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Plaiwan Suttanon, BSc (PT), MSc (PT)

Keith D. Hill, BAppSc (PT), GradDip Falls
(PT), PhD
Catherine M. Said, BAppSc (PT), PhD
Dina LoGiudice, FRACP, PhD
Nicola T. Lautenschlager, MD, RANZCP
Karen J. Dodd, BAppSc (PT), MBA, PhD
From the Department of
Physiotherapy, Faculty of Health
Sciences, La Trobe University, Balance and Mobility Dysfunction
Bundoora, Victoria (PS, KJD);
Preventive and Public Health Division,
National Ageing Research Institute,
and Falls Risk in Older People with
Victoria (PS, KDH); Musculoskeletal
Research Centre, Faculty of Health
Mild to Moderate Alzheimer Disease
Sciences, La Trobe University,
Bundoora, Victoria (KDH, KJD); Allied
Health Division (KDH), Northern ABSTRACT
Health, c/o BECC, Bundoora, Victoria;
Physiotherapy, The University of Suttanon P, Hill KD, Said CM, LoGiudice D, Lautenschlager NT, Dodd KJ:
Melbourne, Parkville, Victoria (CMS); Balance and mobility dysfunction and falls risk in older people with mild to
Physiotherapy Department, Heidelberg
moderate Alzheimer disease. Am J Phys Med Rehabil 2012;91:12Y23.
Repatriation Hospital, Heidelberg
West, Victoria (CMS); Aged Care Objective: This study aimed to identify the magnitude and type of balance and
Division, Royal Melbourne Hospital
(RPC), Parkville, Victoria (DL); mobility impairments in people with Alzheimer disease by comparing their per-
Academic Unit for Psychiatry of Old formance with that of older people without cognitive impairment.
Age, St. Vincent’s Health, Department
of Psychiatry, University of Design: Twenty-five community-dwelling people with mild to moderate Alz-
Melbourne, Melbourne (NTL); heimer disease and a comparison group of 25 cognitively intact age- and sex-
and School of Psychiatry and Clinical
Neurosciences and WA Centre for matched people completed a comprehensive balance and mobility assessment.
Health & Ageing, University of Western This included computerized posturography measures of static and dynamic balance
Australia, Perth, Australia (NTL). under various conditions, clinical balance, and mobility measures, and measures
of falls and falls risk.
All correspondence and requests for Results: The level of falls risk was higher in people with Alzheimer disease.
reprints should be addressed to: Standing balance in people with Alzheimer disease was significantly impaired
Plaiwan Suttanon, BSc (PT), MSc (PT),
Royal Melbourne Hospital (Royal across a range of static and dynamic balance conditions. Activity level, gait, and
Park Campus), NARI, PO Box 2127, mobility measures were also impaired, particularly turning and dual tasks.
VIC, Australia 3050.
Conclusions: The findings of the study highlight the value of including bal-
Disclosures: ance screening as a routine component of early dementia assessment. This would
Financial disclosure statements have allow for the early detection of balance dysfunction and the introduction of balance
been obtained, and no conflicts of retraining before impairments progress to more advanced levels.
interest have been reported by
the authors or by any individuals Key Words: Alzheimer Disease, Balance, Mobility, Falls
in control of the content of this article.
Funded by the National Ageing
Research Institute.

American Journal of Physical
Medicine & Rehabilitation
Copyright * 2011 by Lippincott
Williams & Wilkins

DOI: 10.1097/PHM.0b013e31823caeea

12 Am. J. Phys. Med. Rehabil. & Vol. 91, No. 1, January 2012

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
sensitive measurements of balance performance.20,21
O lder people have an increased risk of falls,
which may lead to disabling injury and death,1 with
In addition, some force platform assessments can
systematically assess underlying impairments con-
30% of people 65 years or older falling one or more tributing to balance dysfunction or can assess balance
times each year.2 Falls are also a well-recognized control under various conditions.22 For example,
problem for older people with advanced dementia, the small number of studies that have compared
who have even higher incidence and adverse conse- balance performance between people with AD and
quences compared with healthy older people. In one healthy controls using force platform technology
study, 42% of a community sample of people with suggest that people with mild to moderately severe
mild to moderately severe Alzheimer disease (AD) AD do have balance impairment, particularly when
fell within a 12-mo period,3 and in a residential care visual information is limited or when dual tasks are
sample, more than 60% of people with advanced being undertaken.6,10,23
dementia fell within a similar period of time.4 The second limitation of previous studies is
Balance impairment is a strong indicator of that most falls occur during dynamic tasks such as
falls risk in older people.1 Motor impairments and stepping, reaching, and turning24 and that falls
particularly balance dysfunction have been identi- occur not only in the forward direction but also in
fied as important contributors to the increased risk the lateral and backward directions.25 However, the
of falls in people with cognitive impairment.5,6 How- commonly reported balance or mobility measures
ever, relatively little is known about changes in in people with AD have been reported by either a
balance performance in people with cognitive im- simple reaching forward test (Functional Reach
pairment, particularly in those with mild to moder- test) or by total score only (e.g., Berg Balance Scale)
ate symptoms of dementia. and have not clearly identified the specific dynamic
Differences in the underlying etiology asso- tasks that were impaired.11,12
ciated with the different types of dementia could In summary, no studies to date have utilized a
result in variable cognitive or physical limitations.7 comprehensive suite of clinical and laboratory (force
AD is the most common form of dementia, account- platform) balance assessment tasks, including dy-
ing for more than 50% of newly diagnosed cases each namic tasks reflective of falls circumstances (such
year.8 Commonly used criteria for the clinical diag- as walking, reaching/leaning, turning, and stepping
nosis of AD state that it is characterized by gradual up onto a block/step) as well as dual task activities,
onset of cognitive impairment, followed by a con- to describe the magnitude and type of balance dys-
tinued cognitive deterioration in which motor sys- function in people with AD. These limitations high-
tem abnormalities are unlikely to present until the light the need for further investigation of balance
advanced stages of the condition.9 These motor sys- performance in people with AD, using a compre-
tem abnormalities may include balance and gait dis- hensive assessment battery. A better understanding
turbances. However, previous studies have reported of balance impairment in people with AD may pro-
gait and balance dysfunction in people with rela- vide a framework to guide clinicians in the most
tively early stages of AD,10Y12 although there are appropriate tools for assessing the presence of bal-
limitations to the approaches used in many of these ance dysfunction and in the development of inter-
studies. First, although balance is multidimen- vention programs specifically designed to improve
sional13 and it has been reported that no single test balance and reduce falls risk for people with AD.
provides an overall perspective of balance perfor- The aim of this study was to identify differ-
mance,14 these studies have mostly used only one or ences in balance performance using a detailed bal-
a small number of clinical measures, such as single ance assessment suite (including clinical and force
leg stance,15,16 Berg Balance Scale, and the Timed platform measures) between people with mild to
Up and Go (TUG) test.11,12 In addition, although moderately severe Alzheimer disease and a compar-
clinical balance measures have been shown to dis- ison group of age- and sex-matched cognitively in-
criminate falls risk,17,18 concerns have been reported tact older people.
that ceiling effects might limit the sensitivity of some
of these tests to detect mild levels of balance dys-
function,19 such as those that are likely to be evi- METHODS
dent in the early stages of cognitive impairment.
Force platform technology, which uses transducers Participants
to detect postural sway and weight transference Participants with AD were recruited through the
while performing tasks, potentially provides more Memory Clinics of two large metropolitan tertiary Falls Risk in Alzheimer Disease 13

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
hospitals as well as through public notices in lo- Measures of Balance and Mobility
cal and state newspapers and community groups Performance
providing support for people with AD. Participants A comprehensive suite of laboratory and clini-
were included if they had a diagnosis of AD con- cal measures of balance performance were used for
firmed from a medical specialist or through a Mem- this study, aiming to include measures of the vari-
ory Clinic assessment, if there are AD symptoms ous domains of balance, including static and dy-
that were of mild to moderate severity (Mini-Mental namic balance, with and without sensory challenge
State Examination [MMSE] score, Q10), and if they and with single and dual task. All laboratory and
could walk outdoors with or without a single point clinical measures of balance and mobility perfor-
stick. They also had to be living in the community mance used in this study have been shown to be
and have no other serious orthopedic condition (e.g., feasible and safely administered to people with mild
recent lower limb surgery, severe arthritis of a lower to moderate AD, with fair to excellent retest
limb) or major neurologic disorder (e.g., stroke, reliability.29
Parkinson disease) that could potentially restrict
functional mobility. Laboratory Measures
A comparison group of cognitively intact people A set of static and dynamic balance tasks were
matched to the participants with AD for age (T3 yrs) assessed on the Neurocom Balance Master (Neuro-
and sex were recruited from community notices in a Com International Inc, Clackmas, OR). The Neu-
local newspaper and an existing volunteer database roCom Balance Master test battery has been shown
from a research institute. Participants in the com- to have moderate to high test-retest reliability (in-
parison group needed to have a MMSE score of traclass correlation coefficient, 90.84) in assessing
24 or higher, have no serious neurologic or ortho- balance dysfunction in healthy older people and
pedic condition that could impact balance and clinical groups,30,31 to be sufficiently sensitive to be
mobility performance, and be able to walk inde- able to identify patients who have previously fallen,
pendently outdoors with or without a single point and to be able to predict the risk of multiple falls.32
stick. With respect to people with AD, a recent study29 has
shown that both the static and dynamic measures
testing on the NeuroCom Balance Master force plat-
Measurements and Procedures form were feasible and had fair to excellent retest
Assessments included measures of cognition, a reliability in assessing balance and mobility in peo-
comprehensive series of laboratory and clinical mea- ple with AD. All tests were performed with shoes
sures of balance and mobility performance, and removed. In the first two tests (modified Clinical
measures of falls and falls risk. To avoid fatigue, a Test of Sensory Interaction on Balance, the Limits
short break was scheduled, but participants were of Stability tests), the feet were positioned apart
invited to have additional breaks at any time. at one of three standardized foot positions accord-
Measures of cognition and behavioral distur- ing to manufacturer’s instructions, depending on
bances consisted of the following: the participant’s height. In these two tests, a safety
1. MMSE,26 a cognitive screening tool comprising harness attached to an overhead rail was worn by
11 items covering orientation, registration, at- participants (loose enough to allow trunk movement,
tention and calculation, recall, language, a three- but firm enough to prevent a fall during testing).
step praxis item, and a graphic copy of a geometric The following laboratory (force platform) measures
design. Lower scores indicate greater levels of from the NeuroCom Balance Master long plate (di-
cognitive impairment, with a cutoff of less than mensions, 152  46 cm) (NeuroCom Balance Master
24 being used to indicate cognitive impair- Operator V3) were used:
ment,27 and 1. Modified Clinical Test of Sensory Interaction
2. Frontal Assessment Battery,28 a short cognitive on Balance, a static stance test of postural sway,
and behavioral battery for screening frontal/ measured under four sensory conditions (eyes
executive dysfunction. The Frontal Assessment open and eyes closed, on a firm and a foam sur-
Battery consists of six subtests exploring con- face). Sway velocity (degrees per second) in each
ceptualization, mental flexibility, motor pro- condition was assessed;
gramming, sensitivity to interference, inhibitory 2. Limits of Stability, a test of speed and amplitude
control, and environmental autonomy. Frontal of weight shift (movement of center of gravity
Assessment Battery scores range from 0 to 18, with [COG] within the body’s limits of stability) in
lower scores indicating more severe impairment. eight directions toward a preset target at 100%

14 Suttanon et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 1, January 2012

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
limits of stability. For each of the eight direc- and quick tests routinely used in clinical practice
tions, the measures included the following: and research:
& Reaction time (seconds), which is the time 1. Functional Reach test,33 a test of dynamic bilateral
between the instruction to move (the COG) stance balance. This test measures the maximum
and the initiation of movement; distance that participants can reach forward with
& Movement velocity (degrees per second), which their dominant arm raised to 90 degrees without
is the average speed of COG movement; moving their feet, which were positioned 10 cm
& Maximum excursion (percentage of limits of apart. The distance of additional reach from the
stability boundary), which represents the fur- starting position was recorded (in centimeters).
thest distance of the COG movement during 2. Step Test,34 a test of dynamic single leg standing
testing; and balance. The number of times the participant
& Directional control (percentage) reports a steps one foot fully on and then off a 7.5-cmYhigh
comparison of the amount of movement to- block as quickly as possible in 15 secs was recorded.
ward the target-direction to the amount of Both legs were tested separately, and performance
movement in any direction other than the on the side with the least number of steps was
intended direction. used for data analysis.
3. Timed Chair Stands,35 a test measuring global leg
A summary composite score integrating data muscle strength, assessed by timing the speed of
from each of the eight directions assessed, reported standing up/sitting down as fast as possible five
from the NeuroCom data analysis for each measure, times from a 45-cmYhigh chair, with arms crossed
was used for analyses. across the chest.
3. Walk Across, a test of step width (centimeters), 4. TUG test,36 an assessment that measures speed
step length (centimeters), and walking speed during standing up from a standard 45 cm high
(centimeters per second) as the participant walked chair, walking 3 m at usual speed, turning, then
at comfortable speed across the long plate; returning to sit again in the chair (seconds). This
4. Step/Quick Turn, a test of stability when tak- task was reassessed under dual task conditions,
ing two steps then turning and returning to the with a secondary cognitive task (counting back-
starting position. Performance was assessed turn- ward by 3s while performing the TUG) and with a
ing separately to the left and to the right. Aver- secondary motor task (carrying a full cup of water
age turn time (seconds) and turn sway (degrees while performing the TUG).17
per second) were reported for turning to both the
right and left direction from three trials in each The measures of falls and falls risk consisted
direction, and the highest (worse) average score of the following:
between the right and left turn sway measures 1. The number of falls in the preceding 12 mos as
and right and left turn time measures were used reported by the participants or their caregivers;
for analyses; and 2. The Falls Risk for Older People, community version
5. Sit to Stand, a test of stability during fast sit to (FROP-Com),37 a detailed falls risk questionnaire
stand without upper limb assistance (degrees per evaluating 13 risk factors. The FROP-Com has been
second). The measures were as follows: shown to have good retest reliability (intraclass
& Rising index (percentage of body weight), which correlation coefficient, 0.93 and 0.81). It has also
is the amount of force exerted by the legs dur- been shown to have moderate accuracy to pre-
ing the rising phase of sitting to standing; and dict falls (sensitivity, 71%; specificity, 56%).37 Two
& Sway velocity (degrees per second), which is modifications were made to the FROP-Com be-
the average amount of COG sway during the cause of the nature of the study protocol. Because
rise to stand and for the first 5 secs follow- the assessment was not conducted at the partici-
ing the rise. pants’ home, the home assessment item was ex-
cluded. This makes the total possible FROP-Com
For all tests on the NeuroCom Balance Master score 57 instead of 60 points. The score in the
except for the Limits of Stability test, three trials were cognitive status domain of the FROP-Com was
conducted, and the average scores were reported. originally rated based on the results of the Ab-
breviated Mental Test Score. Instead, we used
Clinical Measures MMSE scores to rate this domain into four cate-
A number of clinical measures of balance and gories (MMSE score, 926 [0 point], 20Y26 [1 point],
mobility were also used. These measures are simple 10Y19 [2 points], and G10 [3 points]) because this Falls Risk in Alzheimer Disease 15

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
cognitive screening tool was already being used committees. All participants or, where necessary,
in this study. their next of kin or caregiver provided written in-
3. Physiologic Profile Assessment (PPA),38 an ab- formed consent before taking part in the study.
breviated assessment evaluating standing balance
(eyes open on foam, swaymeter), hand reaction
Statistical Analysis
time, knee joint proprioception, visual contrast SPSS Graduate Student Version 16.0 for Win-
sensitivity, and quadriceps muscle strength. Raw dows and a Web-based effect size calculator (http://
PPA data from each item were entered into Web-
based software created for the PPA and adjusted 30325071) were used to analyze data. Descriptive
for age and sex, and an overall PPA falls risk score, statistics were used to report the participant profile
which could range from j2 to higher than 4 was and scores for all measures, and the Kolmogorov-
computed for the participant. The retest reliabil- Smirnov test was used to investigate the distribu-
ity of the PPA has been reported as ranging from tion of data for all continuous measures.
intraclass correlation coefficients38 of 0.50 to 0.97 Balance-related measures that were continu-
and has been reported to be feasible to conduct in ous and normally distributed were compared be-
older people with mild to moderate AD.39 tween the AD and the comparison groups using
independent-samples t tests. Nonparametric equiv-
Measure of Physical Activity alent statistics were used for comparisons between
The Human Activity Profile,40 a measure of the two groups where continuous variables were not
physical activity level, evaluated 94 activities listed normally distributed (Mann-Whitney U test). Balance-
in hierarchical order of increasing energy expendi- related measures were grouped according to subdo-
ture, each rated as Bstill doing,[ Bhave stopped do- mains of the different nature of tests (static balance
ing,[ or Bnever did.[ The Maximum Activity Score tests, dynamic one-leg stance tests, dynamic bilateral
was the highest numbered activity still being un- stance tests, gait measures, sit to stand tests, and
dertaken. The Adjusted Activity Score was calculated muscle strength measures). To account for multiple
by deducting from the Maximum Activity Score, the comparisons, a Bonferroni adjustment was applied
number of lower numbered items that the partici- where more than one measure was used to assess
pant has ceased doing. The Adjusted Activity Score the same subdomain. This resulted in different sig-
was used for data analysis in this study because it nificance levels for the different subdomains of as-
was recommended to be a more stable estimate of sessment, depending on the number of assessment
the individual’s daily activities than the original items within each subdomain (Table 2).
Maximum Activity Score.40 A power analysis calculated for this study,
The study was approved by the relevant uni- based on the pilot results, indicated that a minimum
versity and health services human research ethics sample size of 15 participants per group would be

TABLE 1 Participant characteristics

Controls (n = 25) Participants with AD (n = 25) P
Male/female ratio, n:n 9:16 9:16
Mean age, yrs (95% CI) 80.4 (78.0Y82.7) 81.0 (78.4Y83.5) 0.721
Mean weight, kg (95% CI) 68.74 (64.26Y73.23) 62.82 (58.20Y67.44) 0.063
Mean height, cm (95% CI) 162.52 (158.95Y166.09) 159.10 (155.46Y162.74) 0.172
Medical conditions, n (%)
Arthritis (not affecting functional ability) 8 (32%) 8 (32%)
Osteoporosis 5 (20%) 3 (12%)
Lower limb joint replacement 6 (24%) 3 (12%)
Respiratory condition 5 (20%) 4 (16%)
Cardiac condition 8 (32%) 4 (16%)
Diabetes mellitus 1 (4%) 2 (8%)
Hypertension 10 (40%) 13 (52%)
Dizziness symptoms 1 (4%) 2 (8%)
Mean MMSE score (95% CI)a 29.2 (28.5Y29.8) 21.1 (19.2Y23.0) 0.000b
Mean FAB score (95% CI) 16.3 (15.9Y16.8) 13.0 (12.0Y14.0) 0.000b
Tested using Mann-Whitney U test.
Significant difference between participants with AD and healthy controls.
AD, Alzheimer disease; FAB, Frontal Assessment Battery; MMSE, Mini-mental State Examination.

16 Suttanon et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 1, January 2012

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
required to detect a significant difference between with eyes closed on firm surface and eyes open on
the two groups for two outcome measures: maxi- foam surface, NeuroCom Balance Master Limits of
mum excursion (measured from the Limits of Sta- Stability test movement velocity measure, and PPA
bility test on the NeuroCom Balance Master), and hand reaction time test), performance was worse in
the Step Test, at 90% power and at > = 0.05. the AD participants, with comparisons approaching
RESULTS Time taken for all three subtests of the TUG test
(general, dual-task manual, and dual-task cognition)
Twenty-five people with AD (mean age, 81.0 yrs;
were significantly longer (indicating greater mobility
range, 68Y93 yrs; 36% men) and 25 age- and sex-
impairment) in the AD group than in the compar-
matched cognitively intact people (mean age, 80.4 yrs;
ison group, with the greatest difference in the TUG
range, 68Y90 yrs; 36% men) were recruited. No sig-
performed simultaneously with a cognitive task (ef-
nificant between-group differences were detected for
fect size, 1.44). All participants in the AD group were
age, weight, height, or the number of other exist-
able to perform the TUG as a single task and with a
ing medical conditions. In the AD group, 19 of the
manual secondary task; however, five participants
25 people were accompanied by their caregiver on
were unable to perform the TUG with a cognitive
the assessment day, 1 was accompanied by her case
secondary task. All participants in the comparison
manager, and the other 5 came alone. Table 1 pre-
group were able to perform all the TUG tests (either
sents the baseline characteristics of participants and
as a single test or in dual-task conditions).
the percentages of self-reported (verified by the care-
Between-group difference was found for the
givers when possible) major medical conditions. For
quadriceps muscle strength (strain gauge). The AD
both groups, hypertension, arthritis, and cardiac
group reported significantly lower levels of physical
conditions were the most common health problems
activity (on average, 16 more items rated as Bhave
reported. All participants with AD were categorized
stopped doing[) compared with the healthy group
as having mild to moderately severe dementia (mean
(effect size, 1.25).
MMSE, 21.1; SD, 4.6). The mean Frontal Assess-
ment Battery score of the participants with AD was
13.0 of 18 (76% having a score G15, indicating im- Falls and Falls Risk
paired executive function).
Eleven (44%) of the AD participants had one or
more falls in the previous 12 mos, which was not
Balance and Mobility Performance significantly different to the proportion of fallers in
The comparison of the motor and balance per- the comparison group (nine people; 36%). The AD
formance and the number of falls between the AD group had a total of 19 falls reported in the preced-
and comparison group are presented in Table 2. ing year, compared with 12 falls in the comparison
There were significant group differences (with worse group, although this difference was not significant
performance by the AD group) on most balance- (P = 0.26). Falls risk, as measured by both the FROP-
related measures, including clinical measures of dy- Com risk assessment tool and the PPA identified that
namic balance (Step Test and Functional Reach), people with AD had significantly higher risk of falls
Limits of Stability measures on the NeuroCom Bal- relative to the comparison group (FROP-Com, P =
ance Master (maximum excursion and directional 0.000; PPA, P = 0.007).
control), gait measures (velocity and step length),
mobility (TUG single and dual task), and turning
measures on the NeuroCom Balance Master (turn DISCUSSION
time and turn sway) (Table 2). Effect sizes for the The results of this study highlight the broad
significant differences ranged from 0.57 for quad- range of balance and mobility impairments in peo-
riceps muscle strength test to 1.44 for limits of sta- ple with mild to moderate severity AD. Although
bility boundary measured on the NeuroCom Balance there was no significant difference in the number of
Master and for time taken to complete TUG with falls, the AD group had double the level of falls risk
cognitive task (Table 2). Two of the static balance test on two falls risk assessment tools (the FROP-Com
measures on the NeuroCom Balance Master (eyes and the PPA). Impaired balance and mobility per-
open on firm surface, eyes closed on foam surface) formance were observed across the range of mea-
were also significantly worse for the participants sures in this study, highlighting the global nature
with AD. For most of the remaining tests (PPA sway of balance and mobility dysfunction in people with
measure and NeuroCom Balance Master measures mild to moderately severe AD. The results reinforce Falls Risk in Alzheimer Disease 17

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 2 Comparisons between AD and age- and sex-matched comparison group

Participants with AD,

Outcomes (Significance Values) Controls, Mean (95% CI) Mean (95% CI) P Effect Size
1. Static balance (Bonferroni, P G 0.05/5 = 0.01)

Suttanon et al.
Balance sway (part of PPA) 124.58 (93.15Y156.00) 173.15 (136.18Y210.13) 0.044 0.58
mCTSIB_EO, degrees/seca 0.24 (0.21Y0.26) 0.31 (0.25Y0.36) 0.006b V
mCTSIB_EC, degrees/sec 0.33 (0.28Y0.37) 0.44 (0.34Y0.53) 0.042 0.58
mCTSIB_EOF, degrees/sec 0.94 (0.84Y1.04) 1.48 (0.97Y1.98) 0.025 0.60
mCTSIB_ECF, degrees/seca,c 2.66 (2.04Y3.27) 4.11 (3.27Y4.95) 0.006b V
2. Dynamic balance
2.1 Dynamic one-leg stance (P G 0.05)
Step test (worst leg), steps 15.96 (14.84Y17.08) 13.60 (12.46Y14.74) 0.004b 0.84
2.2 Dynamic bilateral stance (feet apart position) (Bonferroni P G 0.05/4 = 0.013)
Functional reach, cm 31.40 (29.36Y33.44) 26.78 (24.31Y29.25) 0.005b 0.82
LOS_MVL, degrees/sec 3.35 (2.86Y3.84) 2.87 (2.40Y3.33) 0.147 0.41
LOS_MXE, % LOS boundary 82.88 (79.66Y86.09) 67.32 (61.97Y72.66) 0.000b 1.44
LOS_DCL, % 74.54 (72.19Y76.89) 61.50 (56.72Y66.28) 0.000b 1.42
3. Gait, mobility, and function
3.1 Single task_not involving turning (Bonferroni, P G 0.05/3 = 0.017)
Walk across_speed, cm/sec 58.02 (51.75Y64.29) 40.24 (35.89Y44.60) 0.000b 1.32
Walk across_step length, cm 47.68 (42.55Y52.82) 34.96 (30.30Y39.61) 0.000b 1.04
Walk across_step width, cm 15.54 (14.20Y16.88) 15.52 (13.84Y17.21) 0.991 0.01
3.2 Single task_involving turning (Bonferroni P G 0.05/3 = 0.017)
TUG, secs 11.89 (10.93Y12.85) 15.04 (13.71Y16.37) 0.000b 1.09
Step Quick Turn_time (worst performance), secs 1.79 (1.57Y2.01) 3.59 (3.07Y4.11) 0.000b 1.08
Step Quick Turn_Sway (worst performance), degrees 38.90 (34.67Y43.12) 48.37 (44.77Y51.97) 0.001b 0.97
3.3 Dual task (Bonferroni P G 0.05/2 = 0.025)
TUG (with manual task), secs 13.09 (11.95Y14.23) 17.40 (15.35Y19.45) 0.000b 1.04
TUG (with cognitive task), secsd 14.56 (13.22Y15.90) 21.82 (18.82Y24.81) 0.001b 1.44
3.4 Sit-to-stand (Bonferroni P G 0.05/3 = 0.017)
Timed chair stand, secse 10.54 (9.70Y11.37) 11.39 (10.22Y12.56) 0.221 0.34
Sit-to-stand_rising index, % body weight 16.64 (14.90Y18.38) 14.83 (12.92Y16.74) 0.155 0.40
Sit-to-stand_sway velocity, degrees/sec 4.65 (4.32Y4.97) 3.98 (3.52Y4.45) 0.018 0.68
4. Muscle strength (P G 0.05)
Quadriceps muscle strength (part of PPA), kg 23.15 (19.82Y26.48) 18.76 (15.80Y21.72) 0.047b 0.57
5. Reaction time (Bonferroni P G 0.05/2 = 0.025)
Hand reaction time (part of PPA), msecs 291.88 (263.96Y319.79) 351.53 (303.60Y399.45) 0.032 0.62
Reaction time (from LOS test), secs 0.96 (0.87Y1.10) 1.25 (1.11Y1.38) 0.004b 0.85
6. Human Activity Profile 63.20 (58.90Y67.50) 47.32 (41.55Y53.10) 0.000b 1.25

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
7. Falls risk (Bonferroni P G 0.05/2 = 0.025)
FROP-Com score 6.52 (5.13Y7.91) 13.68 (11.73Y15.63) 0.000b 1.70
PPA total score 0.71 (0.26Y1.16) 1.67 (1.12Y2.22) 0.007b 0.78

(Continued on next page)

Am. J. Phys. Med. Rehabil. & Vol. 91, No. 1, January 2012
the potential value for clinicians to assess balance

Effect Size

DCL, directional control; ECF, eyes closed on foam surface; EO, eyes open, EC, eyes closed; EOF, eyes open on foam surface; FROP-Com, Falls Risk for Older PeopleYcommunity version; LOS, Limits of Stability;
performance in this group at relatively early stages

of AD progression.
Static balance has been found to be impaired
in people with AD in previous studies. Our results
suggest that people with AD have significantly greater

mCTSIB, modified Clinical Test of Sensory Interaction on Balance; MVL, movement velocity; MXE, maximum excursion; PPA, Physiological Profile Assessment; TUG, Timed Up and Go test.
sway during standing on foam with eyes closed than
the comparison group. This corresponds with the
result of a previous study that found that people with
AD increased their reliance on vision for controlling

balance to a greater level than did healthy controls.10



In the eyes closed on foam condition, vestibular

input is the most important sensory information
used to maintain balance because the other two
sensory systems, vision and somatosensory, are not
available or are inaccurate.41 In their health histo-
ries, few participants in our study reported symp-
toms of dizziness, and none reported a diagnosis of
Participants with AD, n (%)

vestibular disorder. As such, increased sway in the

ECF condition was unlikely to have been influenced
solely by the peripheral vestibular system but may


also reflect impairments in other components of the

balance control system. These include the organi-

zation and integration of all sensory information

from the visual, somatosensory, and vestibular sys-
tems; the ability to select appropriate sensory refer-
ences and to correctly interpret those elements of
Significant difference between participants with AD and healthy controls after Bonferroni adjustment.

information for balance control41; impairments in

afferent and efferent reaction times; and motor out-
put responses.
Although a small number of previous studies
have assessed dynamic balance in people with AD,
Controls, n (%)

these have used a single or only a small number of

16 (64%)
6 (24%)
2 (8%)
1 (4%)

balance tests. To our knowledge, this is the first

Missing data from one person with AD who could not perform the test.

study to comprehensively examine dynamic balance

Missing data from two people with AD who could not perform the test.
Missing data from five people with AD who could not perform the test.

in people with mild- to moderate-severity AD using

a battery of tests. The results revealed impaired bal-
ance control during dynamic tasks that are reflective
of the circumstances of many falls,24 with signifi-
cant impairments on tests including the Step Test,
Functional Reach, and the Limits of Stability test.
Effect sizes for the difference between groups on
these measures were large,42 ranging from 0.84
8. Number of falls in previous 12 mosa

to 1.44.
Tested using Mann-Whitney U test.

Because all of the dynamic balance measures

included in the study are voluntary tasks, the decline
in capacity to perform those tasks might suggest

Three or more falls

an impairment of the anticipatory or feed-forward

movement planning process in people with AD. In
addition, the decreased directional control score in
Two falls
One fall
No falls

the Limits of Stability test in people with AD may


also reflect poor movement coordination that has



been previously reported in people with different

types of dementia, including AD.43,44 Falls Risk in Alzheimer Disease 19

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Compared with the comparison group, the peo- lengths might be preferred compensatory mecha-
ple with AD in our study had difficulty performing nisms for people with AD to improve postural in-
the turning task of the Step Quick Turn test and the stability, rather than widening the step width.
walking with turning task in the TUG test. The dif- People with AD had significantly lower levels of
ficulty experienced in the TUG test occurred when physical activity than the comparison group, with
performed both as a single-task and in dual-task more than 15 points of average reduction in the
conditions. The AD group had particular difficulty physical activities rated as Bstill doing[ using the
when performing the TUG test when the secondary Human Activity Profile. Deterioration in balance
task was a cognitive task, resulting in a more than performance might have contributed to the decline
30% increase in the magnitude of impairment (based in physical activity observed in the AD group. It is
on the difference in effect size). Furthermore, 5 of possible that either the participants or their care-
the 25 participants in the AD group were unable to givers respond to their awareness of the increased
complete the cognitive dual task. These findings risks of falling by limiting physical activity of the
support previous evidence of the deficits in divided person with AD. It remains unclear whether a de-
attention (ability to respond simultaneously to mul- crease in physical activities leads to reduced de-
tiple tasks) and selective attention (ability to focus mand on the motor and balance system, which then
attention in the presence of distraction) commonly impacts on balance control performance and the
observed in the early stages of AD.45,46 They also confidence to perform activities independently, or
correspond with decreased stability during dual- whether the decline in balance performance results
task conditions observed in people with AD.6 The in reduced activities. This relationship warrants fur-
greater impairment found when the secondary task ther investigation. Furthermore, recent systematic
was a cognitive task rather than a manual task sug- review evidence suggests that increasing physical
gests that when performing dual tasks, the motor activity may reduce the risk of AD48,49 or delay pro-
impairment can differ depending on the type of ad- gression of cognitive impairment.50
ditional task performed. Secondary tasks that re- Importantly, most of the clinical measures such
quire high cognitive involvement (such as counting as the Step Test, Functional Reach Test, and TUG
backward) seem to have a higher impact on motor test helped identify significant and clinical differ-
performance (primary task such as walking) for peo- ences in balance and mobility performances (based
ple with AD in comparison with healthy older peo- on effect size). These tests take little time, equip-
ple. These results highlight the potential importance ment, or training to perform, so they could be eas-
of (1) targeting turning and dual-task activities in ily added to assessments of people presenting with
balance exercises in people with mild to moderate mildly to moderately severe AD (e.g., at Memory
AD in an attempt to improve performance, and/or Clinics and other assessment services for people
(2) informing the person with AD and their care- with cognitive impairment) to screen for the pres-
givers of their difficulties with these tasks and ence of balance dysfunction.
highlighting the importance of taking extra care or It is worth noting that this group of partici-
minimizing exposure to these tasks (e.g., stop walk- pants with AD also exhibited a decrease in quadri-
ing while talking in a manner that requires high ceps muscle strength and reduced performance
attention). Further research is warranted to explore (although not statistically significant) on the func-
the effectiveness of these approaches in reducing tional activity of sit to stand. Sit to stand is a com-
the risk of falls in this high-risk group. plex motor task, incorporating the synchronization
Both in our study and in previous studies,44,47 of a group of muscles generating large forces in a
the participants with AD walked more slowly than short time to achieve the required task. At least part
the nonYcognitively impaired participants. The sig- of the muscle strength deterioration may be asso-
nificant reductions in gait speed and step length ciated with secondary deconditioning, given the
identified in the present study might both reflect moderate reduction in physical activity reported in
and be a response to the reduced postural stability the AD participants. Because muscle strength par-
in people with AD during walking. However, no ticularly in lower limb muscles is one of the key
difference in step width was identified between the components of the balance control process,41 ex-
two groups. This finding is consistent with that of ercise interventions aiming to improve balance and
a previous study of ten people with AD, ten peo- mobility in people with AD should include lower
ple with dementia with lewy bodies, and ten healthy limb strength training.
controls, which examined gait using an electronic Nearly 45% of people with AD reported a fall
walkway.47 Walking slower or with shorter step in the preceding 12 mos. This is consistent with a

20 Suttanon et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 1, January 2012

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
previous finding, in which 42.3% of 124 people with However, the TUG test, when performed simulta-
mild to moderate AD fell in the preceding year.3 Our neously with the cognitive task (counting backward
study used retrospective falls recall during the past by 3s), was too difficult for some of our participants
12 mos to document falls history, which has been to complete. Future studies should include a sin-
shown to underestimate actual fall incidents by gle cognitive task condition before performing this
approximately 20% in cognitively intact older peo- task in combination with the mobility task to give a
ple compared with prospective monitoring through clearer picture of the influence of the secondary task
falls calendars.24 As such, the real rate of falls in on mobility performance in people with AD.
community-dwelling older people with AD may be
even higher than our results suggest. CONCLUSIONS
Although identifying the presence of balance
Balance and mobility impairments are identi-
impairment and the associated increase in falls
fied in people with mildly to moderately severe AD,
risk in people with mild to moderate severity AD is
impairments that may contribute to an increased
important, the main potential value is determin-
risk of falling in this population. Both laboratory
ing whether there is a capacity to improve balance
(force platform) and clinical measures used in this
performance in this group. There is strong evidence
study identified balance dysfunction in people with
that balance training can improve balance perfor-
AD. In clinical settings, where computerized force
mance and reduce falls in older people without spe-
platform equipment is not available, clinical measures
cific health conditions who are living either in the
such as the Step Test, Functional Reach test, and the
community or in institutional care51,52; however, to
TUG test may be practical and useful. Further re-
date, there is relatively little research investigating
search is required to evaluate whether people with
this in people with cognitive impairment, especially
mildly to moderately severe AD identified with bal-
those with AD. A recent systematic review by our
ance impairments will benefit from exercise pro-
team has found that there were only seven ran-
grams to improve balance and minimize future risk
domized controlled studies that included balance or
of falls.
falls measures as outcomes and included balance-
related exercise in the exercise program for people
with dementia.53 Although this review clearly high- ACKNOWLEDGMENTS
lights the need for more high-quality research in this We are grateful to all the participants who
area, it does provide some support that these iden- agreed to be part of the study. We also acknowledge
tified balance impairments may be amenable to the kind help and support from staff at the Cogni-
exercise intervention in people with mild to mod- tive, Dementia and Memory Services (CDAMS) of the
Heidelberg Repatriation Hospital (Austin Health) and
erate AD.
of the Royal Melbourne Hospital; and Alzheimer
There are several limitations to this study. The
Association of Victoria.
inclusion of four people with AD who were living
alone meant that the number of falls these partici-
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