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

140 Copyright © SLACK Incorporated

Lach, Harrison, & Phongphanngam

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

141Research in Gerontological Nursing • Vol. 10, No. 3, 2017

Falls and Fall Prevention

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.

142 Copyright © SLACK Incorporated

Lach, Harrison, & Phongphanngam

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

143Research in Gerontological Nursing • Vol. 10, No. 3, 2017

Falls and Fall Prevention

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

144 Copyright © SLACK Incorporated

Lach, Harrison, & Phongphanngam

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.

145Research in Gerontological Nursing • Vol. 10, No. 3, 2017

Falls and Fall Prevention

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.

146 Copyright © SLACK Incorporated

Lach, Harrison, & Phongphanngam

REFERENCESAlbert, M.S., DeKosky, S.T., Dickson, D., Dubois, B., Feldman,

H.H., Fox, N.C.,…Phelps, C.H. (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recom-mendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 270-279. doi:10.1016/j.jalz.2011.03.008

Allan, L.M., Ballard, C.G., Rowan, E.N., & Kenny, R.A. (2009). Incidence and prediction of falls in dementia: A prospective study in older people. PloS One, 4, e5521. doi:10.1371/journal.pone.0005521

Alzheimer’s Association. (2016). Diagnosis of Alzheimer’s disease and dementia. Retrieved from http://www.alz.org/alzheimers_disease_diagnosis.asp

Beauchet, O., Allali, G., Berrut, G., Hommet, C., Dubost, V., & Assal, F. (2008). Gait analysis in demented subjects: Interests and per-spectives. Neuropsychiatric Disease and Treatment, 4, 155-160.

Booth, V., Logan, P., Harwood, R., & Hood, V. (2015). Falls preven-tion interventions in older adults with cognitive impairment: A systematic review of reviews. International Journal of Therapy & Rehabilitation, 22, 289-296. doi:10.12968/ijtr.2015.22.6.289

Borges Sde, M., Radanovic, M., & Forlenza, O.V. (2015). Fear of falling and falls in older adults with mild cognitive impairment and Alzheimer’s disease. Aging Neuropsychology & Cognition, 22, 312-321. doi:10.1080/13825585.2014.933770

Boripuntakul, S., Lord, S.R., Brodie, M.A.D., Smith, S.T., Methapatara, P., Wongpakaran, N., & Sungkarat, S. (2014). Spatial vari-ability during gait initiation while dual tasking is increased in individuals with mild cognitive impairment. Journal of Nutrition, Health and Aging, 18, 307-312. doi:10.1007/s12603-013-0390-3

Bruce-Keller, A.J., Brouillette, R.M., Tudor-Locke, C., Foil, H.C., Gahan, W.P., Nye, D.M.,…Keller, J.N. (2012). Relationship between cognitive domains, physical performance, and gait in elderly and demented subjects. Journal of Alzheimer’s Disease, 30, 899-908. doi:10.3233/JAD-2012-120025

Buracchio, T., Dodge, H.H., Howieson, D., Wasserman, D., & Kaye, J. (2010). The trajectory of gait speed preceding mild cognitive impairment. Archives of Neurology, 67, 980-986. doi:10.1001/archneurol.2010.159

Burton, E., Cavalheri, V., Adams, R., Browne, C.O., Bovery-Spencer, P., Fenton, A.M.,…Hill, K.D. (2015). Effectiveness of exercise programs to reduce falls in older people with dementia living in the community: A systematic review and meta-analysis. Clinical Interventions in Aging, 10, 421-434. doi:10.2147/cia.s71691

Camicioli, R., Bouchard, T., & Licis, L. (2006). Dual-tasks and walking fast: Relationship to extra-pyramidal signs in advanced Alzheimer disease. Journal of the Neurological Sciences, 248, 205-209.

Camicioli, R., Howieson, D., Lehman, S., & Kaye, J. (1997). Talking while walking: The effect of a dual task in aging and Alzheimer’s disease. Neurology, 48, 955-958.

Cedervall, Y., Halvorsen, K., & Aberg, A.C. (2014). A longitudinal study of gait function and characteristics of gait disturbance in individuals with Alzheimer’s disease. Gait and Posture, 39, 1022-1027. doi:10.1016/j.gaitpost.2013.12.026

Centers for Disease Control and Prevention. (2016). Older adult falls. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/falls

Cigolle, C.T., Ha, J., Min, L.C., Lee, P.G., Gure, T.R., Alexander, N.B., & Blaum, C.S. (2015). The epidemiologic data on falls, 1998-2010:

More older Americans report falling. JAMA Internal Medicine, 175, 443-445. doi:10.1001/jamainternmed.2014.7533

Coelho, F.G., Stella, F., de Andrade, L.P., Barbieri, F.A., Santos-Galdurz, R.F., Gobbi, S.,…Gobbi, L.T. (2012). Gait and risk of falls associated with frontal cognitive functions at different stages of Alzheimer’s disease. Aging Neuropsychology & Cognition, 19, 644-656. doi:10.1080/13825585.2012.661398

Davis, J.C., Best, J., Hsu, C.L., Nagamatsu, L.S., Dao, E., & Liu-Ambrose, T. (2015). Examining the effect of the relationship between falls and mild cognitive impairment on mobility and executive functions in community-dwelling older adults. Journal of the American Geriatrics Society, 63, 590-593. doi:10.1111/jgs.13290

Delbaere, K., Close, J.C., Taylor, M., Wesson, J., & Lord, S.R. (2013). Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. Journals of Gerontology. Series A, Bio-logical Sciences & Medical Sciences, 68, 1098-1102. doi:10.1093/gerona/glt007

Delbaere, K., Kochan, N.A., Close, J.C., Menant, J.C., Sturnieks, D.L., Brodaty, H.,…Lord, S.R. (2012). Mild cognitive impairment as a predictor of falls in community-dwelling older people. American Journal of Geriatric Psychiatry, 20, 845-853. doi:10.1097/JGP.0b013e31824afbc4

Doi, T., Shimada, H., Park, H., Makizako, H., Tsutsumimoto, K., Uemura, K.,…Suzuki, T. (2015). Cognitive function and falling among older adults with mild cognitive impairment and slow gait. Geriatrics & Gerontology International, 15, 1073-1078. doi:10.1111/ggi.12407

Eggermont, L.H., Gavett, B.E., Volkers, K.M., Blankevoort, C.G., Scherder, E.J., Jefferson, A.L.,…Stern, R.A. (2010). Lower-extremity function in cognitively healthy aging, mild cognitive impairment, and Alzheimer’s disease. Archives of Physical Medicine and Rehabilitation, 91, 584-588. doi:10.1016/j.apmr.2009.11.020

Epstein, N.U., Guo, R., Farlow, M.R., Singh, J.P., & Fisher, M. (2014). Medication for Alzheimer’s disease and associated fall hazard: A retrospective cohort study from the Alzheimer’s Disease Neuro-imaging Initiative. Drugs and Aging, 31, 125-129. doi:10.1007/s40266-013-0143-3

Fischer, B.L., Gleason, C.E., Gangnon, R.E., Janczewski, J., Shea, T., & Mahoney, J.E. (2014). Declining cognition and falls: Role of risky performance of everyday mobility activities. Physical Therapy, 94, 355-362. doi:10.2522/ptj.20130195

Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.

Gleason, C.E., Gangnon, R.E., Fischer, B.L., & Mahoney, J.E. (2009). Increased risk for falling associated with subtle cogni-tive impairment: Secondary analysis of a randomized clinical trial. Dementia and Geriatric Cognitive Disorders, 27, 557-563. doi:10.1159/000228257

Guo, J.-L., Tsai, Y.-Y., Liao, J.-Y., Tu, H.-M., & Huang, C.-M. (2014). Interventions to reduce the number of falls among older adults with/without cognitive impairment: An exploratory meta-analysis. International Journal of Geriatric Psychiatry, 29, 661-669. doi:10.1002/gps.4056

Hagovská, M., & Olekszyová, Z. (2015). Impact of the combination of cognitive and balance training on gait, fear and risk of falling and quality of life in seniors with mild cognitive impairment. Geri-atrics & Gerontology International. Advance online publication. doi:10.1111/ggi.12593

Härlein, J., Dassen, T., Halfens, R.J., & Heinze, C. (2009). Fall risk

147Research in Gerontological Nursing • Vol. 10, No. 3, 2017

Falls and Fall Prevention

factors in older people with dementia or cognitive impairment: A systematic review. Journal of Advanced Nursing, 65, 922-933. doi:10.1111/j.1365-2648.2008.04950.x

Hauer, K., Becker, C., Lindemann, U., & Beyer, N. (2006). Effective-ness of physical training on motor performance and fall preven-tion in cognitively impaired older persons: A systematic review. American Journal of Physical Medicine and Rehabilitation, 85, 847-857.

Hughes, C.P., Berg, L., Danziger, W.L., Coben, L.A., & Martin, R.L. (1982). A new clinical scale for the staging of dementia. British Journal of Psychiatry, 140, 566-572.

Katzman, R., Brown, T., Fuld, P., Peck, A., Schechter, R., & Schimmel, H. (1983). Validation of a short orientation-memory-concentration test of cognitive impairment. American Journal of Psychiatry, 140, 734-739.

Kovács, E., Sztruhár Jónásné, I., Karóczi, C.K., Korpos, A., & Gondos, T. (2013). 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. Euro-pean Journal of Physical and Rehabilitation Medicine, 49, 639-648.

Lach, H.W. (2005). Incidence and risk factors for developing fear of falling in older adults. Public Health Nursing, 22, 45-52.

Lamb, S.E., Jørstad-Stein, E.C., Hauer, K., & Becker, C. (2005). Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe Consensus. Journal of the American Geriatrics Society, 53, 1618-1622. doi:10.1111/j.1532-5415.2005.53455.x

Liu-Ambrose, T.Y., Ashe, M.C., Graf, P., Beattie, B.L., & Khan, K.M. (2008). Increased risk of falling in older community-dwelling women with mild cognitive impairment. Physical Therapy, 88, 1482-1491. doi:10.2522/ptj.20080117

Luck, T., Luppa, M., Briel, S., Matschinger, H., König, H.H., Bleich, S.,…Riedel-Heller, S.G. (2010). Mild cognitive impairment: Incidence and risk factors: Results of the leipzig longitudinal study of the aged. Journal of the American Geriatrics Society, 58, 1903-1910.

Mahoney, J.E., Shea, T.A., Przybelski, R., Jaros, L., Gangnon, R., Cech, S., & Schwalbe, A. (2007). Kenosha County falls preven-tion study: A randomized, controlled trial of an intermediate-intensity, community-based multifactorial falls intervention. Journal of the American Geriatrics Society, 55, 489-498.

Makizako, H., Shimada, H., Doi, T., Park, H., Yoshida, D., Uemura, K.,…Suzuki, T. (2013). Poor balance and lower gray matter volume predict falls in older adults with mild cognitive impair-ment. BMC Neurology, 13, ArtID 102. doi:10.1186/1471-2377-13-102

Meyer, C., Hill, S., Dow, B., Synnot, A., & Hill, K. (2015). Translating falls prevention knowledge to community-dwelling older PLWD: A mixed-method systematic review. The Gerontologist, 55, 560-574. doi:10.1093/geront/gnt127

Mignardot, J.-B., Beauchet, O., Annweiler, C., Cornu, C., & Deschamps, T. (2014). Postural sway, falls, and cognitive status: A cross-sectional study among older adults. Journal of Alzheimer’s Disease, 41, 431-439. doi:10.3233/JAD-132657

Montero-Odasso, M., Muir, S.W., & Speechley, M. (2012). Dual-task complexity affects gait in people with mild cognitive impairment: The interplay between gait variability, dual tasking, and risk of falls. Archives of Physical Medicine and Rehabilitation, 93, 293-299. doi:10.1016/j.apmr.2011.08.026

Montero-Odasso, M., Oteng-Amoako, A., Speechley, M., Gopaul, K., Beauchet, O., Annweiler, C., & Muir-Hunter, S.W. (2014). The motor signature of mild cognitive impairment: Results from the

gait and brain study. Journals of Gerontology. Series A, Biological Sciences & Medical Sciences, 69, 1415-1421. doi:10.1093/gerona/glu155

Morris, J.C. (1993). The Clinical Dementia Rating (CDR): Current version and scoring rules. Neurology, 43, 2412-2414.

Morris, J.C., Rubin, E.H., Morris, E.J., & Mandel, S.A. (1987). Senile dementia of the Alzheimer’s type: An important risk factor for serious falls. Journal of Gerontology, 42, 412-417.

Muir, S.W., Gopaul, K., & Montero Odasso, M.M. (2012). The role of cognitive impairment in fall risk among older adults: A sys-tematic review and meta-analysis. Age and Ageing, 41, 299-308. doi:10.1093/ageing/afs012

Muir, S.W., Speechley, M., Wells, J., Borrie, M., Gopaul, K., & Montero-Odasso, M. (2012). Gait assessment in mild cognitive impairment and Alzheimer’s disease: The effect of dual-task chal-lenges across the cognitive spectrum. Gait and Posture, 35, 96-100. doi:10.1016/j.gaitpost.2011.08.014

Nasreddine, Z.S., Phillips, N.A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I.,…Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53, 695-699.

Panel on Prevention of Falls in Older Persons, American Geriatrics Society, & British Geriatrics Society. (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older per-sons. Journal of the American Geriatrics Society, 59, 148-157. doi:10.1111/j.1532-5415.2010.03234.x

Pedersen, M.M., Holt, N.E., Grande, L., Kurlinski, L.A., Beauchamp, M.K., Kiely, D.K.,…Bean, J.F. (2014). Mild cognitive impairment status and mobility performance: An analysis from the Boston RISE study. Journals of Gerontology. Series A, Biological Sciences & Medical Sciences, 69, 1511-1518. doi:10.1093/gerona/glu063

Petersen, R.C. (2011). Clinical practice. Mild cognitive impairment. New England Journal of Medicine, 364, 2227-2234. doi:10.1056/NEJMcp0910237

Petersen, R.C., Caracciolo, B., Brayne, C., Gauthier, S., Jelic, V., & Fratiglioni, L. (2014). Mild cognitive impairment: A con-cept in evolution. Journal of Internal Medicine, 275, 214-228. doi:10.1111/joim.12190

Ries, J.D., Drake, J.M., & Marino, C. (2010). A small-group functional balance intervention for individuals with Alzheimer disease: A pilot study. Journal of Neurologic Physical Therapy, 34, 3-10. doi:10.1097/NPT.0b013e3181d00f2e

Russell, C.L. (2005). An overview of the integrative research review. Progress in Transplantation, 15, 8-13.

Ryan, J.J., McCloy, C., Rundquist, P., Srinivasan, V., & Laird, R. (2011). Fall risk assessment among older adults with mild Alzheimer dis-ease. Journal of Geriatric Physical Therapy, 34, 19-27. doi:10.1519/JPT.0b013e31820aa829

Schulz, R., Wahl, H.-W., Matthews, J.T., De Vito Dabbs, A., Beach, S.R., & Czaja, S.J. (2015). Advancing the aging and technology agenda in gerontology. The Gerontologist, 55, 724-734. doi:10.1093/geront/gnu071

Shin, B.M., Han, S.J., Jung, J.H., Kim, J.E., & Fregni, F. (2011). Effect of mild cognitive impairment on balance. Journal of the Neurological Sciences, 305, 121-125. doi:10.1016/j.jns.2011.02.031

Stevens, J.A., & Rudd, R.A. (2014). Circumstances and contributing causes of fall deaths among persons aged 65 and older: United States, 2010. Journal of the American Geriatrics Society, 62, 470-475. doi:10.1111/jgs.12702

148 Copyright © SLACK Incorporated

Lach, Harrison, & Phongphanngam

Suttanon, P., Hill, K.D., Said, C.M., & Dodd, K.J. (2013). A longi-tudinal study of change in falls risk and balance and mobility in healthy older people and people with Alzheimer disease. American Journal of Physical Medicine and Rehabilitation, 92, 676-685. doi:10.1097/PHM.0b013e318278dcb3

Suttanon, P., Hill, K.D., Said, C.M., Logiudice, D., Lautenschlager, N.T., & Dodd, K.J. (2012). Balance and mobility dysfunction and falls risk in older people with mild to moderate Alzheimer dis-ease. American Journal of Physical Medicine and Rehabilitation, 91, 12-23. doi:10.1097/PHM.0b013e31823caeea

Suttanon, P., Hill, K.D., Said, C.M., Williams, S.B., Byrne, K.N., Logiudice, D.,…Dodd, K.J. (2013). Feasibility, safety and pre-liminary evidence of the effectiveness of a home-based exercise programme for older people with Alzheimer’s disease: A pilot randomized controlled trial. Clinical Rehabilitation, 27, 427-438. doi:10.1177/0269215512460877

Taylor, M.E., Delbaere, K., Lord, S.R., Mikolaizak, A., & Close, J.C. (2013). Physical impairments in cognitively impaired older people: Implications for risk of falls. International Psychogeriatrics, 25, 148-156. doi:10.1017/S1041610212001184

Taylor, M.E., Delbaere, K., Lord, S.R., Mikolaizak, A.S., Brodaty, H., & Close, J.C.T. (2014). Neuropsychological, physical, and functional mobility measures associated with falls in cognitively impaired older adults. Journals of Gerontology. Series A, Biological Sciences & Medical Sciences, 69, 987-995. doi:10.1093/gerona/glt166

Taylor, M.E., Delbaere, K., Mikolaizak, A.S., Lord, S.R., & Close, J.C. (2013). Gait parameter risk factors for falls under simple and dual task conditions in cognitively impaired older people. Gait and Posture, 37, 126-130. doi:10.1016/j.gaitpost.2012.06.024

Taylor, M.E., Lord, S.R., Delbaere, K., Mikolaizak, A.S., & Close, J.C. (2012). Physiological fall risk factors in cognitively impaired older people: A one-year prospective study. Dementia and Geriatric Cognitive Disorders, 34, 181-189. doi:10.1159/000343077

Tchalla, A.E., Lachal, F., Cardinaud, N., Saulnier, I., Rialle, V., Preux, P.M., & Dantoine, T. (2013). Preventing and managing indoor falls with home-based technologies in mild and mod-erate Alzheimer’s disease patients: Pilot study in a community dwelling. Dementia and Geriatric Cognitive Disorders, 36, 251-261. doi:10.1159/000351863

Uemura, K., Hasegawa, T., Tougou, H., Shuhei, T., & Uchiyama, Y. (2015). Analysis of choice stepping with visual interference can detect prolonged postural preparation in older adults with mild cognitive impairment at high risk of falling. Dementia and Geri-atric Cognitive Disorders, 40, 13-21. doi:10.1159/000375408

Uemura, K., Shimada, H., Makizako, H., Doi, T., Tsutsumimoto, K., Yoshida, D.,…Suzuki, T. (2014). Effects of mild and global cognitive impairment on the prevalence of fear of falling in community-dwelling older adults. Maturitas, 78, 62-66. doi:10.1016/j.maturitas.2014.02.018

Uemura, K., Shimada, H., Makizako, H., Yoshida, D., Doi, T., Tsutsumimoto, K., & Suzuki, T. (2012). A lower prevalence of self-reported fear of falling is associated with memory decline among older adults. Gerontology, 58, 413-418. doi:10.1159/000336988

U.S. Preventive Services Task Force. (2014). Cognitive impairment in older adults: Screening, March 2014. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/cognitive-impairment-in-older-adults-screening

Verghese, J., Robbins, M., Holtzer, R., Zimmerman, M., Wang, C., Xue, X., & Lipton, R.B. (2008). Gait dysfunction in mild cogni-tive impairment syndromes. Journal of the American Geriatrics Society, 56, 1244-1251. doi:10.1111/j.1532-5415.2008.01758.x

Wesson, J., Clemson, L., Brodaty, H., Lord, S., Taylor, M., Gitlin, L., & Close, J. (2013). A feasibility study and pilot randomised trial of a tailored prevention program to reduce falls in older people with mild dementia. BMC Geriatrics, 13, 89. doi:10.1186/1471-2318-13-89

Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52, 546-553. doi:10.1111/j.1365-2648.2005.03621.x

World Health Organization. (2016). Dementia. Retrieved from http://www.who.int/mediacentre/factsheets/fs362/en

Yao, L., Giordani, B.J., Algase, D.L., You, M., & Alexander, N.B. (2013). Fall risk-relevant functional mobility outcomes in dementia following dyadic tai chi exercise. Western Journal of Nursing Research, 35, 281-296. doi:10.1177/0193945912443319

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

)