s Disease Scale (QOL-AD), Modified Falls Efficacy Scale (MFES) and Goal Attainment Scaling (GAS). PWD outcome measures completed by an informal carer will include Disability Assessment for Dementia (DAD), EQ-5D-5L Proxy, QoL-AD Proxy and a Health Utilisation Questionnaire (HUQ). The carer outcome measure will be the Zarit Burden Interview (ZBI). An embedded process evaluation will explore barriers and facilitators to recruitment and intervention delivery.

Discussion

The study results will inform whether and how a larger multicentre RCT should be undertaken. A full RCT would have the potential to show how outcomes can be improved for people with dementia who have fallen.

Ethics and dissemination

The National Research Ethics Service Committee Newcastle and North Tyneside 2 approved the feasibility study.

Trial registration

International Standard Randomised Controlled Trial Registry. Registration number: ISRCTN41760734. Date of registration: 16/11/2015.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0364-7) contains supplementary material, which is available to authorized users.

The risk of fall accidents for home dwellers with dementia-A register- and population-based case-control study

Introduction

Institutionalized people with dementia have an increased risk of fall accidents, but little is known about whether this increased risk holds for home dwellers.

Methods

This register- and population-based study comprised 115,584 cases and 394,679 controls. Cases were individuals with any fall between 2009 and 2014, and matched with up to six controls on age, sex, and geographic location. Individuals were excluded if they (1) had any fall in 2008, or (2) lived in a nursing home on the date of the fall. Dementia, other chronic diseases, and sedative medicines were assessed from Danish national registers.

Results

After adjusting for potential confounders, older people with dementia living at home had a 1.89-fold higher risk of fall (odds ratio = 1.89, 95% confidence interval [1.84–1.94], P < .001).

Discussion

Dementia almost doubles the risk of fall for older Danish people living at home. This highlights the need for effective fall preventions that target people with dementia.

Effectiveness of interventions aimed at improving physical and psychological outcomes of fall-related injuries in people with dementia: a narrative systematic review

BACKGROUND

The annual prevalence of falls in people with dementia ranges from 47 to 90%. Falls are a common reason for hospital admission in people with dementia, and there is limited research evidence regarding the care pathways experienced by this population. In addition to immediate management of an injury, prevention of further falls is likely to be an important part of any successful intervention. This review aims to assess the effectiveness of interventions for improving the physical and psychological wellbeing of people with dementia who have sustained a fall-related injury.

METHODS

Systematic review methodologies were employed utilising searches across multiple databases (MEDLINE, CENTRAL, Health Management Information Consortium, EMBASE, CINAHL, Web of Science, Allied and Complementary Medicine Database, and Physiotherapy Evidence Database (PEDro)) and citation chaining. Studies including people with a known diagnosis of dementia living in the community and who present at health services with a fall, with or without injury, were included. Outcomes of interest included mobility, recurrent falls, activities of daily living, length of hospital stay, and post-discharge residence. Results were independently reviewed and quality assessed by two researchers, and data extracted using a customised form. A narrative synthesis was performed due to heterogeneity of the included studies.

RESULTS

Seven studies were included. Interventions clustered into three broad categories: multidisciplinary in-hospital post-surgical geriatric assessment; pharmaceuticals; and multifactorial assessment. Multidisciplinary care and early mobilisation showed short-term improvements for some outcomes. Only an annual administration of zoledronic acid showed long-term reduction in recurrent falls.

CONCLUSIONS

Due to high heterogeneity across the studies, definitive conclusions could not be reached. Most post-fall interventions were not aimed at patients with dementia and have shown little efficacy regardless of cognitive status. Minor improvements to some quality of life indicators were shown, but these were generally not statistically significant. Conclusions were also limited due to most studies addressing hip fracture; the interventions provided for this type of injury may not be suitable for other types of fractures or soft tissue injuries, or for use in primary care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016029565 .

Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review

QUESTION

Does physical exercise training improve physical function and quality of life in people with cognitive impairment and dementia? Which training protocols improve physical function and quality of life? How do cognitive impairment and other patient characteristics influence the outcomes of exercise training?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

People with mild cognitive impairment or dementia as the primary diagnosis.

INTERVENTION

Physical exercise.

OUTCOME MEASURES

Strength, flexibility, gait, balance, mobility, walking endurance, dual-task ability, activities of daily living, quality of life, and falls.

RESULTS

Forty-three clinical trials (n=3988) were included. According to the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system, the meta-analyses revealed strong evidence in support of using supervised exercise training to improve the results of 30-second sit-to-stand test (MD 2.1 repetitions, 95% CI 0.3 to 3.9), step length (MD 5cm, 95% CI 2 to 8), Berg Balance Scale (MD 3.6 points, 95% CI 0.3 to 7.0), functional reach (3.9cm, 95% CI 2.2 to 5.5), Timed Up and Go test (-1second, 95% CI -2 to 0), walking speed (0.13m/s, 95% CI 0.03 to 0.24), and 6-minute walk test (50m, 95% CI 18 to 81) in individuals with mild cognitive impairment or dementia. Weak evidence supported the use of exercise in improving flexibility and Barthel Index performance. Weak evidence suggested that non-specific exercise did not improve dual-tasking ability or activity level. Strong evidence indicated that exercise did not improve quality of life in this population. The effect of exercise on falls remained inconclusive. Poorer physical function was a determinant of better response to exercise training, but cognitive performance did not have an impact.

CONCLUSION

People with various levels of cognitive impairment can benefit from supervised multi-modal exercise for about 60minutes a day, 2 to 3days a week to improve physical function. [Lam FMH , Huang MZ, Liao LR, Chung RCK, Kwok TCY, Pang MYC (2018) Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review. Journal of Physiotherapy 64: 4-15].

Clinical differences among the elderly admitted to the emergency department for accidental or unexplained falls and syncope

It is difficult to distinguish unexplained falls (UFs) from accidental falls (AFs) or syncope in older people. This study was designed to compare patients referred to the emergency department (ED) for AFs, UFs or syncope. Data from a longitudinal study on adverse drug events diagnosed at the ED (ANCESTRAL-ED) in older people were analyzed in order to select cases of AF, syncope, or UF. A total of 724 patients (median age: 81.0 [65-105] years, 66.3% female) were consecutively admitted to the ED (403 AF, 210 syncope, and 111 UF). The number of psychotropic drugs was the only significant difference in patients with AF versus those with UF (odds ratio [OR] 1.44; 95% confidence interval 1.17-1.77). When comparing AF with syncope, female gender, musculoskeletal diseases, dementia, and systolic blood pressure >110 mmHg emerged as significantly associated with AF (OR 0.40 [0.27-0.58], 0.40 [0.24-0.68], 0.35 [0.14-0.82], and 0.31 [0.20-0.49], respectively), while valvulopathy and the number of antihypertensive drugs were significantly related to syncope (OR 2.51 [1.07-5.90] and 1.24 [1.07-1.44], respectively). Upon comparison of UF and syncope, the number of central nervous system drugs, female gender, musculoskeletal diseases, and SBP >110 mmHg were associated with UF (OR 0.65 [0.50-0.84], 0.52 [0.30-0.89], 0.40 [0.20-0.77], and 0.26 [0.13-0.55]), respectively. These results indicate specific differences, in terms of demographics, medical/pharmacological history, and vital signs, among older patients admitted to the ED for AF and syncope. UF was associated with higher use of psychotropic drugs than AF. Our findings could be helpful in supporting a proper diagnostic process when evaluating older patients after a fall.

Risk factors for recurrent injurious falls that require hospitalization for older adults with dementia: a population based study

Background

Older adults with dementia are at an increased risk of falls, however, little is known about risk factors for recurrent injurious falls (a subsequent fall after the first fall has occurred) among this group. This study aimed to identify risk factors for recurrent injurious falls requiring hospitalization among adults aged 60+ years with dementia.

Methods

This retrospective, whole-population cohort study was conducted using the Western Australian Hospital Morbidity Data System and Western Australian Death Registrations from 2001 to 2013. Survival analysis using a stratified conditional Cox model (type 1) was undertaken to identify risk factors for recurrent injurious falls requiring hospitalization.

Results

There were 32,519 participants with an index hospital admission with dementia during the study period. Over 27 % (n = 8970) of the cohort experienced a total of 11,073 injurious falls requiring hospitalization during follow up with 7297 individuals experiencing a single fall, 1330 experiencing two falls and 343 experiencing three or more falls. The median follow-up time for each individual was 2.49 years. Females were at a significantly increased risk of 7 % for recurrent injurious falls resulting in hospitalization (adjusted hazard ratio 1.07, 95 % CI 1.01–1.12), compared to males. Increasing age, living in rural areas, and having an injurious fall in the year prior to the index hospital admission with dementia also increased the risk of recurrent injurious falls resulting in hospitalization.

Conclusions

Screening those with dementia for injurious falls history could help to identify those most at risk of recurrent injurious falls. Improvement of heath care and falls prevention services for those with dementia who live in rural areas may also reduce recurrent injurious falls.

A New Approach to Improve Cognition, Muscle Strength, and Postural Balance in Community-Dwelling Elderly with a 3-D Virtual Reality Kayak Program

Aging is usually accompanied with deterioration of physical abilities, such as muscular strength, sensory sensitivity, and functional capacity. Recently, intervention methods with virtual reality have been introduced, providing an enjoyable therapy for elderly. The aim of this study was to investigate whether a 3-D virtual reality kayak program could improve the cognitive function, muscle strength, and balance of community-dwelling elderly. Importantly, kayaking involves most of the upper body musculature and needs the balance control. Seventy-two participants were randomly allocated into the kayak program group (n = 36) and the control group (n = 36). The two groups were well matched with respect to general characteristics at baseline. The participants in both groups performed a conventional exercise program for 30 min, and then the 3-D virtual reality kayak program was performed in the kayak program group for 20 min, two times a week for 6 weeks. Cognitive function was measured using the Montreal Cognitive Assessment. Muscle strength was measured using the arm curl and handgrip strength tests. Standing and sitting balance was measured using the Good Balance system. The post-test was performed in the same manner as the pre-test; the overall outcomes such as cognitive function (p < 0.05), muscle strength (p < 0.05), and balance (standing and sitting balance, p < 0.05) were significantly improved in kayak program group compared to the control group. We propose that the 3-D virtual reality kayak program is a promising intervention method for improving the cognitive function, muscle strength, and balance of elderly.

Psychometric Properties of the Post-Fall Index

Evaluation and prevention of falls begin with a thorough understanding of their occurrence. Post-fall assessment (PFA) tools should be available to sufficiently guide nursing staff in identification of all possible causes. Absence of empirically tested PFA tools led to the development of the Post-Fall Index (PFI). Developed and validated in three phases, a 76-item PFI was first tested for content validity by national experts. Next, it was tested for feasibility with registered nurses practicing in nursing homes. Last, it was piloted with a sample of 30 falls by older residents of a skilled nursing unit in a continuing care retirement community. Review of data from these 30 falls provided the item analysis. Reflective of evidenced-based guidelines, a 30-item PFI emerged, containing essential items causing falls. Although lengthier than incident reports, its comprehensiveness was deemed of higher value. Large absolute agreement of items (70%-100%) indicates good interrater reliability. The PFI is valid, reliable, and feasible and has clinical utility for the secondary prevention of falls.

Views from health professionals on accessing rehabilitation for people with dementia following a hip fracture

The literature reports that rehabilitation for elderly patients with mild-to-moderate dementia who have a hip fracture improves functional outcomes. However, access to rehabilitation may be difficult due to misconceptions about the ability of these patients to engage in and benefit from rehabilitation. Additionally, people who are admitted from residential care may not have the same options for rehabilitation as those admitted from home. This study sought to understand from expert clinicians how and why decisions are made to accept a person with dementia post-fracture for rehabilitation. In this Australian-based qualitative study, 12 health professionals across a state and territory were interviewed. These clinicians were the primary decision makers in accepting or rejecting elderly patients with dementia post-fracture into rehabilitation. Three key themes emerged from the data: criteria for accessing rehabilitation, what works well and challenges to rehabilitation. The participants were unanimous in the view that access to rehabilitation should be based on the ability of the patient to engage in a rehabilitation programme and not assessed solely on cognition. In terms of clinical care, a coherent rehabilitation pathway with integration of geriatric and ortho-geriatric services was reported as ideal. Challenges remain, importantly, the perception of some health care staff that people with dementia have limited capability to benefit from rehabilitation. Rehabilitation for this growing group of patients requires multiple resources, including skilled practitioners, integrated clinical systems and staff education regarding the capabilities of people with dementia. Future research in this area with patients with moderate-to-severe dementia in residential care is warranted.

[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.