Lewy Body Dementia Association, Inc.

Incidence/Prediction of Falls in Dementia, including DLB+PDD
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Author:  robin [ Thu May 14, 2009 8:57 pm ]
Post subject:  Incidence/Prediction of Falls in Dementia, including DLB+PDD

In this UK study, there were 179 participants over age 65 including 38 with AD, 32 with vascular dementia, 30 with DLB, 40 with PDD, and 39 healthy controls. "A multifactorial assessment of baseline risk factors was performed and fall diaries were completed prospectively for 12 months. Dementia participants experienced nearly 8 times more incident falls than controls..." Those with a diagnosis of DLB or PDD were more likely to experience at least one fall. Those with OH (orthostatic hypotension - a drop in blood pressure upon standing) or autonomic symptoms (incontinence, constipation, etc) were more likely to experience falls; these symptoms can be managed. Interestingly, those with a high depression score were more likely to fall; this symptom can also be managed. "Higher levels of physical activity were protective."

The abstract is copied below along with a link to the webpage on which the article appears and a few excerpts.


http://www.plosone.org/article/info%3Ad ... ne.0005521 (full article is available for free)

Incidence and Prediction of Falls in Dementia: A Prospective Study in Older People

Louise M. Allan1*, Clive G. Ballard2, Elise N. Rowan1, Rose Anne Kenny3
1 Institute for Ageing and Health, Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, United Kingdom, 2 Wolfson Centre for Age Related Disorders, King's College London, London, United Kingdom, 3 Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Ireland

PLoS ONE 4(5): e5521. May 13, 2009


Falls are a major cause of morbidity and mortality in dementia, but there have been no prospective studies of risk factors for falling specific to this patient population, and no successful falls intervention/prevention trials. This prospective study aimed to identify modifiable risk factors for falling in older people with mild to moderate dementia.

Methods and Findings

179 participants aged over 65 years were recruited from outpatient clinics in the UK (38 Alzheimer’s disease (AD), 32 Vascular dementia (VAD), 30 Dementia with Lewy bodies (DLB), 40 Parkinson’s disease with dementia (PDD), 39 healthy controls).

A multifactorial assessment of baseline risk factors was performed and fall diaries were completed prospectively for 12 months.

Dementia participants experienced nearly 8 times more incident falls (9118/1000 person-years) than controls (1023/1000 person-years; incidence density ratio: 7.58, 3.11–18.5). In dementia, significant univariate predictors of sustaining at least one fall included diagnosis of Lewy body disorder (proportional hazard ratio (HR) adjusted for age and sex: 3.33, 2.11–5.26), and history of falls in the preceding 12 months (HR: 2.52, 1.52–4.17). In multivariate analyses, significant potentially modifiable predictors were symptomatic orthostatic hypotension (HR: 2.13, 1.19–3.80), autonomic symptom score (HR per point 0–36: 1.055, 1.012–1.099), and Cornell depression score (HR per point 0–40: 1.053, 1.01–1.099). Higher levels of physical activity were protective (HR per point 0–9: 0.827, 0.716–0.956).


The management of symptomatic orthostatic hypotension, autonomic symptoms and depression, and the encouragement of physical activity may provide the core elements for the most fruitful strategy to reduce falls in people with dementia. Randomised controlled trials to assess such a strategy are a priority.

A few excerpts:

"Dementia specific scales were used to assess activities of daily living (Bristol scale), depression (Cornell scale) and behavioural and psychological symptoms of dementia (Neuropsychiatric Inventory), in addition to detailed autonomic assessments as described below. These factors have all been postulated as potential causes of falls in dementia, particularly in the LB dementias." [LB = Lewy Body; LB dementias = DLB and PDD]

This article on the Cornell depression test might be worth reading:
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA (1988) Cornell Scale for Depression in Dementia. Biological Psychiatry 23: 271–284.

"Orthostatic hypotension (OH) was defined as a fall in systolic blood pressure of greater than 20 mm Hg or diastolic blood pressure of greater than 10 mm Hg that did not return to baseline within 30 seconds from the start of the active stand. Return to baseline was defined as the start of a series of 3 consecutive beats in which the blood pressure was within one standard deviation of the baseline blood pressure. Participants were asked to report symptoms on standing; if dizziness, lightheadedness, unsteadiness or presyncope were reported in the presence of OH this was defined as symptomatic OH."

"Other clinical autonomic function tests included isometric exercise, Valsalva manoeuvre and deep breathing. Ewing's battery was used to identify the presence of a clinical autonomic neuropathy for each patient who had complied with sufficient tests for the classification scheme to be applied."

"Univariate predictors of falls in dementia
Significant modifiable and non-modifiable predictors of falls in all participants with dementia are shown in table 3. Significant predictors included diagnosis of Lewy body disorder, history of falls or recurrent falls in the preceding 12 months, use of cardioactive medication, abnormal gait or balance score, Cornell depression score >=10, autonomic symptom scale >7, autonomic neuropathy, symptomatic OH and time taken for blood pressure to return to baseline on standing. Age and increased physical activity were protective.

However, when univariate analyses were stratified by diagnosis, only duration of dementia, history of falls or recurrent falls in the preceding 12 months, use of cardioactive medication, autonomic symptom scale greater than 7 and time taken for blood pressure to return to baseline on standing remained significant predictors of falls. Increased physical activity remained protective."

"Multivariate predictors of falls and recurrent falls in dementia
Significant potentially modifiable predictors were entered into multivariate analyses in the order: age, gender, Tinetti gait score, Cornell depression score, physical activity score, autonomic symptom score, symptomatic orthostatic hypotension, use of cardioactive medication and time for systolic blood pressure to return to baseline on standing.

In the first model including all participants with dementia, predictors retained were Cornell depression score, total autonomic symptom score and symptomatic orthostatic hypotension. In the second model, stratified by diagnosis, predictors retained were symptomatic orthostatic hypotension, use of cardioactive medication and physical activity score, which was protective (Table 4)."

In the largest prospective study of predictors of falls in dementia to date, we have demonstrated that older people with dementia experience 8 times more incident falls than those without dementia. These figures are even more striking when only community dwelling people with dementia are considered, with incidence in people with dementia nearly 10 times higher than in those without dementia. Patients with Lewy Body dementias (DLB or PDD) were at the highest risk, with DLB patients sustaining 6 times the number of falls in the control group and PDD 20 times more falls. The annual incidence of falls was higher in the LB dementias than in all other groups studied and much higher than any previous reports in older people. Incidence of falls was higher in PDD than in DLB."

"To our knowledge, this is the first study which has identified predictors specific to dementia, including the identification of non-modifiable predictors such as a diagnosis of Lewy body disorder, longer duration of dementia and previous history of falls or recurrent falls. These factors will be useful in identifying individuals at particular risk, who may benefit from further assessment and intervention. Even more importantly, a number of the predictors identified are potentially modifiable, and should be included as key elements of a multifactorial intervention. These factors included use of cardioactive medications, autonomic symptoms, symptomatic orthostatic hypotension, depression and limitation of physical activity. We suggest that interventions targeted towards these predictors could reduce the burden of falls related morbidity and mortality in community dwelling people with mild-moderate dementia."

"We believe that randomised multifactorial intervention trials to prevent falls in mild-moderate dementia should now be made a priority. Possible management strategies could include management of the potentially modifiable factors identified in this study; for example, the use of selective serotonin reuptake inhibitors for depression, manipulation of cardiovascular medications, adequate hydration and targeted drug therapies such as fludrocortisone and midodrine for OH. Such a focus would differ from multifactorial interventions in older people without dementia, which prioritise strength and balance exercises that are more difficult for those with impairment of recall to continue following initial intervention. It is possible that encouragement of overall physical activity may be successful in prevention of falls in dementia. However, such an approach may increase opportunities for falling in individuals at risk; similarly, aggressive treatment of motor features in LB dementias might increase activity related opportunities to fall, and also exacerbate OH. There is also a possibility that changes in psychotropic medication might result in side effects such as hypotension or somnolence, which could paradoxically increase the risk of falls. This emphasises the importance of the conduction of randomised controlled trials to ensure that modification of the risk factors identified is the correct strategy."

"We conclude that whilst the outcome of future trials are awaited best clinical practice should focus on identification and management of orthostatic hypotension, depression and maintenance of physical activity in individuals who do not have severely impaired gait and balance, whilst bearing in mind the need to monitor patients carefully because of the potential side effects of these changes."

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