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What is the natural course of ambulation for dementia patients? Are falls part of the progression?. Diane W. Healey November 18, 2008 . Functional progression of dementia: FAST Scale. 1 No functional decline. 2 Personal awareness of some functional decline.
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What is the natural course of ambulation for dementia patients?Are falls part of the progression? Diane W. Healey November 18, 2008
Functional progression of dementia: FAST Scale • 1 No functional decline. • 2 Personal awareness of some functional decline. • 3 Noticeable deficits in demanding job situations. • 4 Requires assistance in complicated tasks such as handling finances, planning parties, etc. • 5 Requires assistance in choosing proper attire. • 6 Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence. • 7 Speech ability declines to about a half-dozen intelligible words. • Progressive loss of abilities to walk, sit up, smile, and hold head up.
Cycle of frailty ? Dementia
Falls risk • Gait and balance disorder • Psychotropic drug use • Arthritis • Visual impairment • Orthostasis • Neurologic disease • Cardiovascular disease • Hypovitaminosis D
Falls risk for dementia vs no dementia • 1017 people fell 5,438 times during the 2-year study • Rate of falls: 4.05 per person-year with dementia, 2.33 per person-year without dementia (P<.0001) 1.74relative risk (95% confidence interval (CI)=1.34-2.25) • Van Doorn C, et al. J Am Geriatr Soc 51(9):1213-1218, 2003.
Stage of dementia and falls risk • Unimpaired (*scoring 0-1) were less likely to fall Mild or moderate cognitive impairment (*scoring 2- 4) RR=0.67, 95% CI=0.49-0.92 Severe cognitive impairment (*scoring 5-10) no more likely to fall than residents with mild or moderate cognitive impairment (scoring 2-4) (RR=0.99, 95% CI=0.80-1.21)*MDS cognition scale • Van Doorn C, et al. J Am Geriatr Soc 51(9):1213-1218, 2003.
Injurious falls per person-year • *Dementia : 1.61 • Non-dementia: 0.99 • (P<.002) *This is related to the number of increased falls with dementia patients, not that each fall is more injurious Van Doorn C, et al. J Am Geriatr Soc 51(9):1213-1218, 2003
Interventions for falls • Treat postural hypotension • Modification of environmental hazards • Minimizing psychotropic medications • Cardiovascular disorder treatment • Muscle strengthening and balance training • Tai Chi • No data specific for dementia
Mrs. R • 78 yo WF with >5 year history of Alzheimer’s disease, taken care of at home by her husband • Previously has been an avid swimmer, hiker and biker • No longer able to do her own ADLs • Not sleeping well • 8/11 husband admits her to the healthcare center of the CCRC where they have been residing in an independent home
Medications on admit: • Irbesartan (Avapro) 150mg daily • Memantine (Namenda) 10mg bid • Galantamine (Razadyne ER) 16mg daily • Simvastatin (Zocor) 60mg daily
Admission • Weight 101 lbs, thin • Gait slightly unsteady, with forward center of gravity, leaning to the left, takes short steps, and looks to the floor when walking • No focal neurologic findings • Pt appears fearful, aphasic • Plan: Physical therapy evaluation due to falls risk
Pt. not sleeping day or night: concern for increased risk of falls due to fatigue. Gait becoming more apraxic. • 9/5 ramelteon (Rozerem) started • Falls: 9/8, 9/13,14,15,15 • 9/16 ramelteon discontinued • Fall: 9/17 • 9/19 Melatonin started • Falls: 9/26, 30, 10/13, 17