Preventing falls in people with dementia: Is there any evidence? Jacqueline CT Close Neuroscience Research Australia Prince of Wales Clinical School University of New South Wales
Fall Related Hospitalisations Methods NSW Admitted Patients Data Collection (APDC), from 1 July 1998 to 30 June 2011. Persons aged 65 years and over A principal diagnosis of injury (ICD-10-AM range: S00-T75 or T79) ; A fall-related external cause code (ICD-10-AM range: W00-W19) Percentage annual change in incidence with 95% confidence intervals within each age group were estimated by fitting negative binomial regression models
Results – Absolute Numbers Results All fall related hospitalisations increased from 14,577 to 25,929 - (78% increase) Fracture related hospitalisations increased from 11,107 to 16,105 – (45% increase) Non-fracture related hospitalizations increased from 3,470 to 9,824 – (183% increase )
The Future Fall related hospitalisation in NSW 0.8 Fracture-related hospitalisation 0.7 Non-fracture related hospitalisation 0.6 Proportion 0.5 0.4 0.3 0.2 Year
Age-specific TBI admission rates by year, persons aged 65 years and older, NSW 1998/99 to 2010/11 450 65-69 years (PAC, 5.2%; 95%CI 3.8-6.6, p<0.0001) 400 70-74 years (PAC, 5.0%; 95%CI 3.6-6.3, p<0.0001) 75-79 years (PAC, 7.9%; 95%CI 6.9-9.0 p<0.0001) 350 80-84 years (PAC, 8.6%; 95%CI 7.3-9.9 p<0.0001) 300 85+ years (PAC, 9.1%; 7.8-10.4 p<0.0001) Rate per 100,000 popultion 250 200 150 100 50 0 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 Year
Age standardised TBI admission rates by type of injury and year, persons aged 65 years and older, NSW 1998/99-2010/11 80 Traumatic subdural haemorrhage (PAC, 10.5%: 95%CI 9.6-11.4, p<0.0001) Concussive injury (PAC, 0.2: 95%CI -0.8-1.4, p=0.66) 70 Traumatic arachnoid haemorrhage (PAC, 16.2%: 95%CI 14.4-18.0, p<0.0001) Diffuse brain injury (PAC, 4.2%: 95%CI 2.2-6.1, p<0.0001) Focal brain injury (PAC, 9.8%: 95%CI 8.0-11.8, p<0.0001) 60 Other intracranial injuries (PAC, 5.9%: 95%CI 2.6-9.2, p=0.0003) Unspecified intracranial injury (PAC, -7.0%: 95%CI -10.3-3.7, p<0.0001) Rate per 100,000 population 50 Epidural haemorrhage (PAC, 2.9%: 95%CI -1.0-6.9, p=0.1499) Traumatic cerebral oedema * 40 30 20 10 0 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 Year
Age-standardised TBI admission rates by faller status, persons aged 65 years and older, NSW 1998/99 to 2010/11 160 Fallers_male 140 Fallers_females Fallers_persons (PAC, 8.4%; 95%CI 7.5-9.3, p<.0001) Non-fallers_males 120 Non-fallers_females Non-falles_persons (PAC,2.1%; 95%CI 0.9-3.3, p<.0001) Rate per 100,000 population 100 80 60 40 20 0 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 Year
AGS/BGS Guidelines – Jan 2010 “There is insufficient evidence to recommend for or against multi-factorial or single interventions to prevent falls in older persons with known dementia living in the community or in long-term care facilities” .
Results from a prospective risk factor study F alls O lder C ognitively I mpaired S ubjects
Understanding the increased risk of falls in dementia F Physica l O C Person with Multiple Falls Dementia I S Cognitive
Falls in Cognitively Impaired Subjects F Prospective risk factor study O Aged 60+ C Cognitive impairment (MMSE <24 or ACE-R <82 or specialist diagnosis of dementia) I Recruited from hospital, clinics, adverts etc S Had to have consenting “carer”
Follow Up F 1 year follow up O Monthly falls calendars C Fall defined using ProFaNE consensus definition I Multiple faller defined as someone with 2 or more S falls in the one year follow-up
Multivariate Model Variable Median Cut Point OR (95% CI) 2.589 (1.193 – 5.615) >1907mm 2 Sway on foam 3.879 (1.707 – 8.813) Coordinated Stability >29 errors 3.317 (1.513 – 7.272) GDS >3 Adjusted for: age, sex, years of education, total medications and cardiac arrhythmias (all non- significant)
Explanatory Model Physica l F Sway on Foam Co-Stab O C Model Person with Multiple Falls correctly Dementia classifies 75% I of people S GDS Cognitive
Conclusions from Prospective Study F People with cognitive impairment are at an increased risk of falls O Physiological performance is an important determinant of falls risk C Deficits identified are potentially amenable to intervention I Cognitive performance is less useful in differentiating between S fallers and non-fallers Logical step is to move on to pilot approach to intervention
i-FOCIS Pilot Study - Overview INTERVENTION GROUP 12 weeks Home Hazards Reduction & Exercise Program Recruitment Monthly Falls Calendars Baseline Re Assessment Measures & Measures Randomisation CONTROL GROUP Usual Care
i-FOCIS Intervention Protocol OT OT OT OT OT visit visit visit visit visit Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk Wk 1 2 3 4 5 6 7 8 9 10 11 12 PT PT PT PT visit visit visit visit
Home Safety Recommendations based on Westmead Home Safety Ax Included reasoning to highlight hazards Three sections: Habits to change Things to buy HMMS referral
Exercise Program Five exercises given Standing balance activities Strength – sit to stand Step ups Upgrades repetitions reduced support eyes closed
Home Safety Adherence Total Number of Recommendations 207 Number of recommendations per 20.7 (13- 29) participant - mean (range) Number implemented – mean (range) 10 (3 – 24) 48.6% 10 Percent adherence per participant Reasons for non-adherence: • No perception of need or risk • Financial considerations
Exercise Program Adherence i All participants reported adherence 2 x week F minimum Limitations: O Carer availability to supervise C Illness and holidays I Limited dynamic activities used Minimal challenges to base of support S
Results No significant differences in Physical Activity any physical measures 35 (analysis of median 30 Baseline Hours per week 25 change scores using Mann Follow-up 20 Whitney tests) 15 10 Trend in the right directions 5 for median change scores on 0 physical activity hours/ week Intervention Control
Results 12 Carer Burden Carer Strategy Use 20 10 18 Number of Strategies 16 8 Zarit Score (/48) 14 12 6 10 8 4 6 4 2 2 0 0 Intervention Baseline Intervention Control
Falls Data Intervention (n=11) Control (n=11) 2.09 ( 2.5) 2.45 ( 3.17) Falls in prior year – Baseline mean (SD) Range 0-8 0-11 Percent fallen 63% 81.2% Fallen > 2 times 45.4% 45.4% 0.45 ( 0.82) 1.0 ( 1.48) Follow Up Falls to re-Ax - mean (SD) Range 0-2 0-4 Percent fallen 27.3% 36.4% Fallen > 2 times 18.2% 36.4% 58% reduction in falls rate - IRR = 0.42 (p = 0.28)
Lessons learnt Intensity / duration of exercise program Flexibility of intervention protocol itself Tailored approach accommodating both physical & cognitive abilities critical Important to have an understanding of cognitive “ strengths ” Strong integration & collaboration between the occupational therapist and physiotherapist crucial
THE i-FOCIS Overview Can a professionally prescribed, carer assisted exercise and home hazard reduction program reduce falls in people with dementia Rate of falls (control 1.8 falls/yr – 30% reduction, mean follow-up 11 months) Number of fallers Secondary aims – function, QoL, uptake and adherence, cost and cost-effectiveness
THE i-FOCIS Overview RCT 360 subjects Clinical diagnosis of cognitive impairment Community dwelling Carer – 3.5hrs+/ week contact
THE i-FOCIS Overview 1 year intervention – 10 visits in total OT Physiotherapy Also includes telephone support Tailored to physical and cognitive abilities Includes carer engagement sessions Reassess at 6 months and 1 year.
What do I do at this point in time
Extrapolation from existing trials If the mechanism by which the intervention has it’s effect is understood and not felt to affected by the presence of cognitive impairment / dementia then it is reasonable to extrapolate data from trials undertaken in cognitively intact populations Example. Treatment of osteoporosis
OI 2012
Community Setting
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