Managing Falls in Patients with Progressive Neurodegenerative Disorders

Introduction to Fall Management

A multifactorial approach combining physical therapy, environmental modifications, and assistive devices is essential for managing falls and maintaining physical independence in patients with progressive corticobasal degeneration (CBD) and other neurodegenerative disorders 1, 2, 3
The American College of Physicians recommends a multifactorial risk assessment followed by targeted interventions, including exercise and physical therapy, for elderly patients with gait abnormalities 2, 3

The Timed Up and Go (TUG) Test score of >12 seconds indicates increased fall risk in elderly patients 4, 3
The 4-Stage Balance Test can identify fall risk in elderly patients, with inability to hold tandem stand for 10 seconds indicating increased risk 4
Three key screening questions can help identify elderly patients at risk of falling: Have you fallen in the past year?, Do you feel unsteady when standing or walking?, and Do you worry about falling? 4
Checking for orthostatic hypotension is an important part of the assessment for elderly patients with gait abnormalities 5
Evaluating posture at rest and during gait, as well as observing the gait pattern in a straight line and during maneuvers such as turning, is recommended by the American Academy of Neurology 6
Assessing the ability to initiate gait, testing balance and postural responses, and evaluating the presence of other parkinsonian signs is suggested by the American College of Radiology 7

Balance training should be performed 3+ days per week for elderly patients at risk of falling 3
Strength training should be performed 2 days per week, focusing on major muscle groups, for elderly patients with gait abnormalities 8
Aerobic activity should be initially brief (10 minutes), gradually increasing to 30 minutes, for elderly patients with gait abnormalities 8
Tai Chi is particularly effective for improving balance in elderly patients with gait abnormalities 3
Individualized exercise programs based on specific deficits can help improve mobility and reduce fall risk in elderly patients with gait abnormalities 2, 3

Conducting home hazard assessment and implementing modifications, such as installing grab rails in bathrooms and along stairs, removing loose rugs and clutter, improving lighting, and installing sensor night lights, can help reduce fall risk 2
Installing grab rails, sensor night lights, and using electronic bracelets with tele-assistance support can reduce fall risk, with grab rails showing a relative risk of 0.50 (95% CI: 0.32 to 0.78) 1
Home hazard assessment and modification can help reduce fall risk in elderly patients with gait abnormalities 3
Proper footwear recommendations can help reduce fall risk in elderly patients with gait abnormalities 4

Introducing appropriate mobility aids early, such as 4-wheeled walkers, canes, or walkers, and evaluating for orientation and mobility training for safe ambulation, can help maintain community ambulation and prevent progression to wheelchair dependence 9
Gait and assistive device evaluation can help identify the need for assistive devices, such as canes or walkers, for elderly patients with gait abnormalities 5
Assistive devices, such as canes or walkers, should be used when appropriate for elderly patients with gait abnormalities 5

Reviewing and minimizing medications that may impair balance, such as benzodiazepines, levodopa, and clonazepam, is crucial to prevent adverse effects in CBD patients, with benzodiazepines causing sedation and levodopa having a typically poor response in CBD 1
Review and minimize psychoactive medications that may impair gait and balance in elderly patients 4, 3
Adjust medications that may cause orthostatic hypotension in elderly patients with gait abnormalities 5
Consider vitamin D supplementation (800 IU daily) for elderly patients at increased fall risk 3

Coordinating care through a multidisciplinary team, including neurologists, physical therapists, occupational therapists, speech therapists, and ophthalmologists, can help manage disease progression and prevent falls in patients with CBD 1
Addressing pain (axial or lower extremity) can help improve mobility and reduce fall risk in elderly patients with gait abnormalities 4
Managing cognitive impairment can help improve mobility and reduce fall risk in elderly patients with gait abnormalities 4
Correcting vision impairment can help improve mobility and reduce fall risk in elderly patients with gait abnormalities 4

Anticipating and preparing for key milestones in CBD progression, such as falls, cognitive impairment, supranuclear gaze palsy, urinary incontinence, and dysphagia, can help improve quality of life and reduce fall risk in patients with CBD 1
Festination is strongly associated with greater disease severity, increased risk of falls, reduced quality of life, and greater need for assistance with daily activities 10
Early and accurate identification of festination is crucial for adequate management of patients with parkinsonism, allowing for targeted therapeutic interventions and fall prevention strategies 6
The use of visual cues, attentional strategies, and external rhythmic stimuli may help alleviate festination 7

Elderly patients can be classified as low risk (no falls or 1 noninjurious fall in past year with no gait/balance impairment) or high risk (multiple falls, gait/balance abnormalities, or acute fall) 2, 3
Focusing on single interventions, rather than addressing multiple risk factors, can reduce the effectiveness of treatment for gait abnormalities in elderly patients 2, 3
Overlooking medication effects, such as psychoactive medications that can impair gait and balance, can increase fall risk in elderly patients 4
Failing to identify and address festination, a gait pattern characterized by progressive acceleration of steps, shortening of step length, and increased cadence, can lead to increased fall risk and reduced quality of life 10