Risk factor identification
Literature review and expert consultation
Literature pertaining to risk factors for falls, especially in people with dementia, was collected and assessed for relevance to the Australian context. Risk factors found to be associated in these studies were assessed for feasibility of inclusion in the present study through exploratory analysis, and suitability through consultation with the Dementia Expert Advisory Group – established to provide expert advice and guidance on dementia to the Australian Institute of Health and Welfare (AIHW).
- Afonso-Argilés FJ, Meyer G, Stephan A, Comas M, Wübker A, Leino-Kilpi H, Lethin C, Saks K, Soto-Martin M, Sutcliffe C and Verbeek H (2020) ‘Emergency department and hospital admissions among people with dementia living at home or in nursing homes: results of the European RightTimePlaceCare project on their frequency, associated factors and costs’, BMC geriatrics, 20, 1–13.
- Allan LM, Ballard CG, Rowan EN and Kenny RA (2009) ‘Incidence and prediction of falls in dementia: a prospective study in older people’, PloS one, 4(5), e5521.
- Baker NL, Cook MN, Arrighi HM and Bullock R (2011) ‘Hip fracture risk and subsequent mortality among Alzheimer's disease patients in the United Kingdom, 1988–2007’, Age and ageing, 40(1), 49–54.
- Chen R, Chien WC, Kao CC, Chung CH, Liu D, Chiu HL and Chou KR (2018) ‘Analysis of the risk and risk factors for injury in people with and without dementia: a 14-year, retrospective, matched cohort study’, Alzheimer's research & therapy, 10, 1–12.
- Cloutier DS, Penning MJ, Nuernberger K, Taylor D and MacDonald S (2019) ‘Long-term care service trajectories and their predictors for persons living with dementia: Results from a Canadian study’, Journal of Aging and Health, 31(1), 139–164.
- Dementia Care in the acute Hospital Setting: Issues and Strategies. June 2014, Report for Dementia Australia.
- Fernando E, Fraser M, Hendriksen J, Kim CH and Muir-Hunter SW (2017) ‘Risk factors associated with falls in older adults with dementia: a systematic review’, Physiotherapy Canada, 69(2), 161–170.
- Fox A, MacAndrew M and Ramis MA (2020) ‘Health outcomes of patients with dementia in acute care settings—a systematic review’, International Journal of Older People Nursing, 15(3), e12315.
- 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.
- Harvey L, Mitchell R, Brodaty H, Draper B and Close J (2016) ‘Differing trends in fall-related fracture and non-fracture injuries in older people with and without dementia’, Archives of gerontology and geriatrics, 67, 61–67.
- Hauer K, Dutzi I, Gordt K and Schwenk M (2020) ‘Specific motor and cognitive performances predict falls during ward-based geriatric rehabilitation in patients with dementia’, Sensors, 20(18), 5385.
- Health Quality & Safety Commission New Zealand (2019) ‘Interventions for reducing falls and harm from falls in older people with cognitive impairment’, Health Quality & Safety Commission New Zealand.
- Johnell K, Jonasdottir Bergman G, Fastbom J, Danielsson B, Borg N and Salmi P (2017) ‘Psychotropic drugs and the risk of fall injuries, hospitalisations and mortality among older adults’, International journal of geriatric psychiatry, 32(4), 414–420.
- Lord SR, Sherrington C and Naganathan V (2021) Falls in Older People, Cambridge University Press.
- Mehdizadeh S, Sabo A, Ng KD, Mansfield A, Flint AJ, Taati B and Iaboni A (2021) ‘Predicting short-term risk of falls in a high-risk group with dementia’, Journal of the American Medical Directors Association, 22(3), 689–695.
- Metzger ED, Racine AM and Inouye SK (2018) ‘Advanced dementia in long-term care: avoiding the pitfalls of fall prevention’, The American Journal of Geriatric Psychiatry, 26(4), 416–418.
- Meuleners LB, Fraser ML, Bulsara MK, Chow K and Ng JQ (2016) ‘Risk factors for recurrent injurious falls that require hospitalization for older adults with dementia: a population based study’, BMC neurology, 16, 1–8.
- Mitchell R, Draper B, Brodaty H, Close J, Ting HP, Lystad R, Harris I, Harvey L, Sherrington C, Cameron ID and Braithwaite J (2020) ‘An 11-year review of hip fracture hospitalisations, health outcomes, and predictors of access to in-hospital rehabilitation for adults≥ 65 years living with and without dementia: a population-based cohort study’, Osteoporosis International, 31, 465–474.
- Mitchell R, Draper B, Harvey L, Wadolowski M, Brodaty H and Close J (2019) ‘Comparison of hospitalised trends, treatment cost and health outcomes of fall-related hip fracture for people aged ≥ 65 years living in residential aged care and the community’, Osteoporosis international, 30, 311–321.
- 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.
- Motzek T, Werblow A, Tesch F, Marquardt G and Schmitt J (2018) ‘Determinants of hospitalization and length of stay among people with dementia–An analysis of statutory health insurance claims data’ Archives of Gerontology and Geriatrics, 76, 227–233.
- Perttila NM, Öhman H, Strandberg TE, Kautiainen H, Raivio M, Laakkonen ML, Savikko N, Tilvis RS and Pitkälä KH (2018) ‘Effect of exercise on drug-related falls among persons with Alzheimer's disease: A secondary analysis of the FINALEX study’, Drugs & Aging, 35, 1017–1023.
- Rathod‐Mistry T, Marshall M, Campbell P, Bailey J, Chew‐Graham CA, Croft P, Frisher M, Hayward R, Negi R, Robinson L and Singh S (2021) ‘Indicators of dementia disease progression in primary care: An electronic health record cohort study’, European Journal of Neurology, 28(5), 1499–1510.
- Sato S, Kakamu T, Hayakawa T, Kumagai T, Hidaka T, Masuishi Y, Endo S and Fukushima T (2018) ‘Predicting falls from behavioral and psychological symptoms of dementia in older people residing in facilities’, Geriatrics & Gerontology International, 18(11), 1573–1577.
- Scandol JP, Toson B and Close JC (2013) ‘Fall-related hip fracture hospitalisations and the prevalence of dementia within older people in New South Wales, Australia: an analysis of linked data’, Injury, 44(6), 776–783.
- Sharma S, Mueller C, Stewart R, Veronese N, Vancampfort D, Koyanagi A, Lamb SE, Perera G and Stubbs B (2018) ‘Predictors of falls and fractures leading to hospitalization in people with dementia: a representative cohort study’, Journal of the American Medical Directors Association, 19(7), 607–612.
- Stubbs B, Perara G, Koyanagi A, Veronese N, Vancampfort D, Firth J, Sheehan K, De Hert M, Stewart R and Mueller C (2020) ‘Risk of hospitalized falls and hip fractures in 22,103 older adults receiving mental health care vs 161,603 controls: a large cohort study’, Journal of the American Medical Directors Association, 21(12), 1893–1899.
- Suzuki M, Yamamoto R, Ishiguro Y, Sasaki H and Kotaki H (2020) ‘Deep learning prediction of falls among nursing home residents with Alzheimer's disease’, Geriatrics & gerontology international, 20(6), 589–594.
- Taylor ME, Delbaere K, Close JC and Lord SR (2012) ‘Managing falls in older patients with cognitive impairment’, Aging health, 8(6), 573–588.
- Toson B, Harvey LA and Close JC (2015) ‘The ICD-10 Charlson Comorbidity Index predicted mortality but not resource utilization following hip fracture’, Journal of clinical epidemiology, 68(1), 44–51.
- Zhang W, Low LF, Schwenk M, Mills N, Gwynn JD and Clemson L (2019) ‘Review of gait, cognition, and fall risks with implications for fall prevention in older adults with dementia’, Dementia and geriatric cognitive disorders, 48(1-2), 17–29.
Risk factor codes
The risk factors (health conditions and medications) included in this study are listed in Table A1. People with dementia were flagged as having a risk factor if it was recorded prior to their first fall hospital admission (or the no fall reference date for those in the comparison group). Risk factors were identified using the following datasets:
- Pharmaceutical benefits (Pharmaceutical Benefits Scheme (PBS)/ Repatriation Pharmaceutical Benefits Scheme (RPBS)) data: a medication dispensed less than or equal to 90 days prior to fall hospitalisation admission/ reference date for individual medications identified as risk factors, or within one year of admission/ reference date for identification of polypharmacy.
- Hospital data: chronic conditions across all hospital records from 1 July 2010 and prior to the admission/ reference date, and other conditions within 3 years prior to admission/ reference date.
| Risk factor | Type | Source | Coding system | Code | Description |
|---|---|---|---|---|---|
| Agitation | Condition | NHMD | ICD-10AM | 'R45' | Encompasses agitation as well as symptoms and signs involving emotional state (nervousness, agitation, unhappiness, apathy, irritability and anger, hostility, physical violence, emotional shock and stress) |
| Anti-depressants | Medication | PBS | ATC | 'N06AA','N06AF', 'N06AG','N06AX' | Non-selective monoamine reuptake inhibitors, Monoamine oxidase inhibitors, non-selective, Monoamine oxidase A inhibitors, Other antidepressants |
| Antiepileptics | Medication | PBS | ATC | 'N03' | Antiepileptics |
| Antihypertensives | Medication | PBS | ATC | 'S01ED', 'C02', 'C07','C08','C09' | Beta blocking agents, Antihypertensives, Beta blocking agents |
| Anti-inflammatories | Medication | PBS | ATC | 'M01','M04','M03' | Anti-inflammatory and antirheumatic products, muscle relaxants, antigout preparations |
| Antipsychotics | Medication | PBS | ATC | 'N05A' | Antipsychotics |
| Anxiolytics or sedatives | Medication | PBS | ATC | 'N05B', 'N05C' | Anxiolytics, Hypnotics and sedatives |
| Bone disease medication | Medication | PBS | ATC | 'M05' | Drugs for treatment of bone diseases |
| Cardiovascular disease | Chronic condition | NHMD | ICD-10AM | 'I20', 'I21', 'I22', 'I23', 'I24', 'I25', 'I48', 'I43', 'I50', 'I25.5', 'I42.0', 'I42.5', 'I42.6', 'I42.7', 'I42.8', 'I42.9', 'U82.1','U82.2' | Ischaemic heart diseases, Cardiomyopathy in diseases classified elsewhere, Atrial fibrillation and flutter, Heart failure, Cardiomyopathy and Chronic heart failure |
| Cerebrovascular disease | Chronic condition | NHMD | ICD-10AM | 'G45', 'I60', 'I61', 'I62', 'I63', 'I64', 'I65', 'I66', 'I67', 'I68', 'I69' | Cerebrovascular diseases and transient cerebral ischaemic attacks and related syndromes |
| COPD or asthma | Chronic condition | NHMD | ICD-10AM | 'J41', 'J42', 'J43', 'J44', 'J45', 'U83.1', 'U83.2', 'U83.3' | Chronic obstructive pulmonary disease, asthma and emphysema |
| Delirium | Condition | NHMD | ICD-10AM | 'F05' | Delirium, not induced by alcohol and other psychoactive substances |
| Diabetes | Chronic condition | NHMD | ICD-10AM | 'E10', 'E11', 'E13','E14' | Type 1 diabetes mellitus, Type 2 diabetes mellitus, Other specified diabetes mellitus, Unspecified diabetes mellitus |
| Diabetes medication | Medication | PBS | ATC | 'A10' | Drugs used in diabetes |
| Epilepsy | Chronic condition | NHMD | ICD-10AM | 'G40', 'G41', 'U80.3' | Epilepsy and Status epilepticus |
| Hearing impairment | Chronic condition | NHMD | ICD-10AM | 'H90', 'H91' | Conductive and sensorineural hearing loss and Other hearing loss |
| Hyperlipidaemia | Chronic condition | NHMD | ICD-10AM | 'E78.0', 'E78.1', 'E78.2', 'E78.3', 'E78.4', 'E78.5' | Hyperlipidaemia |
| Hypertension | Chronic condition | NHMD | ICD-10AM | 'I10', 'I11', 'I12', 'I13', 'I14', 'I15', 'U82.3' | Hypertensive disorders |
| Hypertensives | Medication | PBS | ATC | 'H02AA','C01C' | Mineralocorticoids |
| Hypotension | Chronic condition | NHMD | ICD-10AM | 'I95' | Hypotension |
| Joint pain | Chronic condition | NHMD | ICD-10AM | 'M05', 'M06', 'M10', 'M13', 'M15', 'M16', 'M17', 'U861', 'U862' | Seropositive rheumatoid arthritis, Other rheumatoid arthritis, Gout, Other arthritis, Polyarthrosis, Coxarthrosis |
| Kidney disease | Chronic condition | NHMD | ICD-10AM | 'N17', 'N18', 'N19', 'U871' | Acute kidney failure, Chronic kidney disease, Unspecified kidney failure |
| Mood disorders | Chronic condition | NHMD | ICD-10AM | 'F40', 'F41','F30', 'F31', 'F32', 'F33', 'F34', 'F38', 'F39', 'U793' | Phobic anxiety disorders, Other anxiety disorders, Manic episode, Bipolar affective disorder, Depressive episode, Persistent mood disorders, Other mood disorders, Unspecified mood disorder, Depression |
| Movement disorders | Chronic condition | NHMD | ICD-10AM | 'G81', 'G82', 'G83', 'G20', 'G21','G22','G23','G24','G25','G26', U80.5', 'U80.1' | Hemiplegia, paraplegia and tetraplegia, extrapyramidal and movement disorders and Parkinson's disease |
| Nervous system-acting drugs | Medication | PBS | ATC | 'N04', 'S01EA','S01EB', 'N07XX' | Anti-Parkinson drugs, sympathomimetics in glaucoma therapy, parasympathomimetics, other nervous system drugs |
| Neuropathies and myopathies | Chronic condition | NHMD | ICD-10AM | 'G57', 'G60', 'G61','G62', 'G63', 'G70', 'G71', 'G72', 'G73', 'G900' | Neuropathies and myopathies |
| Obesity | Chronic condition | NHMD | ICD-10AM | 'U78.1' | Obesity (BMI 30.00 kg/m2) |
| Osteoporosis | Chronic condition | NHMD | ICD-10AM | 'M80', 'M81', 'M82', 'M83', 'M87', 'M88', 'M85.0', 'M85.3', 'Q78.2', 'U86.4' | Osteoporosis, other disorders of bone density and structure and disorders of the musculoskeletal system and connective tissue |
| Polypharmacy | Medication | PBS | ATC | 5 or more unique ATC4 codes | >5 unique medications with minimum 4 supplies each |
| Sensory or cognitive impairments | Chronic condition | NHMD | ICD-10AM | 'R41', 'R44', 'R400', 'R401' | Somnolence, stupor, other symptoms and signs involving cognitive functions and awareness and other symptoms and signs involving general sensations and perceptions |
| SSRIs | Medication | PBS | ATC | 'N06AB' | Selective serotonin reuptake inhibitors |
| Systemic atrophies affecting the nervous system | Chronic condition | NHMD | ICD-10AM | 'G10', 'G11', 'G12', 'G13', 'G14' | Systemic atrophies primarily affecting the central nervous system (including Huntington's disease) |
| Thyroid disorders | Chronic condition | NHMD | ICD-10AM | 'E05','E03' | Hyperthyroidism and hypothyroidism |
| Thyroid medication | Medication | PBS | ATC | 'H03A','H03B' | Thyroid preparations, antithyroid preparations |
| Urinary incontinence | Chronic condition | NHMD | ICD-10AM | 'R32', 'N39.3', 'N39.4' | Unspecified urinary incontinence, stress incontinence and other specified urinary incontinence |
| Urinary incontinence medication | Medication | PBS | ATC | 'G04BD' | Drugs for urinary frequency and incontinence |
| Vestibular, balance and gait issues | Chronic condition | NHMD | ICD-10AM | 'R26', 'R27', 'R29.5', 'R29.6' | Abnormalities of gait and mobility, Other lack of coordination, Neurologic neglect and Tendency to fall, not elsewhere classified |
| Visual impairment | Chronic condition | NHMD | ICD-10AM | 'H25', 'H26', 'H35', 'H40', 'H47', 'H53', 'H54', 'E10.3', 'E11.3' | Senile cataract, Other cataract, Other retinal disorders, Glaucoma, Other disorders of optic nerve and visual pathways, Visual disturbances, H54 Visual impairment including binocular or monocular blindness, Type 1 diabetes mellitus with ophthalmic complication, Type 2 diabetes mellitus with ophthalmic complication |
| Vitamin D deficiency | Condition | NHMD | ICD-10AM | 'E55' | Vitamin D deficiency |
| Vitamin D medication | Medication | PBS | ATC | 'A11CC' | Vitamin D and analogues |