139 Research in Gerontological Nursing • Vol. 10, No. 3, 2017 Falls are a significant cause of morbidity and mortality among older adults, despite continued research to iden- tify preventive measures (Cigolle et al., 2015). Falls occur in 30% of community-dwelling older adults and rates are higher among those who are institutionalized (Centers for Disease Control and Prevention [CDC], 2016). Deaths from falls may be increasing due to the growing aging pop- ulation, improved reporting of falling as a cause of death, and increased chronic diseases (Stevens & Rudd, 2014). One growing subgroup of older adults at risk for falling is those with mild cognitive impairment (MCI) and early- stage dementia. Fall prevention interventions tailored to these special populations may help reduce fall rates. Older adults with neurocognitive disorders, such as Alzheimer’s disease and MCI, have long been identified as having a high risk of falling (Morris, Rubin, Morris, & Mandel, 1987). ese conditions are common worldwide. e World Health Organization (2016) estimates that more than 47 million older adults have dementia, and rates of MCI range from 51 to 76.8 per 1,000 person years (Luck et al., 2010). With the U.S. population aging, the number of older adults with these conditions is expected to increase, which has implications for the future impact of falls. Numerous studies support the increased risk of falling in individuals with dementia and MCI. A recent system- atic review indicated that adults 60 and older with cogni- ABSTRACT Older adults with mild cognitive impairment (MCI) and early-stage dementia have an increased risk of falling, with risks to their health and quality of life. The purpose of the current integrative review was to evaluate evidence on fall risk and fall prevention in this population. Studies were included if they exam- ined falls or fall risk factors in older adults with MCI or early-stage dementia, or reported interventions in this population; 40 studies met criteria. Evidence supports the increased risk of falls in individuals even in the early stages of dementia or MCI, and changes in gait, balance, and fear of falling that may be related to this increased fall risk. Interventions included exercise and multifactorial interventions that demon- strated some potential to reduce falls in this population. Few studies had strong designs to provide evi- dence for recommendations. Further study in this area is warranted. [Res Gerontol Nurs. 2017; 10(3):139-148.] Dr. Lach is Professor of Nursing, School of Nursing, Saint Louis University, St. Louis, Missouri; Dr. Harrison is Associate Professor of Nursing, West Chester University of Pennsylvania, West Chester, Pennsylvania; and Dr. Phongphanngam is Faculty, University of Phayao School of Nursing– Thailand, Muang Phayao, Thailand. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Helen W. Lach, PhD, CNL, FGSA, FAAN, Professor of Nursing, School of Nursing, Saint Louis University, 3525 Caroline Mall, St. Louis, MO, 63104; e-mail: [email protected]. Received: June 28, 2016; Accepted: August 12, 2016 doi:10.3928/19404921-20160908-01 Falls and Fall Prevention in Older Adults With Early-Stage Dementia An Integrative Review Helen W. Lach, PhD, CNL, FGSA, FAAN; Barbara E. Harrison, PhD, APRN, GNP-BC, FGSA; and Sutthida Phongphanngam, PhD, APN State of the Science
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139Research in Gerontological Nursing • Vol. 10, No. 3, 2017
Falls are a significant cause of morbidity and mortality among older adults, despite continued research to iden-tify preventive measures (Cigolle et al., 2015). Falls occur in 30% of community-dwelling older adults and rates are higher among those who are institutionalized (Centers for Disease Control and Prevention [CDC], 2016). Deaths from falls may be increasing due to the growing aging pop-ulation, improved reporting of falling as a cause of death, and increased chronic diseases (Stevens & Rudd, 2014). One growing subgroup of older adults at risk for falling is those with mild cognitive impairment (MCI) and early-stage dementia. Fall prevention interventions tailored to these special populations may help reduce fall rates.
Older adults with neurocognitive disorders, such as Alzheimer’s disease and MCI, have long been identified as having a high risk of falling (Morris, Rubin, Morris, & Mandel, 1987). These conditions are common worldwide. The World Health Organization (2016) estimates that more than 47 million older adults have dementia, and rates of MCI range from 51 to 76.8 per 1,000 person years (Luck et al., 2010). With the U.S. population aging, the number of older adults with these conditions is expected to increase, which has implications for the future impact of falls.
Numerous studies support the increased risk of falling in individuals with dementia and MCI. A recent system-atic review indicated that adults 60 and older with cogni-
ABSTRACT
Older adults with mild cognitive impairment (MCI) and early-stage dementia have an increased risk of falling, with risks to their health and quality of life. The purpose of the current integrative review was to evaluate evidence on fall risk and fall prevention in this population. Studies were included if they exam-ined falls or fall risk factors in older adults with MCI or early-stage dementia, or reported interventions in this population; 40 studies met criteria. Evidence supports the increased risk of falls in individuals even in the early stages of dementia or MCI, and changes in gait, balance, and fear of falling that may be related to this increased fall risk. Interventions included exercise and multifactorial interventions that demon-strated some potential to reduce falls in this population. Few studies had strong designs to provide evi-dence for recommendations. Further study in this area is warranted.[Res Gerontol Nurs. 2017; 10(3):139-148.]
Dr. Lach is Professor of Nursing, School of Nursing, Saint Louis University, St. Louis, Missouri; Dr. Harrison is Associate Professor of Nursing,
West Chester University of Pennsylvania, West Chester, Pennsylvania; and Dr. Phongphanngam is Faculty, University of Phayao School of Nursing–
Thailand, Muang Phayao, Thailand.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Helen W. Lach, PhD, CNL, FGSA, FAAN, Professor of Nursing, School of Nursing, Saint Louis University, 3525 Caroline
tive impairment were twice as likely to have fallen as those without cognitive impairment (Muir, Gopaul, & Montero Odasso, 2012). Fischer et al. (2014) noted an increase in falls for every decline in score on the Short Portable Mental Status Questionnaire in an older sample when followed for more than 1 year. Another study found the incidence of falls increased approximately eight times in older adults with dementia when compared to healthy older adults (Allan, Ballard, Rowan, & Kenny, 2009).
Changes to brain function noted in cognition, balance, and gait may be responsible for increased fall risks in these populations. Risk factors for falls include disease-specific motor impairment, vision impairment, type and severity of dementia, behavioral problems, impaired function, history of falls, and low bone mineral density (Härlein, Dassen, Halfens, & Heinze, 2009). Research has found gait, balance, and physical performance associated with cogni-tive impairment and falls (Taylor et al., 2014). All of these factors may contribute to the increased risk of falling in dementia.
Neurocognitive changes that begin in MCI and early stages of dementia appear to impact fall risk. Mechanisms hypothesized to account for this increased risk include impaired executive function (e.g., attention, planning), which in turn impact gait characteristics such as speed, stride, and dynamic balance, and ability to complete dual tasks (Beauchet et al., 2008). Delbaere et al. (2012) identi-fied changes in executive function that increased fall risk among community-dwelling older adults.
Interventions for fall prevention may be different for individuals in the early stages of dementia than those with more advanced disease, as cognitive abilities and func-tion become more impaired. Several recent reviews have addressed fall prevention in individuals with dementia (Booth, Logan, Harwood, & Hood, 2015; Burton et al., 2015; Guo, Tsai, Liao, Tu, & Huang, 2014; Hauer, Becker, Lindemann, & Beyer, 2006; Meyer, Hill, Dow, Synnot, & Hill, 2015), but do not focus specifically on samples with early-stage disease. Therefore, the purpose of the current article is to present a review of the literature on the risk factors for falls and interventions to aid prevention in individuals with MCI or early-stage dementia, and identify implications for practice and future research.
METHODThe current review was conducted based on the methods
described by Russell (2005) and Whittemore and Knafl (2005). CINAHL, SCOPUS, OVID Medline, EMBASE, PsycINFO, and Eric were searched using the terms “falls,”
“accidental falls,” “Alzheimer’s disease,” “dementia,” “mild cognitive impairment,” “cognitive impairment,” and “fear of falling,” without limits, through December 2015. The initial search yielded 2,235 articles. Duplicates were removed and titles and abstracts were reviewed for rel-evance; 177 studies were retrieved. After final review by at least two of the current authors, 35 articles met inclu-sion criteria. An additional 27 studies were identified for review through an ancestry search. A total of 40 studies met criteria for the final review (Figure).
Research studies were included if they were published in English and addressed falls in individuals with early-stage dementia/Alzheimer’s disease or MCI. Studies were included if MCI or mild severity of dementia was deter-mined by diagnosis or mental status testing. Samples had to have a mean score >20 on the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) or the equivalent level on other cognitive tests. Other tests included the Clinical Dementia Rating (Hughes, Berg, Dan-ziger, Coben, & Martin, 1982; Morris, 1993), Short Blessed Information–Memory–Concentration test (Katzman et al., 1983), and Montreal Cognitive Assessment (Nasreddine et al., 2005). If studies included participants with other levels of cognitive impairment, they were included if results for those with MCI were reported separately. Studies were excluded if they were not published in English (n = 2), did not address falls (n = 11), were not research studies (n = 36), or did not study older adults with early-stage dementia/Alzheimer’s disease or MCI (n = 106). Informa-tion sources did not include books, theses, dissertations, or conference proceedings (n = 9).
Data were extracted on study details and findings and put into a literature matrix. Analysis was conducted to synthesize methods and findings of studies and iden-tify themes related to falls and early-stage dementia. After review of the selected studies, three main categories of findings emerged: (a) increased risk for falls, (b) factors related to increased fall risk (i.e., gait, balance, and fear of falling), and (c) interventions. A review of studies in each category follows.
FINDINGSAll but one study included in the current review
was published in the past 10 years, with most published between 2010 and 2015 (Table A, available in the online version of this article). Researchers were from a range of countries, including the United States, Canada, Australia, and Brazil, as well as Asian, European, and Eastern European countries. Methods ranged from descriptive
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and observational designs to quasi-experimental and randomized controlled trials (RCTs). A variety of methods were used to identify MCI or early-stage dementia. One study addressed MCI subtypes of amnestic and non-amnestic MCI (Petersen, 2011). Amnestic MCI is defined as memory impairment but no detectable execu-tive or attentional impair-ment (Verghese et al., 2008). Non-amnestic MCI is defined as no detectable memory impairment but documented decline in at least two other cognitive functions, such as language, attention, and fluency (Albert et al., 2011). Some studies used the cognitive tests noted above, and all studies but one reported sample mean scores on the MMSE (Table A).
Increased Risk of FallingTen studies explored the risk of falling in individuals
with MCI and early-stage dementia. Ryan, McCloy, Rundquist, Srinivasan, and Laird (2011) found poor scores on the Physical Performance Test and use of a gait aid associated with a history of falls in individuals with mild Alzheimer’s disease (N = 43). Gleason, Gangnon, Fischer, and Mahoney (2009) conducted a secondary analysis of falls in older adults from the control group of a RCT (N = 172), and reported increased falls over 1 year associated with each decrement in MMSE scores ranging from 22 to 29. In a 1-year prospective case-control study (Taylor, Delbaere, Lord, Mikolaizak, & Close, 2013), par-ticipants with cognitive impairment (n = 138) had in-creased fall risk (as measured by physical performance measures) compared to cognitively intact control partici-pants (n = 276). Likewise, Suttanon, Hill, Said, and Dodd (2013) found greater falls and fall risk in individuals with mild Alzheimer’s disease (n = 15) compared to normal controls (n = 15; p = 0.003).
Four of these studies measured self-reported falls. Mea-surements varied and defined individuals with one fall in 12 months, more than one fall in 12 months, and any fall in the past 4 months as “fallers.” Taylor, Delbaere, Mikolaizak, Lord, and Close (2013) measured both single fallers and multiple fallers (N = 63) over 12 months and reported 54% reported at least one fall and 35% reported two or more falls. Makizako et al. (2013) reported that 26.2% of par-ticipants (N = 42) reported at least one fall over 1 year. The percentage of fallers ranged from 10% to 42% (Montero-Odasso, Muir, & Speechley, 2012; Taylor, Delbaere, Lord, et al., 2013; Uemura et al., 2014).
Three studies had prospective cohort designs. Delbaere et al. (2012) reported increased falls over 1 year for individuals with MCI (n = 77, odds ratio [OR] 1.72; 95% confidence interval [CI] [1.03, 2.89]) compared to normal controls (n = 342). The risk was even higher in partici-pants with non-amnestic MCI (n = 58, OR 1.98; 95% CI [1.11, 3.53]). In another study of individuals ages 70 to 80 (91 with MCI, 58 without MCI), MCI and a history of falls was a significant predictor of decline in mobility, but not an increase in fall risk (Davis et al., 2015). Taylor, Lord,
Delbaere, Mikolaizak, and Close (2012) found a high rate of falls in a sample of older adults with cognitive impair-ment (N = 177); 65% of participants had at least one fall and 43% had two or more falls. Most studies consistently showed that individuals with MCI/early-stage dementia have an increased risk of falls.
Changes in Gait and BalanceSix studies identified impaired standing balance, one
leg standing time, and postural sway as associated with increased risk of falls in individuals with MCI (Beauchet et al., 2008; Liu-Ambrose, Ashe, Graf, Beattie, & Khan, 2008; Makizako et al., 2013; Mignardot, Beauchet, Annweiler, Cornu, & Deschamps, 2014; Pedersen et al., 2014; Suttanon et al., 2012). Two studies found postural changes related to balance among individuals with MCI. Uemura, Hasegawa, Tougou, Shuhei, and Uchiyama (2015) found delays in postural control (longer time in anticipatory postural adjustment) associated with a history of falling among 376 older adults with MCI. Shin, Han, Jung, Kim, and Fregni (2011) used posturography with eyes open and closed and reported increased mediolateral sway speed and distance (but not anteroposterial) among individuals with MCI compared to normal controls.
Seven studies examined gait characteristics under single task conditions (STCs) among individuals with MCI (Bura-cchio, Dodge, Howieson, Wasserman, & Kaye, 2010; Ceder-vall, Halvorsen, & Aberg, 2014; Eggermont et al., 2010; Liu-Ambrose et al., 2008; Makizako et al., 2013; Pedersen et al., 2014; Verghese et al., 2008). Research designs included cross-sectional (n = 4) and longitudinal (n = 3).
Three longitudinal studies found that (a) older adults had a decline in gait speed that occurred up to 12 years before MCI diagnosis (Buracchio et al., 2010), (b) gait speed and step length declined over 2 years (Cedervall et al., 2014), and (c) those who reported a fall had significantly slower gait speed and poorer one leg balance standing times over 12 months (Makizako et al., 2013). The four cross-sectional studies also found slower gait speeds in the 4-m walk test (Eggermont et al., 2010), 2.4-m mea-surement during a 6.6-m walk test (Doi et al., 2015), and straight and curved walking paths (Pedersen et al., 2014) and motorized walkways (Verghese et al., 2008). Doi et al. (2015) found slow gait speed and MCI were independently associated with falling (p < 0.05), and that individuals with MCI and slow gait speed had the highest risk for falling (adjusted OR 1.99; 95% CI = [1.08, 3.65]).
Six studies examined gait characteristics under dual task conditions (DTCs) among individuals with MCI
(Boripuntakul et al., 2014; Cedervall et al., 2014; Coelho et al., 2012; Montero-Odasso et al., 2012; Muir, Speechley, et al., 2012; Taylor, Delbaere, Mikolaizak, et al., 2013). DTCs involve use of attentional resources or distraction activities while walking, which can vary in complexity. This phenomenon was identified early as a fall risk (Cami-cioli, Howieson, Lehman, & Kaye, 1997). Two studies compared gait characteristics between STCs and DTCs using counting backwards tasks (Boripuntakul et al., 2014; Coelho et al., 2012) of varying difficulty (i.e., counting backward by one, three, or seven). One study used two naming tasks (naming human names and animals) as the DTC (Cedervall et al., 2014), whereas two studies com-pared three DTCs (naming animals, counting backward by one and seven from 100) (Montero-Odasso et al., 2012; Muir, Speechley, et al., 2012). One study compared simple walking with walking while counting backwards and walking while carrying a glass of water (Taylor, Delbaere, Mikolaizak, et al., 2013). Research studies included cross-sectional (n = 5) and longitudinal (n = 1) designs.
Results for DTC studies using counting or spelling backwards found that gait speed (and other characteris-tics) declined and variability (e.g., step length, step width, cadence) increased (Boripuntakul et al., 2014; Coelho et al., 2012). Significant correlations between fluency (naming of animals) and executive function (Clock Drawing scores), and DTC gait characteristics (e.g., cadence, stride length, velocity) were found in a sample (N = 50) of par-ticipants with early-stage dementia (Bruce-Keller et al., 2012). Researchers from another study compared differ-ent DTCs using naming tasks (names and animals) and found that gait speed (6-minute walk test) and step length (using a computerized motion capture system) declined in all DTCs over a 2-year period (Cedervall et al., 2014). Steeper declines in gait speed occurred when naming ani-mals compared to human names and this difference per-sisted over the 2-year follow up. When comparing DTCs of counting backward to carrying a glass of water, Taylor, Delbaere, Mikolaizak, et al. (2013) found significantly slower gait speed and increased gait variability when par-ticipants were counting. In the two studies comparing three different DTCs, individuals with amnestic MCI had significantly slower gait speed and demonstrated the highest DTC declines in gait speed in all three DTCs (i.e., counting, naming, and serial seven subtraction) (Muir, Speechley, et al., 2012). One study found that individuals with amnestic MCI had slower gait speeds compared to those with non-amnestic MCI and steeper declines in gait speed and stride times in all DTCs (Montero-Odasso et
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al., 2012). Interestingly, Taylor, Delbaere, Mikolaizak, et al. (2013) compared a simple task, a functional dual task (carrying a glass of water), and a cognitive DTC (counting backward from 30) and found no significant differences by gait condition in a sample with MCI, suggesting DTCs may not provide additional benefit in fall risk assessment compared to STCs.
Fear of FallingFear of falling is a risk factor for falls and common in
older adults with MCI. The prevalence in three studies was noted to be 53.4% (Uemura et al., 2012), 50.6% (Uemura et al., 2014), and 74% (Borges Sde, Radanovic, & Forlenza, 2015). Although the prevalence was high, Uemura et al. (2012) did not find fear of falling associated with memory decline. Uemura et al. (2014) conducted a 15-month follow-up study in community-dwelling older adults and found that those with MCI were more likely to develop a fear of falling than healthy participants after controlling for age, gender, educational level, living alone, MMSE scores, walking speed, timed up and go scores, walking aid use, depression, self-reported health status, and number of medications (OR 1.41; 95% CI [1.07, 1.87]). This risk increased considerably for participants who also had a fall (OR 7.34; 95% CI [4.06, 13.3]).
One study included a new measure of fear of falling for older adults with MCI or dementia (Delbaere, Close, Taylor, Wesson, & Lord, 2013). The measure was icono-graphic, with pictures and short phrases used rather than text. When tested in older adults with early-stage dementia (N = 50), the measure had good internal consistency and could discriminate between groups based on fall risk fac-tors. Overall, fear of falling was common in this population and may be another factor related to increased fall risk in individuals with MCI.
Intervention StudiesEight studies addressed interventions to reduce falls
or fall risks among older adults with MCI and early-stage dementia. Most were pilot studies with small samples; only one was a large RCT (Mahoney et al., 2007). Interventions included group exercise (Ries, Drake, & Marino, 2010) or home-based exercises either alone (Kovács, Sztruhár Jónásné, Karóczi, Korpos, & Gondos, 2013; Suttanon, Hill, Said, Williams, et al., 2013) or combined with other components (Hagovská & Olekszyová, 2015; Mahoney et al., 2007; Wesson et al., 2013; Yao, Giordani, Algase, You, & Alexander, 2013). The length of exercise interventions ranged from exercise sessions two times per week for
8 weeks to 12 months, to a 6-month home-based program of strengthening and walking.
Other interventions included home visits from a physical therapist or nurse (Mahoney et al., 2007; Suttanon, Hill, Said, Williams, et al., 2013; Wesson et al., 2013), home hazard reduction (Wesson et al., 2013), and education (Suttanon, Hill, Said, Williams, et al., 2013). One study explored a technological intervention of special lighting leading from the bed to bathroom at night, along with an electronic bracelet and emergency response system (Tchal-la et al., 2013). Yao et al. (2013) designed a tai chi interven-tion to be performed with a caregiver and added a reward component. In another study, Hagovská and Olekszyová (2015) compared daily 10-week balance training sessions combined with a cognitive training program to balance training alone.
Outcomes of studies included falls (Kovács et al., 2013; Mahoney et al., 2007; Suttanon, Hill, Said, Williams, et al., 2013; Tchalla et al., 2013; Wesson et al., 2013), fall risks (Suttanon, Hill, Said, Williams, et al., 2013; Wesson et al., 2013), balance (Hagovská & Olekszyová, 2015; Ries et al., 2010; Suttanon, Hill, Said, Williams, et al., 2013; Yao et al., 2013), gait (Kovács et al., 2013; Ries et al., 2010; Suttanon, Hill, Said, Williams, et al., 2013), and hospitalizations and nursing home admissions (Mahoney et al., 2007). Most studies had non-significant findings, most likely due to small samples. Hagovská and Olekszyová (2015) found improvements in gait speed and balance that were greater in the experimental group who received cognitive training with exercise. In most studies, the interventions were feasible to implement, with some benefits to participants. Alternatively, adherence to the 6-month home-based exer-cise intervention was poor (Suttanon, Hill, Said, Williams, et al., 2013).
The one large RCT (N = 349) was not targeted specifi-cally to individuals with MCI, but rather a community pop-ulation (Mahoney et al., 2007). The intervention included home visits and follow-up telephone calls, a balance exer-cise plan, and referrals. Fewer falls were seen in individuals with MMSE scores <27 (mean MMSE scores >20). In addi-tion, fewer hospitalizations, nursing home admissions, and nursing home days were noted among participants who lived with someone. The findings suggest that the inter-vention may benefit individuals with early-stage dementia who have caregivers.
DISCUSSIONThe current review examined research on falls and
fall prevention in older adults with MCI or early-stage
dementia, addressing a gap in the prior literature. Although the increased risk of falls for individuals with dementia has long been noted, the literature specific to MCI or early-stage dementia was recent. Studies were mostly from the past 5 years, most likely due to the increased interest in early stages of dementia, as well as improved identifica-tion of MCI and Alzheimer’s disease in the early stages. Although the U.S. Preventive Services Task Force (2014) did not find sufficient evidence to recommend routine dementia screening of older adults, they encourage evalu-ation of early signs of cognitive impairment, as advocated by the Alzheimer’s Association (2016). These studies con-firm the need to evaluate cognitive changes because even in early stages they are associated with an increased risk of falling. The current review identified key changes in gait and balance that may be detected through testing and potential interventions for this population. When there is early identification of MCI or Alzheimer’s disease, fall risks must be addressed.
Researchers consistently identified an increased fall risk among older adults with MCI and early-stage dementia. Stronger evidence was found in the current review than in the review by Harlein et al. (1999), who reviewed studies with a broader severity of dementia. Stronger evidence included prospective studies following individuals over 1 year with strong designs to track fall events. Fall rates were double (30% versus 65%) those for the general older population (CDC, 2016). Further, fall risk appears to increase as cognition declines, with higher risk of falling with a decline in MMSE scores (Gleason et al., 2009). A meta-analysis on the risk for falls in older adults by Muir, Gopaul, et al. (2012) found cognitive impairment increased the risk for falls and falls with serious injuries, but did not identify the level of decline at which the risk begins. The current review found some evidence that fall risk increases early, but further research with larger samples and longitu-dinal designs is needed to confirm these findings.
After reviewing studies on gait and balance related to falls, the current authors found the state of the science is still emerging and that there is a need for research to more clearly identify gait and balance changes that occur with MCI and its subtypes. Older adults with MCI have declines in cogni-tive and ambulatory functions, and researchers are explor-ing a mutual explanation for these outcomes. The research on gait characteristics during STCs and DTCs is especially interesting. Some DTCs simulate real-world environments and identify deficits in planning and executing steps in com-plex pathways (Taylor, Delbaere, Mikolaizak, et al., 2013; Uemura et al., 2015). However, their real value may lie in
their ability to unmask declining cognitive reserve, demon-strating the cognitive effort (i.e., selective attention) needed for safe ambulation in challenging settings. The DTC design provides measurement of the cognitive contribution to safe gait and balance so that future DTC testing may be a part of screening for MCI.
The methodology for assessment of balance and gait has changed significantly over the past two decades. An early study of the effect of DTCs on gait (Camicioli, Bouchard, & Licis, 2006) had participants walk a hallway while reciting male and female names. Methods are now more sophis-ticated with the use of posturography (Shin et al., 2011), computerized walkways (Taylor, Delbaere, Mikolaizak, et al., 2013), and software that measures anticipatory postural reactions (Uemura et al., 2015). These methodologies may soon be useful for clinical assessment of balance and gait in populations newly diagnosed with MCI or early-stage dementia. Future studies may be able to tailor fall preven-tion interventions based on the “motor signature” of MCI (Montero-Odasso et al., 2014, p. 1415).
Recent studies confirmed that performing tasks while walking had adverse effects on gait and balance character-istics (e.g., speed, number of steps, variability) and those changes are associated with falling in an MCI population. Interventions aimed at reducing falls in an MCI population may need to focus on minimizing tasks during ambulation. Future intervention studies could teach groups about mindfulness during walking and other tasks to explore changes in fall risks.
Fear of falling was not widely addressed, but researchers found rates of 50% to 74%. This finding is similar to the highest rates in general populations of older adults; how-ever, most rates are closer to 35% to 50% (Lach, 2005). Fear of falling may be more common in older adults with MCI or early-stage dementia than those with normal cognition. The development of the iconographic measure (Delbaere, Close, Taylor, Wesson, & Lord, 2013) may improve screening to provide more evidence to understand fear of falling as a risk factor for falls in this population.
Other factors or mechanisms for falls have been noted in populations with dementia, but were not studied in older adults with early-stage dementia or MCI, warranting further research. These factors/mechanisms include orthostatic hypotension and depression, as noted by Allan et al. (2009), and vision (Härlein et al., 2009). Vitamin D supplementation was not studied (Guo et al., 2014). Epstein, Guo, Farlow, Singh, and Fisher (2014) explored fall risk associated with dementia drugs, but not in an early-stage population.
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The few intervention studies targeting older adults with MCI or early-stage dementia were primarily pilot studies or had small samples, indicating a need for more research with strong designs to determine appropriate fall preven-tion interventions. The large RCT was not targeted to this population, but had a significant impact. Despite these limi-tations, most studies found some improvements in fall risk. The current findings are consistent with reviews focused on fall prevention in adults with a broader severity of dementia (Burton et al., 2015; Hauer et al., 2006; Muir, Gopaul, et al., 2012). Little overlap was noted between the current review and others, and included two articles in common with one review and two with another. Over the past 10 years, stud-ies continue to explore fall prevention and interventions, but little can be concluded from these findings.
Exercise was the most common intervention, with or without other components, but many types of exercises were used. The current authors cannot make specific rec-ommendations based on these findings; however, most interventions were found acceptable to participants and safe. In a meta-analysis of interventions for dementia of any severity level (Burton et al., 2015), exercise was effec-tive in reducing falls. Future research may focus on current evidence-based programs for fall prevention that include the exercise elements shown to help reduce falls, including balance, strength, and gait training (Panel on Prevention of Falls in Older Persons, American Geriatrics Society, & British Geriatrics Society, 2011). Tailoring interventions to the early-stage dementia population may be needed. A particularly interesting approach was the use of paired tai chi performed in tandem facing a caregiver and touching hands, as prior research has demonstrated benefits of tai chi (CDC, 2016). Pairing the activity with a caregiver may enhance the longevity of the exercise program for individ-uals with dementia.
Other interesting approaches to prevent falls included night lights, telehealth, and cognitive training. Further evaluation of these interventions is warranted. Technology for monitoring, testing, and assisting older adults, including those with dementia, continues to be developed and tested (Schulz et al., 2015). In addition, factors related to delivery success, such as involvement of a caregiver and group versus home-based programs, need further explo-ration. Overall, translation of fall prevention guidelines is needed for this population, as noted by Meyer et al. (2015). Other fall prevention approaches may be identified in the future as researchers learn more about the changes in cog-nition, gait, and balance related to fall risk among individ-uals with MCI or early-stage dementia.
LIMITATIONSThe current review’s method was narrative, so results
of the included studies were not able to be pooled. Studies were not excluded based on quality or level of evidence, as the purpose was exploratory. However, given the range of methods and topics, the findings provide an appropriate review of current research related to falls. Although there were exclusions and some studies may have been missed, the use of several databases and search of the references of retrieved articles resulted in a comprehensive search.
A possible limitation is the inclusion of studies that used varying methods to identify the severity of dementia among participants. However, over time, as diagnostic guidelines for MCI were developed (Petersen et al., 2014), it was noted that individuals with MCI were in a transi-tional state between expected cognitive declines of normal aging and early-stage dementia. Differentiating these conditions may be a challenge. Although various testing methods were used, only studies that used a standardized scale identifying early-stage were included to attempt to keep the samples across articles similar.
Methods used in these studies limit the strength of the evidence that can be drawn from them. Many small samples and pilot studies were found. Reasons for this may include the challenges in recruiting participants with dementia, limitations in funding, and the need for large samples to address fall prevention. Other limitations of designs were the variety of test measures used for some parameters (e.g., gait, balance), lack of a consistent definition of a fall, and a lack of strong measures to prospectively measure falls. Future research should draw on the recommendations for fall prevention studies (Lamb, Jørstad-Stein, Hauer, & Becker, 2005) and consider the use of multiple sites to increase sample sizes and follow participants over time.
CONCLUSIONThe current findings confirm the increased risk of
falling among older adults with MCI and early-stage dementia, warranting early diagnosis and attention to the significant issue of fall prevention. Risks and poten-tial interventions to reduce falls in this population were explored. Few recommendations can be made based on these findings and more research is needed to provide evidence for reducing falls in individuals with MCI and early-stage dementia. Given the lack of progress in re-ducing rates of falls and injuries in older adults, research on factors and interventions to reduce falls in important subgroups, such as individuals with early-stage dementia and MCI, should be a priority.
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