What is the best approach to manage falls in a patient with Parkinson's disease (PD)?

Managing Falls in Parkinson's Disease

Exercise interventions should be the primary fall prevention strategy for patients with mild to moderate Parkinson's disease, as they reduce the fall rate by approximately 26% and decrease the number of people experiencing falls by 10%. 1

Initial Fall Risk Assessment

When evaluating a PD patient for fall risk, prioritize identifying these specific high-risk features:

• History of previous falls - the single strongest predictor of future falls 2, 3
• Freezing of gait - a critical risk factor requiring targeted intervention 4
• Reduced gait speed and increased stride time variability - particularly when assessed in the OFF medication state, this combination is superior to clinical predictors alone 3
• Fear of falling - independently predicts future falls 3
• Disease severity - higher Hoehn & Yahr stage and more severe motor impairment in OFF state increase risk 3
• Depressive symptoms - correlate with increased fall risk 3
• Higher daily levodopa dose - suggests more advanced disease and greater fall risk 3

Exercise-Based Interventions (First-Line for Mild-Moderate PD)

For patients with mild to moderate PD, implement structured exercise programs immediately, as this is the intervention with the strongest evidence base. 1

Exercise interventions should include:

• Balance and strength training - these are the core components that reduce fall rates 1, 4
• Supervised programs for advanced or complex PD - patients with cognitive impairment, freezing, or advanced disease require direct supervision for safety and efficacy 4
• Minimum duration and frequency - while specific parameters need further study, programs should be sustained and structured rather than sporadic 1

The evidence shows exercise probably reduces falls (moderate-certainty evidence), though the optimal type, intensity, and supervision level for different PD subgroups remains an area requiring further research 1, 4.

Medication Interventions (Consider for Moderate-Advanced PD)

Cholinesterase inhibitors (rivastigmine or donepezil) may reduce the fall rate by 50% and should be considered for patients with more advanced disease, though this benefit must be weighed against a 60% increase in non-fall-related adverse events. 1

Key considerations for medication interventions:

• Cholinesterase inhibitors show promise - they may substantially reduce fall rates, though certainty of evidence is low 1, 4
• Adverse events are predominantly mild and transient - the increased rate of non-fall adverse events (primarily gastrointestinal symptoms) should be discussed with patients 1
• Uncertainty about effect on fall frequency - while these medications may reduce the rate of falls, we are uncertain if they reduce the number of people who fall at least once 1
• Best suited for advanced disease - medication trials included participants with more advanced PD compared to exercise trials 1

Multidisciplinary Assessment and Management

A multidisciplinary team approach is essential, typically involving a neurologist and PD-nurse specialist, with tailored screening based on specific fall types. 2

The consensus-based approach recommends:

• Identify the specific fall type first - tailor subsequent screening and treatment to the fall pattern rather than applying generic protocols 2
• Reserve comprehensive evaluation for high-risk patients - routine evaluation of all 31 identified risk factors should be performed for high-risk patients without prior falls or those with unexplained falls 2
• Multiple disciplines required - nearly all risk factors necessitate involvement from multiple specialties 2

Critical Safety Measures

Patients and families must receive counseling about fall risk at the time of diagnosis, including assessment of home safety, activity restrictions, and need for supervision. 5

Essential safety interventions include:

• Home environment modification - assess and address environmental hazards 5
• Medication review - evaluate all medications for fall risk-increasing drugs, particularly vestibular suppressants and psychotropic medications which are independent risk factors for falls 5
• Vision and cardiovascular interventions - these should be part of the comprehensive assessment 5
• Footwear evaluation - proper footwear reduces fall risk 5
• Gait and balance testing - use standardized assessments to stratify risk 5

Education Interventions

While education alone has uncertain benefit, combining education with exercise may be reasonable, though current evidence is insufficient to make strong recommendations. 1

• Education as sole intervention - we are uncertain of its effectiveness based on very limited evidence 1
• Combined exercise plus education - may make little or no difference to fall rates or number of fallers (low-certainty evidence), though this approach addresses multiple risk factors 1
• Barriers to implementation - engaging patients, families, and health professionals in falls education remains a significant challenge 4

Follow-Up and Monitoring

Reassess patients within one month after initiating interventions to document resolution or persistence of symptoms and adjust the treatment plan accordingly. 5

• Monthly monitoring recommended - use fall diaries and regular phone calls to track falls prospectively 3
• Red flags requiring immediate attention - worsening symptoms, new neurological deficits, persistent nausea/vomiting, gait disturbance, or subjective hearing loss 5, 6
• Recurrence is common - patients should be counseled that fall risk may fluctuate with disease progression and medication adjustments 5

Common Pitfalls to Avoid

• Don't delay exercise interventions - waiting for falls to occur before implementing exercise programs misses the preventive window 1
• Don't ignore OFF state assessment - gait and balance testing should ideally be performed in both OFF and ON medication states, as OFF state measures are superior predictors 3
• Don't overlook freezing of gait - this specific symptom requires targeted intervention as it substantially increases fall risk 4
• Don't prescribe vestibular suppressants routinely - these medications, especially benzodiazepines, are independent risk factors for falls and should be avoided 5
• Don't assume absence of cognitive impairment - cognitive decline affects fall risk and may require modified exercise approaches 4