An Introduction Julie Whitney Falls and cognitive impairment Twice as likely to fall in a year More likely to be a multiple faller More likely to have injurious falls 34 times more likely to sustain a hip fracture ID: 930159
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Slide1
Falls and Cognitive ImpairmentAn Introduction
Julie Whitney
Slide2Falls and cognitive impairment
Twice as likely to fall in a yearMore likely to be a multiple fallerMore likely to have injurious falls
3-4 times more likely to sustain a hip fracture
20% those who sustain a hip fracture have dementia
40% of those who sustain a hip fracture have cognitive impairment
A faller with cognitive dementia / CI more likely to experience poor outcomes after a fall (functional impairment, institutionalisation, death)
Slide3Why do people with cognitive impairment fall?
Higher prevalence of risk factors
Cognition specific risk factors
Slide4Higher prevalence of risk factors
More likely to have sensori-motor, gait and balance impairments
Shorter step length, more gait variability, slower gait speed, poorer obstacle clearance
Changes in gait and balance found to precede gait and balance instability
Increased dual task costs
More likely to be prescribed psychotropic medications
More sedentary behaviour
Increased prevalence of fear of fallingMore autonomic dysfunction / orthostatic hypotension
Slide5Specific risk factors
Global cognition associated with increased riskVisuospatial functionExecutive function
Processing speed
Attention
Many BPS are associated with increased risk:
apathy, sleep disturbance, agitation, psychosis, hallucinations impulsivity and wandering
Depression
Anxiety
Slide6What about hospital inpatients?
25% acute hospital inpatients have dementiaDelirium:20-30% acute medical wards
10-50% people having surgery
70-90% falls in inpatient setting, patients had identified delirium
Slide7Delirium
“Delirium (sometimes called 'acute confusional
state') is a common clinical syndrome
characterised
by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.”
Acute impairment in attention and judgment, impulsivity, agitation
Acute impairment in gait and balance
Challenge – delirium type:HyperactiveHypoactiveMixed
Slide8Interventions to address falls in CI
Frailty
Impaired cognition
Exercise
Single interventions to address risk factors
Exercise (with more supervision)
Single interventions to address risk factors
Exercise / activity / SB reduction
Multi-factorial assessment and intervention
Comprehensive geriatric assessment
Multi-factorial risk assessment
Holistic interventions – address more general well-being
Carer training
Slide9Exercise interventions in cognitive impairment
Possible to improve gait and balance parameters
Small low quality studies, heterogeneity
Evidence that it reduced falls in community dwelling populations
Cochrane found 67% exercise trials exclude people with cognitive impairment
Sherrington et al (2016) – community populations
Slide10Other interventions – in community dwellers
Multi-factorial studies in community dwelling populations = more than half the studies exclude people with cognitive impairmentSome evidence that Donepezil decreases the risk of falls
Slide11Interventions in care homes
70% people in care homes have dementia / CIMulti-factorial: supervised exercise, medication review, vitamin D supplementation, continence management and staff education
Unclear evidence as to whether severity of cognitive impairment impacts on this
No evidence that exercise alone is effective in care homes
Slide12Hospital inpatients
Few studies focused on cognitive impairmentMulti-factorial interventions effective in sub-acute / mixed settings but not in acute settings (where delirium incidence is higher)
Multi-component interventions for delirium appear to reduce falls
No evidence for movement sensors
Slide13What might work?
Risk factors
Agitation
Impulsivity
“Wandering”
Poor attention
Possible interventions
Meeting basic psychological needs
Slide14Meeting basic psychological needs
Kitwood
Address pain, pressure, toileting, poor seating, hunger, thirst, stiffness, environment
MEANINGFUL ACTIVITY
Own clothes, belongings, “This is me”.
Include in ward activity, greet and speak to regularly
Carer presence, dolls / other item
Slide15Meaningful activity
Needs to be graded to cater for different abilities
Slide16Summary
Increased risk of falls and fractures in people with cognitive impairmentCognitive impairment has been an exclusion criterion in many falls studies
Evidence that exercise is effective in community dwellers who are not severely frail and with intensive support
Multi-factorial interventions have a small effect in care homes
Evidence for efficacy of interventions in hospital limited – potential for good delirium care
Approach probably needs to consider the risk factors specific to cognitive impairment