Professor Ngaire Kerse

School of Population Health, Brain Research New Zealand, Faculty of Medical and Health Science, University of Auckland

Falls and dementia: keeping upright with memory problems

Age distribution

Ministry of Health. 2011. Tatau Kura Tangata: Health of Older Māori Chart Book 2011. Wellington: Ministry of Health.

The answer: 290, 577, 814 people in 2000

612, 888, 500 people in 2050

How many people need daily care?

Falls – 1/3 of 65+

50% - residential care, 85+

Intrinsic • Acute illness • Cardiovascular • Leg weakness • Stroke, Parkinson’s

Extrinsic • Hazards • Other residents • Staff, processes

Causes of falls

• Falls and balance retraining

exercises

• Home hazard assessment

• Good medical care

• Vitamin D

Prevention of falls

http://www.acc.co.nz/otagoexerciseprogramme

Home based Exercises Individualised Progressive Ankle weights Walking 3 x week 6 visits over 6 months Trained nurse Physiotherapist

Otago Exercise Programme

Functional reserve and thresholds

eg.

muscle strength

30 Age (time) 80

threshold reserve

Acute illness

Impacting the threshold

eg.

Aerobic capacity

30 Age (time) 80

reserve

Athletes

Hodgeson

Gender

FEMALEMALEM

ean

amou

nt o

f act

ivity

ove

r 2 w

eeks

(min

utes

) 800

600

400

200

0

other

housework

sports

gardening

walking

164 women, 103 men

age 73.6

Walking, 2 hrs 30 / 2 wks

Oldest old had similar pattern

What activities?

Deloitte, economic impact of dementia is NZ 2012

Estimates in 80+ vary 5-20% dementia

No studies of incidence or prevalence in NZ

Incidence greater in non-European pops

Financial cost high esp res care

UK CFAS – 65+ yrs • 8.3% 1989-94 • 6.8% 2008-11 Mathews FD, Lancet 2013

What about cognition?

Time

Global cognitive functioning Normal ageing

Linguistic skill and general intelligence decline over decades

A B

C D

Dementia trajectory

E

Symptomatic but pre-diagnostic phase with brain compensation occurring, over several years

Symptomatic & post-diagnosis phase, with progressive decline over years

D1

D2

Cognitive impairment & dementia

A fall related event with or without fracture is the most common reason for hospitalisation in people with dementia, accounting for approximately 26% of all admissions

Falls in people with dementia

• Disturbances in cognitive processes = slower gait and gait instability • Attention, executive function, working memory • predict future mobility loss, falls, and progression to dementia • Better for amnestic MCI • Not all dementias are the same

Cognition and gait

14

Montero-Odasso, M., J. "Gait and cognition:…..." J Am Geriatr Soc 60(11): 2127-2136.

Activity programmes for people with cognitive problems might not work

Person with dementia

Confusion Orientation Agitation

Trip over things Can’t find the toilet Medication increases falls

Gait and balance Reaction times Amount of activity

Incontinence

Footwear

Randomisation (no stratification)

41 Rest-homes in Christchurch and Auckland Falls, function, QOL, 682, mean age 87 years.

Outcome evaluation No Impr QOL Function (on average, signif subgroup) No increase in falls

Promoting Independence in Residential Care

Social Group •2 visits

Activity Group •PIRC, functional assessment, goal set, PIP to caregiver • falls surveillance

Cognition important Good cognition • Function • Depression

• Falls

Poor cognition

• Function

• Depression

• Falls

Understand the population, target the intervention Kerse BMJ 2008;337:al445

Variation in residential care

01

23

4m

ean

of e

xtra

falls

average number of falls per resthome

Do not anticipate hazards or effects of actions.

Do not know that dizziness may be a symptom of other causes.

Does not scan the environment effectively, for hazards.

Reaction times are slower, gait is different

fluorescent step edge removal of below knee height hazards Reorganising furniture for improved access

People with dementia

Meaningful activities

Safe environment

Avoid agitation and exacerbation of BPSD

Family

Staff

People around the person with dementia

Things to do state of mind

Wai Chi Chan et al. Efficacy of Physical Exercise in Preventing Falls in Older Adults With Cognitive Impairment: A Systematic Review and Meta-Analysis JAMDA 16 (2015) 149e154 22

Exercise for falls in people with cognitive impairment

Group and individual – lower leg strength and balance retraining, good adherence

Hazards

• Persons with dementia fall frequently • Specific exercises for lower leg

strengthening and balance retraining • Sensible suggestions • Keep calm and carry on

Summary