Staying upright and strong with dementia Ngaire Kerse. School of Population Health, Brain Research New Zealand, Faculty of Medical and Health Science, University of Auckland

Thank you from LiLACS NZ The kaitiaki esp paea The sites for the work The participants Thank you from LiLACS NZ

Te Puāwaitanga o Ngā Tapuwae Kia Ora Tonu-LiLACS NZ Bay of Plenty and Lakes DHBs Longitudinal cohorts – 2010 Māori 80- 90 years – Kaupapa methods 421 out 766 (56%) Non Māori -85 years 516 out of 870 (59%) Visit every year until death Measures – Core and Full Health, social, cultural, environmental Multimorbidity, 15 diagnoses Cognition – 3MS Function Social connections Cultural practices Have a process for data sharing, an invitation LilACs NZ Emphasise the kaupapa Maori methods, M`aori investogators, maori project managers, maori interveiwers and recruiter, Reasonable recruitment rate Breadth of measures Invitation to engage for analysis Cohort profile: 2015 International Journal of Epidemiology

Prior falls and fracture: LiLACS NZ Baseline: fall in last 12m Predictors of prior fracture and prior fall are shown here. life time fracture was ascertained by self report so there is the potential for recall bias. These data with about 40-50% of people ever having a fracture by advanced age are roughly consistent with other nations studies of lifetime fracture risk. Falls shown here are the proportion of the sample falling in the 12 months prior to Wave 1. Any fractures in lifetime. NonMaori Men 47 percent NonMaori Women 52 Maori Men 48 Maori Women 34 Any fall – wmen were more likely to fall than men UK fracture rates 48% women, 38% men by age 85 (Scholes S Age Ageing 2014)

Over 5 years 28 Māori and 74 non-Māori -fracture related hospitalizations -3,700 person-years follow-up. Accumulated fracture risk -5 years 20 per 1000 person years for Māori 34 per 1000 person years for non-Māori non-Māori and women more fractures.

Hospitalisation from fracture – 5 yr

Causes of falls Intrinsic Extrinsic Acute illness Cardiovascular Leg weakness Stroke, Parkinsons Extrinsic Hazards Other residents Staff, processes

Prevention of falls Falls and balance retraining exercises Home hazard assessment Good medical care Vitamin D

Home based Exercises Individualised Progressive Ankle weights Walking 3 x week 6 visits over 6 months Trained nurse Physiotherapist http://www.acc.co.nz/otagoexerciseprogramme

Otago Exercise Programme

Functional reserve and thresholds eg. muscle strength reserve threshold Acute illness 30 Age (time) 80

Impacting the threshold Athletes eg. Aerobic capacity reserve 30 Age (time) 80 Hodgeson

What activities? 164 women, 103 men age 73.6 Walking, 2 hrs 30 / 2 wks Oldest old had similar pattern

What about cognition Estimates in 80+ vary 5-20% dementia 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

Accrued dementia prevalence -Māori

Accrued dementia prevalence -non-Māori No diff by ethnicity, adj Age, sex, SES

Impact of dementia Quality of life lower in those with dementia

Cognitive impairment & dementia Global cognitive functioning Normal ageing A B D1 Linguistic skill and general intelligence decline over decades D2 C Symptomatic but pre-diagnostic phase with brain compensation occurring, over several years D E Symptomatic & post-diagnosis phase, with progressive decline over years Dementia trajectory Time

Falls in people with 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

Cognition and gait Activity programmes for people with 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 the same Activity programmes for people with cognitive problems might not work Montero-Odasso, M., J. "Gait and cognition:…..." J Am Geriatr Soc 60(11): 2127-2136.

Person with dementia Confusion Orientation Agitation Trip over things Cant find the toilet Medication increases falls Gait and balance Reaction times Amount of activity Incontinence Footware

Promoting Independence in Residential Care 41 Rest-homes in Christchurch and Auckland Falls, function, QOL, 682, mean age 87 years. Randomisation (no stratification) Activity Group PIRC, functional assessment, goal set, PIP to caregiver falls surveillance Social Group 2 visits Outcome evaluation No Impr QOL Function (on average, signif subgroup) No increase in falls

Why didn’t it work? The wrong programme The wrong exercises Cognition important Good cognition Function Depression Falls Poor cognition Function Depression Falls Why didn’t it work? The wrong programme The wrong exercises Understand the population, target the intervention Kerse BMJ 2008;337:al445

Variation in residential care

People with dementia fluorescent step edge do not anticipate hazards or effects of actions do not know that dizziness may be a symptom of other causes do 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 around the person with dementia Meaningful activities Safe environment Avoid agitation and exacerbation of BPSD Family Staff

Things to do state of mind

Exercise for falls in people with cognitive impairment Group and individual – lower leg strength and balance retraining, good adherence 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

Hazards

Summary Persons with dementia fall frequently Specific exercises for lower leg strengthening and balance retraining Sensible suggestions Keep calm and carry on

Funders 30/11/2018