Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial.
Shaw FE, et al.;
Commented by , 30 Jan 2003
Aim of the Study
This RCT conducted in two Accident and Emergency (A&E) Departments in Newcastle-Upon-Tyne, UK, sought to determine the effectiveness of multifactorial intervention after a fall in older patients with cognitive impairment and dementia.
Method
Patients aged 65+ with MMSE scores <24 presenting to A&E after a fall were randomised to two groups: one group received multifactorial assessment and intervention, the other (control) group received the assessment followed by conventional care. Subjects were recruited from two inner city A&E departments over one year.
The multifactorial assessment comprised medical, physiotherapy, occupational therapy, and cardiovascular assessment.
Data on falls, injuries, A&E attendance, hospital admission, and mortality was collected prospectively for one year.
Outcome Measures
The primary outcome measure was number of participants who fell at least once in the year after intervention. Secondary outcome measures were number of falls (as recorded by a weekly diary), time to first fall, injury rates, fall-related attendance.
Results
308 patients were recruited of whom 24 died and 10 withdrew shortly after recruitment; data was collected on 274 patients. A high proportion of these were from residential and nursing homes.
The main finding was that the intervention group had 652 falls, the control group 728 falls during the one year follow up. There were no significant differences in baseline characteristics, risk factors for falls, or any study outcomes between intervention and control groups. Around 10 % fewer patients in the intervention group fell, though this did not reach statistical significance.
Discussion
This was the first RCT to evaluate an intervention in this patient group. Previous research suggests a 30 % reduction in falls in cognitively intact people who receive this sort of multifactorial intervention.
The authors conclude that limited resources may be used most effectively if targeted towards cognitively normal people who fall. However, given the scale of the public health problem of people with dementia who fall, they advocate further research effort to determine optimal delivery of interventions to demented/cognitively impaired patients who fall, and the most important modifiable risk factors.
In this study, which was by a multidisciplinary research group, no attempt was made to refine the diagnosis to type of dementia (eg., Alzheimer’s, Lewi Body Dementia). Further research in this area, therefore, should incorporate accurate clinical diagnosis and treatment of the dementia, to see if this influenced outcome in terms of falls.
This study found, therefore, that a traditional approach to rehabilitation in people with dementia who fell, did not work. This should not encourage therapeutic nihilism, however, as alternative approaches to rehabilitation, incorporating management of the dementia, have not been studied and may work.