Risk Factors for Falls in Older Adults With Mild Cognitive Impairment and Mild Alzheimer Disease

Abstract

Background and purpose:
Understanding fall risk factors in people with mild cognitive impairment (MCI) and Alzheimer disease (AD) can help to establish specific plans for prevention of falls. The purpose of this study was to identify fall risk factors in older adults with MCI and mild AD.

Methods:
A prospective study was conducted with community-dwelling older adults (40 MCI; 38 mild AD). The assessments consisted of sociodemographic and health variables, caloric expenditure, functional status, functional mobility (10-m walk test, dual-task test, and transition Timed Up and Go phases), cognitive domains, and depressive symptoms. Falls were recorded for 6 months by a falls calendar and monthly telephone calls.

Results:
Falls were reported in 52.6% and 51.4% of people with MCI and mild AD, respectively. Among people with MCI, lower functional status, higher time spent on walk and dual task tests, and higher depressive symptom scores were associated with falls. Higher time spent on the dual-task test was independently associated with falls. Among people with mild AD, falls were associated with lower time spent on the walk test and turn-to-sit phase, and a higher visuospatial domain score. Lower time spent on the turn-to-sit phase was identified as an independent predictor of falls.

Conclusions:
Careful attention should be given to dual-task and turn-to-sit activities when detecting risk of falls among older people with MCI and mild AD.

Full text

Copyright © 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Journal of GERIATRIC Physical Therapy 1
Research Report
INTRODUCTION
The annual prevalence of falls is close to 60% in older
people with cognitive impairment (ie, twice the prevalence
of community-dwelling older people).
1 The consequences
tend to be more serious in this population. Fallers with
cognitive impairment are 5 times more likely to be insti-
tutionalized than nonfallers with cognitive impairment.
2
Reasons for the increased risk are still poorly understood
and interventions to prevent falls in older adults with cog-
nitive impairment have not been effective.
3
,
4
A 1-year prospective study showed that higher fall rates
were associated with limited balance and functional mobility,
increased medication use, worse executive function, risk of
depression and anxiety, and fear of falling in 177 community-
dwelling older people with low scores in the Mini-Mental
State Examination/Addenbrooke’s Cognitive Examination-
Revised.
5 Other prospective studies identifi ed risk factors for
falls in community-dwelling adults with dementia
6
,
7 and mild
to moderate Alzheimer disease (AD).
8 Although these stud-
ies have contributed to the knowledge about risk factors for
falls in people with cognitive impairment, they mixed older
adults with different types of cognitive impairment in the
same sample. The prevalence of falls changes according to
cognitive impairment and type and phase of dementia.
7
,
9 In
addition, people with mild cognitive impairment (MCI) and
mild AD seem to present distinct characteristics regarding
history of falls.
9 Therefore, it is important to investigate the
different risk factors for falls in older people with MCI and
mild AD to establish specifi c planning for prevention of falls.
Better understanding of which risk factors are related
to falls in older people with MCI and mild AD could
improve approaches to the prevention of falls and help
to delay the progression to functional disability. The
purpose of this prospective study was to identify fall risk
factors in older adults with MCI and mild AD.
ABSTRACT
Background and Purpose: Understanding fall risk factors in
people with mild cognitive impairment (MCI) and Alzheimer
disease (AD) can help to establish specifi c planning for pre-
vention of falls. The purpose of this study was to identify fall
risk factors in older adults with MCI and mild AD.
Methods: A prospective study was conducted with
community-dwelling older adults (40 MCI; 38 mild AD).
The assessments consisted of sociodemographic and health
variables, caloric expenditure, functional status, functional
mobility (10-m walk test, dual-task test, and transition Timed
Up and Go phases), cognitive domains, and depressive
symptoms. Falls were recorded for 6 months by a falls calen-
dar and monthly telephone calls.
Results: Falls were reported in 52.6% and 51.4% of people
with MCI and mild AD, respectively. Among people with MCI,
lower functional status, higher time spent on walk and dual
task tests, and higher depressive symptom scores were asso-
ciated with falls. Higher time spent on the dual-task test was
independently associated with falls. Among people with mild
AD, falls were associated with lower time spent on the walk
test and turn-to-sit phase, and a higher visuospatial domain
score. Lower time spent on the turn-to-sit phase was identifi ed
as an independent predictor of falls.
Conclusions: Careful attention should be given to dual-task
and turn-to-sit activities when detecting risk of falls among
older people with MCI and mild AD.
Risk Factors for Falls in Older Adults With
Mild Cognitive Impairment and Mild
Alzheimer Disease
Juliana Hotta Ansai , PT, MS 1 ; Larissa Pires de Andrade , PT, PhD 1 ;
Fernando Arturo Arriagada Masse , PT 1 ; Jessica Gonçalves , PT 1 ;
Anielle Cristhine de Medeiros Takahashi , PT, PhD 1 ;
Francisco Assis Carvalho Vale , MD, PhD 2 ; José Rubens Rebelatto , PT, PhD 1
1 Department of Physical Therapy, Federal University of São
Carlos, Brazil.
2 Department of Medicine, Federal University of São Carlos,
Brazil.
Supported by Coordination for the Improvement of Higher
Education Personnel (CAPES).
The authors declare no confl icts of interest.
Address correspondence to: Juliana Hotta Ansai, PT, MS,
Department of Physical Therapy, Rodovia Washington
Luiz, km 235, CEP 13565-905, Brazil ( julianaansai@
gmail.com ).
Copyright © 2017 Academy of Geriatric Physical Therapy,
APTA.
DOI: 10.1519/JPT.0000000000000135
Key Words: accidental falls , cognitive function , dementia , mobility
(J Geriatr Phys Ther 2017;00:1-6.)
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Copyright © 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Research Report
2Volume 00 • Number 00 • 000 2017
METHODS
Participants
A prospective study was carried out at 2 points in
time (baseline and after 6 months), conducted at the
Federal University of São Carlos (UFSCar, São Paulo,
Brazil) between January 2015 and February 2016. The
UFSCar ethics research committee approved the study
(819.668/2014), and all participants signed an informed
consent form.
Community-dwelling older adults 65 years and older
were recruited from health centers/units, the School Health
Unit of UFSCar, and the Open University for older adults
(São Carlos-SP). Only older people with the ability to walk
at least 10 m without a walking aid, availability to partici-
pate in the assessments, and admission in 1 of the groups
studied (MCI and mild AD) were included in this study.
Exclusion criteria were the presence of motor alterations
after stroke, other types of dementia, neurological disorders
that interfered in cognition or mobility, severe uncorrected
visual or auditory disorders, and advanced or moderate
AD. An experienced neurologist confi rmed the diagnosis
of MCI and AD (mild stage), based on the Diagnosis and
Statistical Manual of Mental Disorders (Fifth Edition, Text
Revision). Finally, only people with a Clinical Dementia
Rating score of 0.5 and 1.0 were included in the MCI and
mild AD groups, respectively. Details about diagnosis cri-
teria have been previously described.
10
Baseline Assessment
Before the assessment, the participants were instructed to
wear comfortable clothing and closed usual shoes, to eat
at least 1 hour before the tests, to avoid vigorous exercise
the day before, and bring visual or auditory aids, if neces-
sary. The participants were assessed by 2 trained physical
therapists in a closed environment with minimum visual
and auditory stimuli.
The assessment consisted of collecting data related to
socioeconomic and health variables, caloric expenditure,
functional status, functional mobility, cognitive domains,
and depressive symptoms. With the help of an informant
in cases of cognitive impairment (ie, a person who stayed
with the subject for at least half a day, 4 times per week),
sociodemographic and health variables (age, gender, edu-
cational level, medication use, use of multi/bifocal glasses,
and use of walking aids) were collected. In addition, the
body mass index was calculated using height and weight
data, which were measured by a mechanical physician
scale with a height rod. Caloric expenditure was obtained
by the Minnesota Leisure Time Activities Questionnaire.
11
This questionnaire has been used in community-dwelling
older people to assess level of physical activity, sports and
leisure, according to caloric expenditure.
11 Functional
status was assessed by the Pfeffer’s Functional Activities
Questionnaire.
12 The informant answers the questionnaire
according to the degree of independence in 10 instrumental
activities of daily living.
12
Functional mobility was assessed by the 10-m walk test,
dual-task test, and time of transition Timed Up and Go
(TUG) phases. The participants were instructed to begin
walking at usual gait speed 1.2 m before the beginning of
the course and to fi nish 1.2 m after the end of the course
to eliminate acceleration and deceleration components.
13
The dual task was assessed using the TUG associated
with a motor-cognitive task (calling a phone number).
10
The TUG and the motor-cognitive task were assessed
separately. Specifi c instructions for the dual-task test have
been described in a previous study.
10 A single assessor dem-
onstrated the task once and a pretest was conducted for
familiarization in each test. Total time of each test was ana-
lyzed. Furthermore, transition TUG phases (sit-to-stand,
turn-to-walk, and turn-to-sit) were chosen because of the
major motor and cognitive demands required to perform
the tasks and thus the possibility that they could be more
associated with falls.
14
,
15 The transition TUG phases were
assessed by the Qualisys motion-capture system with 7
cameras (Qualisys AB, Gothenburg, Sweden) (1280 × 1024
resolution; 1.3 megapixels), using a sampling frequency of
120 Hz. The Qualisys Track Manager (Qualisys AB) and
Visual3D (C-Motion, Inc, Germantown, Maryland) soft-
ware programs were used for data processing. A MATLAB
routine was applied to detect, separate, and analyze time of
transition TUG subtasks, using the average of 3 trials and
following the methods of Salarian et al.
16
Cognition was assessed by Addenbrooke’s Cognitive
Examination-Revised (ACE-R)
17 for global cognitive func-
tion and Frontal Assessment Battery for executive func-
tion.
18 Through ACE-R, we analyzed the total and cogni-
tive domains (orientation and attention, memory, verbal fl u-
ency, language, and visuospatial ability) scores. Depressive
symptoms were assessed by the Geriatric Depression Scale
(GDS).
19
Falls Follow-up
After baseline assessment, each subject or informant (ie, a
person who stayed with the subject for at least half a day, 4
times per week) received a falls calendar and monthly tele-
phone calls asking about falls and reminding them to com-
plete the calendar, to ensure accurate data collection over 6
months. The fall defi nition was “an event which results in a
person coming to rest inadvertently on the ground or fl oor
or other lower level and other than as a consequence of
the following: sustaining a violent blow; loss of conscious-
ness; sudden onset of paralysis; or an epileptic seizure.”
20
Each group was subdivided into fallers (ie, a person who
fell at least once during the follow-up) and nonfallers. The
informant of the person with MCI confi rmed all doubtful
information collected and the informant of the person with
AD was responsible for completing the calendar and giving
all information.
Statistical Analysis
A signifi cance level of α = .05 was adopted, and the data
were analyzed with SPSS Software (version 20.0). Initially,
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Journal of GERIATRIC Physical Therapy 3
Research Report
data normality was tested using the Kolmogorov-Smirnov
test. The independent t test and the χ
2 test were used to
analyze differences in descriptive data between fallers and
nonfallers in each group studied. Univariate logistic regres-
sion (adjusted for age) was used to identify the association
between potentially modifi able sociodemographic and
health variables (ie, body mass index, medication use, psy-
chotropic drug use, use of Bi/multifocal glasses, and use of
walking aids), weekly caloric expenditure, functional sta-
tus, functional mobility, and cognition/depression variables
with falls follow-up for each group studied separately.
Only the variables with signifi cant association were entered
into a multiple backward stepwise logistic regression to
predict falls (adjusted for age). The groups were analyzed
separately in the logistic regression models. Selection of
variables in the multiple model was based on the likelihood
ratio test P values (.05 for entry, .1 for removal).
RESULTS
At baseline, 40 participants with MCI and 38 participants
with mild AD were evaluated. During follow-up, 2 women
with MCI and 1 woman with AD died and therefore their
data were not analyzed. Among the older people with MCI,
18 (47.4%) had 0 fall, 5 (13.1%) had 1 fall, 4 (10.5%)
had 2 falls, 5 (13.1%) had 3 falls, and 6 (15.7%) had 4 or
more falls over the 6-month follow-up. Among the older
people with mild AD, 18 (48.6%) had 0 fall, 6 (16.2%)
had 1 fall, 6 (16.2%) had 2 falls, 3 (8.1%) had 3 falls, and
4 (10.8%) had 4 or more falls over the 6-month follow-up.
No signifi cant differences in descriptive data were found
between fallers and nonfallers in each group (MCI and
AD) ( Table 1 ).
The univariate predictors of falls related to
sociodemographic/health status, weekly caloric expendi-
ture, functional status, and functional mobility variables,
adjusted for age, are displayed in Table 2 . Among the MCI
group, falls were signifi cantly associated with functional
status, time spent on the 10-m walk test, and dual-task
test. Among the AD group, falls were signifi cantly asso-
ciated with time spent on the 10-m walk test and turn-
to-sit phase. We did not fi nd any relationship between
sociodemographic/health status and weekly caloric expen-
diture variables with falls.
Table 3 displays the univariate predictors of falls related
to cognition/depression measures and adjusted for age.
Only the GDS score in the MCI group and the visuospatial
domain in the AD group were associated with falls.
The variables with signifi cant association were entered
into the multiple logistic regression (adjusted for age and
constant added to the model). In the MCI group, only
the dual-task test remained in the fi nal model as indepen-
dently associated with falls (odds ratio [95% confi dence
interval] = 1.13 [1.02-1.25], P = .017; χ
2 (2 df ) = 15.08,
P = .001, pseudo- R
2 = 0.437). The mean time of the
dual-task test was 23.46 seconds for nonfallers and 35.27
seconds for fallers.
In the AD group, only the turn-to-sit TUG phase
remained in the fi nal model as an independent predic-
tor of falls (odds ratio [95% confi dence interval] = 0.35
[0.14-0.90], P = .029; χ
2 (1 df ) = 6.86, P = .009, pseudo-
R
2 = 0.226). The mean time of the turn-to-sit TUG phase
was 3.18 seconds for nonfallers and 2.28 seconds for fallers.
DISCUSSION
This prospective study aimed to identify risk factors for
falls in older people with MCI and mild AD. A little more
than half of the participants fell during the 6-month follow-
up (MCI: 52.6%; AD: 51.4%). Among the MCI group,
functional status, time spent on the 10-m walk test and
dual-task test, and GDS score were signifi cantly associated
with falls, with only time on the dual-task test being an
independent predictor of falls. Among the AD group, falls
were signifi cantly associated with time spent on the 10-m
walk test and on the turn-to-sit TUG phase and visuospa-
tial domain, with only time on the turn-to-sit phase consid-
ered as an independent predictor of falls.
The prevalence of fallers in the present study is in accor-
dance with a longitudinal study with older people present-
ing a low Mini-Mental State Examination score ( < 26
points).
1 In a transversal study, Borges et al
21 also found
a high prevalence of fallers among Brazilian older people
with MCI (59%) and mild AD (65%). On the other hand,
Makizako et al
22 verifi ed that only 26.2% of participants
with MCI fell over a 12-month follow-up. Fall frequency
was measured with 2 face-to-face interviews at 6 and 12
months after baseline,
22 which could explain the different
Table 1. Descriptive Data of Fallers and Nonfallers
a
Variable, Mean (SD) MCI Group Fallers (n  20)
MCI Group Nonfallers
(n  18) AD Group Fallers (n  19)
AD Group Nonfallers
(n  18)
Age, y 77.3 (6.2) 74.1 (6.5) 78.1 (6.1) 77.0 (6.2)
Female gender, n (%) 16 (80.0) 16 (88.9) 10 (52.6) 11 (61.1)
Body mass index, kg/m
2 28.6 (3.9) 30.6 (4.4) 27.6 (5.5) 27.2 (5.4)
Educational level, y 4.5 (4.3) 5.7 (3.6) 5.8 (4.5) 5.2 (4.8)
Drug use, n (%) 5.1 (2.8) 5.2 (3.8) 5.9 (4.1) 4.5 (1.9)
Psychotropic drug use,n (%) 8 (40.0) 6 (33.3) 17 (89.5) 12 (66.7)
Abbreviations: AD, Alzheimer disease; MCI, mild cognitive impairment.
a P > .05 in all analyses.
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Research Report
4Volume 00 • Number 00 • 000 2017
results from our study. Allan et al
7 found that 47% of par-
ticipants with mild-to-moderate AD fell over a 12-month
follow-up. As the risk of falling can increase with the
progression of cognitive impairment,
23 more longitudinal
studies are needed to confi rm the high prevalence of fallers
in people with MCI and mild AD.
The association between falls and dual task among
the MCI group is in accordance with previous prospec-
tive studies in community-dwelling older adults with
normal global cognitive function.
24
,
25 Muir-Hunter and
Wittwer
25 also concluded, in their systematic review, that
this association is stronger than for single-task conditions.
Boripuntakul et al
26 and Montero-Odasso et al
2 verifi ed
worse dual-task performance in people with MCI, specifi -
cally in spatial variability and gait speed, and suggested that
dual task may be used to explain the high risk of falls in this
population. Although functional status was not identifi ed
as an independent predictor of falls in older people with
MCI, we found an association between falls and functional
status, which could have infl uenced dual-task performance.
In contrast, although Taylor et al
27 found that dual-task
activities adversely affected gait in cognitively impaired
Table 3. Univariate Predictors of Falls in Participants With MCI and AD: Cognition And Depression Measures
Measures
MCI Group (n  38) AD Group (n  37)
OR (95% CI) P Value OR (95% CI) P Value
Cognition
FAB 0.75 (0.56-1.01) .062 1.13 (0.85-1.50) .391
ACE-R, total score 0.98 (0.93-1.03) .548 1.03 (0.99-1.07) .139
Attention/orientation 1.13 (0.86-1.49) .363 1.17 (0.96-1.41) .102
Memory 0.89 (0.73-1.08) .250 1.09 (0.93-1.28) .261
Fluency 0.84 (0.65-1.10) .217 1.13 (0.92-1.39) .237
Language 0.96 (0.84-1.09) .549 1.03 (0.92-1.16) .553
Visuospatial 1.03 (0.84-1.25) .767 1.29 (1.00-1.65) .044
a
GDS 1.51 (1.06-2.15) .022
a 0.95 (0.73-1.22) .692
Abbreviations: ACE-R, Addenbrooke’s Cognitive Examination-Revised; AD, Alzheimer disease; CI, confi dence interval; FAB, Frontal Assessment Battery; GDS, Geriatric Depression Scale; MCI, mild
cognitive impairment; OR, odds ratio.
a Italicized P values highlight signifi cant fi ndings.
Table 2. Univariate Predictors of Falls in Participants With MCI and AD: Sociodemographic/Health, Physical Activity, and Functional
Measures
Measures
MCI Group (n  38) AD Group (n  37)
OR (95% CI) P Value OR (95% CI) P Value
Sociodemographic/health variables
Body mass index 0.91 (0.76-1.08) .283 1.01 (0.90-1.14) .784
Medication use 0.99 (0.81-1.20) .930 1.24 (0.88-1.76) .215
Psychotropic drug use 1.04 (0.25-4.23) .951 5.69 (0.85-37.9) .072
Use of bi-/multifocal glasses 0.75 (0.19-2.92) .689 0.35 (0.08-1.40) .140
Use of walking aids 4.64 (0.45-47.15) .194 0.22 (0.02-2.58) .231
Minnesota Questionnaire 1.00 (1.00-1.00) .516 1.00 (0.99-1.00) .674
Pfeffer 1.55 (1.04-2.30) .029
a 1.02 (0.95-1.10) .440
Functional mobility
10-m walk test 1.53 (1.01-2.34) .045
a 0.72 (0.55-0.95) .024
a
Timed Up and Go test 1.30 (0.97-1.74) .071 0.83 (0.70-1.00) .054
Motor-cognitive task 1.03 (0.96-1.11) .329 0.97 (0.92-1.03) .424
Dual-task test
b 1.13 (1.01-1.26) .021
a 0.95 (0.90-1.00) .089
Sit-to-stand phase 1.90 (0.19-18.88) .581 0.41 (0.05-3.28) .408
Turn phase 3.33 (0.97-11.35) .055 0.88 (0.55-1.39) .595
Turn-to-sit phase 1.41 (0.59-3.36) .434 0.30 (0.10-0.83) .021
a
Abbreviations: AD, Alzheimer disease; CI, confi dence interval; MCI, mild cognitive impairment; OR, odds ratio.
a Italicized P values highlight signifi cant fi ndings.
b TUG associated with the motor-cognitive task, adjusted for age.
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Journal of GERIATRIC Physical Therapy 5
Research Report
older people, the addition of a secondary task during gait
provided no added benefi t in discriminating fallers from
nonfallers with cognitive impairment. Both simple and
dual-task measures were associated with falls. However,
they did not specify the type of dementia or the degree of
cognitive impairment, which infl uence dual-task perfor-
mance
2
,
26 and risk of falls.
23 Our fi ndings suggest that dual
task is a promising predictor of falls in older people with
MCI, but not in older people with mild AD.
The association between the turn-to-sit TUG phase and
falls in older people with mild AD is consistent with the
fi ndings of Zakaria et al,
28 who verifi ed that analysis of
TUG phases is an improved method for evaluating fall risk
in older people. According to Mancini et al,
29 the quality
of turning (duration, peak speed, and number of steps) dur-
ing daily activities was associated with falls, balance, and
specifi c cognitive domains (ie, visuospatial and memory) in
older people without dementia.
Ryan et al
30 found that turning and walking perfor-
mances were different between participants with and with-
out a history of falls in community-dwelling older people
with mild AD. Age-related mobility defi cits can be offset by
cognitive strategies, but people with altered cognitive func-
tion present limited access to neural plasticity.
31 Altered
frontal cognitive function, mainly executive function, such
as in people with mild AD, may reduce the allocation of
attention resources, which compromises postural stability
and increases the risk of falls.
32 As transition and turning
TUG subtasks may require a high level of executive func-
tion, attention, perception, and orientation in space,
14 the
turn-to-sit TUG phase can be complex and challenging for
older adults with mild AD. Therefore, this task seems to be
a good predictor of falls in this population. It is important
to highlight that fallers with mild AD spent less time to per-
form the turn-to-sit phase than nonfallers. Fallers with mild
to moderate AD present a higher grade of periventricular
white matter lesions than nonfallers and possibly altera-
tions in cognition and mobility.
8 Also, older people with
mild AD present a high prevalence of falls but less fear of
falling than people with preserved cognition.
21 Therefore, a
lack of perception of their own abilities and consciousness
of their alterations may have infl uenced the mobility per-
formance of fallers with AD; however, further exploration
is needed to confi rm this assumption.
The functional status, 10-m walk test, and GDS score
in older people with MCI and the 10-m walk test and
visuospatial domain in older people with mild AD were
associated with falls in the univariate analyses. Although
these variables were not signifi cant in the fi nal multiple
model, they merit attention when considering strategies
for fall prevention in older adults with MCI and mild AD.
The fi ndings identifi ed by the univariate regression models
emphasize the importance of working with an interdisci-
plinary team.
We highlighted the 10-m walk test because of its asso-
ciation with falls in both groups. These fi ndings are in
accordance with Taylor et al,
27 who studied older people
with cognitive impairment, including MCI and AD. In
addition, Makizako et al
22 found that fallers and nonfallers
with MCI present differences in the walk test performance,
which could be related to poor balance.
22 The relationship
between gait impairment and falls seems to be mediated
primarily by sensorimotor function (such as vision, simple
reaction time, proprioception, knee extension strength, and
postural sway) and to a lesser extent by neuropsychological
mediators in cognitively impaired older adults.
33
The main study limitation is the small sample size and
the nonrandom sampling, which makes generalization of
our fi ndings diffi cult. On the other hand, we restricted
the study population, as other studies found different risk
factors for falls in other cognitive profi les and stages of
AD.
6
,
7
,
8 We conducted a prospective study with rigorous
falls follow-up procedures and emphasized potentially
modifi able risk factors to help prevention strategies. Future
research involving different MCI types and prospective
designs is needed for early detection of fall risk in indi-
viduals with MCI and mild AD and to prevent injuries and
moderate costs of care. In addition, to prevent falls, it is
important to assess the effi cacy of interventions targeting
dual task in cases of MCI and transition postural activities
in cases of mild AD.
CONCLUSIONS
Functional status, the 10-m walk test, dual-task test, and
GDS score were associated with falls in the MCI group.
In the AD group, falls were associated with the 10-m walk
test, turn-to-sit TUG phase, and visuospatial domain. The
dual-task test and turn-to-sit TUG phase were identifi ed
as independent predictors of falls among older people
with MCI and mild AD, respectively. As these factors are
potentially modifi able, exercises concerned with dual-task
and transitional postural activities should be considered in
interventions for preventing falls in people with MCI and
mild AD.
REFERENCES
1. Tinetti ME , Doucette J , Claus E , Marottoli R . Risk factors for serious
injury during falls by older persons in the community . J Am Geriatr Soc .
1995 ; 43 ( 11 ): 1214-1221 .
2. Montero-Odasso M , Muir SW , Speechley M . Dual-task complexity affects
gait in people with mild cognitive impairment: the interplay between
gait variability, dual tasking, and risk of falls . Arch Phys Med Rehabil .
2012 ; 93 ( 2 ): 293-299 .
3. Kovács E , Sztruhár Jónásné I , Karóczi CK , Korpos A , Gondos T . Effects of a
multimodal exercise program on balance, functional mobility and fall risk in
older adults with cognitive impairment: a randomized controlled single-blind
study . Eur J Phys Rehabil Med . 2013 ; 49 ( 5 ): 639-648 .
4. Shaw FE , Bond J , Richardson DA , et al. Multifactorial intervention after a
fall in older people with cognitive impairment and dementia presenting to
the accident and emergency department: randomised controlled trial . BMJ .
2003 ; 326 ( 7380 ): 73 .
5. Taylor ME , Delbaere K , Lord SR , Mikolaizak AS , Brodaty H , Close JC .
Neuropsychological, physical, and functional mobility measures associated
with falls in cognitively impaired older adults . J Gerontol A Biol Sci Med Sci .
2014 ; 69 ( 8 ): 987-995 .
6. Salvà A , Roqué M , Rojano X , et al. Falls and risk factors for falls in
community-dwelling adults with dementia (NutriAlz trial) . Alzheimer Dis
Assoc Disord . 2012 ; 26 ( 1 ): 74-80 .
JGPT-D-17-00009_LR 5JGPT-D-17-00009_LR 5 30/03/17 9:45 AM30/03/17 9:45 AM

Copyright © 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Research Report
6Volume 00 • Number 00 • 000 2017
7. Allan LM , Ballard CG , Rowan EN , Kenny RA . Incidence and prediction
of falls in dementia: a prospective study in older people . PLoS One .
2009 ; 4 ( 5 ): e5521 .
8. Horikawa E , Matsui T , Arai H , Seki T , Iwasaki K , Sasaki H . Risk of falls in
Alzheimer’s disease: a prospective study . Intern Med . 2005 ; 44 ( 7 ): 717-721 .
9. Coelho FG , Stella F ,
de Andrade LP , et al. Gait and risk of falls associated
with frontal cognitive functions at different stages of Alzheimer’s disease .
Neuropsychol Dev Cogn B Aging Neuropsychol Cogn . 2012 ; 19 ( 5 ): 644-656 .
10. Ansai JH , Andrade LP , Rossi PG , Takahashi ACM , Vale FAC , Rebelatto JR . Gait,
dual task and history of falls in elderly with preserved cognition, mild cognitive
impairment and mild Alzheimer’s disease . Braz J Phys Ther . In press.
11. Lustosa LP , Pereira DS , Dias RC , Britto RR , Parentoni AN , Pereira LSM . Translation
and cultural adaptation of the Minnesota Leisure Time Activities Questionnaire in
community-dwelling older people . Geriatr Gerontol . 2011 ; 5 (
2 ): 57-65 .
12. Assis LO , de Paula JJ , Assis MG , de Moraes EN , Malloy-Diniz LF .
Psychometric properties of the Brazilian version of Pfeffer’s Functional
Activities Questionnaire . Front Aging Neurosci . 2014 ; 6 : 255 .
13. Novaes RD , Miranda AS , Dourado VZ . Usual gait speed assessment in middle-
aged and elderly Brazilian subjects . Braz J Phys Ther . 2011 ; 15 ( 2 ): 117-122 .
14. Donoghue OA , Horgan F , Savva GM , Cronin H
, O’Regan C , Kenny RA .
Association between Timed Up and Go and memory, executive function,
and processing speed . J Am Geriatr Soc . 2012 ; 60 ( 9 ): 1681-1686 .
15. Herman T , Giladi N , Hausdorff JM . Properties of the “Timed Up and Go”
test: more than meets the eye . Gerontology . 2011 ; 57 ( 3 ): 203-210 .
16. Salarian A , Horak FB , Zampieri C , Carlson-Kuhta P , Nutt JG , Aminian K .
iTUG, a sensitive and reliable measure of mobility . IEEE Trans Neural Syst
Rehabil Eng . 2010 ; 18 (
3 ): 303-310 .
17. Mioshi E , Dawson K , Mitchell J , Arnold R , Hodges JR . The Addenbrooke’s
Cognitive Examination revised (ACE-R): a brief cognitive test battery for
dementia screening . Int J Geriatr Psychiatry . 2006 ; 21 ( 11 ): 1078-1085 .
18. Beato RG , Nitrini R , Formigoni AP , Caramelli P . Brazilian version of the
Frontal Assessment Battery (FAB): preliminary data on administration to
healthy elderly . Dement Neuropsychol . 2007 ; 1 ( 1 ): 59-65 .
19. Castelo MS , Coelho-Filho JM , Carvalho AF
, et al. Validity of the Brazilian
version of the Geriatric Depression Scale (GDS) among primary care
patients . Int Psychogeriatr . 2010 ; 22 ( 1 ): 109-113 .
20. Kellogg International Work Group on the Prevention of Falls by the Elderly .
The prevention of falls in later life . Dan Med Bull . 1987 ; 34 ( 4 ): 1-24 .
21. Borges SM , Radanovic M , Forlenza OV . Fear of falling and falls in older adults
with mild cognitive impairment and Alzheimer’s disease . Neuropsychol Dev
Cogn B Aging Neuropsychol Cogn . 2015 ; 22 ( 3 ): 312-321 .
22. Makizako H , Shimada H , Doi T , et al. Poor balance and lower gray matter
volume predict falls in older adults with mild cognitive impairment . BMC
Neurol . 2013 ; 13 : 102 .
23. Buchner DM , Larson EB . Falls and fractures in patients with Alzheimer type
dementia . JAMA . 1987 ; 257 ( 11 ): 1492-1495 .
24. Muhaidat J , Kerr A , Evans JJ , Pilling M , Skelton DA . Validity of simple gait-
related dual-task tests in predicting falls in community-dwelling older adults .
Arch Phys Med Rehabil . 2014 ; 95 ( 1 ): 58-64 .
25. Muir-Hunter SW , Wittwer JE . Dual-task testing to predict falls in community-
dwelling older adults: a systematic review . Physiotherapy . 2016 ; 102 ( 1 ):
29-40 .
26.
Boripuntakul S , Lord SR , Brodie MAD , et al. Spatial variability during gait
initiation while dual tasking is increased in individuals with mild cognitive
impairment . J Nutr Health Aging . 2014 ; 18 ( 3 ): 307-312 .
27. Taylor ME , Delbaere K , Mikolaizak S , Lord SR , Close JC . Gait parameter
risk factors for falls under simple and dual task conditions in cognitively
impaired older people . Gait Posture . 2013 ; 37 ( 1 ): 126-130 .
28. Zakaria NA , Kuwae Y , Tamura T , Minato K , Kanaya S . Quantitative analysis
of fall risk using TUG test . Comput Methods Biomech Biomed Engin .
2015 ; 18 ( 4 ): 426-437 .
29. Mancini M , Schlueter H , El-Gohary M , et al. Continuous monitoring of
turning mobility and its association to falls and cognitive function: a pilot
study . J Gerontol A Biol Sci Med Sci . 2016 ; 71 ( 8 ): 1102-1108 .
30. Ryan JJ , McCloy C , Rundquist P , Srinivasan V , Laird R . Fall risk assessment
among older adults with mild Alzheimer disease . J Geriatr Phys Ther .
2011 ; 34 ( 1 ): 19-27 .
31. Beurkens R , Bock
O . Age-related defi cits of dual-task walking: a review .
Neural Plast . 2012 ; 2012 : 131608 .
32. Montero-Odasso M , Verghese J , Beauchet O , Hausdorff JM . Gait and
cognition: a complementary approach to understanding brain function and
the risk of falling . J Am Geriatr Soc . 2012 ; 60 ( 11 ): 2127-2136 .
33. Taylor ME , Ketels MM , Delbaere K , Lord SR , Mikolaizak AS , Close JC . Gait
impairment and falls in cognitively impaired older adults: an explanatory
model of sensorimotor and neuropsychological mediators . Age Ageing .
2012 ; 41 : 665-669 .
[AQ01]
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AUTHOR QUERY
TITLE: Risk Factors for Falls in Older Adults With Mild Cognitive Impairment and Mild Alzheimer Disease
AUTHORS: Juliana Hotta Ansai , Larissa Pires de Andrade , Fernando Arturo Arriagada Masse , Jessica Gonçalves , Anielle
Cristhine de Medeiros Takahashi , Francisco Assis Carvalho Vale , and José Rubens Rebelatto
[AQ01]: Please update Ref 10 with the volume, year, and page range.
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