Why are people with PD at risk of falling?
What can health care providers do to evaluate falls risk in the home?
- Keus SHJ
- Munneke M
- Graziano M
- et al.
- •Ask the patient about prior falls during each encounter. If the person answers 1 or more, then he/she is at increased risk of falls. Clarify the context of the fall (eg, how, when, where, and why the fall occurred) and use standardized, valid, and reliable falls assessment tools. Cutoff scores for estimating risk of falling in patients living with PD can be useful to differentiate between fallers from nonfallers (table 1).Table 1Tests and cutoff scores supportive of increased falls risk among people living with PD
Fall Tools* Equipment Needed Instructions Hoehn and Yahr Stage Cutoff Score for Increased Fall Risk Sensitivity (%), AUC or OR History of falls
(12 mo)†Predictive of fall in 6 months; Hoehn and Yahr stage column indicates the stage of Parkinson disease. AUC and sensitivity/OR are the AUC for discriminating between fallers and nonfallers and sensitivity/OR. In general, AUC of 0.7-0.8 is considered acceptable, 0.8-0.9 is considered excellent, and >0.9 is considered outstanding; an OR of 5.0 indicates 5 times higher odds of falls.
Ask patient how many falls they have experienced in 12 mo 1-5 ≥1 fall 77 1-3 ≥1 fall 77, OR 5.36 1-4 ≥1 fall OR 4.0 10MWT
- •Measuring tape
Walk 10 m at a self-selected speed 1-4 <0.98 m/s 80, AUC 0.80 FTSTS
Start seated in a chair, stand up and sit down 5 times 1-4 >16 s 75, AUC 0.77 TUG
- •Cone or tape mark
- •Measuring tape
Start seated in a chair, stand up, walk 3 m to the cone or tape mark, walk back to the chair, and sit down 2-3 ≥7.95 s 93 1-4 ≥8.5 s 68 2.8 ≥16 s OR 3.86 3-Step Falls Prediction Model
- •10MWT†falls/12 moPredictive of fall in 6 months; Hoehn and Yahr stage column indicates the stage of Parkinson disease. AUC and sensitivity/OR are the AUC for discriminating between fallers and nonfallers and sensitivity/OR. In general, AUC of 0.7-0.8 is considered acceptable, 0.8-0.9 is considered excellent, and >0.9 is considered outstanding; an OR of 5.0 indicates 5 times higher odds of falls.
- •History of falls taking
Administer the 10MWT, ask about falls in past 12 mo, and administer the NFOG-Q 1-4 <1.1 m/s and ≥1 fall and FOG 1 mo AUC 0.80 (95% CI, 0.73-0.86) 4-Step Falls Prediction Model6
- •TUG time
- •NFOG-Q sum score for items 3+4+5+6
- •UPDRS item 15 (walking) disease duration
- •History of falls taking
Administer TUG, NFOG-Q, and the UPDRS tool and ask what year the patient was diagnosed with PD 2-4 ≥2 UPDRS OR 2.97 (95% CI, 1.26-7.00) ≥5 NFOG-Q OR 3.56 (95% CI, 1.65-7.68) ≥15.6 s TUG OR 3.29 (95% CI, 1.48-7.30) ≥8.3 y dd OR 2.16 (95% CI, 1.01-4.62) 71% for identifying fallersAbbreviations: AUC, area under the curve; CI, confidence interval; dd, disease durations; FOG, freezing of gait; FTSTS, 5 times sit to stand test; NFOG-Q, New Freezing of Gait Questionnaire; OR, odds ratio; 10MWT, 10 meter walk test at self-selected walking speed; TUG, Timed Up and Go test; UPDRS, original version of the Unified Parkinson's Disease Rating Scale.Measures see: www.sralab.org/rehabilitation-measures/database.
- •Administer a test to assess fear of falling, freezing of gait, cognitive status, attention, and executive function (see table 1).
- •Record number of years since PD diagnosis. If ≥8 years since PD diagnosis, then the patient is at increased risk of falls.
- •Record medications known to interfere with cognition and/or lower the blood pressure. Antidepressants, addition of amantadine, and potentially anticholinergics or antipsychotics contribute to falls risk.4
- •Record co-occurring health conditions that may increase risk of falls, including urinary incontinence or nocturia (getting up to use the bathroom at night), arthritis, depression, dementia (eg, Mini Mental Status Exam score <24), or visual deficits.
- •Observe the patient walking (note lack of arm swing, freezing, flexed posturing, shuffling pattern, use of assistive devices) and performing transfers.
- •Make note of potential environmental hazards (eg, loose rugs, clutter, power cords, poor lighting, slippery floor, inadequate footwear).
- •Ask the patient if there is any change in the level of participation in Activities of Daily Living. If there is decrease or avoidance in participation in Activities of Daily Living due to social isolation refer to specialist such as neuropsychologist.
- •If possible, track the amount of physical activity (steps) using wearable sensors.
What are potential barriers to consider during virtual assessment of falls risk in PD?
- •People with advanced PD might have difficulty using digital technology owing to cognitive impairments or dementia.
- •Remote rural areas may not have sufficient internet infrastructure to provide adequate video conferencing facilities or people with PD living in rural areas may not have access to internet.
- •Concern over privacy issues may limit patients’ willingness to connect remotely to care providers.
- •Difficulty with/unable to use standardized assessment tools.
Why are in-home falls prevention exercises important for people with PD?
Parkinson disease resources
- Global Burden of Disease Neurological Collaboration. Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Neurol. 2019; 18: 459-480
- Survival and health care use after deep brain stimulation for Parkinson's disease.Can J Neurol Sci. 2020; 28: 1-11
- Clinical and anatomical predictors for freezing of gait and falls after subthalamic deep brain stimulation in Parkinson's disease patients.Parkinsonism Relat Disord. 2019; 62: 91-97
- What predicts falls in Parkinson disease?: Observations from the Parkinson's Foundation registry.Neurol Clin Pract. 2018; 8: 214-222
- European Physiotherapy guideline for Parkinson's disease.KNGF/ParkinsonNet, the Netherlands2014Accessed June 24, 2021)
- Identifying fallers with Parkinson's disease using home-based tests: who is at risk?.Mov Disord. 2008; 23: 2411-2415
- Effects of exercise on falls, balance, and gaitability in Parkinson's disease: a meta-analysis.Neurorehabil Neural Repair. 2016; 30: 512-527
Disclosures: Mark A. Hirsch reports grants from Merz Neurosciences outside the submitted work. The other authors have nothing to disclose.