Falls, Fear of Falling, and Preventive Measures in Huntington's Disease: The Perspectives of Individuals with Huntington's Disease and Caregivers in Long-Term Care

Differences in fall-related characteristics across cognitive disorders

Approximately 40-60% of falls in the elderly lead to injuries, resulting in disability and loss of independence. Despite the higher prevalence of falls and morbidity rates in cognitively impaired individuals, most fall risk assessments fail to account for mental status. In addition, successful fall prevention programmes in cognitively normal adults have generally failed in patients with cognitive impairment. Identifying the role of pathological aging on fall characteristics can improve the sensitivity and specificity of fall prevention approaches. This literature review provides a thorough investigation into fall prevalence and fall risk factors, the accuracy of fall risk assessments, and the efficacy of fall prevention strategies in individuals with diverse cognitive profiles. We show that fall-related characteristics differ between cognitive disorders and fall risk assessment tools as well as fall prevention strategies should critically consider each patient's cognitive status to facilitate the identification of fallers at an earlier stage and support clinical decision-making.

Safety and efficacy of valbenazine for the treatment of chorea associated with Huntington's disease (KINECT-HD): a phase 3, randomised, double-blind, placebo-controlled trial

BACKGROUND

Valbenazine is a highly selective vesicular monoamine transporter 2 (VMAT2) inhibitor approved for treatment of tardive dyskinesia. To address the ongoing need for improved symptomatic treatments for individuals with Huntington's disease, valbenazine was evaluated for the treatment of chorea associated with Huntington's disease.

METHODS

KINECT-HD (NCT04102579) was a phase 3, randomised, double-blind, placebo-controlled trial, performed in 46 Huntington Study Group sites in the USA and Canada. The study included adults with genetically confirmed Huntington's disease and chorea (Unified Huntington's Disease Rating Scale [UHDRS] Total Maximal Chorea [TMC] score of 8 or higher) who were randomly assigned (1:1) via an interactive web response system (with no stratification or minimisation) to oral placebo or valbenazine (≤80 mg, as tolerated) for 12 weeks of double-blinded treatment. The primary endpoint was a least-squares mean change in UHDRS TMC score from the screening and baseline period (based on the average of screening and baseline values for each participant) to the maintenance period (based on the average of week 10 and 12 values for each participant) in the full-analysis set using a mixed-effects model for repeated measures. Safety assessments included treatment-emergent adverse events, vital signs, electrocardiograms, laboratory tests, clinical tests for parkinsonism, and psychiatric assessments. The double-blind placebo-controlled period of KINECT-HD has been completed, and an open-label extension period is ongoing.

FINDINGS

KINECT-HD was performed from Nov 13, 2019, to Oct 26, 2021. Of 128 randomly assigned participants, 125 were included in the full-analysis set (64 assigned to valbenazine, 61 assigned to placebo) and 127 were included in the safety-analysis set (64 assigned to valbenazine, 63 assigned to placebo). The full-analysis set included 68 women and 57 men. Least-squares mean changes from the screening and baseline period to the maintenance period in the UHDRS TMC score were -4·6 for valbenazine and -1·4 for placebo (least-squares mean difference -3·2, 95% CI -4·4 to -2·0; p<0·0001). The most commonly reported treatment-emergent adverse event was somnolence (ten [16%] with valbenazine, two [3%] with placebo). Serious treatment-emergent adverse events were reported in two participants in the placebo group (colon cancer and psychosis) and one participant in the valbenazine group (angioedema because of allergic reaction to shellfish). No clinically important ch anges in vital signs, electrocardiograms, or laboratory tests were found. No suicidal behaviour or worsening of suicidal ideation was reported in participants treated with valbenazine.

INTERPRETATION

In individuals with Huntington's disease, valbenazine resulted in improvement in chorea compared with placebo and was well tolerated. Continued research is needed to confirm the long-term safety and effectiveness of this medication throughout the disease course in individuals with Huntington's disease-related chorea.

FUNDING

Neurocrine Biosciences.

Caregivers' fear of older care recipients falling: A systematic review of qualitative studies

OBJECTIVE

This qualitative systematic review aimed to describe informal caregivers' and health personnel's experiences of the FOF (fear of falling) of older adults under their care.

METHODS

A systematic search of databases included not only the PubMed, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library but also the Chinese databases of CNKI, WanFang, and Vip. The Critical Appraisal Skills Programme (CASP) tool was used to assess the quality of the included studies.

RESULTS

In total, 17 studies were included in the systematic evaluation. Four themes were identified, and an evidence model was developed that includes multiple attributions of FOF, management strategies for fall prevention, dynamic challenges and adaptation, and external support and unmet needs.

CONCLUSIONS

The fear of falling felt by informal caregivers and health personnel is mainly affected by internal factors in older adults, and harms the health of older adults through overprotective behavior. Thus, there is an urgent need of external support to improve the quality of life and promote the healthy aging of older adults.

Accidental Falls in Patients with Hyperkinetic Movement Disorders: A Systematic Review

Background

The significance of falls and their repercussions in Parkinson's disease has been extensively researched. However, despite potentially serious effects on health and quality of life and negative impact on the healthcare system, there is not a sufficient understanding of the role of falls in hyperkinetic movement disorders (HKMDs). This review aims to provide an overview of the prevalence of falls, injuries, and preventive measures in the most common HKMDs.

Methods

Studies up to May 1, 2022 were searched in PubMed using Medical Subjects Headings of relatively prevalent HKMDs associated with the terms "accidental falls", "injuries", "fractures", and "accident prevention".

Results

In our review of 37 studies out of 155, we found evidence that for several HKMDs, such as spinocerebellar ataxia, essential tremor, Huntington's disease, and dystonia, fall risk is increased. Falls were reported in up to 84% of spinocerebellar ataxia patients, 59% of essential tremor patients, and 79% of Huntington's patients, with 65% of the latter falling frequently. Injuries occurred in up to 73% in Huntington and 74% in ataxia patients. Most of the common diseases characterized by HKMDs were investigated for both fall causes and consequences, but prevention studies were limited to spinocerebellar ataxia and Huntington's disease.

Discussion

The limited available data suggest that patients with several HKMDs can be considered to be at increased risk of falling and that the consequences can be serious. As a result, physicians should be advised to include fall exploration in their routine workup and provide advice for safer mobility. In general, more research into fall-related concerns in HKMDs is necessary.

Highlights

In contrast to Parkinson's disease, the prevalence of accidental falls, their repercussions, and preventive strategies are under-investigated in hyperkinetic movement disorders (HKMDs). Several HKMDs such as essential tremor, ataxia, and Huntington's disease have reported fall rates of up to 84% and fall-related injury rates of up to 74%. Therefore, routine examinations of HKMD patients should include a fall exploration and provide advice on safe mobility.