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Fall Prevention in Dementia Patients with Increased Daytime Activity and Exercise

Abigail Powers

James Madison University

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Abstract

This paper uses several studies to explore dementia. Studies and data used indicate the cognitive,

functional, and psychosocial impacts of dementia as well as the characteristics of the disorder.

Fall risk for dementia patients is dramatically increased and those reasons are explored. Risk

factors of falls for cognitively impaired patients are identified such as balance, gait, vision,

medications, previous falls, environment, and other medical conditions. Promoting Independence

in Dementia (PRIDE) intervention was analyzed that works to increase independence in

cognitively impaired patients. Exercise programs are studied to determine the effects of physical

activity on falls in dementia patients. Moreover, an initiative was evaluated in effective fall care

called Developing an Intervention for Fall-Related Injuries in Dementia (DIFRID). Nursing

practice is reviewed and analyzed.

Keywords: cognitively impaired, dementia, exercise programs, fall interventions

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Fall Prevention in Dementia Patients with Increased Daytime Activity and Exercise

Dementia is becoming a large health issue within the aging population. Today, there are

44 million individuals living with dementia and by 2050 approximately 135.5 million people will

be diagnosed with the cognitive disorder (Burton et al., 2015). With the cognitive impairment of

dementia, individuals with the diagnosis are more likely to experience falls. In fact, patients with

dementia are 50 to 80 percent more likely to fall within a 12 month period compared to those 65

years or older without dementia. Individuals of 65 years or older have a 30 percent likelihood of

falling within a 12 month period (Burton et al., 2015). Therefore, can increased daytime activity

as well as exercise reduce the fall risk for dementia patients?

Dementia is an umbrella term for several conditions including Alzheimer's disease,

vascular dementia, Lewy bodies dementia, frontotemporal dementia, as well as mixed dementia.

These are progressive disorders in nature and affect the cognitive and psychological systems.

The most identifiable characteristic to dementia is memory loss, but other symptoms such as

difficulty reasoning, communicating, planning or organizing, handling complex tasks, and

overall confusion are included in the cognitive changes of the disorder. Psychological changes

comprise of personality changes, depression and anxiety, inappropriate behavior, halluications,

paranoia, and agaition (Mayo Clinic., 2019).

The causes of all types of dementia are the same in nerve damage as well as nerve loss

occur. In addition, proteins or plaques develop which contributes to the cognitive changes seen in

dementia (Mayo Clinic., 2019). According to the Alzheimer's Association, high levels of protein

within and outside brain cells makes it hard for the cells to stay healthy and do their job; to

communicate with other brain cells. Moreover, the hippocampus is the first part of the brain

affected which contributes to memory loss being one of first clinical symptoms (Alzheimer's
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Association., 2021). However, new research is being made in pathologic biomarkers for

Alzheimer's disease which could include identifying one's likelihood of getting the disorder

before clinical symptoms occur. This could shift clinical practice of dementia to primary

prevention, the use of assessments, as well as secondary prevention, early detection of an illness

through screenings, compared to the use of today's practice of tertiary prevention which involves

treating an illness that has already occurred. In other words, clinical practice will focus more on

treating dementia before symptoms and while symptoms are present (Dubois et al., 2016).

Before fall prevention or fall inventions can be produced, the risk factors to falls must be

understood. According to Fernando et al., (2017), individuals with dementia are more likely to

experience falls than those who are cognitively healthy. Moreover, a study was performed to

figure out the risk factors, because falls are a multifactorial issue. The study researched the

dynamics of previous falls including the population of cognitively and non-cognitively impaired

individuals, dementia patients that were community-dwelling (CD) or intuition-dwelling (ID), as

well as persons that were 55 years or older. In addition, the study included previous fall

prevention trials to create a baseline.

Gender and age were found to be major factors in intuition-dwelling (ID) dementia

patients. Furthermore, men and increasing age are factors that increase fall risk. Moreover,

factors that influence fall risk for ID patients include balance, gait, vision, functional status such

as being able to stand from a chair or bathe oneself, medications that impact the central nervous

system including antipsychotics, anxiolytics, hypnotics, sedatives, and antidepressants. In

addition, psychosocial factors like increased anxiety and impulsivity, severity of dementia, and

history of previous falls can influence or increase fall risk.

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Within the community-dwelling (CD) dementia patients, gender and age were not found

to be influential in increasing fall risk. Once again, factors such as balance, gait, vision,

functional status, neuroleptic medications, psychosocial conditions like depression, dementia

severity, history of previous falls, and other medical conditions like orthostatic hypotension were

found to increase fall risk (Fernando et al., 2017).

A new dementia initiative is being brought into the research field which aims to promote

independence in dementia patients. The initiative is called the Promoting Independence in

Dementia (PRIDE) intervention. Within developing the intervention evidence based stimulating

was performed on cognitive, social, as well as physical activities or aspects. Thirty-two

participants were in the study such as patients with dementia, caregivers, dementia advisors, and

older adults. The participants analyzed the drafts of the intervention on seven topics including

“making decisions” and “getting the message across.” The idea or aim of the initiative is to

increase independence, which therefore, decreases fall risk (Yates et al., 2019) .

In the United States, 400,000 hospitalizations for falls were reported in 2007 (DeSure et

al., 2013). Moreover, dementia patients have major fall-related injuries such as hip fractures and

an increased mortality rate due to the injuries (Fernando et al., 2017). In fact, individuals that

have suffered from a hip fracture due to a fall, have a 20 to 30 percent mortality rate within a

year of the fall. Besides the physical damage of falling, mental health is also affected. Therefore,

exercise programs have been studied based on the benefits of exercise on physical as well as

mental health.

One exercise program study was conducted that included institutionalized elderly with

cognitive impairment. The study was performed at an assisted-living facility in Hawaii for

twenty-four weeks and was based on physical and mental components of exercise. Sixty
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activities were involved that included strength, balance, and cognitive tasks. For example,

participants were to thrust their arms out and call out the direction of an arrow or march in place

while touching their opposite hand to their knee (DeSure et al., 2013). According to DeSure et

al., (2013), in 2012, the program was selected by the American Society on Aging and the

MetLife Foundation as the winner of the MindAlert Award in the category for programs

designed to enhance mental fitness in older adults. Furthermore, the study indicated a significant

reduction in falls, however, a larger duration and sample size are needed for more certain and

accurate results (DeSure et al., 2013).

Another exercise program study was performed on dementia patients. This study was

conducted on a longer basis, for two years, and had a total of eighty participants (Chen et al.,

2020). The previous study only took place for a total of twenty-four weeks and had thirty-seven

participants (DeSure et al., 2013). Participants were divided into exercise and no-exercise groups

of which weekly physical activity habits were performed. In addition, patients were evaluated

before the start of the study using the Mini-Mental State Examination (MMSE), clinical

dementia rating (CDR), and senior fitness tests.

Results of the study were significant in that all patients with dementia that participated in

weekly physical activity had increased upper body strength, aerobic endurance, and balance.

Furthermore, in the exercise group there were fewer unexpected hospitalizations compared to the

no-exercise group. Hospitalizations include falls, pneumonia, and urinary tract infections. In

addition, falls decreased in the exercise group. Three falls were reported with the no-exercise

group whereas no falls were reported with the exercise group (Chen et al., 2020).

However, if a fall occurs what is the best option for a patient with dementia? A study

called Developing an Intervention for Fall-Related Injuries in Dementia (DIFRID) gathered

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information on the topic using a panel of twenty-four experts within health and social care. The

experts came together through interviews and focus groups to create the ideal intervention.

Within the model or initiative, there was a focus on three themes; ensuring that the circumstances

of rehabilitation are optimised for people with dementia, compensating for the reduced ability of

people with dementia to self-manage, and equipping the workforce with the necessary skills and

information to care for this patient group. Moreover, each theme aimed at sub-themes including

managing pain, establishing a supportive environment, having a holistic approach, embedding

the intervention in daily life, providing support, allowing caregivers to be involved, providing a

patient-centered approach, equipping staff with essential tools and skills, as well as improving

pathways and referrals. The study is still in the theorcial process and hasn’t been accounted for

accectabily or feasibility in clinical practice (Wheatley et al., 2019). However, the focal points

and sub-themes in the DIFRID intervention can still be used in clinical practice since they

encompass the practices of nursing.

Within nursing practice it is essential to provide support, manage pain, participate in

patient-centered care as well as use a holistic approach to patient care. These aspects are seen

through nursing and clinical practice no matter of the patient's condition or whether or not they

are cognitively impaired. Each nursing field uses these themes each day in practice. Furthermore,

it’s important to keep in mind these nursing goals as well as the evidence found in the studies

such as providing independence through the PRIDE intervention, providing physical activity,

and using the DIFRID intervention focal points.

In 2015, the World Health Organization (WHO) identified that every four seconds a new

case of dementia is detected (Chen et al., 2020). In addition, every year there are 10 million new

cases. Dementia is an umbrella term used to characterize several progressive and chronic
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conditions that include cognitive as well as functional loss (World Health Organization., 2020).

Due to the cognitive impairments of dementia, individuals with the disorder are more likely to

fall compared to those who are cognitively normal. Risk factors to falls in dementia patients

include cognition, balance, gait, medications, vision as well as the environment such as poor

lighting or clutter that’s in the way (Burton et al., 2015). Physical activity and exercise programs

have shown to be beneficial in reducing falls and hospizations compared to dementia patients

who participated in no exercise (Chen et al., 2020).

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