Falls in Parkinson's: Are we winning?
Statistics show that up to 80% of people with Parkinson’s (PwPD) experience a fall at some point following their diagnosis. Many of those individuals will experience multiple falls. Living with the risk of falls is significant, so much so that it tops the list of questions that PwPD identify as the most important topic for future research. This is not surprising given the negative impact of a fall which ranges from fear to take part in activities and go out of the house, to the risk of fall-related injuries, potential of hospitalisation, and the inability to remain independent at home. The impact of a fall also extends to loved ones, carers and society in general.
Much effort has gone into understanding falls and how to prevent them in PwPD. Have things improved as a result – are we better able to identify people who are at the greatest risk of falling and what about identifying risk BEFORE the first fall to try to prevent or delay falls onset? What can we do to reduce falls risk? What advice should we give in the clinic? How do we know who is going to fall and why is this important? These are some of the questions for the WPC meeting to be held in Kyoto in 2019.
Research has identified 31 risk factors! Fallers are most likely to go on to fall again and a previous fall remains our strongest predictor of future falls. Perhaps given the rates of falls – we can just be of the opinion that everyone is at risk so it doesn’t matter. In fact it does matter – for the following reasons. Identifying risk allows early intervention and the possibility to target the intervention to tackle the specific problems each individual faces – we could consider this a ‘personalised approach’ to falls risk. This is not easy because risk changes depending on Parkinson’s severity, medication, personal circumstances, age and other health conditions. Falls risk also changes over time – it is not static. Some of the features of risk can be tackled in an intervention, whilst others can’t (for example a person’s age). This makes understanding fall risk inherently complex; it is unique to the individual (function and capacity), influenced by disease severity and symptoms (such as freezing), and varies with environmental demands. Imagine trying to design an intervention to test in a clinical trial that addresses risk – it is very difficult. Findings from clinical trials are promising and indicate a role for challenging strength and balance through targeted training, particularly in those with less severe disease. Exercise interventions that incorporate different types of activity show promise, however, unanswered questions regarding long-term compliance combined with often only short term benefits indicate that other preventative measures are required. Still there is a long way to go.
To complicate matters further risk changes in a dynamic way as each person moves around in their home and community. So not only do we need to understand how fall risk evolves over time – we need to consider the interplay between the individual and the environment, and laboratory based research does not help so much here. Think about the challenges our environment (i.e. low lighting, changing weather conditions, cluttered spaces). Consider also how these challenges can change on a moment by moment basis – this makes planning ahead difficult. For example, interruptions that distract attention, or the need to avoid unexpected obstacles (the cat!). Do these complicating factors explain why current treatment options are not achieving the intended results?
Interdisciplinary research provides the platform for investigating the answer and developing the solution. Moving around our home and community is challenging on multiple levels and falls occur predominantly when people are moving. Understanding the environmental challenges that people with PD encounter in the real world and the dynamic nature of these responses is important to understand and mitigate risk. Addressing this could revolutionise falls prevention strategies and the clinical management of falls risk in people with PD.
It seems therefore, that ‘one size does not fit all’ and we need to start earlier and adapt with time! Work carried out by our group examining the natural history of falls from diagnosis presents a few surprises. Falls are already present before diagnosis, and 80% of PwPD have fallen 4.5 years from diagnosis. This highlights that much earlier intervention is needed than previously anticipated to try to address risk at a far earlier stage. Moving to an approach that aims to the delay the first fall would be the most optimal. We also know that people who fall may fall for very different reasons. Consider three different individuals: someone who is older and more frail; someone who has balance problems but still maintains their usual activities; and someone who is very impulsive and less aware of risk. Addressing falls in each of these individuals requires a very different clinical approach. Personalised advice is very relevant. This may also explain why clinical trials have mixed findings because we conflate everyone into a single or multiple faller and target falls as a number or frequency rather than considering the environment and context. Maybe it’s time to target a falls ‘type’ – or falls phenotype?
What is clear is that more research is needed to address the optimal way to identify risk, identify the type of faller, develop adaptive approaches and target the dynamic challenges inherent in the real-world. We need better tools to identify risk in a dynamic manner and tools that are easy to implement clinically. Wearable technology and smart homes will ultimately provide pragmatic solutions objectively quantify and monitor risk in the real-world in a highly personalised manner – watch this space!
However, while we are waiting for this – what can we do now to prevent falls? Here are a few ‘must-haves’ - not necessarily in order of priority and not intended to be exhaustive: Falls need to be managed by a multidisciplinary team taking a detailed history to understand risk specific to the individual and to classify the types of falls they experience; advice must be tailored to match those demands and promote a personalised approach to minimise risk; start the conversations early; be active and exercise where possible, targeting walking and balance problems; optimise medication, regime and minimise environmental risk through adaptive approaches to mobility and the environment. Embracing the bigger picture may provide the important insights to understand the what, where and why of falls at a personal level and provide PwPD with some additional skills to understand and adapt. In the future we would hope that we can delay that all-important first fall.
Lynn Rochester, PhD holds Chair in Human Movement Science, is Director of the Clinical Ageing Research Unit (CARU) at the Institute of Neuroscience, Newcastle University and is also a physiotherapist. She has presented at every World Parkinson Congress since inception and will be presenting at the 5th World Parkinson Congress in Kyoto, Japan.
Ideas and opinions expressed in this post reflect that of the author(s) solely. They do not necessarily reflect the opinions of the World Parkinson Coalition®