What interventions are recommended for a patient with Parkinson's disease (PD) who experiences frequent falls and declines rehabilitation or home health services?

From the Guidelines

For a Parkinson's patient who keeps falling but refuses rehabilitation or home health services, the most effective approach is to create a safer home environment and address modifiable risk factors, as this can reduce the rate of falls by 23% compared to usual care or attention control, as supported by a Cochrane review 1. To achieve this, several strategies can be implemented:

• Removing tripping hazards like loose rugs, installing grab bars in bathrooms, ensuring adequate lighting, and arranging furniture to create clear pathways.
• Considering adaptive equipment such as a cane, walker, or wheelchair depending on mobility level.
• Medication optimization is crucial - speaking with their neurologist about adjusting dopaminergic medications (like levodopa/carbidopa) to reduce "off" periods that increase fall risk, as falls are a major problem in community-dwelling older persons due to their prevalence and consequences 1. Non-pharmacological approaches include:
• Encouraging the patient to move slowly during transitions, wear supportive footwear, and use assistive devices consistently.
• Family members should check on the patient regularly and consider a medical alert system for emergency assistance.
• Physical therapy exercises can be introduced gradually at home, focusing on balance and strength training, as effective exercise and physical therapy interventions include group classes and at-home physiotherapy strategies 1. These interventions are important because Parkinson's affects balance control systems through dopamine depletion and basal ganglia dysfunction. While respecting patient autonomy, persistent gentle encouragement toward formal rehabilitation may eventually overcome resistance as the benefits of reduced falls become apparent. It is key to address important implementation issues such as the barriers and facilitators (determinants) and select suitable strategies at different levels of the context (i.e., older person, healthcare professional, organization, community, policy/society) to implement multifactorial falls prevention interventions in the community setting, as research on the implementation of multifactorial falls prevention interventions rarely assesses determinants and derives appropriate implementation strategies 1.

From the FDA Drug Label

Falling Asleep during Activities of Daily Living and Somnolence Alert patients to the potential sedating effects caused by ropinirole tablets, including somnolence and the possibility of falling asleep while engaged in activities of daily living Because somnolence is a frequent adverse reaction with potentially serious consequences, patients should not drive a car, operate machinery, or engage in other potentially dangerous activities until they have gained sufficient experience with ropinirole tablets to gauge whether or not it adversely affects their mental and/or motor performance Advise patients that if increased somnolence or episodes of falling asleep during activities of daily living (e.g., conversations, eating, driving a motor vehicle) are experienced at any time during treatment, they should not drive or participate in potentially dangerous activities until they have contacted their physician.

The patient should be advised to exercise caution while driving or operating machines during treatment. If the patient has already experienced somnolence or an episode of sudden sleep onset, they should not participate in these activities during treatment.

• The patient should be monitored for signs and symptoms of orthostatic hypotension, especially during dose escalation.
• The patient should be informed of the risk for syncope and hypotension.
• Dose reduction or stopping the medication should be considered if the patient develops increased somnolence or episodes of falling asleep during activities of daily living.
• The patient should be advised to contact their physician if they experience increased somnolence or episodes of falling asleep during activities of daily living 2.
• The patient should be advised not to drive and to avoid other potentially dangerous activities that might result in harm if the patients become somnolent 2.
• The patient should be advised to exercise caution while driving or operating machines during treatment with carbidopa and levodopa orally disintegrating tablets 3.

From the Research

Strategies for Managing Falls in Parkinson's Patients

When dealing with a Parkinson's patient who keeps falling and refuses to go to rehab or have any home health, several strategies can be considered:

• Exercise interventions: Studies have shown that exercise interventions can probably reduce the rate of falls by 26% and slightly reduce the number of people falling in people with mild to moderate Parkinson's disease 4.
• Medication interventions: Cholinesterase inhibitors may reduce the rate of falls, but the decision to use these medications needs to be balanced against the risk of non-fall-related adverse events 4.
• Fall prevention education: While the evidence is uncertain, education on fall prevention may be beneficial in reducing the number of people who fall at least once 4.
• Combination of exercise and education: Exercise combined with education may make little or no difference to the number of people experiencing one or more falls, but further research is needed to determine the effectiveness of this approach 4.

Addressing Fear of Falling

Fear of falling is a significant concern for Parkinson's patients, and addressing this fear is crucial in improving health-related quality of life:

• Impact of fear of falling: Fear of falling is a more important determinant of health-related quality of life than actual falling 5.
• Balance confidence: Balance confidence is also an essential factor in determining health-related quality of life in Parkinson's patients 5.
• Objective measurement of balance impairment: Using tools like Tinetti's Mobility Index can help objectively measure balance impairment and identify patients at risk of falls 5.

Future Research Directions

Further research is needed to determine the effectiveness of different interventions in preventing falls and improving health-related quality of life in Parkinson's patients:

• Large-scale randomized controlled trials: Larger scale trials are required to determine the relative impact of different types of exercise and different levels of supervision on falls 4.
• Exploring falls prevention education: Further research is needed to explore the effectiveness of falls prevention education interventions, both delivered alone and in combination with exercise 4, 6.