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Three Part Question

In [elderly people with dementia who have fallen] do [physiotherapy interventions delivered on an acute hospital ward] improve [falls outcomes]?

Clinical Scenario

You are a physiotherapist working in acute elderly medicine on an acute hospital ward. The team practices a multidisciplinary approach to falls prevention and rehabilitation according to current UK guidelines, consisting of multidisciplinary assessment and multifactorial interventions.
A significant part of your caseload consists of patients with dementia who have been admitted following a fall.
You wonder which interventions within the scope of physiotherapy practice are effective in improving falls outcomes (number of falls, severity of falls, balance related outcome measures) in patients with dementia who have fallen.

Search Strategy

• PEDro (Physiotherapy Evidence Database www.pedro.org.au; selected only RCTs rated 7/10 or higher to ensure quality of study):
Date of search 7/11/09: [dementia] in abstract and title, 106 results
Date of search 14/11/09: [dementia AND fall*] in abstract and title, 10 results
Date of search 14/11/09: [cognit* impair* fall*] in abstract and title, 11 results
• The Cochrane Library (all subcategories, www.mrw.interscience.wiley.com/ cochrane/cochrane_search_fs.html):
Date of search 8/11/09: [dementia AND (fall* prevent* OR fall* rehab*)] in title, abstract and keywords, 2 results in Cochrane Reviews, 22 results in Clinical Trials, no results in other subsections
• AMED (1985 to present), BNI (1985 to present), CINAHL (1981 to present), EMBASE (1980 to present), MEDLINE (1950 to present), and PsychINFO (1806 to present) searched via NHS Evidence Health Information Resources, formerly National Library for Health, www.library.nhs.uk/Default.aspx:
Date of search 8/11/09: [dementia] AND [(fall* AND prevent*) OR (fall* AND rehab*)] in title and abstract, 469 results, 257 results after duplicates removed

Search Outcome

Out of 408 search results, four systematic reviews were thought relevant and are summarized below. All relevant RCTs found were included in at least one of these systematic reviews.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Christofoletti G, et al 2007 Brazil	People with dementia, at home or in an institution (10 RCTs)	Systematic review (1a-)	Psychosocial function, physical health and function, affective status, caregiver’s distress, mobility, behaviour, cognitive performance, activities of daily living, risk of falls	Motor intervention (described as physiotherapy, occupational therapy, physical education, or interdisciplinary intervention) showed a positive effect on psychosocial function, physical health and function, affective status, and caregiver’s distress. No significant effect on mobility. Contradicting results for effects on behaviour, cognitive performance, activities of daily living, and risk of falls.	Inconsistencies within the report of this systematic review with regards to results (p-values in Table 1 and results section of text). Heterogeneity between included RCTs with regards to populations, settings, interventions, and outcomes. Actual outcome measures used in included studies and their validity and reliability not reported. Type and severity of dementia not taken into account.
Oliver D, et al 2007 United Kingdom	Patients in hospitals and care homes with varying prevalence of cognitive impairment (16 individualised RCTs, 12 cluster randomised RCTs, 9 prospective trials with historical control, 2 retrospective observational cohort studies, 2 prospective observational cohort studies, 1 prospective case-control study, 1 quasi-experimental study with multiple interrupted time series)	Systematic review and meta-analysis (1a-)	Falls per person year, fractures/1000 person years, percentage of people falling	Multifaceted falls prevention in hospital: 13 studies, heterogeneous with regards to components of interventions, settings, populations, and study design and quality. Meta-analysis of 3 high quality studies showed significant reduction of rate of falls by 18%, but no significant effect on fractures or fallers. Exercise in hospital or care home: 2 studies, no effect on falls or fractures, but range of other benefits (not described further).	Heterogeneity between included studies. Analysis of single interventions included data from studies where the ‚single’ intervention was part of a multifaceted approach. Prevalence of cognitive impairment varied between studies from <40% to ≥70%. Analysis not accounting for level of cognitive impairment.
Hauer K, et al 2006 Germany	Older people with cognitive impairment, community-dwelling or living in care homes (11 RCTs)	Systematic review (1a-)	Over 20 different outcome measures related to physical function outcomes and falls-related outcomes	Only few studies reported significant improvements in motor function and prevention of falls by physical training. Inappropriate for meta-analysis due to large heterogeneity between studies with regards to populations, methodological quality, type of intervention, and outcome measures.	Most included studies lacked established diagnosis of dementia, therefore reported on cognitive impairment and not dementia.
Heyn P, Abreu BC & Ottenbacher KG 2004 USA	Older people with cognitive impairment and/or dementia (30 RCTs)	Systematic review and meta-analysis (1a-)	Effect sizes for: health-related physical fitness (cardiovascular, strength, flexibility, body mass index), functional outcomes, cognitive outcomes, and behavioural outcomes	Exercise training showed a significant moderately positive effect for cardiovascular, strength, cognitive, functional and behavioural outcomes. A moderately positive effect was defined as an effect size of 0.50 to 0.79.	Mean MMSE score for 6 included studies is reported as 24 or 25, no range given – this could mean very homogeneous samples of people with borderline normal cognition, or samples including people with normal cognition. 8 included studies did not report MMSE scores but reported that subjects had cognitive impairment – unclear to what degree. Setting (care home, community dwelling, etc.) not reported. Actual outcome measures used in included studies and their validity and reliability not reported. Heterogeneity in populations, interventions, and probably outcome measures.

Comment(s)

It was thought relevant to include evidence on community-dwelling populations and populations living in care homes, as falls prevention and rehabilitation usually continues beyond an acute hospital admission. The systematic review by Heyn, Abreu & Ottenbacher did not analyse any falls related outcomes, but did include strength and flexibility in their outcomes, which are often targeted in exercise interventions for fallers.

Clinical Bottom Line

Available evidence is too heterogeneous (with regards to methodological quality of studies, investigated populations, interventions, outcome measures, and reported results) to draw conclusions. In the absence of high level evidence we would recommend the use of national guidelines for dementia (5) and for falls prevention and rehabilitation (6-8) to guide clinical practice.

References

1. Christofoletti G, et al Effects of motor intervention in elderly patients with dementia: an analysis of randomized controlled trials Topics in Geriatric Rehabilitation 2007 Apr-Jun;23(2):149-154
2. Oliver D, et al Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses BMJ 2007 Jan 13;334(7584):82-88
3. Hauer K, et al Effectiveness of physical training on motor performance and fall prevention in cognitively impaired older persons: a systematic review American Journal of Physical Medicine & Rehabilitation 2006 Oct;85(10):847-857
4. Heyn P, Abreu BC & Ottenbacher KG The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis Archives of Physical Medicine and Rehabilitation 2004 Oct;85(10):1694-1704
5. Social Care Institute for Excellence, National Institute for Clinical Excellence Dementia. A NICE-SCIE Guideline on supporting people with dementia and their carers in health and social care The British Psychological Society, Leicester 2007
6. National Institute for Clinical Excellence NICE Clinical Practice Guideline for the Assessment and Prevention of Falls in Older People Royal College of Nursing, London 2004
7. The Chartered Society of Physiotherapy Effectiveness of falls prevention and rehabilitation strategies in older people: implications for physiotherapy The Chartered Society of Physiotherapy, London 2001
8. Department of Health National Service Framework for Older People Department of Health, London 2001