Effects of case management on motor and environmental risk factors for falls in older people with cognitive impairment: a randomized clinical trial

doi:10.21203/rs.3.rs-3755269/v1

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Effects of case management on motor and environmental risk factors for falls in older people with cognitive impairment: a randomized clinical trial

https://doi.org/10.21203/rs.3.rs-3755269/v1

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Objective: To verify the effectiveness of an intervention based on case management on motor and environmental risk factors for falls in community-dwelling faller older people with cognitive impairment.

Design: This is a randomized clinical trial.

Setting: The study developed in the year 2021 and 2022.

Participants: Participants were faller older people with cognitive deficits. The participants were divided into two groups: Control Group (CG) and Intervention Group (IG).

nterventions: The IG underwent case management for 16 weeks conducted remotely, which involved a multidimensional assessment, explanation of the identified risk factors for falls, completion of intervention proposal based on the identified risks.

Main outcome measures: There were an initial assessment, a final assessment after 16 weeks, and a follow-up assessment after 6 weeks, remotely. The Short Physical Performance Battery (SPPB), Timed up and Go test (TUG) and TUG dual task, Manchester Index, Home Falls and Accidents Screening Tool (HOME FAST) were used, as well as foot inspection and shoe questionnaire.

Results: The total sample consisted of 52 older people, 25 from the CG and 27 from the IG. There was no significant interaction between groups and moments. The CG presented a worse performance in muscle strength when compared to the IG, regardless of the assessment. In feet and footwear, there was a significant difference between groups (CG and IG) in the initial assessment and between assessments in both CG and IG.

Conclusion:There was no effectiveness of an intervention based on case management on the motor risk factors for falls in faller older people with cognitive impairment. However, regarding environmental risk factors, specifically the use of footwear, it was possible to verify changes regarding the use after the intervention and follow-up, with adherence to the recommendations given.

Aged

Risk Factors

Muscle Strength

Falls

Falls and their resulting injuries are now considered a public health problem worldwide with serious consequences for countries with rapidly aging populations, such as Brazil¹. Elderly people with cognitive deficits have a higher frequency of falls than the elderly population in general, which justifies in-depth studies that explore this topic².

Falls occur as a result of a complex interaction between risk factors, which are multifactorial and involve intrinsic and extrinsic elements³. Thus, it is essential to include different types of interventions in preventive programs, which can be administered alone or in combination⁴. One of these interventions, case management, identifies the characteristics of elderly people and their families, offers adequate planning to meet their needs, and assembles the necessary services to meet those needs⁵.

In 2020, the World Health Organization (WHO) declared COVID-19 a pandemic, and the elderly population was one of the most vulnerable groups for complications of the disease. Therefore, case management, performed remotely during a public health crisis was especially important to elderly individuals at risk of falls. Further, the quality care and improved quality of life demonstrated during the pandemic can be continued.

The hypothesis supported by this study is that elderly fallers with cognitive deficits, when subjected to a case management intervention focused on falls during the pandemic period, had reduced motor and environmental risks of falls. This reduction was maintained in the follow-up period.

Study design

This was a single-center, parallel (Intervention Group (IG) and Control Group (CG)) randomized controlled clinical trial, with an allocation ratio of 1:1, and single-blind (evaluators). The project was conducted in the University of São Carlos (UFSCar) of the Brazil, located in the city of São Carlos, in 2021 and 2022. The project complied with CONSORT (2010).

Ethical approval and Consent to Participate

The Ethics Committee of UFSCar approved the experiment (34350620.7.0000.5504). The informed consent was obtained from all subjects. Also, the work was included in the Brazilian Registry of Clinical Trials (REBEC) in 25/09/2020 and updated in 2023 with the number RBR − 3t85fd.

Participants

The inclusion criteria were as follows: older people who had a history of at least 2 falls in the past 12 months, who were able to walk alone with or without walking aids, were available to participate in evaluations and interventions, who scored on the Mini Mental State Examination (MMSE) below the cutoff point for education level⁶ and/or scored in Addenbrooke's Cognitive Examination– Revised (ACE-R) below 78 points⁷. Participants were also required to have access to virtual communication with audio and camera or have a family member with access and familiarity with virtual communications to enable the proposed evaluations and intervention.

The exclusion criteria were as follows: older people with severe and uncorrected auditory or visual disturbance that hindered communication during evaluation and interventions, with motor sequelae of stroke, active inflammatory diseases (acute, uncontrolled), Parkinson's disease in the advanced stages, multiple sclerosis, Huntington’s disease, dementia, uncontrolled vestibulopathy, epilepsy and traumatic brain injury or who were taking medications that indicate the presence of these diseases.

The study included an initial evaluation, a final evaluation after 16 weeks of interventions and a follow-up evaluation after 6 weeks. The evaluations and interventions were performed remotely through video calls on WhatsApp or Google Meet, according to the access and preference of each participant. The participants were divided into two groups (CG, IG), and their randomization was performed by a researcher who was not involved in the recruitment, evaluations or interventions.

The participants allocated to the CG were encouraged to maintain their routine and were monitored monthly regarding their general health, in addition to completing a falls calendar.

Intervention

The IG was subjected to case management through weekly calls. In the 1st week, a multidimensional evaluation was performed, which included screening of the main risk factors for falls. In the 2nd week, the case managers explained the risks identified for each participant and his or her caregivers and the proposed interventions, in addition to encouraging participants to adhere to the physical and cognitive exercise program. In the 3rd week, an individualized fall intervention plan was developed with the help of the elderly person, taking into account the priority fall risk treatments and the individual’s personal preferences. From the 4th to the 16th weeks, the plan for the participant was put into practice, with the necessary guidelines and recommendations. Detailed information about the protocols are available^8,9.

The physical exercise program consisted of a warm-up, muscle strengthening, balance exercises and stretching. The determination of the muscle strengthening load was assessed using the Borg CR-10 Scale⁹. In the 1st week, familiarization of the exercises was performed, and in the following weeks, videos were sent so that the volunteers could perform at the times they preferred. They also received calls every 15 days to answer possible doubts, make corrections and progressions^8,9. The cognitive stimulation program consisted of memorization strategies, interactive games, attention and concentration strategies, conversation circles about memory loss, health education actions and blood pressure measurement and monitoring. The intervention occurred over the course of 16 weeks in 2 weekly meetings for monitoring and elimination of doubts regarding the performance of activities^8,9.

Assessment

Muscle strength, mobility and balance were assessed using the Brazilian version of the Short Physical Performance Battery (SPPB), which consists of three tests: balance tests, gait speed test and stand-up test¹⁰. Mobility was also assessed by TUG and dual-task TUG, which aimed to evaluate postural control systems and mobility¹¹. The Manchester index of disability associated with foot pain in the elderly population was used¹². Safety at home was assessed using the Home Falls and Accidents Screening Tool (HOME FAST) to identify the risk factors for falls and domestic accidents¹³. The evaluation of footwear was performed according to the environmental assessment and risk of falls¹⁴, which describes the use of footwear most used during the night and day by elderly individuals. In addition, the participant showed the model of footwear most used by them daily¹⁵.

All the assessments were recorded and the volunteer could request a copy of the videos at any time during the study. The storage files with the recordings of the evaluations were stored in Google Drive (virtual file storage service) at the Magic Program, where this research took place. Only the researchers who carried out the assessments and the teachers coordinating the research have access to check the information, if necessary. The security of the videos is guaranteed by Google and access to them is only granted through two-step authentication, which makes it difficult for hackers to gain access.

Data Analysis

A significance level of α = 0.05 was adopted, and SPSS software (22.0) was used to perform the statistical tests. The analysis was performed by intention-to-treat. The Kolmogorov‒Smirnov normality test was applied to all continuous variables to verify data distribution. The chi-square test of association was used for categorical variables to compare groups regarding clinical and sociodemographic characteristics. The independent t test was used for continuous variables with a normal distribution. Two-way ANOVA was used to test the interaction between groups and moments. In case there was interaction, analyses of simple main effects were performed, with adjustment for multiple comparisons (Bonferroni). In the sample size calculation, an effect size of moderate magnitude (0.2) was delimited¹⁶.

Initially, 523 older people were selected for this study. Of these, 52 met the study criteria and consented to participate. Sixteen weeks after the initial evaluation, four volunteers, two from each group, did not undergo the reevaluation due to dropout, even though they were invited to participate in it. Thus, the final sample consisted of 48 participants, 25 participants in the IG and 23 participants in the CG. At follow-up, the number of older individuals in the CG was 21 and 24 in the IG, as 3 participants, 2 from the CG and 1 from the IG, were excluded due to lack of interest in continuing to perform the reassessments, health problems or loss of contact.

Regarding the adherence in the case management intervention, the average was 80.27%, and 81.25% of the participants in the IG showed satisfactory adherence, that is equal to or above 70% frequency. Among the IG participants, 62.5% had only 1 fall. In contrast, in the CG, 17 individuals suffered at least one fall for a total of 50 falls, and the percentage of participants who had more than one fall was 52.95%. It is noteworthy that 19 participants agreed to adhere to the physical and cognitive interventions, and 6 agreed to participate only in the physical intervention.

Regarding the initial clinical and sociodemographic characteristics (n = 48), there were no significant differences between groups in any variable. In both groups, there was a prevalence of females, with a mean age between 73 and 74 years and a mean year of schooling of 9 years. The mean total ACE-R score was between 69 and 73 points (Table 1).

Table 1

Initial clinical and sociodemographic characteristics of the sample **(n = 48)**
Characteristics, Md (IIQ) ou n (%)	Control Group (n = 23)	Intervention Group (n = 25)	Valor p
Age (years)	74,4 (70,1–78,7)	73,4 (69,9–76,8)	0,698
Female, n (%)	20 (87,0)	22 (88,0)	0,913
Race
White	18 (78,3)	19 (76,0)	0,678
Brown	3 (13,0)	5 (20,0)
Black	2 (8, 7)	1 (4,0)
Marital status			0,394
Married	8 (34,8)	8 (32,0)
Single	0 (0,0)	2 (8,0)
Widower	11 (47,8)	13 (52,0)
Separated	2 (8, 7)	0 (0,0)
Divorced	2 (8, 7)	2 (8,0)
Years of schooling	9,9 (7, 7–12, 3)	9,3 (6, 9–11, 7)	0,739
Number of diseases	2,2 (1,6 − 2,9)	2,2 (1,6 − 2,7)	0,879
SAH	14 (60,9)	15 (60,0)	0,951
DM	7 (30,4)	8 (32,0)	0,907
Monthly income
Up to 1 MS	6 (26,1)	3 (12,0)	0,779
1 to 2 MS	4 (17, 4)	5 (20,0)
2 to 3 MS	5 (21, 7)	3 (12,0)
3 to 5 MS	3 (13,0)	4 (16,0)
5 to 10 MS	3 (13,0)	6 (24,0)
10 to 20 MS	1 (4, 3)	2 (8,0)
More than 20 MS	1 (4, 3)	1 (4,0)
IMC (kg/m²)	27,2 (25,1–29,4)	27,6 (25,4–29,9)	0,798
Number of falls	3,5 (2, 4–4, 7)	2,6 (2,2–3,0)	0,081
Level of physical activity
QBMI	4,7 (2,7 − 6,8)	4,5 (2,7 − 6,3)	0,856
ACE-R (0–78)	69,0 (60,8–77,1)	73,3 (67,2–79,4)	0,379
Number of medications	4,8 (100)	3,4 (100)	0,143

SAH = Systemic Arterial Hypertension, DM = Diabetes Mellitus, MS = Minimum Wage, BMI = Body Mass Index, QBMI = Modified Baecke Questionnaire for the Elderly, ACE-R = Addenbrooke's Cognitive Examination - Revised. n (%) - number of individuals (percentage); Quantitative data presented in Md (IIQ) = Median (interquartile range 25–75%) due to most data showed non-normal distribution (Shapiro-Wilk normality test); p-value - significance level ≤ 0.05 (Mann-Whitney and Chi-square tests).

Motor risk factors for people who adhered to intervention

Regarding motor functions, early motor disorders in both the CG and IG were evidenced by low scores in the gait performance and stand-up test in the SPPB. The participants had a physical mobility deficit with an indication of risk of falls, according to performance on the TUG, and disability associated with foot pain, according to the Manchester index. There was no significant interaction between groups and time points or differences between time points for any variable. There was a significant difference between groups only in the time spent in the test to get up from a chair (seconds), regardless of the time points.

Regarding the environmental variables, the sample had a low risk of falls and accidents at home, according to the average HOME FAST score. In addition, there was no significant interaction between groups and time points or differences between time points and groups in HOME FAST (Table 2).

Table 2

Results between groups and motor function assessments of the sample **(n = 48).**
	Moment 1	Moment 2	Moment 3	Moment 1	Moment 2	Moment 3	p-value Group* Assessment	p-value Group	Value p Value
	CG (n = 23)	CG (n = 23)	CG (n = 21)	IG (n = 25)	IG (n = 25)	IG (n = 24)
SPPB (0–12)	5,4 ± 1,9	6,0 ± 2,2	6,0 ± 2,2	5,6 ± 2,4	6,0 ± 2,9	6,0 ± 2,4	0,906	0,775	0,097
Balance (0–4)	3,0 ± 1,2	2,7 ± 1,3	2,7 ± 1,3	3,1 ± 1,3	2,9 ± 1,4	3,0 ± 1,2	0,617	0,807	0,827
Gait (0–4)	1,3 ± 0,7	2,0 ± 0,6	2,0 ± 0,6	1,4 ± 0,9	1,6 ± 1,1	1,7 ± 1,1	0,319	0,807	0,846
Getting up from chair (seconds)	20,2 ± 11,7	20,5 ± 7,0	20,5 ± 7,0	15,1 ± 10,0	18,4 ± 5,8	19,0 ± 6,5	0,755	0,049	0,144
Getting up from chair (0–4)	1,1 ± 0,6	1,2 ± 1,1	1,2 ± 1,1	1,1 ± 0,9	1,4 ± 1,1	1,2 ± 1,0	0,824	0,517	0,898
Manchester Index (0–38)	9,0 ± 12,0	3,8 ± 1,9	3,8 ± 1,9	8,5 ± 11,4	4,3 ± 2,8	4,1 ± 2,4	0,123	0,652	0,653
TUG (seconds)	22,4 ± 16,8	22,0 ± 20,3	22,0 ± 20,3	17,7 ± 9,0	16,7 ± 9,9	17,8 ± 13,3	0,417	0,360	0,703
Dual tasking (number of animals spoken)	10,0 ± 2,9	9,1 ± 2,9	9,1 ± 2,9	7,4 ± 4,1	8,9 ± 3,9	8,1 ± 2,5	0,702	0,534	0,652
Dual tasking (seconds)	32,5 ± 33,9	34,1 ± 37,5	34,1 ± 37,5	26,3 ± 18,5	22,6 ± 15,9	23,8 ± 16,3	0,963	0,278	0,864

CG = Control Group; IG = Intervention Group; SPPB = Short Physical Performance Battery; TUG = Timed Up and Go Test; M ± SD = Mean ± standard deviation; p value = level of significance > 0.05 in all analyses (ANOVA two-way test).

Environmental risk factors of people who joined the intervention

Regarding the feet and footwear, the use of flip-flops was the footwear most used during the day and when getting up at night. Regarding the most used footwear model, at time 1, it was sneakers/shoes/boots in the CG and flip-flops in the IG. In addition, there was a significant difference between groups (CG and IG) at time 1 of feet and footwear in relation to the type of footwear normally used when getting up at night. In IG, there were significant differences between time points 2 and 3, where two people stopped wearing shoes and went barefoot and one person started using flip-flops (Table 3).

Regarding the footwear most commonly used during the day, there were no differences between groups. In the CG, there were significant differences between time points 1 and 2, with one participant no longer wearing flip-flops, and between time points 2 and 3, with a decrease in the use of shoes and an increase in the use of flip-flops. In the most commonly used footwear model, there was no difference between groups at any time. In IG, there was a significant difference between time points 1 and 2, where two people started to wear sneakers/shoes/boots and two people stopped wearing sneakers/shoes/boots, and between time points 2 and 3, there was a decrease in the use of sneakers/shoes/boots and sandals and an increased use of sneakers (Table 3).

Table 3

Results between groups and assessments of the environmental variables in the sample **(n = 48).**
	Moment 1	Moment 2	Moment 3	Moment 1	Moment 2	Moment 3	Group p-value* Rating	p-value Group	p-value Evaluation
	CG (n = 23)	CG (n = 23)	CG (n = 21)	IG (n = 25)	IG (n = 25)	IG (n = 24)
HOME FAST (0–25)	5,7 ± 3,0	4,4 ± 2,5	3,8 ± 1,9	5,4 ± 3,2	4,3 ± 2,8	4,1 ± 2,4	0,854	0,929	0,929
Feet and footwear
When you are in your (home/apartment) during the day, what type of shoes do you usually wear?							-	0,674 (Av. 1), 0,652 (Av.2), 0,630 (Av. 3)	GC: 0,026 (Av.1-Av.2), 0,329 (Av.1-Av.3), 0,007 (Av.2-Av.3) GI: <0,001 (Av.1-Av.2), 0,001 (Av.1-Av.3), < 0,001 (Av.2-Av.3)
Shoes/ Barefoot	8 (34,8)	8 (36,4)	5 (23,8)	7 (28,6)	7 (28,6)	7 (29,2)
Slippers	14 (69,9)	13 (59,1)	16 (76,2)	16 (64,0)	17 (68,0)	17 (70,8)
Socks only	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
Others/ Don't know	1 (4, 3)	1 (4, 5)	0 (0)	2 (8,0)	1 (4,0)	0 (0)
Which model of footwear do you use the most?							-	0,322 (Av. 1), 0,457 (Av.2), 0,214 (Av. 3)	GC: 0,158 (Av.1-Av.2), 0,133 (Av.1-Av.3), 0,012 (Av.2-Av.3) GI: 0,033 (Av.1-Av.2), 0,506 (Av.1-Av.3), 0,004 (Av.2-Av.3)
Tennis shoes/boots	11 (47,8)	7 (31,8)	8 (38,1)	9 (36,0)	9 (36,0)	6 (20, 8)
Slippers	6 (26,1)	12 (54,5)	9 (42,9)	9 (36,0)	10 (40,0)	8 (33,3)
Sneakers	6 (26,1)	3 (13, 6)	4 (19,0)	7 (28,0)	6 (24,0)	11 (45,8)
Heels over 2cm	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
What kind of shoes do you usually wear when you get up at night?							-	0,035 (Av. 1), 0,184 (Av.2), 0,067(Av. 3)	GC: 0,099 (Av.1-Av.2), 0,001 (Av.1-Av.3), 0,002 (Av.2-Av.3) GI: 0,401 (Av.1-Av.2), 0,650 (Av.1-Av.3), 0,023 (Av.2-Av.3)
Shoes/ Barefoot	5 (22,7)	2 (9,0)	3 (14, 3)	9 (36,0)	8 (32,0)	6 (25,0)
Slippers	17 (77,3)	19 (86,4)	18 (85,7)	14 (56,0)	17 (68,0)	18 (75,0)
Socks only	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
Others/ Don't know	0 (0)	1 (4, 5)	0 (0)	2 (8,0)	0 (0)	0 (0)

CG = Control Group; IG = Intervention Group; HOME FAST = Home Falls and Accidents Screening Tool; n (%) = number of subjects (percent); M ± SD = Mean ± standard deviation; Av.=Assessment; p-value = level of significance > 0.05 in all analyses (ANOVA two-way and Chi-square test).

The present study aimed to verify the effectiveness of a case management protocol on motor risk factors for falls in elderly fallers with cognitive impairment. Regarding the main results, there was no significant interaction between groups and time points. The CG showed worse performance in muscle strength than the IG, regardless of the evaluation. Regarding feet and footwear, there was a significant difference between groups in the initial evaluation and between evaluations.

According to the selection criteria, all volunteers had experienced more than two falls, with a mean between 2 and 3 falls in the previous year. In addition, in relation to the ACE-R, all participants scored below 78 points, suggestive of cognitive impairment⁷. The importance of working with this population is emphasized, as elderly people with cognitive impairment are 5 times more exposed to this phenomenon than the general elderly population¹⁶. Regarding motor disorders, the sample showed poor performance in gait and lower limb muscle strength¹⁰, in addition to physical mobility impairment with an indication of risk of falls¹¹ and disability associated with painful foot¹⁷. Another study involving 177 community-dwelling older people with cognitive impairment also associated higher rates of falls with slower reaction time, impaired balance, reduced functional mobility and worse cognitive performance¹⁸. Regarding the effects of interventions on motor functions, the intervention based on case management associated with a physical exercise program was not sufficient to improve mobility, lower limb muscle strength, postural balance and changes in the feet of the participants.

Regarding the Manchester index, although we did not find a significant difference, there was a decrease in the score in both groups after the intervention/follow-up. In the IG, from evaluation 1 to evaluation 2, there was a difference of 4.2 points, and from evaluation 1 to evaluation 3, there was a difference of 4.4 points. In the study by van der Zwaard, the minimum clinically relevant difference was evaluated by the Manchester index subscale using Cronbach's α. Those with a difference between 0.7–0.95 were considered acceptable¹⁹. Thus, we can consider that both interventions had positive effects, and the difference in the score found in the study can be considered relevant for clinical practice.

In the present study, the sample had a low risk of falls and accidents at home, according to the average HOME FAST score¹³. It is important to note that this evaluation was based on what the participant reported, so there was no home visit by the evaluator to identify risk factors for falls in the environment. Regarding the effects of the intervention on environmental risk factors, Fischer et al. (2014) found no significant effects on motor and environmental risk factors with a multifactorial intervention among 245 older people who had cognitive impairment and a risk for falls. The authors suggest that to modify the risk of falls in elderly people with cognitive impairment, approaches different from those used with cognitively healthy older people are needed, and these should be individualized and multifaceted²⁰. Thus, it is important to note that the case management intervention, as well as the physical intervention and its progression, occurred on an individual basis, respecting the preferences of the participants in the present study.

In the evaluation of feet and footwear, the use of flip-flops was the footwear most used at home during the day and when getting up at night. The most used footwear model, at baseline, was sneakers in the CG and sandals in the IG. Koepsell et al. (2004) conducted a study with 1,371 older people for 2 years to determine how the risk of a fall varied in relation to the style of footwear used. As a result, the authors found that tennis shoes were the footwear styles associated with a lower risk of falling, and walking barefoot or wearing socks was associated with a greater risk of falls²¹. There were also significant differences between evaluations in both CG and IG, with adherence to the given recommendations, especially between evaluations 1 and 2, but still with sandals being the most used footwear during the day at home. This result may have occurred because the managers during the meetings indicated the use of sandals with elastic bands holding the heels of the feet because the vast majority of the participants were already accustomed to this type of footwear, alleging comfort and practicality.

Thus, the case management intervention, despite presenting some changes in relation to the use of shoes, was not able to modify the routine of participants in the short term, a result that could be modified in a long-term intervention, where managers would have more time to work with health education and awareness of the risk of falls related to the use of footwear.

Study limitations

As a limitation, this study lacks a heterogeneous sample when taking into account the profile of a faller or nonfaller in Brazil, since there were no representations of this population in all states and the program was open to the country integer. In addition, due to the scarcity of resources, it was not possible to add a third comparison group with the physical exercise protocol alone. Furthermore, there was no medical evaluation confirming the absence of dementia in the sample, only self-report. However, the study also brings innovation to remote evaluation and intervention, showing that it is possible to work prevention protocols at a distance, even with elderly people who have cognitive deficits.

For future research, a comparative study is suggested to verify the effectiveness of a case management protocol on the motor and environmental risk factors for falls in elderly fallers with partially remote cognitive impairment.

The results of this study may be relevant in the clinical practice of professionals who work with elderly fallers and case management. The protocol used can be easily reapplied because it is remote, low cost and can be performed in a group. In addition, remote intervention is a viable and safe alternative even for elderly people who fall and have difficulties adhering to face-to-face programs. The importance of this study is emphasized because it can serve to create and improve public intervention programs for elderly fallers with cognitive impairment, as this population has a higher frequency of falls².

The present study concludes that although the IG showed satisfactory adherence (equal to or above 70%), there was no efficacy of an intervention based on case management of the motor risk factors for falls in elderly fallers with cognitive impairment. However, regarding the environmental risk factors, specifically the use of footwear, it was possible to observe changes regarding adherence to the recommendations after the intervention and during follow-up. Such changes were not maintained after 6 weeks of follow-up. More randomized clinical trials with case management-based interventions are suggested to corroborate the findings.

Acknowledgment

The authors acknowledge the intellectual support given by CAPES (financial code 001) and the financial support given by CNPq and FAPESP.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding statement

CNPq, FAPESP and CAPES (financial code 001).

Availability of Data and Materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Effects of case management on motor and environmental risk factors for falls in older people with cognitive impairment: a randomized clinical trial

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