Exercise Interventions to Reduce the Risk of Falls in Dementia
In her presentation to the DCRC's National Dementia Research Forum, Associate Professor Jacqueline Close reviewed her work on a pilot approach to intervention aimed at preventing falls in people with dementia. This approach was recently tested in a feasibility study including 22 community dwelling participants over the age of 65 years with memory problems. The study consisted of a baseline assessment, followed by 12 weeks of intervention after which the baseline assessment was repeated. Participants taking part in the intervention group were compared to a control group who continued their normal care practices. For this study, the intervention consisted of an individually tailored exercise program accompanied by home safety recommendations. The exercise programs were professionally prescribed, carer led interventions, aided by 4 visits from a physiotherapist and 5 visits from an occupational therapist over the 12 week study period.
Participants were advised of home safety recommendations based on the Westmead Home Safety Assessments; they included a home safety booklet and a suggested list of habits to change. Of the home safety recommendations made, approximately half were implemented. There are several reasons why recommendations were not implemented. Having to change a large number of safety hazards in 12 weeks is a hard task for carers. Other significant factors included financial considerations and no perception of need or risk.
As part of the intervention program participants were given tailored exercises to repeat including standing balance activities, sitting to standing (strength) exercises and step ups. They recorded their activity in a log book. The goal was to progress the exercises over time. All participants reported that they were able to undertake the activities at least twice week. Challenges to further participation included carer availability to supervise, illness and holidays. Because the intervention lasted only 12 weeks and incorporated only 9 professional visits in total there was limited time to progress exercise challenge and no time to introduce exercises with weights. This is likely to have played a part in the inability of the study to detect any significant differences in physical measures, but there was a positive trend for an effect based on physical activity hours per week.
Ass Prof. Close and her colleagues found that one potential issue is the increase in carer burden. An average of 20 recommendations for changes to the household environment and the demands of implementing an exercise program were substantial in the intervention timeframe. This indicated that when implementing interventions, overwhelming both the patient and carer are concerns that must be considered together. This pilot study suggests that the intensity and duration of the exercise program may be important. The protocol has to be flexible in order to be able to respond to the age range of participants and any time they may not be able to exercise, such as when they are ill or spending time in hospital. The intervention has to be a tailored approach accommodating both physical and cognitive abilities, and there needs to be strong integration and collaboration between the occupational therapist and physiotherapist.
Ass Prof. Close also used the Forum as an opportunity to briefly espouse the benefits of a number of other measures that may reduce the risk of falls in hospital, residential care and community settings: decreasing the use of centrally acting medications if clinically appropriate, increasing use of vitamin D and calcium, considering falls in relation to all other quality markers of care of older people, treating bone health, considering fall alarms, hip protectors and helmets, treating orthostatic hypotension, proactively managing incontinence, recognising the need to modify staff behaviour, removing cataracts, using pace makers if required, increasing home visits, establishing a way to get people with dementia to exercise safely and effectively, and investigating whether exercise interventions alone are sufficient.
Implications for knowledge translation
Falls in people with dementia is an area where a great deal of value can be gained by translating research into practice. Falls are statistically a larger problem for the population of people with dementia however many practices that contribute to this continue to be widely used. The annual incidence of falls in cognitively impaired populations is double that of the normal population. Fractures are three times more common and gait abnormalities are more common in people with dementia.
There are many reasons why the presence of dementia increases the risk of falls. Evidence from a prospective study highlights problems with simple measures of strength, balance and reaction time. Antipsychotics are well known to increase the risk of falls and are often prescribed to people with dementia. People with dementia may also have an unrealistic perception of their own motor abilities resulting in impulsivity and risk taking behaviour. They may also have reduced attention span, impaired visuospatial skills, impaired executive function and motor planning skills, all contributing to the risk of falls.
Effective strategies to prevent falls in older people with dementia are lacking. Having strong evidence of best practice to reduce the risk of dementia provides an opportunity to translate this knowledge into an area where practice can be greatly improved, resulting in better health outcomes and quality of life. However, more information is required on the relative contribution of physical and cognitive factors in this population to help develop effective approaches to prevention.
A copy of Ass Prof Close's presentation can be found on the link below:
Reported by Samantha Gardener, DCRC - Early Diagnosis and Prevention, Edith Cowan University.