The Hidden Cost of Cognition: Examining the Link Between Dual-Task Interference and Falls

Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Jeffrey D. Holmes, MSc(OT), PhD, Assistant Professor, School of Occupational Therapy, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Kevin Wood, BHSc, Research Assistant, Health and Rehabilitation Sciences, Faculty of Health Sciences, The University of Western Ontario, London, ON.
Mary E. Jenkins, BSc(PT), BEd, MD, FRCPC, Associate Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.

Abstract
“Accidents” (specifically falls) are a major contributor to death among older adults (defined as individuals over the age of 65). Falls contribute to ongoing mobility issues, and make it difficult for individuals that have sustained a fall, or who are at significant risk for a fall, to live independently.
Keywords: cognition, falls, dual-task interference

Psychoactive Medications and Falls

James W. Cooper, RPh, PhD, BCPS, CGP, FASCP, FASHP, Emeritus Professor and Consultant Pharmacist, College of Pharmacy, University of Georgia, Athens, and Assistant Clinical Professor of Family Medicine, Medical College of Georgia, Augusta, GA, USA.
Allison H. Burfield, RN, PhD, Assistant Professor, School of Nursing, College of Health and Human Services, University of North Carolina-Charlotte, Charlotte, NC, USA.

The high incidence of falls among older adults leads to increased health care costs and decrements in functional status. Psychoactive medications consumed by older adults are often implicated in falls. This article briefly reviews the associations between falls and psychoactive medications, with a focus on the long-term care setting, and offers an assessment method and strategies to reduce the risk of certain classes of medications known to contribute to fall risk.
Key words: falls, medications, psychoactive load, interventions, older adults.

After the Fall: The ABCs of Fracture Prevention

Susan B. Jaglal, PhD, Toronto Rehabilitation Institute Chair, Associate Professor, Faculty of Medicine, Department of Physical Therapy, University of Toronto, Toronto, ON.

A wrist fracture is associated with an increased risk of another fracture and should prompt investigation for osteoporosis in both men and women. If the fracture was caused by low trauma (a fall from a standing height or less), a bone density test should be ordered. If the T score is <–1.5, pharmacological treatment with a bisphosphonate and calcium (1,500 mg/d) and vitamin D3 (≥800 IU/d) is recommended. Management should also include balance, posture, and muscle-strengthening exercises and walking, as well as a review of fall-prevention strategies.
Key words: wrist fracture, osteoporosis, diagnosis, treatment, exercise, falls.

Prescribing Exercise

Alison Mudge, MBBS, FRACP, Physician, Department of Internal Medicine and Aged Care, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.
Robert Mullins, MAppSci (Clin Ex Sci), Clinical Exercise Physiologist, Heart Failure Service, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.
Julie Adsett, BPhty (Hons), Physiotherapist, Heart Failure Service, Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.

Exercise offers significant health benefits to older people, but may also carry risks of injury and cardiovascular events. These can be minimized with appropriate screening, prescription, and monitoring of an exercise program. Tailored exercise prescription is developed in consultation with the participant, taking into account identified risks, functional limitations, and individual goals. Exercise professionals can provide valuable assistance with screening, prescription, and supervision of an exercise program, but limited access to experienced staff and supervised programs remains a significant barrier to exercise participation. Innovative models of care are required to investigate optimal participant targeting, long-term exercise adherence, and cost-effectiveness.
Key words: exercise therapy, physical fitness health services for older adults, risk assessment, patient compliance.

Vertebral Compression Fractures Among Older Adults

Simona Abid, MD, FRCP(C), Geriatric Medicine Fellow, McMaster University, Hamilton, ON.
Alexandra Papaioannou, MD, FRCP(C) MSc, Professor, Department of Medicine, Division of Geriatric Medicine, McMaster University, Hamilton, ON.

Vertebral compression fractures (VCF) are the hallmark of osteoporosis, yet two-thirds of all VCF remain undiagnosed and untreated. Both symptomatic and occult VCF are associated with considerable increases in morbidity and mortality, hospitalization rates, admissions to long-term care, and health care-related costs. These fractures increase the risk of future osteoporotic fractures, both vertebral and nonvertebral, independent of bone mineral density. Older adults have lower rates of diagnosis and treatment compared with younger patients, although clinical studies have shown the efficacy and safety of currently available therapies for osteoporosis in older adults are comparable with those in younger individuals.
Key words: vertebral compression fractures, osteoporosis, bone mineral density, antiresorptive therapy, anabolic agents.

Fitness, Falls and Older Adults

Our focus in this issue is Fitness and Falls. The benefit of regular exercise was well established with the MacArthur Foundation’s study of healthy aging in 1998,¹ but the difficulties in implementing its recommendations are twofold: how do we encourage our patients to exercise, and how do we prescribe the right kinds of exercise? These two questions are interconnected and the article “Prescribing Exercise” by Dr. Alison Mudge, Robert Mullins, and Julie Adsett offers some answers. Fractures are common sequelae of falls and one type of fracture is discussed in the article “Vertebral Compression Fractures Among Older Adults” by Dr. Simona Abid and Dr. Alexandra Papaioannou. This article is also the basis for our February CME program. I like to say that there is no such thing as a trivial fall for an older adult. Some falls result in trivial injury, but often that is poor good fortune, and a slightly different angle of fall could result in serious damage. Dr. Susan Jaglal, a noted authority in the area of falls among older adults, addresses this in her article “After the Fall: The ABCs of Fracture Prevention.”

We also have our usual collection of articles on various important areas of geriatric care. Our Cardiovascular Disease column provides an “Update in Endocarditis Prophylaxis” and is written by Dr. Jason Andrade, Dr. Aneez Mohamed, and Dr. Chris Rauscher. The changes are quite significant from previous guidelines. Our Dementia column is on “Recreational Activities to Reduce Behavioural Symptoms in Dementia” by Dr. Ann Kolanowski, Dr. Donna Fick, and Dr. Linda Buettner. This issue’s Drugs and Aging column is part one of two on “Vitamin D Deficiency in Older Adults: Implications for Improving Immune System Health and the Prevention of Chronic Degenerative Disease” by Dr. Aileen Burford-Mason. Our Palliative Care column is entitled ”Prescribing Opioids to Older Adults: A Guide to Choosing and Switching Among Them” by Marc Ginsburg, Dr. Shawna Silver, and Dr. Hershl Berman. Our Men’s Health column is “Sexuality and the Aging Couple Part II: The Aging Man” by Drs. Irwin Kuzmarov and Jerald Bain of our partner organization, the Canadian Society for the Study of the Aging Male.

This issue, the first of the new year, also sees some changes in our pages. We’ve added a new section to each article called Clinical Pearls. These short notes suggest directly implementable changes, practices that clinicians can implement in the office to improve their care of older adults. Also, in our ongoing quest for excellence, we’ve expanded our system of peer review to include not only each issue’s CME article but also all the articles on the issue theme. Starting with this issue, all the Focus articles will undergo the same rigorous peer-review process that readers have come to expect of our CME article.

Enjoy this issue,
Barry Goldlist

1. Rowe JW, Kahn RL. Successful Aging: The MacArthur Foundation Study. New York: Dell Publishing, 1998.

Falls Prevention in Hospital

Andrea Németh, MA, Managing Editor, Geriatrics & Aging.

Introduction
Australian researchers who conducted a randomized controlled trial of a targeted multifactorial intervention to prevent falls among hospitalized older adults have found that the approach was not effective for those with relatively short hospital stays.¹ Researchers gathered falls data from 24 acute and older adult rehabilitation wards in 12 Sydney, Australia, hospitals between October 2003 and October 2006. Investigators paired wards on the basis of type (acute care or rehabilitation), fall rates, length of stay, and patient age before randomization: each ward was studied for 3 months. All patients in the ward at the time of the study were included, and data were collected on the health, medication, and physical function of each patient from their medical records. A total of 3999 patients, mean age 79 years and with a median hospital stay of 7 days, were included in the study.

Method
A part-time nurse and a part-time physiotherapist delivered select interventions during the 3-month study. The interventions used were selected from published recommendations^2-4 that could be implemented with the available resources (additional staff time and alarms) of the study. The study nurse assessed patients; provided education to patients and their families; arranged for appropriate walking aids (together with the physiotherapist), eyewear, modifications at bedside, and increased patient supervision; and worked with other staff regarding the necessity of changing medications, managing confusion, and the possibility of foot problems. The study nurse also provided education to groups of staff and individual staff members.

The study physiotherapist saw those patients who were referred by the study nurse and other ward staff. She led patients, individually or in groups, through exercises designed to enhance balance and ability with functional tasks, and practiced safe mobility with patients around the ward.

Ambulant patients assessed to be at high risk of a fall due to delirium or cognitive impairment were fitted with a custom-designed alarm in the form of a neoprene rubber sock with a pressure switch under the heel and a small loudspeaker in a pocket in the sock. The alarm emitted a loud, high-pitched tone when weight was put on the pressure switch, indicating that the patient was standing and required support.

Results
Among the 24 hospital wards (12 acute and 12 rehabilitation), 3,999 patients were studied; the average total number per ward during the 3-month study period was 167 overall, 233 (range 113-332) for the acute wards and 100 (range 56-170) for rehabilitation wards.

During the study period, 381 falls occurred, with an overall rate of falls of 9.2 per 1,000 bed days. The authors saw no difference between the rate of falls in acute care wards (9.4 per 1,000 bed days) and rehabilitation wards (9.0 falls per 1,000 bed days), nor did they find a differing rate of falls in the intervention versus control wards during the period studied. The mean fall rate in the intervention wards was 9.26 per 1,000 bed days, while the control wards saw 9.20 falls per 1000 bed days.

The intervention was also found to have no effect on the rate of injurious falls, for which the unadjusted incidence rate ratio was 1.12 (95% confidence interval 0.71 to 1.77).

The study authors posit that previous falls prevention studies^5,6 may have demonstrated a positive effect of intervention due to the relatively long length of stay in those studies (30 days and 20 days). In this study, the median length of hospital stay for patients was just 7 days. The investigators suggest that prevention interventions such as exercise require longer than a few days to take effect. They conclude that preventing falls among older adults in the hospital may require innovative approaches, including better ways to assess cognitive impairment, the use of low beds and hip protectors for preventing injury, a redesign of wards so that high-risk patients are easily seen at all times by staff, continual supervision of those patients at highest risk of falling, and a system-wide approach to falls prevention led by ward staff themselves.

References

1. Cumming RG, Sherrington C, Lord SR, et al. Cluster randomized trial of a targeted multifactorial intervention to prevent falls among older people in hospital. BMJ 2008;336:758-60.
2. Shanely C. Putting your best foot forward: preventing and managing falls in aged care facilities. Sydney: Centre for Education and Research on Ageing, 1998.
3. Lord SR, Sherrington C, Menz H. Falls in older people: risk factors and strategies for prevention. Cambridge: Cambridge University Press, 2001.
4. Australian Council for Safety and Quality in Health Care. Preventing falls and harm from falls in older people. Best practice guidelines for Australian hospitals and residential aged care facilities. Canberra: Australian Council for Safety and Quality in Health Care, 2005.
5. Haines TP, Bennell KL, Osbourne RH, et al. Effectiveness of targeted falls prevention programme in subculture hospital setting: randomized controlled trial. BMJ 2007;334:82-7.
6. Healey F, Monro A, Cockram A, et al. Using a targeted risk factor reduction to prevent falls in older in-patients: a randomized controlled trial. Age Aging 2004;33:390-5.

Multifaceted Interventions, Hip Protectors Useful Strategies in Fall and Fracture Programs

Kristin Casady, MA, Editorial Director, Geriatrics & Aging, Toronto, ON.

Falls are the leading cause of unintentional death among Canadians. According to a report of the Canadian Task Force on Preventive Health Care, falls resulting in serious injury or death are much more frequent among those age 55 and over; 70% of fatal falls occurred among persons 75 years and over. Ninety-five percent of injuries among older adults living in long-term care facilities were due to falls. One percent of falls by individuals aged 65 and over result in hip fracture.¹ Given these statistics, studies examining the efficacy of interventions to prevent falls and/or address the negative sequelae of falls are of significant interest to health care practitioners working with an older adult patient population.

A recent study has analyzed strategies employed in long-term care facilities and hospitals to prevent falls and fractures, as well as the evidence on the effects of cognitive impairment on fall risk.² The authors conducted a systematic review and meta-analysis, using meta-regression to investigate the effects of dementia. Researchers found that some interventions employed in hospitals lead to falls reduction, and that the use of hip protectors in care facilities prevents hip fractures. However, the evidence detected for the use of other single interventions was not significant.

Fall prevention strategies, the authors point out, are often derived from procedures and models suited for the community-dwelling, which do not precisely map on to the needs for fall and injury prevention among transient and institutionalized segments of the population. One particular reason that this is so is that many of those in hospital or long-term care have varying degrees of cognitive impairment. The authors suggest that awareness of the effect of cognitive impairment in incidences of falls should guide the development of best practice in order to avoid the implementation of ineffective prevention strategies.

The range of the 43 studies examined included multifaceted incorporated programs in hospitals and care settings that evaluated a wide range of items from risk factor assessment to medication review to education and exercise programs. The single-intervention programs studied tended to be components represented in the multi-intervention programs.

Among the key findings were that the multifaceted approach programs to prevent falls in hospital yielded the highest benefits, with meta-analysis showing a rate of falls reduction of 18%, but no significant effects on fracture (rate ratio of 0.82 [95% confidence interval 0.68 to 0.997]). Review of 11 studies of the effect of hip protectors showed an overall positive effect of the use of the devices: the rate ratio for hip fractures was 0.67 (0.46 to 0.98), but there was no significant effect on falls and, the authors asserted, not enough studies on fallers. There was no evidence as to the efficacy of exercise as a single intervention; however, it was a component of successful multifaceted programs. There was no evidence to suggest that removal of physical restraints was efficacious. However, the authors did find two studies in which oral supplementation with calcium and vitamin D reduced rates of falls and fractures in long-term care facilities. Importantly, they found no evidence that effect size of interventions were modified by the prevalence of dementia.

The authors concluded that significant gaps remain in the data yielded by studies of fall reduction interventions. They singled out the need for studies specifically examining programs for the cognitively impaired, the cost-effectiveness of single interventions, and alterations of physical environment, among others, as sources of needed evidence. They surmise that at present health care providers are incurring significant costs by using injury prevention strategies of unproven value.

References

1. Elford RW, for the Canadian Task Force on Preventive Health Care. Prevention of household and recreational injuries in the elderly. Online at http://www.ctfphc.org/ Full_Text/Ch76full.htm
2. Oliver D, Connolly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ 2006 Dec 8; [Epub ahead of print].

Ophthalmic Interventions to Help Prevent Falls

John G. Buckley, PhD, Senior Research Fellow, Vision & Mobility Laboratory, Department of Optometry, University of Bradford, Bradford, UK.
David B. Elliott, PhD, MCOptom, FAAO, Professor of Clinical Vision Science, Department of Optometry, University of Bradford, Bradford, UK.

There is mounting evidence that visual impairment is significantly associated with the increased incidence of falling in the older adult. Surprisingly, the leading causes of visual impairment in the aging adult population are correctable and due to undercorrected refractive errors and/or cataract. This highlights that, to reduce fall risk, older people should be encouraged to have regular eye examinations to detect and subsequently correct such problems as early as possible.
Key words: falls prevention, visual impairment, ophthalmic intervention, older adult.