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

Disclosures

J Am Geriatr Soc. 2003;51(9) 

In This Article

Discussion

Nursing home residents with dementia were nearly twice as likely to fall as those without dementia even when other important risk factors were controlled for. Although residents with dementia were not more likely to injure themselves once they fell, they did have significantly higher injurious fall rates because they experienced more falls. Even more injury may be occurring in residents with dementia after falls than what this study's data indicated, because minor injuries may be more likely to go unnoticed because of fewer self-reports by these individuals. Furthermore, their fall rates are also likely to be higher than reported here, for the same reason.

Although prior studies have reported that rates of falling are higher in nursing home residents with dementia,[2,3,23] these studies have not focused on dementia as a risk factor, nor have they determined that dementia is a risk factor for falling when demographic, health-related, and environmental factors are taken into account. Several methodological shortcomings also characterize prior research on falling. Generalizability has been limited in studies sampling small numbers of facilities or including only ambulatory patients.[4,10,24] Study design has been cross-sectional or based on a synthetic admission cohort (constructed from current resident or discharge samples) rather than longitudinal. In other studies, data sources have been limited; only MDS data have been used,[23] or chart data have been the sole determinant of dementia status (which may underestimate the prevalence of dementia by at least 10-15%[25]). Finally, in the few studies examining dementia and falling, there has been no comparison group without dementia or cognitive impairment, making it impossible to identify dementia as an independent fall risk factor.[10]

The current study overcomes these methodological difficulties by examining dementia in a multivariable context and by including residents with and without dementia. Generalizability was enhanced by including residents of any mobility status and sampling a large and diverse group of nursing homes. Multiple data sources were used, and residents were evaluated for dementia based on clinical panel assessment. Residents were followed for up to 2 years, and facility variables not available in previous studies also were examined.

Two facility variables were significant risk factors for falling: presence of an Alzheimer care unit in the facility and a better environmental score. Although having an Alzheimer unit was not related to the proportion of residents in the facility with dementia (correlation coefficient (r)= -0.04, P=.11), the presence of an Alzheimer unit may be a marker for dementia severity, further supporting the relationship between dementia and falls. On the surface, the positive association between environmental quality and falls is counterintuitive, but the environmental quality score is associated with the percentage paid by Medicare (r=0.31, P<.001), indicating a more logical relationship between resident status (i.e., rehabilitative) and falls. This finding highlights the importance of considering resident acuity in reports of facility quality, a point receiving attention as public reporting of facility quality becomes available for providers and consumers.

One limitation of this study was that there was no information on the circumstances of the fall, such as activity during fall[3] and time of fall, both of which may be informative in establishing the cause of a fall.[7] Falling has been linked to performing particular ADLs such as sitting or transferring[3] and to hypotension just after mealtime.[26] Establishing the specific causes of and circumstances surrounding falling in nursing home residents with dementia compared with those without dementia could lead to better-directed prevention programs. Other limitations of the study include the potentially low reliability of panel diagnosis of dementia, the use of charts to document falls and injuries, and possible unmeasured confounding variables.

Given the increasing numbers of residents with dementia in nursing homes and the fact that these residents are more likely to fall, one can expect more falls, more morbidity and mortality related to falls, and higher costs of care in the future. The long-term care setting may provide special opportunities for prevention and intervention,[9] including identifying at admission residents who are at high risk for falling and evaluating their risk factors regularly to determine which residents require particular fall-prevention measures.[2,27] Use of community-developed fall-prevention methods such as strength training and exercise programs may be difficult with some residents who have dementia, and many such interventions have not even been tested on persons with dementia.[28] Residents with dementia may require closer supervision to implement and maintain basic fall-prevention methods such as assuring that residents are wearing proper footwear and learning how to identify weakness or dizziness. In addition, assessment of conditions besides dementia that place residents at risk of falling, close monitoring of high-risk residents, continuous reduction of environmental hazards, use of hip protectors, management with bone active medication, vitamin D and calcium supplements,[29] vigilant management of psychotropic medications,[27,30,31] eliminating inappropriate or excessive medications,[2] and moving residents with dementia who have fallen closer to nursing stations to increase observation[2] may be useful in reducing falls or fall injuries. Residents with dementia should also be evaluated with extra care after a fall to avoid missing postfall injuries that might not be self-reported. Establishing dementia as an independent risk factor for falling should increase screening and the use of fall prevention strategies in this population.


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