Assessment and management of dementia in relation to falls ... · Why is it important Annual falls...
Transcript of Assessment and management of dementia in relation to falls ... · Why is it important Annual falls...
Professor Jacqueline CT Close
Neuroscience Research Australia
Prince of Wales Clinical School
University of New South Wales
Assessment and management of dementia in relation to falls risk: Tools and tips for
community, hospital and residential care
Why is it important
Annual falls incidence is 70-80%.
Fractures are up to 3x commoner in people with dementia.
Psychotropic drug use more common in people with
dementia.
26% of admissions to hospital for people with dementia are
fall related.
When admitted to hospital, people with dementia have
poorer outcomes including adverse events.
What do we need to know?
Is this person cognitively impaired (screen).
What domains of cognition seem to be affected most.
How is it impacting on function.
How will the identified impairments impact of potential
choice of intervention/s.
How will the impairments impact on how I deliver the
intervention.
Is dementia subtype important in relation to falls assessment and management
Allan LM, Ballard CG, Rowan EN, Kenny RA (2009) Incidence and
Prediction of Falls in Dementia: A Prospective Study in Older People.
PLoS ONE 4(5): e5521. doi:10.1371/journal.pone.0005521
Be clear as to why you are testing – it should determine the choice of test
Screening
Assessment of undiagnosed cognitive decline
Assessment with a view to tailoring falls prevention approach
How will the information gathered affect your management
Testing
Tests
AMTS
MMSE / sMMSE
MOCA
RUDAS
ACE-III
MMSE (Folstein 1975)
Affected by level of education, age & language
Low reliability
Too many easy items
Wrongly used as a unidimensional tool
Wrongly used to diagnose dementia
Wrongly(?) used to justify prescription of cholinesterase
inhibitors
MMSE / SMMSE
The ability to plan, organise, sequence tasks, problem solve etc.
Simple clinical examples
Clock drawing
Verbal fluency – letter, animals, supermarket
Alternating hand sequence
Luria’s three step
Trails A and B
Executive Function
MMSE 25 ACE-R 77
MMSE 28 ACE-R 74 MMSE 28 ACE-R 78 MMSE 26 ACE-R 72
Verbal Fluency
Assessing cognition though gait assessment
Assessing cognition though gait assessment
Higher level gait disorder
Apraxia - Inability to perform a skilled or learned act that
cannot be explained by an elementary motor or sensory deficit
or language comprehension disorder.
Initiation of gait
Posture
Velocity (m/s)
Cadence (steps/min)
Armswing
Heel strike
Turning / freezing
Foot clearance
Step length (cm)
Step length variability
Stride length variability
Impact of dual tasking
Assessment of gait
Overall falls risk score 1.88
66 year old woman with multiple falls MMSE 24/30 and knee pain
Painful knee but predominantly falling backwards
Upright posture and gait apraxia
Complex processing speed - slowed.
Acquisition of new visual information - impaired
Visuospatial skills - variable
Problem solving skills - poor
Orientation, attention, working memory and verbal memory
skills remain preserved
Cognitive Assessment
How did the assessment help
Explained functional decline which was being attributed to
knee OA
Provided clarity as to indication for TKR
Prepared clinical team in advance of admission for TKR
Realistic goals for rehabilitation and discharge planning
Future planning
Intervention
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
Extrapolation from existing trials
Intervention - Community Rate of falls Risk of falling
Multicomponent group exercise (16, 22) RaR 0.71 (0.63-0.82) RR 0.85 (0.76-0.96)
Multicomponent home exercise (7, 6) RaR 0.68 (0.58-0.8) RR 0.78 (0.64-0.94)
Tai Chi (5, 6) RaR 0.72 (0.52-1.0) RR 0.71 (0.57-0.87)
Multifactorial interventions (19, 34) RaR 0.76 (0.67-0.86) RR 0.93(0.86-1.02)
Vitamin D (7, 13) RaR 1.00 (0.9-1.11) RR 0.96 (0.89-1.03)
OT intervention (6, 7) RaR 0.81 (0.68-0.97) RR 0.88 (0.8-0.96)
Vision intervention (1) RaR 1.57 (1.19-2.06) RR 1.54 (1.24-1.91)
Cataract extraction (1) RaR 0.66 0.45-0.95 -
Bifocal / multifocal glasses (1) RaR 0.92 (0.73-1.17) RR 0.97 (0.85-1.11)
Psychotropic withdrawal (1) RaR 0.34 0.16-0.73
Pharmacy detailing - RR 0.61 (0.41-0.91)
Pacemakers (3) RaR 0.73 0.57-0.93
Podiatry for painful feet (1) RaR 0.64 0.45-0.91
Anti-slip shoe (1) RaR 0.420.22-0.78 -
Increase knowledge/educate /CBT (2,6)
FOCIS - Prospective risk factor study. n=174
Recruitment
Re Assessment Measures
Baseline Measures &
Randomisation
Monthly Falls Calendars
INTERVENTION 26 weeks
Exercise Program
i-FOCIS Pilot 2
Intervention - Hospitals Rate of falls Risk of falls
General hospital setting
Trained nurse targeting individual fall risk factors (1)
_ RR 0.29 (0.11-0.74)
Multifactorial interventions (4, 3) RaR 0.69 (0.49-0.96) RR 0.71 (0.46-1.09)
Orthogeriatric MoC (1, 1) RaR 0.38 (0.19-0.74) RR 0.41 (0.20-0.83)
Subacute setting
Exercise (1, 2) RaR 0.54 (0.16-1.81) RR 0.36 (0.14-0.93)
Carpet flooring (1) RaR 14.73 (1.88-115.35)
RR 8.33 (0.95-73.97)
Hospital
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
Jan-1
1Fe
bM
arA
pr
May
Jun
Jul
Au
gSe
pO
ctN
ov
De
cJan
-12
Feb
Mar
Ap
rM
ayJu
nJu
lA
ug
Sep
Oct
No
vD
ec
Jan-1
3Fe
bM
arA
pr
May
Jun
Jul
Au
gSe
pO
ctN
ov
De
cJan
-14
SAC
2 F
alls
/ 1
00
0 O
BD
s
SAC2 falls / 1000 OBDs - POWH
Hypnotic use - POWH
700
1200
1700
2200
2700
Jan-0
6M
arM
ayJu
lSe
pt
No
vJan
-07
Mar
May
Jul
Sep
tN
ov
Jan-0
8M
arM
ayJu
lSe
pt
No
vJan
-09
Mar
May
Jul
Sep
No
vJanM
arM
ayJu
lSe
pN
ov
Jan-1
1M
arM
ayJu
lSe
pN
ov
Jan-1
2M
arM
ayJu
lSe
pN
ov
Jan-1
3M
arM
ayJu
lSe
pN
ov
Jan-1
4
No
of
tab
lets
dis
pen
sed
Number of sedatives dispensed per month - POWH
Antipsychotic use - POWH
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Jan-1
1
Ap
r-11
Jul-1
1
Oct-1
1
Jan-1
2
Ap
r-12
Jul-1
2
Oct-1
2
Jan-1
3
Ap
r-13
Jul-1
3
Oct-1
3
Jan-1
4
mill
igra
ms
POW Med & Surg: mg Haloperidol / mth
0
500
1000
1500
2000
2500
3000
Jan-1
1
Ap
r-11
Jul-1
1
Oct-1
1
Jan-1
2
Ap
r-12
Jul-1
2
Oct-1
2
Jan-1
3
Ap
r-13
Jul-1
3
Oct-1
3
Jan-1
4
mill
igra
ms
POW Med & Surg mg Olanzapine / mth
0
100
200
300
400
500
600
700
800
900
Jan-1
1
Mar-1
1
May-1
1
Jul-1
1
Sep
-11
No
v-11
Jan-1
2
Mar-1
2
May-1
2
Jul-1
2
Sep
-12
No
v-12
Jan-1
3
Mar-1
3
May-1
3
Jul-1
3
Sep
-13
No
v-13
Jan-1
4
mill
igra
ms
POW Med & Surg mg Risperidone/ mth
Intervention - RACFs Rate of falls Risk of falling
Exercise (8,8) RaR 1.03 (0.81-1.31) RR 1.07 (0.94-1.23)
Vitamin D (5,6) RaR 0.63 (0.46-0.86) RR 0.99 (0.90-1.08)
Multifactorial interventions (7,7) RaR 0.78 (0.59-1.04) RR 0.89 (0.77-1.02)
Post hoc analysis suggests that people in intermediate care facilities may
benefit from exercise but in high level care the risk may be increased
How will the presence of cognitive impairment impact on how I deliver
my intervention/s
Identifies underlying cognitive processes – focuses on preserved cognitive abilities
Helps tailor content and instruction process
Helps educate carers re
expectations for behaviour
Functional cognition
Assessment of Functional Cognition
The Future
THE i-FOCIS Overview
• RCT
• 360 subjects
• Diagnosis of cognitive impairment
• Community dwelling
• Carer – 3.5hrs+/ week contact
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
Acknowledgements
Morag Taylor
Stephen Lord
Cathie Sherrington
Kim Delbaere
Jacki Wesson
Lindy Clemson
Henry Brodaty
Laura Gitlin
Stef Mikolaizak
Barbara Toson
James Scandol