An important intervention for patients with dementia and their family is education about fall risks and prevention strategies.
Falls are a complex and multifactorial issue that can result in patient injury and morbidity, especially in older adults. People with dementia are 5 times more likely to be institutionalized than people with dementia who do not fall (Myers et al., 1991).
Occupational therapists often educate patients about falls in general. What are some important factors that OTs should consider based on research?
Using assessments from PT and OT that classify patients based on their fall risk, is the patient a low, moderate, or high fall risk? In addition to the classification, consider looking at the underlying components of the assessment that helps you derive the score. For example, the morse fall scale itself looks at fall history, secondary diagnosis, ambulatory aid, mental status. You’ll see that a lot of these factors are related and there are repeating themes. Clients may benefit from continued balance exercise or outpatient balance programs.
In addition to ambulation, look at transfers, different surfaces, and the level of assist. Factors associated with higher fall risk include gait velocity, mean stride length, heel-to-heel base of support variability, and double support-time to be associated with an increased fall risk (Sterke et al., 2012). Gait, balance, and other body systems are all interconnected so remember not to consider just gait in isolation but remember to be holistic.
Train caregivers on fall safety considerations, gait belt use, level of assist, and level of supervision – including at night during sundowning.
Visual impairment has been known to be related to increased fall risk. Educate on being up to date with eye exams, visual adaptations, and other medical referrals. The environment can be addressed to improve visual function. See post on some interventions. See this post on quick visual screening for evaluations.
Medication side effects can result in increased falls. However, the medication class, in general, can also be related to increased falls. Medications with CNS effects such as antipsychotics, anxiolytics, hypnotics, sedatives, and antidepressants—were uniformly associated with an increased fall risk (Fernando et. al, 2017).
Taking multiple prescribed medications (four) is also associated with increased fall risk. As populations such as older adults often take multiple medications, OTs can educate patients and their caregivers that in general that they are at a higher fall risk just by nature of their condition and need to take multiple medications. Empower patients to talk to their doctor about updating their medication list and potentially reducing the amount they need to take daily.
Factors such as verbal disruption, attention-seeking behavior, anxiety, and impulsivity are associated with increased fall risk (Pellfolk et al., Whitney et al.). Based on my intuition, other potential conditions and symptoms e.g., depression, are also likely to increase fall risk as well. Consider addressing symptoms such as anxiety to reduce likelihood of falls.
Severity of Dementia
Clinical measures such as the Alzheimer’s Disease Assessment Scale can help to determine the severity of fall risk. Diagnostically, grade 2 periventricular white matter lesions adjacent to the lateral entricle were associated with increased falls. Deep white matter grade 1-3, grade 1 PWML, or silent brain infarction were not associated with falls (Horikawa et al., 2005).
Therapists often consider the fall history for patients with dementia for potential falls. Address fear of falling (psychosocial), and review the history of what caused prior falls and if they can be addressed to prevent the same incident from occurring in the future. As patients may be unreliable historians, it is important to obtain this information from caregivers if possible.
Function – at the heart of OT, what is the patient motivated by and interested in doing? In later state dementia, falls prevention programs sound good in general, but are patients really motivated to go to these classes? Consider other activities that are meaningful that the patient wants to participate in with social aspect, e.g. dancing with grandchildren, sports activities, walking etc.
Fernando, E., Fraser, M., Hendriksen, J., Kim, C. H., & Muir-Hunter, S. W. (2017). Risk factors associated with falls in older adults with dementia: a systematic review. Physiotherapy Canada, 69(2), 161-170.
Horikawa E, Matsui T, Arai H, et al. . Risk of falls in Alzheimer’s disease: a prospective study. Intern Med. 2005;44(7):717–21.
Myers, A. H., Baker, S. P., Van Natta, M. L., Abbey, H., & Robinson, E. G. (1991). Risk factors associated with falls and injuries among elderly institutionalized persons. American journal of epidemiology, 133(11), 1179-1190.
Pellfolk T, Gustafsson T, Gustafson Y, et al. . Risk factors for falls among residents with dementia living in group dwellings. Int Psychogeriatr. 2009;21(1):187–94.
Sterke CS, van Beeck EF, Looman CWN, et al. . An electronic walkway can predict short-term fall risk in nursing home residents with dementia. Gait Posture. 2012;36(1):95–101.
Whitney J, Close JCT, Lord SR, et al. . Identification of high risk fallers among older people living in residential care facilities: a simple screen based on easily collectable measures. Arch Gerontol Geriatr. 2012;55(3):690–5.
Whitney J, Close JCT, Jackson SHD, et al. . Understanding risk of falls in people with cognitive impairment living in residential care. J Am Med Dir Assoc. 2012;13(6):535–40.