1. Diane W. Healey November 18, 2008
What is the natural course of ambulation for dementia patients? Are falls part of the progression?
Diane W. Healey
November 18, 2008

2. Functional progression of dementia: FAST Scale
1 No functional decline.
2 Personal awareness of some functional decline.
3 Noticeable deficits in demanding job situations.
4 Requires assistance in complicated tasks such as handling finances, planning parties, etc.
5 Requires assistance in choosing proper attire.
6 Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence.
7 Speech ability declines to about a half-dozen intelligible words.
Progressive loss of abilities to walk, sit up, smile, and hold head up.

4. Cycle of frailty ? Dementia Taste, smell Dementia Illness Depression
Poor dentition
Depression
Illness
Hospitalization ?
Dementia

5. Falls risk Gait and balance disorder Psychotropic drug use Arthritis
Visual impairment
Orthostasis
Neurologic disease
Cardiovascular disease
Hypovitaminosis D

6. Falls risk for dementia vs no dementia
1017 people fell 5,438 times during the 2-year study
Rate of falls: 4.05 per person-year with dementia, per person-year without dementia (P<.0001) relative risk (95% confidence interval (CI)= )
Van Doorn C, et al. J Am Geriatr Soc 51(9): , 2003.

7. Stage of dementia and falls risk
Unimpaired (*scoring 0-1) were less likely to fall Mild or moderate cognitive impairment (*scoring 2- 4) RR=0.67, 95% CI= Severe cognitive impairment (*scoring 5-10) no more likely to fall than residents with mild or moderate cognitive impairment (scoring 2-4) (RR=0.99, 95% CI= ) *MDS cognition scale
Van Doorn C, et al. J Am Geriatr Soc 51(9): , 2003.

8. Injurious falls per person-year
*Dementia : 1.61
Non-dementia: 0.99
(P<.002)
*This is related to the number of increased falls with dementia patients, not that each fall is more injurious
Van Doorn C, et al. J Am Geriatr Soc 51(9): , 2003

9. Interventions for falls
Treat postural hypotension
Modification of environmental hazards
Minimizing psychotropic medications
Cardiovascular disorder treatment
Muscle strengthening and balance training
Tai Chi
No data specific for dementia

10. Mrs. R
78 yo WF with >5 year history of Alzheimer’s disease, taken care of at home by her husband
Previously has been an avid swimmer, hiker and biker
No longer able to do her own ADLs
Not sleeping well
8/11 husband admits her to the healthcare center of the CCRC where they have been residing in an independent home

11. Medications on admit: Irbesartan (Avapro) 150mg daily
Memantine (Namenda) 10mg bid
Galantamine (Razadyne ER) 16mg daily
Simvastatin (Zocor) 60mg daily

12. Admission Weight 101 lbs, thin
Gait slightly unsteady, with forward center of gravity, leaning to the left, takes short steps, and looks to the floor when walking
No focal neurologic findings
Pt appears fearful, aphasic
Plan: Physical therapy evaluation due to falls risk

13. Pt. not sleeping day or night: concern for increased risk of falls due to fatigue. Gait becoming more apraxic.
9/5 ramelteon (Rozerem) started
Falls: 9/8, 9/13,14,15,15
9/16 ramelteon discontinued
Fall: 9/17
9/19 Melatonin started
Falls: 9/26, 30, 10/13, 17

14. Date/time Circumstances Injury Interventions 9/8 8am
Fell in room after bkft
Abrasion R forehead
Assist with meals
9/13
? Fall
Bump L forehead, L shoulder
?fall. Husband took comforter home
9/14 8:15pm
Walking, fell on buttocks in room
No injury
Encourage rest periods
9/15 7:30 am
FOF in BR “painting” with feces
Hold ramelteon
9/15 8pm
?Sat down on floor
Hipsters
9/17 6:30pm
Tripped over another residents foot pedals
Skin tear L shin
Assist with all ADLs
9/26 5:40am
Found sitting on floor, scooting
9/30 3:25pm
Tried to sit in chair and missed
10/13 6:30pm
Found on floor
Therapy screen
Pharmacist review
10/17 5am
Found on floor,scooting