Authors:

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
ORIGINAL RESEARCH ARTICLE
Affiliations:
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.
Correspondence:
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.

0894-9115/11/9101-0012/0
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.

O lder people have an increased risk of falls,
which may lead to disabling injury and death,1 with
30% of people 65 years or older falling one or more
times each year.2 Falls are also a well-recognized
problem for older people with advanced dementia,
who have even higher incidence and adverse conse-
quences compared with healthy older people. In one
study, 42% of a community sample of people with
mild to moderately severe Alzheimer disease (AD)
fell within a 12-mo period,3 and in a residential care
sample, more than 60% of people with advanced
dementia fell within a similar period of time.4
Balance impairment is a strong indicator of
falls risk in older people.1 Motor impairments and
particularly balance dysfunction have been identi-
fied as important contributors to the increased risk
of falls in people with cognitive impairment.5,6 How-
ever, relatively little is known about changes in
balance performance in people with cognitive im-
pairment, particularly in those with mild to moder-
ate symptoms of dementia.
Differences in the underlying etiology asso-
ciated with the different types of dementia could
result in variable cognitive or physical limitations.7
AD is the most common form of dementia, account-
ing for more than 50% of newly diagnosed cases each
year.8 Commonly used criteria for the clinical diag-
nosis of AD state that it is characterized by gradual
onset of cognitive impairment, followed by a con-
tinued cognitive deterioration in which motor sys-
tem abnormalities are unlikely to present until the
advanced stages of the condition.9 These motor sys-
tem abnormalities may include balance and gait dis-
turbances. However, previous studies have reported
gait and balance dysfunction in people with rela-
tively early stages of AD,10Y12 although there are
limitations to the approaches used in many of these
studies. First, although balance is multidimen-
sional13 and it has been reported that no single test
provides an overall perspective of balance perfor-
mance,14 these studies have mostly used only one or
a small number of clinical measures, such as single
leg stance,15,16 Berg Balance Scale, and the Timed
Up and Go (TUG) test.11,12 In addition, although
clinical balance measures have been shown to dis-
criminate falls risk,17,18 concerns have been reported
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-
dent in the early stages of cognitive impairment.
Force platform technology, which uses transducers
to detect postural sway and weight transference
while performing tasks, potentially provides more
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sensitive measurements of balance performance.20,21
In addition, some force platform assessments can
systematically assess underlying impairments con-
tributing to balance dysfunction or can assess balance
control under various conditions.22 For example,
the small number of studies that have compared
balance performance between people with AD and
healthy controls using force platform technology
suggest that people with mild to moderately severe
AD do have balance impairment, particularly when
visual information is limited or when dual tasks are
being undertaken.6,10,23
The second limitation of previous studies is
that most falls occur during dynamic tasks such as
stepping, reaching, and turning24 and that falls
occur not only in the forward direction but also in
the lateral and backward directions.25 However, the
commonly reported balance or mobility measures
in people with AD have been reported by either a
simple reaching forward test (Functional Reach
test) or by total score only (e.g., Berg Balance Scale)
and have not clearly identified the specific dynamic
tasks that were impaired.11,12
In summary, no studies to date have utilized a
comprehensive suite of clinical and laboratory (force
platform) balance assessment tasks, including dy-
namic tasks reflective of falls circumstances (such
as walking, reaching/leaning, turning, and stepping
up onto a block/step) as well as dual task activities,
to describe the magnitude and type of balance dys-
function in people with AD. These limitations high-
light the need for further investigation of balance
performance in people with AD, using a compre-
hensive assessment battery. A better understanding
of balance impairment in people with AD may pro-
vide a framework to guide clinicians in the most
appropriate tools for assessing the presence of bal-
ance dysfunction and in the development of inter-
vention programs specifically designed to improve
balance and reduce falls risk for people with AD.
The aim of this study was to identify differ-
ences in balance performance using a detailed bal-
ance assessment suite (including clinical and force
platform measures) between people with mild to
moderately severe Alzheimer disease and a compar-
ison group of age- and sex-matched cognitively in-
tact older people.
METHODS
Participants
Participants with AD were recruited through the
Memory Clinics of two large metropolitan tertiary
Falls Risk in Alzheimer Disease 13
 hospitals as well as through public notices in lo-
cal and state newspapers and community groups
providing support for people with AD. Participants
were included if they had a diagnosis of AD con-
firmed from a medical specialist or through a Mem-
ory Clinic assessment, if there are AD symptoms
that were of mild to moderate severity (Mini-Mental
State Examination [MMSE] score, Q10), and if they
could walk outdoors with or without a single point
stick. They also had to be living in the community
and have no other serious orthopedic condition (e.g.,
recent lower limb surgery, severe arthritis of a lower
limb) or major neurologic disorder (e.g., stroke,
Parkinson disease) that could potentially restrict
functional mobility.
A comparison group of cognitively intact people
matched to the participants with AD for age (T3 yrs)
and sex were recruited from community notices in a
local newspaper and an existing volunteer database
from a research institute. Participants in the com-
parison group needed to have a MMSE score of
24 or higher, have no serious neurologic or ortho-
pedic condition that could impact balance and
mobility performance, and be able to walk inde-
pendently outdoors with or without a single point
stick.
Measurements and Procedures
Assessments included measures of cognition, a
comprehensive series of laboratory and clinical mea-
sures of balance and mobility performance, and
measures of falls and falls risk. To avoid fatigue, a
short break was scheduled, but participants were
invited to have additional breaks at any time.
Measures of cognition and behavioral distur-
bances consisted of the following:
1. MMSE,26 a cognitive screening tool comprising
11 items covering orientation, registration, at-
tention and calculation, recall, language, a three-
step praxis item, and a graphic copy of a geometric
design. Lower scores indicate greater levels of
cognitive impairment, with a cutoff of less than
24 being used to indicate cognitive impair-
ment,27 and
2. Frontal Assessment Battery,28 a short cognitive
and behavioral battery for screening frontal/
executive dysfunction. The Frontal Assessment
Battery consists of six subtests exploring con-
ceptualization, mental flexibility, motor pro-
gramming, sensitivity to interference, inhibitory
control, and environmental autonomy. Frontal
Assessment Battery scores range from 0 to 18, with
lower scores indicating more severe impairment.
14 Suttanon et al.
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Measures of Balance and Mobility
Performance
A comprehensive suite of laboratory and clini-
cal measures of balance performance were used for
this study, aiming to include measures of the vari-
ous domains of balance, including static and dy-
namic balance, with and without sensory challenge
and with single and dual task. All laboratory and
clinical measures of balance and mobility perfor-
mance used in this study have been shown to be
feasible and safely administered to people with mild
to moderate AD, with fair to excellent retest
reliability.29
Laboratory Measures
A set of static and dynamic balance tasks were
assessed on the Neurocom Balance Master (Neuro-
Com International Inc, Clackmas, OR). The Neu-
roCom Balance Master test battery has been shown
to have moderate to high test-retest reliability (in-
traclass correlation coefficient, 90.84) in assessing
balance dysfunction in healthy older people and
clinical groups,30,31 to be sufficiently sensitive to be
able to identify patients who have previously fallen,
and to be able to predict the risk of multiple falls.32
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-
form were feasible and had fair to excellent retest
reliability in assessing balance and mobility in peo-
ple with AD. All tests were performed with shoes
removed. In the first two tests (modified Clinical
Test of Sensory Interaction on Balance, the Limits
of Stability tests), the feet were positioned apart
at one of three standardized foot positions accord-
ing to manufacturer’s instructions, depending on
the participant’s height. In these two tests, a safety
harness attached to an overhead rail was worn by
participants (loose enough to allow trunk movement,
but firm enough to prevent a fall during testing).
The following laboratory (force platform) measures
from the NeuroCom Balance Master long plate (di-
mensions, 152  46 cm) (NeuroCom Balance Master
Operator V3) were used:
1. Modified Clinical Test of Sensory Interaction
on Balance, a static stance test of postural sway,
measured under four sensory conditions (eyes
open and eyes closed, on a firm and a foam sur-
face). Sway velocity (degrees per second) in each
condition was assessed;
2. Limits of Stability, a test of speed and amplitude
of weight shift (movement of center of gravity
[COG] within the body’s limits of stability) in
eight directions toward a preset target at 100%
Am. J. Phys. Med. Rehabil. & Vol. 91, No. 1, January 2012
 limits of stability. For each of the eight direc-
tions, the measures included the following:
& Reaction time (seconds), which is the time
between the instruction to move (the COG)
and the initiation of movement;
& Movement velocity (degrees per second), which
is the average speed of COG movement;
& Maximum excursion (percentage of limits of
stability boundary), which represents the fur-
thest distance of the COG movement during
testing; and
& Directional control (percentage) reports a
comparison of the amount of movement to-
ward the target-direction to the amount of
movement in any direction other than the
intended direction.
A summary composite score integrating data
from each of the eight directions assessed, reported
from the NeuroCom data analysis for each measure,
was used for analyses.
3. Walk Across, a test of step width (centimeters),
step length (centimeters), and walking speed
(centimeters per second) as the participant walked
at comfortable speed across the long plate;
4. Step/Quick Turn, a test of stability when tak-
ing two steps then turning and returning to the
starting position. Performance was assessed turn-
ing separately to the left and to the right. Aver-
age turn time (seconds) and turn sway (degrees
per second) were reported for turning to both the
right and left direction from three trials in each
direction, and the highest (worse) average score
between the right and left turn sway measures
and right and left turn time measures were used
for analyses; and
5. Sit to Stand, a test of stability during fast sit to
stand without upper limb assistance (degrees per
second). The measures were as follows:
& Rising index (percentage of body weight), which
is the amount of force exerted by the legs dur-
ing the rising phase of sitting to standing; and
& Sway velocity (degrees per second), which is
the average amount of COG sway during the
rise to stand and for the first 5 secs follow-
ing the rise.
For all tests on the NeuroCom Balance Master
except for the Limits of Stability test, three trials were
conducted, and the average scores were reported.
Clinical Measures
A number of clinical measures of balance and
mobility were also used. These measures are simple
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and quick tests routinely used in clinical practice
and research:
1. Functional Reach test,33 a test of dynamic bilateral
stance balance. This test measures the maximum
distance that participants can reach forward with
their dominant arm raised to 90 degrees without
moving their feet, which were positioned 10 cm
apart. The distance of additional reach from the
starting position was recorded (in centimeters).
2. Step Test,34 a test of dynamic single leg standing
balance. The number of times the participant
steps one foot fully on and then off a 7.5-cmYhigh
block as quickly as possible in 15 secs was recorded.
Both legs were tested separately, and performance
on the side with the least number of steps was
used for data analysis.
3. Timed Chair Stands,35 a test measuring global leg
muscle strength, assessed by timing the speed of
standing up/sitting down as fast as possible five
times from a 45-cmYhigh chair, with arms crossed
across the chest.
4. TUG test,36 an assessment that measures speed
during standing up from a standard 45 cm high
chair, walking 3 m at usual speed, turning, then
returning to sit again in the chair (seconds). This
task was reassessed under dual task conditions,
with a secondary cognitive task (counting back-
ward by 3s while performing the TUG) and with a
secondary motor task (carrying a full cup of water
while performing the TUG).17
The measures of falls and falls risk consisted
of the following:
1. The number of falls in the preceding 12 mos as
reported by the participants or their caregivers;
2. The Falls Risk for Older People, community version
(FROP-Com),37 a detailed falls risk questionnaire
evaluating 13 risk factors. The FROP-Com has been
shown to have good retest reliability (intraclass
correlation coefficient, 0.93 and 0.81). It has also
been shown to have moderate accuracy to pre-
dict falls (sensitivity, 71%; specificity, 56%).37 Two
modifications were made to the FROP-Com be-
cause of the nature of the study protocol. Because
the assessment was not conducted at the partici-
pants’ home, the home assessment item was ex-
cluded. This makes the total possible FROP-Com
score 57 instead of 60 points. The score in the
cognitive status domain of the FROP-Com was
originally rated based on the results of the Ab-
breviated Mental Test Score. Instead, we used
MMSE scores to rate this domain into four cate-
gories (MMSE score, 926 [0 point], 20Y26 [1 point],
10Y19 [2 points], and G10 [3 points]) because this
Falls Risk in Alzheimer Disease 15
 cognitive screening tool was already being used
in this study.
3. Physiologic Profile Assessment (PPA),38 an ab-
breviated assessment evaluating standing balance
(eyes open on foam, swaymeter), hand reaction
time, knee joint proprioception, visual contrast
sensitivity, and quadriceps muscle strength. Raw
PPA data from each item were entered into Web-
based software created for the PPA and adjusted
for age and sex, and an overall PPA falls risk score,
which could range from j2 to higher than 4 was
computed for the participant. The retest reliabil-
ity of the PPA has been reported as ranging from
intraclass correlation coefficients38 of 0.50 to 0.97
and has been reported to be feasible to conduct in
older people with mild to moderate AD.39
Measure of Physical Activity
The Human Activity Profile,40 a measure of
physical activity level, evaluated 94 activities listed
in hierarchical order of increasing energy expendi-
ture, each rated as Bstill doing,[ Bhave stopped do-
ing,[ or Bnever did.[ The Maximum Activity Score
was the highest numbered activity still being un-
dertaken. The Adjusted Activity Score was calculated
by deducting from the Maximum Activity Score, the
number of lower numbered items that the partici-
pant has ceased doing. The Adjusted Activity Score
was used for data analysis in this study because it
was recommended to be a more stable estimate of
the individual’s daily activities than the original
Maximum Activity Score.40
The study was approved by the relevant uni-
versity and health services human research ethics
committees. All participants or, where necessary,
their next of kin or caregiver provided written in-
formed consent before taking part in the study.
Statistical Analysis
SPSS Graduate Student Version 16.0 for Win-
dows and a Web-based effect size calculator (http://
www.cemcentre.org/renderpage.asp?linkid=
30325071) were used to analyze data. Descriptive
statistics were used to report the participant profile
and scores for all measures, and the Kolmogorov-
Smirnov test was used to investigate the distribu-
tion of data for all continuous measures.
Balance-related measures that were continu-
ous and normally distributed were compared be-
tween the AD and the comparison groups using
independent-samples t tests. Nonparametric equiv-
alent statistics were used for comparisons between
the two groups where continuous variables were not
normally distributed (Mann-Whitney U test). Balance-
related measures were grouped according to subdo-
mains of the different nature of tests (static balance
tests, dynamic one-leg stance tests, dynamic bilateral
stance tests, gait measures, sit to stand tests, and
muscle strength measures). To account for multiple
comparisons, a Bonferroni adjustment was applied
where more than one measure was used to assess
the same subdomain. This resulted in different sig-
nificance levels for the different subdomains of as-
sessment, depending on the number of assessment
items within each subdomain (Table 2).
A power analysis calculated for this study,
based on the pilot results, indicated that a minimum
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
a
Tested using Mann-Whitney U test.
b
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
the two groups for two outcome measures: maxi-
mum excursion (measured from the Limits of Sta-
bility test on the NeuroCom Balance Master), and
the Step Test, at 90% power and at > = 0.05.
RESULTS
Twenty-five people with AD (mean age, 81.0 yrs;
range, 68Y93 yrs; 36% men) and 25 age- and sex-
matched cognitively intact people (mean age, 80.4 yrs;
range, 68Y90 yrs; 36% men) were recruited. No sig-
nificant between-group differences were detected for
age, weight, height, or the number of other exist-
ing medical conditions. In the AD group, 19 of the
25 people were accompanied by their caregiver on
the assessment day, 1 was accompanied by her case
manager, and the other 5 came alone. Table 1 pre-
sents the baseline characteristics of participants and
the percentages of self-reported (verified by the care-
givers when possible) major medical conditions. For
both groups, hypertension, arthritis, and cardiac
conditions were the most common health problems
reported. All participants with AD were categorized
as having mild to moderately severe dementia (mean
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-
paired executive function).
Balance and Mobility Performance
The comparison of the motor and balance per-
formance and the number of falls between the AD
and comparison group are presented in Table 2.
There were significant group differences (with worse
performance by the AD group) on most balance-
related measures, including clinical measures of dy-
namic balance (Step Test and Functional Reach),
Limits of Stability measures on the NeuroCom Bal-
ance Master (maximum excursion and directional
control), gait measures (velocity and step length),
mobility (TUG single and dual task), and turning
measures on the NeuroCom Balance Master (turn
time and turn sway) (Table 2). Effect sizes for the
significant differences ranged from 0.57 for quad-
riceps muscle strength test to 1.44 for limits of sta-
bility boundary measured on the NeuroCom Balance
Master and for time taken to complete TUG with
cognitive task (Table 2). Two of the static balance test
measures on the NeuroCom Balance Master (eyes
open on firm surface, eyes closed on foam surface)
were also significantly worse for the participants
with AD. For most of the remaining tests (PPA sway
measure and NeuroCom Balance Master measures
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with eyes closed on firm surface and eyes open on
foam surface, NeuroCom Balance Master Limits of
Stability test movement velocity measure, and PPA
hand reaction time test), performance was worse in
the AD participants, with comparisons approaching
significance.
Time taken for all three subtests of the TUG test
(general, dual-task manual, and dual-task cognition)
were significantly longer (indicating greater mobility
impairment) in the AD group than in the compar-
ison group, with the greatest difference in the TUG
performed simultaneously with a cognitive task (ef-
fect size, 1.44). All participants in the AD group were
able to perform the TUG as a single task and with a
manual secondary task; however, five participants
were unable to perform the TUG with a cognitive
secondary task. All participants in the comparison
group were able to perform all the TUG tests (either
as a single test or in dual-task conditions).
Between-group difference was found for the
quadriceps muscle strength (strain gauge). The AD
group reported significantly lower levels of physical
activity (on average, 16 more items rated as Bhave
stopped doing[) compared with the healthy group
(effect size, 1.25).
Falls and Falls Risk
Eleven (44%) of the AD participants had one or
more falls in the previous 12 mos, which was not
significantly different to the proportion of fallers in
the comparison group (nine people; 36%). The AD
group had a total of 19 falls reported in the preced-
ing year, compared with 12 falls in the comparison
group, although this difference was not significant
(P = 0.26). Falls risk, as measured by both the FROP-
Com risk assessment tool and the PPA identified that
people with AD had significantly higher risk of falls
relative to the comparison group (FROP-Com, P =
0.000; PPA, P = 0.007).
DISCUSSION
The results of this study highlight the broad
range of balance and mobility impairments in peo-
ple with mild to moderate severity AD. Although
there was no significant difference in the number of
falls, the AD group had double the level of falls risk
on two falls risk assessment tools (the FROP-Com
and the PPA). Impaired balance and mobility per-
formance were observed across the range of mea-
sures in this study, highlighting the global nature
of balance and mobility dysfunction in people with
mild to moderately severe AD. The results reinforce
Falls Risk in Alzheimer Disease 17
 18
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

Y
Y
Y
Y
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
0.262

balance to a greater level than did healthy controls.10

P

Y
Y
Y

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
(56%)
(12%)

(24%)
(8%)

also reflect impairments in other components of the

balance control system. These include the organi-
14
3
2
6

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
Continued

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

TABLE 2

also reflect poor movement coordination that has

a

d
c

been previously reported in people with different

types of dementia, including AD.43,44

www.ajpmr.com 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-
ple with AD in our study had difficulty performing
the turning task of the Step Quick Turn test and the
walking with turning task in the TUG test. The dif-
ficulty experienced in the TUG test occurred when
performed both as a single-task and in dual-task
conditions. The AD group had particular difficulty
when performing the TUG test when the secondary
task was a cognitive task, resulting in a more than
30% increase in the magnitude of impairment (based
on the difference in effect size). Furthermore, 5 of
the 25 participants in the AD group were unable to
complete the cognitive dual task. These findings
support previous evidence of the deficits in divided
attention (ability to respond simultaneously to mul-
tiple tasks) and selective attention (ability to focus
attention in the presence of distraction) commonly
observed in the early stages of AD.45,46 They also
correspond with decreased stability during dual-
task conditions observed in people with AD.6 The
greater impairment found when the secondary task
was a cognitive task rather than a manual task sug-
gests that when performing dual tasks, the motor
impairment can differ depending on the type of ad-
ditional task performed. Secondary tasks that re-
quire high cognitive involvement (such as counting
backward) seem to have a higher impact on motor
performance (primary task such as walking) for peo-
ple with AD in comparison with healthy older peo-
ple. These results highlight the potential importance
of (1) targeting turning and dual-task activities in
balance exercises in people with mild to moderate
AD in an attempt to improve performance, and/or
(2) informing the person with AD and their care-
givers of their difficulties with these tasks and
highlighting the importance of taking extra care or
minimizing exposure to these tasks (e.g., stop walk-
ing while talking in a manner that requires high
attention). Further research is warranted to explore
the effectiveness of these approaches in reducing
the risk of falls in this high-risk group.
Both in our study and in previous studies,44,47
the participants with AD walked more slowly than
the nonYcognitively impaired participants. The sig-
nificant reductions in gait speed and step length
identified in the present study might both reflect
and be a response to the reduced postural stability
in people with AD during walking. However, no
difference in step width was identified between the
two groups. This finding is consistent with that of
a previous study of ten people with AD, ten peo-
ple with dementia with lewy bodies, and ten healthy
controls, which examined gait using an electronic
walkway.47 Walking slower or with shorter step
20 Suttanon et al.
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
lengths might be preferred compensatory mecha-
nisms for people with AD to improve postural in-
stability, rather than widening the step width.
People with AD had significantly lower levels of
physical activity than the comparison group, with
more than 15 points of average reduction in the
physical activities rated as Bstill doing[ using the
Human Activity Profile. Deterioration in balance
performance might have contributed to the decline
in physical activity observed in the AD group. It is
possible that either the participants or their care-
givers respond to their awareness of the increased
risks of falling by limiting physical activity of the
person with AD. It remains unclear whether a de-
crease in physical activities leads to reduced de-
mand on the motor and balance system, which then
impacts on balance control performance and the
confidence to perform activities independently, or
whether the decline in balance performance results
in reduced activities. This relationship warrants fur-
ther investigation. Furthermore, recent systematic
review evidence suggests that increasing physical
activity may reduce the risk of AD48,49 or delay pro-
gression of cognitive impairment.50
Importantly, most of the clinical measures such
as the Step Test, Functional Reach Test, and TUG
test helped identify significant and clinical differ-
ences in balance and mobility performances (based
on effect size). These tests take little time, equip-
ment, or training to perform, so they could be eas-
ily added to assessments of people presenting with
mildly to moderately severe AD (e.g., at Memory
Clinics and other assessment services for people
with cognitive impairment) to screen for the pres-
ence of balance dysfunction.
It is worth noting that this group of partici-
pants with AD also exhibited a decrease in quadri-
ceps muscle strength and reduced performance
(although not statistically significant) on the func-
tional activity of sit to stand. Sit to stand is a com-
plex motor task, incorporating the synchronization
of a group of muscles generating large forces in a
short time to achieve the required task. At least part
of the muscle strength deterioration may be asso-
ciated with secondary deconditioning, given the
moderate reduction in physical activity reported in
the AD participants. Because muscle strength par-
ticularly in lower limb muscles is one of the key
components of the balance control process,41 ex-
ercise interventions aiming to improve balance and
mobility in people with AD should include lower
limb strength training.
Nearly 45% of people with AD reported a fall
in the preceding 12 mos. This is consistent with a
Am. J. Phys. Med. Rehabil. & Vol. 91, No. 1, January 2012
previous finding, in which 42.3% of 124 people with
mild to moderate AD fell in the preceding year.3 Our
study used retrospective falls recall during the past
12 mos to document falls history, which has been
shown to underestimate actual fall incidents by
approximately 20% in cognitively intact older peo-
ple compared with prospective monitoring through
falls calendars.24 As such, the real rate of falls in
community-dwelling older people with AD may be
even higher than our results suggest.
Although identifying the presence of balance
impairment and the associated increase in falls
risk in people with mild to moderate severity AD is
important, the main potential value is determin-
ing whether there is a capacity to improve balance
performance in this group. There is strong evidence
that balance training can improve balance perfor-
mance and reduce falls in older people without spe-
cific health conditions who are living either in the
community or in institutional care51,52; however, to
date, there is relatively little research investigating
this in people with cognitive impairment, especially
those with AD. A recent systematic review by our
team has found that there were only seven ran-
domized controlled studies that included balance or
falls measures as outcomes and included balance-
related exercise in the exercise program for people
with dementia.53 Although this review clearly high-
lights the need for more high-quality research in this
area, it does provide some support that these iden-
tified balance impairments may be amenable to
exercise intervention in people with mild to mod-
erate AD.
There are several limitations to this study. The
inclusion of four people with AD who were living
alone meant that the number of falls these partici-
pants reported could not be validated. In addition,
using a retrospective falls data collection approach
probably underestimated the falls data. Prospective
falls data collection will provide a more accurate
estimate of frequency of falls in people with AD. In
addition, even though a range of balance and mo-
bility impairments and a high level of falls risk were
observed in participants with AD in this study, we
cannot conclude that these impairments have been
caused only by AD. Despite the efforts that were
made to match the two groups and the inclusion
criteria that excluded people with other major health
conditions that could potentially have an impact on
balance and mobility (such as stroke and Parkinson
disease), it is possible that there were other possible
systematic differences between the two groups. We
also sought to examine the influence of a secondary
task on mobility performance using the TUG test.
www.ajpmr.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
However, the TUG test, when performed simulta-
neously with the cognitive task (counting backward
by 3s), was too difficult for some of our participants
to complete. Future studies should include a sin-
gle cognitive task condition before performing this
task in combination with the mobility task to give a
clearer picture of the influence of the secondary task
on mobility performance in people with AD.
CONCLUSIONS
Balance and mobility impairments are identi-
fied in people with mildly to moderately severe AD,
impairments that may contribute to an increased
risk of falling in this population. Both laboratory
(force platform) and clinical measures used in this
study identified balance dysfunction in people with
AD. In clinical settings, where computerized force
platform equipment is not available, clinical measures
such as the Step Test, Functional Reach test, and the
TUG test may be practical and useful. Further re-
search is required to evaluate whether people with
mildly to moderately severe AD identified with bal-
ance impairments will benefit from exercise pro-
grams to improve balance and minimize future risk
of falls.
ACKNOWLEDGMENTS
We are grateful to all the participants who
agreed to be part of the study. We also acknowledge
the kind help and support from staff at the Cogni-
tive, Dementia and Memory Services (CDAMS) of the
Heidelberg Repatriation Hospital (Austin Health) and
of the Royal Melbourne Hospital; and Alzheimer
Association of Victoria.
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