1. Professor Keith Hill, Head, School of Physiotherapy and Exercise Science, email Keith.Hill@Curtin.edu.auKeith.Hill@Curtin.edu.au Gippsland Forum: Falls prevention for people with dementia (Sept 2014) Falls and dementia: Epidemiology and interventions

2. Main focus of presentation: community setting Falls prevention for older people  Magnitude of the problem  Risk factors  Evidence of effective interventions Fall prevention for people with dementia  Magnitude of the problem  Risk factors  Evidence of effective interventions  Falls prevention and injury prevention Overview

3. What is dementia: “a set of symptoms that may include memory loss and difficulties with thinking, problem-solving or language. Dementia is caused when the brain is damaged by diseases, such as Alzheimer's disease or a series of strokes. Dementia is progressive disorder…” Different types of dementia Alzheimer's disease (AD): 62% Vascular dementia (VaD): 17% Mixed dementia (AD and VaD): 10% Dementia with Lewy bodies: 4% Fronto-temporal dementia: 2% Parkinson's dementia: 2% Other dementias: 3% Dementia Alzheimer’s Society (UK)

4.  Alzheimer’s disease (m ost common form of dementia)  Progressive degenerative disorder  Currently leading cause of disability in Australia  Incidence of new cases in Australia projected to increase from:  69000 new cases in 2009, to  385000 new cases in 2050 (Access Economics 2009)  Falls  One in three older people fall each year  10% of falls cause serious injury  Leading cause of injury related hospitalisations among older people in Australia (78600 fall related hospitalisations 2008-9) (AIHW 2012)  10% of bed days for older people attributable to falls (AIHW 2012)  Direct costs to the health care system in Australia was $648million in 2007-8 The importance of dementia and falls FALLS Dementia Ageing populations

5. Lord et al, 1993; Forster & Young, 1995; Hill, 1998; Hill & Stinson, 2004 ??? Falls in clinical groups

6. Survival curve (time to first fall) - community sample – Out-patient clinic Allan et al, 2009 Falls in 12 months (prospective) Alzheimers disease – 47% Vascular dementia – 47% Dementia with Lewy Bodies – 77% Parkinson’s disease dementia – 90%

7.  aspects of the neurological condition  unrecognised falls risk factors  other Why the increased falls risk in people with dementia?

8. Intrinsic factors Extrinsicfactors Medications Health Problems (incl balance dysfunction) Ageing Environment Activityrelatedrisks eg. eg.psychoactive meds meds Behavioral factors Falls are multi factorial

9. Tinetti et al, 1988 NB: Modifiable vs non-modifiable risk factors Number of risk factors

10. Factors commonly associated with fallers:  previous falls  lower extremity weakness  arthritis (hips / knees)  gait / balance disorders  cognitive disorders (depression / dementia / poor judgement...)  visual disorders  postural hypotension  bladder dysfunction (frequency / urgency / nocturia / incontinence...)  medications (psychotropics/ sedatives / hypnotics / antihypertensives...)  Others (stroke, PD) Falls risk assessment tools to classify risk Tideiksaar, 1995 Identifying who is at risk of falls…

11. Shaw et al 2003 (Geriatrics & Ageing) * Risk factors for falls for people with dementia

12. The importance of reporting falls or near falls One of the strongest risk factors for future falls Only 25% of older people report a fall to a Doctor or health professional accept falls as inevitable part of ageing concern of consequences of reporting a fall Better chance of successful interventions Avoid development of secondary complications such as loss of confidence and reduced activity

13. Falls risk assessment tools – examples:  Physiological Profile Assessment – PPA (FallScreen)  http://www.neura.edu.au/fbrg  Quickscreen  http://www.neura.edu.au/research /facilities/falls-and-balance- research-group/quickscreen  Falls risk for older People – Community version (FROP-Com)  National Ageing Research Institute Some reliability research with people with cognitive impairment http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html

14. The FROP-Com

15. COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants) What works in falls prevention for older people in the community setting  There is good research (at least one randomised trial) evidence that a number of single interventions can reduce falls / injuries: exercise (home exercise; tai chi, group exercise) cataract extraction / change multifocal glasses to 2 sets of glasses psychotropic medication withdrawal / medication review home visits by Occupational Therapists improved post hospital discharge follow-up approaches to support client uptake in recommended interventions vitamin D and calcium supplementation (in low vit D cases) cardiac pacemaker for carotid sinus hypersensitivity foot exercise, footwear and orthoses  multiple interventions based on a falls risk assessment have also been shown to be effective (including in high falls risk groups, eg older fallers presenting to ED) Common exclusion criteria: cognitive impairment

16. Safe footwear Treat postural hypotension Eyesight review Treat incontinence Change gait aid Other interventions ??????

17. Summary of what works: falls prevention interventions in the community setting for people with dementia (randomised controlled trials)

18. Shaw et al, 2003 - RCT Unsuccessful RCT – results (??some trends)

19. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Recently published meta-analysis: Exercise vs usual care for fallers versus non-fallers – participants with dementia (community) Burton E et al, e-pub ahead of publication, Clinical Interventions in Aging

20. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Some learnings from successful RCTs in cognitively intact older people

21. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Evidence of what works in exercise in falls prevention  Group exercise programs  Home exercise programs (often prescribed by a physiotherapist  Tai Chi- (note: different types of Tai Chi may have different effects)  Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011)

22. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Exercise and falls prevention: what we know… 22 Sherrington C, et al. NSW Public Health Bull. 2011 Jun;22(3-4):78-83 54 RCTs (all settings, though most in community)

23. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Appropriate exercise prescription - Horses for courses Very frail/ High falls risk Healthy older people CONTINUUM OF FRAILTY Tai chi for arthritis – Sun style24 form Beijing style – Yang style Otago Exercise Program“Otago Plus” – incl VHI kit

24. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Exercise interventions (recent study)  Sample with disabling foot pain and increased falls risk  Intervention=foot & ankle exercise, footwear subsidy, and orthoses provision  Intervention group had 36% fewer falls, p<0.05 Spink M et al,,.BMJ. 2011 Jun 16;342:

25. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Vision - Single vs multi focal lens glasses  Sample=regular wearers of multi-focal glasses  Intervention=provision of single lens glasses for walking and outdoor activities  8% (non significant) reduction in falls in intervention group  Significant reduction in outdoor falls in those with regular outdoor activity Haran M et al,,.BMJ. 2010 May 25;340:c2265

26. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Medication review  Sample=older patients of 20 general practitioners  Intervention=education (academic detailing, provision of prescribing information, medication risk assessment, medication review, financial incentives)  Intervention group had improved medication use at 4 mths, and reduced risk of having a fall or injury at 12 mths (p<0.05) Pit S et al, Med J Aust, 2007 ;187(1):23-30.

27. Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Cumming R et al, 1999 JAGS; 1397-402  Sample= 530 older people discharged from hospital  Intervention=home visit by OT targeted at reducing home hazards  Significant reduction in falls in home modification group  50% of home modifications remained in place 12 months later  Improved outcomes with higher adherence Home safety modifications

28. 42% of a community sample with mild-moderate dementia fall at least once each year (9% fallers suffered leg #) Most common falls related hazards in homes: included:  low chairs (57%),  absence of grab rails (toilet – 48%),  loose rugs (48%),  missing 2 nd bannister on steps (38%) and  absent night lights (28%) Horikawa et al 2005 (124 out-patients with diagnosis of probable AD); Lowery et al, 2000 Importance of home safety for people with dementia: Community setting

29. Best practice falls prevention with dementia Evidence from community setting Falls risk assessment Exercise (balance focus) Cataract surgery Environmental modification Behaviour change Medication review Vitamin D Hip protectors Other best practice options Appropriate footwear / glasses Correct use of walking aid Manage orthostatic hypotension Manage incontinence Injury minimisation Hip protectors Vitamin D / calcium Anti-resorptive medication

30.  Dementia is an independent risk factor for falls  Despite good evidence of many single and multifaceted falls prevention programs being effective for older people without cognitive impairment, there is very little research demonstrating effectiveness for people with dementia  Need to identify and manage existing falls risk factors of people with dementia  Promising research results using exercise for people with mild to moderate dementia Summary