Shortcomings Of This Study
The authors recognise that there are shortcomings of this study.
It may be argued that subjects should have been assessed a certain time after taking their antiparkinsonian medication. This could not happen, largely for logistical reasons such as patient transportation and the need for patients to be assessed by a variety of professionals.
No controls were used. This was because the study was designed to be descriptive and to compare the differences between fallers and non-fallers with PD, rather than the healthy elderly population.
Despite the methods used for prospective assessment, some falls are still likely to have been missed. The high incidence of falls quoted is likely to be an underestimate of the number of falls that occurred. Perhaps only highly sophisticated long term mechanical monitoring methods would be able to give the true incidence, but these would be impractical.
The confidence intervals in the logistic regression model are wide probably due to the small numbers of subjects. All patients who were available to the authors were recruited, however, so this was unavoidable. Multicentre studies or perhaps meta-analysis would perhaps fully address these issues.
It should also be noted that 32 potential subjects did not participate. These patients were older with more severe disease of longer duration. If they had been included, the incidence of falls may have been even higher.
Are Multiple Tests More Clinically Useful Than An Individual Test
Once we felt confident that the clinical balance tests were valid, the next diagnostic decision analyzed was the relative benefit of individual test interpretation versus collective interpretation of multiple tests. This analysis was done with a priority placed on ruling out a diagnosis of fall risk . The results of the present study indicated that the collective interpretation of multiple clinical balance tests reduced the false-negative rate to a greater degree than did the interpretation of any individual test alone. To our knowledge, although this type of analysis was previously suggested,,, such a study had not been previously reported.
Despite the improved sensitivity of collective interpretation, the results of the present study in isolation are of limited clinical utility. As stated in the Method section, sensitivity and specificity alone are limited in their diagnostic abilities because they require a clinician to know the fall diagnosis . The more clinically useful tools derived from our data are the LRs.
To emphasize the clinical utility of our calculated LRs, a clinical case example is provided. Clinical case 1 illustrates the utility of the negative LR in answering the following question: How much more likely is a negative result on multiple clinical balance tests to be found in a person who has PD but no fall history than in a person who has PD and a fall history?
Figure 1.
Dealing With Overlap Of Primary Studies
Overlap of primary studies within included systematic reviews is a challenge exclusive to umbrella reviews. Currently, there is a lack of guidance on how best to manage this occurrence . To maximise comprehensiveness of this umbrella review, we employed a full inclusion scenario where all Cochrane reviews and non-Cochrane reviews were included . A list of the primary studies included in each systematic review was assembled and a matrix of evidence table was created to determine the amount of overlap between systematic reviews. To avoid double-counting outcome data the following were decided:
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Any systematic review that contained a relevant primary study that was not in any other systematic review was included so that data were not lost.
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Any systematic review that did not contain any unique primary study was excluded to minimise duplication of data.
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In the presence of complete overlap between reviews, the highest quality review, as determined by the A MeaSurement Tool to Assess Systematic Reviews 2 was included in data synthesis and analysis.
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In cases where there was a complete overlap between reviews and they received the same AMSTAR 2 rating, then the most recently published review was included.
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In the presence of partial overlap, all reviews were included but the degree of overlap was noted and its implications on the findings of this umbrella review were discussed.
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Prospective Assessment Of Falls
A fall was defined as an unexpected event where the person inadvertently came to rest on the ground or other lower level not due to a major intrinsic or extrinsic event.
Following baseline screening, each subject was given a set of weekly prepaid postcards to return for one year. On each card subjects had to write a single number documenting the number of occasions that they had fallen in the previous week. Subjects were encouraged to include anything that might constitute a fall, including slips, trips, and stumbles. Assistance from carers in this respect was obtained where necessary.
A positive number recorded on a card was followed up by telephone to outline the exact circumstances of the fall event and to ensure that this event met the definition of the fall outlined above. If cards were not returned one week after expected, this would also prompt telephone contact to inquire about the number of falls in the week in question.
It’s Not All Dopamine: Possible Mechanisms And Interventions For Falls In Pd
In this 1-hour talk Rober Albin, movement disorder specialist and researcher, describes the impact of dopamine and acetylcholine in Parkinson’s through some animal and human trials. Research has found a nicotine-like drug is very safe, well tolerated and seems to improve attention in those with PD.
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Potential Underlying Pathophysiological Mechanisms
Although falls are one of the key features of advanced PD, and dopaminergic medications can improve balance impairment in PD, postural instability in PD is comparatively less responsive to levodopa therapy than limb akinesia or tremor to levodopa therapy, and it is likely that other pathophysiological mechanisms are involved in gait disturbance in these patients., It has been postulated that noradrenergic deficits such as in the locus coeruleus and cholinergic pathways like the pedunculopontine have an important role. In support of the noradrenergic hypothesis, a large randomized controlled study using methylphenidate in advanced PD patients, improvements were observed for gait bradykinesia and freezing of gait. In animal models, in rats, dual cholinergic-dopaminergic lesions were found to result in falls more frequently than those with either cholinergic or dopaminergic lesions.
The findings of this study confirm from a clinical point of view that falls are associated with nonmotor features related to non-dopaminergic dysfunction, i.e., autonomic dysfunction, psychosis, sleep disorders, and cognitive impairment. All of these are thought to arise at least in part from deficits in the noradrenergic and cholinergic pathways with complex interaction of several neurotransmitter systems.,
Problems With Blood Pressure
Problems with blood pressure can affect people generally as they get older, but some Parkinsons medication can cause side effects, including problems with blood pressure. This can lead to dizziness and falls. If youve felt dizzy, or fallen because of dizziness, ask your GP or practice nurse to check your blood pressure both when youre sitting and standing, to see if its too low.
Drugs used to treat other medical conditions, such as high blood pressure, can potentially make dizziness worse, especially if you are losing weight or not eating and drinking as well as you used to.
Postural hypotension is a sudden drop in blood pressure when changing position, for example getting up out of a chair. It can make you feel very light-headed, which will affect your balance. You may experience postural hypotension as a symptom of Parkinsons. But it can also be caused by the drugs used to treat Parkinsons.
You can avoid some dizzy spells by taking your time. For example, before you get out of bed, sit with your feet touching the floor for a few minutes to get your blood flowing. Then stand up slowly, but try not to walk away immediately stand for a while until you feel steady.
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Validity Of Collective Interpretation Of Multiple Clinical Balance Tests
The combination of one or more positive tests resulted in the highest levels of sensitivity and negative LR : 0.97 and 0.14 , respectively however, the levels of specificity and positive LR were relatively low. In the context of one or more positive clinical balance tests, such sensitivity and negative LR values indicate very few false-negative results and clinical significance through reduction of the posttest probability of being in the fall group to a larger extent than that realized with any individual test.
The combination of 3 or more positive tests resulted in the highest levels of specificity and positive LR : 0.80 and 2.48 , respectively however, the levels of sensitivity and negative LR were relatively low. In the context of 3 or more positive clinical balance tests, such specificity and positive LR values indicate a moderate number of false-positive results. However, such positive LR values support clinical significance by helping to rule in fall risk through amplification of the pretest probability of being in the fall group.
The combination of 2 or more positive tests resulted in validity indexes between the extremes seen with the other 2 combinations .
Impact Of Falls And Parkinson’s Disease
This 8-minute video alternates between an interview with a man sharing his experience of falling due to Parkinson’s disease, with a doctor, physical therapist and occupational therapist explaining why people with PD fall, the benefit of physical therapy and exercise before a person has ever fallen to prevent falls and what an occupational therapist can do to prevent falling at home and in the broader environment.
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Inclusion And Exclusion Criteria
The inclusion criteria for PD patients will be: a) subjects> 65 years old suffering from Parkinsons at an intermediate stage as defined by Hoeen and Yahr 1.53 b) the ability to understand and provide informed consent c) preserved cognitive skills, tested as defined by a mini mental state examination score of> 24.
The inclusion criteria for healthy controls without gait problems will be: a) subjects> 65 years old b) not suffering from any disease that could alter their gait c) ability to understand and provide informed consent c) preserved cognitive skills, as defined by a MMSE score of> 24.
The following conditions will be the exclusion criteria:
a) hospitalized subjects or nursing home residents b) bedridden subjects c) PD patients undergoing advanced therapy d) subjects with severe choreic dyskinesias e) subjects with a concomitant disease that could increase their risks of falling f) subjects with neurological disorders other than idiopathic PD g) subjects affected by atypical Parkinsonism, psychiatric disorders, or any other condition that, in the researchers opinion, could compromise the eligibility for the present study .
Data Shows Poor Sleep Quality Is Linked To Higher Fall Risk
The importance of each digital measure, that may be used as a digital biomarker, was then evaluated. In the fall-risk outcome based on the TUG dataset, high overall in-bed activity, such as restlessness or poor sleep quality, was related to higher fall risk.
We found indications that fall risk could significantly depend on certain sleep parameters, said Nef.
Based on POMA data, older adults with more movement in the home had a lower fall risk, and older adults who open the refrigerator later in the day may be frailer. In addition, those that tend to spend more time in bed may reflect worse depressive symptoms, and adults with mild cognitive impairment appear to have more variation in nightly heart rate dipping.
We introduce a comprehensive set of digital measures, what may be referred to as a digital exhaust, for long-term remote health-monitoring in the older adult demographic, the researchers wrote. We show how ageing-relevant outcomes such as fall risk, frailty, and may be assessed.
Last, we highlight the possibility of using the digital exhaust to discover novel digital biomarker candidates, the researchers added.
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How Can I Help Myself
It is important that you do not allow a fear of falling to stop you doing things, provided that you are sensible. Keeping active is good for your mobility and independence, and doing the things you like is good for your morale. Try not to let falls curb your activities too much as this can have a negative impact on your quality of life.
The following information and practical suggestions may help you in adapting your daily routine so as to minimise the risk of falls:
Recurrent Falls In Parkinsons Disease: A Systematic Review
Natalie E. Allen
1Clinical and Rehabilitation Sciences Research Group, Faculty of Health Sciences, The University of Sydney, P.O. Box 170, Lidcombe, NSW 1825, Australia
Abstract
Most people with Parkinsons disease fall and many experience recurrent falls. The aim of this review was to examine the scope of recurrent falls and to identify factors associated with recurrent fallers. A database search for journal articles which reported prospectively collected information concerning recurrent falls in people with PD identified 22 studies. In these studies, 60.5% of participants reported at least one fall, with 39% reporting recurrent falls. Recurrent fallers reported an average of 4.7 to 67.6 falls per person per year . Factors associated with recurrent falls include: a positive fall history, increased disease severity and duration, increased motor impairment, treatment with dopamine agonists, increased levodopa dosage, cognitive impairment, fear of falling, freezing of gait, impaired mobility and reduced physical activity. The wide range in the frequency of recurrent falls experienced by people with PD suggests that it would be beneficial to classify recurrent fallers into sub-groups based on fall frequency. Given that there are several factors particularly associated with recurrent falls, fall management and prevention strategies specifically targeting recurrent fallers require urgent evaluation in order to inform clinical practice.
1. Introduction
2. Method
3. Results
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Reducing The Risk Of Falls
It is important that you take all your Parkinsons medications as prescribed so that symptoms such as poor gait and freezing are well controlled.
Some Parkinsons medications may, unintentionally, lower blood pressure and this can cause dizziness and increase the risk of falling. If this happens you should ask your doctor or nurse to check your blood pressure both when standing and sitting. Your doctor may be able to advise on medication to help with low blood pressure and dizziness, although this can be complicated because of possible interference with Parkinsons medications.
Some dizziness can be avoided. For example, when getting out of bed let your feet dangle over the side of the bed for a few minutes before standing and then rise slowly. When getting up from a chair, pause for a few moments and only start walking when you feel steady.
Some Parkinsons medications can actually aggravate falls by causing dyskinesias Again, it is important to tell your doctor if you fall so that medication can be adjusted if necessary.
Caution!
You are more likely to fracture a bone if you fall frequently, particularly if you have osteoporosis. If you fall frequently, ask your doctor for an osteoporosis assessment. If osteoporosis is diagnosed, he or she will be able to give you s advice on minimising its effects or refer you to another professional who can help.
Factors Associated With Falling In Pd
Unsurprisingly a history of prior falls was associated with a higher risk of future falls. These results are similar to those found by Bloem et al and are mirrored in a study looking at falls in the general population. Patients with PD who describe prior falls should be thought of as being at risk of future falls.
The association between duration and severity of disease and falling is also important. In this study the risk of falling increased with greater disease severity, but it is important to note that only one subject was in stage IV and none were in stage V. It has been postulated that at more advanced stages the risk of falling may decrease owing to limitations on mobility. Dyskinesia, bradykinesia, and wearing off phenomena may be particularly important for falls risk.
Cognitive impairment was an independent predictor of falling. This is very important because dementia is a common problem in PD and has been minimally studied. Falls prevention in patients with dementia is difficult but recent work suggests that tailored interventions are of benefit in dementia sufferers and this may be extrapolated to dementia in PD. Further studies should address this area.
The association between falls and depression and quality of life is an important finding but many potential confounding variables may affect the scales used. Common sense would dictate that falls are going to impinge upon both mood and quality of life.
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Limitations And Directions For Future Research
Although our findings appear to have clinical relevance, they should be interpreted cautiously. From a research design standpoint, our sample was relatively small and was derived from only one outpatient facility. For this reason, people with mild PD and people with severe PD were not represented in large numbers. In addition, although the research plan and data gathering were prospective, we relied on each participant’s self-reported fall history as the diagnostic gold standard for fall risk. A similar method should be applied to a sample of people with PD, with prospective observation of fall history as the diagnostic gold standard. Finally, we used the cutoff scores most commonly referenced in the literature, as opposed to altering the cutoff scores, as has been suggested in other research., The rationales for the recalculation of cutoff scores and the collective interpretation of multiple tests are similar, that is, minimizing false-negative results. In the present study, we chose to constrain our analysis and examine only the effect of collective interpretation. Future research should compare these methods directly.