Risk factors for falls in older people with cognitive impairment living in the community: Systematic review and meta-analysis.

PURPOSE: This systematic review aimed to identify risk factors for prospectively ascertained falls, focusing on those that are potentially modifiable (physical and neuropsychological factors), in older people with cognitive impairment living in the community. RESULTS: A comprehensive search of five databases identified 16 high quality (Newcastle-Ottawa Scale ≥8/9) relevant articles. Meta-analyses were undertaken for five potential fall risk factors. Of these, fallers had significantly poorer balance (standardized mean difference = 0.62, 95 %CI 0.45, 0.79) with low heterogeneity. Global cognition was not significantly associated with faller status in a meta-analysis with low heterogeneity. Meta-analyses of mobility (Timed Up-and-Go), gait speed and depressive symptoms had high heterogeneity and were not statistically significant or were borderline significant (p = 0.05). Sensitivity analyses (removing one study sample's results that differed markedly from the other included samples) reduced heterogeneity to 0% and revealed fallers had significantly poorer mobility and more depressive symptoms than non-fallers. Fallers also walked significantly slower, but heterogeneity remained high. CONCLUSIONS: In older people with cognitive impairment, fallers presented with balance deficits, poor mobility, slow gait speed and depressive symptoms. Reduced global cognition was not associated with falls. These findings suggest that interventions should target balance impairment and reveal that more high-quality research is needed.

Tailored Exercise and Home Hazard Reduction Program for Fall Prevention in Older People With Cognitive Impairment: The i-FOCIS Randomized Controlled Trial.

BACKGROUND: The evidence to support effective fall prevention strategies in older people with cognitive impairment (CI) is limited. The aim of this randomized controlled trial (RCT) was to determine the efficacy of a fall prevention intervention in older people with CI. METHOD: RCT involving 309 community-dwelling older people with CI. The intervention group (n = 153) received an individually prescribed home hazard reduction and home-based exercise program during the 12-month study period. The control group (n = 156) received usual care. The primary outcome was rate of falls. Secondary outcomes included faller/multiple faller status, physical function, and quality of life. RESULTS: Participants' average age was 82 years (95% CI 82-83) and 49% were female. There was no significant difference in the rate of falls (incidence rate ratio [IRR] 1.05; 95% confidence interval [95% CI] 0.73-1.51). A sensitivity analysis, controlling for baseline differences and capping the number of falls at 12 (4 participants), revealed a nonsignificant reduction in fall rate in the intervention group (IRR 0.78; 95% CI 0.57-1.07). Analyses of secondary outcomes indicated the intervention significantly reduced the number of multiple fallers by 26% (RR 0.74; 95% CI 0.54-0.99) when adjusting for baseline differences. There was a differential impact on falls in relation to physical function (interaction term p-value = .023) with a significant reduction in fall rate in intervention group participants with better baseline physical function (IRR 0.60; 95% CI 0.37-0.98). There were no significant between-group differences for other secondary outcomes. CONCLUSIONS: This intervention did not significantly reduce the fall rate in community-dwelling older people with CI. The intervention did reduce the fall rate in participants with better baseline physical function. CLINICAL TRIALS REGISTRATION NUMBER: Australian and New Zealand Trials Registry ACTRN12614000603617.

Pilot feasibility study of a home-based fall prevention exercise program (StandingTall) delivered through a tablet computer (iPad) in older people with dementia.

OBJECTIVE: To assess the feasibility and safety of StandingTall-an individually tailored, progressive exercise program delivered through tablet computers-in community-dwelling older people with dementia. METHODS: Fifteen community-dwelling older people with dementia (mean age = 83 ± 8 years; Montreal Cognitive Assessment 16 ± 5) received StandingTall for 12 weeks with caregiver assistance. Feasibility and safety were assessed using the System Usability Scale (SUS; scores = 0-100; a priori target >65), Physical Activity Enjoyment Scale (PACES-8; scores = 8-56), adherence (exercise minutes) and adverse events. RESULTS: Mean SUS scores were 68 ± 21/69 ± 15 (participants/caregivers). The mean PACES-8 score was 44 ± 8. In week 2, week 7 and week 12, mean (bias-corrected and accelerated 95% CI) exercise minutes were 37 (25-51), 49 (30-69) and 65 (28-104), respectively. In week 12, five participants exercised >115 minutes. One participant fell while exercising, without sustained injury. CONCLUSIONS: StandingTall had acceptable usability, scored well on enjoyment and was feasible for participants. These results provide support for further evaluation of StandingTall in a randomised controlled trial with falls as the primary outcome.

Older People with Dementia Have Reduced Daily-Life Activity and Impaired Daily-Life Gait When Compared to Age-Sex Matched Controls.

Understanding the characteristics of physical activity and daily-life gait in older people with dementia may help identify those at risk of negative health outcomes and inform targeted interventions. Questionnaires are often used to assess physical activity but may be more affected by recall bias in people with dementia and provide little information about daily-life gait characteristics. The aim of the study was to assess differences in daily-life activity levels and gait characteristics between community-dwelling older people with mild to moderate dementia (n = 45; mean age 81±6 years, 42% female) and age-sex matched (1:2) cognitively-healthy controls (n = 90). Participants wore a tri-axial accelerometer (DynaPort MoveMonitor, McRoberts) on their lower back for 7 days and were assessed on neuropsychological and physical performance. Compared to age-sex matched controls, participants with dementia demonstrated reduced daily-life activity (fewer steps per day, fewer and shorter walking bouts, and lower daily walk time) and walking intensity (reduced speed, stride length and cadence). Participants with dementia also had significantly increased within-walk variability (stride time) and less regular gait (higher sample entropy). Within the group of participants with dementia, higher daily-life activity levels were associated with greater self-reported physical activity and better executive function. Fallers (1+ falls past year) with dementia had significantly reduced daily-life activity and walking speed when compared to non-fallers with dementia. In conclusion, people with dementia are less active in daily-life and present with significant impairments across multiple gait domains when compared to age-sex matched controls. These findings highlight opportunities for targeted interventions and support further research to examine interventions aimed at addressing these deficits.

A multidisciplinary intervention to prevent subsequent falls and health service use following fall-related paramedic care: a randomised controlled trial.

Background: approximately 25% of older people who fall and receive paramedic care are not subsequently transported to an emergency department (ED). These people are at high risk of future falls, unplanned healthcare use and poor health outcomes. Objective: to evaluate the impact of a fall-risk assessment and tailored fall prevention interventions among older community-dwellers not transported to ED following a fall on subsequent falls and health service use. Design, setting, participants: Randomised controlled trial involving 221 non-transported older fallers from Sydney, Australia. Intervention: the intervention targeted identified risk factors and used existing services to implement physiotherapy, occupational therapy, geriatric assessment, optometry and medication management interventions as appropriate. The control group received individualised written fall prevention advice. Measurements: primary outcome measures were rates of falls and injurious falls. Secondary outcome measures were ambulance re-attendance, ED presentation, hospitalisation and quality of life over 12 months. Analysis was by intention-to-treat and per-protocol according to self-reported adherence using negative binominal regression and multivariate analysis. Results: ITT analysis showed no significant difference between groups in subsequent falls, injurious falls and health service use. The per-protocol analyses revealed that the intervention participants who adhered to the recommended interventions had significantly lower rates of falls compared to non-adherers (IRR: 0.53 (95% CI : 0.32-0.87)). Conclusion: a multidisciplinary intervention did not prevent falls in older people who received paramedic care but were not transported to ED. However the intervention was effective in those who adhered to the recommendations. Trial registration: the trial is registered at the Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921, 13/05/2011.

A home-based, carer-enhanced exercise program improves balance and falls efficacy in community-dwelling older people with dementia.

BACKGROUND: Older people with dementia are at increased risk of physical decline and falls. Balance and mood are significant predictors of falls in this population. The aim of this study was to determine the effect of a tailored home-based exercise program in community-dwelling older people with dementia. METHODS: Forty-two participants with mild to moderate dementia were recruited from routine health services. All participants were offered a six-month home-based, carer-enhanced, progressive, and individually tailored exercise program. Physical activity, quality of life, physical, and psychological assessments were administered at the beginning and end of the trial. RESULTS: Of 33 participants (78.6%) who completed the six-month reassessment ten (30%) reported falls and six (18%) multiple falls during the follow-up period. At reassessment, participants had better balance (sway on floor and foam), reduced concern about falls, increased planned physical activity, but worse knee extension strength and no change in depression scores. The average adherence to the prescribed exercise sessions was 45% and 22 participants (52%) were still exercising at trial completion. Those who adhered to ≥70% of prescribed sessions had significantly better balance at reassessment compared with those who adhered to <70% of sessions. CONCLUSIONS: This trial of a tailored home-based exercise intervention presents preliminary evidence that this intervention can improve balance, concern about falls, and planned physical activity in community-dwelling older people with dementia. Future research should determine whether exercise interventions are effective in reducing falls and elucidate strategies for enhancing uptake and adherence in this population.