Summary
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Falls are Australia’s largest contributor to hospitalised injuries and a leading cause of injury deaths (AIHW 2023). People living with dementia have at least twice the risk of falling as those without dementia and are more likely to experience severe outcomes following a fall (Australian Commission on Safety and Quality in Health Care 2016; Lord et al. 2007).
People living with dementia are particularly prone to what is called ‘cascade iatrogenesis’, where an initial event, such as the presence of a certain risk factor or a minor fall, leads to the serial development of multiple medical complications that decrease the likelihood of recovery (George et al. 2013). Being hospitalised due to a fall is especially difficult for people living with dementia as the unfamiliar environment and distress associated with hospitalisation, as well as the prolonged immobility during recovery if a serious injury is sustained, can often lead to an increase in severe symptoms such as delirium and agitation (Dementia Australia 2020).
People living with dementia are 2–3 times more likely to experience adverse events, such as further falls and delirium, during hospitalisation than people of the same age who do not have dementia (Panayiotou 2018). There is also a greater risk for people living with dementia to experience longer hospital stays, premature entry to residential aged care, and death during or following a hospitalisation (Australian Commission on Safety and Quality in Health Care 2016; Mitchell et al. 2017).
Study overview
While person-level risk factors such as specific medical conditions and age are often explored for their association with falls in people living with dementia (and in the broader population), they are rarely explored in conjunction with comorbid illnesses and factors such as medications. Understanding which risk factors occur in combination may highlight certain risk factor profiles that are associated with falls, and further, how the outcomes of falls (such as injury severity or mortality) differ by these risk profiles.
This report presents findings from a study which investigated which health condition and medication-related risk factors were associated with an increased risk of first hospitalised falls, and developed risk profiles based on combinations of factors that occurred together. Outcomes following a first hospitalised fall, including injuries sustained, recurrent falls, entry to residential aged care and mortality, were then compared by risk factor profile. Understanding what puts people living with dementia at risk of falling can inform targeted prevention strategies to minimise fall risks and/or reduce the severity of fall outcomes.
The study focused on people living with dementia, in the community and in residential aged care, who were hospitalised due to a fall for the first time, referred to as ‘first hospitalised fall’ or ‘first fall’. The study included just under 19,600 people living with dementia who experienced a first hospitalised fall in 2019, and for comparison, almost 113,000 people living with dementia with no record of a hospitalised fall prior to, or during, 2019 (referred to as ‘no fall’).
This study used the National Health Data Hub (NHDH), previously referred to as the National Integrated Health Services Information (NIHSI) analytical asset. The NHDH links de-identified, person-level data from public and private hospitals and emergency departments, aged care facilities, the Medicare Benefits Schedule, the Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme, the Australian Immunisation Register and the National Death Index. This linkage permits a person-centred analysis of those living with dementia who were hospitalised due to a fall, bringing together information on a person before and after a fall, including health and aged care service use, and health outcomes. For details on data sources and dementia identification, see the technical notes.
Residential aged care can be provided on a permanent basis (for people living in a residential aged care facility) or respite basis (for people living in the community who access respite care in a residential aged care facility). The present study determined place of residence for each individual on the day of their fall hospital admission or for the no fall group, on a randomly generated reference date within 2019.
- People living in the community: includes people without an episode of residential aged care that surrounded or ended on the date of admission or no fall reference date. This covers a wide range of living settings; data were not available to assess factors such as the use of community aged care services or whether people were living alone.
- People living in residential aged care: includes people who had an episode of permanent or respite residential aged care that surrounded or ended on the admission or no fall reference date.
A literature review and expert consultation process identified risk factors (health conditions and medications) that potentially increase the risk of falls among people living with dementia.
The presence of these risk factors, prior to a first hospitalised fall occurring, were then flagged for each individual in the cohort through analysis of pharmaceutical benefits data and admitted patient hospital data. The method for identification of risk factors was as follows:
- Pharmaceutical benefits data: a medication dispensed less than or equal to 90 days prior to fall hospitalisation admission date for individual medications identified as risk factors, or within one year of admission date for identification of polypharmacy.
- Hospital data: chronic conditions identified across all hospital records from 1 July 2010 and prior to the fall admission, and other health conditions identified as risk factors within 3 years prior to admission date.
A synthetic reference date was generated for people in the comparison group in place of the fall admission date for determining the presence of risk factors. Further details on risk factor identification and generation of the reference date can be found in the technical notes.
Key findings
Some fall-related risk factors were common across people living with dementia, including:
- high blood pressure
- polypharmacy
- cardiovascular disease.
While these are good targets for prevention strategies, the results of this study also show which risk factors were contributing most significantly to first fall risk and how this differed by place of residence, allowing targeted prevention to be further refined:
- among people living with dementia in the community, balance issues and nervous system drugs were most associated with first hospitalised falls
- among people living in residential aged care, agitation and drugs for depression (selective serotonin reuptake inhibitors) were most associated with first hospitalised falls.
Other key findings can help to inform the type of interventions which may help to reduce the severity of outcomes following a fall. For example:
- about 2 in 5 people living with dementia in the community entered residential aged care after a first hospitalised fall
- Interventions which target specific risks, such as home-based exercise programs and home modifications for people with balance issues, may help to reduce the risk of falls, and consequently, prevent premature entry to residential aged care (Gillespie et al. 2012; Luker et al. 2019).
- 9 in 10 people living with dementia in residential aged care who had a first fall hospitalisation had an injury recorded
- Measures aimed at minimising injuries, such as using floor mats, removing bed rails and improving supervision (Iaboni et al. 2018) would be beneficial to people living with dementia in residential aged care, and may also help to minimise recurrent falls in this population.
AIHW (Australian Institute of Health and Welfare) (2023) Injury in Australia: Falls, AIHW, Australian Government, accessed 16 April 2024.
Australian Commission on Safety and Quality in Health Care (2016) Caring for Cognitive Impairment – A National Campaign, Australian Commission on Safety and Quality in Health Care, accessed 16 April 2024.
Dementia Australia (2020) Health and hospital services for people living with dementia in rural, regional and remote NSW, Dementia Australia, accessed 16 April 2024.
George J, Long S, and Vincent C (2013) ‘How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions’, Journal of the Royal Society of Medicine, 106(9), 355–361, doi:10.1177/0141076813476497.
Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM and Lamb SE (2012) ‘Interventions for preventing falls in older people living in the community’, Cochrane database of systematic reviews, (4):CD000340, doi:10.1002/14651858.CD007146.pub3.
Iaboni A, Van Ooteghem K, Marcil MN, Cockburn A, Flint AJ, Grossman D, and Keren R (2018) ‘A Palliative Approach to Falls in Advanced Dementia’, The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry, 26(4), 407–415, doi:10.1016/j.jagp.2017.11.014.
Lord S, Sherrington C, Menz H, and Close J (2007) Falls in Older People: Risk Factors and Strategies for Prevention, 2nd edn, Cambridge: Cambridge University Press. doi:10.1017/CBO9780511722233.
Luker JA, Worley A, Stanley M, Uy J, Watt AM and Hillier SL (2019) ‘The evidence for services to avoid or delay residential aged care admission: a systematic review’, BMC Geriatrics, 19, 217, doi:10.1186/s12877-019-1210-3.
Mitchell R, Harvey L, Draper B, Brodaty H and Close J (2017) ‘Risk factors associated with residential aged care, respite and transitional aged care admission for older people following an injury-related hospitalisation’, Archives of Gerontology and Geriatrics, 72, 59–66, doi:10.1016/j.archger.2017.05.012.
Panayiotou A (2018) Preventing Avoidable Hospital Admissions for People with Dementia, Final Report, Melbourne Ageing Research Collaboration.