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1.  Altered visual-spatial attention to task-irrelevant information is associated with falls risk in older adults 
Neuropsychologia  2013;51(14):3025-3032.
Executive cognitive functions play a critical role in falls risk – a pressing health care issue in seniors. In particular, intact attentional processing is integral for safe mobility and navigation. However, the specific contribution of impaired visual-spatial attention in falls remains unclear. In this study, we examined the association between visual-spatial attention to task-irrelevant stimuli and falls risk in community-dwelling older adults. Participants completed a visual target discrimination task at fixation while task-irrelevant probes were presented in both visual fields. We assessed attention to left and right peripheral probes using event-related potentials (ERPs). Falls risk was determined using the valid and reliable Physiological Profile Assessment (PPA). We found a significantly positive association between reduced attentional facilitation, as measured by the N1 ERP component, and falls risk. This relationship was specific to probes presented in the left visual field and measured at ipsilateral electrode sites. Our results suggest that fallers exhibit reduced attention to the left side of visual space and provide evidence that impaired right hemispheric function and/or structure may contribute to falls.
PMCID: PMC4318690  PMID: 24436970 CAMSID: cams4313
Visual-spatial attention; Aging; Older adults; Falls risk; Event-related potentials (ERPs); Neuroimaging
2.  Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
Objective
To identify interventions that may be effective in reducing the probability of an elderly person’s falling and/or sustaining a fall-related injury.
Background
Although estimates of fall rates vary widely based on the location, age, and living arrangements of the elderly population, it is estimated that each year approximately 30% of community-dwelling individuals aged 65 and older, and 50% of those aged 85 and older will fall. Of those individuals who fall, 12% to 42% will have a fall-related injury.
Several meta-analyses and cohort studies have identified falls and fall-related injuries as a strong predictor of admission to a long-term care (LTC) home. It has been shown that the risk of LTC home admission is over 5 times higher in seniors who experienced 2 or more falls without injury, and over 10 times higher in seniors who experienced a fall causing serious injury.
Falls result from the interaction of a variety of risk factors that can be both intrinsic and extrinsic. Intrinsic factors are those that pertain to the physical, demographic, and health status of the individual, while extrinsic factors relate to the physical and socio-economic environment. Intrinsic risk factors can be further grouped into psychosocial/demographic risks, medical risks, risks associated with activity level and dependence, and medication risks. Commonly described extrinsic risks are tripping hazards, balance and slip hazards, and vision hazards.
Note: It is recognized that the terms “senior” and “elderly” carry a range of meanings for different audiences; this report generally uses the former, but the terms are treated here as essentially interchangeable.
Evidence-Based Analysis of Effectiveness
Research Question
Since many risk factors for falls are modifiable, what interventions (devices, systems, programs) exist that reduce the risk of falls and/or fall-related injuries for community-dwelling seniors?
Inclusion and Exclusion Criteria
Inclusion Criteria
English language;
published between January 2000 and September 2007;
population of community-dwelling seniors (majority aged 65+); and
randomized controlled trials (RCTs), quasi-experimental trials, systematic reviews, or meta-analyses.
Exclusion Criteria
special populations (e.g., stroke or osteoporosis; however, studies restricted only to women were included);
studies only reporting surrogate outcomes; or
studies whose outcome cannot be extracted for meta-analysis.
Outcomes of Interest
number of fallers, and
number of falls resulting in injury/fracture.
Search Strategy
A search was performed in OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published between January 2000 and September 2007. Furthermore, all studies included in a 2003 Cochrane review were considered for inclusion in this analysis. Abstracts were reviewed by a single author, and studies meeting the inclusion criteria outlined above were obtained. Studies were grouped based on intervention type, and data on population characteristics, fall outcomes, and study design were extracted. Reference lists were also checked for relevant studies. The quality of the evidence was assessed as high, moderate, low, or very low according to the GRADE methodology.
Summary of Findings
The following 11 interventions were identified in the literature search: exercise programs, vision assessment and referral, cataract surgery, environmental modifications, vitamin D supplementation, vitamin D plus calcium supplementation, hormone replacement therapy (HRT), medication withdrawal, gait-stabilizing devices, hip protectors, and multifactorial interventions.
Exercise programs were stratified into targeted programs where the exercise routine was tailored to the individuals’ needs, and untargeted programs that were identical among subjects. Furthermore, analyses were stratified by exercise program duration (<6 months and ≥6 months) and fall risk of study participants. Similarly, the analyses on the environmental modification studies were stratified by risk. Low-risk study participants had had no fall in the year prior to study entry, while high-risk participants had had at least one fall in the previous year.
A total of 17 studies investigating multifactorial interventions were identified in the literature search. Of these studies, 10 reported results for a high-risk population with previous falls, while 6 reported results for study participants representative of the general population. One study provided stratified results by fall risk, and therefore results from this study were included in each stratified analysis.
Summary of Meta-Analyses of Studies Investigating the Effectiveness of Interventions on the Risk of Falls in Community-Dwelling Seniors*
CI refers to confidence interval; RR, relative risk.
Hazard ratio is reported, because RR was not available.
Summary of Meta-Analyses of Studies Investigating the Effectiveness of Interventions on the Risk of Fall-Related Injuries in Community-Dwelling Seniors*
CI refers to confidence interval; RR, relative risk.
Odds ratio is reported, because RR was not available.
Conclusions
High-quality evidence indicates that long-term exercise programs in mobile seniors and environmental modifications in the homes of frail elderly persons will effectively reduce falls and possibly fall-related injuries in Ontario’s elderly population.
A combination of vitamin D and calcium supplementation in elderly women will help reduce the risk of falls by more than 40%.
The use of outdoor gait-stabilizing devices for mobile seniors during the winter in Ontario may reduce falls and fall-related injuries; however, evidence is limited and more research is required in this area.
While psychotropic medication withdrawal may be an effective method for reducing falls, evidence is limited and long-term compliance has been demonstrated to be difficult to achieve.
Multifactorial interventions in high-risk populations may be effective; however, the effect is only marginally significant, and the quality of evidence is low.
PMCID: PMC3377567  PMID: 23074507
3.  The influence of fear of falling on gait variability: results from a large elderly population-based cross-sectional study 
Objective
To compare gait variability among older community-dwellers with and without fear of falling and history of falls, and 2) to examine the association between gait variability and fear of falling while taking into account the effect of potential confounders.
Methods
Based on a cross-sectional design, 1,023 French community-dwellers (mean age ± SD, 70.5 ± 5.0 years; 50.7% women) were included in this study. The primary endpoints were fear of falling, stride-to-stride variability of stride time and walking speed measured using GAITRite® system. Age, gender, history of falls, number of drugs daily taken per day, body mass index, lower-limb proprioception, visual acuity, use of psychoactive drugs and cognitive impairment were used as covariables in the statistical analysis. P-values less than 0.05 were considered as statistically significant.
Results
A total of 60.5% (n = 619) participants were non-fallers without fear of falling, 19% (n = 194) fallers without fear of falling, 9.9% (n = 101) non-fallers with fear of falling, and 10.7% (n = 109) fallers with fear of falling. Stride-to-stride variability of stride time was significantly higher in fallers with fear of falling compared to non-fallers without fear of falling. Full adjusted linear regression models showed that only lower walking speed value was associated to an increase in stride-to-stride variability of stride time and not fear of falling, falls or their combination. While using a walking speed ≥1.14 m/s (i.e., level of walking speed that did not influence stride-to-stride variability of stride time), age and combination of fear of falling with history of previous falls were significantly associated with an increased stride-to-stride variability of stride time.
Conclusions
The findings show that the combination of fear of falling with falls increased stride-to-stride variability of stride time. However, the effect of this combination depended on the level of walking speed, increase in stride-to-stride variability of stride time at lower walking speed being related to a biomechanical effect overriding fear of falling-related effects.
doi:10.1186/1743-0003-11-128
PMCID: PMC4156618  PMID: 25168467
Fear; Accidental falls; Gait disorders; Aged
4.  Delirium markers in older fallers: a case-control study 
Background
When a hospitalized older patient falls or develops delirium, there are significant consequences for the patient and the health care system. Assessments of inattention and altered consciousness, markers for delirium, were analyzed to determine if they were also associated with falls.
Methods
This retrospective case-control study from a regional tertiary Veterans Affairs referral center identified falls and delirium risk factors from quality databases from 2010 to 2012. Older fallers with complete delirium risk assessments prior to falling were identified. As a control, non-fallers were matched at a 3:1 ratio. Admission risk factors that were compared in fallers and non-fallers included altered consciousness, cognitive performance, attention, sensory deficits, and dehydration. Odds ratio (OR) was reported (95% confidence interval [CI]).
Results
After identifying 67 fallers, the control population (n=201) was matched on age (74.4±9.8 years) and ward (83.6% medical; 16.4% intensive care unit). Inattention as assessed by the Months of the Year Backward test was more common in fallers (67.2% versus 50.8%, OR=2.0; 95% CI: 1.1–3.7). Fallers tended to have altered consciousness prior to falling (28.4% versus 12.4%, OR=2.8; 95% CI: 1.3–5.8).
Conclusion
In this case-control study, alterations in consciousness and inattention, assessed prior to falling, were more common in patients who fell. Brief assessments of consciousness and attention should be considered for inclusion in fall prediction.
doi:10.2147/CIA.S71033
PMCID: PMC4246925  PMID: 25473272
geriatrics; patient centered outcomes research; patient safety
5.  A Common Cognitive Profile in Elderly Fallers and in Patients with Parkinson’s Disease: The Prominence of Impaired Executive Function and Attention 
Experimental aging research  2006;32(4):411-429.
The present study examined the cognitive profile of fallers relative to healthy controls and patients with Parkinson’s disease (PD), a positive control group, using a computerized battery. Fallers performed more poorly than controls on executive function, attention, and motor skills, but performed comparably on memory, information processing and the Mini Mental State Exam. A similar profile was evident for PD patients. However, unlike PD patients, fallers were abnormally inconsistent in their reaction times. These findings indicate that elderly fallers may have a unique cognitive processing deficit (i.e., variability of response timing) and underscore the importance of executive function and attention as potential targets for fall risk screening and interventions.
doi:10.1080/03610730600875817
PMCID: PMC1868891  PMID: 16982571
cognitive function; aging; executive function; falls
6.  Performance Based Assessment of Falls Risk in Older Veterans with Executive Dysfunction 
Falling is a serious hazard for older veterans that may lead to severe injury, loss of independence, and death. While the American Geriatric Society (AGS) provides guidelines to screen individuals at-risk for falls, the guidelines may be less successful with specific subgroups of patients. In a veteran sample, we examined whether the Timed Up and Go (TUG) test, including a modified version, the TUG-cognition, effectively detected potential fallers whose risk was associated with cognitive deficits. Specifically, we sought to determine whether TUG tasks and AGS criteria were differentially associated with executive dysfunction, whether the TUG tasks identified potential fallers outside of those recognized by AGS criteria, and whether these tasks distinguished groups of fallers. Participants included 120 mostly male patients referred to the Memory Assessment Clinic due to cognitive impairment. TUG-cognition scores were strongly associated with executive dysfunction and differed systematically between fallers grouped by number of falls. These findings suggest that the TUG-cognition shows promise in identifying fallers whose risk is related to, or compounded by cognitive impairment. Future research should study the predictive validity of these measures by following patients prospectively.
doi:10.1682/JRRD.2013.03.0075
PMCID: PMC4330968  PMID: 24933724
American Geriatric Society falls risk guidelines; cognitive impairment; executive function; falls; falls prevention; identification of falls risk; older adults; physical therapy; Timed Up and Go test; veterans
7.  Gait disturbances as specific predictive markers of the first fall onset in elderly people: a two-year prospective observational study 
Falls are common in the elderly, and potentially result in injury and disability. Thus, preventing falls as soon as possible in older adults is a public health priority, yet there is no specific marker that is predictive of the first fall onset. We hypothesized that gait features should be the most relevant variables for predicting the first fall. Clinical baseline characteristics (e.g., gender, cognitive function) were assessed in 259 home-dwelling people aged 66 to 75 that had never fallen. Likewise, global kinetic behavior of gait was recorded from 22 variables in 1036 walking tests with an accelerometric gait analysis system. Afterward, monthly telephone monitoring reported the date of the first fall over 24 months. A principal components analysis was used to assess the relationship between gait variables and fall status in four groups: non-fallers, fallers from 0 to 6 months, fallers from 6 to 12 months and fallers from 12 to 24 months. The association of significant principal components (PC) with an increased risk of first fall was then evaluated using the area under the Receiver Operator Characteristic Curve (ROC). No effect of clinical confounding variables was shown as a function of groups. An eigenvalue decomposition of the correlation matrix identified a large statistical PC1 (termed “Global kinetics of gait pattern”), which accounted for 36.7% of total variance. Principal component loadings also revealed a PC2 (12.6% of total variance), related to the “Global gait regularity.” Subsequent ANOVAs showed that only PC1 discriminated the fall status during the first 6 months, while PC2 discriminated the first fall onset between 6 and 12 months. After one year, any PC was associated with falls. These results were bolstered by the ROC analyses, showing good predictive models of the first fall during the first six months or from 6 to 12 months. Overall, these findings suggest that the performance of a standardized walking test at least once a year is essential for fall prevention.
doi:10.3389/fnagi.2014.00022
PMCID: PMC3933787  PMID: 24611048
risk of fall; gait analysis; gait variability; gait speed; accelerometric device; fall-related injuries; home-dwelling people; principal components analysis
8.  Can cognitive enhancers reduce the risk of falls in older people with Mild Cognitive Impairment? A protocol for a randomised controlled double blind trial 
BMC Neurology  2009;9:42.
Background
Older adults with cognitive problems have a higher risk of falls, at least twice that of cognitively normal older adults. The consequences of falls in this population are very serious: fallers with cognitive problems suffer more injuries due to falls and are approximately five times more likely to be admitted to institutional care. Although the mechanisms of increased fall risk in cognitively impaired people are not completely understood, it is known that impaired cognitive abilities can reduce attentional resource allocation while walking. Since cognitive enhancers, such as cholinesterase inhibitors, improve attention and executive function, we hypothesise that cognitive enhancers may reduce fall risk in elderly people in the early stages of cognitive decline by improving their gait and balance performance due to an enhancement in attention and executive function.
Method/Design
Double blinded randomized controlled trial with 6 months follow-up in 140 older individuals with Mild Cognitive Impairment (MCI). Participants will be randomized to the intervention group, receiving donepezil, and to the control group, receiving placebo. A block randomization by four and stratification based on fall history will be performed. Primary outcomes are improvements in gait velocity and reduction in gait variability. Secondary outcomes are changes in the balance confidence, balance sway, attention, executive function, and number of falls.
Discussion
By characterizing and understanding the effects of cognitive enhancers on fall risk in older adults with cognitive impairments, we will be able to pave the way for a new approach to fall prevention in this population. This RCT study will provide, for the first time, information regarding the effect of a medication designed to augment cognitive functioning have on the risk of falls in older adults with Mild Cognitive Impairment. We expect a significant reduction in the risk of falls in this vulnerable population as a function of the reduced gait variability achieved by treatment with cognitive enhancers. This study may contribute to a new approach to prevent and treat fall risk in seniors in early stages of dementia.
Trial Registration
The protocol for this study is registered with the Clinical Trials Registry, identifier number: NCT00934531 http://www.clinicaltrials.gov
doi:10.1186/1471-2377-9-42
PMCID: PMC3224736  PMID: 19674471
9.  Caregiver- and Patient-Directed Interventions for Dementia 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
This report features the evidence-based analysis on caregiver- and patient-directed interventions for dementia and is broken down into 4 sections:
Introduction
Caregiver-Directed Interventions for Dementia
Patient-Directed Interventions for Dementia
Economic Analysis of Caregiver- and Patient-Directed Interventions for Dementia
Caregiver-Directed Interventions for Dementia
Objective
To identify interventions that may be effective in supporting the well-being of unpaid caregivers of seniors with dementia living in the community.
Clinical Need: Target Population and Condition
Dementia is a progressive and largely irreversible syndrome that is characterized by a loss of cognitive function severe enough to impact social or occupational functioning. The components of cognitive function affected include memory and learning, attention, concentration and orientation, problem-solving, calculation, language, and geographic orientation. Dementia was identified as one of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home, in that approximately 90% of individuals diagnosed with dementia will be institutionalized before death. In addition, cognitive decline linked to dementia is one of the most commonly cited reasons for institutionalization.
Prevalence estimates of dementia in the Ontario population have largely been extrapolated from the Canadian Study of Health and Aging conducted in 1991. Based on these estimates, it is projected that there will be approximately 165,000 dementia cases in Ontario in the year 2008, and by 2010 the number of cases will increase by nearly 17% over 2005 levels. By 2020 the number of cases is expected to increase by nearly 55%, due to a rise in the number of people in the age categories with the highest prevalence (85+). With the increase in the aging population, dementia will continue to have a significant economic impact on the Canadian health care system. In 1991, the total costs associated with dementia in Canada were $3.9 billion (Cdn) with $2.18 billion coming from LTC.
Caregivers play a crucial role in the management of individuals with dementia because of the high level of dependency and morbidity associated with the condition. It has been documented that a greater demand is faced by dementia caregivers compared with caregivers of persons with other chronic diseases. The increased burden of caregiving contributes to a host of chronic health problems seen among many informal caregivers of persons with dementia. Much of this burden results from managing the behavioural and psychological symptoms of dementia (BPSD), which have been established as a predictor of institutionalization for elderly patients with dementia.
It is recognized that for some patients with dementia, an LTC facility can provide the most appropriate care; however, many patients move into LTC unnecessarily. For individuals with dementia to remain in the community longer, caregivers require many types of formal and informal support services to alleviate the stress of caregiving. These include both respite care and psychosocial interventions. Psychosocial interventions encompass a broad range of interventions such as psychoeducational interventions, counseling, supportive therapy, and behavioural interventions.
Assuming that 50% of persons with dementia live in the community, a conservative estimate of the number of informal caregivers in Ontario is 82,500. Accounting for the fact that 29% of people with dementia live alone, this leaves a remaining estimate of 58,575 Ontarians providing care for a person with dementia with whom they reside.
Description of Interventions
The 2 main categories of caregiver-directed interventions examined in this review are respite care and psychosocial interventions. Respite care is defined as a break or relief for the caregiver. In most cases, respite is provided in the home, through day programs, or at institutions (usually 30 days or less). Depending on a caregiver’s needs, respite services will vary in delivery and duration. Respite care is carried out by a variety of individuals, including paid staff, volunteers, family, or friends.
Psychosocial interventions encompass a broad range of interventions and have been classified in various ways in the literature. This review will examine educational, behavioural, dementia-specific, supportive, and coping interventions. The analysis focuses on behavioural interventions, that is, those designed to help the caregiver manage BPSD. As described earlier, BPSD are one of the most challenging aspects of caring for a senior with dementia, causing an increase in caregiver burden. The analysis also examines multicomponent interventions, which include at least 2 of the above-mentioned interventions.
Methods of Evidence-Based Analysis
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials (RCTs) that examined the effectiveness of interventions for caregivers of dementia patients.
Questions
Section 2.1
Are respite care services effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Do respite care services impact on rates of institutionalization of these seniors?
Section 2.2
Which psychosocial interventions are effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Which interventions reduce the risk for institutionalization of seniors with dementia?
Outcomes of Interest
any quantitative measure of caregiver psychological health, including caregiver burden, depression, quality of life, well-being, strain, mastery (taking control of one’s situation), reactivity to behaviour problems, etc.;
rate of institutionalization; and
cost-effectiveness.
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Conclusions in Table 1 are drawn from Sections 2.1 and 2.2 of the report.
Summary of Conclusions on Caregiver-Directed Interventions
There is limited evidence from RCTs that respite care is effective in improving outcomes for those caring for seniors with dementia.
There is considerable qualitative evidence of the perceived benefits of respite care.
Respite care is known as one of the key formal support services for alleviating caregiver burden in those caring for dementia patients.
Respite care services need to be tailored to individual caregiver needs as there are vast differences among caregivers and patients with dementia (severity, type of dementia, amount of informal/formal support available, housing situation, etc.)
There is moderate- to high-quality evidence that individual behavioural interventions (≥ 6 sessions), directed towards the caregiver (or combined with the patient) are effective in improving psychological health in dementia caregivers.
There is moderate- to high-quality evidence that multicomponent interventions improve caregiver psychosocial health and may affect rates of institutionalization of dementia patients.
RCT indicates randomized controlled trial.
Patient-Directed Interventions for Dementia
Objective
The section on patient-directed interventions for dementia is broken down into 4 subsections with the following questions:
3.1 Physical Exercise for Seniors with Dementia – Secondary Prevention
What is the effectiveness of physical exercise for the improvement or maintenance of basic activities of daily living (ADLs), such as eating, bathing, toileting, and functional ability, in seniors with mild to moderate dementia?
3.2 Nonpharmacologic and Nonexercise Interventions to Improve Cognitive Functioning in Seniors With Dementia – Secondary Prevention
What is the effectiveness of nonpharmacologic interventions to improve cognitive functioning in seniors with mild to moderate dementia?
3.3 Physical Exercise for Delaying the Onset of Dementia – Primary Prevention
Can exercise decrease the risk of subsequent cognitive decline/dementia?
3.4 Cognitive Interventions for Delaying the Onset of Dementia – Primary Prevention
Does cognitive training decrease the risk of cognitive impairment, deterioration in the performance of basic ADLs or instrumental activities of daily living (IADLs),1 or incidence of dementia in seniors with good cognitive and physical functioning?
Clinical Need: Target Population and Condition
Secondary Prevention2
Exercise
Physical deterioration is linked to dementia. This is thought to be due to reduced muscle mass leading to decreased activity levels and muscle atrophy, increasing the potential for unsafe mobility while performing basic ADLs such as eating, bathing, toileting, and functional ability.
Improved physical conditioning for seniors with dementia may extend their independent mobility and maintain performance of ADL.
Nonpharmacologic and Nonexercise Interventions
Cognitive impairments, including memory problems, are a defining feature of dementia. These impairments can lead to anxiety, depression, and withdrawal from activities. The impact of these cognitive problems on daily activities increases pressure on caregivers.
Cognitive interventions aim to improve these impairments in people with mild to moderate dementia.
Primary Prevention3
Exercise
Various vascular risk factors have been found to contribute to the development of dementia (e.g., hypertension, hypercholesterolemia, diabetes, overweight).
Physical exercise is important in promoting overall and vascular health. However, it is unclear whether physical exercise can decrease the risk of cognitive decline/dementia.
Nonpharmacologic and Nonexercise Interventions
Having more years of education (i.e., a higher cognitive reserve) is associated with a lower prevalence of dementia in crossectional population-based studies and a lower incidence of dementia in cohorts followed longitudinally. However, it is unclear whether cognitive training can increase cognitive reserve or decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs or reduce the incidence of dementia.
Description of Interventions
Physical exercise and nonpharmacologic/nonexercise interventions (e.g., cognitive training) for the primary and secondary prevention of dementia are assessed in this review.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and RCTs that examined the effectiveness, safety and cost effectiveness of exercise and cognitive interventions for the primary and secondary prevention of dementia.
Questions
Section 3.1: What is the effectiveness of physical exercise for the improvement or maintenance of ADLs in seniors with mild to moderate dementia?
Section 3.2: What is the effectiveness of nonpharmacologic/nonexercise interventions to improve cognitive functioning in seniors with mild to moderate dementia?
Section 3.3: Can exercise decrease the risk of subsequent cognitive decline/dementia?
Section 3.4: Does cognitive training decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs, or reduce the incidence of dementia in seniors with good cognitive and physical functioning?
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology. As per GRADE the following definitions apply:
Summary of Findings
Table 2 summarizes the conclusions from Sections 3.1 through 3.4.
Summary of Conclusions on Patient-Directed Interventions*
Previous systematic review indicated that “cognitive training” is not effective in patients with dementia.
A recent RCT suggests that CST (up to 7 weeks) is effective for improving cognitive function and quality of life in patients with dementia.
Regular leisure time physical activity in midlife is associated with a reduced risk of dementia in later life (mean follow-up 21 years).
Regular physical activity in seniors is associated with a reduced risk of cognitive decline (mean follow-up 2 years).
Regular physical activity in seniors is associated with a reduced risk of dementia (mean follow-up 6–7 years).
Evidence that cognitive training for specific functions (memory, reasoning, and speed of processing) produces improvements in these specific domains.
Limited inconclusive evidence that cognitive training can offset deterioration in the performance of self-reported IADL scores and performance assessments.
1° indicates primary; 2°, secondary; CST, cognitive stimulation therapy; IADL, instrumental activities of daily living; RCT, randomized controlled trial.
Benefit/Risk Analysis
As per the GRADE Working Group, the overall recommendations consider 4 main factors:
the trade-offs, taking into account the estimated size of the effect for the main outcome, the confidence limits around those estimates, and the relative value placed on the outcome;
the quality of the evidence;
translation of the evidence into practice in a specific setting, taking into consideration important factors that could be expected to modify the size of the expected effects such as proximity to a hospital or availability of necessary expertise; and
uncertainty about the baseline risk for the population of interest.
The GRADE Working Group also recommends that incremental costs of health care alternatives should be considered explicitly alongside the expected health benefits and harms. Recommendations rely on judgments about the value of the incremental health benefits in relation to the incremental costs. The last column in Table 3 reflects the overall trade-off between benefits and harms (adverse events) and incorporates any risk/uncertainty (cost-effectiveness).
Overall Summary Statement of the Benefit and Risk for Patient-Directed Interventions*
Economic Analysis
Budget Impact Analysis of Effective Interventions for Dementia
Caregiver-directed behavioural techniques and patient-directed exercise programs were found to be effective when assessing mild to moderate dementia outcomes in seniors living in the community. Therefore, an annual budget impact was calculated based on eligible seniors in the community with mild and moderate dementia and their respective caregivers who were willing to participate in interventional home sessions. Table 4 describes the annual budget impact for these interventions.
Annual Budget Impact (2008 Canadian Dollars)
Assumed 7% prevalence of dementia aged 65+ in Ontario.
Assumed 8 weekly sessions plus 4 monthly phone calls.
Assumed 12 weekly sessions plus biweekly sessions thereafter (total of 20).
Assumed 2 sessions per week for first 5 weeks. Assumed 90% of seniors in the community with dementia have mild to moderate disease. Assumed 4.5% of seniors 65+ are in long-term care, and the remainder are in the community. Assumed a rate of participation of 60% for both patients and caregivers and of 41% for patient-directed exercise. Assumed 100% compliance since intervention administered at the home. Cost for trained staff from Ministry of Health and Long-Term Care data source. Assumed cost of personal support worker to be equivalent to in-home support. Cost for recreation therapist from Alberta government Website.
Note: This budget impact analysis was calculated for the first year after introducing the interventions from the Ministry of Health and Long-Term Care perspective using prevalence data only. Prevalence estimates are for seniors in the community with mild to moderate dementia and their respective caregivers who are willing to participate in an interventional session administered at the home setting. Incidence and mortality rates were not factored in. Current expenditures in the province are unknown and therefore were not included in the analysis. Numbers may change based on population trends, rate of intervention uptake, trends in current programs in place in the province, and assumptions on costs. The number of patients was based on patients likely to access these interventions in Ontario based on assumptions stated below from the literature. An expert panel confirmed resource consumption.
PMCID: PMC3377513  PMID: 23074509
10.  The impact of neurological disorders on the risk for falls in the community dwelling elderly: a case-controlled study 
BMJ Open  2013;3(11):e003367.
Objectives
Owing to a lack of data, our aim was to evaluate and compare the impact of various common neurological diseases on the risk for falls in independent community dwelling senior citizens.
Design
Prospective case-controlled study.
Setting
General hospital.
Participants
Of 298 consecutive patients and 214 controls enrolled, 228 patients (aged 74.5±7.8; 61% women) and 193 controls (aged 71.4±6.8; 63% women) were included. The exclusion criteria were as follows: for patients, severe disability, disabling general condition or severe cognitive impairment; for controls, any history of neurological disorders or disabling medical conditions; and for both, age below 60 years. A matching process led to 171 age-matched and gender-matched pairs of neurological patients and healthy controls.
Main outcome measures
A 1-year incidence of falls based on patients' 12-month recall; motor and non-motor function tests to detect additional risk factors.
Results
46% of patients and 16% of controls fell at least once a year. Patients with stroke (89%), Parkinson’s disease (77%), dementia (60%) or epilepsy (57%) had a particularly high proportion of fallers, but even subgroups of patients with the least fall-associated neurological diseases like tinnitus (30%) and headache (28%) had a higher proportion of fallers than the control group. Neuropathies, peripheral nerve lesions and Parkinson's disease were predisposing to recurrent falls. A higher number of neurological comorbidities (p<0.001), lower Barthel Index values (p<0.001), lower Activities-Specific Balance Confidence scores (p<0.001) and higher Center of Epidemiological Studies Depression scores (p<0.001) as well as higher age (p<0.001) and female gender (p=0.003) proved to further increase the risk of falls.
Conclusions
Medical practitioners, allied health professionals and carers should be aware that all elderly neurological patients seen in outpatient settings are potentially at high risk for falls; they should query them routinely about previous falls and fall risks and advise them on preventive strategies.
doi:10.1136/bmjopen-2013-003367
PMCID: PMC3845038  PMID: 24282241
Falls; fall risk; elderly; community dwelling; neurological disorders
11.  Identification of functional parameters for the classification of older female fallers and prediction of ‘first-time’ fallers 
Falls remain a challenge for ageing societies. Strong evidence indicates that a previous fall is the strongest single screening indicator for a subsequent fall and the need for assessing fall risk without accounting for fall history is therefore imperative. Testing in three functional domains (using a total 92 measures) were completed in 84 older women (60–85 years of age), including muscular control, standing balance, and mean and variability of gait. Participants were retrospectively classified as fallers (n = 38) or non-fallers (n = 42) and additionally in a prospective manner to identify first-time fallers (FTFs) (n = 6) within a 12-month follow-up period. Principal component analysis revealed that seven components derived from the 92 functional measures are sufficient to depict the spectrum of functional performance. Inclusion of only three components, related to mean and temporal variability of walking, allowed classification of fallers and non-fallers with a sensitivity and specificity of 74% and 76%, respectively. Furthermore, the results indicate that FTFs show a tendency towards the performance of fallers, even before their first fall occurs. This study suggests that temporal variability and mean spatial parameters of gait are the only functional components among the 92 measures tested that differentiate fallers from non-fallers, and could therefore show efficacy in clinical screening programmes for assessing risk of first-time falling.
doi:10.1098/rsif.2014.0353
PMCID: PMC4208368  PMID: 24898021
falls; functional assessment; gait; balance; force control; principal component analysis
12.  Review of fall risk assessment in geriatric populations using inertial sensors 
Background
Falls are a prevalent issue in the geriatric population and can result in damaging physical and psychological consequences. Fall risk assessment can provide information to enable appropriate interventions for those at risk of falling. Wearable inertial-sensor-based systems can provide quantitative measures indicative of fall risk in the geriatric population.
Methods
Forty studies that used inertial sensors to evaluate geriatric fall risk were reviewed and pertinent methodological features were extracted; including, sensor placement, derived parameters used to assess fall risk, fall risk classification method, and fall risk classification model outcomes.
Results
Inertial sensors were placed only on the lower back in the majority of papers (65%). One hundred and thirty distinct variables were assessed, which were categorized as position and angle (7.7%), angular velocity (11.5%), linear acceleration (20%), spatial (3.8%), temporal (23.1%), energy (3.8%), frequency (15.4%), and other (14.6%). Fallers were classified using retrospective fall history (30%), prospective fall occurrence (15%), and clinical assessment (32.5%), with 22.5% using a combination of retrospective fall occurrence and clinical assessments. Half of the studies derived models for fall risk prediction, which reached high levels of accuracy (62-100%), specificity (35-100%), and sensitivity (55-99%).
Conclusions
Inertial sensors are promising sensors for fall risk assessment. Future studies should identify fallers using prospective techniques and focus on determining the most promising sensor sites, in conjunction with determination of optimally predictive variables. Further research should also attempt to link predictive variables to specific fall risk factors and investigate disease populations that are at high risk of falls.
doi:10.1186/1743-0003-10-91
PMCID: PMC3751184  PMID: 23927446
Geriatric; Elderly; Older adults; Fall risk; Inertial sensor; Accelerometer; Gyroscope; Wearable sensor
13.  Age-related changes in the attentional control of visual cortex: A selective problem in the left visual hemifield 
Neuropsychologia  2011;49(7):1670-1678.
To what extent does our visual-spatial attention change with age? In this regard, it has been previously reported that relative to young controls, seniors show delays in attention-related sensory facilitation. Given this finding, our study was designed to examine two key questions regarding age-related changes in the effect of spatial attention on sensory-evoked responses in visual cortex –– are there visual field differences in the age-related impairments in sensory processing, and do these impairments co-occur with changes in the executive control signals associated with visual spatial orienting? Therefore, our study examined both attentional control and attentional facilitation in seniors (aged 66 to 74 years) and young adults (aged 18 to 25 years) using a canonical spatial orienting task. Participants responded to attended and unattended peripheral targets while we recorded event-related potentials (ERPs) to both targets and attention-directing spatial cues. We found that not only were sensory-evoked responses delayed in seniors specifically for unattended events in the left visual field as measured via latency shifts in the lateral occipital P1 elicited by visual targets, but seniors also showed amplitude reductions in the anterior directing attentional negativity (ADAN) component elicited by cues directing attention to the left visual field. At the same time, seniors also had significantly higher error rates for targets presented in the left vs. right visual field. Taken together, our data thus converge on the conclusion that age-related changes in visual spatial attention involve both sensory-level and executive attentional control processes, and that these effects appear to be strongly associated with the left visual field.
doi:10.1016/j.neuropsychologia.2011.02.040
PMCID: PMC3514549  PMID: 21356222 CAMSID: cams2320
Aging; Visual-spatial attention; Attentional control; Event-related potentials
14.  Objective Assessment of Fall Risk in Parkinson's Disease Using a Body-Fixed Sensor Worn for 3 Days 
PLoS ONE  2014;9(5):e96675.
Background
Patients with Parkinson's disease (PD) suffer from a high fall risk. Previous approaches for evaluating fall risk are based on self-report or testing at a given time point and may, therefore, be insufficient to optimally capture fall risk. We tested, for the first time, whether metrics derived from 3 day continuous recordings are associated with fall risk in PD.
Methods and Materials
107 patients (Hoehn & Yahr Stage: 2.6±0.7) wore a small, body-fixed sensor (3D accelerometer) on lower back for 3 days. Walking quantity (e.g., steps per 3-days) and quality (e.g., frequency-derived measures of gait variability) were determined. Subjects were classified as fallers or non-fallers based on fall history. Subjects were also followed for one year to evaluate predictors of the transition from non-faller to faller.
Results
The 3 day acceleration derived measures were significantly different in fallers and non-fallers and were significantly correlated with previously validated measures of fall risk. Walking quantity was similar in the two groups. In contrast, the fallers walked with higher step-to-step variability, e.g., anterior-posterior width of the dominant frequency was larger (p = 0.012) in the fallers (0.78±0.17 Hz) compared to the non-fallers (0.71±0.07 Hz). Among subjects who reported no falls in the year prior to testing, sensor-derived measures predicted the time to first fall (p = 0.0034), whereas many traditional measures did not. Cox regression analysis showed that anterior-posterior width was significantly (p = 0.0039) associated with time to fall during the follow-up period, even after adjusting for traditional measures.
Conclusions/Significance
These findings indicate that a body-fixed sensor worn continuously can evaluate fall risk in PD. This sensor-based approach was able to identify transition from non-faller to faller, whereas many traditional metrics were not successful. This approach may facilitate earlier detection of fall risk and may in the future, help reduce high costs associated with falls.
doi:10.1371/journal.pone.0096675
PMCID: PMC4011791  PMID: 24801889
15.  Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
Objective
To assess the effectiveness of behavioural interventions for the treatment and management of urinary incontinence (UI) in community-dwelling seniors.
Clinical Need: Target Population and Condition
Urinary incontinence defined as “the complaint of any involuntary leakage of urine” was identified as 1 of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home. Urinary incontinence is a health problem that affects a substantial proportion of Ontario’s community-dwelling seniors (and indirectly affects caregivers), impacting their health, functioning, well-being and quality of life. Based on Canadian studies, prevalence estimates range from 9% to 30% for senior men and nearly double from 19% to 55% for senior women. The direct and indirect costs associated with UI are substantial. It is estimated that the total annual costs in Canada are $1.5 billion (Cdn), and that each year a senior living at home will spend $1,000 to $1,500 on incontinence supplies.
Interventions to treat and manage UI can be classified into broad categories which include lifestyle modification, behavioural techniques, medications, devices (e.g., continence pessaries), surgical interventions and adjunctive measures (e.g., absorbent products).
The focus of this review is behavioural interventions, since they are commonly the first line of treatment considered in seniors given that they are the least invasive options with no reported side effects, do not limit future treatment options, and can be applied in combination with other therapies. In addition, many seniors would not be ideal candidates for other types of interventions involving more risk, such as surgical measures.
Note: It is recognized that the terms “senior” and “elderly” carry a range of meanings for different audiences; this report generally uses the former, but the terms are treated here as essentially interchangeable.
Description of Technology/Therapy
Behavioural interventions can be divided into 2 categories according to the target population: caregiver-dependent techniques and patient-directed techniques. Caregiver-dependent techniques (also known as toileting assistance) are targeted at medically complex, frail individuals living at home with the assistance of a caregiver, who tends to be a family member. These seniors may also have cognitive deficits and/or motor deficits. A health care professional trains the senior’s caregiver to deliver an intervention such as prompted voiding, habit retraining, or timed voiding. The health care professional who trains the caregiver is commonly a nurse or a nurse with advanced training in the management of UI, such as a nurse continence advisor (NCA) or a clinical nurse specialist (CNS).
The second category of behavioural interventions consists of patient-directed techniques targeted towards mobile, motivated seniors. Seniors in this population are cognitively able, free from any major physical deficits, and motivated to regain and/or improve their continence. A nurse or a nurse with advanced training in UI management, such as an NCA or CNS, delivers the patient-directed techniques. These are often provided as multicomponent interventions including a combination of bladder training techniques, pelvic floor muscle training (PFMT), education on bladder control strategies, and self-monitoring. Pelvic floor muscle training, defined as a program of repeated pelvic floor muscle contractions taught and supervised by a health care professional, may be employed as part of a multicomponent intervention or in isolation.
Education is a large component of both caregiver-dependent and patient-directed behavioural interventions, and patient and/or caregiver involvement as well as continued practice strongly affect the success of treatment. Incontinence products, which include a large variety of pads and devices for effective containment of urine, may be used in conjunction with behavioural techniques at any point in the patient’s management.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials that examined the effectiveness, safety, and cost-effectiveness of caregiver-dependent and patient-directed behavioural interventions for the treatment of UI in community-dwelling seniors (see Appendix 1).
Research Questions
Are caregiver-dependent behavioural interventions effective in improving UI in medically complex, frail community-dwelling seniors with/without cognitive deficits and/or motor deficits?
Are patient-directed behavioural interventions effective in improving UI in mobile, motivated community-dwelling seniors?
Are behavioural interventions delivered by NCAs or CNSs in a clinic setting effective in improving incontinence outcomes in community-dwelling seniors?
Assessment of Quality of Evidence
The quality of the evidence was assessed as high, moderate, low, or very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Executive Summary Table 1 summarizes the results of the analysis.
The available evidence was limited by considerable variation in study populations and in the type and severity of UI for studies examining both caregiver-directed and patient-directed interventions. The UI literature frequently is limited to reporting subjective outcome measures such as patient observations and symptoms. The primary outcome of interest, admission to a LTC home, was not reported in the UI literature. The number of eligible studies was low, and there were limited data on long-term follow-up.
Summary of Evidence on Behavioural Interventions for the Treatment of Urinary Incontinence in Community-Dwelling Seniors
Prompted voiding
Habit retraining
Timed voiding
Bladder training
PFMT (with or without biofeedback)
Bladder control strategies
Education
Self-monitoring
CI refers to confidence interval; CNS, clinical nurse specialist; NCA, nurse continence advisor; PFMT, pelvic floor muscle training; RCT, randomized controlled trial; WMD, weighted mean difference; UI, urinary incontinence.
Economic Analysis
A budget impact analysis was conducted to forecast costs for caregiver-dependent and patient-directed multicomponent behavioural techniques delivered by NCAs, and PFMT alone delivered by physiotherapists. All costs are reported in 2008 Canadian dollars. Based on epidemiological data, published medical literature and clinical expert opinion, the annual cost of caregiver-dependent behavioural techniques was estimated to be $9.2 M, while the annual costs of patient-directed behavioural techniques delivered by either an NCA or physiotherapist were estimated to be $25.5 M and $36.1 M, respectively. Estimates will vary if the underlying assumptions are changed.
Currently, the province of Ontario absorbs the cost of NCAs (available through the 42 Community Care Access Centres across the province) in the home setting. The 2007 Incontinence Care in the Community Report estimated that the total cost being absorbed by the public system of providing continence care in the home is $19.5 M in Ontario. This cost estimate included resources such as personnel, communication with physicians, record keeping and product costs. Clinic costs were not included in this estimation because currently these come out of the global budget of the respective hospital and very few continence clinics actually exist in the province. The budget impact analysis factored in a cost for the clinic setting, assuming that the public system would absorb the cost with this new model of community care.
Considerations for Ontario Health System
An expert panel on aging in the community met on 3 occasions from January to May 2008, and in part, discussed treatment of UI in seniors in Ontario with a focus on caregiver-dependent and patient-directed behavioural interventions. In particular, the panel discussed how treatment for UI is made available to seniors in Ontario and who provides the service. Some of the major themes arising from the discussions included:
Services/interventions that currently exist in Ontario offering behavioural interventions to treat UI are not consistent. There is a lack of consistency in how seniors access services for treatment of UI, who manages patients and what treatment patients receive.
Help-seeking behaviours are important to consider when designing optimal service delivery methods.
There is considerable social stigma associated with UI and therefore there is a need for public education and an awareness campaign.
The cost of incontinent supplies and the availability of NCAs were highlighted.
Conclusions
There is moderate-quality evidence that the following interventions are effective in improving UI in mobile motivated seniors:
Multicomponent behavioural interventions including a combination of bladder training techniques, PFMT (with or without biofeedback), education on bladder control strategies and self-monitoring techniques.
Pelvic floor muscle training alone.
There is moderate quality evidence that when behavioural interventions are led by NCAs or CNSs in a clinic setting, they are effective in improving UI in seniors.
There is limited low-quality evidence that prompted voiding may be effective in medically complex, frail seniors with motivated caregivers.
There is insufficient evidence for the following interventions in medically complex, frail seniors with motivated caregivers:
habit retraining, and
timed voiding.
PMCID: PMC3377527  PMID: 23074508
16.  Fragmented Perception: Slower Space-Based but Faster Object-Based Attention in Recent-Onset Psychosis with and without Schizophrenia 
PLoS ONE  2013;8(3):e59983.
Background
Schizophrenia is associated with impairments of the perception of objects, but how this affects higher cognitive functions, whether this impairment is already present after recent onset of psychosis, and whether it is specific for schizophrenia related psychosis, is not clear. We therefore tested the hypothesis that because schizophrenia is associated with impaired object perception, schizophrenia patients should differ in shifting attention between objects compared to healthy controls. To test this hypothesis, a task was used that allowed us to separately observe space-based and object-based covert orienting of attention. To examine whether impairment of object-based visual attention is related to higher order cognitive functions, standard neuropsychological tests were also administered.
Method
Patients with recent onset psychosis and normal controls performed the attention task, in which space- and object-based attention shifts were induced by cue-target sequences that required reorienting of attention within an object, or reorienting attention between objects.
Results
Patients with and without schizophrenia showed slower than normal spatial attention shifts, but the object-based component of attention shifts in patients was smaller than normal. Schizophrenia was specifically associated with slowed right-to-left attention shifts. Reorienting speed was significantly correlated with verbal memory scores in controls, and with visual attention scores in patients, but not with speed-of-processing scores in either group.
Conclusions
deficits of object-perception and spatial attention shifting are not only associated with schizophrenia, but are common to all psychosis patients. Schizophrenia patients only differed by having abnormally slow right-to-left visual field reorienting. Deficits of object-perception and spatial attention shifting are already present after recent onset of psychosis. Studies investigating visual spatial attention should take into account the separable effects of space-based and object-based shifting of attention. Impaired reorienting in patients was related to impaired visual attention, but not to deficits of processing speed and verbal memory.
doi:10.1371/journal.pone.0059983
PMCID: PMC3607576  PMID: 23536901
17.  Effect of Dopaminergic Medication on Postural Sway in Advanced Parkinson’s Disease 
Background: The effect of dopaminergic therapy on balance in Parkinson’s disease (PD) remains unclear, including previous studies that excluded the effect of dyskinesias or other involuntary movements on postural sway. Additionally, medication’s effects may differ between fallers and non-fallers. In this study, the authors quantify the effect of dopaminergic medication on postural balance (sway) in advanced PD, with and without dyskinesias, and consider the patient’s history of falls.
Methods: In 24 patients with advanced idiopathic PD, postural balance was measured using a strain-gage force platform. Before and after taking dopaminergic medication, the patient’s postural sway was measured at 30-s intervals to determine sway length (SL) and sway area (SA). Data analysis included the presence of dyskinesias during “ON” medication condition and history of previous falls.
Results: No significant changes occurred in SL or SA with dopaminergic treatment for fallers without dyskinesias or non-fallers with dyskinesias. However, after dopaminergic treatment, SL and SA were 37.8 and 45% lower, respectively, in non-fallers without dyskinesias (indicating better balance) and were 87.4 and 162.8% higher, respectively, in fallers with dyskinesias (indicating poorer balance). In the ON-medication condition, SL and SA were larger in patients with dyskinesias when compared with patients without dyskinesias; SL was larger in fallers than non-fallers in both groups with or without dyskinesias.
Conclusion: Dopaminergic medication effects on postural sway could be a predictive factor for fall risk in PD patients with and without dyskinesias: specifically, decreased sway could indicate minimal fall risk whereas no change or increased postural sway could indicate a high risk.
doi:10.3389/fneur.2013.00202
PMCID: PMC3861789  PMID: 24379799
Parkinson’s disease; postural; balance; sway; dyskinesia; fall; dopaminergic; levodopa
18.  Dynamic Parameters of Balance Which Correlate to Elderly Persons with a History of Falls 
PLoS ONE  2013;8(8):e70566.
Poor balance in older persons contributes to a rise in fall risk and serious injury, yet no consensus has developed on which measures of postural sway can identify those at greatest risk of falling. Postural sway was measured in 161 elderly individuals (81.8y±7.4), 24 of which had at least one self-reported fall in the prior six months, and compared to sway measured in 37 young adults (34.9y±7.1). Center of pressure (COP) was measured during 4 minutes of quiet stance with eyes opened. In the elderly with fall history, all measures but one were worse than those taken from young adults (e.g., maximal COP velocity was 2.7× greater in fallers than young adults; p<0.05), while three measures of balance were significantly worse in fallers as compared to older persons with no recent fall history (COP Displacement, Short Term Diffusion Coefficient, and Critical Displacement). Variance of elderly subjects' COP measures from the young adult cohort were weighted to establish a balance score (“B-score”) algorithm designed to distinguish subjects with a fall history from those more sure on their feet. Relative to a young adult B-score of zero, elderly “non-fallers” had a B-score of 0.334, compared to 0.645 for those with a fall history (p<0.001). A weighted amalgam of postural sway elements may identify individuals at greatest risk of falling, allowing interventions to target those with greatest need of attention.
doi:10.1371/journal.pone.0070566
PMCID: PMC3734288  PMID: 23940592
19.  Feature extraction and selection for objective gait analysis and fall risk assessment by accelerometry 
Background
Falls in the elderly is nowadays a major concern because of their consequences on elderly general health and moral states. Moreover, the aging of the population and the increasing life expectancy make the prediction of falls more and more important. The analysis presented in this article makes a first step in this direction providing a way to analyze gait and classify hospitalized elderly fallers and non-faller. This tool, based on an accelerometer network and signal processing, gives objective informations about the gait and does not need any special gait laboratory as optical analysis do. The tool is also simple to use by a non expert and can therefore be widely used on a large set of patients.
Method
A population of 20 hospitalized elderlies was asked to execute several classical clinical tests evaluating their risk of falling. They were also asked if they experienced any fall in the last 12 months. The accelerations of the limbs were recorded during the clinical tests with an accelerometer network distributed on the body. A total of 67 features were extracted from the accelerometric signal recorded during a simple 25 m walking test at comfort speed. A feature selection algorithm was used to select those able to classify subjects at risk and not at risk for several classification algorithms types.
Results
The results showed that several classification algorithms were able to discriminate people from the two groups of interest: fallers and non-fallers hospitalized elderlies. The classification performances of the used algorithms were compared. Moreover a subset of the 67 features was considered to be significantly different between the two groups using a t-test.
Conclusions
This study gives a method to classify a population of hospitalized elderlies in two groups: at risk of falling or not at risk based on accelerometric data. This is a first step to design a risk of falling assessment system that could be used to provide the right treatment as soon as possible before the fall and its consequences. This tool could also be used to evaluate the risk several times during the revalidation procedure.
doi:10.1186/1475-925X-10-1
PMCID: PMC3022766  PMID: 21244718
20.  Development of an assessment sheet for fall prediction in stroke inpatients in convalescent rehabilitation wards in Japan 
Objective
We conducted a study to develop an assessment sheet for fall prediction in stroke inpatients that is handy and reliable to help ward staff to devise a fall prevention strategy for each inpatient immediately upon admission.
Methods
The study consisted of three steps: (1) developing a data sampling form to record variables related to risk of falls in stroke inpatients and conducting a follow-up survey for stroke inpatients from their admission to discharge by using the form; (2) carrying out analyses of characteristics of the present subjects and selecting variables showing a high hazard ratio (HR) for falls using the Cox regression analysis; (3) developing an assessment sheet for fall prediction involving variables giving the integral coefficient for each variable in accordance with the HR determined in the second step.
Results and discussion
(1) Subjects of the present survey were 704 inpatients from 17 hospitals including 270 fallers. (2) We selected seven variables as predictors of the first fall: central paralysis, history of previous falls, use of psychotropic medicines, visual impairment, urinary incontinence, mode of locomotion and cognitive impairment. (3) We made 960 trial models in combination with possible coefficients for each variable, and among them we finally selected the most suitable model giving coefficient number 1 to each variable except mode of locomotion, which was given 1 or 2. The area under the ROC curve of the selected model was 0.73, and sensitivity and specificity were 0.70 and 0.69, respectively (4/5 at the cut-off point). Scores calculated from the assessment sheets of the present subjects by adding coefficients of each variable showed normal distribution and a significantly higher mean score in fallers (4.94 ± 1.29) than in non-fallers (3.65 ± 1.58) (P = 0.001). The value of the Barthel Index as the index of ADL of each subject was indicated to be in proportion to the assessment score of each subject.
Conclusion
We developed an assessment sheet for fall prediction in stroke inpatients that was shown to be available and valid to screen inpatients with risk of falls immediately upon admission.
doi:10.1007/s12199-007-0023-8
PMCID: PMC2698258  PMID: 19568898
Fall; Stroke; Risk factor; Rehabilitation; Assessment
21.  Social Isolation in Community-Dwelling Seniors 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
Objective of the Evidence-Based Analysis
The objective was to systematically review interventions aimed at preventing or reducing social isolation and loneliness in community-dwelling seniors, that is, persons ≥ 65 years of age who are not living in long-term care institutions. The analyses focused on the following questions:
Are interventions to reduce social isolation and/or loneliness effective?
Do these interventions improve health, well-being, and/or quality of life?
Do these interventions impact on independent community living by delaying or preventing functional decline or disability?
Do the interventions impact on health care utilization, such as physician visits, emergency visits, hospitalization, or admission to long-term care?
Background: Target Population and Condition
Social and family relationships are a core element of quality of life for seniors, and these relationships have been ranked second, next to health, as the most important area of life. Several related concepts—reduced social contact, being alone, isolation, and feelings of loneliness—have all been associated with a reduced quality of life in older people. Social isolation and loneliness have also been associated with a number of negative outcomes such as poor health, maladaptive behaviour, and depressed mood. Higher levels of loneliness have also been associated with increased likelihood of institutionalization.
Note: It is recognized that the terms “senior” and “elderly” carry a range of meanings for different audiences; this report generally uses the former, but the terms are treated here as essentially interchangeable.
Methods of the Evidence-Based Analysis
The scientific evidence base was evaluated through a systematic literature review. The literature searches were conducted with several computerized bibliographic databases for literature published between January 1980 and February 2008. The search was restricted to English-language reports on human studies and excluded letters, comments and editorials, and case reports. Journal articles eligible for inclusion in the review included those that reported on single, focused interventions directed towards or evaluating social isolation or loneliness; included, in whole or in part, community-dwelling seniors (≥ 65 years); included some quantitative outcome measure on social isolation or loneliness; and included a comparative group. Assessments of current practices were obtained through consultations with various individuals and agencies including the Ontario Community Care Access Centres and the Ontario Assistive Devices Program. An Ontario-based budget impact was also assessed for the identified effective interventions for social isolation.
Findings
A systematic review of the published literature focusing on interventions for social isolation and loneliness in community-dwelling seniors identified 11 quantitative studies. The studies involved European or American populations with diverse recruitment strategies, intervention objectives, and limited follow-up, with cohorts from 10 to 15 years ago involving mainly elderly women less than 75 years of age. The studies involved 2 classes of interventions: in-person group support activities and technology-assisted interventions. These were delivered to diverse targeted groups of seniors such as those with mental distress, physically inactive seniors, low-income groups, and informal caregivers. The interventions were primarily focused on behaviour-based change. Modifying factors (client attitude or preference) and process issues (targeting methods of at-risk subjects, delivery methods, and settings) influenced intervention participation and outcomes.
Both classes of interventions were found to reduce social isolation and loneliness in seniors. Social support groups were found to effectively decrease social isolation for seniors on wait lists for senior apartments and those living in senior citizen apartments. Community-based exercise programs featuring health and wellness for physically inactive community-dwelling seniors also effectively reduced loneliness. Rehabilitation for mild/moderate hearing loss was effective in improving communication disabilities and reducing loneliness in seniors. Interventions evaluated for informal caregivers of seniors with dementia, however, had limited effectiveness for social isolation or loneliness.
Research into interventions for social isolation in seniors has not been broadly based, relative to the diverse personal, social, health, economic, and environmentally interrelated factors potentially affecting isolation. Although rehabilitation for hearing-related disability was evaluated, the systematic review did not locate research on interventions for other common causes of aging-related disability and loneliness, such as vision loss or mobility declines. Despite recent technological advances in e-health or telehealth, controlled studies evaluating technology-assisted interventions for social isolation have examined only basic technologies such as phone- or computer-mediated support groups.
Conclusions
Although effective interventions were identified for social isolation and loneliness in community-dwelling seniors, they were directed at specifically targeted groups and involved only a few of the many potential causes of social isolation. Little research has been directed at identifying effective interventions that influence the social isolation and other burdens imposed upon caregivers, in spite of the key role that caregivers assume in caring for seniors. The evidence on technology-assisted interventions and their effects on the social health and well-being of seniors and their caregivers is limited, but increasing demand for home health care and the need for efficiencies warrant further exploration. Interventions for social isolation in community-dwelling seniors need to be researched more broadly in order to develop effective, appropriate, and comprehensive strategies for at-risk populations.
PMCID: PMC3377559  PMID: 23074510
22.  Utility of the Mini-BESTest, BESTest, and BESTest Sections for Balance Assessments in Individuals with Parkinson Disease 
Background and Purpose
The Balance Evaluation Systems Test (BESTest) has been shown to be a reliable and valid measure of balance in individuals with Parkinson disease (PD). A less time-consuming assessment may increase clinical utility. We compared the discriminative fall risk ability of the Mini-BESTest to that of the BESTest, and determined the reliability and normal distribution of scores for each section of the BESTest and the Mini-BESTest in individuals with PD.
Methods
Eighty individuals with idiopathic PD were assessed using the BESTest and Mini-BESTest. A faller was defined as an individual with 2 or more falls in the prior 6-months. Subsets of individuals were used to determine inter-rater (n=15) and test-retest reliability (n=24).
Results
The Mini-BESTest, total BESTest score, and all sections of the BESTest, showed a significant difference between the average scores of fallers and non-fallers. For both the Mini-BESTest and BESTest, inter-rater (intraclass correlation ICC≥0.91) and test-retest (ICC≥0.88) reliability was high. The Mini-BESTest and BESTest were highly correlated (r=0.955). Accuracy of identifying a faller was comparable for the Mini-BESTest and BESTest (area under the ROC plots =0.86 and =0.84, respectively).
Discussion
No specific section of the BESTest captured the primary balance deficit for individuals with PD. The post-test probabilities for discriminating fallers versus non-fallers were comparable-to-slightly stronger when using the Mini-BESTest.
Conclusion
Although the Mini-BESTest has fewer than half of the items in the BESTest and takes only 15 minutes to complete, it is as reliable as the BESTest and has comparable-to-slightly greater discriminative properties for identifying fallers in individuals with Parkinson Disease.
doi:10.1097/NPT.0b013e31821a620c
PMCID: PMC3178037  PMID: 21934364
23.  Recurrent Falls in Parkinson's Disease: A Systematic Review 
Parkinson's Disease  2013;2013:906274.
Most people with Parkinson's disease (PD) fall and many experience recurrent falls. The aim of this review was to examine the scope of recurrent falls and to identify factors associated with recurrent fallers. A database search for journal articles which reported prospectively collected information concerning recurrent falls in people with PD identified 22 studies. In these studies, 60.5% (range 35 to 90%) of participants reported at least one fall, with 39% (range 18 to 65%) reporting recurrent falls. Recurrent fallers reported an average of 4.7 to 67.6 falls per person per year (overall average 20.8 falls). Factors associated with recurrent falls include: a positive fall history, increased disease severity and duration, increased motor impairment, treatment with dopamine agonists, increased levodopa dosage, cognitive impairment, fear of falling, freezing of gait, impaired mobility and reduced physical activity. The wide range in the frequency of recurrent falls experienced by people with PD suggests that it would be beneficial to classify recurrent fallers into sub-groups based on fall frequency. Given that there are several factors particularly associated with recurrent falls, fall management and prevention strategies specifically targeting recurrent fallers require urgent evaluation in order to inform clinical practice.
doi:10.1155/2013/906274
PMCID: PMC3606768  PMID: 23533953
24.  Falls among community-residing stroke survivors following inpatient rehabilitation: a descriptive analysis of longitudinal data 
BMC Geriatrics  2009;9:46.
Background
Stroke victims are at relatively high risk for injurious falls. The purpose of this study was to document longitudinal fall patterns following inpatient rehabilitation for first-time stroke survivors.
Methods
Participants (n = 231) were recruited at the end of their rehab stay and interviewed monthly via telephone for 1 to 32 months regarding fall incidents. Analyses were conducted on: total reports of falls by month over time for first-time and repeat fallers, the incidence of falling in any given month; and factors differing between fallers and non fallers.
Results
The largest percentage of participants (14%) reported falling in the first month post-discharge. After month five, less than 10% of the sample reported falling, bar months 15 (10.4%) and 23 (13.2%). From months one to nine, the percentage of those reporting one fall with and without a prior fall were similar. After month nine, the number of individuals who reported a single fall with a fall history was twice as high compared to those without a prior fall who reported falling. In both cases the percentages were small. A very small subset of the population emerged who fell multiple times each month, most of whom had a prior fall history. At least a third of the sample reported a loss of balance each month. Few factors differed significantly between fallers and non-fallers in months one to six.
Conclusion
Longitudinal data suggest that falls most likely linked to first time strokes occur in the first six months post discharge, particularly month one. Data routinely available at discharge does not distinguish fallers from non-fallers. Once a fall incident has occurred however, preventive intervention is warranted.
doi:10.1186/1471-2318-9-46
PMCID: PMC2771071  PMID: 19828029
25.  Trait Impulsivity Is Associated with the Risk of Falls in Parkinson’s Disease 
PLoS ONE  2014;9(3):e91190.
Objective
Impulsivity is a “tendency to act prematurely without foresight.” Clinical experience suggests that such impulsive behavior can impact on the fall risk in Parkinson’s disease (PD), but this has never been tested. We investigated whether trait impulsivity is related to fall risk in a large cohort of PD patients. We also investigated whether trait impulsivity affects the fall risk differently for patients with more or less postural instability and gait disability (PIGD).
Methods
388 patients with PD (H&Y≤3) completed the Barratt Impulsiveness Scale (BIS-11, higher scores indicating greater impulsivity) to assess trait impulsivity, including three subscales: motor impulsivity (e.g. “I do things without thinking”), attentional impulsivity (e.g. “I concentrate easily”) and non-planning (e.g. “I plan tasks carefully”). Falls were registered prospectively for 6 months. Patients classified as non-fallers (0 falls, n = 237) were compared to recurrent PD fallers (>1 fall, n = 78).
Results
Total impulsivity scores were higher for recurrent fallers (59.5) compared to non-fallers (56.8; p = .012). This effect was predominantly driven by higher scores on the subscale for attentional impulsivity (p = .003). The difference in attentional impulsivity was independent of gender, disease severity, dopaminergic medication, and cognitive function. Motor and non-planning impulsivity did not differ between recurrent fallers and non-fallers. There was no evidence that impulsivity modulated the association between PIGD and fall risk.
Discussion
This is the first evidence that impulsivity, in particular in the attentional domain, is related to fall risk in PD.
doi:10.1371/journal.pone.0091190
PMCID: PMC3946755  PMID: 24608747

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