STEPPING OUT: Reducing & Preventing Falls in Older Adults With Mild Cognitive Impairment

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1 STEPPING OUT: Reducing & Preventing Falls in Older Adults With Mild Cognitive Impairment BARBARA FISCHER, PSY.D. AND AUNDREA HOFFMANN, PT, DPT WISCONSIN HEALTHY AGING SUMMIT JUNE 8, 2018

2 OUTLINE Background Theoretical underpinnings of the Stepping Out model Recruitment Program content and modifications Outcome measures and findings Successes and challenges from the initial pilot program Next Steps

3 Background: Burden of Falls, Wisconsin /3 people over age 60 fall every year Falls: leading cause of injury-related death in Wisconsin 87% fall related deaths, 70% inpatient hospitalizations involve individuals >65

Cognitive Impairment and Falls Cognitive deficits increase falls risk (Gleason et al., 2009, Doi et al., 2015, Fischer et al., 2014, Montero-Odassa et al., 2012, Liu-Ambrose et al., 2008).

4 Cognitive Impairment and Falls Cognitive deficits increase falls risk (Gleason et al., 2009, Doi et al., 2015, Fischer et al., 2014, Montero-Odassa et al., 2012, Liu-Ambrose et al., 2008). Memory Attention Processing Speed Executive Function Visuospatial Insight/Judgment

5 Falls Continuum

6 Mild Neurocognitive Disorder Evidence of mild cognitive decline noticed by patient, family member Deficits in at least one cognitive domain (at least 1.5 SD below average) Deficits do not significant affect instrumental activities of daily living Deficits do not occur exclusively within the context of delirium or another medical/mental disorder DSM 5 American Psychiatric Association, 2013

7 Mild Neurocognitive Disorder Prevalence and incidence in population: Incidence of Cognitive Impairment > age 65 15% Roberts, R., & Knopman, D. S. (2013) In Wisconsin: estimate 131,250 MCI Dementia Intact

8 Why are so few falls programs designed for pts with declining cognition? Cognitive impairment may reflect neurological changes Atrophy White matter ischemic changes Decreased dendritic and synaptic density Decreased network efficiency Peterson, 2011 N Engl J Med 2011

9 OUTLINE Background Theoretical underpinnings of the Stepping Out model Recruitment Program content and modifications Outcome measures and findings Successes and challenges from the initial pilot program Next Steps

10 Could individuals with cognitive impairment benefit? Patients with MCI and dementia benefit from exercise-based interventions (Montero-Odasso and Speechley, 2018, Sungkarat et al., 2016; Burton et al., 2015, Pitkala et al., 2013, Heyn et al., 2004). Home-based falls intervention program improved balance and reduced concern about falls in individuals with mild to mod. dementia. (Taylor et al., 2017) Older individuals with dementia living in a nursing home, participants who engaged in a simple physical activity exhibited improved mobility and quality of life relative to controls (Slaughter et al., 2015). Participation in a long term exercise program was associated with slower declines in function among ind. w MCI. (Pitkala et al., 2013)

11 Could individuals with cognitive impairment benefit? Why? Neurogenesis Exercise improved cognitive performance, and was associated with less brain atrophy and higher levels of the neurotrophic protein BDNF (Suzuki et al., 2013). Exercise associated with decreased Aβ in transgenic mice, and with faster learning Transgenic mice with double mutant form of amyloid precursor protein were housed in cages with and without a running wheel. Long term exercise was associated with significant decreases in in the frontal cortex, cortex around the hippocampus, and in the hippocampus itself, relative to sedentary mice

12 Figure 2. Change in MTA-ERC and WBC volumes in response to the 6-month intervention. Suzuki T, Shimada H, Makizako H, Doi T, Yoshida D, et al. (2013) A Randomized Controlled Trial of Multicomponent Exercise in Older Adults with Mild Cognitive Impairment. PLOS ONE 8(4): e

13 WRAP studies Associational studies with WRAP participants suggest modifiable factors: physical and cognitive activity glucose and metabolic regulation stress sleep May be avenues for interventions that enhance brain health, reduce likelihood and severity of AD pathology Johnson et al., (2018) The Wisconsin Registry for Alzheimer s Prevention: A review of findings and current directions. Alzheimer s & Dementia: Diagnosis, Assessment & Disease Monitoring 10 (2018)

14 What about people with dementia?

15 Outline Background Theoretical underpinnings of the Stepping Out model Recruitment Program content and modifications Outcome measures and findings Successes and challenges from the initial pilot program Next Steps

16 Recruitment Issues Participants require screening to ensure eligibility MOCA score How to know if patient has cognitive impairment prior to screening Sources of referral: Primary care providers Neuropsychologist Past physical therapy patients Social work

17 Recruitment Issues Reduced insight- patients with MCI do not think they need help S. Haller, et al. American Journal of Neuroradiology July 2017, 38 (7) ; DOI:

18 Recruitment Issues Increased burden on wife/family Highlights shifting roles Patient drop out- medically frail

19 OUTLINE Background Theoretical underpinnings of the Stepping Out model Recruitment Program content and modifications Outcome measures and findings Successes and challenges from the initial pilot program Next Steps

20 Stepping Out Developed in consultation with Stepping On leaders Stepping On model Similar format

21 STEPPING OUT Session 1: Introduction. Overview Session 2: The Exercises, Moving about safely Session 3: Home Hazards, Footwear Session 4: Vision and Falls, Community Safety Session 5: Medication Management, Vitamin D Session 6: Getting Out and About Session 7: Review and Plan Ahead 3 Month Booster 6 Month Booster

22 Learning Principles for working with individuals with cognitive impairment Reduced information Multi-sensory learning Repetition External Cues Procedural and Prospective Memory

23 Modifications Patients must attend with a partner Reduce content Increase physical activity in session (practice all exercises) Practice skills being discussed (e.g. walking while avoiding obstacles) Add opportunities for active learning Add constructive communication segment

Tandem walking Strength exercises performed 3 times per week Side-hip strengthening

24 Exercises Exercises are at the core of Stepping Out and taken directly from Stepping On Balance exercises performed daily Side stepping Sit to stands Tandem stance Tandem walking Strength exercises performed 3 times per week Side-hip strengthening exercise (hip abduction) Knee strengthening exercise (knee extension) Heel raises Toe raises

Strength exercises: increase number of repetitions, use ankle weights,

25 Exercises Progression of exercises Balance: reduce amount of upper body support, increase number of repetitions, holding position longer Strength exercises: increase number of repetitions, use ankle weights, reduce amount of upper body support Giving permission to snack on exercises

26 Advantages of Physical Therapists as Leaders Able to identify needs and implement changes immediately Extensive training and experience in: Progression and modification of exercises Safe mobility strategies and fall risk assessment Training of functional mobility (sit to/from stand, floor transfers, etc.) Assistive devices and home safety equipment

27 OUTLINE Background Theoretical underpinnings of the Stepping Out model Recruitment Program content and modifications Outcome measures and findings Successes and challenges from the initial pilot program Next Steps

28 Outcome Measures Timed Up and Go (TUG) Assesses mobility, balance, walking ability and fall risk in older adults Normal healthy elderly individuals usually complete the task in 10 seconds or less Very frail or weak elderly individuals with poor mobility may take 2 minutes or more Timed Up and Go Cognitive (TUGcog) Participants asked to count backward from 100 by 3s while completing TUG Participant should be counting backward and walking simultaneously 5 Times Sit to Stand Assesses lower limb functional strength

Outcome Measures Functional Reach Test Dynamic balance test Assesses individual s ability to maintain balance during a functional task 10 Meter Walk Test Used to calculate

29 Outcome Measures Functional Reach Test Dynamic balance test Assesses individual s ability to maintain balance during a functional task 10 Meter Walk Test Used to calculate gait speed Household ambulators 0.18 m/s Limited community ambulators m/s Community ambulators m/s Normal walking speed/ability to cross street 1.34 m/s

30 Findings to date Preliminary results NOT statistically significant. Performance measures averaged over two classes (8 vets): Timed Up and Go (TUG): seconds (improved mobility) TUG with cognitive task (TUGcog): seconds (improved mobility) Functional Reach: inches (reduced reach) Gait Speed: m/ sec. (faster walk rate) Timed Sit to Stand: seconds (improved mobility) Total falls by both groups before intervention (within 4 month window): 22 Total falls by both groups following intervention (within 4 month window) : 4 Total hospital visits due to fall by both groups before intervention: 3 Total hospital visits due to fall by both groups after intervention: 0

31 Self Report measures Zarit Burden Scale points (less worried) Falls Behavioral Scale points (more careful with behavior) Falls Efficacy Scale points (less worried about engaging in activity)

32 Outline Background Theoretical underpinnings of the Stepping Out model Recruitment Program content and modifications Outcome measures and findings Successes and challenges from the initial pilot program Next Steps

33 Successes People with cognitive impairment can benefit from cognitively based program Fewer falls and more awareness Caregivers derive support from program

34 Challenges Communication Adherence: Not everyone performed their exercises at home Insight: Some participants did not think they needed to exercise

35 Challenges Medically frail population; not sure whether this would be as true in non-veteran group Varying weekly attendance Securing space within Green Bay VA CBOC for 12 adults, availability of chairs without wheels Lack of partner availability for all participants

36 Risk Profiles for Injurious Falls in People Over 60: A Population-Based Cohort Study Ek et al., (2018) Cluster 1: Healthy Cluster 2: Well-functioning with multi-morbidity Cluster 3: Well-functioning, with multi-morbidity and high medication Cluster 4: Physically and cognitively impaired Cluster 5: Disabled

37 Increasing motivation Intrinsic vs. extrinsic motivation (Deci and Ryan) Tricky in MCI 3 Basic Needs: Autonomy: By doing exercises, I remain autonomous vs. Competence Relatedness By doing exercises, my wife stops nagging

38 OUTLINE Background Theoretical underpinnings of the Stepping Out model Recruitment Program content and modifications Outcome measures and findings Successes and challenges from the initial pilot program Next Steps

39 Next steps Increase intrinsic motivation, perception, pursuit of autonomy, competence Discuss their interest in Stepping Out Discuss falls they generate every week Discuss their goals, suggestions for adherence & fall prevention Consider level of disability, comorbidity: risk of injurious falls increase with increasing comorbidities (Ek et al, 2018) E x p a n d

41 Acknowledgements Greater Green Bay Foundation WIHA Deb Urben Lynn DeWitt Tayna Didier Kyle Newkirk Denver Johnson Milo C. Huempfner GB VA Jane Mahoney Lindy Clemson Betsy Abramson Shannon Myers

42 Thank You!

Exercise, Physical Therapy and Fall Prevention

Exercise, Physical Therapy and Fall Prevention University of Davis Medical Center Rosy Chow Neuro Clinical Specialist Physical Therapist Outline of Talk Role of Physical Therapy in care of people with