Vascular gait dyspraxia

A Systematic Review of Falls Risk of Frail Patients with Dementia in Hospital: Progress, Challenges, and Recommendations

This review article assesses the effectiveness and limitations of strategies to reduce falls among hospitalized older adults with frailty and dementia. It explores the efficacy of existing fall prevention strategies for a cohort that is acutely susceptible to falls and fall-related consequences. A systematic literature search was conducted across MEDLINE, Embase, CINAHL, and PsycINFO, employing Medical Subject Headings (MeSH) to identify studies on fall prevention strategies in hospitalized older adults with both dementia and frailty published from 2013 to 2023. The initial 643 records were distilled to eight articles, with Structured Interdisciplinary Bedside Rounds (SIBR) emerging as a notable intervention. SIBR demonstrated a reduction in falls by fostering improved interdisciplinary communication and care planning. However, a decline in family engagement during consecutive sessions suggests a need for strategies to sustain familial involvement. The findings advocate for patient-centered interventions that address the cognitive and functional challenges faced by this cohort of older adults. This review advocates for comprehensive and inclusive research in hospital environments to improve fall prevention strategies for frail older adults with dementia.

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.

Asymptomatic orthostatic hypotension and risk of falls in community-dwelling older people

INTRODUCTION

Many older people with orthostatic hypotension (OH) may not report typical symptoms of dizziness, light-headedness or unsteadiness. However, the relationships between OH and falls in the absence of typical symptoms are not yet established.

METHODS

Continuous orthostatic blood pressure (BP) was measured during active stand using a Finometer at Wave 1 of The Irish Longitudinal Study on Ageing in participants aged ≥ 70 years.OH, with and without dizziness, was defined as a sustained drop in systolic BP ≥ 20 and/or diastolic BP ≥ 10 mm Hg at 30, 60 and 90 seconds post-standing.The association between symptoms of dizziness and orthostatic BP was assessed with multi-level mixed-effects linear regression; logistic regression models assessed the longitudinal relationship between OH and falls at 6-year follow-up (Waves 2-5).

RESULTS

Almost 11% (n = 934, mean age 75 years, 51% female) had OH, two-thirds of whom were asymptomatic.Dizziness was not associated with systolic BP drop at 30 (β = 1.54 (-1.27, 4.36); p = 0.256), 60 (β = 2.64 (-0.19, 5.47); p = 0.476) or 90 seconds (β = 2.02 (-0.91, 4.95); p = 0.176) after standing in adjusted models.Asymptomatic OH was independently associated with unexplained falls (odds ratio 2.01 [1.11, 3.65]; p = 0.022) but not explained falls (OR 0.93 [0.53, 1.62]; p = 0.797) during follow-up.

CONCLUSIONS

Two-thirds of older people with OH did not report typical symptoms of light-headedness. Dizziness or unsteadiness after standing did not correlate with the degree of orthostatic BP drop or recovery. Participants with asymptomatic OH had a significantly higher risk of unexplained falls during follow-up, and this has important clinical implications for the assessment of older people with falls.

A Safe Mobilisation Program to Improve Functional Mobility and Reduce Fall Risks in Cognitively Impaired Older Adults with Higher Level Gait Disorders: A Pilot Study

BACKGROUND

The association between gait and cognition, and their combined impact on postural stability may underlie the increased fall risk in older adults with dementia. However, there are few interventions to improve functional mobility and reduce fall risks in people with cognitive impairment.

OBJECTIVES

This study aims to investigate the feasibility and acceptability of a Safe Mobilisation Program for cognitively impaired older adults with higher level gait disorders. It also explores the potential effectiveness of the program on mobility and fall risks.

METHODS

Fifteen community-dwelling older adults participated in a 3-week pre-post intervention study. They were trained to take steady steps in transfers and mobilization using errorless learning and spaced retrieval teaching techniques.

RESULTS

The intervention program was feasible, all the participants completed the program and were able to mobilize safely. The program was acceptable and participants reported an increase in safety awareness, improvement in confidence while transferring and mobilising, and better quality of life. There was a trend of improvement in Falls Efficacy Scale-international (FES-I), 360° turn and Tinetti Performance Oriented Mobility Assessment (POMA), which may indicate improvement in balance and mobility.

CONCLUSION

The Safe Mobilisation Program was feasible and acceptable in older adults with cognitive impairment and gait disorders and warrants further evaluation.

Gait speed, cognition and falls in people living with mild-to-moderate Alzheimer disease: data from NILVAD

Background

Previous evidence suggests that slower gait speed is longitudinally associated with cognitive impairment, dementia and falls in older adults. Despite this, the longitudinal relationship between gait speed, cognition and falls in those with a diagnosis of dementia remains poorly explored. We sought to assess this longitudinal relationship in a cohort of older adults with mild to-moderate Alzheimer Disease (AD).

Methods

Analysis of data from NILVAD, an 18-month randomised-controlled trial of Nilvadipine in mild to moderate AD. We examined: (i) the cross-sectional (baseline) association between slow gait speed and cognitive function, (ii) the relationship between baseline slow gait speed and cognitive function at 18 months (Alzheimer Disease Assessment Scale, Cognitive Subsection: ADAS-Cog), (iii) the relationship between baseline cognitive function and incident slow gait speed at 18 months and finally (iv) the relationship of baseline slow gait speed and incident falls over the study period.

Results

Overall, one-tenth (10.03%, N = 37/369) of participants with mild-to-moderate AD met criteria for slow gait speed at baseline and a further 14.09% (N = 52/369) developed incident slow gait speed at 18 months. At baseline, there was a significant association between poorer cognition and slow gait speed (OR 1.05, 95% CI 1.01–1.09, p = 0.025). Whilst there was no association between baseline slow gait speed and change in ADAS-Cog score at 18 months, a greater cognitive severity at baseline predicted incident slow gait speed over 18 months (OR 1.04, 1.01–1.08, p = 0.011). Further, slow gait speed at baseline was associated with a significant risk of incident falls over the study period, which persisted after covariate adjustment (IRR 3.48, 2.05–5.92, p < 0.001).

Conclusions

Poorer baseline cognition was associated with both baseline and incident slow gait speed. Slow gait speed was associated with a significantly increased risk of falls over the study period. Our study adds further evidence to the complex relationship between gait and cognition in this vulnerable group and highlights increased falls risk in older adults with AD and slow gait speed.

Trial registration

Secondary analysis of the NILVAD trial (Clincaltrials.gov NCT02017340; EudraCT number 2012–002764-27). First registered: 20/12/2013.

What Is the Relationship Between Orthostatic Blood Pressure and Spatiotemporal Gait in Later Life?

BACKGROUND/OBJECTIVES

Little work to date has examined the relationship between gait performance and blood pressure (BP) recovery after standing in later life. The aim of this study is to clarify the association of orthostatic BP with spatiotemporal gait parameters in a large cohort of older people.

DESIGN

Cross-sectional study using multilevel linear regression to ascertain the difference in orthostatic BP patterns across tertiles of gait speed, and linear regression to analyze the association of orthostatic hypotension 30 seconds after standing (OH-30) with specific gait characteristics.

SETTING

The Irish Longitudinal Study on Ageing.

PARTICIPANTS

A total of 4311 community-dwelling adults, aged 50 years or older (mean age = 62.2 years; 54% female), one fifth (n = 791) of whom had OH-30.

MEASUREMENTS

Continuous orthostatic BP was measured during active stand. OH-30 was defined as a drop in systolic BP of 20 mm Hg or more or drop in diastolic BP of 10 mm Hg or more at 30 seconds. Spatiotemporal gait was assessed using the GAITRite system, reporting gait speed, step length, step width, and double support time in both single and dual (cognitive task) conditions.

RESULTS

OH-30 was associated with slower gait speed (β = -3.01; 95% confidence interval [CI] = -4.46 to -1.56) and shorter step length (β = -.73; 95% CI = -1.29 to -.16) in fully adjusted models during single task walking. Similar findings were observed in dual task conditions, in addition to increased double support phase (β = .45; 95% CI = .02-.88). Multilevel models demonstrated that participants in the slowest tertile for gait speed had a significantly larger drop in systolic BP poststanding compared to those with faster gait speeds in single and dual task conditions.

CONCLUSIONS

This study demonstrates that slower recovery of BP after standing is independently associated with poorer gait performance in community-dwelling older adults. Given the adverse outcomes independently associated with OH and gait problems in later life, increasing awareness that they commonly coexist is important, particularly as both are potentially modifiable. J Am Geriatr Soc 68:1286-1292, 2020.

Do Differences in Spatiotemporal Gait Parameters Predict the Risk of Developing Depression in Later Life?

BACKGROUND/OBJECTIVES

There is growing interest in the association between gait disturbance and depression in later life. The aim of this study is to clarify the longitudinal relationship between specific gait parameters and incident depression within a population-representative sample of older people.

DESIGN

Longitudinal analysis of spatiotemporal gait parameters at baseline (wave 1) and incident depression at 2 and 4 years (waves 2/3). Logistic regression models were used to assess the relationship between tertiles of gait parameters and incident depression.

SETTING

The Irish Longitudinal Study on Aging.

PARTICIPANTS

Over 3600 nondepressed community-dwelling people aged 50 years or older.

MEASUREMENTS

A score of 9 or greater on the eight-item Center for Epidemiological Studies Depression Scale at wave 2 or 3 was indicative of incident depression. The GAITRite system was used to measure gait speed, step length, step width, and double support phase during usual speed walking and under dual task conditions.

RESULTS

Participants with incident depression (344/3615) had slower gait speed (129.9 [95% confidence interval {CI} = 127.2-132.6] cm/s vs 134.1 [95% CI = 133.0-135.1] cm/s; F = 8.82; P = .003) and shorter step length (68.0 [95% CI = 66.9-69.2] cm vs 70.3 [95% CI = 69.9-70.7] cm; F = 13.99; P < .001) at baseline than those who did not develop depression. Logistic regression models demonstrated that those within the slowest tertile for gait speed and shortest tertile for step length had significantly increased likelihood of incident depression in fully adjusted models, with odds ratios of 1.54 (95% CI = 1.08-2.19) and 1.54 (95% CI = 1.01-2.35), respectively. Measures of step width and double support time were not associated with depression.

CONCLUSIONS

This study demonstrates that older people with incident depression have significantly slower gait speed and shorter step length at initial assessment. These findings are clinically significant given the impact both conditions have on functional status in later life, as well as the possibility that gait problems may represent a potentially modifiable risk factor for depression. J Am Geriatr Soc 67:1050-1056, 2019.

What is the Longitudinal Relationship between Gait Abnormalities and Depression in a Cohort of Community-Dwelling Older People? Data From the Irish Longitudinal Study on Ageing (TILDA)

OBJECTIVE

Does baseline gait disturbance predict incident depression in a cohort of community-dwelling older people?

METHODS

This is a longitudinal study, embedded within the Irish Longitudinal Study on Ageing (TILDA), examining the association between baseline depression and incident gait abnormalities, as well as between baseline gait abnormalities and incident depression at 2 year follow-up. Depression was defined as a score of ≥16 on the Centre for Epidemiological Studies Depression Scale (CES-D). Gait abnormality was defined as a Timed Up and Go Test (TUG) ≥12 seconds. Assessments were carried out at baseline and at 2 year follow-up.

RESULTS

7% (179/2,638) had baseline depression and 11% (296/2,638) had a gait abnormality at baseline. The incidence of new-onset depression and gait abnormality at Wave 2 was 4% (95/2,364) and 13% (308/2,342) respectively. Logistic regression models demonstrated that baseline gait abnormality was a significant predictor of incident depression with an Incidence Rate Ratio (IRR) of 2.00 (95% CI: 1.18 - 3.40, p =0.010, t =2.57, df =625), which was not attenuated after controlling for covariates. Baseline depression was a predictor of incident gait abnormality at Wave 2 with an IRR of 1.68 (95% CI: 1.16 - 2.43, p =0.006, t =2.75, df =625) but this association was no longer statistically significant when analysis was adjusted for clinical variables.

CONCLUSIONS

This study demonstrates that baseline gait disturbance, measured by TUG, predicts incident depression, defined by CES-D, in a population-representative cohort of community-dwelling older people. Possible biological mechanisms for this relationship include white matter disease and executive dysfunction.

Does admission to a specialist geriatric medicine ward lead to improvements in aspects of acute medical care for older patients with dementia?

OBJECTIVE

The objective of this study is to clarify if admission to a specialist geriatric medicine ward leads to improvements in aspects of acute medical care for patients with dementia.

METHODS

We analysed combined data involving 900 patients from the Irish and Northern Irish audits of dementia care. Data on baseline demographics, admission outcomes, clinical aspects of care, multidisciplinary assessment and discharge planning processes were collected.

RESULTS

Less than one-fifth of patients received their inpatient care on a specialist geriatric medicine ward. Patients admitted to a geriatric medicine ward were less likely to undergo a formal assessment of mobility compared with those in non-geriatric wards (119/143 (83%) vs 635/708 (90%), odds ratio (OR) = 0.57 (0.35 to 0.94)) and were more likely to receive newly prescribed antipsychotic medication during the admission (27/54 (50%) vs 95/2809 (36%), OR = 1.95 (1.08 to 3.51)). Patients admitted to a geriatric medicine ward were more likely to have certain aspects of discharge planning initiated, including completion of a single plan for discharge (78/118 (66%) vs 275/611 (45%), OR = 2.38 (1.58 to 3.60)). Surgical wards performed more poorly on certain aspects including having a named discharge co-ordinator (32/71, 45%) and documentation of decisions regarding resuscitation status (18/95, 19%).

CONCLUSION

Relatively low numbers of patients with dementia received care on a specialist geriatric medicine ward. There appears to be a more streamlined discharge planning process in place on these wards, but they did not perform as well as one would expect in certain areas, such as compliance with multidisciplinary assessment and antipsychotic prescribing. Copyright © 2016 John Wiley & Sons, Ltd.

Gait dyspraxia as a clinical marker of cognitive decline in Down syndrome: A review of theory and proposed mechanisms

Down syndrome (DS) is the most common genetic cause of intellectual disability in children. With aging, DS is associated with an increased risk for Alzheimer's disease (AD). The development of AD neuropathology in individuals with DS can result in further disturbances in cognition and behavior and may significantly exacerbate caregiver burden. Early detection may allow for appropriate preparation by caregivers. Recent literature suggests that declines in gait may serve as an early marker of AD-related cognitive disorders; however, this relationship has not been examined in individuals with DS. The theory regarding gait dyspraxia and cognitive decline in the general population is reviewed, and potential applications to the population with individuals with DS are highlighted. Challenges and benefits in the line of inquiry are discussed. In particular, it appears that gait declines in aging individuals with DS may be associated with known declines in frontoparietal gray matter, development of AD-related pathology, and white matter losses in tracts critical to motor control. These changes are also potentially related to the cognitive and functional changes often observed during the same chronological period as gait declines in adults with DS. Gait declines may be an early marker of cognitive change, related to the development of underlying AD-related pathology, in individuals with DS. Future investigations in this area may provide insight into the clinical changes associated with development of AD pathology in both the population with DS and the general population, enhancing efforts for optimal patient and caregiver support and propelling investigations regarding safety/quality of life interventions and disease-modifying interventions.