Objectives
To provide an overview of the role of cognition in falls, with potential implications for managing and preventing falls in older adults.
Design
Review.
Setting
Observational and ...interventional studies addressing the role of cognition on falls.
Participants
Community‐dwelling older adults (65 years and older).
Measurements
The relationship between gait and cognition in aging and neurodegeneration was reviewed in the medical literature to highlight the role of brain motor control deficits in fall risk. The benefits of dual‐task gait assessments as a marker of fall risk were reviewed. Therapeutic approaches for reducing falls by improving certain aspects of cognition were appraised.
Results
Low performance in attention and executive function are associated with gait slowing, instability, and future falls. Drug‐enhancement of cognition may reduce falls in Parkinson's disease, and cognitive training, dual‐task training, and virtual reality modalities are promising to improve mobility in sedentary older adults and in those with cognitive impairment and dementia.
Conclusion
Falls remain common in older people, with higher prevalence and morbidity in those who are cognitively impaired. Disentangling the mechanism and contribution of cognitive deficits in fall risk may open new treatment approaches. Mounting evidence supports that cognitive therapies help reduce falls.
cognitive impairment is an established fall risk factor; however, it is unclear whether a disease-specific diagnosis (i.e. dementia), measures of global cognition or impairments in specific cognitive ...domains (i.e. executive function) have the greatest association with fall risk. Our objective was to evaluate the epidemiological evidence linking cognitive impairment and fall risk.
studies were identified through systematic searches of the electronic databases of MEDLINE, EMBASE, PyschINFO (1988-2009). Bibliographies of retrieved articles were also searched. A fixed-effects meta-analysis was performed using an inverse-variance method.
twenty-seven studies met the inclusion criteria. Impairment on global measures of cognition was associated with any fall, serious injuries (summary estimate of OR = 2.13 (1.56, 2.90)) and distal radius fractures in community-dwelling older adults. Executive function impairment, even subtle deficits in healthy community-dwelling older adults, was associated with an increased risk for any fall (summary estimate of OR = 1.44 (1.20, 1.73)) and falls with serious injury. A diagnosis of dementia, without specification of dementia subtype or disease severity, was associated with risk for any fall but not serious fall injury in institution-dwelling older adults.
the method used to define cognitive impairment and the type of fall outcome are both important when quantifying risk. There is strong evidence global measures of cognition are associated with serious fall-related injury, though there is no consensus on threshold values. Executive function was also associated with increased risk, which supports its inclusion in fall risk assessment especially when global measures are within normal limits.
Objectives
To systematically review and quantitatively synthesize the effect of vitamin D supplementation on muscle strength, gait, and balance in older adults.
Design
Systematic review and ...meta‐analysis.
Setting
MEDLINE, EMBASE, Cochrane Library, bibliographies of selected articles, and previous systematic reviews were searched between January 1980 and November 2010 for eligible articles.
Participants
Older adults (≥60) participating in randomized controlled trials of the effect of supplemental vitamin D without an exercise intervention on muscle strength, gait, and balance.
Measurements
Data were independently extracted, and study quality was evaluated. Meta‐analysis using a fixed‐effects model was performed and the I2 statistic was used to assess heterogeneity.
Results
Of 714 potentially relevant articles, 13 met the inclusion criteria. In the pooled analysis, vitamin D supplementation yielded a standardized mean difference of −0.20 (95% confidence interval (CI) = −0.39 to −0.01, P = .04, I2 = 0%) for reduced postural sway, −0.19 (95% CI = −0.35 to −0.02, P = .03, I2 = 0%) for decreased time to complete the Timed Up and Go Test, and 0.05 (95% CI = −0.11 to 0.20, P = .04, I2 = 0%) for lower extremity strength gain. Regarding dosing frequency regimen, only one study demonstrated a beneficial effect on balance with a single large dose. All studies with daily doses of 800 IU or more demonstrated beneficial effects on balance and muscle strength.
Conclusion
Supplemental vitamin D with daily doses of 800 to 1,000 IU consistently demonstrated beneficial effects on strength and balance. An effect on gait was not demonstrated, although further evaluation is recommended.
Until recently, clinicians and researchers have performed gait assessments and cognitive assessments separately when evaluating older adults, but increasing evidence from clinical practice, ...epidemiological studies, and clinical trials shows that gait and cognition are interrelated in older adults. Quantifiable alterations in gait in older adults are associated with falls, dementia, and disability. At the same time, emerging evidence indicates that early disturbances in cognitive processes such as attention, executive function, and working memory are associated with slower gait and gait instability during single‐ and dual‐task testing and that these cognitive disturbances assist in the prediction of future mobility loss, falls, and progression to dementia. This article reviews the importance of the interrelationship between gait and cognition in aging and presents evidence that gait assessments can provide a window into the understanding of cognitive function and dysfunction and fall risk in older people in clinical practice. To this end, the benefits of dual‐task gait assessments (e.g., walking while performing an attention‐demanding task) as a marker of fall risk are summarized. A potential complementary approach for reducing the risk of falls by improving certain aspects of cognition through nonpharmacological and pharmacological treatments is also presented. Untangling the relationship between early gait disturbances and early cognitive changes may be helpful in identifying older adults at risk of experiencing mobility decline, falls, and progression to dementia.
Introduction
Gait impairment is common in neurodegenerative disorders. Specifically, gait variability—the stride‐to‐stride fluctuations in distance and time—has been associated with neurodegeneration ...and cognitive impairment. However, quantitative comparisons of gait impairments across the cognitive spectrum of dementias have not been systematically investigated.
Methods
Older adults (N = 500) with subjective cognitive impairment, Parkinson disease (PD), mild cognitive impairment (MCI), PD‐MCI, Alzheimer's disease (AD), PD‐dementia, Lewy body dementia, and frontotemporal dementia, as well cognitive normal controls, who were assessed for their gait and cognitive performance.
Results
Factor analyses grouped 11 quantitative gait parameters and identified four independent gait domains: rhythm, pace, variability, and postural control, for group comparisons and classification analysis. Among these domains, only high gait variability was associated with lower cognitive performance and accurately discriminated AD from other neurodegenerative and cognitive conditions.
Discussion
Our findings indicate that high gait variability is a marker of cognitive‐cortical dysfunction, which can help to identify Alzheimer's disease dementia.
Objectives
To compare the trajectories of motor and cognitive decline in older adults who progress to dementia with the trajectories of those who do not. To evaluate the added value of measuring ...motor and cognitive decline longitudinally versus cross‐sectionally for predicting dementia.
Design
Prospective cohort study with 5 years of follow‐up.
Setting
Clinic based at a university hospital in London, Ontario, Canada.
Participants
Community‐dwelling participants aged 65 and older free of dementia at baseline (N=154).
Measurements
We evaluated trajectories in participants' motor performance using gait velocity and cognitive performance using the MoCA test twice a year for 5 years. We ascertained incident dementia risk using Cox regression models and attributable risk analyses. Analyses were adjusted using a time‐dependent covariate.
Results
Overall, 14.3% progressed to dementia. The risk of dementia was almost 7 times as great for those whose gait velocity declined (hazard ratio (HR)=6.89, 95% confidence interval (CI)=2.18–21.75, p=.001), more than 3 times as great for those with cognitive decline (HR=3.61, 95% CI=1.28–10.13, p=.01), and almost 8 times as great in those with combined gait velocity and cognitive decline (HR=7.83, 95% CI=2.10–29.24, p=.002), with an attributable risk of 105 per 1,000 person years. Slow gait at baseline alone failed to predict dementia (HR=1.16, 95% CI=0.39–3.46, p=.79).
Conclusion
Motor decline, assessed according to serial measures of gait velocity, had a higher attributable risk for incident dementia than did cognitive decline. A decline over time of both gait velocity and cognition had the highest attributable risk. A single time‐point assessment was not sufficient to detect individuals at high risk of dementia.
See related editorial by Snitz.
Background
There is growing recognition of the importance of sex and gender differences within falls literature, but the characterization of such literature is uncertain. The aim of this scoping ...review was to (1) map the nature and extent of falls literature examining sex or gender differences among older adults, and (2) identify gaps and opportunities for further research and practice.
Methods
We used a scoping review methodology. Eligible studies included participants with a mean age of ≥60 years and study aims specifying falls and either sex or gender concepts. MEDLINE, Embase, CINAHL, Ageline, and Psychinfo databases were searched from inception to March 2, 2022. Records were screened and charted by six independent reviewers. Descriptive and narrative reports were generated.
Results
A total of 15,266 records were screened and 74 studies were included. Most studies reported on sex and gender differences in fall risk factors (n = 52, 70%), incidence/prevalence (n = 26, 35%), fall consequences (n = 22, 30%), and fall characteristics (n = 15, 20%). The majority of studies (n = 70, 95%) found significant sex or gender differences in relation to falls, with 39 (53%) identifying significant sex differences and 31 (42%) identifying significant gender differences. However, only three (4%) studies defined sex or gender concepts and only nine (12%) studies used sex or gender terms appropriately. Fifty‐six (76%) studies had more female participants than males. Four (5%) were intervention studies. Studies did not report falls in line with guidelines nor use common fall definitions.
Conclusion
Sex and gender differences are commonly reported in falls literature. It is critical for future research to use sex and gender terms appropriately and include similar sample sizes across all genders and sexes. In addition, there is a need to examine more gender‐diverse populations and to develop interventions to prevent falls that address sex and gender differences among older adults.
BACKGROUND AND OBJECTIVES
Polypharmacy, defined as the use of five or more medications, has been repeatedly linked to fall incidence, and recently it was cross‐sectionally associated with gait ...disturbances. Our objectives were to evaluate cross‐sectional and longitudinal associations between polypharmacy and gait performance in a well‐established clinic‐based cohort study. We also assessed whether gait impairments could mediate associations between number of medications and fall incidence.
DESIGN
Prospective cohort of community‐dwelling older adults, with 5 years of follow‐up.
SETTING
Geriatric clinics in an academic hospital in London, ON, Canada.
PARTICIPANTS
Community‐dwelling older adults aged 65 and older (n = 249; 76.6 ± 8.6 y; 63% women).
MEASUREMENTS
Number of medications, quantitative spatiotemporal gait parameters, and fall incidence during follow‐up.
RESULTS
The number of medications was cross‐sectionally associated with poor gait performance (slow gait, speed p < .001; higher variability, p < .001; and higher stride, p < .001; step, p = .013, and double support times, p < .001). Prospectively, the number of medications was associated with overall gait decline (odds ratio = 1.23; 95% confidence interval CI = 1.13‐1.33; p < .001), faster gait decline (hazard ratio = 4.62; 95%CI = 1.82‐11.73; p < .001), and higher falls incidence (p = .006). These associations remained true after adjusting for age, sex, and accounting for “confounding by indication bias” by using a comorbidity propensity score adjustment. Each additional medication taken, significantly increased gait decline risk by 12% to 16% and fall incidence risk by 5% to 7%. Mediation analyses revealed that gait impairments in stride length, step length, and step width mediated the strength of the association between medications and fall incidence.
CONCLUSION
Polypharmacy was cross‐sectionally associated with poor gait performance and longitudinally associated with gait decline and fall incidence. Despite our use of propensity matching, confounding by indication could have influenced the results. Quantitative spatial gait parameters performance mediated the strength of the association between medications and falls, suggesting a role of gait disturbances in the medication‐related falls pathway.
Apathy, gait disturbances, and executive dysfunction (AGED) often occur together. Although they can arise independently, the presence of one might portend another. This recognition suggests the ...possible etiology. We focus on the most common, the vascular. We explain the AGED vascular mechanism through the ambibaric brain concept. The brain contains two complementary blood pressure systems: One high in the primitive brain (brainstem, basal ganglia, and thalamus) and a low‐pressure system in the Homo sapiens brain (cerebral hemispheres). Hypertension inflicts the most damage on the primitive brain. The frontal systems connect to the basal ganglia, then the thalamus and back to the cortex. Many connections converge on the primitive brain where they are damaged by vascular disease. We need methods of determining optimal, individual blood pressures. Although the AGED triad can result from other causes, it should first signal a vascular etiology, the most prevalent, treatable, and preventable one.
Canadian Geriatrics in the Time of COVID‐19 Hogan, David B.; MacKnight, Chris; Madden, Kenneth M. ...
Journal of the American Geriatrics Society (JAGS),
June 2020, Letnik:
68, Številka:
6
Journal Article
PDF
