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Lower-income seniors with dementia more likely to be admitted to hospital for falls

Seniors with dementia from lower-income neighbourhoods in Canada are more likely to visit hospitals for falls than those from more affluent areas, CIHI analysis shows.

It is well documented that seniors with dementia have a higher risk of falls in both long-term care and the community, compared with other seniors.Reference1 As a result, they are also more likely to visit emergency departments (EDs) for fall-related injuries and to be admitted to hospital.Reference2Reference3

Seniors with dementia in lower-income neighbourhoods are more disadvantaged: the rate of hospital admissions for falls is about 23% higher for these seniors compared with those living in high-income neighbourhoods. For this analysis, CIHI examined falls by 5 income levels; these were primarily determined based on average neighbourhood-level income, in line with analyses previously done in Canada. In general, seniors from lower-income neighbourhoods are more likely to visit the hospital for other health-related reasons (regardless of the presence of dementia). Lower socio-economic status is often correlated with negative health outcomes.Reference4

Our findings show that seniors with dementia consistently have higher rates of falls than seniors without dementia:

 

15%

of ED visits by seniors living with dementia are fall-related, compared with 9% among other seniors

16%

of hospital admissions by seniors living with dementia are fall-related, compared with 7% among other seniors

16%

of seniors living with dementia who live in a long-term care facility had fallen in the past 30 days, compared with 11% of other seniors

39%

of seniors living with dementia who are receiving home care fall, similar to 37% of other seniors

“The reasons why people living with dementia are more likely to fall include having problems with mobility, balance and strength. They are prone to pacing, have trouble finding their way around and paying attention to hazards, and tend to walk too fast for their abilities. As well, they often are taking medications like antipsychotics that might make them drowsy, lower their blood pressure or cause problems with coordination. Like other older persons, they can have other risk factors for falling that may have nothing to do with their dementia,” said Dr. David Hogan, academic lead at the Brenda Strafford Centre on Aging, O’Brien Institute for Public Health, at the University of Calgary.

CIHI’s work with Accreditation Canada emphasizes the vital importance of preventing falls among seniors. Falls often result in hospitalization and surgery, increased physical dependence, long-term care admissions and death. The direct health care costs for fall-related injuries are $2 billion annually,Reference5 and the per capita cost is 3.7 times higher for Canadian seniors than for non-seniors.Reference6

 

Fall-related ED visits

Falls may lead to injuries and require a visit to the ED. 15% of ED visits by seniors with dementia are fall-related, compared with 9% by other seniors.

Seniors living with dementia have more fall-related ED visits

Fall-related ED visits for seniors with dementia vs. without dementia. From long-term care: overall, 21.4% vs. 18.2%; females, 24.3% vs. 20.3%; males, 16.3% vs. 13.9%. From home: overall, 11.8% vs. 8.2%; females, 13.5% vs. 9.8%; males, 9.8% vs. 6.5%.

Proportion of ED visits due to falls, 2015–2016

Among seniors with and without dementia, fall-related visits are more common from long-term care. In addition, seniors with dementia have a higher proportion of ED visits related to falls compared with seniors without dementia, regardless of the setting.

Source
National Ambulatory Care Reporting System, 2015–2016, Canadian Institute for Health Information.

 

Fall-related hospital admissions

Seniors are admitted to hospital when fall-related injuries are serious and require extensive treatment.

Seniors with dementia more frequently admitted to hospitals for fall-related injuries

Fall-related hospital admissions for seniors with dementia vs. without dementia were 15.9% vs. 7.4% of all admissions in 2015. More females were admitted for falls than males; with dementia: 19.2% vs. 11.6%; without dementia, 9.7% vs. 5.0%.

Percentage of hospitalizations for fall-related injuries, 2015–2016

In 2015, seniors with dementia had more than 22,700 fall-related hospital admissions. For seniors living with dementia, 15.9% of all hospital admissions are fall-related, compared with 7.4% for seniors without dementia.

Sources
Discharge Abstract Database and Hospital Morbidity Database, 2015–2016, Canadian Institute for Health Information.

Fall-related hospitalization rates among all seniors vary by income, as highlighted in the report Trends in Income-Related Health Inequalities.Reference7 For seniors living with dementia, this income-related difference is also present. This disparity could be due to a number of reasons. Factors that affect fall risk vary and include (but are not limited to) types of medication, severity of the diseaseReference8 and the physical and social community environment.Reference9

Fall-related hospitalizations higher among seniors from lower-income neighbourhoods

Fall-related hospitalization rates among seniors vary by income. From lowest-income to highest-income neighbourhood, for seniors with dementia, the hospitalization rate per 1,000 individuals ranges from 58.5, to 51.0, to 50.8, to 53.0, to 47.5.

Fall-related hospitalization rate for seniors living with dementia, by income, per 1,000

The hospitalization rate among seniors living with dementia varies from 58.5 per 1,000 individuals in the lowest income group to 47.5 per 1,000 in the highest income group.

Sources
Discharge Abstract Database and Hospital Morbidity Database, 2015–2016, Canadian Institute for Health Information.

“There is a variety of factors that might explain this disparity, but more work is required to fully understand what underlies it. Being from a wealthier neighbourhood could influence outside walkability, access to care, the adequacy of the dwelling and ability to afford modifications that would improve safety, or hiring help for supervision and assistance,” said Dr. Hogan.

 

Falls in long-term care

The proportion of seniors with dementia in long-term care or nursing homes who’d fallen in the past 30 days was 1.5 times higher than the proportion of seniors without dementia. In Ontario, Alberta and British Columbia, there was moderate variation in falls over the 5 years 2011 to 2015, with a slight increase (less than 2 percentage points) in fall rates among all senior residents, particularly in Ontario and Alberta.

Seniors living with dementia in long-term care more likely to fall

In Ontario, Alberta and British Columbia, falls among all senior residents living in long-term care increased slightly, at less than 2 percentage points over the 5- year period of 2011 to 2015, particularly in Ontario and Alberta. During that same 5- year period, more seniors living with dementia in long-term care experienced a fall within the past 30 days, at 16%, than those without dementia, at 11%.

Proportion of seniors with dementia who fell in the last 30 days in long-term care (unadjusted rates)

16% of seniors living with dementia fell, compared with 11% of residents without dementia.

Source
Continuing Care Reporting System, 2011–2012 to 2015–2016, Canadian Institute for Health Information.

About 7% of seniors living with dementia and 6% of other seniors who reported a fall in the 30 days before they were assessed had a hip fracture. The proportions were similar across jurisdictions.

 

Falls in the home

For seniors who receive home care services, about 39% with dementia had a fall in the 90 days before their assessment, similar to the percentage of seniors without dementia (37%). More men with dementia who received home care fell (42%) than women (37%). There was large provincial variation in the percentage of home care clients with dementia with a record of falls. Ontario and B.C. reported that 40% fell, while Alberta reported that about 30% fell. These percentages represent unadjusted rates. Targeting fall prevention programs and safe practices to those receiving home care services should be a priority due to the high rates of falls.

What can be done?

In Canada, national and provincial organizations undertake efforts to reduce falls by seniors. For example, the Canadian Patient Safety Institute’s Safer Healthcare Now! implemented the Reducing Falls and Injuries From Falls Intervention.

The intervention includesReference10

  • The Falls Prevention/Injury Reduction Getting Started Kit, a guide to help professionals working across health sectors implement falls prevention/injury reduction programs for people age 65 and older
  • A series of national patient safety webinars that disseminate emerging evidence and help stimulate knowledge transfer
  • A measurement system to assess progress toward improvement goals

“Things that might be done to decrease fall risk among those living with dementia include reviewing their medications and discontinuing, where possible, those that are associated with falling, ensuring a safe environment, and optimizing physical fitness and strength through promoting activity and exercise. However, management can get complicated. For example, their impaired thinking might make the proper use of a cane or a walker difficult — in fact, it may increase the risk of trips and falls. More work is needed to identify the best approaches of minimizing the risk of falling among this group of seniors,” said Dr. Hogan.

 
 

References

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Baker NL, Cook MN, Arrighi HM, Bullock R. Hip fracture risk and subsequent mortality among Alzheimer’s disease patients in the United Kingdom, 1988–2007 External link, opens in new window. Age and Ageing. January 2011.
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Taylor ME, Delbaere K, Close JCT, Lord SR. Managing falls in older patients with cognitive impairment External link, opens in new window. Aging Health. 2012.
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Maxwell CJ, et al. Elevated hospitalization risk of assisted living residents with dementia in Alberta, Canada External link, opens in new window. Journal of the American Medical Directors Association. 2015.
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Canadian Institute for Health Information. Reducing Gaps in Health: A Focus on Socio-Economic Status in Urban Canada. 2008.
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Accreditation Canada, Canadian Institute for Health Information and Canadian Patient Safety Institute. Preventing Falls: From Evidence to Improvement in Canadian Health Care. 2014.
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SMARTRISK. The Economic Burden of Injury in Canada External link, opens in new window. 2009.
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Canadian Institute for Health Information. Trends in Income-Related Health Inequalities in Canada: Summary Report. 2015.
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Fernando E, et al. Risk factors associated with falls in older adults with dementia: A systematic review External link, opens in new window. Physiotherapy Canada. 2017.
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Nicklett EJ, Lohman MC, Smith ML. Neighborhood environment and falls among community-dwelling older adults External link, opens in new window. International Journal of Environmental Research and Public Health. 2017.
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Safer Healthcare Now!. Reducing Falls and Injuries From Falls Getting Started Kit External link, opens in new window. 2015.