Essay: Preventing falls in those with dementia

Functional Training and Balance Training in Preventing Falls on a 79-year old female with Dementia: A Case Report

ABSTRACT

Background and Purpose:

Dementia is one of the leading causes of morbidity and mortality in the elderly. Falls are another major problem the elderly population living in assisted-living facilities are facing. Patients with dementia are reported to have higher incidence of falls. Functional training uses movements similar to performing activities of daily living and may be more appropriate for people with difficulty in recall, like patients with dementia. The purpose of this case report is to describe the effectiveness of balance training and functional training in preventing falls on a 79 year old female with dementia.

Case Description:

The patient was a 79 year old female with dementia living in an assisted living facility. She was a good candidate for balance and functional training due to dementia being moderate and having a willingness to participate in the program. The patient received 2 times a week of individualized physical therapy for 9 weeks.

Outcomes:

Berg Balance Scale (BBS) had an improvement of 10 points from 12/56 on admission to 22/56 at discharge. Gait speed improved from 1.0 ft/sec on admission to 1.6 ft/sec at discharge. Timed Up and Go Test (TUG) improved from a failed score on admission to 13 secs at discharge. Modified Clinical Test of Sensory Interaction in Balance (mCTSIB) also improved from 30/30, 8/30, 2/30, and 0/30 on positions 1, 2, 3 and 4 respectively on admission to 30/30, 25/30, 8/30, and 3/30 at discharge. SPPB had improved from 1/2 on admission to 5/12 at discharge. Six-Minute Walk Test improved from failed on admission to 505 meters at discharge.

Discussion:

This case report suggests that functional training in combination with balance training is a promising approach in fall prevention in patients with dementia. Due to the nature of functional training, it has a positive impact and better carry over in patients with dementia.

INTRODUCTION

Dementia is a condition that is characterised by a decline in mental ability resulting in significant impairments in memory, communication and language, ability to focus and pay attention, reasoning, and judgement, and visual perception.1 Dementia is one of the leading causes of morbidity and mortality in the United States. It has been found to be the 6th leading cause of death in the US. There are different types of dementia including vascular, Lewy Body, subcortical, mixed, and pre-senile dementia but the most common is Alzheimer’s dementia, accounting for 60-80% of cases.1 Several procedures are used to diagnose dementia. A thorough physical exam, review of medical history, neurological tests, cognitive and neuropsychological tests, laboratory tests, psychiatric evaluation, genetic tests, and brain scans are done to accurately diagnose dementia. The most common diagnostic imaging used are computed tomography (CT) scan, magnetic resonance imaging (MRI), and positron emission tomography (PET).3 Medical management includes medicines like cholinesterase inhibitors and N-methyl-D-aspartate (NMDA) blockers.1
In this case, the type of dementia was undetermined. However, the patient exhibited difficulty remembering names and recent events, difficulty walking, confusion, and impaired judgment which are typical of patient’s with Alzheimer’s dementia. Alzheimer’s dementia is caused by beta-amyloid plaques and neurofibrally tangles in the brain. Dementia with Lewy Bodies is caused by aggregations of alpha-synuclein protein in the brain. Vascular dementia, on the other hand, is caused by blood vessel problems. Mixed dementia is the occurrence of more than one cause of dementia.1
The prognosis for different types of dementia varies. The average life expectancy for different types of dementia is summarized in Table 1. Several studies have found that factors like age, male gender, low functional status, and presence of comorbid conditions are related to lower life expectancy.2
Fall is described as an unexpected event in which an individual comes to rest on a lower level like ground or floor.4 It is a major problem the elderly population living in assisted-living facilities are facing and patients with dementia are even reported to have higher incidence of falls. Unintentional falls are the major cause of death from injury in people 65 and above.5 Due to the impairments in judgment, visuo-spatial perception, and ability to recognize and avoid hazard related to dementia, it is considered to be an independent risk factor for falls.6 The elderly population with dementia is five times more likely to fall.7 Furthermore, patients ages 65-74 have three fold increase in fall incidence.8 Approximately 60% of people with dementia in residential care are falling at least once each year.9 The most significant predictors of falls in people with dementia include gait and balance impairment, fall in previous 6 months, and use of assistive device. 10, 11, 12, 13,14,15 In a study by Christofoletti in 2008, institutionalized individuals with dementia who underwent physical therapy showed significant improvements in balance.16 Fall prevention interventions for patients with dementia is composed of exercise- and motor-based interventions, staff-directed interventions, and multidisciplinary interventions.9 The effectiveness of exercises and motor skill strategies have been investigated in people with dementia. In a study conducted by Schwenk, et. al., clinically significant improvements in gait characteristics were noted in people with dementia after undergoing dementia-adjusted training.17 Dementia-adjusted training was composed of progressive resistance and functional training and done under the supervision of a trained instructor. The resistance training focused on functionally-relevant muscle groups at 70-80% of 1 repetition maximum (RM) and progressed as needed. Functional training was composed of basic activity of daily living like sit to stand, static and dynamic balance training, and ambulation.17 Moreover, improvements in muscle strength, balance, mobility, and activities of daily living were shown after undergoing functional training.18
Functional training is a form of activity-based, task-oriented training that uses normal movement patterns to accomplish a task.19 Because functional training uses movements similar to performing activities of daily living, it may be more appropriate for people with difficulty in recall, like patients with dementia. Patients with dementia were found to have intact implicit motor learning capacity. An article by E.D. Vidoni and L.A. Boyd in 2007 entitled Achieving Enlightenment: What do we know about the implicit learning system and its interaction with explicit knowledge states, ”The hallmark of implicit motor learning is the capacity to acquire skill through physical practice without conscious recollection of what elements of performance improved.”20 Individuals with dementia may benefit from functional training to facilitate implicit learning. Other considerations applicable to this population include approaching patient on the dominant side and always on eye-level also helped due to limited visual eye field of patients with dementia.20 Treatment sessions have to be one-on-one and made in a quiet room to prevent distractions. These considerations were applied in this case report.
While numerous studies have investigated the effectiveness of balance training in the elderly population, further studies in its effectiveness when combined with functional training in preventing falls in elderly with dementia is required. The purpose of this case report is to describe the effectiveness of functional training when combined with balance training in preventing falls on a 79 year old female with dementia.

CASE DESCRIPTION

The Director of Brookdale Hampton Cove Assisted Living Facility had granted permission to conduct this case study. Informed consent was signed by the patient and countersigned by the patient’s son who is the power of attorney allowing complete review of medical history necessary to complete this case study. Approval by the Institutional Review Board (IRB) was not required.
The patient was a 79 year old female diagnosed with dementia, assisted living facility resident. She was referred to physical therapy after having a fall while trying to get out of a chair. She was considered to be a good candidate for balance and functional training due to dementia being moderate and willingness to participate in the program.
The patient’s medical history included hypertension, hyperlipidemia, hypothyroidism, gastro-esophageal reflux disease, chronic kidney disease, and osteoporosis. Surgical history included right hip replacement, cataract surgery, and tonsillectomy. Her medications were as follows: Amlodipine Besylate (10 mg once daily), Atorvastatin Calcium (40 mg once daily), Donepezil HCl (10 mg once daily), Levothyroxine Sodium (50 mcg once daily), and Pantoprazole Sodium (40 mg once daily).
The patient’s chief complaint was generalized weakness and unsteadiness during ambulation. The patient’s goals included improving her strength, balance, and endurance so she can walk independently to the facility’s dining area and back to her room during meals.

EXAMINATION AND EVALUATION

Patient’s medical records were reviewed and assessment completed. Due to dementia, some pertinent information were gathered through interviewing the facility nurse and through chart review. During evaluation, patient was noted to have decreased safety in sit to stand, slow rise, and uses rollator to steady self upon standing. She also demonstrated slow cadence, frequent stops and starts, decreased heel strike and lacks hip extension with terminal stance during ambulation using a rollator. Moreover, she was noted to have great fear of falling and verbalized being scared to walk as she might fall. Initial vital signs are as follows: heart rate of 68 bpm, blood pressure of 130/64 mmHg, temperature of 97.2 Fahrenheit, and respiratory rate of 18 cpm. She denied any pain and skin was warm, dry, and intact. Braden score was 19/23 which indicated no risk for pressure ulcers. All major muscles of bilateral upper and lower extremities were assessed and has range of motion within functional range. MMT of bilateral hips, knees, and ankles were 3+/5. Table 2 presents the comparison of tests and measures and outcome measures on initial evaluation, on 30-day reassessment, and at discharge for TUG, gait speed, mCTSIB, SPPB, BBS, MMT, MMSE, and 6MWT.

CLINICAL IMPRESSION #1

The patient presented with characteristics typical of an individual with dementia and was considered good candidate to receive the evaluation and intervention procedures. Due to the nature of dementia, tests that integrated all of the major systems were required. These tests included measures of balance, gait speed, endurance, cognitive level, and strength.There were no differential diagnosis to be addressed after initial evaluation.
Despite moderate dementia, she remained to be a good candidate due to her willingness to participate, good level of motivation, positive support from family, availability of caregivers, and absence of behavioral disturbances.
Tests and Measures:
Timed Up and Go Test (TUG). TUG is a test used to determine fall risk and measures balance, sit to stand, and ambulation. The person being tested is asked to stand up from a chair, walk three meters, turn around, walk back to the chair and sit down. A score >15 seconds indicates fall risk and a score >30 predicts need for ambulatory device and assist with activities of daily living (ADL). It has a reliability of 0.985-0.988 and minimally detectable change (MDC) of 5.88 seconds in patients with dementia.22,23
Gait speed. Gait speed is used to assess and monitor overall well-being and functional capacity in the elderly.18 Patient is asked to walk normally for 4 meters and allowed to use an assistive device as needed. This test has an MDC of 0.27 m/sec.22,24
Modified Clinical Test of Sensory Interaction in Balance (mCTSIB). MCTSIB measures the amount of postural sway under four conditions: eyes open and eyes closed on firm surface and eyes open and eyes closed on foam. The test is composed of four different conditions. In condition 1, patient is asked to stand on a firm surface, feet together with eyes open, hands crossed on the chest and maintains the position for 30 seconds. In condition 2, patient stands on a firm surface, feet together with eyes closed, hands crossed on the chest for 30 seconds. In condition 3, patient stands on a foam surface, feet together with eyes open, hands crossed on the chest for 30 seconds. Lastly, in condition 4, patient stands on a foam surface, feet together with eyes closed, hands crossed on the chest also for 30 seconds. All sensory systems for balance (i.e. vision, somatosensory, and vestibular) are present in condition 1. In condition 2, visual system is removed and patient relies on the somatosensory and vestibular systems, In condition 3, patient must rely on visual and vestibular systems as somatosensory system has been compromised. In condition 4, visual and somatosensory systems have been compromised and patient has to rely on vestibular system.25
Short Physical Performance Battery (SPPB). The SPPB is a group of tests that measures chair stand, gait speed, and balance with scores ranging from 0 (worst performance) to 12 (best). A score of 10 and below is indicative of increased risk of mobility disability. Scores 0-3 is severe limitation, 4-6 is moderate limitation, 7-9 is mild limitation, and 10-12 is minimal limitation. The test is composed of 5 items: feet together for 10 seconds, semi-tandem for 10 seconds, tandem for 10 seconds, gait speed, and chair rises 5 times without arm support. Patient gets 1 point for doing feet together for 10 seconds, 1 point for semi-tandem for 10 seconds, 1 point for tandem if able to do 3 to 9.9 seconds and 2 points if able to complete 10 seconds. For gait speed covering 13.12 feet/4 meters, patient receives 1 point for >8.7 seconds, 2 points for 6.21 to 8.7 seconds, 3 points for 4.82 to 6.2 seconds, and 4 points for <4.82 second. For chair stand x 5, patient gets 1 points if able to do test for 16.7 seconds and above but less than 60 seconds, 2 points if done between 13.7 and 16.69 seconds, 3 points for 11.2 to 13.69 seconds, and 4 points if done in less than or equal to 11.19 seconds. It has a high test-retest reliability 0.87 and interrupter reliability of 0.72 for patients with dementia. MDC is 1-2 points.26
Berg Balance Scale (BBS): Berg balance test is used to measure balance by assessing the performance of functional tasks. It is composed of 14 item list. Score ranges from 0-4 each item, with 0 being the lowest and 4 being the highest. It is administered for approximately 20 minutes. A score of 56 indicates functional balance while scores <45 indicates an individual may be at high risk of falling. It has a test-retest reliability of 0.95 and corresponds with number of falls in patients with moderate dementia 27 and a good predictor of falls. MDC = 8 points. 28
Manual Muscle Testing (MMT). MMT is widely used to evaluate function and strength of muscles in relation to gravity and use of manual resistance. An individual is asked to resist external force being applied by the therapist on the muscle being tested. Grade 0 is no visible or palpable contraction, Grade 1 is visible contraction, Grade 2- is partial range of motion (ROM), gravity eliminated, Grade 2 is full ROM, gravity eliminated, Grade 2+ is gravity eliminated/slight resistance or <1/2 range against gravity, Grade 3- is >1/2 but < full ROM, against gravity, Grade 3 is full ROM against gravity, Grade 3+ is full ROM against gravity, slight resistance, Grade 4- is full ROM against gravity, mild resistance, Grade 4 is full ROM against gravity, moderate resistance, Grade 4+ is full ROM against gravity, almost full resistance, and Grade 5 is normal, maximal resistance. Table 3 provides a summary of MMT Grading System. It has an inter rater reliability of 0.83 to 0.97 and test-retest reliability of 0.96 to 0.98. 29
Six Minute Walk Test (6MWT). The 6MWT is a test utilized to evaluate endurance and aerobic capacity. It measures the distance covered over a 6-minute time period. An individual is instructed to walk as far as possible for 6 minutes in a 30-meter walkway. Patient is allowed to slow down, stop, or rest as needed but resume walking as soon as he/she is able. It has an excellent test-retest reliability for people with Alzheimer’s (ICC=0.98). MDC = 33.47 meters. 21
Mini-Mental State Examination (MMSE). MMSE is the most common test used for individuals with memory problems. It is widely used to assist in diagnosis, progression, and severity of dementia. It is composed of 30-point questions. It takes approximately 5-10 minutes to administer the test and examines registration, attention and calculation, recall, language, ability to follow simple commands, and orientation. It does not require specialized equipment and no training for administration is needed. A score of 0-9 points indicates severe cognitive impairment, 10-18 points is moderate, 19-23 points is mild, and 24-30 points is normal cognition. It has an adequate inter rater reliability (ICC = 0.69). The standard error of measurement of the MMSE was 1.0, leading to an MDC of 3 points based on a 95% confidence interval.30

CLINICAL IMPRESSION #2

The examination data confirmed that patient was at risk for falls as evidenced by scores in Berg Balance Test, mCTSIB, TUG, and SPPB and will benefit from balance training. Result of MMSE indicated moderate cognitive impairment which affected patient’s ability to retain information affecting performance of home exercise program during non-therapy days and resulted in slow progress with PT. She was referred to home health physical therapy due to history falls and progressive decline in mobility. She had difficulty in performing bed mobility, transfers, and ambulation using rollator and needed assistance from ALF staff to go to the dining area and back to her room. She was also assisted in activities of daily living like dressing, bathing, and grooming.
Despite her moderate cognitive impairment, she was still considered an appropriate candidate for the case study as she will benefit from skilled PT services to improve functional mobility while decreasing fall risk.
Patient’s prognosis was good. Her previous level of function was modified independent in self-care, transfers, and ambulation using a rollator. Her willingness to participate in therapy, supportive son, and good living environment were positive prognosticating factors. However, her moderate cognitive impairment, age, and presence of comorbidities would likely impact the PT prognosis negatively.
Patient-centered goal was to prevent falls. Other goals included were to strengthen bilateral lower extremity musculature, improve gait speed, increase independence in transfers, improve independence in activities of daily living, and ambulate inside the facility using a rollator independently.

Intervention:

Communication and care coordination with physical therapists, doctor, and ALF nurses involved in patient’s care were done all throughout patient care episode. Progress notes were updated every visit and end-visit reports given to the ALF nurse on duty. From week 1 to 4, the patient participated in balance training for fall prevention composed of 30-45 minute individualized sessions. Activities include feet in different configurations on firm and foam surface, eyes open and eyes closed, 30 secs each position. She was also given strengthening exercises composed of ankle weight exercises, standing heel and toe raises, marching in place, hip abduction/adduction, mini squats, and hamstring curls. She was gait trained using a rollator focusing on correct body alignment, increasing lower extremity clearance, assistive device placement, and safety in directional changes. However, after patient was seen for 30 day reassessment, results of the standardized tests did not yield significant improvements and patient continued to be at risk for falls. Therefore, from week 5 to 9, same activities were given but functional training was added composed of turning, overcoming obstacles, stooping, pushing a rolling walker, sit to stand, and tiptoeing. These movements were used because they mimic common daily activities. Tables 4, 5, and 6 summarize the types of exercises given. Progression was made by increasing repetitions as appropriate starting at 10 reps each on week one up to 20 reps on week 9. Activities were also progressed by decreasing rest breaks in between exercises. Aside from the individualized physical therapy sessions, she also received group exercises twice a week led by a team member of the assisted living facility. Due to nature of dementia, patient was given simple commands. Demonstrations, verbal cues, and manual cues were provided to facilitate performance. Patient was approached on the right side, her dominant side and always on eye-level. Treatment sessions were done in the patient’s room to prevent distractions.

OUTCOMES

TUG score was failed on admission and was 38 seconds on the 30-day reassessment, both indicating high risk for falls. A score greater than 15 seconds is indicative of high fall risk. This improved to 13 seconds at discharge. Berg balance test scores were 12/56 on admission, 16/56 on 30-day reassessment and 22/56 at discharge. Gait speed was 1.0 ft/sec on admission but decreased to 0.8 ft/sec on 30-day reassessment and increased to 1.6 ft/sec at discharge. All major joints of bilateral lower extremities were graded 3+/5 on admission, 3+ to 4-/5 on 30-day reassessment and 4 to 5/5 at discharge. She received a failed score on 6MWT during admission and was not tested on 30-day reassessment but was able to cover 505 meters at discharge. SPPB score of 1/12 was recorded on admission which increased to 3/12 during 30-day reassessment and further increased to 5/12 at discharge. On admission, mCTSIB position 1 was 30/30, position 2 was 8/20, position 3 was 2/30 and position 4 was 0/30. mCTSIB tests not done on 30-day reassessment but improvements in scores noted at discharge: 30/30 for position 1, 25/30 position 2, 8/30 position 3, and 3/30 for position 4.
Summary of test results on admission, 30-day reassessment and discharge are shown in Table 2.

DISCUSSION

This case report has shown how effective functional training is when combined with balance training in preventing falls on a 79-year-old female with moderate dementia.
Clinically significant improvements in gait characteristics of patients with dementia have been shown. Improvements were noted in TUG score. She went from a failed score on admission and 38 seconds on the 30-day reassessment, patient scored 13 seconds on discharge which is indicative of decreased risk for falls. Berg balance test scores were 12/56 on admission and 16/56 on 30-day reassessment which are suggestive of high fall risk. She had a 22/56 at discharge meeting the MDC of 8 points which was not met on 30 day reassessment when patient was just participating in balance training without the addition of functional training. Gait speed was 1.0 ft/sec on admission which decreased to 0.8 ft/sec on 30-day reassessment and increased to 1.6 ft/sec at discharge also meeting MDC of 0.27 ft/sec. Strength of bilateral lower extremities improved to 4 to 5/5 at discharge from 3+/5 on admission and 3+ to 4-/5 on 30-day reassessment. Patient was unable to complete 6MWT during admission but was able to cover 505 meters at discharge, also meeting MDC of 33.47 meters. Improvements were noted on SPPB score from 1/12 on admission, 3/12 on 30-day reassessment to 5/12 at discharge, meeting MDC of 1-2 points. Lastly, mCTIB position 1 was 30/30, position 2 was 8/20, position 3 was 2/30 and position 4 was 0/30 improved to 30/30 for position 1, 25/30 position 2, 8/30 position 3, and 3/30 for position 4 at discharge. No falls were reported during the time frame that patient was being seen by physical therapy.
One of the limitations of this case study is that 6MWT and mCTSIB tests were not performed on 30 day reassessment. Moreover, evaluation was performed by another therapist different from the one who did both the reassessment and discharge visits. Another limitation is that patient also participated in group exercises twice a week led by ALF staff but attendance was not mandatory and not monitored. This could have affected the result of the interventions provided. Furthermore, the type of dementia the patient has in this case study is unknown.
This case study indicates that functional training is an effective adjunct to balance training in preventing falls in patients with dementia. This finding supports current evidence which states that functional training program is beneficial for improving gait characteristics for people with dementia.17 Furthermore, balance training helps in balance performance as dementia progresses, which may minimize the risk for falls in the later stages of the disease.25
Special considerations have to be made in applying the treatment due to the nature of dementia limiting patient’s ability to participate in therapy and to respond to instructions given. The type of commands given, in this case were limited to simple commands. Moreover, frequent cues have to be given in the form of demonstrations, verbal cues, and manual cues. Other factors that may have affected result of the study include severity of dementia, presence of comorbid conditions, living environment, behavioral aspects, and compliance to program. In this case study, patient was diagnosed with moderate dementia, was living in an assisted-living facility having assistance available at all times and had positive attitude towards physical therapy. Further studies regarding effect of balance training and functional training in fall prevention on individuals with other stages of dementia and living in a different environmental setting have to made. It would also be interesting to determine the effect of the program to different types of dementia.

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Table 1. Average Life Expectancy From Symptom Onset to Death in Different Types of Dementia
Table 2. Comparison of Test Results on Admission, 30-day Reassessment, and Discharge
Table 3. Manual Muscle Test Grading System
Table 4. Strengthening Exercises
Table 5. Balance Exercises
Table 6. Functional Training