Assessment and management of dementia in relation to falls risk: Tools and tips for community, hospital and residential care

Transcription

1 Assessment and management of dementia in relation to falls risk: Tools and tips for community, hospital and residential care Professor Jacqueline CT Close Neuroscience Research Australia Prince of Wales Clinical School University of New South Wales

2 Why is it important Annual falls incidence is 70-80%. Fractures are up to 3x commoner in people with dementia. Psychotropic drug use more common in people with dementia. 26% of admissions to hospital for people with dementia are fall related. When admitted to hospital, people with dementia have poorer outcomes including adverse events.

3 What do we need to know? Is this person cognitively impaired (screen). What domains of cognition seem to be affected most. How is it impacting on function. How will the identified impairments impact of potential choice of intervention/s. How will the impairments impact on how I deliver the intervention.

4 Is dementia subtype important in relation to falls assessment and management

5 Allan LM, Ballard CG, Rowan EN, Kenny RA (2009) Incidence and Prediction of Falls in Dementia: A Prospective Study in Older People. PLoS ONE 4(5): e5521. doi: /journal.pone

6 Testing Be clear as to why you are testing it should determine the choice of test Screening Assessment of undiagnosed cognitive decline Assessment with a view to tailoring falls prevention approach How will the information gathered affect your management

7 Tests AMTS MMSE / smmse MOCA RUDAS ACE-III

8 MMSE (Folstein 1975)

9 MMSE / SMMSE Affected by level of education, age & language Low reliability Too many easy items Wrongly used as a unidimensional tool Wrongly used to diagnose dementia Wrongly(?) used to justify prescription of cholinesterase inhibitors

10 Executive Function The ability to plan, organise, sequence tasks, problem solve etc. Simple clinical examples Clock drawing Verbal fluency letter, animals, supermarket Alternating hand sequence Luria s three step Trails A and B

11 MMSE 25 ACE-R 77

12 Verbal Fluency MMSE 26 ACE-R 72 MMSE 28 ACE-R 74 MMSE 28 ACE-R 78

13 Assessing cognition though gait assessment

14 Assessing cognition though gait assessment

15 Higher level gait disorder Apraxia - Inability to perform a skilled or learned act that cannot be explained by an elementary motor or sensory deficit or language comprehension disorder.

16 Assessment of gait Initiation of gait Posture Velocity (m/s) Cadence (steps/min) Armswing Foot clearance Step length (cm) Step length variability Stride length variability Impact of dual tasking Heel strike Turning / freezing

17 66 year old woman with multiple falls MMSE 24/30 and knee pain Painful knee but predominantly falling backwards Upright posture and gait apraxia Overall falls risk score 1.88

18 Cognitive Assessment Complex processing speed - slowed. Acquisition of new visual information - impaired Visuospatial skills - variable Problem solving skills - poor Orientation, attention, working memory and verbal memory skills remain preserved

19 How did the assessment help Explained functional decline which was being attributed to knee OA Provided clarity as to indication for TKR Prepared clinical team in advance of admission for TKR Realistic goals for rehabilitation and discharge planning Future planning

20 Intervention

21 Extrapolation from existing trials If the mechanism by which the intervention has it s effect is understood and not felt to affected by the presence of cognitive impairment / dementia then it is reasonable to extrapolate data from trials undertaken in cognitively intact populations Example. Treatment of osteoporosis

22 Intervention - Community Rate of falls Risk of falling Multicomponent group exercise (16, 22) RaR 0.71 ( ) RR 0.85 ( ) Multicomponent home exercise (7, 6) RaR 0.68 ( ) RR 0.78 ( ) Tai Chi (5, 6) RaR 0.72 ( ) RR 0.71 ( ) Multifactorial interventions (19, 34) RaR 0.76 ( ) RR 0.93( ) Vitamin D (7, 13) RaR 1.00 ( ) RR 0.96 ( ) OT intervention (6, 7) RaR 0.81 ( ) RR 0.88 ( ) Vision intervention (1) RaR 1.57 ( ) RR 1.54 ( ) Cataract extraction (1) RaR Bifocal / multifocal glasses (1) RaR 0.92 ( ) RR 0.97 ( ) Psychotropic withdrawal (1) RaR Pharmacy detailing - RR 0.61 ( ) Pacemakers (3) RaR Podiatry for painful feet (1) RaR Anti-slip shoe (1) RaR Increase knowledge/educate /CBT (2,6)

23 FOCIS - Prospective risk factor study. n=174

24 i-focis Pilot 2 Recruitment Baseline Measures & Randomisation INTERVENTION 26 weeks Exercise Program Re Assessment Measures Monthly Falls Calendars

25 Hospital Intervention - Hospitals Rate of falls Risk of falls General hospital setting Trained nurse targeting individual fall risk factors (1) _ RR 0.29 ( ) Multifactorial interventions (4, 3) RaR 0.69 ( ) RR 0.71 ( ) Orthogeriatric MoC (1, 1) RaR 0.38 ( ) RR 0.41 ( ) Subacute setting Exercise (1, 2) RaR 0.54 ( ) RR 0.36 ( ) Carpet flooring (1) RaR ( ) RR 8.33 ( )

26 SAC 2 Falls / 1000 OBDs 0.35 SAC2 falls / 1000 OBDs - POWH Jan-14 Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan-13 Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan-12 Dec Nov Oct Sep Aug Jul Jun May Apr Mar Feb Jan-11

27 No of tablets dispensed Hypnotic use - POWH Number of sedatives dispensed per month - POWH Jan-14 Nov Sep Jul May Mar Jan-13 Nov Sep Jul May Mar Jan-12 Nov Sep Jul May Mar Jan-11 Nov Sep Jul May Mar Jan Nov Sep Jul May Mar Jan-09 Nov Sept Jul May Mar Jan-08 Nov Sept Jul May Mar Jan-07 Nov Sept Jul May Mar Jan-06

28 milligrams milligrams milligrams Antipsychotic use - POWH POW Med & Surg: mg Haloperidol / mth Jan-11 Apr-11 Jul-11 Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan POW Med & Surg mg Olanzapine / mth Jan-14 Oct-13 Jul-13 Apr-13 Jan-13 Oct-12 Jul-12 Apr-12 Jan-12 Oct-11 Jul-11 Apr-11 Jan Jan-11 Mar-11 POW Med & Surg mg Risperidone/ mth May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep-12 Nov-12 Jan-13 Mar-13 May-13 Jul-13 Sep-13 Nov-13 Jan-14

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30 Intervention - RACFs Rate of falls Risk of falling Exercise (8,8) RaR 1.03 ( ) RR 1.07 ( ) Vitamin D (5,6) RaR 0.63 ( ) RR 0.99 ( ) Multifactorial interventions (7,7) RaR 0.78 ( ) RR 0.89 ( ) Post hoc analysis suggests that people in intermediate care facilities may benefit from exercise but in high level care the risk may be increased

31 How will the presence of cognitive impairment impact on how I deliver my intervention/s

32 Functional cognition Identifies underlying cognitive processes focuses on preserved cognitive abilities Helps tailor content and instruction process Helps educate carers re expectations for behaviour

33 Assessment of Functional Cognition

34 The Future

35 THE i-focis Overview RCT 360 subjects Diagnosis of cognitive impairment Community dwelling Carer 3.5hrs+/ week contact

36 THE i-focis Overview Can a professionally prescribed, carer assisted exercise and home hazard reduction program reduce falls in people with dementia Rate of falls (control 1.8 falls/yr 30% reduction, mean follow-up 11 months) Number of fallers Secondary aims function, QoL, uptake and adherence, cost and cost-effectiveness

37 Acknowledgements Morag Taylor Stephen Lord Cathie Sherrington Kim Delbaere Jacki Wesson Lindy Clemson Henry Brodaty Laura Gitlin Stef Mikolaizak Barbara Toson James Scandol