Vol. 15 Issue 1
Subacute and Long-term Care
Helping Patients With Dementia Avoid Falls
One of the most common reasons patients with dementia are referred to physical therapy is for repeated falls or injuries due to falls. As the population of patients with dementia is one of the most rapidly growing, it is critical that our profession use both traditional and creative methods to address these needs.
Patients with dementia have a risk of falling that is two to three times higher than that of cognitively intact elders. The current annual incidence of falls for patients with dementia is nearly 60 percent. There is also a much higher risk for serious injury for patients with dementia who fall than for that of normal elders.
Many of the factors that are related to falls with this population are treatable by our traditional methods, such as improving ankle ROM, lower extremity strength, static and dynamic balance, transfers and gait. The challenge is to find a way to connect with the patient with dementia so that they can participate in these traditional interventions.
One strategy that can help is to re-establish rapport with patients on each visit and use their life story information. Life story information would include such topics as their life on their farm, their hobbies, their past careers, or their family (be sure to know a few key names). Patients with dementia often experience fear at the beginning of a treatment session. Briefly talking about some details of their life helps patients realize that you care enough to take the time to talk with them. This often increases their willingness to participate with you in physical therapy.
Once you have established this critical rapport, work creatively to incorporate the specific physical therapy intervention into whatever the patient is willing to do at that particular moment. One strategy that can be very effective is to ask a patient to help do something. For example, patients with dementia are often fearful of getting up from the safe haven of their beds after a fall. Ask for their help by telling them that you need to make the bed; ask them to help by getting into a chair. Be sure to have new bed linens, so that the patient can receive a visual cue for what is going on.
You can also ask a patient to help you find something, or assist with bringing something to a staff person's office. Increasing the amount of visual and tactile cues and increasing time for processing can also make a big difference in the patients' ability to participate in traditional interventions.
Many therapists express concerns that patients with dementia can't follow therapeutic exercises attempted during a treatment session. A frequent mistake with exercises with this population is excessive use of verbal cues, which can over-stimulate patients. For example, one approach to lower extremity exercises is to use primarily visual cues. Demonstrate first, and then do the exercises along with the patient, either sitting or standing beside them for a parallel visual cue. Performing repetitions of familiar functional tasks is another strategy that works well for patients with dementia.
There are many other factors that may contribute to falls for patients with dementia that go beyond our traditional interventions. One factor includes the common side effects of psychotropic medications that are frequently used for patients with dementia. If a patient is placed on a psychotropic medication without a first attempt at a non-pharmacological approach, it is considered a chemical restraint.
For example, a patient with dementia may be placed on psychotropic medication after an episode of agitation during a transfer. Physical therapy can assist with the non-pharmacological approach by assessing if the agitation could have been prevented or minimized with specific caregiver education or addressing untreated pain issues. Assessing if there were problems with the transfer method, if improper communication was used by the nursing assistant, or if the patient's exacerbating arthritic knee pain may have caused the agitation, are all within the realm of physical therapy intervention. Once problems are identified, the therapy team can proceed with addressing the issues, thus preventing the patient being placed on inappropriate high risk medications that frequently contribute to falls.
Another common factor relating to falls of patients with dementia is the lack of meaningful activities throughout the day. Many patients with dementia are unable to participate in large group activities at their facilities, so they often sit with nothing to do for hours on end. As a result, they become bored and attempt to get up without assistance and fall. Working closely with both the occupational therapy and the activities department, the interdisciplinary team can determine what time of the day most of the falls occur, and establish well supervised small group activities during those particular times of the day. One skilled nursing facility that implemented this type of program reduced their fall rates by 40 percent.
Treating falls in patients with dementia can be both challenging and highly rewarding. As specialists in this area, we can dramatically improve patients' quality of life by providing both creative and effective treatment.
Asada, T., et al. (1996). Predictors of fall-related injuries among community-dwelling elderly people with dementia. Age and Aging, 25(1), 22-28.
Campbell, A., et al. (1999). Psychotropic medication withdrawal and a home based exercise program to prevent falls: A randomized controlled trial. Journal of the American Geriatric Society, 47(7), 850-853.
Robertson, M., et al. (2002). Preventing injuries in older persons by preventing falls: A meta-analysis of individual level data. Journal of the American Geriatric Society, 50(5), 905-911.
Tinetti, M. & Williams, C., et al. (1997). Falls, injuries due to falls and risk of admission to a nursing home. New England Journal of Medicine, 337(18), 1279-1284.
Toulotte, C., et al. (2003). Effects of physical training on the physical capacity of frail, demented patients with a history of falling: A randomized controlled trial. Age and Aging, 32(1), 67-73.
Bob Thomas is a physical therapist and director of the rehab division of Avamere Health Services. He has contributed to numerous publications on the frail older population and lectures for GREAT Seminars on Rehabilitation Solutions for the Frail Elderly. He is an adjunct professor at Pacific University and can be reached at email@example.com. Susan Staples is a senior physical therapist at a skilled nursing facility in Annapolis, MD, and speaks for GREAT Seminars on Innovative Rehabilitation for the Patient with Dementia. She can be contacted at SStaples.PTGCS@msn.com or visit the GREAT seminars Website at www.greatseminarsandbooks.com