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139Research in Gerontological Nursing • Vol. 10, No. 3, 2017
Falls are a significant cause of morbidity and mortality among older adults, despite continued research to iden-tify preventive measures (Cigolle et al., 2015). Falls occur in 30% of community-dwelling older adults and rates are higher among those who are institutionalized (Centers for Disease Control and Prevention [CDC], 2016). Deaths from falls may be increasing due to the growing aging pop-ulation, improved reporting of falling as a cause of death, and increased chronic diseases (Stevens & Rudd, 2014). One growing subgroup of older adults at risk for falling is those with mild cognitive impairment (MCI) and early-stage dementia. Fall prevention interventions tailored to these special populations may help reduce fall rates.
Older adults with neurocognitive disorders, such as Alzheimer’s disease and MCI, have long been identified as having a high risk of falling (Morris, Rubin, Morris, & Mandel, 1987). These conditions are common worldwide. The World Health Organization (2016) estimates that more than 47 million older adults have dementia, and rates of MCI range from 51 to 76.8 per 1,000 person years (Luck et al., 2010). With the U.S. population aging, the number of older adults with these conditions is expected to increase, which has implications for the future impact of falls.
Numerous studies support the increased risk of falling in individuals with dementia and MCI. A recent system-atic review indicated that adults 60 and older with cogni-
ABSTRACT
Older adults with mild cognitive impairment (MCI) and early-stage dementia have an increased risk of falling, with risks to their health and quality of life. The purpose of the current integrative review was to evaluate evidence on fall risk and fall prevention in this population. Studies were included if they exam-ined falls or fall risk factors in older adults with MCI or early-stage dementia, or reported interventions in this population; 40 studies met criteria. Evidence supports the increased risk of falls in individuals even in the early stages of dementia or MCI, and changes in gait, balance, and fear of falling that may be related to this increased fall risk. Interventions included exercise and multifactorial interventions that demon-strated some potential to reduce falls in this population. Few studies had strong designs to provide evi-dence for recommendations. Further study in this area is warranted.[Res Gerontol Nurs. 2017; 10(3):139-148.]
Dr. Lach is Professor of Nursing, School of Nursing, Saint Louis University, St. Louis, Missouri; Dr. Harrison is Associate Professor of Nursing,
West Chester University of Pennsylvania, West Chester, Pennsylvania; and Dr. Phongphanngam is Faculty, University of Phayao School of Nursing–
Thailand, Muang Phayao, Thailand.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Helen W. Lach, PhD, CNL, FGSA, FAAN, Professor of Nursing, School of Nursing, Saint Louis University, 3525 Caroline
Mall, St. Louis, MO, 63104; e-mail: lachh@slu.edu.
Received: June 28, 2016; Accepted: August 12, 2016
doi:10.3928/19404921-20160908-01
Falls and Fall Prevention in Older Adults With Early-Stage DementiaAn Integrative Review
Helen W. Lach, PhD, CNL, FGSA, FAAN; Barbara E. Harrison, PhD, APRN, GNP-BC, FGSA; and Sutthida Phongphanngam, PhD, APN
State of the Science
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tive impairment were twice as likely to have fallen as those without cognitive impairment (Muir, Gopaul, & Montero Odasso, 2012). Fischer et al. (2014) noted an increase in falls for every decline in score on the Short Portable Mental Status Questionnaire in an older sample when followed for more than 1 year. Another study found the incidence of falls increased approximately eight times in older adults with dementia when compared to healthy older adults (Allan, Ballard, Rowan, & Kenny, 2009).
Changes to brain function noted in cognition, balance, and gait may be responsible for increased fall risks in these populations. Risk factors for falls include disease-specific motor impairment, vision impairment, type and severity of dementia, behavioral problems, impaired function, history of falls, and low bone mineral density (Härlein, Dassen, Halfens, & Heinze, 2009). Research has found gait, balance, and physical performance associated with cogni-tive impairment and falls (Taylor et al., 2014). All of these factors may contribute to the increased risk of falling in dementia.
Neurocognitive changes that begin in MCI and early stages of dementia appear to impact fall risk. Mechanisms hypothesized to account for this increased risk include impaired executive function (e.g., attention, planning), which in turn impact gait characteristics such as speed, stride, and dynamic balance, and ability to complete dual tasks (Beauchet et al., 2008). Delbaere et al. (2012) identi-fied changes in executive function that increased fall risk among community-dwelling older adults.
Interventions for fall prevention may be different for individuals in the early stages of dementia than those with more advanced disease, as cognitive abilities and func-tion become more impaired. Several recent reviews have addressed fall prevention in individuals with dementia (Booth, Logan, Harwood, & Hood, 2015; Burton et al., 2015; Guo, Tsai, Liao, Tu, & Huang, 2014; Hauer, Becker, Lindemann, & Beyer, 2006; Meyer, Hill, Dow, Synnot, & Hill, 2015), but do not focus specifically on samples with early-stage disease. Therefore, the purpose of the current article is to present a review of the literature on the risk factors for falls and interventions to aid prevention in individuals with MCI or early-stage dementia, and identify implications for practice and future research.
METHODThe current review was conducted based on the methods
described by Russell (2005) and Whittemore and Knafl (2005). CINAHL, SCOPUS, OVID Medline, EMBASE, PsycINFO, and Eric were searched using the terms “falls,”
“accidental falls,” “Alzheimer’s disease,” “dementia,” “mild cognitive impairment,” “cognitive impairment,” and “fear of falling,” without limits, through December 2015. The initial search yielded 2,235 articles. Duplicates were removed and titles and abstracts were reviewed for rel-evance; 177 studies were retrieved. After final review by at least two of the current authors, 35 articles met inclu-sion criteria. An additional 27 studies were identified for review through an ancestry search. A total of 40 studies met criteria for the final review (Figure).
Research studies were included if they were published in English and addressed falls in individuals with early-stage dementia/Alzheimer’s disease or MCI. Studies were included if MCI or mild severity of dementia was deter-mined by diagnosis or mental status testing. Samples had to have a mean score >20 on the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) or the equivalent level on other cognitive tests. Other tests included the Clinical Dementia Rating (Hughes, Berg, Dan-ziger, Coben, & Martin, 1982; Morris, 1993), Short Blessed Information–Memory–Concentration test (Katzman et al., 1983), and Montreal Cognitive Assessment (Nasreddine et al., 2005). If studies included participants with other levels of cognitive impairment, they were included if results for those with MCI were reported separately. Studies were excluded if they were not published in English (n = 2), did not address falls (n = 11), were not research studies (n = 36), or did not study older adults with early-stage dementia/Alzheimer’s disease or MCI (n = 106). Informa-tion sources did not include books, theses, dissertations, or conference proceedings (n = 9).
Data were extracted on study details and findings and put into a literature matrix. Analysis was conducted to synthesize methods and findings of studies and iden-tify themes related to falls and early-stage dementia. After review of the selected studies, three main categories of findings emerged: (a) increased risk for falls, (b) factors related to increased fall risk (i.e., gait, balance, and fear of falling), and (c) interventions. A review of studies in each category follows.
FINDINGSAll but one study included in the current review
was published in the past 10 years, with most published between 2010 and 2015 (Table A, available in the online version of this article). Researchers were from a range of countries, including the United States, Canada, Australia, and Brazil, as well as Asian, European, and Eastern European countries. Methods ranged from descriptive
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and observational designs to quasi-experimental and randomized controlled trials (RCTs). A variety of methods were used to identify MCI or early-stage dementia. One study addressed MCI subtypes of amnestic and non-amnestic MCI (Petersen, 2011). Amnestic MCI is defined as memory impairment but no detectable execu-tive or attentional impair-ment (Verghese et al., 2008). Non-amnestic MCI is defined as no detectable memory impairment but documented decline in at least two other cognitive functions, such as language, attention, and fluency (Albert et al., 2011). Some studies used the cognitive tests noted above, and all studies but one reported sample mean scores on the MMSE (Table A).
Increased Risk of FallingTen studies explored the risk of falling in individuals
with MCI and early-stage dementia. Ryan, McCloy, Rundquist, Srinivasan, and Laird (2011) found poor scores on the Physical Performance Test and use of a gait aid associated with a history of falls in individuals with mild Alzheimer’s disease (N = 43). Gleason, Gangnon, Fischer, and Mahoney (2009) conducted a secondary analysis of falls in older adults from the control group of a RCT (N = 172), and reported increased falls over 1 year associated with each decrement in MMSE scores ranging from 22 to 29. In a 1-year prospective case-control study (Taylor, Delbaere, Lord, Mikolaizak, & Close, 2013), par-ticipants with cognitive impairment (n = 138) had in-creased fall risk (as measured by physical performance measures) compared to cognitively intact control partici-pants (n = 276). Likewise, Suttanon, Hill, Said, and Dodd (2013) found greater falls and fall risk in individuals with mild Alzheimer’s disease (n = 15) compared to normal controls (n = 15; p = 0.003).
Four of these studies measured self-reported falls. Mea-surements varied and defined individuals with one fall in 12 months, more than one fall in 12 months, and any fall in the past 4 months as “fallers.” Taylor, Delbaere, Mikolaizak, Lord, and Close (2013) measured both single fallers and multiple fallers (N = 63) over 12 months and reported 54% reported at least one fall and 35% reported two or more falls. Makizako et al. (2013) reported that 26.2% of par-ticipants (N = 42) reported at least one fall over 1 year. The percentage of fallers ranged from 10% to 42% (Montero-Odasso, Muir, & Speechley, 2012; Taylor, Delbaere, Lord, et al., 2013; Uemura et al., 2014).
Three studies had prospective cohort designs. Delbaere et al. (2012) reported increased falls over 1 year for individuals with MCI (n = 77, odds ratio [OR] 1.72; 95% confidence interval [CI] [1.03, 2.89]) compared to normal controls (n = 342). The risk was even higher in partici-pants with non-amnestic MCI (n = 58, OR 1.98; 95% CI [1.11, 3.53]). In another study of individuals ages 70 to 80 (91 with MCI, 58 without MCI), MCI and a history of falls was a significant predictor of decline in mobility, but not an increase in fall risk (Davis et al., 2015). Taylor, Lord,
Figure. Flow diagram of the search strategy.
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Delbaere, Mikolaizak, and Close (2012) found a high rate of falls in a sample of older adults with cognitive impair-ment (N = 177); 65% of participants had at least one fall and 43% had two or more falls. Most studies consistently showed that individuals with MCI/early-stage dementia have an increased risk of falls.
Changes in Gait and BalanceSix studies identified impaired standing balance, one
leg standing time, and postural sway as associated with increased risk of falls in individuals with MCI (Beauchet et al., 2008; Liu-Ambrose, Ashe, Graf, Beattie, & Khan, 2008; Makizako et al., 2013; Mignardot, Beauchet, Annweiler, Cornu, & Deschamps, 2014; Pedersen et al., 2014; Suttanon et al., 2012). Two studies found postural changes related to balance among individuals with MCI. Uemura, Hasegawa, Tougou, Shuhei, and Uchiyama (2015) found delays in postural control (longer time in anticipatory postural adjustment) associated with a history of falling among 376 older adults with MCI. Shin, Han, Jung, Kim, and Fregni (2011) used posturography with eyes open and closed and reported increased mediolateral sway speed and distance (but not anteroposterial) among individuals with MCI compared to normal controls.
Seven studies examined gait characteristics under single task conditions (STCs) among individuals with MCI (Bura-cchio, Dodge, Howieson, Wasserman, & Kaye, 2010; Ceder-vall, Halvorsen, & Aberg, 2014; Eggermont et al., 2010; Liu-Ambrose et al., 2008; Makizako et al., 2013; Pedersen et al., 2014; Verghese et al., 2008). Research designs included cross-sectional (n = 4) and longitudinal (n = 3).
Three longitudinal studies found that (a) older adults had a decline in gait speed that occurred up to 12 years before MCI diagnosis (Buracchio et al., 2010), (b) gait speed and step length declined over 2 years (Cedervall et al., 2014), and (c) those who reported a fall had significantly slower gait speed and poorer one leg balance standing times over 12 months (Makizako et al., 2013). The four cross-sectional studies also found slower gait speeds in the 4-m walk test (Eggermont et al., 2010), 2.4-m mea-surement during a 6.6-m walk test (Doi et al., 2015), and straight and curved walking paths (Pedersen et al., 2014) and motorized walkways (Verghese et al., 2008). Doi et al. (2015) found slow gait speed and MCI were independently associated with falling (p < 0.05), and that individuals with MCI and slow gait speed had the highest risk for falling (adjusted OR 1.99; 95% CI = [1.08, 3.65]).
Six studies examined gait characteristics under dual task conditions (DTCs) among individuals with MCI
(Boripuntakul et al., 2014; Cedervall et al., 2014; Coelho et al., 2012; Montero-Odasso et al., 2012; Muir, Speechley, et al., 2012; Taylor, Delbaere, Mikolaizak, et al., 2013). DTCs involve use of attentional resources or distraction activities while walking, which can vary in complexity. This phenomenon was identified early as a fall risk (Cami-cioli, Howieson, Lehman, & Kaye, 1997). Two studies compared gait characteristics between STCs and DTCs using counting backwards tasks (Boripuntakul et al., 2014; Coelho et al., 2012) of varying difficulty (i.e., counting backward by one, three, or seven). One study used two naming tasks (naming human names and animals) as the DTC (Cedervall et al., 2014), whereas two studies com-pared three DTCs (naming animals, counting backward by one and seven from 100) (Montero-Odasso et al., 2012; Muir, Speechley, et al., 2012). One study compared simple walking with walking while counting backwards and walking while carrying a glass of water (Taylor, Delbaere, Mikolaizak, et al., 2013). Research studies included cross-sectional (n = 5) and longitudinal (n = 1) designs.
Results for DTC studies using counting or spelling backwards found that gait speed (and other characteris-tics) declined and variability (e.g., step length, step width, cadence) increased (Boripuntakul et al., 2014; Coelho et al., 2012). Significant correlations between fluency (naming of animals) and executive function (Clock Drawing scores), and DTC gait characteristics (e.g., cadence, stride length, velocity) were found in a sample (N = 50) of par-ticipants with early-stage dementia (Bruce-Keller et al., 2012). Researchers from another study compared differ-ent DTCs using naming tasks (names and animals) and found that gait speed (6-minute walk test) and step length (using a computerized motion capture system) declined in all DTCs over a 2-year period (Cedervall et al., 2014). Steeper declines in gait speed occurred when naming ani-mals compared to human names and this difference per-sisted over the 2-year follow up. When comparing DTCs of counting backward to carrying a glass of water, Taylor, Delbaere, Mikolaizak, et al. (2013) found significantly slower gait speed and increased gait variability when par-ticipants were counting. In the two studies comparing three different DTCs, individuals with amnestic MCI had significantly slower gait speed and demonstrated the highest DTC declines in gait speed in all three DTCs (i.e., counting, naming, and serial seven subtraction) (Muir, Speechley, et al., 2012). One study found that individuals with amnestic MCI had slower gait speeds compared to those with non-amnestic MCI and steeper declines in gait speed and stride times in all DTCs (Montero-Odasso et
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al., 2012). Interestingly, Taylor, Delbaere, Mikolaizak, et al. (2013) compared a simple task, a functional dual task (carrying a glass of water), and a cognitive DTC (counting backward from 30) and found no significant differences by gait condition in a sample with MCI, suggesting DTCs may not provide additional benefit in fall risk assessment compared to STCs.
Fear of FallingFear of falling is a risk factor for falls and common in
older adults with MCI. The prevalence in three studies was noted to be 53.4% (Uemura et al., 2012), 50.6% (Uemura et al., 2014), and 74% (Borges Sde, Radanovic, & Forlenza, 2015). Although the prevalence was high, Uemura et al. (2012) did not find fear of falling associated with memory decline. Uemura et al. (2014) conducted a 15-month follow-up study in community-dwelling older adults and found that those with MCI were more likely to develop a fear of falling than healthy participants after controlling for age, gender, educational level, living alone, MMSE scores, walking speed, timed up and go scores, walking aid use, depression, self-reported health status, and number of medications (OR 1.41; 95% CI [1.07, 1.87]). This risk increased considerably for participants who also had a fall (OR 7.34; 95% CI [4.06, 13.3]).
One study included a new measure of fear of falling for older adults with MCI or dementia (Delbaere, Close, Taylor, Wesson, & Lord, 2013). The measure was icono-graphic, with pictures and short phrases used rather than text. When tested in older adults with early-stage dementia (N = 50), the measure had good internal consistency and could discriminate between groups based on fall risk fac-tors. Overall, fear of falling was common in this population and may be another factor related to increased fall risk in individuals with MCI.
Intervention StudiesEight studies addressed interventions to reduce falls
or fall risks among older adults with MCI and early-stage dementia. Most were pilot studies with small samples; only one was a large RCT (Mahoney et al., 2007). Interventions included group exercise (Ries, Drake, & Marino, 2010) or home-based exercises either alone (Kovács, Sztruhár Jónásné, Karóczi, Korpos, & Gondos, 2013; Suttanon, Hill, Said, Williams, et al., 2013) or combined with other components (Hagovská & Olekszyová, 2015; Mahoney et al., 2007; Wesson et al., 2013; Yao, Giordani, Algase, You, & Alexander, 2013). The length of exercise interventions ranged from exercise sessions two times per week for
8 weeks to 12 months, to a 6-month home-based program of strengthening and walking.
Other interventions included home visits from a physical therapist or nurse (Mahoney et al., 2007; Suttanon, Hill, Said, Williams, et al., 2013; Wesson et al., 2013), home hazard reduction (Wesson et al., 2013), and education (Suttanon, Hill, Said, Williams, et al., 2013). One study explored a technological intervention of special lighting leading from the bed to bathroom at night, along with an electronic bracelet and emergency response system (Tchal-la et al., 2013). Yao et al. (2013) designed a tai chi interven-tion to be performed with a caregiver and added a reward component. In another study, Hagovská and Olekszyová (2015) compared daily 10-week balance training sessions combined with a cognitive training program to balance training alone.
Outcomes of studies included falls (Kovács et al., 2013; Mahoney et al., 2007; Suttanon, Hill, Said, Williams, et al., 2013; Tchalla et al., 2013; Wesson et al., 2013), fall risks (Suttanon, Hill, Said, Williams, et al., 2013; Wesson et al., 2013), balance (Hagovská & Olekszyová, 2015; Ries et al., 2010; Suttanon, Hill, Said, Williams, et al., 2013; Yao et al., 2013), gait (Kovács et al., 2013; Ries et al., 2010; Suttanon, Hill, Said, Williams, et al., 2013), and hospitalizations and nursing home admissions (Mahoney et al., 2007). Most studies had non-significant findings, most likely due to small samples. Hagovská and Olekszyová (2015) found improvements in gait speed and balance that were greater in the experimental group who received cognitive training with exercise. In most studies, the interventions were feasible to implement, with some benefits to participants. Alternatively, adherence to the 6-month home-based exer-cise intervention was poor (Suttanon, Hill, Said, Williams, et al., 2013).
The one large RCT (N = 349) was not targeted specifi-cally to individuals with MCI, but rather a community pop-ulation (Mahoney et al., 2007). The intervention included home visits and follow-up telephone calls, a balance exer-cise plan, and referrals. Fewer falls were seen in individuals with MMSE scores <27 (mean MMSE scores >20). In addi-tion, fewer hospitalizations, nursing home admissions, and nursing home days were noted among participants who lived with someone. The findings suggest that the inter-vention may benefit individuals with early-stage dementia who have caregivers.
DISCUSSIONThe current review examined research on falls and
fall prevention in older adults with MCI or early-stage
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dementia, addressing a gap in the prior literature. Although the increased risk of falls for individuals with dementia has long been noted, the literature specific to MCI or early-stage dementia was recent. Studies were mostly from the past 5 years, most likely due to the increased interest in early stages of dementia, as well as improved identifica-tion of MCI and Alzheimer’s disease in the early stages. Although the U.S. Preventive Services Task Force (2014) did not find sufficient evidence to recommend routine dementia screening of older adults, they encourage evalu-ation of early signs of cognitive impairment, as advocated by the Alzheimer’s Association (2016). These studies con-firm the need to evaluate cognitive changes because even in early stages they are associated with an increased risk of falling. The current review identified key changes in gait and balance that may be detected through testing and potential interventions for this population. When there is early identification of MCI or Alzheimer’s disease, fall risks must be addressed.
Researchers consistently identified an increased fall risk among older adults with MCI and early-stage dementia. Stronger evidence was found in the current review than in the review by Harlein et al. (1999), who reviewed studies with a broader severity of dementia. Stronger evidence included prospective studies following individuals over 1 year with strong designs to track fall events. Fall rates were double (30% versus 65%) those for the general older population (CDC, 2016). Further, fall risk appears to increase as cognition declines, with higher risk of falling with a decline in MMSE scores (Gleason et al., 2009). A meta-analysis on the risk for falls in older adults by Muir, Gopaul, et al. (2012) found cognitive impairment increased the risk for falls and falls with serious injuries, but did not identify the level of decline at which the risk begins. The current review found some evidence that fall risk increases early, but further research with larger samples and longitu-dinal designs is needed to confirm these findings.
After reviewing studies on gait and balance related to falls, the current authors found the state of the science is still emerging and that there is a need for research to more clearly identify gait and balance changes that occur with MCI and its subtypes. Older adults with MCI have declines in cogni-tive and ambulatory functions, and researchers are explor-ing a mutual explanation for these outcomes. The research on gait characteristics during STCs and DTCs is especially interesting. Some DTCs simulate real-world environments and identify deficits in planning and executing steps in com-plex pathways (Taylor, Delbaere, Mikolaizak, et al., 2013; Uemura et al., 2015). However, their real value may lie in
their ability to unmask declining cognitive reserve, demon-strating the cognitive effort (i.e., selective attention) needed for safe ambulation in challenging settings. The DTC design provides measurement of the cognitive contribution to safe gait and balance so that future DTC testing may be a part of screening for MCI.
The methodology for assessment of balance and gait has changed significantly over the past two decades. An early study of the effect of DTCs on gait (Camicioli, Bouchard, & Licis, 2006) had participants walk a hallway while reciting male and female names. Methods are now more sophis-ticated with the use of posturography (Shin et al., 2011), computerized walkways (Taylor, Delbaere, Mikolaizak, et al., 2013), and software that measures anticipatory postural reactions (Uemura et al., 2015). These methodologies may soon be useful for clinical assessment of balance and gait in populations newly diagnosed with MCI or early-stage dementia. Future studies may be able to tailor fall preven-tion interventions based on the “motor signature” of MCI (Montero-Odasso et al., 2014, p. 1415).
Recent studies confirmed that performing tasks while walking had adverse effects on gait and balance character-istics (e.g., speed, number of steps, variability) and those changes are associated with falling in an MCI population. Interventions aimed at reducing falls in an MCI population may need to focus on minimizing tasks during ambulation. Future intervention studies could teach groups about mindfulness during walking and other tasks to explore changes in fall risks.
Fear of falling was not widely addressed, but researchers found rates of 50% to 74%. This finding is similar to the highest rates in general populations of older adults; how-ever, most rates are closer to 35% to 50% (Lach, 2005). Fear of falling may be more common in older adults with MCI or early-stage dementia than those with normal cognition. The development of the iconographic measure (Delbaere, Close, Taylor, Wesson, & Lord, 2013) may improve screening to provide more evidence to understand fear of falling as a risk factor for falls in this population.
Other factors or mechanisms for falls have been noted in populations with dementia, but were not studied in older adults with early-stage dementia or MCI, warranting further research. These factors/mechanisms include orthostatic hypotension and depression, as noted by Allan et al. (2009), and vision (Härlein et al., 2009). Vitamin D supplementation was not studied (Guo et al., 2014). Epstein, Guo, Farlow, Singh, and Fisher (2014) explored fall risk associated with dementia drugs, but not in an early-stage population.
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The few intervention studies targeting older adults with MCI or early-stage dementia were primarily pilot studies or had small samples, indicating a need for more research with strong designs to determine appropriate fall preven-tion interventions. The large RCT was not targeted to this population, but had a significant impact. Despite these limi-tations, most studies found some improvements in fall risk. The current findings are consistent with reviews focused on fall prevention in adults with a broader severity of dementia (Burton et al., 2015; Hauer et al., 2006; Muir, Gopaul, et al., 2012). Little overlap was noted between the current review and others, and included two articles in common with one review and two with another. Over the past 10 years, stud-ies continue to explore fall prevention and interventions, but little can be concluded from these findings.
Exercise was the most common intervention, with or without other components, but many types of exercises were used. The current authors cannot make specific rec-ommendations based on these findings; however, most interventions were found acceptable to participants and safe. In a meta-analysis of interventions for dementia of any severity level (Burton et al., 2015), exercise was effec-tive in reducing falls. Future research may focus on current evidence-based programs for fall prevention that include the exercise elements shown to help reduce falls, including balance, strength, and gait training (Panel on Prevention of Falls in Older Persons, American Geriatrics Society, & British Geriatrics Society, 2011). Tailoring interventions to the early-stage dementia population may be needed. A particularly interesting approach was the use of paired tai chi performed in tandem facing a caregiver and touching hands, as prior research has demonstrated benefits of tai chi (CDC, 2016). Pairing the activity with a caregiver may enhance the longevity of the exercise program for individ-uals with dementia.
Other interesting approaches to prevent falls included night lights, telehealth, and cognitive training. Further evaluation of these interventions is warranted. Technology for monitoring, testing, and assisting older adults, including those with dementia, continues to be developed and tested (Schulz et al., 2015). In addition, factors related to delivery success, such as involvement of a caregiver and group versus home-based programs, need further explo-ration. Overall, translation of fall prevention guidelines is needed for this population, as noted by Meyer et al. (2015). Other fall prevention approaches may be identified in the future as researchers learn more about the changes in cog-nition, gait, and balance related to fall risk among individ-uals with MCI or early-stage dementia.
LIMITATIONSThe current review’s method was narrative, so results
of the included studies were not able to be pooled. Studies were not excluded based on quality or level of evidence, as the purpose was exploratory. However, given the range of methods and topics, the findings provide an appropriate review of current research related to falls. Although there were exclusions and some studies may have been missed, the use of several databases and search of the references of retrieved articles resulted in a comprehensive search.
A possible limitation is the inclusion of studies that used varying methods to identify the severity of dementia among participants. However, over time, as diagnostic guidelines for MCI were developed (Petersen et al., 2014), it was noted that individuals with MCI were in a transi-tional state between expected cognitive declines of normal aging and early-stage dementia. Differentiating these conditions may be a challenge. Although various testing methods were used, only studies that used a standardized scale identifying early-stage were included to attempt to keep the samples across articles similar.
Methods used in these studies limit the strength of the evidence that can be drawn from them. Many small samples and pilot studies were found. Reasons for this may include the challenges in recruiting participants with dementia, limitations in funding, and the need for large samples to address fall prevention. Other limitations of designs were the variety of test measures used for some parameters (e.g., gait, balance), lack of a consistent definition of a fall, and a lack of strong measures to prospectively measure falls. Future research should draw on the recommendations for fall prevention studies (Lamb, Jørstad-Stein, Hauer, & Becker, 2005) and consider the use of multiple sites to increase sample sizes and follow participants over time.
CONCLUSIONThe current findings confirm the increased risk of
falling among older adults with MCI and early-stage dementia, warranting early diagnosis and attention to the significant issue of fall prevention. Risks and poten-tial interventions to reduce falls in this population were explored. Few recommendations can be made based on these findings and more research is needed to provide evidence for reducing falls in individuals with MCI and early-stage dementia. Given the lack of progress in re-ducing rates of falls and injuries in older adults, research on factors and interventions to reduce falls in important subgroups, such as individuals with early-stage dementia and MCI, should be a priority.
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TA
BL
E A
Re
vie
we
d S
tud
ies
by
Pri
ma
ry C
ate
go
ry
Auth
or/Y
ear/L
ocat
ion
Desig
n/In
terv
entio
nPa
rticip
ants
Mea
sure
men
t/Out
com
es
Fall R
iskD
avis
et a
l. (2
015)
; Ca
nada
12-m
onth
pro
spec
tive
stud
y to
ex
plor
e co
gniti
on, m
obili
ty, a
nd
fall
risk
• Com
mun
ity-d
wel
ling
olde
r adu
lts (9
1 w
ith M
CI,
58 w
ithou
t MCI
)• M
MSE
>24
• MoC
a >2
6
• Mob
ility
, SPP
B, fa
lls• F
alls
and
MCI
pre
dict
ed d
eclin
e in
mob
ility
, but
indi
vidu
als
with
MCI
did
not
hav
e in
crea
sed
fall
risk
Del
baer
e et
al.
(201
2);
Aust
ralia
12-m
onth
pro
spec
tive
coho
rt
stud
y to
inve
stig
ate
if M
CI is
as
soci
ated
with
falls
• Com
mun
ity-d
wel
ling
olde
r adu
lts w
ith m
ild A
D
(N =
419
, 77
with
MCI
and
342
con
trol
s)• W
ith M
CI M
MSE
= 2
7.5
(1.7
)• C
ontr
ol M
MSE
= 2
8.2
(1.4
)
• Fal
ls (i
njur
ious
fall
or >
1 no
n-in
jurio
us fa
ll)• R
isk
for f
allin
g gr
eate
r in
MCI
gro
up (O
R 1.
72; 9
5% C
I [1.
03,
2.89
])• N
on-a
mne
stic
MCI
gre
ater
risk
than
am
nest
ic M
CI (O
R 1.
98;
95%
CI [
1.11
, 3.5
3])
• Rel
atio
nshi
p ex
plai
ned
by e
xecu
tive
func
tioni
ng
Gle
ason
, Gan
gnon
, Fi
sche
r, &
Mah
oney
(2
009)
; Uni
ted
Stat
es
Seco
ndar
y da
ta a
naly
sis
of
12-m
onth
fall
prev
entio
n RC
T• C
omm
unity
-dw
ellin
g ol
der a
dults
at r
isk
of fa
lling
, fr
om th
e co
ntro
l gro
up (N
= 1
72)
• MM
SE =
27.
2 (4
.6)
• Fal
ls o
ver 1
2 m
onth
s• E
ach
unit
decr
ease
in M
MSE
sco
re in
crea
sed
risk
of fa
lling
from
29
to 2
2 (r
ate
ratio
1.2
5, 9
5% C
I [1.
09, 1
.45]
, p =
0.0
026)
Ryan
, McC
loy,
Ru
ndqu
ist,
Srin
ivas
an,
& L
aird
(201
1); U
nite
d St
ates
Cros
s-se
ctio
nal,
desc
riptiv
e st
udy
to d
eter
min
e fa
ll ris
k an
d A
D• C
omm
unity
-dw
ellin
g ol
der a
dults
with
mild
AD
(N
= 4
3, 1
3 fa
llers
and
30
non-
falle
rs)
• Fal
lers
MM
SE =
24
• Non
-falle
rs M
MSE
= 2
3
• Fal
ls in
the
past
6 m
onth
s, PP
T-7
• Diff
eren
ce in
PPT
-7 in
falle
rs, b
ut o
nly
gait
aid
use
pred
icte
d fa
lling
Sutt
anon
, Hill
, Sai
d, &
D
odd
(201
3); A
ustr
alia
12-m
onth
follo
w u
p to
com
pare
fa
ll ra
tes
in o
lder
adu
lts w
ith A
D
and
heal
thy
cont
rols
• Com
mun
ity-d
wel
ling
olde
r adu
lts (N
= 3
0, 1
5 w
ith
mild
AD
and
15
with
out A
D)
• With
mild
AD
MM
SE =
21.
73 (4
.88)
• With
out A
D M
MSE
= 2
9.4
(0.8
3)
• Sta
tic a
nd d
ynam
ic b
alan
ce, g
ait s
peed
, ste
p le
ngth
, TU
G, S
tep
Test
, Sit
to S
tand
, Ste
p/Q
uick
Tur
n, fa
ll hi
stor
y• M
ild A
D g
roup
had
incr
ease
d fa
lls a
nd g
reat
er fa
ll ris
k th
an th
e co
ntro
l gro
up (p
= 0
.003
), an
d gr
eate
r det
erio
ratio
n on
bal
ance
an
d m
obili
ty m
easu
res
Tayl
or, L
ord,
Del
baer
e,
Mik
olai
zak,
& C
lose
(2
012)
; Aus
tral
ia
1-ye
ar p
rosp
ectiv
e st
udy
of
fall
risk,
bal
ance
, and
cog
nitiv
e im
pairm
ent
• Com
mun
ity-d
wel
ling
olde
r adu
lts w
ith c
ogni
tive
impa
irmen
t (N
= 1
65, 7
1 m
ultip
le fa
llers
and
94
non-
mul
tiple
falle
rs)
• Mul
tiple
falle
rs M
MSE
= 2
2.1
(4.4
)• N
on-m
ultip
le fa
llers
MM
SE =
23.
1 (4
)
• PPA
, fal
ls• R
eact
ion
time,
pos
tura
l sw
ay, l
eani
ng b
alan
ce, a
nd in
crea
sed
PPA
fall
risk
scor
es a
ssoc
iate
d w
ith m
ultip
le fa
lls
TA
BL
E A
Re
vie
we
d S
tud
ies
by
Pri
ma
ry C
ate
go
ry
Auth
or/Y
ear/L
ocat
ion
Desig
n/In
terv
entio
nPa
rticip
ants
Mea
sure
men
t/Out
com
esTa
ylor
, Del
baer
e, L
ord,
M
ikol
aiza
k, &
Clo
se
(201
3); A
ustr
alia
12-m
onth
pro
spec
tive
stud
y of
fa
ll ris
k in
old
er a
dults
with
and
w
ithou
t cog
nitiv
e im
pairm
ent
• Com
mun
ity-d
wel
ling
olde
r adu
lts (N
= 4
14, 1
38 w
ith
MCI
, 276
with
out M
CI)
• With
MCI
MM
SE =
23.
1 (4
.1)
• With
out M
CI M
MSE
= 2
7.8
(1.6
)
• Fal
ls, f
all r
isk,
bal
ance
, mob
ility
, TU
G, r
eact
ion
time
• MCI
gro
up w
orse
in re
actio
n tim
e, b
alan
ce, m
obili
ty, T
UG
, with
m
ore
falls
(66%
ver
sus
45%
) and
mul
tiple
falle
rs• I
ncre
ased
fall
risk
than
con
trol
gro
up, 1
+fal
l OR
2.4
(95%
CI
[1.5
5, 3
.71]
), 2+
fall
OR
2.84
(95%
CI [
1.79
, 4.5
])
Gait
and B
alan
ceBe
auch
et e
t al.
(200
8);
Fran
ceCr
oss-
sect
iona
l stu
dy o
f gai
t and
M
CI• O
lder
adu
lts w
ith m
emor
y co
mpl
aint
s (N
= 1
16, 3
9 w
ith M
CI, 3
3 w
ith m
ild A
D, a
nd 4
4 he
alth
y co
ntro
ls)
• With
MCI
MM
SE =
27.
8 (1
.4)
• Mild
AD
MM
SE =
25
(2.3
)• H
ealth
y co
ntro
l MM
SE =
29
(1.1
)
• Gai
t spe
ed u
sing
the
GA
ITRi
te®
wal
kway
• Reg
ress
ion
mod
els
show
ed h
igh
strid
e-to
-str
ide
varia
bilit
y at
fa
st-p
ace
wal
king
spe
ed w
as a
sig
nifi c
ant g
ait d
istu
rban
ce in
M
CI g
roup
(p =
0.0
15)
Borip
unta
kul e
t al.
(201
4); T
haila
ndCr
oss-
sect
iona
l stu
dy o
f gai
t and
M
CI• O
lder
adu
lts fr
om o
utpa
tient
uni
t (N
= 6
0, 3
0 w
ith M
CI
and
30 h
ealth
y co
ntro
ls)
• With
MCI
MM
SE =
27.
6 (1
.5)
• Hea
lthy
cont
rol M
MSE
= 2
9.1
(1)
• Spa
tiote
mpo
ral s
tepp
ing
unde
r sin
gle
(STC
s) a
nd d
ual t
ask
cond
ition
s (D
TCs)
usi
ng G
AIT
Rite
• Und
er th
e D
TCs,
MCI
gro
up h
ad g
reat
er v
aria
bilit
y in
ste
p le
ngth
and
ste
p w
idth
var
iabi
lity
than
the
cont
rol g
roup
(p
< 0
.05)
Bruc
e-Ke
ller e
t al.
(201
2); U
nite
d St
ates
Cros
s-se
ctio
nal s
tudy
to c
ompa
re
gait
and
bala
nce
and
early
-sta
ge
dem
entia
• Pat
ient
s w
ith d
emen
tia fr
om re
sear
ch c
linic
(N =
50)
; M
MSE
= 2
0.6
(6.4
)• A
ge, g
ende
r, an
d ed
ucat
ion
mat
ched
con
trol
s fr
om
long
itudi
nal s
tudy
(N =
50)
; MM
SE =
28.
7 (1
.6)
• DTC
gai
t ass
essm
ent u
sing
GA
ITRi
te, S
PPB
• Cog
nitiv
e pe
rfor
man
ce c
orre
late
d w
ith g
ait a
nd p
hysi
cal
perf
orm
ance
, ind
icat
ing
incr
ease
d fa
ll ris
k
Bura
cchi
o, D
odge
, H
owie
son,
Was
serm
an,
& K
aye
(201
0); U
nite
d St
ates
Long
itudi
nal c
ohor
t stu
dy• C
omm
unity
-dw
ellin
g ol
der a
dults
(N =
204
, 95
MCI
co
nver
ters
and
109
non
-con
vert
ers)
• MCI
con
vert
ers
MM
SE =
26.
2 (2
.9)
• Non
-con
vert
ers
MM
SE =
28.
3 (1
.5)
• Ann
ual n
euro
logi
cal a
nd m
otor
eva
luat
ions
ove
r 20
year
s• G
ait s
peed
dec
line
in M
CI c
onve
rter
s gr
eate
r tha
n in
non
-co
nver
ters
(p <
0.0
01),
occu
rrin
g 12
.1 y
ears
bef
ore
the
onse
t of
MCI
• Gen
der a
naly
sis
reve
aled
wom
en h
ad c
hang
es a
t 6 y
ears
and
m
en a
t 14
year
s be
fore
con
vers
ion
Cam
icio
li, H
owie
son,
Le
hman
, & K
aye
(199
7);
Uni
ted
Stat
es
Cros
s-se
ctio
nal s
tudy
of D
TCs
whi
le w
alki
ng• C
omm
unity
-dw
ellin
g ol
der a
dults
with
and
with
out
AD
from
two
coho
rt s
tudi
es (N
= 5
8, 1
5 w
ith li
kely
AD
, 23
hea
lthy
youn
g-ol
d [m
ean
age
= 72
], an
d 20
hea
lthy
old-
old
[mea
n ag
e =
86])
• Lik
ely
AD
MM
SE =
21
(4.3
)• H
ealth
y yo
ung-
old
MM
SE =
29
(1)
• Hea
lthy
old-
old
MM
SE =
28
(1.1
)
• Gai
t usi
ng D
TC• G
ait s
peed
of l
ikel
y A
D p
atie
nts
was
slo
wer
than
the
youn
g-ol
d (p
= 0
.005
) and
old
-old
(p =
0.0
02)
(CO
NT
INU
ED
)
TA
BL
E A
Re
vie
we
d S
tud
ies
by
Pri
ma
ry C
ate
go
ry
Auth
or/Y
ear/L
ocat
ion
Desig
n/In
terv
entio
nPa
rticip
ants
Mea
sure
men
t/Out
com
esCe
derv
all,
Hal
vors
en, &
A
berg
(201
4); S
wed
en24
-mon
th lo
ngitu
dina
l stu
dy o
f ga
it an
d A
D• O
lder
adu
lts w
ith m
ild A
D fr
om a
n ou
tpat
ient
mem
ory
clin
ic (N
= 2
1)• A
t bas
elin
e: M
MSE
med
ian
= 25
, ran
ge =
21
to 3
0• A
t 1-y
ear f
ollo
w u
p: M
MSE
med
ian
= 22
, ran
ge =
16
to 2
9
• Gai
t with
STC
s an
d D
TCs
usin
g m
otio
n ca
ptur
e sy
stem
• Gai
t spe
ed a
nd s
tep
leng
th d
eclin
ed s
igni
fi can
tly in
bot
h ST
Cs
and
DTC
s ov
er th
e 2-
year
follo
w-u
p pe
riod
(p <
0.0
5)
Coel
ho e
t al.
(201
2);
Braz
ilCr
oss-
sect
iona
l stu
dy• C
omm
unity
-dw
ellin
g ol
der a
dults
with
AD
(N =
23,
CD
R 1:
n =
12,
CD
R 2:
n =
11)
• CD
R 1
MM
SE =
22.
0 (2
.2)
• CD
R 2
MM
SE =
16.
2 (2
.2)
• Gai
t usi
ng S
TCs
and
DTC
s, TU
G• M
ild A
D h
ad lo
nger
str
ide
leng
th a
nd s
peed
s in
STC
s co
mpa
red
to C
DR
2. D
urin
g th
e D
TCs,
both
gro
ups
show
ed
sign
ifi ca
nt d
ecre
ase
in c
aden
ce, s
trid
e sp
eed,
and
str
ide
leng
th
(p <
0.0
01)
Doi
et a
l. (2
015)
; Jap
anCr
oss-
sect
iona
l stu
dy o
f cog
nitiv
e fu
nctio
n an
d ga
it sp
eed
• Com
mun
ity-d
wel
ling
olde
r adu
lts (N
= 3
,400
, 673
with
M
CI, 1
68 w
ith M
CI a
nd s
low
gai
t, 27
8 w
ith s
low
gai
t, 2,
281
cont
rols
)• W
ith M
CI M
MSE
= 2
6.7
(1.8
)• M
CI w
ith s
low
gai
t MM
SE =
26.
1 (1
.8)
• Slo
w g
ait M
MSE
=27
(1.8
)• C
ontr
ol M
MSE
= 2
7.4
(1.8
)
• Gai
t abi
lity
defi n
ed a
s ga
it sp
eed
• MCI
and
slo
w g
ait a
ssoc
iate
d w
ith w
orse
per
form
ance
and
hi
ghes
t ris
k fo
r fal
ling
(adj
uste
d O
R 1.
99, 9
5% C
I [1.
08, 3
.65]
), an
d in
depe
nden
tly a
ssoc
iate
d w
ith fa
lling
(p <
0.0
5)
Egge
rmon
t et a
l. (2
010)
; Uni
ted
Stat
esCr
oss-
sect
iona
l stu
dy o
f low
er
extr
emity
func
tion
and
cogn
itive
im
pairm
ent
• Old
er a
dults
with
MCI
and
AD
mat
ched
for a
ge,
gend
er, a
nd e
duca
tion
with
cog
nitiv
ely
norm
al c
ontr
ols
from
a u
nive
rsity
AD
clin
ical
and
rese
arch
regi
stry
(N
= 6
6, 2
2 w
ith M
CI, 2
2 w
ith p
roba
ble
AD
, and
22
con-
trol
s)• M
CI C
DR
0.5,
MM
SE =
28.
4 (1
.5)
• Pro
babl
e A
D C
DR
1, M
MSE
= 2
1.6
(4.8
)• C
ontr
ol C
DR
0, M
MSE
= 2
9.4
(0.9
)
• Gai
t spe
ed, 4
m w
alk
test
, sit
to s
tand
, TU
G• G
ait s
peed
s of
MCI
gro
up (p
= 0
.041
) was
low
er th
an th
e co
n-tr
ol g
roup
, but
not
for T
UG
or s
it to
sta
nd
Liu-
Am
bros
e, A
she,
G
raf,
Beat
tie, &
Kha
n (2
008)
; Uni
ted
Stat
es
Cros
s-se
ctio
nal s
tudy
of f
all r
isk
and
MCI
in w
omen
• Com
mun
ity-d
wel
ling
olde
r wom
en (N
= 1
58, 7
2 w
ith
MCI
and
86
with
out M
CI)
• With
MCI
MM
SE =
28.
3 (1
.4)
• With
out M
CI M
MSE
= 2
8.9
(1.2
)
• Fal
l ris
k m
easu
red
by th
e PP
A• M
CI g
roup
had
hig
her c
ompo
site
PPA
sco
res
(p <
0.0
1) a
nd
grea
ter p
ostu
ral s
way
(p =
0.0
3) th
an c
ontr
ols
Mak
izak
o et
al.
(201
3);
Japa
nLo
ngitu
dina
l stu
dy o
f phy
sica
l pe
rfor
man
ce, f
alls
, and
gra
y m
atte
r vol
ume
• Old
er a
dults
with
MCI
from
a lo
ngitu
dina
l stu
dy
(N =
42,
11
falle
rs a
nd 3
1 no
n-fa
llers
)• F
alle
rs M
MSE
= 2
5.5
(3.9
)• N
on-fa
llers
MM
SE =
26.
6 (2
)
• Gai
t, ba
lanc
e, a
nd M
RI a
t bas
elin
e an
d 12
-mon
th fo
llow
up
• Fal
lers
with
MCI
sho
wed
slo
wer
gai
t spe
ed a
nd s
hort
er o
ne-le
g st
andi
ng ti
me
than
non
-falle
rs (p
< 0
.01)
, and
low
er g
ray
mat
ter
dens
ities
in fr
onta
l gyr
us a
t bas
elin
e co
mpa
red
to n
on-fa
llers
(CO
NT
INU
ED
)
TA
BL
E A
Re
vie
we
d S
tud
ies
by
Pri
ma
ry C
ate
go
ry
Auth
or/Y
ear/L
ocat
ion
Desig
n/In
terv
entio
nPa
rticip
ants
Mea
sure
men
t/Out
com
esM
igna
rdot
, Bea
uche
t, A
nnw
eile
r, Co
rnu,
&
Des
cham
ps (2
014)
; Fr
ance
Cros
s-se
ctio
nal s
tudy
of p
ostu
ral
sway
, fal
ls, a
nd c
ogni
tion
• Com
mun
ity-d
wel
ling
olde
r adu
lts (N
= 6
11, 1
40 w
ith
MCI
, 243
with
mild
to m
oder
ate
AD
, and
228
con
trol
s)• W
ith M
CI M
MSE
= 2
6.1
(2.4
)• M
ild to
mod
erat
e A
D M
MSE
= 1
9.3
(4.4
)• C
ontr
ol M
MSE
= 2
8 (2
.3)
• TU
G, f
all h
isto
ry, p
ostu
ral s
way
usi
ng th
e Bi
oRes
cue®
forc
e pl
atfo
rm• I
n a
dyna
mic
mea
sure
of p
ostu
ral s
way
(ana
lysi
s of
cen
ter o
f pr
essu
re),
in b
oth
eyes
ope
n an
d cl
osed
con
ditio
ns, t
he h
ighe
st
valu
es w
ere
asso
ciat
ed w
ith c
ogni
tive
impa
irmen
t (p
= 0.
048)
an
d fa
lls (p
= 0
.033
)
Mon
tero
-Oda
sso,
Mui
r, &
Spe
echl
ey (2
012)
; Ca
nada
Cros
s-se
ctio
nal s
tudy
of g
ait a
nd
MCI
• Com
mun
ity d
wel
ling
olde
r adu
lts (N
= 6
8, 4
3 w
ith M
CI
and
25 c
ontr
ols)
• MCI
MM
SE =
27.
8 (1
.6)
• Con
trol
MM
SE =
29.
5 (0
.6)
• Gai
t und
er S
TCs
and
DTC
s us
ing
GA
ITRi
te• D
urin
g th
e D
TCs,
gait
velo
city
dec
reas
ed in
bot
h gr
oups
; the
m
agni
tude
of g
ait v
aria
bilit
y in
STC
s an
d D
TCs
was
gre
ater
in
the
MCI
gro
up (p
= 0
.041
)
Mon
tero
-Oda
sso
et a
l. (2
014)
; Can
ada
Cros
s-se
ctio
nal s
tudy
of g
ait a
nd
MCI
by
subt
ype
of M
CI• O
lder
adu
lts w
ith M
CI a
nd n
orm
al c
ontr
ols
from
co
hort
stu
dy (N
= 9
9, 4
2 w
ith a
mne
stic
MCI
, 22
with
no
n-am
nest
ic M
CI, a
nd 3
5 co
ntro
ls)
• Am
nest
ic M
CI M
MSE
= 2
7.24
(2.0
7)• N
on-a
mne
stic
MCI
MM
SE =
29.
14 (0
.83)
• Con
trol
MM
SE =
29.
31 (1
.02)
• Bas
elin
e te
stin
g of
gai
t und
er S
TCs
and
DTC
s us
ing
GA
ITRi
te• I
ndiv
idua
ls w
ith a
mne
stic
MCI
had
poo
rest
gai
t per
form
ance
(i.
e., g
reat
er im
pact
of D
CT
on g
ait t
han
in th
ose
with
non
-am
nest
ic M
CI a
nd c
ontr
ols)
Mui
r, G
opau
l, &
M
onte
ro-O
dass
o (2
012)
; Can
ada
Cros
s-se
ctio
nal s
tudy
of g
ait a
nd
CI• O
lder
adu
lts w
ith M
CI a
nd A
D fr
om a
mem
ory
clin
ic
and
norm
al c
ontr
ols
from
the
com
mun
ity (N
= 7
4, 2
2 co
ntro
ls, 2
9 w
ith M
CI, a
nd 2
3 w
ith e
arly
AD
)• C
ontr
ol M
MSE
= 2
9.5
(0.6
)• M
CI M
MSE
= 2
7.5
(1.9
)• E
arly
AD
MM
SE =
24.
2 (2
.3)
• Gai
t und
er S
TCs
and
DTC
s us
ing
GA
ITRi
te• D
urin
g th
e D
TCs,
indi
vidu
als
with
MCI
and
ear
ly A
D s
how
ed
sign
ifi ca
ntly
dec
reas
ed g
ait v
eloc
ity (p
< 0
.001
), in
crea
sed
strid
e tim
e (p
= 0
.005
7), a
nd in
crea
sed
strid
e tim
e va
riabi
lity
(p =
0.0
037)
. D
ual t
ask
impr
oved
iden
tifi c
atio
n of
fall
risk.
Pede
rsen
et a
l. (2
014)
; U
nite
d St
ates
Cros
s-se
ctio
nal a
naly
sis
of a
co
hort
stu
dy o
f MCI
by
subt
ypes
(i.
e., a
mne
stic
, non
-am
nest
ic, a
nd
mul
tiple
dom
ain)
• Com
mun
ity-d
wel
ling
olde
r adu
lts in
coh
ort s
tudy
(N
= 4
30, 1
5 w
ith n
on-a
mne
stic
MCI
, 68
with
am
nest
ic
MCI
, 98
with
mul
ti-do
mai
n am
nest
ic M
CI, a
nd 2
49 c
on-
trol
s)• N
on-a
mne
stic
MCI
MM
SE =
25.
9 (3
.1)
• Am
nest
ic M
CI M
MSE
= 2
7.8
(1.6
)• M
ulti-
dom
ain
amne
stic
MCI
MM
SE =
25.
5 (2
.9)
• Con
trol
MM
SE =
28.
2 (1
.6)
• Bas
elin
e ga
it, fi
gure
8 w
alk,
SPP
B• A
ll gr
oups
with
MCI
per
form
ed s
igni
fi can
tly w
orse
than
the
cont
rols
on
all m
obili
ty p
erfo
rman
ces
(i.e.
, hab
itual
gai
t spe
ed,
fi gur
e 8
wal
k, S
PPB,
bas
ic lo
wer
ext
rem
ity fu
nctio
n, a
nd a
d-va
nced
low
er e
xtre
mity
func
tion)
(p ≤
0.0
01)
(CO
NT
INU
ED
)
TA
BL
E A
Re
vie
we
d S
tud
ies
by
Pri
ma
ry C
ate
go
ry
Auth
or/Y
ear/L
ocat
ion
Desig
n/In
terv
entio
nPa
rticip
ants
Mea
sure
men
t/Out
com
esSh
in, H
an, J
ung,
Kim
, &
Freg
ni (2
011)
; Kor
eaCr
oss-
sect
iona
l stu
dy o
f the
eff e
ct
of M
CI o
n ba
lanc
e an
d fa
ll ris
k• O
lder
adu
lts w
ith s
ubje
ctiv
e m
emor
y im
pairm
ent
(N =
87,
30
with
MCI
and
57
cont
rols
)
• MCI
MM
SE =
24.
2 (4
.1)
• Con
trol
MM
SE =
26.
4 (2
.7)
• Goo
d Ba
lanc
e® p
ostu
rogr
aphy
• The
med
iola
tera
l sw
ay s
peed
and
dis
turb
ance
wer
e hi
gher
in
the
MCI
gro
up th
an th
e co
ntro
l gro
up fo
r bot
h ey
es o
pen
and
clos
ed c
ondi
tions
(p <
0.0
5)
Sutt
anon
, Hill
, Sai
d,
Logi
udic
e, e
t al.
(201
2);
Aust
ralia
Cros
s-se
ctio
nal s
tudy
to e
valu
ate
bala
nce,
mob
ility
, and
cog
nitiv
e im
pairm
ent
• Old
er a
dults
with
mild
AD
from
mem
ory
clin
ics
(N =
50,
25
with
AD
and
25
com
mun
ity c
ontr
ols)
• AD
MM
SE =
21.
1• C
ontr
ol M
MSE
= 2
9.2
• Ste
p te
st, f
unct
iona
l rea
ch, T
UG
sin
gle
and
dual
task
, tur
ning
• Sta
tic a
nd d
ynam
ic b
alan
ce s
igni
fi can
tly m
ore
impa
ired
in
mild
AD
gro
up, e
spec
ially
turn
ing
and
DTC
s
Tayl
or, D
elba
ere,
Mik
o-la
izak
, Lor
d, &
Clo
se
(201
3); A
ustr
alia
Cros
s-se
ctio
nal s
tudy
to e
xplo
re
gait
in S
TCs
and
DTC
s, CI
, and
falls
• Com
mun
ity-d
wel
ling
olde
r adu
lts w
ith C
I (N
= 6
3,
41 n
on-fa
llers
and
22
mul
tiple
falle
rs)
• Non
-falle
rs M
MSE
= 2
4.8
(3.6
)• M
ultip
le fa
llers
MM
SE =
22.
7 (5
.1)
• Spa
tiote
mpo
ral p
aram
eter
s us
ing
GA
ITRi
te, f
alls
in th
e 12
-mon
th fo
llow
-up
perio
d• 5
4% re
port
ed a
t lea
st o
ne fa
ll; 3
5% re
port
ed tw
o or
mor
e fa
lls• M
CI a
nd m
ultip
le fa
lls a
ssoc
iate
d w
ith s
low
er g
ait (
p =
0.08
1),
shor
ter s
trid
e le
ngth
(p =
0.0
13),
long
er ti
me
in d
oubl
e su
ppor
t (p
= 0
.014
), an
d m
ore
varia
bilit
y in
str
ide
leng
th (p
= 0
.003
) and
sw
ing
time
(p =
0.0
06) t
han
MCI
with
non
-mul
tiple
falls
Uem
ura,
Has
egaw
a,
Toug
ou, S
huhe
i, &
U
chiy
ama
(201
5);
Japa
n
Cros
s-se
ctio
nal s
tudy
of p
ostu
ral
cont
rol a
nd M
CI u
sing
ana
lysi
s of
st
ep c
hoic
e
• Com
mun
ity-d
wel
ling
olde
r adu
lts in
a c
ohor
t stu
dy
(N =
376
, 37
falle
rs a
nd 3
39 n
on-fa
llers
)• F
alle
rs M
MSE
= 2
6.6
(2.1
)• N
on-fa
llers
MM
SE =
26.
8 (1
.8)
• Fal
l his
tory
and
pos
tura
l con
trol
test
ing
usin
g th
e Tw
in-g
ravi
cord
er®
• Ind
ivid
uals
with
MCI
with
falls
had
pro
long
ed a
ntic
ipat
ory
post
ural
adj
ustm
ent e
rror
s (p
= 0
.005
) and
long
er re
actio
n ph
ase
in s
tep
tria
ls w
ith th
e co
rrec
t ant
icip
ator
y po
stur
al a
djus
t-m
ent (
p =
0.01
)
Verg
hese
et a
l. (2
008)
; U
nite
d St
ates
Cros
s-se
ctio
nal s
tudy
of g
ait a
nd
MCI
by
subt
ype
• Par
ticip
ants
from
a c
ohor
t stu
dy (N
= 4
11, 5
4 w
ith
amne
stic
MCI
, 62
with
non
-am
nest
ic M
CI, a
nd 2
95
cont
rols
)• A
mne
stic
MCI
Sho
rt B
less
ed In
form
atio
n–M
emor
y–Co
ncen
trat
ion
test
= 3
.1 (2
.3)
• Non
-am
nest
ic M
CI S
hort
Ble
ssed
Info
rmat
ion–
Mem
ory–
Conc
entr
atio
n te
st =
2.6
(2.1
)• C
ontr
ol S
hort
Ble
ssed
Info
rmat
ion–
Mem
ory–
Conc
entr
atio
n te
st =
1.4
(1.5
)
• Clin
ical
ass
essm
ent a
nd p
aram
eter
s us
ing
GA
ITRi
te
• Bot
h M
CI g
roup
s ha
d w
orse
pac
e, rh
ythm
, and
var
iabi
lity
in
gait
perf
orm
ance
than
the
cont
rol g
roup
. The
am
nest
ic M
CI
grou
p ha
d w
orse
rhyt
hm a
nd v
aria
bilit
y sc
ores
than
the
non-
amne
stic
MCI
and
con
trol
gro
ups.
(CO
NT
INU
ED
)
TA
BL
E A
Re
vie
we
d S
tud
ies
by
Pri
ma
ry C
ate
go
ry
Auth
or/Y
ear/L
ocat
ion
Desig
n/In
terv
entio
nPa
rticip
ants
Mea
sure
men
t/Out
com
es
Fear
of Fa
lling
Borg
es S
de, R
adan
ovic
, &
For
lenz
a (2
015)
; Bra
zil
Cros
s-se
ctio
nal s
tudy
of f
alls
and
FO
F an
d CI
• Com
mun
ity-d
wel
ling
olde
r adu
lts fr
om a
coh
ort s
tudy
(N
= 1
04, 4
2 w
ith M
CI, 2
6 w
ith A
D, a
nd 3
6 co
ntro
ls)
• MCI
CD
R =
0.5,
MM
SE =
27.
4 (2
.1)
• AD
CD
R =
1, M
MSE
= 2
2.6
(3)
• Con
trol
CD
R =
0, M
MSE
= 2
8.6
(1.4
)
• Fal
ls, F
OF,
Falls
Effi
cacy
Sca
le–I
nter
natio
nal (
FES-
I)• F
OF:
MCI
74%
, A
D 3
1%, c
ontr
ol 5
0%• M
CI g
roup
repo
rted
hig
her F
OF
than
con
trol
s or
AD
gro
up
(p <
0.0
02),
and
high
er F
ES-I
(p =
0.0
1) a
nd m
ore
falls
than
co
ntro
ls
Del
baer
e, C
lose
, Tay
lor,
Wes
son,
& L
ord
(201
3);
Aust
ralia
Mea
sure
men
t stu
dy o
f psy
cho-
met
ric p
rope
rtie
s of
the
Icon
o-gr
aphi
c Fa
lls E
ffi ca
cy S
cale
(ICO
N-
FES)
in c
ogni
tivel
y im
paire
d ol
der
adul
ts
• 50
indi
vidu
als
with
CI,
MM
SE =
22.
4 (4
.4)
• ICO
N-F
ES, F
ES-I
• ICO
N-F
ES s
how
ed g
ood
inte
rnal
con
sist
ency
(alp
ha =
0.9
7)
and
abili
ty to
dis
crim
inat
e gr
oups
bas
ed o
n ag
e, fa
lls, a
nd b
al-
ance
, mod
est c
orre
latio
n w
ith F
ES-I
Uem
ura
et a
l. (2
014)
; Ja
pan
Cros
s-se
ctio
nal s
tudy
of F
OF
and
falls
• Com
mun
ity-d
wel
ling
olde
r adu
lts in
coh
ort s
tudy
(N
= 4
,474
, 938
with
MCI
, 801
with
Glo
bal C
ogni
tive
Impa
irmen
t, an
d 2,
735
heal
thy
cont
rols
)• M
CI M
MSE
= 2
6.6
(1.8
)• G
loba
l Cog
nitiv
e Im
pairm
ent M
MSE
= 2
1.6
(1.8
)• H
ealth
y co
ntro
l MM
SE =
27.
4 (1
.8)
• Bas
elin
e FO
F an
d fa
ll hi
stor
y• 5
0.6%
of i
ndiv
idua
ls w
ith M
CI h
ad F
OF.
Thos
e w
ith M
CI h
ad
high
est p
reva
lenc
e of
FO
F (5
0.6%
) (p
< 0.
001)
, with
low
er ra
tes
than
indi
vidu
als
with
Glo
bal C
ogni
tive
Impa
irmen
t and
hig
her
falls
his
tory
(7.1
%) t
han
the
heal
thy
cont
rol g
roup
.
Uem
ura
et a
l. (2
012)
; Ja
pan
Cros
s-se
ctio
nal s
tudy
to d
eter
-m
ine
rela
tions
hip
betw
een
cogn
i-tiv
e de
clin
e an
d FO
F
• Com
mun
ity-d
wel
ling
olde
r adu
lts (N
= 1
01, 5
4 in
the
fear
gro
up a
nd 4
7 in
the
no fe
ar g
roup
)• F
ear g
roup
MM
SE =
26.
9 (2
.2)
• No
fear
gro
up M
MSE
= 2
7.2
(1.6
)
• Sin
gle-
item
FO
F, TU
G, o
ne-le
g st
and,
5-m
wal
k te
st, c
ogni
tive
test
ing
• 53.
4% h
ad F
OF;
FO
F as
soci
ated
with
the
TUG
(OR
1.43
, 95%
CI
[1.1
2, 1
.83]
, p =
0.0
04) a
nd W
echs
ler L
ogic
al M
emor
y (O
R 1.
20,
95%
CI [
1.07
, 1.3
5], p
= 0
.002
), an
d fa
ll hi
stor
y (O
R 4.
38, 9
5% C
I [1
.53,
12.
51],
p =
0.00
6)],
but l
ower
pre
vale
nce
of F
OF
asso
ciat
ed
with
mem
ory
decl
ine.
Inte
rven
tion S
tudi
esH
agov
ská
& O
leks
zyov
á (2
015)
; Slo
vak
Repu
blic
• RC
T• C
ogni
tive
trai
ning
two
times
pe
r wee
k fo
r 30
min
utes
and
30
min
utes
of b
alan
ce tr
aini
ng
daily
for 1
0 w
eeks
ver
sus
bala
nce
trai
ning
onl
y
• 40
in e
xper
imen
tal g
roup
and
40
in c
ontr
ol g
roup
• Clin
ic re
ferr
als
with
mild
dem
entia
• Exp
erim
enta
l gro
up M
MSE
= 2
5.97
(2.5
7)• C
ontr
ol g
roup
MM
SE =
26.
02 (1
.47)
• TU
G, P
OM
A a
t bas
elin
e an
d 10
wee
ks• B
oth
grou
ps im
prov
ed o
n M
MSE
, TU
G w
ith b
alan
ce, F
OF
(ns)
; gr
eate
r im
prov
emen
ts in
exp
erim
enta
l gro
up a
nd c
ogni
tive
trai
ning
incr
ease
d im
prov
emen
ts.
(CO
NT
INU
ED
)
TA
BL
E A
Re
vie
we
d S
tud
ies
by
Pri
ma
ry C
ate
go
ry
Auth
or/Y
ear/L
ocat
ion
Desig
n/In
terv
entio
nPa
rticip
ants
Mea
sure
men
t/Out
com
esKo
vács
, Szt
ruhá
r Jó
násn
é, K
aróc
zi,
Korp
os, &
Gon
dos
(201
3); H
unga
ry
• Sin
gle-
blin
d RC
T• M
ultim
odal
exe
rcis
e of
fl ex
-ib
ility
, str
engt
h, a
nd b
alan
ce
two
times
wee
kly
for 1
2 m
onth
s ve
rsus
usu
al c
are
• Res
iden
tial o
lder
adu
lts w
ith C
I (43
in in
terv
entio
n gr
oup
and
43 in
con
trol
gro
up)
• Int
erve
ntio
n M
MSE
= 2
0.85
(3.2
)• C
ontr
ol M
MSE
= 2
0.93
(3.8
)
• Fal
ls, T
UG
, PO
MA
at b
asel
ine
and
12 m
onth
s• S
igni
fi can
t: PO
MA
–B: 6
and
12
mon
ths;
PO
MA
–G: 1
2 m
onth
s;
POM
A–T
: 6 a
nd 1
2 m
onth
s; T
UG
: 12
mon
ths;
Fal
ls: n
s.• P
rogr
am im
prov
ed s
tatic
bal
ance
—ne
ed m
ore
emph
asis
on
wal
king
and
env
ironm
ent
Mah
oney
et a
l. (2
007)
; U
nite
d St
ates
• RC
T to
dec
reas
e fa
lls• H
ome
visi
ts to
ass
ess
and
addr
ess
fall
risk
fact
ors,
reco
m-
men
datio
ns to
pro
vide
r, th
erap
y,
tele
phon
e fo
llow
up,
bal
ance
ex
erci
ses
• Com
mun
ity-d
wel
ling
olde
r adu
lts a
t hig
h ris
k of
fa
lling
(N =
349
, 174
in in
terv
entio
n gr
oup
and
175
in
cont
rol g
roup
)• I
nter
vent
ion
MM
SE =
26.
9 (4
.2)
• Con
trol
MM
SE =
27.
3 (4
.6)
• Fal
ls, h
ospi
taliz
atio
ns, n
ursi
ng h
ome
days
• No
sign
ifi ca
nt d
iff er
ence
in fa
ll ra
tes;
few
er n
ursi
ng h
ome
days
in
inte
rven
tion
grou
p• I
nter
vent
ion
part
icip
ants
with
MM
SE <
27 h
ad fe
wer
falls
(ris
k ra
tio =
0.5
5; p
= 0
.015
), ho
spita
lizat
ions
, and
nur
sing
hom
e da
ys
Ries
, Dra
ke, &
Mar
ino
(201
0); U
nite
d St
ates
• Exp
lora
tory
qua
si-e
xper
imen
tal
pre-
post
stu
dy• 8
-wee
k fu
nctio
nal b
alan
ce
exer
cise
s; tw
o 45
-min
ute
sess
ions
/wee
k
• Ind
ivid
uals
with
AD
(N =
5)
• MM
SE m
ean
= 23
.2• T
UG
, Ber
g Ba
lanc
e Sc
ale
at b
asel
ine
and
1-w
eek
post
-in
terv
entio
n• I
mpr
ovem
ents
: Ber
g Ba
lanc
e Sc
ale
scor
e—5/
5 pa
rtic
ipan
ts;
TUG
impr
oved
4/5
; sel
f-sel
ecte
d ga
it sp
eed—
3/5;
feas
ible
with
be
nefi t
s
Sutt
anon
, Hill
, Sai
d,
Will
iam
s, et
al.
(201
3);
Aust
ralia
• RC
T si
ngle
blin
d pi
lot
• 6-m
onth
hom
e-ba
sed
exer
cise
su
perv
ised
by
PT—
tailo
red
stre
ngth
enin
g an
d w
alki
ng v
ersu
s ho
me-
base
d ed
ucat
ion
• 19
in e
xerc
ise
grou
p an
d 21
in c
ontr
ol g
roup
• Exe
rcis
e M
MSE
= 2
0.89
(4.7
4)• C
ontr
ol M
MSE
= 2
1.67
(4.4
3)
• Bas
elin
e an
d po
st-s
tudy
–Fun
ctio
nal r
each
, bal
ance
, fal
l ris
k pr
ofi le
• Im
prov
emen
t in
func
tiona
l rea
ch (p
= 0
.002
) and
fall
risk
(p =
0.0
08) i
n ex
erci
se g
roup
, som
e tr
ends
in o
ther
bal
ance
and
m
obili
ty te
sts.
Onl
y 58
% c
ompl
eted
exe
rcis
e, b
ut it
was
feas
ible
an
d sa
fe.
Tcha
lla e
t al.
(201
3);
Fran
ce• E
xper
imen
tal p
rosp
ectiv
e st
udy
• Fal
l eva
luat
ion
and
tech
nolo
gy
syst
em v
ersu
s fa
ll ev
alua
tion
• Com
mun
ity-d
wel
ling
indi
vidu
als
with
AD
(49
in in
ter-
vent
ion
grou
p an
d 47
in c
ontr
ol g
roup
)• I
nter
vent
ion
med
ian
MM
SE =
21
(ran
ge =
19
to 2
3)• C
ontr
ol m
edia
n M
MSE
= 2
1 (r
ange
= 1
9 to
24)
• Fal
ls o
ver 1
yea
r as
repo
rted
by
prov
ider
s• D
ecre
ased
indo
or fa
lls in
inte
rven
tion
grou
p (O
R =
0.37
, 95%
CI
[0.1
5, 0
.88]
).• S
yste
m in
clud
ed n
ight
ligh
t pat
h fr
om b
ed to
bat
hroo
m,
tele
-ass
ista
nce
prog
ram
(int
erco
m, e
lect
roni
c br
acel
et, a
nd
tele
phon
e em
erge
ncy
resp
onse
). Bo
th g
roup
s ha
d fa
ll as
sess
-m
ent b
y pr
ovid
er.
(CO
NT
INU
ED
)
TA
BL
E A
Re
vie
we
d S
tud
ies
by
Pri
ma
ry C
ate
go
ry
Auth
or/Y
ear/L
ocat
ion
Desig
n/In
terv
entio
nPa
rticip
ants
Mea
sure
men
t/Out
com
esW
esso
n et
al.
(201
3);
Aust
ralia
• Pilo
t RC
T• H
ome-
base
d 12
-wee
k PT
and
O
T ho
me
visi
ts, h
azar
d re
duc-
tion,
and
bal
ance
and
str
engt
h ex
erci
ses
vers
us u
sual
car
e
• Dya
ds o
f ind
ivid
uals
with
mild
dem
entia
and
car
ers
(11
in in
terv
entio
n gr
oup
and
11 in
con
trol
gro
up)
• Int
erve
ntio
n M
MSE
= 2
4.5
(3.1
)• C
ontr
ol M
MSE
= 2
2.5
(4.3
)
• Bas
elin
e an
d 4
mon
ths:
falls
, fal
l rat
e, a
dher
ence
• Dec
reas
ed ri
sk o
f fal
ling
and
rate
of f
allin
g bu
t ns;
72%
ex
erci
sing
. All
impl
emen
ted
som
e ho
me
safe
ty re
com
men
da-
tions
. Int
erve
ntio
n w
as a
ccep
tabl
e an
d fe
asib
le, w
ith s
ome
bene
fi ts.
• Pro
gram
tailo
red
base
d on
the
Larg
e A
llen’
s Co
gniti
ve L
evel
s Sc
reen
ing
Tool
-5
Yao,
Gio
rdan
i, A
lgas
e,
You,
& A
lexa
nder
(2
013)
; Uni
ted
Stat
es
• Pre
test
–pos
ttes
t sin
gle
grou
p st
udy
• 4-w
eek
grou
p tr
aini
ng—
paire
d ta
i chi
pro
gram
; 60
min
utes
two
times
per
wee
k fo
llow
ed b
y 12
wee
ks o
f hom
e pr
actic
e th
ree
times
per
wee
k w
ith a
dded
pos
i-tiv
e em
otio
n th
erap
y
• Com
mun
ity-d
wel
ling
olde
r adu
lts w
ith A
D a
nd
care
give
r dya
ds (N
= 22
, 12
with
mild
AD
and
10
with
m
oder
ate-
seve
re A
D)
• Mild
gro
up M
MSE
≥21
• Mod
erat
e-se
vere
gro
up M
MSE
≤20
• Bas
elin
e, 4
wee
ks, a
nd 1
6 w
eeks
: TU
G, u
nipe
dal s
tanc
e• I
ndiv
idua
ls w
ith m
ild im
pairm
ent h
ad m
ost i
mpr
ovem
ent i
n TU
G a
nd u
nipe
dal s
tanc
e tim
e, a
lthou
gh n
s.• P
ositi
ve e
mot
ion
ther
apy
used
Ple
asan
t Eve
nts
Sche
dule
for
ince
ntiv
es/r
ewar
ds• A
ll ex
erci
se d
one
in ta
ndem
with
car
egiv
er
Not
e. So
me r
efer
ence
s are
use
d in
mor
e tha
n on
e cat
egor
y. M
MSE
= M
ini-M
enta
l Sta
te E
xam
inat
ion;
MoC
A =
Mon
treal
Cog
nitiv
e Ass
essm
ent;
SPPB
= S
hort
Phy
sical
Per
form
ance
Bat
tery
; MCI
= m
ild co
gniti
ve im
pairm
ent;
AD
= A
lzhei
mer
’s di
seas
e; RC
T =
rand
omiz
ed co
ntro
lled
tria
l; PP
T-7
= Ph
ysic
al P
erfo
rman
ce T
est–
7; T
UG
= ti
med
up
and
go; P
PA =
Phy
sical
Pro
fi le A
sses
smen
t; ST
C =
singl
e tas
k co
nditi
on; D
TC =
dua
l tas
k co
nditi
on; C
DR
= Cl
inic
al D
emen
tia R
atin
g; F
OF
= fe
ar o
f fal
ling;
ns =
not
sig
nifi c
ant;
MRI
= m
agne
tic re
sona
nce i
mag
ing;
CI =
cogn
itive
impa
irmen
t; PO
MA
= P
erfo
rman
ce O
rient
ed M
obili
ty A
sses
smen
t; PT
= p
hysic
al th
erap
ist; O
T =
occu
patio
nal t
hera
pist.
(CO
NT
INU
ED
)