A Longitudinal Study of Change in Falls Risk and Balance and Mobility in Healthy Older People and People with Alzheimer Disease

Anticipatory reaching motor behavior characterizes patients within the Alzheimer's disease continuum in a virtual reality environment

BACKGROUND

Alzheimer's Disease (AD) is characterized by progressive declines in cognitive and motor functions, impairing daily activities. Traditionally, AD diagnosis relies on cognitive assessments, but emerging evidence highlights motor function deficits as early indicators of AD and Mild Cognitive Impairment (MCI). These motor declines, which often precede cognitive symptoms, include slower and less accurate reaching movements. This study explored reaching actions in a Virtual Reality (VR) environment in AD and MCI patients to identify motor deficits and their link to cognitive decline.

METHODS

The study involved 61 right-handed participants (19 AD, 21 MCI, and 21 healthy age-matched controls), screened for cognitive health using a Mini-Mental State Examination (MMSE). Participants performed upper-limb motor tasks (sequentially reaching targets) in a Virtual Reality (VR). Kinematic data was recorded and analyzed focusing on task success rate, frequency of anticipatory responses, and direction of anticipatory responses. Statistical analysis was performed using Generalized Linear Mixed Models to differentiate the three groups of participants based on performance metrics, anticipation behavior, and the correlation between anticipation rate and MMSE score.

RESULTS

Both AD and MCI patients showed more anticipatory responses than healthy controls (HC), inversely related to success rates and cognitive function. AD patients exhibited lower success rates and a higher frequency of anticipatory responses, often biased toward previous trial targets, suggesting impaired motor planning or difficulty adapting to new cues. MCI patients showed an intermediate pattern, with more anticipatory responses than HC but comparable success rates. These results highlight the crucial role of anticipatory behavior in motor task performance, with AD patients displaying the most pronounced deficits.

CONCLUSIONS

This study highlights significant impairments of reaching movements in AD patients, particularly in terms of anticipatory behavior and success rates. The observed deficits suggest that kinematic metrics could serve as early biomarkers for diagnosis and intervention. These findings emphasize the importance of combining cognitive and sensorimotor assessments for the early detection of AD-related motor dysfunctions. Additionally, they highlight the potential of VR-based motor rehabilitation as a promising approach to address sensorimotor deficits in the AD continuum, improving both motor and cognitive outcomes.

Research Among People Living With Dementia or Mild Cognitive Impairment in Physiotherapy Journals: A Scoping Review

BACKGROUND AND PURPOSE

Global estimates forecast an increase in the number of people living with dementia (PLWD) or mild cognitive impairment (MCI). Physiotherapists play an important role in the delivery of care to PLWD or MCI; however, physiotherapists report less confidence when working with PLWD or MCI, citing limited educational opportunities. Our scoping review sought to quantify and assess the type of research published in physiotherapy journals related to these groups of people.

METHODS

Fifteen journals were selected based on global physiotherapy representation, indexing, and online accessibility of archives. Extraction of all articles published within a decade (2011-2021) for the selected journals was completed. Inclusion criteria: (1) research reports, reviews, case studies, or expert opinion pieces related to PLWD or MCI and (2) published in English. Each article was categorized by type of article, clinical setting, type of dementia, physiotherapy focus, and Sackett's system of hierarchy of evidence. An analysis of trends over time and a bibliometric assessment of research impact were performed.

RESULTS AND DISCUSSION

Of 11 091 articles identified, 67 were included. The most common country of origin was the United States (38.8%). Articles were mainly research reports (70.1%), from a community-dwelling setting (50.8%), with a combined physiotherapy focus (28.4%), and a level IV (37.3%) of hierarchy of evidence. Close to half of studies did not identify the underlying dementia type (43.3%, n = 29), followed by people living with Alzheimer's dementia (28.4%, n = 19), combined groups of PLWD or MCI (20.9%, n = 14), and individuals with only MCI (7.5%, n = 5). Six articles on average related to PLWD or MCI were published annually (32.7 citation per article), and no growing trend was observed.

CONCLUSIONS

Few articles published in prominent physiotherapy journals over the last decade were related to PLWD or MCI. Publication trends remained unchanged, and publication origins were from the Americas which impacts generalizability. Physiotherapists should attain complementary information on care for PLWD or MCI through more general rehabilitation journals. Physiotherapy journals should seek to promote research related to PLWD or MCI through different avenues (eg, special issues) as increased information is needed for clinicians to feel confident in providing informed care.

Changing the focus: Facilitating engagement in physical activity for people living with mild dementia in a local community-Protocol for a pre-post mixed methods feasibility study

This study aims to address and improve the low physical activity levels among people with mild dementia by implementing a novel shared decision-making and motivational support program, named "Changing the Focus". It will utilise a pre-post mixed methods approach, aiming to recruit 60 community living older people with mild dementia and their care-partners. The shared decision-making process will involve the person living with dementia, their care-partner, and a research therapist, using a purpose-designed discussion tool including factors such as preferred physical activities, health status, local opportunities and program accessibility. This process aims to identify personalised local physical activity opportunities. Participants will be supported with the help of a research therapist to engage in targeted community-based physical activities for 12-months, to progress towards the recommended physical activity guidelines of 150 minutes per week. The intervention provided by the research therapist will include three home visits (baseline, 6- and 12-months) and seven motivational support phone calls (within the first six months). Research therapists may provide additional home visits and support calls as needed. Primary outcomes include program participation (participants living with dementia continuing with the program after 12-months), total physical activity time per week (measured using the Active Australia Survey at baseline, 6- and 12- months) and program acceptability (assessed through semi-structured interviews with participants, care-partners, referrers, and physical activity providers). Secondary outcomes include physical performance, mental health, wellbeing measures, and impact on care-partners (evaluated through physical tests or validated scales at baseline, 6- and 12-months). Other implementation aspects include reach, maintenance, safety (falls, other adverse events) and an economic evaluation. Results will inform feasibility, potential benefits, and challenges associated with this innovative shared decision-making and supported physical activity program for people living with mild dementia. Findings will guide future large-scale studies and contribute to enhancing physical activity opportunities for this population.

A Meta-Analysis of Fall Risk in Older Adults With Alzheimer's Disease

OBJECTIVES

Falls are the leading cause of injuries in older adults. Although it is well recognized that Alzheimer's disease (AD) increases the fall risk of older adults, the reported fall risk in people with AD varies drastically. The principal purpose of this study was to summarize and synthesize previous studies reporting fall risk-related metrics in people with AD.

DESIGN

This was a meta-analysis.

SETTING AND PARTICIPANTS

Thirty-one studies reporting relevant fall data among 4654 older adults with AD were included.

METHODS

The fall prevalence, average number of falls, rate of recurrent fallers, and rate of injured fallers of included studies were meta-analyzed using random-effects models with inverse variance weights.

RESULTS

The pooled annual fall prevalence in older people with AD is 44.27% with an average annual number of falls of 1.30/person and a yearly rate of recurrent fallers of 42.08%. The reported rate of injured fallers was 45.0%.

CONCLUSIONS AND IMPLICATIONS

Our results reinforce that people with AD experience a higher fall risk than their cognitively healthy counterparts. The pooled fall metrics in this meta-analysis extend our understanding of the fall risk in people with AD. In addition, standardized approaches are needed to report fall-related data for people with AD.

Examining gait aid use and user safety by older people with dementia: Perspectives of informal carers to inform practice

PURPOSE

To determine gait aid use and decision-making related to usage in people with dementia, and examine factors influencing (1) gait aid use or not; and (2) falls in past year.

MATERIALS AND METHODS

A survey of informal carers of older people with dementia in the community. Closed questions on gait aid use, falls, timing and sources of gait aid acquisition, and advice received to support use were used. Chi-squared tests (Fisher's Exact) compared: (1) gait aid users vs non-users and carers' report of (i) unsteadiness in walking/turning, (ii) dementia severity, (iii) falls in past year, and (2) fallers vs non-fallers and (i) timing of gait aid commencement relative to dementia diagnosis, (ii) whether health professional advice was received regarding use, and iii) regularity of use.

RESULTS

Forty-seven completed surveys, 63.8% of care recipients used a gait aid; 56.9% had ≥2 falls in past year; 66.7% commenced use after dementia diagnosis; 25% acquired their aids from non-health professionals; and 37% did not receive advice regarding use. Gait aid users and non-users differed on carer ratings of unsteadiness in walking/turning (p = 0.02).

CONCLUSION

Carers reported important aspects regarding gait aid acquisition, safe gait aid use and benefits which warrant further investigation.IMPLICATIONS FOR REHABILITATIONIn our small sample, use of gait aids by people with dementia was related to the level of unsteadiness in walking and/or turning, and not associated with falling in the past year.People with dementia do not routinely receive professional advice about how to use gait aids, highlighting the potential value of maximizing health professional involvement in gait aid prescription and training.Deterioration in the ability of gait aid use after the diagnosis of dementia indicates a need for re-assessment or re-training of gait aid use over time.Clinical guidelines to facilitate decision-making regarding under what conditions gait aids are beneficial, what duration and aspects require instruction to ensure effective use by people with dementia are needed.

Investigation of the relationship between trunk control and balance, gait, functional mobility, and fear of falling in people with Alzheimer's disease

INTRODUCTION

Optimal trunk control relies on adequate musculoskeletal, motor, and somatosensory systems that are often affected in people with Alzheimer's disease (AD). Therefore, the aim of this study was to compare trunk control between people with AD and healthy older adults, and investigate the relationship between trunk control and balance, gait, functional mobility, and fear of falling in people with AD.

METHODS

The study was completed with 35 people with AD and 33 healthy older adults with matching age and gender. Trunk control was evaluated with Trunk Impairment Scale (TIS); balance with Berg Balance Scale (BBS), Functional Reach Test (FRT), One-Leg Standing Test (OLST) and Five-Repeat Sit-and-Stand Test (5STS); gait with Dynamic Gait Index (DGI); functional mobility with Timed Up and Go (TUG) Test; fear of falling with Falls Efficacy Scale-International (FES-I).

RESULTS

BBS, FRT, OLST, and DGI scores were lower and 5STS and TUG Test scores were higher in people with AD compared to healthy older adults (p < 0.05). There was no difference in FES-I score between people with AD and healthy older adults (p > 0.05). TIS was associated with BBS, FRT, OLST, 5STS, DGI, TUG Test, and FES-I (r between - 0.341 and 0.738; p < 0.05 for all).

CONCLUSION

Trunk control is affected and related with balance, gait, functional mobility, and fear of falling in people with AD. For this reason, we think that trunk control should be evaluated in the early period, and applications for trunk control should be included in rehabilitation approaches in order to improve balance, gait, functional mobility, and reduce fear of falling.

Gait aid use for people with and without dementia: A comparison of practice between health and non-health professionals among Australian community care staff

Gait aid provision is a standard approach to improve mobility and balance for older people. This research aims to understand and compare community care staff practice (health vs. non-health professionals) for gait aid use by people with and without dementia. A cross-sectional survey was conducted with Australian community care staff between October 2020 and February 2021. Survey items consisted of closed/open-ended questions to explore staff practice for people with/without dementia, and assessments/procedures health professionals used for people with dementia. Likert-scale items gauged staff agreement on factors that influenced their decisions regarding gait aid use for people with dementia. Univariate logistic regression analyses were used to examine staff practice for people with/without dementia and their interaction effects, and factors that influenced decision-making regarding gait aid use for people with dementia. Content analyses were used to collate responses on assessments/procedures used for people with dementia. Health (n = 109) and non-health professionals (n = 138) completed the survey. Compared with non-health professionals, health professionals were more likely to (1) refer the person without dementia [odds ratio, 95% CI: 23.9 (12.1, 47.3), p < .01] and person with dementia [27.8 (12.5, 61.7), p < .01] to a physiotherapist for gait aid assessment, (2) agree with gait aid use if the person with dementia: (a) lives with someone who can monitor gait aid safety [coefficient, 95% CI: -0.75 (-1.29, -0.21), p = .01], (b) performs well on a cognitive functional screen [-0.68 (-1.20, -0.16), p = .01] and (c) gives feedback about gait aid use [-0.64 (-1.15, -0.12), p = .02]. No interaction effects existed between health/non-health professionals and whether the person had dementia/no dementia on the practice options examined. Health professionals infrequently reported using single/dual task, simple/complex gait or motor sequence testing to assess people with dementia for gait aid use. Strategies such as developing decision aid tool(s) may guide mobility practice for community care staff.

The Effects on Gait of 4-Wheeled Walker Use in People with Alzheimer’s Disease Dementia and Gait Impairment: A Pilot Study

In people with dementia, provision of mobility aids is standard treatment for those with impaired gait. However, mobility aid use is independently associated with increased falls risk. In this short communication, gait velocity and stride time variability were recorded in eleven adults with Alzheimer’s disease dementia. Three conditions were tested: single-task (no aid), walking with a walker, and dual-task (walker use and counting backwards) under both a straight path and Figure-of-8 walking configuration. Gait velocity increased when using a walker compared to no aid in the Figure-of-8 walking configuration. Walker use improved gait in simple walking, but benefits diminished upon dual-task.

Effects of fundamental movement skills based dual-task and dance training on single- and dual-task walking performance in older women with dementia

OBJECTIVE

The purpose of this study was to compare the effects of fundamental movement skills (FMS)-based dual-task training and dance training on spatio-temporal characteristics of gait performance under single- and dual-task walking conditions among older women with dementia.

METHOD

Thirty-eight elderly females with dementia were randomly assigned to one of two groups: (1) dual-task intervention (DTI, age: 73 ± 6.5 years) or (2) Iranian dance intervention (IDI, age: 72.52 ± 6.01 years). Both groups participated in a 10-week intervention program (3 sessions per week, each lasting 50 min). Gait performance parameters (gait speed, cadence, and stride length) and dual-task costs (DTC) were examined using a gait analysis system. The participants completed three walking trials under two conditions: single- and dual-task. The video data was analyzed using motion analysis software (Frame-DIAS II, DKH, DKH Inc., Tokyo, Japan).

RESULTS

The results showed that both groups significantly improved in terms of all gait variables, and DTC decreased (p < .001) from pre- to post-test for both conditions. However, the main effects for the group and the group-by-time interactions were not significantly different between the two groups (p > .05).

CONCLUSION

These findings showed that DTI and IDI effectively improved gait performance following a 10-week intervention for older women with dementia. Therefore, it is suggested that either training program could decrease DTC and increase gait speed, stride length, and cadence among older females with dementia.

A survey of nurses, physiotherapists and occupational therapists in mobility care and gait aid use for hospital patients with dementia

This study described mobility care practice of nurses, physiotherapists and occupational therapists and gait aid use for hospital patients with dementia. Two surveys, tailored to staff mobility care roles were distributed in Australian hospitals. Physiotherapists and occupational therapists were asked additional questions regarding assessments and factors for prescribing gait aids to patients with dementia. Descriptive statistics for closed-ended and summative content analyses for open-ended questions were undertaken. Nurses (n=56), physiotherapists (n=11) and occupational therapists (n=23) used various practices to ensure ambulation safety for patients with dementia. Nurses and occupational therapists commonly referred patients with dementia to physiotherapists for mobility and gait aid assessments. Therapists predominantly considered the severity of dementia, the person's learning ability and mobility history in deciding about gait aid use. Exploring ways to strengthen nursing and health professional education, and inter-professional practice for safe mobility in patients with dementia, with and without gait aids, could be helpful.

Deterioration, Compensation and Motor Control Processes in Healthy Aging, Mild Cognitive Impairment and Alzheimer's Disease

Aging is associated with modifications of several brain structures and functions. These modifications then manifest as modified behaviors. It has been proposed that some brain function modifications may compensate for some other deteriorated ones, thus maintaining behavioral performance. Through the concept of compensation versus deterioration, this article reviews the literature on motor function in healthy and pathological aging. We first highlight mechanistic studies that used paradigms, allowing us to identify precise compensation mechanisms in healthy aging. Subsequently, we review studies investigating motor function in two often-associated neurological conditions, i.e., mild cognitive impairment and Alzheimer's disease. We point out the need to expand the knowledge gained from descriptive studies with studies targeting specific motor control processes. Teasing apart deteriorated versus compensating processes represents precious knowledge that could significantly improve the prevention and rehabilitation of age-related loss of mobility.

Functional Decline and Body Composition Change in Older Adults With Alzheimer Disease: A Retrospective Cohort Study at a Japanese Memory Clinic

BACKGROUND

There is a dearth of longitudinal data on body composition, function, and physical performance in persons with Alzheimer's disease (AD).

OBJECTIVES

The aim was to describe the trajectories of function, body composition, and physical performance in older adults with AD.

METHODS

In this retrospective cohort study, data were collected from older adults (n=1402) diagnosed with AD (mean age: 78.1 y old, women: 69.3%). Cognitive function was assessed using the mini-mental state examination. Proxy-reported instrumental and basic activities of daily living were assessed using the Lawton and Barthel indexes. Body composition was assessed using bioelectrical impedance analysis. Physical performance was assessed using the timed up and go test and grip strength.

RESULTS

Median (interquartile range) of follow-up time was 2.2 (1.2 to 3.6) years. Participants' mini-mental state examination score, Barthel index, and Lawton index declined over time. Skeletal muscle mass index and physical performance (timed up and go test and grip strength) decreased, while fat mass index increased with time. No significant changes or slight decline in weight and body mass index was observed.

CONCLUSIONS

Muscle mass and physical performance are likely to decline in older adults with AD. Clinicians should assess muscle mass and physical performance trajectories regularly in these patients and intervene appropriately.

Physical Therapy for Gait, Balance, and Cognition in Individuals with Cognitive Impairment: A Retrospective Analysis

Objectives

The purpose of this study was to determine if a pragmatic physical therapy (PT) program was associated with improved cognition, gait, and balance in individuals with cognitive impairment. This study investigated these associations for individuals with Alzheimer disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), and mild cognitive impairment (MCI) in order to better characterize outcomes to PT for each diagnostic group.

Methods

Data before and after one month of physical therapy were extracted from patient records (67 with AD, 34 with VaD, 35 with DLB, and 37 with MCI). The mean number of PT sessions over a month was 3.4 (±1.8). Outcomes covered the domains of gait, balance, and cognition with multiple outcomes used to measure different constructs within the balance and gait domains.

Results

All groups showed improvements in balance and at least one gait outcome measure. Those with MCI improved in every measure of gait and balance performance. Lastly, cognition as measured by Montreal Cognitive Assessment improved in individuals in the AD, VaD, and MCI groups.

Conclusion

While this retrospective analysis is not appropriate for causal inference, results of one month of physical therapy were associated with decreases in gait, balance, and cognitive impairment in individuals with AD, VaD, DLB<, and MCI. Clinical Implications. While physical therapy is not typically a primary treatment strategy for individuals with cognitive impairment, the results of this study are consistent with the literature that demonstrates improvement from physical therapy for other neurodegenerative diseases. Further clinical and research exploration for physical therapy as a primary treatment strategy in these populations is warranted.

Development, reliability and validity of the Safe Use of Mobility Aids Checklist (SUMAC) for 4-wheeled walker use in people living with dementia

BACKGROUND

Balance and gait problems are common and progressive in dementia. Use of a mobility aid provides physical support and confidence. Yet, mobility aid use in people with dementia increases falls three-fold. An assessment tool of mobility aid safety in people with dementia does not currently exist. The objectives of this study were: 1) to develop a tool for the evaluation of physical function and safe use of a 4-wheeled walker in people with dementia, and 2) to evaluate its construct and criterion validity, inter-rater and test-retest reliability and minimal detectable change.

METHODS

Healthcare professionals (HCP) experienced in rehabilitation of people with dementia participated in focus groups for item generation of the new tool, The Safe Use of Mobility Aid Checklist (SUMAC). The SUMAC evaluates physical function (PF) and safe use of the equipment (EQ) on nine tasks of daily life. Reliability was evaluated by HCP (n = 5) scored participant videos of people with dementia (n = 10) using a 4-wheeled walker performing the SUMAC. Inter-rater and test-retest reliability was assessed using intra-class correlation coefficients (ICC). Construct validity evaluated scores of the HCPs to a consensus HCP panel using Spearman's rank-order correlations. Criterion validity evaluated SUMAC-PF to the Performance-Oriented Mobility Assessment (POMA) gait subscale using Spearman's rank-order correlations.

RESULTS

Three focus groups (n = 17) generated a tool comprised of nine tasks and the components within each task for physical function and safe use. Inter-rater reliability was statistically significant for SUMAC-PF (ICC = 0.92, 95%CI (0.81, 0.98), p < 0.001) and SUMAC-EQ. (ICC = 0.82, 95%CI (0.54, 0.95), p < 0.001). Test-retest reliability was statistically significant for SUMAC-PF (ICC = 0.89, 95%CI (0.81, 0.94), p < 0.001) and SUMAC-EQ. (ICC = 0.88, 95%CI (0.79, 0.93), p < 0.001). As hypothesized, the POMA gait subscale correlated strongly with the SUMAC-PF (r_s = 0.84), but not EQ (r_s = 0.39).

CONCLUSIONS

The focus groups and research team developed a tool of nine tasks with evaluation on physical function and safe use of a 4-wheeled walker for people with dementia. The SUMAC tool has demonstrated content validity for the whole scale and good construct and criterion validity for the SUMAC-PF and SUMAC-EQ. The subscores of the SUMAC demonstrated excellent to good inter-rater and test-retest reliability.

Effect of Learning to Use a Mobility Aid on Gait and Cognitive Demands in People with Mild to Moderate Alzheimer's Disease: Part II - 4-Wheeled Walker

BACKGROUND

Cognitive deficits and gait problems are common and progressive in Alzheimer's disease (AD). Prescription of a 4-wheeled walker is a common intervention to improve stability and independence, yet can be associated with an increased falls risk.

OBJECTIVES

1) To examine changes in spatial-temporal gait parameters while using a 4-wheeled walker under different walking conditions, and 2) to determine the cognitive and gait task costs of walking with the aid in adults with AD and healthy older adults.

METHODS

Twenty participants with AD (age 79.1±7.1 years) and 22 controls (age 68.5±10.7 years) walked using a 4-wheeled walker in a straight (6 m) and Figure of 8 path under three task conditions: single-task (no aid), dual-task (walking with aid), and multi-task (walking with aid while counting backwards by ones).

RESULTS

Gait velocity was statistically slower in adults with AD than the controls across all conditions (all p values <0.025). Stride time variability was significantly different between groups for straight path single task (p = 0.045), straight path multi-task (p = 0.031), and Figure of 8 multi-task (0.036). Gait and cognitive task costs increased while multi-tasking, with performance decrement greater for people with AD. None of the people with AD self-prioritized gait over the cognitive task while walking in a straight path, yet 75% were able to shift prioritization to gait in the complex walking path.

CONCLUSION

Learning to use a 4-wheeled walker is cognitively demanding and any additional tasks increases the demands, further adversely affecting gait. The increased cognitive demands result in a decrease in gait velocity that is greatest in adults with AD. Future research needs to investigate the effects of mobility aid training on gait performance.

Constitutive melanin density is associated with prevalent and short-term, but not long-term, incident fracture risk in older Caucasian adults

Higher cutaneous melanin reduces vitamin D3 production. This may increase fracture risk. We found that cutaneous melanin density was associated with prevalent and short-term, but not long-term, incident fracture risk in older Caucasian adults. Melanin density either acts as a surrogate marker or its relationship with fracture changes with time.

INTRODUCTION

Higher cutaneous melanin reduces vitamin D3 production. This may impact lifetime vitamin D status and increase fracture risk. This study aimed to describe the relationship between spectrophotometrically determined constitutive melanin density, prevalent and incident fractures in a cohort of exclusively older Caucasian adults.

METHODS

1072 community-dwelling adults aged 50-80 years had constitutive melanin density quantified using spectrophotometry. Participants were followed up at 2.5 (n = 879), 5 (n = 767), and 10 (n = 571) years after the baseline assessment. Prevalence and number of symptomatic fractures were assessed by questionnaire.

RESULTS

Higher melanin density was independently associated with greater prevalence of any fracture (RR 1.08, p = 0.03), vertebral fracture (RR 1.41, p = 0.04) and major fracture (RR 1.12, p = 0.04) and the number of fractures (RR 1.09, p = 0.04) and vertebral fractures (RR 1.47, p = 0.04) in cross-sectional analysis. At the 2.5-year follow-up, higher melanin density was associated with incident fractures (RR 1.42, p = 0.01) and major fractures (RR 1.81, p = 0.01) and the number of incident fractures (RR 1.39, p = 0.02) and major fractures (RR 2.14, p = 0.01). The relationship between melanin density and incident fracture attenuated as the duration of follow-up increased and was not significant at the 5- or 10-year follow-up.

CONCLUSIONS

Constitutive melanin density was associated with prevalent and short-term, but not long-term, incident fracture risk in older Caucasian adults. This suggests melanin density either acts as a surrogate marker for an unmeasured fracture risk factor or the relationship between melanin density and fracture changes with time.

Minimal Detectable Change in Dual-Task Cost for Older Adults With and Without Cognitive Impairment

BACKGROUND AND PURPOSE

Dual-task (DT) training has become a common intervention for older adults with balance and mobility limitations. Minimal detectable change (MDC) of an outcome measure is used to distinguish true change from measurement error. Few studies reporting on reliability of DT outcomes have reported MDCs. In addition, there has been limited methodological DT research on persons with cognitive impairment (CI), who have relatively more difficulty with DTs than persons without CI. The purpose of this study was to describe test-retest reliability and MDC for dual-task cost (DTC) in older adults with and without CI and for DTs of varying difficulty.

METHODS

Fifty participants 65 years and older attended 2 test sessions within 7 to 19 days. Participants were in a high cognitive group (n = 27) with a Montreal Cognitive Assessment (MoCA) score of 26 or more, or a low cognitive group (n = 23) with a MoCA score of less than 26. During both sessions, we used a pressure-sensing walkway to collect gait data from participants. We calculated motor DTC (the percent decline in motor performance under DT relative to single-task conditions) for 4 DTs: the Timed Up and Go (TUG) while counting forward by ones (TUG1) and counting backward by threes (TUG3); and self-selected walking speed (SSWS) with the same secondary tasks (SSWS1 and SSWS3). Intraclass correlation coefficients (ICCs) and MDCs were calculated for DTC for the time to complete the TUG and spatiotemporal gait variables during SSWS. A 3-way analysis of variance was used to compare differences in mean DTC between groups, tasks, and sessions.

RESULTS AND DISCUSSION

ICCs varied across groups and tasks, ranging from 0.02 to 0.76. MDCs were larger for individuals with low cognition and for DTs involving counting backward by threes. For example, the largest MDC was 503.1% for stride width during SSWS3 for individuals with low cognition, and the smallest MDC was 5.6% for cadence during SSWS1 for individuals with high cognition. Individuals with low cognition demonstrated greater DTC than individuals with high cognition. SSWS3 and TUG3 resulted in greater DTC than SSWS1 and TUG1. There were no differences in DTC between sessions for any variable.

CONCLUSIONS

Our study provides MDCs for DTC that physical therapists may use to assess change in older adults who engage in DT training. Persons with low cognition who are receiving DT training must exhibit greater change in DTC before one can be confident the change is real. Also, greater change must be observed for more challenging DTs. Thus, cognitive level and task difficulty should be considered when measuring change with DT training.

[Dance as an intervention to improve mobility and balance in elderly: a literature review]

The aim of the present review was to identify whether dance protocols can benefit mobility and balance in elderly. A literature review was conducted in which 927 potentially relevant studies were identified (published in Portuguese, English, French, German, Spanish or Italian). There was no publication period restriction. After reading the titles, abstracts and review of the exclusion criteria, 15 randomized controlled trials were included. Most of the studies evaluated female subjects, using heterogeneous protocols of intervention and unspecific control groups. In addition, the period of exposure to dance was generally short: 2.6 weekly practices, of 59.1 minutes each, performed through 12.1 weeks. Dance was shown to be beneficial in 77.6% of the evaluated outcomes, exhibiting a moderate effect size for static balance and functional balance; and small effect size for mobility and strength/resistance of the lower limbs. However, future studies with the use of specific control groups and adoption of longer lasting protocols are necessary to evaluate the actual size effect that dance has on the maintenance of mobility and balance in elderly.

Executive function as a mediating factor between visual acuity and postural stability in cognitively healthy adults and adults with Alzheimer's dementia

BACKGROUND

Falls in older adults, notably those with Alzheimer's dementia (AD), are prevalent. Vision and balance impairments are prominent falls risk factors in older adults. However, recent literature in the cognitively impaired suggests that executive function (EF) is important for falls risk assessments. The study objectives were to: 1) to compare balance among people with AD, healthy older adults (OA), and healthy young adults (YA) and 2) to quantify the interaction of visual acuity and EF on postural stability.

METHODS

We recruited 165 individuals (51 YA, 48 OA, and 66 AD). Trail Making Tests (A and B) quantified EF and the Colenbrander mixed contrast chart measured high and low contrast visual acuity. Accelerometers recorded postural sway during the Modified Test for Sensory Integration. A two-way repeated measures ANOVA examined postural sway differences across groups. Mediation analysis quantified the association of EF in the relationship between contrast sensitivity and postural sway.

RESULTS

Significant EF and visual acuity between-group differences were observed (p < 0.001). For postural sway, a significant interaction existed between group and balance condition (p < 0.001). In general, EF was a significant mediator between visual acuity and postural sway. Visual acuity, EF and postural sway was worse with increased age, particularly in the AD group.

CONCLUSIONS

Mediation analysis revealed that individuals with poorer visual acuity had poorer EF, and those with poorer executive function had poorer balance control. These results highlight the importance of assessing not only vision and balance but also EF, especially in older individuals living with AD.

The experiences of people with Alzheimer's dementia and their caregivers in acquiring and using a mobility aid: a qualitative study

PURPOSE

Cognitive deficits and gait and balance problems are progressive in people with Alzheimer's dementia. Yet, mobility aids are associated with an increased falls risk in people with dementia. Our objectives were to identify the perceptions of people living with mild-to-moderate Alzheimer's dementia, and their caregivers, on the use of mobility aids.

METHODS

A qualitative study using semi-structured, face-to-face interviews was conducted. Community-dwelling older adults with dementia attending a day hospital program were recruited. Thematic analysis was conducted and the text was coded into broad themes aligned with the research questions. The coded text was examined for patterns and similarities, and grouped to form inductive themes.

RESULTS

Twenty-four people (12 living with dementia and their 12 caregivers) participated. Five themes were identified: (1) acknowledgement of need; (2) protecting a sense of self; (3) caregiver oversight and relief of burden; (4) healthcare professional involvement; (5) environment and design of aids.

CONCLUSIONS

The findings suggest that people with Alzheimer's dementia and their caregivers regard mobility aid use as increasing independence. There is a role for healthcare professionals to be involved in the prescription, provision and training for use of mobility aids among people living with dementia to ensure uptake and safety.IMPLICATIONS FOR REHABILITATIONMobility aid use is regarded as increasing independence by people with Alzheimer's disease and their caregivers.Falls risk associated with mobility aid use was not well known and caregivers perceived mobility aids as a means to reduce falls.Most people do not see a healthcare professional when they acquire a mobility aid and there is a role for healthcare professionals to be involved in the prescription, provision and training of people living with dementia in the use of mobility aids in order to increase the uptake of aids and their safe use.

Understanding the factors influencing physiotherapists' attitudes towards working with people living with dementia

Background: Research suggests healthcare professionals feel uncomfortable or inadequately prepared to provide care to people living with dementia. Importantly, research on the attitudes of physiotherapists toward people with dementia is limited. The objective was to assess personal, educational, and clinical experiences on physiotherapists' attitudes toward working with people with dementia.Methods: An online survey was completed by registered physiotherapists. Data were collected on their dementia knowledge, confidence, and attitudes. Structural equation modeling (SEM) evaluated the factors associated with attitudes of physiotherapists.Results: A total of 231 physiotherapists completed the survey. Participants' scores on knowledge of dementia were excellent. Interactions with people with dementia were positive (67.4%) and access to rehabilitation was important (70.4%). However, most respondents reported a lack of confidence and strategies to successfully deal with cognitive (42.5%) or behavioral (58.3%) symptoms. In the SEM, only education (p = .048) was significantly related to attitude. Specifically, more education was related to more positive attitudes.Conclusions: Scores on knowledge of dementia were high. Yet, most respondents reported reduced confidence from a lack of skills to manage behavioral or cognitive symptoms associated with dementia. More education related to working with people with dementia was significantly related to positive attitudes among physiotherapists.

The effectiveness of home-based exercise programmes on mobility and functional independence in community-dwelling adults with Alzheimer's disease: a critical review

Background/Aims

In the UK, two-thirds of people with dementia are community-dwelling. Guidelines recommend exercise to promote independence among this population, however evidence to support this is scarce. This study aimed to evaluate the effectiveness of home-based exercise programmes on mobility and functional independence in people with Alzheimer's disease living in the community.

Methods

The following electronic databases were searched: AMED, CINAHL, EMBASE, Medline, SPORTsDiscus, The Cochrane Library, PEDro, OpenGrey and Online Thesis. All included trials were assessed for methodological quality using PEDro bias scores and McMaster's Critical Appraisal Tool and Guideline. English language restrictions were applied.

Results

A total of seven trials were included within the review. Trial quality was mixed. All trials reported measures for mobility, while five trials included measures of functional independence. Results for the effectiveness of home-based exercise on mobility were mixed, with only two studies reporting significant improvements. Functional independence significantly improved in all trials.

Conclusions

The effectiveness of home-based exercise programmes on mobility in community-dwelling people with Alzheimer's disease remains inconclusive, while a growing body of evidence indicates its effectiveness in improving functional independence. However, high quality trials are scarce. Larger, randomised, controlled trials specific to this population are thus warranted.

Validity of the Falls Risk for Older People in the Community (FROP-Com) tool to predict falls and fall injuries for older people presenting to the emergency department after falling

The aims of this study were to (1) externally validate the accuracy of the Falls Risk for Older People in the Community (FROP-Com) falls risk assessment tool in predicting falls and (2) undertake initial validation of the accuracy of the FROP-Com to predict injurious falls (requiring medical attention) in people aged ≥ 60 years presenting to emergency departments (EDs) after falling. Two hundred and thirteen participants (mean age = 72.4 years; 59.2% women) were recruited (control group of a randomised controlled trial). A FROP-Com assessment was completed at a home visit within 2 weeks of ED discharge. Data on falls and injurious falls requiring medical attention were collected via monthly falls calendars for the next 12 months. Predictive accuracy was evaluated using sensitivity and specificity of a high-risk FROP-Com classification (score ≥ 19) in predicting a fall and injurious falls requiring medical attention. Fifty per cent of participants fell, with 60.4% of falls requiring medical attention. Thirty-two per cent were classified as high, 49% as moderate and 19% low falls risk. Low sensitivity was achieved for the FROP-Com high-risk classification for predicting falls (43.4%) and injurious falls (34.4%), although specificity was high (79.4% and 78.6%, respectively). Despite the FROP-Com's low predictive accuracy, the high fall rate and high falls risk of the sample suggest that older people who fall, present to ED and are discharged home are at high risk of future falls. In high-falls-risk populations such as in this study, the FROP-Com is not a valid tool for classifying risk of falls or injurious falls. Its potential value may instead be in identifying risk factors for falling to direct tailoring of falls prevention interventions to reduce future falls.

Gait parameters and characteristics associated with increased risk of falls in people with dementia: a systematic review

BACKGROUND

People with dementia fall twice as often and have more serious fall-related injuries than healthy older adults. While gait impairment as a generic term is understood as a fall risk factor in this population, a clear elaboration of the specific components of gait that are associated with falls risk is needed for knowledge translation to clinical practice and the development of fall prevention strategies for people with dementia.

OBJECTIVE

To review gait parameters and characteristics associated with falls in people with dementia.

METHODS

Electronic databases CINAHL, EMBASE, MedLine, PsycINFO, and PubMed were searched (from inception to April 2017) to identify prospective cohort studies evaluating the association between gait and falls in people with dementia.

RESULTS

Increased double support time variability, use of mobility aids, walking outdoors, higher scores on the Unified Parkinson's Disease Rating Scale, and lower average walking bouts were associated with elevated risk of any fall. Increased double support time and step length variability were associated with recurrent falls. The reviewed articles do not support using the Performance Oriented Mobility Assessment and the Timed Up-and-Go tests to predict any fall in this population. There is limited research on the use of dual-task gait assessments for predicting falls in people with dementia.

CONCLUSION

This systematic review shows the specific spatiotemporal gait parameters and features that are associated with falls in people with dementia. Future research is recommended to focus on developing specialized treatment methods for these specific gait impairments in this patient population.

Falls prevention for people with dementia: a knowledge translation intervention

Purpose

Strong evidence exists for falls prevention, yet uptake of strategies can be fragmented and limited. For people with dementia, adoption of strategies may be impacted by changes in memory and planning. This paper describes the findings of a knowledge translation intervention for adoption of falls prevention strategies for people with dementia.

Methods

Twenty-five dyads (people with dementia and their caregivers) participated in this mixed method intervention. The Knowledge to Action framework guided: collation of existing evidence into a useable format; identification of individual issues; understanding context; and evaluation of change over time. Demographic details, functional status, dementia severity, activity level, self-efficacy, falls risk and readiness to change behaviour were collected at baseline, 6 and 12 months. Goal setting and action planning using a discussion tool drove implementation.

Results

Falls rates were 5.4 falls per 1000 days for the 12-month period, with no significant change in functional capacity or self-efficacy. There was a non-significant trend towards reduced falls risk. Readiness to change behaviour for falls risk increased from 84% to 96% by 6 months, with most moving from contemplation into action ( n = 16), or preparation into action ( n = 36), with adoption of strategies high (82%).

Conclusion

Engagement with the person with dementia and their caregiver, through identification of their needs and preferences, and enabling choice resulted in high adoption of falls prevention strategies.

Age-related deterioration of motor function in male and female 5xFAD mice from 3 to 16 months of age

Alzheimer's disease (AD) is a neurodegenerative disorder that leads to age-related cognitive and sensori-motor dysfunction. There is an increased understanding that motor dysfunction contributes to overall AD severity, and a need to ameliorate these impairments. The 5xFAD mouse develops the neuropathology, cognitive and motor impairments observed in AD, and thus may be a valuable animal model to study motor deficits in AD. Therefore, we assessed age-related changes in motor ability of male and female 5xFAD mice from 3 to 16 months of age, using a battery of behavioral tests. At 9-10 months, 5xFAD mice showed reduced body weight, reduced rearing in the open-field and impaired performance on the rotarod compared to wild-type controls. At 12-13 months, 5xFAD mice showed reduced locomotor activity on the open-field, and impaired balance on the balance beam. At 15-16 months, impairments were also seen in grip strength. Although sex differences were observed at specific ages, the development of motor dysfunction was similar in male and female mice. Given the 5xFAD mouse is commonly on a C57BL/6 × SJL hybrid background, a subset of mice may be homozygous recessive for the Dysf ^im mutant allele, which leads to muscular weakness in SJL mice and may exacerbate motor dysfunction. We found small effects of Dysf ^im on motor function, suggesting that Dysf ^im contributes little to motor dysfunction in 5xFAD mice. We conclude that the 5xFAD mouse may be a useful model to study mechanisms that produce motor dysfunction in AD, and to assess the efficacy of therapeutics on ameliorating motor impairment.

Dizziness

Dizziness is a common symptom encountered by all physicians. Dizziness and related symptoms are frequently linked to 1 or more of a list of contributors that includes benign paroxysmal positional vertigo, Ménière disease, migraine, acute peripheral vestibulopathy, cerebral ischemia, and anxiety disorders. Awareness of these common clinical patterns increases the likelihood of making a rapid, accurate diagnosis.

Which strength and balance activities are safe and efficacious for individuals with specific challenges (osteoporosis, vertebral fractures, frailty, dementia)?: A Narrative review

Physical activity guidelines advocate the inclusion of strength and balance activities, twice a week, for adults and older adults, but with caveat that in some individuals there will be certain movements and activities that could lead to adverse events. This scoping review summarizes the evidence about how safe and efficacious these activities are in older adults with specific challenges that might make them more prone to injury (e.g. having recently fractured or at risk of fracture (osteoporosis) or those who are frail or who have cognitive impairment). The review identified that for prevention of falls in people with a falls history and/or frailer older adults, structured exercise programmes that incorporate progressive resistance training (PRT) with increasing balance challenges over time are safe and effective if performed regularly, with supervision and support, over at least 6 months. Some minor adverse effects mainly transient musculoskeletal pain) have been reported. For those with a higher risk of falls and fractures (very poor balance, vertebral fractures), supervised structured exercise programmes are most appropriate. People with diagnosed osteoporosis should be as active as possible and only avoid activities with a high risk of falls if they are naïve to those activities. For those in transition to frailty who have poor strength and balance, exercises that are known to help maintain strength and balance (such as Tai Chi) are effective in preventing a decline in falls risk. For the very frail older adult, supervised structured exercise that has PRT, balance training and some endurance work, supervised and progressed by a trained person are advocated.

Proton pump inhibitor use and risk of hip fractures among community-dwelling persons with Alzheimer's disease-a nested case-control study

BACKGROUND

Hip fractures are a major health concern among older persons with Alzheimer's disease, who usually use many concomitant drugs for several diseases. Evidence of the association between proton pump inhibitor use and risk of hip fracture is contradictory.

AIM

To investigate whether the long-term use of proton pump inhibitor is associated with risk of hip fractures among community-dwelling persons with Alzheimer's disease.

METHODS

In this nested case-control study, the nationwide MEDALZ data were utilised. Community-dwelling persons with Alzheimer's disease who encountered incident hip fracture (N = 4818; mean age 84.1) were included as cases. Four controls were matched for each case at the date of hip fracture (N = 19 235; mean age 84.0). The association between hip fracture and duration of current PPI use (ongoing use during 0-30 days before the index date), and cumulative duration of use during 10 years before was investigated with conditional logistic regression.

RESULTS

Long-term or cumulative proton pump inhibitor use was not associated with an increased risk of hip fracture. Current proton pump inhibitor use was associated with an increased risk of hip fracture (adjusted OR 1.12, 95% CI 1.03-1.22). The risk was increased in short-term current use (<1 year) (adjusted OR 1.23, 95% CI 1.10-1.37).

CONCLUSIONS

The increased risk of hip fracture was evident only in short-term proton pump inhibitor use, but no association was found for long-term or cumulative use. Thus, our findings do not support previous assumptions that long-term proton pump inhibitor use would be associated with an increased risk of hip fractures.

A Longitudinal Assessment Of Standing Balance In Healthy Adults

Background/Study Context: The study was a longitudinal assessment of age-related changes in standing balance and response strategy usage in healthy adults.

METHODS

Balance of 17 individuals with a mean age of 44.5 years was assessed and then reassessed 19.5 years later. Participants stood on computer-controlled dual-force platforms enclosed by a visual surround and completed six tests in which visual and/or somatosensory information was systematically degraded or eliminated.

RESULTS

Results for each test and a weighted composite balance score revealed no significant change in postural control over the time period studied. However, response strategy scores indicated some significant change with age. Specifically, compensatory movement corrections about the ankle complex increased when standing on a stable support surface with and without vision, and hip-centered corrections were prominent when standing on an unstable surface with eyes open or closed.

CONCLUSION

Increased reliance on response strategy usage with time is interpreted as a compensatory adjustment to age-related increases in postural instability and accounts for the absence of any change in standing balance under different conditions of sensory input.

Slow gait speed is associated with executive function decline in older people with mild to moderate dementia: A one year longitudinal study

OBJECTIVES

This study aimed to document change in neuropsychological, physical and functional performance over one year and to investigate the relationship between baseline gait speed and cognitive decline in this period in older people with dementia.

METHODS

One hundred and seventy-seven older people with dementia (Mini-Mental State Examination 11-23; Addenbrooke's Cognitive Examination-Revised <83) residing in the community or low level care facility completed baseline neuropsychological, physical and functional assessments. Of these, 134 participants agreed to reassessment of the above measures one year later.

RESULTS

Overall, many neuropsychological, physical and functional performance measures declined significantly over the one year study period. Baseline gait speed was significantly associated with decline in verbal fluency (B(109)=2.893, p=0.046), specifically phonemic/letter fluency (B(109)=2.812, p=0.004) while controlling for age, education, dementia drug use and baseline cognitive performance. There was also a trend for an association between baseline gait speed and decline in clock drawing performance (B(107)=0.601, p=0.071).

CONCLUSIONS

Older people with mild to moderate dementia demonstrate significant decline in neuropsychological, physical and functional performance over one year. Baseline gait speed is associated with decline in executive function over one year, suggesting shared pathways/pathology between gait and cognition.

Physical activity limits the effects of age and Alzheimer's disease on postural control

The aim was to study the possible influence of physical activity on the postural performance of subjects with Alzheimer's disease (AD). The postural performance (i.e. surface area of the center of foot pressure displacement) of 3 groups was compared: Alzheimer active group (AA), Alzheimer non-active group (ANA) and healthy non-active group (HNA). The AA group's postural performance was superior to that of the ANA and HNA groups. AD disturbed postural performance but participation in regular physical activity made it possible to limit the disturbing effects of AD to a surprising extent, since the postural performance of active AD subjects was also superior to that of healthy subjects.

Falls and Fall Prevention in Older Adults With Early-Stage Dementia: An Integrative Review

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 examined 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 demonstrated some potential to reduce falls in this population. Few studies had strong designs to provide evidence for recommendations. Further study in this area is warranted. [Res Gerontol Nurs. 2017; 10(03):139-148.].

Group Balance Training Specifically Designed for Individuals With Alzheimer Disease: Impact on Berg Balance Scale, Timed Up and Go, Gait Speed, and Mini-Mental Status Examination

BACKGROUND AND PURPOSE

Individuals with Alzheimer disease (IwAD) experience more frequent and more injurious falls than their cognitively intact peers. Evidence of balance and gait dysfunction is observed earlier in the course of Alzheimer disease (AD) than once believed. Balance training has been demonstrated to be effective in improving balance and decreasing falls in cognitively intact older adults but is not well studied in IwAD. This study was designed to analyze the effects of a group balance training program on balance and falls in IwAD. The program was developed specifically for IwAD, with explicit guidelines for communication/interaction and deliberate structure of training sessions catered to the motor learning needs of IwAD.

DESIGN

This prospective, quasi-experimental, pretest-posttest design study describes the effects of a balance training program for a cohort of IwAD.

METHODS

Thirty IwAD were recruited from 3 adult day health centers; 22 completed at least 1 posttest session. Participants were tested with Berg Balance Scale (BBS), Timed Up and Go (TUG), Self-Selected Gait Speed (SSGS), Fast Gait Speed (FGS), and Mini-Mental Status Examination (MMSE) immediately before and after the 3-month intervention and again 3 months later. Group training was held at the adult day health centers for 45 minutes, twice per week. Sessions were characterized by massed, constant, and blocked practice of functional, relevant activities with considerable repetition. Ratio of participant to staff member never exceeded 3:1. Physical therapist staff members assured that participants were up on their feet the majority of each session and were individually challenged as much as possible.

RESULTS

Repeated-measures analysis of variance (ANOVA) for BBS was significant (F = 15.04; df = 1.67/28.40; P = .000) with post hoc tests, revealing improvement between pretest and immediate posttest (P = .000) and decline in performance between immediate and 3-month posttest (P = .012). Repeated-measures ANOVA posttest for MMSE was significant (F = 5.12; df = 1.73/22.53; P = .018) with post hoc tests, showing no change in MMSE between pretest and immediate posttest but decline in MMSE when comparing immediate posttest with 3-month posttest (P = .038) and pretest with 3-month posttest (P = .019). Repeated-measures ANOVA for TUG, FGS, and SSGS were not significant. Immediate effects of the intervention as assessed by the a priori paired t tests (comparing pre- and immediate posttest data) revealed significant improvement in BBS (t = -7.010; df = 20; P = .000), TUG (t = 3.103; df = 20; P = .006), and FGS (t = -2.115; df = 19; P = .048), but not in SSGS (t = -1.456; df = 20; P = .161).

DISCUSSION AND CONCLUSION

The 3-month group balance training intervention designed specifically for IwAD was effective in improving balance and mobility, as evidenced by improved BBS and TUG performances. Cognition did not decline during the course of the intervention but did decline following the intervention, suggesting a possible protective effect. Given the promising findings, a larger-scale controlled study is warranted.

Effectiveness of exercise programs to reduce falls in older people with dementia living in the community: a systematic review and meta-analysis

Objective

The objective of this systematic review and meta-analysis is to evaluate the effectiveness of exercise programs to reduce falls in older people with dementia who are living in the community.

Method

Peer-reviewed articles (randomized controlled trials [RCTs] and quasi-experimental trials) published in English between January 2000 and February 2014, retrieved from six electronic databases – Medline (ProQuest), CINAHL, PubMed, PsycInfo, EMBASE and Scopus – according to predefined inclusion criteria were included. Where possible, results were pooled and meta-analysis was conducted.

Results

Four articles (three RCT and one single-group pre- and post-test pilot study) were included. The study quality of the three RCTs was high; however, measurement outcomes, interventions, and follow-up time periods differed across studies. On completion of the intervention period, the mean number of falls was lower in the exercise group compared to the control group (mean difference [MD] [95% confidence interval {CI}] =−1.06 [−1.67 to −0.46] falls). Importantly, the exercise intervention reduced the risk of being a faller by 32% (risk ratio [95% CI] =0.68 [0.55–0.85]). Only two other outcomes were reported in two or more of the studies (step test and physiological profile assessment). No between-group differences were observed in the results of the step test (number of steps) (MD [95% CI] =0.51 [−1.77 to 2.78]) or the physiological profile assessment (MD [95% CI] =−0.10 [−0.62 to 0.42]).

Conclusion

Findings from this review suggest that an exercise program may potentially assist in preventing falls of older people with dementia living in the community. However, further research is needed with studies using larger sample sizes, standardized measurement outcomes, and longer follow-up periods, to inform evidence-based recommendations.

Reaching forward: effects of a preceding task and aging

Forward reaching is an integral part of many essential daily activities. It is often performed while standing quietly or after standing up from a seated position. This study sought to determine how a preceding balance task and aging would affect the task performance and movement strategy. Twenty-two healthy young and 20 older adults participated in this study and performed forward reaching under two task conditions. In forward reach (FR), reaching was performed during quiet standing. In up-and-reach (UR), subjects stood up from a seated position and then reached forward. A motion analysis system was used to calculate the location of the center of mass (COM) and joint angles at the initial and final positions, and the finger, COM, and joint angular displacements during the reaching task. For both groups, UR was initiated in a more flexed posture and had a significantly shorter reach distance and greater ankle dorsiflexion angle, compared to FR. The location of the COM, however, did not differ between the two task conditions. Older adults were found to significantly slow down their downward and forward COM motions in UR but not young adults. These findings showed that a preceding balance task increased the task demand and required modifications in the movement strategy. For older adults, the impact of increased task demand was greater, and adopting a cautious strategy could help to complete the task safely.

Sensor-derived physical activity parameters can predict future falls in people with dementia

BACKGROUND

There is a need for simple clinical tools that can objectively assess the fall risk in people with dementia. Wearable sensors seem to have the potential for fall prediction; however, there has been limited work performed in this important area.

OBJECTIVE

To explore the validity of sensor-derived physical activity (PA) parameters for predicting future falls in people with dementia. To compare sensor-based fall risk assessment with conventional fall risk measures.

METHODS

This was a cohort study of people with confirmed dementia discharged from a geriatric rehabilitation ward. PA was quantified using 24-hour motion-sensor monitoring at the beginning of the study. PA parameters (percentage of walking, standing, sitting, and lying; duration of single walking, standing, and sitting bouts) were extracted using specific algorithms. Conventional assessment included performance-based tests (Timed Up and Go Test, Performance-Oriented Mobility Assessment, 5-chair stand) and questionnaires (cognition, ADL status, fear of falling, depression, previous faller). Outcome measures were fallers (at least one fall in the 3-month follow-up period) versus non-fallers.

RESULTS

77 people were included in the study (age 81.8 ± 6.3; community-dwelling 88%, institutionalized 12%). Surprisingly, fallers and non-fallers did not differ on any conventional assessment (p = 0.069-0.991), except for 'previous faller' (p = 0.006). Interestingly, several PA parameters discriminated between the groups. The 'walking bout average duration', 'longest walking bout duration' and 'walking bout duration variability' were lower in fallers, compared to non-fallers (p = 0.008-0.027). The 'standing bout average duration' was higher in fallers (p = 0.050). Two variables, 'walking bout average duration' [odds ratio (OR) 0.79, p = 0.012] and 'previous faller' (OR 4.44, p = 0.007) were identified as independent predictors for falls. The OR for a 'walking bout average duration' <15 s for predicting fallers was 6.30 (p = 0.020). Combining 'walking bout average duration' and 'previous faller' improved fall prediction (OR 7.71, p < 0.001, sensitivity/specificity 72%/76%).

DISCUSSION

RESULTS demonstrate that sensor-derived PA parameters are independent predictors of the fall risk and may have higher diagnostic accuracy in persons with dementia compared to conventional fall risk measures. Our findings highlight the potential of telemonitoring technology for estimating the fall risk. RESULTS should be confirmed in a larger study and by measuring PA over a longer period of time.

Relationships between balance and cognition in patients with subjective cognitive impairment, mild cognitive impairment, and Alzheimer disease

BACKGROUND

Balance impairments are common in patients with Alzheimer disease (AD), but which aspects of balance are affected, at which stage of cognitive impairment, and their associations with cognitive domains remain unexplored.

OBJECTIVES

The aims of this study were: (1) to explore differences in balance abilities among patients with subjective cognitive impairment (SCI) or mild cognitive impairment (MCI), mild AD, and moderate AD and (2) to examine the relationship between the various aspects of balance and cognitive domains.

DESIGN

This was a cross-sectional study.

METHODS

Home-dwelling patients with SCI or MCI (n=33), mild AD (n=99), and moderate AD (n=38) participated in this study. The Balance Evaluation Systems Test (BESTest), comprising 6 subscales-"Biomechanical Constraints," "Stability Limits/Verticality," "Anticipatory Postural Adjustments," "Postural Responses," "Sensory Orientation," and "Stability in Gait"-was used to assess balance. Cognitive domains were assessed using the following measures: Mini-Mental Status Examination, Word-List Learning Test from the Consortium to Establish a Registry for Alzheimer's Disease (CERAD), Verbal Fluency Test, Clock Drawing Test, and Trail Making Test, parts A and B (TMT-A and TMT-B, respectively). Two-way between-group analyses of variance, adjusted for age, were used to analyze differences among the groups. Multiple linear regression analysis was used to explore the associations between balance and cognition.

RESULTS

Differences were found between the groups on all BESTest subscales; the moderate AD group had the worst scores. The TMT-B (measuring executive function) was associated with all of the BESTest subscales after controlling for demographic factors.

LIMITATIONS

The cross-sectional design hampered interpretation of the development of balance impairments.

CONCLUSIONS

The study findings indicate that all aspects of balance control deteriorate with increasing severity of cognitive impairment and that executive function plays an important role in balance control. Physical therapists should pay attention to these findings both in clinical practice and in future research.