1. Staying upright and strong with dementia
Ngaire Kerse.
School of Population Health, Brain Research New Zealand, Faculty of Medical and Health Science, University of Auckland

2. Thank you from LiLACS NZ
The kaitiaki esp paea
The sites for the work
The participants
Thank you from LiLACS NZ

3. Te Puāwaitanga o Ngā Tapuwae Kia Ora Tonu-LiLACS NZ
Bay of Plenty and Lakes DHBs
Longitudinal cohorts – 2010
Māori years – Kaupapa methods
421 out 766 (56%)
Non Māori -85 years
516 out of 870 (59%)
Visit every year until death
Measures – Core and Full
Health, social, cultural, environmental
Multimorbidity, 15 diagnoses
Cognition – 3MS
Function
Social connections
Cultural practices
Have a process for data sharing,
an invitation
LilACs NZ
Emphasise the kaupapa Maori methods, M`aori investogators, maori project managers, maori interveiwers and recruiter,
Reasonable recruitment rate
Breadth of measures
Invitation to engage for analysis
Cohort profile: 2015 International Journal of Epidemiology

4. Prior falls and fracture: LiLACS NZ
Baseline: fall in last 12m
Predictors of prior fracture and prior fall are shown here. life time fracture was ascertained by self report so there is the potential for recall bias. These data with about 40-50% of people ever having a fracture by advanced age are roughly consistent with other nations studies of lifetime fracture risk.
Falls shown here are the proportion of the sample falling in the 12 months prior to Wave 1.
Any fractures in lifetime.
NonMaori Men 47 percent
NonMaori Women 52
Maori Men 48
Maori Women 34
Any fall – wmen were more likely to fall than men
UK fracture rates 48% women, 38% men by age 85
(Scholes S Age Ageing 2014)

5. Over 5 years
28 Māori and 74 non-Māori -fracture related hospitalizations
-3,700 person-years follow-up.
Accumulated fracture risk -5 years
20 per 1000 person years for Māori
34 per 1000 person years for non-Māori
non-Māori and women more fractures.

6. Hospitalisation from fracture – 5 yr

7. Causes of falls Intrinsic Extrinsic Acute illness Cardiovascular
Leg weakness
Stroke, Parkinsons
Extrinsic
Hazards
Other residents
Staff, processes

8. Prevention of falls Falls and balance retraining exercises
Home hazard assessment
Good medical care
Vitamin D

9. Home based
Exercises
Individualised
Progressive
Ankle weights
Walking 3 x week
6 visits over 6 months
Trained nurse
Physiotherapist

10. Otago Exercise Programme

11. Functional reserve and thresholds
eg.
muscle strength
reserve
threshold
Acute illness
30 Age (time) 80

12. Impacting the threshold
Athletes
eg.
Aerobic capacity
reserve
30 Age (time) 80
Hodgeson

13. What activities? 164 women, 103 men age 73.6 Walking, 2 hrs 30 / 2 wks
Oldest old had similar pattern

14. What about cognition Estimates in 80+ vary 5-20% dementia
Deloitte, economic impact of dementia is NZ 2012
Estimates in 80+ vary 5-20% dementia
No studies of incidence or prevalence in NZ
Incidence greater in non-European pops
Financial cost high esp res care
UK CFAS – 65+ yrs
8.3%
6.8%
Mathews FD, Lancet 2013

15. Accrued dementia prevalence -Māori

16. Accrued dementia prevalence -non-Māori
No diff by ethnicity, adj Age, sex, SES

17. Impact of dementia
Quality of life lower in those with dementia

18. Cognitive impairment & dementia
Global cognitive functioning
Normal ageing A B D1
Linguistic skill and general intelligence decline over decades D2 C
Symptomatic but pre-diagnostic phase with brain compensation occurring, over several years D E
Symptomatic & post-diagnosis phase, with progressive decline over years
Dementia trajectory
Time

19. Falls in people with dementia
A fall related event with or without fracture is the most common reason for hospitalisation in people with dementia, accounting for approximately 26% of all admissions

20. Cognition and gait Activity programmes for people with
disturbances in cognitive processes = slower gait and gait instability
attention, executive function, working memory
predict future mobility loss, falls, and progression to dementia
Better for amnestic MCI
Not all dementias the same
Activity programmes
for people with
cognitive problems
might not work
Montero-Odasso, M., J. "Gait and cognition:…..." J Am Geriatr Soc 60(11):

21. Person with dementia
Confusion
Orientation
Agitation
Trip over things
Cant find the toilet
Medication increases falls
Gait and balance
Reaction times
Amount of activity
Incontinence
Footware

22. Promoting Independence in Residential Care
41 Rest-homes in Christchurch and Auckland
Falls, function, QOL, 682, mean age 87 years.
Randomisation (no stratification)
Activity Group
PIRC, functional assessment, goal set, PIP to caregiver
falls surveillance
Social Group
2 visits
Outcome evaluation
No Impr QOL Function
(on average, signif subgroup)
No increase in falls

23. Why didn’t it work? The wrong programme The wrong exercises
Cognition important
Good cognition
Function
Depression
Falls
Poor cognition
Function
Depression
Falls
Why didn’t it work?
The wrong programme
The wrong exercises
Understand the population, target the intervention
Kerse BMJ 2008;337:al445

24. Variation in residential care

25. People with dementia fluorescent step edge
do not anticipate hazards or effects of actions
do not know that dizziness may be a symptom of other causes
do not scan the environment effectively, for hazards,
reaction times are slower, gait is different
fluorescent step edge
removal of below knee height hazards
Reorganising furniture for improved access

26. People around the person with dementia
Meaningful activities
Safe environment
Avoid agitation and exacerbation of BPSD
Family
Staff

27. Things to do state of mind

28. Exercise for falls in people with cognitive impairment
Group and individual – lower leg strength and
balance retraining, good adherence
Wai Chi Chan et al. Efficacy of Physical Exercise in Preventing Falls in Older Adults With Cognitive Impairment: A Systematic Review and Meta-Analysis JAMDA 16 (2015) 149e154

29. Hazards

31. Summary Persons with dementia fall frequently
Specific exercises for lower leg strengthening and balance retraining
Sensible suggestions
Keep calm and carry on

32. Funders
30/11/2018