How can falls be prevented in a patient with Parkinson's disease?

From the Guidelines

Falls in Parkinson's disease can be prevented through a comprehensive approach combining physical therapy, home modifications, and assistive devices, with a focus on multifactorial interventions that address individual fall-risk profiles, as supported by the most recent and highest quality study 1. To prevent falls in patients with Parkinson's disease, it is essential to consider the following strategies:

• Physical therapy: Regular physical therapy focusing on balance training, gait exercises, and strength building is crucial, with programs like Tai Chi showing particular benefit in reducing the incidence of falls 1.
• Home modifications: Removing tripping hazards, installing grab bars in bathrooms, improving lighting, and securing rugs can help reduce the risk of falls.
• Assistive devices: Using canes, walkers with wheels, or U-step walkers can provide stability during movement and help prevent falls.
• Multifactorial interventions: Addressing individual fall-risk profiles through multifactorial interventions, including exercise, home hazard assessment, and medication management, can reduce the rate of falls by 23% compared to usual care or attention control 1. Additional strategies include:
• Wearing proper footwear with non-slip soles
• Avoiding multitasking while walking
• Taking time during transitions from sitting to standing
• Maintaining bone health through vitamin D supplementation and adequate calcium intake These interventions work together to address the multiple factors that contribute to falls in Parkinson's disease, including postural instability, freezing of gait, and reduced reaction time. The most effective approach is to implement a multifaceted intervention that combines these strategies, as supported by the study by Tinetti et al 1, which showed that interventions aimed at postural hypotension, gait, balance, transfers, and strength and range of motion of the lower extremities were most associated with a reduced incidence of falls. However, the most recent and highest quality study 1 suggests that physical activity interventions, including home-based exercises, group exercise programs, strength and balance exercises, and Tai Chi, can significantly reduce the incidence of falls in individuals with mild to moderate vascular cognitive impairment, and this approach can be applied to patients with Parkinson's disease as well.

From the FDA Drug Label

Falls 10 7 Dizziness of sufficient severity to cause trial discontinuation of ropinirole was 4% in patients with early Parkinson’s disease without L-dopa, 3% in patients with advanced Parkinson’s disease, and 1% in patients with RLS Patients with Parkinson’s disease may have impaired ability to respond normally to a fall in blood pressure after standing from lying down or seated position Patients on ropinirole should be monitored for signs and symptoms of orthostatic hypotension, especially during dose escalation, and should be informed of the risk for syncope and hypotension

To prevent falls in a patient with Parkinson's disease, it is essential to:

• Monitor for signs and symptoms of orthostatic hypotension, especially during dose escalation
• Inform the patient of the risk for syncope and hypotension
• Consider the patient's impaired ability to respond normally to a fall in blood pressure after standing from lying down or seated position
• Be aware of the high incidence of falls (10%) and dizziness in patients with Parkinson's disease treated with ropinirole 2 2 However, the provided information does not give specific instructions on how to stop someone with Parkinson’s from falling forward.

From the Research

Preventing Falls in Parkinson's Disease

To prevent falls in patients with Parkinson's disease, several strategies can be employed:

• Exercise interventions, such as progressive resistance strength training and movement strategy training, have been shown to reduce the rate of falls and improve mobility 3, 4, 5
• Falls prevention education can be combined with exercise interventions to further reduce the risk of falls 3, 4, 6
• Home-based integrated physical therapy programs, including progressive resistance strength training, movement strategy training, and falls education, can be effective in reducing falls and improving mobility in people with Parkinson's disease 7, 6
• Balance training, gait training, and virtual reality interventions can also improve balance, function, and reduce fall rate 5

Types of Exercise Interventions

Different types of exercise interventions have been studied, including:

• Progressive resistance strength training, which has been shown to reduce the rate of falls by 84.9% compared to controls 3
• Movement strategy training, which has been shown to reduce the rate of falls by 61.5% compared to controls 3
• Gait training with cues, gait training with treadmill, Nordic walking, brisk walking, balance training, and Tai Chi, which have been shown to improve motor performance and functional mobility 5

Medication Interventions

Cholinesterase inhibitors, such as rivastigmine or donepezil, may reduce the rate of falls, but the evidence is uncertain and the decision to use these medications should be balanced against the risk of non-fall related adverse events 4

Education and Supervision

Falls prevention education can be delivered alone or in combination with exercise interventions, but the evidence for its effectiveness is uncertain 4, 6 Supervision and structured home practice programs can be important components of exercise interventions to reduce falls and improve mobility in people with Parkinson's disease 7, 6