Dementia as a Risk Factor for Falls and Fall Injuries Among Nursing Home Residents

Carol van Doorn, PhD, Ann L. Gruber-Baldini, PhD, Sheryl Zimmerman, PhD, J. Richard Hebel, PhD, Cynthia L. Port, PhD, Mona Baumgarten, PhD, Charlene C. Quinn, PhD, George Taler, MD, Conrad May, MD, Jay Magaziner, PhD, MSHyg


J Am Geriatr Soc. 2003;51(9) 

In This Article


The study population was a cohort of residents newly admitted to 59 randomly selected nursing homes in Maryland stratified by geographic region and facility size. Subjects were enrolled in the Epidemiology of Dementia in New Admissions to Nursing Homes Study.[12] All newly admitted residents aged 65 and older who had not resided in any nursing home or chronic care facility for 8 or more days in the previous year were eligible and were identified by facilities from September 1992 through March 1995.

Residents who were admitted to acute care hospitals within the first 7 days of nursing home admission and then returned to the nursing home were enrolled after their readmission. Participants were followed for up to 2 years or until death or discharge. Of the 2,285 eligible residents, 132 had no follow-up data; 80 had a short stay (less than 8 days) and were excluded from the follow-up, 40 had missing charts, and 12 denied permission to collect follow-up information. For an additional 138 residents, 25% or more of the chart data were missing, and they were excluded. Thus, 2,015 residents were included in the current study.

Eligible subjects who were enrolled were older (81.5 years vs 80.6 years, P<.001) and more often female (71.6% vs 68.6%, P<.05) than those who were excluded. Additional details on the methods of the study may be found elsewhere.[12] The institutional review board of the University of Maryland at Baltimore approved the protocol.

Baseline data were collected from multiple sources, including structured interviews by trained lay interviewers with residents, nursing staff, and significant others; review of medical records from the first week in the nursing facility; the chart-based Minimum Data Set (MDS); and hospital discharge summaries when available.

Dementia status was determined in accordance with Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised criteria[13] by a team consisting of a geriatric psychiatrist and a neurologist, with review by a second team and a geriatrician when there was disagreement. Of the population for this study (N=2,015), 48.2% were designated as having dementia, 32.4% were determined not to have dementia, and 19.4% could not be classified as to their dementia status and were designated as difficult to diagnose. The difficult-to-diagnose designation was used when available evidence was inadequate for rendering a diagnostic decision. Approximately 81% of residents who were difficult to diagnose had suffered a stroke, were comatose, or had another serious medical condition that made diagnosis difficult. A detailed description of the dementia ascertainment methodology is available elsewhere.[14]

Risk factors for falling were included as confounding variables and include age, sex, race, education, and marital status. Additional variables were obtained from the nurse interview: functional impairment (total number of dependencies out of six possible), hearing problems, ambulatory status (bedfast, chairfast), Psychogeriatric Dependency Rating Scales (PGDRS) orientation and behavior scales,[15] a modified version of the Cornell depression scale,[16] and continence status. Data on fall history, comorbid conditions, stroke history, and alcohol use history were obtained from residents' significant others.

The MDS was the source of the following risk factors: severity of dementia (MDS cognition scale); functional decline (recent deterioration in activities of daily living (ADLs); unsteady gait; balance problem; use of assistive device; wandering; dizziness or fainting problems; cardiac dysrhythmias; Parkinson's disease; arthritis; resident and staff belief that resident could be more independent in ADLs; osteoporosis; weight loss; vision problems; number of medications; use of antipsychotic, antianxiety, or anti-depressant medications; and restraint use (bedrails, trunk restraints, chair that prevents rising). The MDS is a federally mandated resident assessment instrument now being used in all Medicare- and Medicaid-supported nursing homes in this country.[17] Admission from a hospital or nursing care facility (rather than from the community) was used as an additional marker for preexisting acute or chronic morbidity. Information on a final risk factor, malnutrition, based on a body mass index of 20 kg/m2 or less at baseline, was obtained from chart data.

Facility characteristics collected at approximately the midpoint of resident follow-up were included in these analyses to examine whether they related to falls or fall injuries. Many of these factors relate to other outcomes:[18,19] facility size, for-profit ownership, presence of Alzheimer's care unit, chain affiliation, urban location, registered nurse turnover, number of full-time nursing aides available per 100 beds, and an environmental quality score derived from the Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH[20]). The TESS-NH summary score consists of 18 items including maintenance, cleanliness, odors, lighting, homelikeness, kitchen availability, floor surface, noise, pictures/mementos, visual stimulation, appearance of residents, and cueing.

Trained abstractors collected outcomes, including falls and fall injuries, from nursing home charts through review of physician order sheets, physician progress notes, and nurses' notes. Information from hospital discharge summaries (after admission, within the 2-year follow-up period) was also used. A fall was inferred when there was chart documentation that the resident fell, that the resident was "found on the floor," or the resident reported that he or she fell. Injuries resulting from falls were recorded as hip fracture only, hip and other fracture, other fracture only, soft tissue only, other, and not documented. Any injury documented within 7 days of a fall was considered a result of that event.


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