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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 1  |  Page : 15-19

Risk factors for falls in older adults with cognitive impairment


1 Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Consultant Geriatrician, Department of Geriatric Medicine, Kauvery Hospital, Chennai, Tamil Nadu, India

Date of Submission20-Jan-2022
Date of Decision28-Feb-2022
Date of Acceptance02-Mar-2022
Date of Web Publication21-Apr-2022

Correspondence Address:
Dr. Aparajit Ballav Dey
Department of Geriatric Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_4_22

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  Abstract 


Background: Falls are one of the leading causes of disability among older people. The risk factors of falls widely vary among the older populations, including the different stages of cognitive impairment. We aim to identify the risk factors for falls among cognitively impaired older adults. Materials and Methods: In a cross-sectional study, older adults attending the memory clinic were screened for falls and their risk factors. A total of 112 subjects who satisfied the inclusion criteria and provided informed consent were subjected to a semi-structured interview and comprehensive geriatric assessment. Cognitive impairment was graded by the Clinical Dementia Rating (CDR). Subjects were divided into fallers and nonfallers. A multivariable logistic regression analysis was done to identify the independent risk factors of falls. Results: The prevalence of falls was 39.28% in the study population. Gender (adjusted odds ratio [aOR] [95% confidence interval (CI)]: 2.21 [0.690–7.117]), body mass index (aOR [95% CI]: 0.89 [0.773–1.028]), socioeconomic status (middle-class aOR [95% CI]: 0.34 [0.077–1.526], lower-class aOR [95% CI]: 2.44 [0.349–17.160]), multimorbidity (aOR [95% CI]: 19.39 [1.043–360.373]), depression (mild aOR [95% CI]: 2.90 [0.896–9.429] and moderate aOR [95% CI]: 4.77 [0.967–23.597]), and impairment in hobbies and home (aOR [95% CI]: 24.78 [6.251–98.294]) part of CDR were the independent predictors of falls. Conclusion: Older adults with cognitive impairment are at high risk of falling with definitive risk factors. Regular screening will help to identify older adults at risk of falls and enable fall prevention to reduce morbidity and dependency.

Keywords: Cognitive impairment, disability, fall prevention, falls, older adults


How to cite this article:
Saini M, Subramanian MS, Soni N, Singh V, Chakrawarty A, Chatterjee P, Dey AB. Risk factors for falls in older adults with cognitive impairment. J Indian Acad Geriatr 2022;18:15-9

How to cite this URL:
Saini M, Subramanian MS, Soni N, Singh V, Chakrawarty A, Chatterjee P, Dey AB. Risk factors for falls in older adults with cognitive impairment. J Indian Acad Geriatr [serial online] 2022 [cited 2022 May 19];18:15-9. Available from: http://www.jiag.com/text.asp?2022/18/1/15/343684




  Introduction Top


Fall is defined as an event, resulting in a person coming to rest inadvertently on the ground or floor or other lower level resulting in fatal or nonfatal injuries.[1] Falls are one of the leading causes of disability. The incidence of falls increases with the aging population as 28%–35% in people aged ≥65 years and 32%–42% in ≥70 years. The incidence of falls among nursing home or long-term care facility dwellers was 30%–50%.[2] Overall, 646,000 people die from fatal falls, and 80% of fatal falls are reported from low- and middle-income countries. Nonfatal falls are responsible for 17 million disability-adjusted life years lost.[1]

The prevalence of falls in moderate and severe cognitive impairment was 70%, and these people were likely to be hospitalized five times more than their normal counterparts. Cognitively impaired older person lose their higher cognitive functions (e.g., attention and executive function) as well as protective strategies.[3] A multinational cross-sectional study identified that the association of falls varies across the cognitive status, with differences noted in dementia when compared to cognitively normal older adults.[4] Older adults with severe cognitive impairment are usually excluded from various studies. There were also differences in how cognitive impairment was defined, according to different scales and scores, and underreporting is common in community-dwelling cognitively impaired older adults.[5]

Worldwide, the estimated number of older people >60 years was approximately 688 million in 2006, and it was anticipated to be two billion by 2050.[2] Older people with dementia are projected to be 152 million in 2050, and 60% of those are from low-to-middle-income countries.[6] The data of falls on cognitively impaired older populations are scarce in developing countries. We aim to identify the risk factors in a health-seeking cognitively impaired older population.


  Materials and Methods Top


Study population and design

This was a cross-sectional study carried out in the memory clinic of a tertiary care hospital. People are referred to a memory clinic for a detailed assessment of their cognitive decline where a comprehensive evaluation is done by a multidisciplinary team including a geriatrician, neuropsychologist, dietician, physiotherapist, and occupational therapist. This study was done from March 2017 to October 2018, and a total of 366 subjects were screened during this period and were included after written informed consent. Subjects with a recent fracture or gait impairment secondary to fractures, advanced heart failure (New York Heart Association Class III and IV), acute exacerbation of chronic obstructive pulmonary disease, hearing and vision impairment that needs assistance, severe depression, reversible dementia (hypothyroidism, Vitamin B12, folic acid deficiency, and normal pressure hydrocephalus), and bedridden subjects were excluded. Finally, 112 subjects were included in the study.

A semi-structured interview in the local language was carried out to identify the demography ad health status of the subjects. Health status and medications were identified by reviewing medical records and the blister packs. Polypharmacy was defined as taking 5 or more medications at the time of assessment.[7] Socioeconomic status was assessed by the Revised Kuppuswamy's Socioeconomic Status Scale which updated periodically.[8] A fall was defined as an event that results in a person coming to rest inadvertently on the ground or floor or other lower level.[1] Anyone with a history of falls in the past 12 months was considered a faller. The vision was assessed by handheld Snellen charts and E charts for subjects who had lacked formal education. The hearing was assessed by the whispering test.[9] Functional status was assessed by the Barthel's Activity-Dependent Daily Living (ADL) Index.[10] The Geriatric Depression Scale-Short Form was used for depression assessment.[11] The Berg Balance Scale was used to objectively determine a patient's ability to balance during a series of predetermined tasks.[12] Cognition was assessed by the Clinical Dementia Rating (CDR) Scale. Global scores were computed by the online calculator available at https://www.alz.washington.edu/cdrnacc.html.[13],[14] Subjects were classified as subjective cognitive impairment (SCI) if CDR global score is 0, mild cognitive impairment (MCI) if CDR scores 0.5, and dementia if CDR score is ≥1.[15]

Statistical analysis

Qualitative variables of participant characteristics were reported as numbers (percentages), while quantitative data were reported as the mean ± standard deviation (SD) and/or median interquartile range. Normality assumption was tested using the Kolmogorov–Smirnov test. To find the association between categorical variables, the Chi-square test or Fisher's exact test was applied, and for quantitative measures, t-test or Wilcoxon test was used to compare between two independent groups according to the distribution of the data. To find out the factors associated with fallers, a logistic regression analysis procedure was used and results were presented in the form of odds ratio and corresponding 95% confidence interval. All the analyses were performed using STATA-SE (version 14.2) (StataCorp, College Station, TX, U. S. A.). P < 0.05 was considered statistically significant.


  Results Top


A total of 112 subjects were included in the study, in which 38 subjects had SCI, 40 had MCI, and 34 were diagnosed with dementia. They were grouped into fallers and nonfallers according to the history of falls. The prevalence of falls was 39.28% among the population, and males (61.36%) fell more than females. For statistical analysis, middle school and primary school, as well as intermediate and high school education, were grouped. In the socioeconomic status, the lower-middle and lower as well as the middle-class and upper-middle classes were grouped. The middle-class social strata experienced more falls (24 [54.55%]). Widowers (fallers 7 (15.91%] vs. nonfallers 10 [14.71%]) and subjects living with family (fallers 31 [70.45%] vs. nonfallers 55 [80.88%]) or spouse (fallers 13 [29.55%] vs. nonfallers 13 [19.12%]; P = 0.20) were equally represented in both groups. None of the study participants was living alone. Financial independence was more in nonfallers than fallers (45 [66.18%] vs. 24 [54.55%]; P = 0.21).

Fallers proportionately had >2 comorbidities than nonfallers (34 [77.27%] vs. 41 [60.29%]; P = 0.09). Fallers had proportionally higher prevalence of osteoarthritis (25 [56.82%] vs. 24 [35.29%]; P = 0.02) and hypertension (26 [59.09%] vs. 34 [50.00%]; P = 0.34). Vision impairment (20 [45.45%] vs. 23 [33.82%]; P = 0.21) and hearing impairment (17 [38.64%] vs. 15 [22.06%]; P = 0.05) were also more prevalent in fallers. Polypharmacy was widely prevalent among both fallers (27.27%) and nonfallers (27.94%). Fallers were more depressed (65.90%) and had more impairments in ADLs (61.36%) and instrumental ADLs (IADLs) (75%). ADL score was less in fallers than nonfallers (mean [SD] 16.88 [±3.44] vs. 19.08 [±2.11]; P < 0.001). IADL score was also impaired in fallers (fallers mean [SD] 4.54 [±2.95] vs. nonfallers 6.73 [±2.15]; P < 0.001). The Berg Balance Score (BBS) is in fallers (mean [SD] 43.84 [±8.80]) and nonfallers (51.48 [±5.80]; P < 0.001). Two-thirds of the fallers had low fall risk (63.64%) when classified by the BBS. In fallers, 52% of subjects were in the dementia group (including mild, moderate, and severe) while maximum nonfaller objects were in SCI (43%) and MCI (41%). The details of the demographic, clinical conditions and socioeconomic status are presented in [Table 1].
Table 1: Demographic variables, clinical conditions, and socioeconomic status of the population

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The comparison between fallers and nonfallers of cognitive impairment based on CDR and domain-based assessment of cognition is presented in [Figure 1]. Significant differences were observed between fallers with cognitive impairment in the ascending order of severity (P < 0.001). Fallers have more impairment in all the domains of the CDR with increasing CDR scores [Figure 1].
Figure 1: Cognitive impairment based on Clinical Dementia Rating and domain-based assessment of cognition. §CDR: Clinical Dementia Rating

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To identify the factors associated with falls in people with cognitive impairment, we took all socioeconomic, clinical, demographic determinants and the domains of CDR. Under univariable analysis, depression (mild [as compared to normal] unadjusted OR [UOR]: 3.25 [95% CI: 1.371–7.743] and moderate [as compared to normal] UOR: 4.39 [95% CI: 1.341–14.428]) and home and hobbies domain (questionable [as compared to no impairment] UOR: 3.46 [95% CI: 1.166–10.272] and impairment [as compared to no impairment] UOR: 10.57 [95% CI: 3.838–29.140]) of the CDR were most probable predictive factors of falls. Lower body mass index (BMI) (UOR: 0.90 [95% CI: 0.815–1.001]) and socioeconomic status (lower class [as compared to upper class] UOR: 2.4 [95% CI: 0.573–10.042]) were also associated with falls. In multivariable analysis, home and hobbies domain (questionable [as compared to no impairment] and impairment [as compared to no impairment]) and >2 comorbidities as compared to no comorbidity were independent predictors of fall [Table 2].
Table 2: Predictors of falls by the logistic regression model from the covariates

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  Discussion Top


This study reports risk factors of falls in people who came to a memory clinic for their cognitive decline assessment. Risk factors include lower socioeconomic status, lower BMI, increased comorbidities, history of arthritis and depression, impaired activities, impaired balance, and severity of cognitive impairment. These are similar to previous studies.[16],[17],[18],[19] However, these factors were not significant in multivariate analysis, due to heterogeneity in the cognitive status, and less sample size.[18] In all these risk factors, impairment in-home and hobbies domain of CDR and ≥ 2 comorbidities are independent predictors of fall in cognitively impaired older people.

Overall, 39.28% (44/112) of the study population were experienced falls. In a prospective study, Allan et al.[20] found that people with dementia experience fall eight times more than normal people. The fall prevalence and incidence also varied among the subtypes and severity of dementia, and range of settings like community, hospital, and long-term care, though our study did not characterize the subtypes. Delbaere et al.[21] suggested that MCI could be an independent risk factor for falls whereas results from the GOOD initiative[4] show falls and their mechanisms differ across the spectrum of cognitive impairment when compared to cognitively healthy people.

In a prospective cohort study by Yaffe et al.,[22] it was found that lower socioeconomic status has significant effects on dementia. The possible explanation could be an inability to get timely and appropriate health care, medical attention, and treatment for their comorbidities. All these factors are intertangled and may have cumulative effects on cognitive decline. People with lower socioeconomic status also have reduced cognitive reserve secondary to poor education in early years (illiterates; fallers vs. nonfallers 20.45% vs. 11.76%) and chronic stress due to poor lifestyle and unemployment.[22] Along with this, low socioeconomic people also have a lack of fall prevention interventions including educational and nutritional components, and they are also at risk of poor diet, all leading to increased falls in this group.[17] This also explains higher comorbidities in the faller group as seen in this study too (fallers vs. nonfallers 77.27% vs. 60.29%) with (adjusted odds ratio [AOR]: 19.39 [1.043–360.373] multimorbidity ≥2), as observed in a previous study.[19]

Memory and cognition play an important role in executive function. In a prospective study by Mirelman et al.,[23] a decline in executive function plays an important role in falling. In this study, the EF was not evaluated separately. Home and hobbies have questionnaires such as arranging beds, cleaning vessels, sticking to their hobbies, i.e., sewing and handicrafts, and simple household tasks. Carrying out these tasks requires safe negotiation of the obstacles as well the environmental stimuli at the same time, requiring intact cognition. Any decline in these tasks which are similar to EFs and dual tasking can lead to falling. Kasai and Meguro[24] described a Dunning–Kruger effect – a poor assessment of self-abilities related to cognitive impairment; this explains the increased fall in older adults with cognitive impairment when they try to carry out complicated task of daily living and household activities. The alternative emerging view also suggests that cognitive decline occurs concurrent with gait impairment, and as the decline progresses the deficits occurred in domains like executive function, working memory will also contribute to falls.[25]

Our study has some limitations. This is a cross-sectional study carried out in an outpatient memory clinic; hence, causality cannot be established. There may be also a recall bias in remembering falls. The study sample is small, so point estimates may not be generalized.


  Conclusion Top


Falls are one of the emerging public health problems in older adults that lead to significant morbidity, dependency, and financial stress. Falls are assessed in older adults once the cognitive impairment is advanced or when they are dependent. Older adults attending memory clinics may be screened for these risk factors at the time of cognitive assessment. This may help to identify at-risk populations and enable detailed fall assessment, prevention, and rehabilitation afterward.

Acknowledgment

The authors acknowledge the study subjects and their family members for co-operation, physiotherapists, research staff, and residents of the department.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Falls. Available from: https://www.who.int/news-room/fact-sheets/detail/falls. [Last accessed on 2021 Jun 24].  Back to cited text no. 1
    
2.
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Mirelman A, Herman T, Brozgol M, Dorfman M, Sprecher E, Schweiger A, et al. Executive function and falls in older adults: New findings from a five-year prospective study link fall risk to cognition. PLoS One 2012;7:e40297.  Back to cited text no. 23
    
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