Risk of Recurrent Falls Evident in Elderly With Gait, Cognitive Problems

Previous falls, hallucinations, and cognitive problems are among the factors that predict a risk of recurrent falls in elderly people with parkinsonian gait, a study suggests.

The study, “Parkinsonian gait in elderly people: Significance of the threshold value of two and more falls per year,” was published in the journal Revue Neurologique.

Difficulties with movement, including walking, are common to Parkinson’s patients, and they have a high incidence of falls. But identifying a person’s risk of falling can be challenging, because this risk is affected by many factors, including those that may not be related to the disease itself.

Researchers at the University Hospitals of Strasbourg, in France, investigated motor and cognitive factors that can be associated to a risk of falling in elderly people with parkinsonian gait, characterized by walking with shuffling or dragging feet, a stooped posture (postural instability), and little arm swinging.

They analyzed the one-year findings from the EVAMARAGEX study (NTC02885493), an observational two-year trial evaluating the risk of falling in people with parkinsonian gait ages 65 and older.

In total, 79 older adults (58% male), an average age of 81.2 and an ability to walk without assistance for at least 10 meters (about 33 feet) were enrolled.

Half were diagnosed Parkinson’s, while the other half had parkinsonian syndrome (14%), vascular parkinsonism (23%), or Lewy body dementia (13%).

Researchers evaluated patients’ motor and non-motor symptoms, and performed follow-up phone interviews every two months, as well as an onsite visit at one year, to identify falls, changes in walking abilities and cognitive skills, traumatic falls, all-cause hospitalizations, or death.

Patients were divided into two groups for comparison: non-recurrent fallers, or those with one or fewer falls each year (33 patients; 42% of total group) and recurrent fallers, or people with at least two falls per year (46 patients, 58%).

With a majority (58%) were classified as recurrent fallers, the researchers noted that yearly falls among these people were “almost twice that of a general population aged over 80 years.”

In the first year of follow-up, a total of 536 falls were recorded. Two patients with freezing of gait — when a person is unable to move their feet forward when trying to walk — accounted for 139 of these falls.

Among the non-recurrent fallers, 8% had one fall each year and 34% had no falls.

Twelve percent of falls were traumatic (causing traumatic injuries like fractures), and 80 hospitalizations were recorded. Non-recurrent fallers accounted for 11 reported hospitalizations and four traumatic falls; seven of 10 patients classified as at the end of life or who died during the study were recurrent fallers, and five of them were Parkinson’s patients.

Significant differences were noted between these patient groups. Recurrent fallers, compared with non-recurrent ones, were older (mean age of 82.34 vs. 79.69), had more cognitive impairments, more evidence of controlled orthostatic hypotension (37% vs. 18%) — a sudden drop in blood pressure when standing up — and were using more of various medications.

Recurrent fallers were also more likely to have a history of hallucination than non-recurrent fallers (63% vs. 18%), a history of falls (80% vs. 24%), and “fluctuating cognition.” Parkinson’s patients were “predominant” in this group compared with those with vascular parkinsonism, or those who disease symptoms — like gait problems — are due to strokes.

A worsening in autonomous mobility, with mobility defined as free walking, walking with aids, or loss of ability, was seen over the study’s year in 37% of recurrent fallers and 9% of non-recurrent fallers.

Statistical analysis showed more than 25 variables significant to a greater risk of recurrent falls, of which a history of falls and of hallucinations were the most common: a median of 11.78 and 7.34 times more likely, respectively.

Compared with Parkinson’s disease, vascular parkinsonism seemed to protect against recurrent falls.

Researchers then used statistical models to predict the probability of patients being recurrent fallers from their medical history as well as from cognitive assessment, gait velocity, vision, and posture.

A history of falls and hallucinations, fluctuating cognition, and loss of postural control or postural disorders were all found to be predictors of recurrent falling in people with parkinsonian gait.

“An elderly patient with parkinsonian gait and a history of falls (two and more) and hallucinations, as well as FC [fluctuating cognition] and executive dysfunction, can be considered to be a potential RF [recurrent faller],” the researchers wrote.

“By contrast, when cognitive functions are preserved, the elderly patient appears to be protected from complications and should be encouraged to maintain … cognitive abilities and physical activity focused on postural stability and posture,” they added.

The team suggests that two or more falls a year is a relevant threshold to distinguish among patients both in terms of falling risk and symptom severity, and the predictive factors they note could help with patient management.