Injurious falls before, during and after dementia diagnosis: a population-based study

Scoping review exploring the impact of hip fracture in older adults with cognitive impairment or dementia

OBJECTIVES

This review summarises the impact of hip fractures on health outcomes including subsequent falls, hospitalisation, length of hospital stay (LOS), functional status, quality of life and mortality in older adults with cognitive impairment or dementia. It also explores the risk of institutionalisation following a hip fracture in this population.

DESIGN

A scoping review following the Arksey and O'Malley framework guided by the Joanna Briggs Institute methodology and adheres to Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews guidelines.

DATA SOURCES

A comprehensive search strategy was developed to search MEDLINE, EMBASE, CINAHL and grey literature, with additional references identified through citation searching and Web of Science.

ELIGIBILITY CRITERIA

Studies were included if they examined older adults with cognitive impairment or dementia who experienced a hip fracture and reported outcomes related to hospitalisation, functional status, quality of life, mortality or institutionalisation.

DATA EXTRACTION AND SYNTHESIS

Study selection and data extraction were conducted independently by two reviewers using Covidence software. A narrative synthesis approach was employed to summarise findings and identify key themes, patterns and gaps in the literature.

RESULTS

We identified 30 studies reporting health outcomes following hip fracture. Overall, the studies indicated that individuals with cognitive impairment or dementia have higher hospitalisation rates, poorer walking ability and functional outcomes, as well as reduced quality of life posthip fracture. The LOS for individuals with dementia following hip fracture was inconsistent across studies, with some reporting shorter LOS and others indicating longer LOS. Individuals with dementia consistently exhibit higher mortality rates at 30 days, 90 days and 1-year postfracture compared with those without dementia. We found 21 studies that evaluated the risk of institutionalisation following a hip fracture. Older adults with dementia were significantly more likely to be institutionalised posthip fracture, with nearly five times the risk of failing to return home compared with those without dementia. This increased risk persists up to 1-year postfracture and is particularly pronounced in those with severe cognitive impairment, with higher rates of nursing home placement observed among individuals with hip fractures.

CONCLUSION

Older adults with cognitive impairment or dementia experience significantly worse outcomes following hip fractures, including higher mortality, poorer functional outcomes, reduced quality of life and a higher risk of institutionalisation postfracture. Future research should focus on developing effective strategies for fracture prevention, including optimising osteoporosis treatment in this high-risk population, and developing targeted interventions to improve the impact of fractures on functional outcomes and reduce institutionalisation rates in this vulnerable population.

Association of falls with risk of dementia and all-cause mortality: a cohort study of Japanese older adults with a 9-year follow-up

OBJECTIVE

Many risk factors affect dementia and all-cause mortality. However, whether falls are a risk factor for dementia and all-cause mortality is unclear. The study examines the association of falls with the risk of dementia and all-cause mortality, and whether dementia mediates the association of falls with all-cause mortality.

METHODS

Data were taken from the Japanese Gerontological Evaluation Study (JAGES) with a 9-year follow-up. Falls information was collected through a questionnaire and categorized into no falls, single and multiple falls. Dementia and all-cause mortality data were obtained from the long-term care insurance (LTCI) system. The Cox proportional hazard models were used to calculate the hazard ratios (HRs) and 95% confidence intervals (95% CIs), and causal mediation analysis (CMA) was used to assess the mediating effects of dementia.

RESULTS

A total of 52,076 participants were included in the study. Compared to participants with no falls, participants with single and multiple falls had an increased risk of dementia (single fall, HRs = 1.18, 95% CIs 1.12-1.24; multiple falls, HRs = 1.66, 95% CIs 1.56-1.77) and all-cause mortality (single fall, HRs = 1.09, 95% CIs 1.04-1.15; multiple falls, HRs = 1.34, 95% CIs 1.26-1.43), and the risk increased with the number of falls (P for trend < 0.01). In addition, dementia significantly mediated the association between falls and risk of all-cause mortality (NIE: HRs = 1.02, 95% CIs 1.00-1.04, PM = 15.0%).

CONCLUSION

Falls are associated with the risk of dementia and all-cause mortality. Dementia has important mediating effects in the association between falls and the risk of all-cause mortality.

Long COVID-19 outcomes of patients with pre-existing dementia

BACKGROUND

Although COVID-19 has been linked to worse acute outcomes in patients with some neurodegenerative disorders, its long-term impact on dementia remains unclear.

OBJECTIVE

To investigate the outcomes of COVID-19 survivors with dementia.

METHODS

This retrospective study evaluated 9806 patients with dementia in the Montefiore Health System (January 2016 to July 2023). Comparisons were made between dementia patients with and without a positive SARS-CoV-2 polymerase-chain-reaction test who had a follow-up at least two weeks post-infection. Outcomes included all-cause mortality, major adverse cardiovascular events (MACE), new-onset dysphagia, dyspnea, fatigue, new-onset sleep disturbances, altered mental status, first-time fall, headache, new-onset depression, and new-onset anxiety. Adjusted hazard ratios (aHR) were computed adjusting for age, sex, race, ethnicity, and pre-existing comorbidities.

RESULTS

Dementia patients with COVID-19 were younger, more likely to be male, and had a higher prevalence of major pre-existing comorbidities compared to those without COVID-19. Patients who survived acute COVID-19 were more likely to die than non-COVID controls after adjusting for covariates (aHR = 1.65 [1.43, 1.91]). COVID-19 was significantly associated with higher risk of MACE (aHR = 1.58 [1.41, 1.78]), new-onset dysphagia (aHR = 1.64 [1.42, 1.91]), dyspnea (aHR = 1.27 [1.12, 1.44]), fatigue (aHR = 1.42 [1.22, 1.65]), new-onset sleep disturbances (aHR = 1.36 [1.15, 1.60]), altered mental status (aHR = 1.36 [1.16, 1.59]), and first-time fall (aHR = 1.34 [1.09, 1.65]).

CONCLUSIONS

COVID-19 increases the risk of mortality and other adverse health outcomes in dementia patients. These findings highlight the need for closer follow-up and management strategies for dementia patients post-COVID-19.

Risk of Dementia Diagnosis After Injurious Falls in Older Adults

Importance

Emerging evidence suggests that mild cognitive impairment, which is a precursor to Alzheimer disease and related dementias (ADRD), places older adults at increased risk for falls. However, the risk that an older adult develops dementia after experiencing a fall is unknown.

Objective

To determine the risk of new ADRD diagnosis after a fall in older adults.

Design, Setting, and Participants

This retrospective cohort study examined Medicare Fee-for-Service data from 2014 to 2015, with follow-up data available for at least 1 year after the index encounter. Participants included adults aged 66 years and older who experienced a traumatic injury that resulted in an emergency department (ED) or inpatient encounter and did not have a preexisting diagnosis of dementia. Data analysis was performed from August 2023 to July 2024.

Exposures

Experiencing a fall compared with other mechanisms of injury, defined by International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 external cause of injury codes.

Main Outcomes and Measures

The hazard of new ADRD diagnosis within 1 year of a fall, assessed by performing a Cox multivariable competing risk model that controlled for potential confounders while accounting for the competing risk of death.

Results

The study included 2 453 655 older adult patients who experienced a traumatic injury; 1 522 656 (62.1%) were female; 124 396 (5.1%) were Black and 2 232 102 (91.0%) were White; and the mean (SD) age was 78.1 (8.1) years. The mechanism of injury was a fall in 1 228 847 incidents (50.1%). ADRD was more frequently diagnosed within 1 year of a fall compared with other injury mechanisms (10.6% [129 910 of 1 228 847] vs 6.1% [74 799 of 1 224 808]; P < .001). The unadjusted hazard ratio (HR) of incident dementia diagnosis after a fall was 1.63 (95% CI, 1.61-1.64; P < .001). On multivariable Cox competing risk analysis, falling was independently associated with an increased risk of dementia diagnosis among older adults (HR, 1.21 [95% CI, 1.20-1.21]; P < .001) after controlling for patient demographics, medical comorbidities, and injury characteristics, while accounting for the competing risk of death. Among the subset of older adults without a recent skilled nursing facility admission, the HR was 1.27 (95% CI, 1.26-1.28; P < .001).

Conclusions and Relevance

In this cohort study, new ADRD diagnoses were more common after falls compared with other mechanisms of injury, with 10.6% of older adults being diagnosed with ADRD in the first year after a fall. To improve the early identification of ADRD, this study's findings suggest support for the implementation of cognitive screening in older adults who experience an injurious fall that results in an ED visit or hospital admission.

Attrition from longitudinal ageing studies and performance across domains of cognitive functioning: an individual participant data meta-analysis

OBJECTIVES

This paper examined the magnitude of differences in performance across domains of cognitive functioning between participants who attrited from studies and those who did not, using data from longitudinal ageing studies where multiple cognitive tests were administered.

DESIGN

Individual participant data meta-analysis.

PARTICIPANTS

Data are from 10 epidemiological longitudinal studies on ageing (total n=209 518) from several Western countries (UK, USA, Mexico, etc). Each study had multiple waves of data (range of 2-17 waves), with multiple cognitive tests administered at each wave (range of 4-17 tests). Only waves with cognitive tests and information on participant dropout at the immediate next wave for adults aged 50 years or older were used in the meta-analysis.

MEASURES

For each pair of consecutive study waves, we compared the difference in cognitive scores (Cohen's d) between participants who dropped out at the next study wave and those who remained. Note that our operationalisation of dropout was inclusive of all causes (eg, mortality). The proportion of participant dropout at each wave was also computed.

RESULTS

The average proportion of dropouts between consecutive study waves was 0.26 (0.18 to 0.34). People who attrited were found to have significantly lower levels of cognitive functioning in all domains (at the wave 2-3 years before attrition) compared with those who did not attrit, with small-to-medium effect sizes (overall d=0.37 (0.30 to 0.43)).

CONCLUSIONS

Older adults who attrited from longitudinal ageing studies had lower cognitive functioning (assessed at the timepoint before attrition) across all domains as compared with individuals who remained. Cognitive functioning differences may contribute to selection bias in longitudinal ageing studies, impeding accurate conclusions in developmental research. In addition, examining the functional capabilities of attriters may be valuable for determining whether attriters experience functional limitations requiring healthcare attention.

Falls and Alzheimer Disease

Falls are the leading cause of injury, disability, and injury-related mortality in the older adult population. Older adults with Alzheimer disease (AD) are over twice as likely to experience a fall compared to cognitively normal older adults. Intrinsic and extrinsic fall risk factors may influence falls during symptomatic AD; intrinsic factors include changes in cognition and impaired functional mobility, and extrinsic factors include polypharmacy and environmental fall hazards. Despite many known fall risk factors, the high prevalence of falls, and the presence of effective fall prevention interventions for older adults without cognitive impairment, effective fall prevention interventions for older adults with AD to date are limited and inconclusive. Falls may precede AD-related cognitive impairment during the preclinical phase of AD, though a narrow understanding of fall risk factors and fall prevention interventions for older adults with preclinical AD limits clinical treatment of falls among cognitively normal older adults with preclinical AD. This mini review explores fall risk factors in symptomatic AD, evidence for effective fall prevention interventions in symptomatic AD, and preclinical AD as an avenue for future falls research, including recommendations for future research directions to improve our understanding of falls and fall risk during preclinical AD. Early detection and tailored interventions to address these functional changes are needed to reduce the risk of falls for those at risk for developing AD. Concerted efforts should be dedicated to understanding falls to inform precision fall prevention strategies for this population.

New horizons in the diagnosis and management of Alzheimer's Disease in older adults

Alzheimer's Disease (ad) is the most common cause of dementia, and in addition to cognitive decline, it directly contributes to physical frailty, falls, incontinence, institutionalisation and polypharmacy in older adults. Increasing availability of clinically validated biomarkers including cerebrospinal fluid and positron emission tomography to assess both amyloid and tau pathology has led to a reconceptualisation of ad as a clinical-biological diagnosis, rather than one based purely on clinical phenotype. However, co-pathology is frequent in older adults which influence the accuracy of biomarker interpretation. Importantly, some older adults with positive amyloid or tau pathological biomarkers may never experience cognitive impairment or dementia. These strides towards achieving an accurate clinical-biological diagnosis are occurring alongside recent positive phase 3 trial results reporting statistically significant effects of anti-amyloid Disease-Modifying Therapies (DMTs) on disease severity in early ad. However, the real-world clinical benefit of these DMTs is not clear and concerns remain regarding how trial results will translate to real-world clinical populations, potential adverse effects (including amyloid-related imaging abnormalities), which can be severe and healthcare systems readiness to afford and deliver potential DMTs to appropriate populations. Here, we review recent advances in both clinical-biological diagnostic classification and future treatment in older adults living with ad. Advocating for access to both more accurate clinical-biological diagnosis and potential DMTs must be done so in a holistic and gerontologically attuned fashion, with geriatricians advocating for enhanced multi-component and multi-disciplinary care for all older adults with ad. This includes those across the ad severity spectrum including older adults potentially ineligible for emerging DMTs.

Psychiatric Disorders Before and After Dementia Diagnosis

Importance

Little is known about the specific timing and sequence of incident psychiatric comorbidities at different stages of dementia diagnosis.

Objectives

To examine the temporal risk patterns of psychiatric disorders, including depression, anxiety, stress-related disorders, substance use disorders, sleep disorders, somatoform/conversion disorders, and psychotic disorders, among patients with dementia before, at the time of, and after receipt of a diagnosis.

Design, Setting, and Participants

This population-based, nationwide cohort study analyzed data from 796 505 participants obtained from 6 registers between January 1, 2000, and December 31, 2017, including the Swedish registry for cognitive/dementia disorders. Patients with dementia were matched on year of birth (±3 years), sex, and region of residence with up to 4 controls. Data were analyzed between March 1, 2023, and August 31, 2023.

Exposures

Any cause of dementia and dementia subtypes.

Main Outcomes and Measures

Flexible parametric survival models to determine the time-dependent risk of initial diagnosis of psychiatric disorders, from 7 years prior to dementia diagnosis to 10 years after diagnosis. Subgroup analysis was conducted for psychiatric drug use among persons receiving a diagnosis of dementia from January 1, 2011, to December 31, 2012.

Results

Of 796 505 patients included in the study (mean [SD] age at diagnosis, 80.2 [8.3] years; 448 869 (56.4%) female), 209 245 had dementia, whereas 587 260 did not, across 7 824 616 person-years. The relative risk of psychiatric disorders was consistently higher among patients with dementia compared with control participants and began to increase from 3 years before diagnosis (hazard ratio, [HR], 1.72; 95% CI, 1.67-1.76), peaked during the week after diagnosis (HR, 4.74; 95% CI, 4.21-5.34), and decreased rapidly thereafter. Decreased risk relative to controls was observed from 5 years after diagnosis (HR, 0.93; 95% CI, 0.87-0.98). The results were similar for Alzheimer disease, mixed dementia, vascular dementia and unspecified dementia. Among patients with dementia, markedly elevated use of psychiatric medications was observed in the year leading up to the dementia diagnosis and peaked 6 months after diagnosis. For example, antidepressant use was persistently higher among patients with dementia compared with controls, and the difference increased from 2 years before dementia diagnosis (15.9% vs 7.9%, P < .001), peaked approximately 6 months after dementia diagnosis (29.1% vs 9.7%, P < .001), and then decreased slowly from 3 years after diagnosis but remained higher than controls 5 years after diagnosis (16.4% vs 6.9%, P < .001).

Conclusions and Relevance

The findings of this cohort study that patients with dementia had markedly increased risks of psychiatric disorders both before and after dementia diagnosis highlight the significance of incorporating psychiatric preventative and management interventions for individuals with dementia across various diagnostic stages.

External Causes of Death From Death Certificates in Patients With Dementia

OBJECTIVES

We aim to analyze the risk of death from specific external causes, including falls, complications of medical and surgical care, unintentional injuries, and suicide, in dementia patients.

DESIGN

Swedish nationwide cohort study integrating 6 registers from May 1, 2007, through December 31, 2018, including the Swedish Registry for Cognitive/Dementia Disorders (SveDem).

SETTING AND PARTICIPANTS

Population-based study. Patients diagnosed with dementia from 2007 to 2018 and up to 4 controls matched on year of birth (±3 years), sex, and region of residence.

METHODS

The exposures of this study were diagnosis of dementia and dementia subtypes. Number of deaths and causes of mortality were obtained from death certificates compiled into the Cause of Death Register. Hazard ratios (HRs) and 95% CIs were estimated using Cox and flexible models, adjusted for sociodemographics, medical and psychiatric disorders.

RESULTS

The study population included 235,085 patients with dementia [96,760 men (41.2%); mean age 81.5 (SD 8.5) years] and 771,019 control participants [341,994 men (44.4%); mean age 79.9 (SD 8.6) years], over 3,721,687 person-years. Compared with control participants, patients with dementia presented increased risk for unintentional injuries (HR 3.30, 95% CI 3.19-3.40) and falls (HR 2.67, 95% CI 2.54-2.80) during old age (≥75 y), and suicide (HR 1.56, 95% CI 1.02-2.39) in middle age (<65 y). Suicide risk was 5.04 times higher (HR 6.04, 95% CI 4.22-8.66) in patients with both dementia and 2 or more psychiatric disorders relative to controls (incidence rate per person-years, 1.6 vs 0.3). For dementia subtypes, frontotemporal dementia had the highest risks of unintentional injuries (HR 4.28, 95% CI 2.80-6.52) and falls (HR 3.83, 95% CI 1.98-7.41), whereas subjects with mixed dementia were less likely to die from suicide (HR 0.11, 95% CI 0.03-0.46) and complications of medical and surgical care (HR 0.53, 95% CI 0.40-0.70) compared to controls.

CONCLUSIONS AND IMPLICATIONS

Suicide risk screening and psychiatric disorders management in early-onset dementia and early interventions for unintentional injuries and falls prevention in older dementia patients should be provided.

The Nebulous Association between Cognitive Impairment and Falls in Older Adults: A Systematic Review of the Literature

BACKGROUND

In older people, dementia is a well-established risk factor for falls. However, the association and the causal relationship between falls and the earlier stages of cognitive impairment remains unclear. The purpose of the study was to review the literature data on the association between falls and cognitive impairment, no dementia, including Mild Cognitive Impairment.

METHODS

According to PRISMA guidelines, we searched five electronic databases (EMBASE, Web of Science, Medline, CINAHL, and PsychINFO) for articles published between January 2011 and August 2022 on observational studies of older people with a cognitive assessment and/or cognitive impairment diagnosis and a recording of falls. Their quality was reviewed according to the STROBE checklist.

RESULTS

We selected 42 of the 4934 initially retrieved publications. In 24 retrospective studies, a statistically significant association between falls and cognitive status was found in only 15 of the 32 comparisons (47%). Of the 27 cross-sectional analyses in prospective studies, only eight (30%) were positive and significant. We counted four longitudinal analyses, half of which suggested a causal relationship between falls and cognitive impairment. The investigational methods varied markedly from one study to another.

CONCLUSION

It is still not clear whether falls are associated with cognitive impairment, no dementia. Data in favor of a causal relationship are scarce. Further studies are needed to clarify their relationship.