Diane W. HealeyNovember 18, 2008

Functional progression of dementia: FAST Scale

1 No functional decline.2 Personal awareness of some functional decline.3 Noticeable deficits in demanding job situations. 4 Requires assistance in complicated tasks such as

handling finances, planning parties, etc.

5 Requires assistance in choosing proper attire.6 Requires assistance dressing, bathing, and toileting.

Experiences urinary and fecal incontinence.

7 Speech ability declines to about a half-dozen intelligible words.

Progressive loss of abilities to walk, sit up, smile, and hold head up.

Cycle of frailty

Falls riskGait and balance disorderPsychotropic drug useArthritisVisual impairmentOrthostasisNeurologic diseaseCardiovascular diseaseHypovitaminosis D

Falls risk for dementia vs no dementia1017 people fell 5,438 times during the 2-year study

Rate of falls: 4.05 per person-year with dementia, 2.33 per person-year without dementia (P<.0001) 1.74relative risk (95% confidence interval (CI)=1.34-2.25)

Van Doorn C, et al. J Am Geriatr Soc 51(9):1213-1218, 2003.

Stage of dementia and falls risk Unimpaired (*scoring 0-1) were less likely

to fall Mild or moderate cognitive impairment (*scoring 2- 4) RR=0.67, 95% CI=0.49-0.92

Severe cognitive impairment (*scoring 5-10) no more likely to fall than residents with mild or moderate cognitive impairment (scoring 2-4) (RR=0.99, 95% CI=0.80-1.21)

*MDS cognition scale

Van Doorn C, et al. J Am Geriatr Soc 51(9):1213-1218, 2003.

Injurious falls per person-year*Dementia : 1.61Non-dementia: 0.99(P<.002)

*This is related to the number of increased falls with dementia patients, not that each fall is more injurious

Van Doorn C, et al. J Am Geriatr Soc 51(9):1213-1218, 2003

Interventions for fallsTreat postural hypotensionModification of environmental hazardsMinimizing psychotropic medicationsCardiovascular disorder treatmentMuscle strengthening and balance trainingTai Chi

No data specific for dementia

Mrs. R78 yo WF with >5 year history of Alzheimer’s

disease, taken care of at home by her husband

Previously has been an avid swimmer, hiker and biker

No longer able to do her own ADLsNot sleeping well 8/11 husband admits her to the healthcare

center of the CCRC where they have been residing in an independent home

Medications on admit:Irbesartan (Avapro) 150mg dailyMemantine (Namenda) 10mg bidGalantamine (Razadyne ER) 16mg dailySimvastatin (Zocor) 60mg daily

AdmissionWeight 101 lbs, thinGait slightly unsteady, with forward center

of gravity, leaning to the left, takes short steps, and looks to the floor when walking

No focal neurologic findingsPt appears fearful, aphasicPlan: Physical therapy evaluation due to falls

risk

Pt. not sleeping day or night: concern for increased risk of falls due to fatigue. Gait becoming more apraxic.

9/5 ramelteon (Rozerem) startedFalls: 9/8, 9/13,14,15,159/16 ramelteon discontinuedFall: 9/179/19 Melatonin startedFalls: 9/26, 30, 10/13, 17

Date/time Circumstances

Injury Interventions

9/8 8am Fell in room after bkft

Abrasion R forehead

Assist with meals

9/13 ? Fall Bump L forehead, L shoulder

?fall. Husband took comforter home

9/14 8:15pm Walking, fell on buttocks in room

No injury Encourage rest periods

9/15 7:30 am FOF in BR “painting” with feces

No injury Hold ramelteon

9/15 8pm ?Sat down on floor No injury Hipsters

9/17 6:30pm Tripped over another residents foot pedals

Skin tear L shin Assist with all ADLs

9/26 5:40am Found sitting on floor, scooting

No injury

9/30 3:25pm Tried to sit in chair and missed

No injury

10/13 6:30pm Found on floor No injury Therapy screenPharmacist review

10/17 5am Found on floor,scooting

No injury