EVIDENCE TABLE TOPIC: What is the evidence for the effect of interventions to prevent falls in persons with dementia?

Intervention approaches to consider include adaptation, remediation, prevention, and maintenance. Performance areas to examine include self-care, (work?), leisure, and social participation. (Client Factors) Author/ Study Objectives Level/Design/Subje Intervention and Results Study Limitations Implications for Year cts Outcome Measures OT The total baseline Supervision and Detweiler, There was a To determine the Level: III Intervention: Plan to and intervention involvement in M. B., Kim, effectiveness of statistically have 2 Certified period was limited. activity-based K. Y., & having a intense significant decrease Design: NonNursing Assistants Taylor, B. in the number of intervention may be fall-focused randomized control (CNAs) provide care One of the CNAs Y. (2005). program provided trial, one group, effective in reducing on the day and evening falls during the left after the end of the number of falls by regular care pretest and posttest. shift to the residents on intervention period. the study period by high-risk providers Eight dementia The total number of consistent basis dementia patients falls during baseline The 8 study patients with the everyday for intense period was 112, participants lived highest fall incidence fall-focused scattered among during intervention were chosen for the supervision. Included other residents period was 62, and study. are in-services related Small sample size the mean reduction to fall prevention and in fall number was keeping participants 6.26. There was not occupied during the difference in fall shift. severity between baseline and Outcome Measures: intervention. Number of falls Hauer, K., To determine Level: 1 The results of 11 Dementia diagnosis This area is Intervention: Becker, C., whether older physical training for RCTs indicate that was not performed understudied and Lindemann, cognitively Systematic review fall prevention for the evidence for the Screening tests further research is U., & impaired people older adults with effectiveness of didnt give specific needed. Although Beyer, N. benefit from Published cognitive impairments physical training in diagnoses. conclusions are (2006). physical training randomized living in a variety of patients with Review addressed tentative, physical with regard to controlled settings. cognitive impairment cognitive interventions such motor intervention trials is unclear. Training impairment not as gait, performance or (RCTs) from 1966 effects on motor Alzheimers strengthening, Outcome Measures: fall risk reduction through 2004 that Outcome measures performance and dementia balance and and to critically focused on persons included measurements consequently on specifically. flexibility training evaluate the with cognitive of muscle strength, reduction of falls, Homogenous study had a positive effect methodologic impairment flexibility, and specific when reported, were samples. on gait variables approach in functional most often related to Some articles had and, therefore,
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Mackintosh & Sheppard, (2005)

performances such as Literature search walking, postural using Cochrane control, global motor Central Register of or functional controlled trials, performance scores MEDLINE, (e.g., activities of daily CINAHL, and GEROLIT published living), physical activity, or falls/fallbetween 1993 and related outcomes. 2004. To assess the Level III Baseline assessments value and included medical feasibility of a Pretest-Posttest history, medications, falls-prevention single group design number of falls last 12 program for months, falls-risk community64 communityassessment. dwelling older dwelling participants people with who were at least 50 Intervention: moderate to severe y.o, had a history of 15 month fallslevels of dementia dementia and were prevention program and prevalent medically stable. 21 embedded within Italian background female / 43 male. healthy lifestyle dementia respite (HLDR) program. Participants generally attended once per week. Although occasionally did so with greater frequency. randomized controlled trials. Outcome Measures: Fall status (based on number of falls within past 12 months at baseline and past 6 months at follow-up); MMSE;

improvements in gait small sample size variables. Meta-analysis could not be performed due to heterogeneity of studies

indirectly may result in reduction of number of falls. OT practitioners should embed features of these interventions in occupation based programs. More research needs to be conducted on this type of program, but limited evidence suggests a falls-prevention program embedded in respite day programs may be a useful model to prevent falls and decrease caregiver burden if transportation, language assistance, small group size, and individual supervision are available.

No significant differences in outcomes measured between baseline and 6-month follow-up

High dropout rate due a variety of reasons including transfer to residential care and death, resulting in a small sample size Feasibility of intervention indicated by authors, but how authors came to their conclusions unclear People who examined assessments also performed intervention

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Oliver, Connelly, Victor, Shaw, Whitehead, Genc, et al., (2006).

To evaluate the evidence for strategies to prevent falls or fractures in residents in care homes and hospital inpatients and to investigate the effect of dementia and cognitive impairment.

Level I Systematic Review, Meta-analysis 43 randomized control trials (RCTs) / case-control studies focused on people with dementia / cognitive impairments published between 1982 and 2005

Berg Balance Scale; Aerobic capacity (6 Min. walk) Interventions: Studies were single- or multifaceted, and included hip protector, removal of physical restraint, fall alarm, exercise, change in environment, calcium/vitamin D, medication review; in care home and/or hospital.

Multifaceted interventions moderately reduce rate of falls in hospital settings. Inconclusive evidence for multifaceted intervention in care home setting and for single faceted interventions in hospital and care home settings. Results of metaregressions to assess effect of dementia insignificant.

Likely recorder bias for outcomes measures in some studies include din the review; Multifaceted interventions undefined; Authors believe RCT design insufficient within same setting, leading to corruption of control group Only one study focused on persons with dementia, and authors made assumption that if prevalence was not mentioned in article, the prevalence was 70%

Results of this metaanalysis suggest that evidence is inconclusive that multifaceted interventions are effective overall in reducing the rate of falls, with exception of hospital settings. While the evidence is limited for people with dementia, occupational therapy professionals should participate in inclusion of such strategies in hospital settings where they are more likely to be effective.

Stenval, Olofsson, Lundstroo

This study evaluates whether a postoperative

Level I Randomized Control

Intervention group had overall fewer Intervention group was number of falls Intervention:

Dementia and cognitive impairment were undefined Fall registration was Although the sample not blinded of participants with according to group dementia was small,

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m, Englund, Borssn, Svensson, Nyberg & Gustafson . (2007).

multidisciplinary, intervention program, including systematic assessment and treatment of fall risk factors, active prevention, detection, and treatment of postoperative complications, could reduce inpatient falls and fall-related injuries after a femoral neck fracture.

in a hospital unit specializing in geriatric 199 participants 70 orthopedic patients. A multidisciplinary team years old; 74 [nurses (RN), licensed females, 125 males; practical nurses (LPN), patients with undisplaced femoral physiotherapists (PT), occupational therapists neck fracture, (OT), dietician, and operated on with internal fixation (IF); geriatricians] received a 4 day course in patients with caring, rehabilitation, displaced fracture teamwork, and operated on with medical knowledge hemiarthroplasty including sessions (HAP). 36/199 patients with about how to prevent, detect, and treat dementia. various postoperative complications such as Exclusion criteria: postoperative delirium -Patients with: rheumatoid arthritis, and falls. All team members assessed severe hip patients within 24 osteoarthritis, pathological fracture, hours of arrival. Team met for goal setting severe renal failure, twice per week and bedridden before provided active fracture occurred prevention, detection, treatment of postoperative rehabilitation with a focus on prevention, daily routine, and nutrition. Home visit by occupational therapist and/or physical therapist Trial (RCT)

results suggest that occupational therapy Small study sample, professionals should advocate for and be particularly of part of people with multidisciplinary, dementia. post-operative intervention programs during inpatient stays to reduce the number of falls and fallFewer number of falls related injuries and fallers among following a femoral people with dementia neck fracture. Occupational therapy professionals can particularly provide basic ADL routine training with particular attention to fall risk factors. distributed over fewer fallers. Fewer number of serious injuries and shorter overall hospital stay (28.017.9 days intervention compared to 38.040.6 days control). allocation There appears to be very little increased costs associated with this intervention program, with exception of education hours.

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Control Group also was on a specialist orthopedic geriatric unit, received usual care, team goals and assessment once per week. Outcome Measures: Abbreviated Injury Scale (AIS); Maximum injury connected with each incident recorded (MAIS); Mini Mental State Examination (MMSE); Organic Brain Syndrome Scale (OBS Scale); Geriatric Depression Scale (GDS-15); OBS Scale) 1. Detweiler, M. B., Kim, K. Y., & Taylor, B. Y. (2005). Focused supervision of high-risk fall dementia patients: a simple method to reduce fall incidence and severity. American Journal of Alzheimers Disease and Other Dementias, 20, 97-104. 2. Hauer, K., Becker, C., Lindemann, U. & Beyer, N. (2006). Effectiveness of physical training on motor performance and fall prevention in cognitively impaired older persons: A systematic review. American Journal of Physical Medicine & Rehabilitation, 85, 847-857. 3. Mackintosh, S.F & Sheppard, L.A. (2005) A pilot falls-prevention programme for older people with dementia from a predominantly Italian background. Hong Kong Physiotherapy Journal, 23, 20-26. 4. Oliver D, Connelly JB, Victor CR, Shaw FE, Whitehead A, Genc Y et al. (2007). Strategies to prevent falls and fractures in hospitals and effect of cognitive impairment: systematic review and meta-analyses. British Medical Journal, 334(7584): 82 5. Stenval, M., Olofsson, B., Lundstroom, M., Englund, U., Borssn, B., Svensson, O., Nyberg, L., & Gustafson, Y. (2007). A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture. Osteoporos International, 18, 167-175.
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