Predictors of falls among institutionalized women with Alzheimer's disease

Differences Between Moderate to Severely Cognitively Impaired Fallers Versus Nonfallers in Nursing Homes

INTRODUCTION

The purpose of this study was to test differences in psychotropic medication, function, physical activity, agitation, resistiveness to care, comorbidities, and depression among moderate to severely cognitively impaired nursing home residents who were fallers versus nonfallers.

METHODS

This was a secondary data analysis using baseline data from a randomized controlled trial testing the Function and Behavior Focused Care intervention across 12 nursing homes. The sample included 336 older adults, the majority of whom were female and white.

RESULTS

There was a significant difference in the total number of comorbidities, agitation, the total number of psychotropic medications, depressive symptoms, and physical activity between those who fell and those who did not fall (Pillai-Bartlett trace = 4.91; P < .001).

DISCUSSION

Findings support prior work except with regard to medication use, cognition, and function. Due to inconsistent findings, additional research is recommended particularly with regard to the use of specific drug groups and medications.

Falls and subjective well-being. Results of the population-based German Ageing Survey

PURPOSE

The aim of the current study was to determine the relationship between falling in the past 12 months and subjective well-being in a broader sense.

METHODS

Cross-sectional data were gathered from a representative sample of community-dwelling individuals in the second half of life (40 to 95 years; n=7808) in Germany. While life satisfaction was quantified using the Satisfaction with Life Scale (SWLS), positive and negative affect was measured using the Positive and Negative Affect Schedule (PANAS).

RESULTS

The prevalence of falling in the preceding 12 months was 17.6%. After controlling for sociodemographic factors, various lifestyle factors, self-rated health, and morbidity, multiple linear regression analysis revealed that falling in the past 12 months was associated with higher negative affect (β=0.08, p<0.001), lower positive affect (β=-0.04, p<0.05) as well as lower life satisfaction (β=-0.12, p<0.001).

CONCLUSION

The present study stresses the relationship between falls and subjective well-being. Future longitudinal studies are needed to validate the findings of the present cross-sectional study and to better understand the nature of this relationship.

Institutional care of dementia patients: A state-wide survey of long-term care facilities and special care units

A two-wave survey gathered information on dementia residents in long-term care (LTC) facilities in the State of Minnesota (76 percent response). Respondents reported that dementia patients represented more than half the total LTC population. Behavior management issues are the chief concern of respondents, but techniques for management are not well-developed. Fourteen percent of the respondents reported they had or planned special care units (SCU) for dementia patients. A sub-survey of these SCU indicated a lack of clarity and precision about diagnosis admission and discharge criteria. The need for evaluation of and standards for these SCU are discussed.

Can a tailored exercise and home hazard reduction program reduce the rate of falls in community dwelling older people with cognitive impairment: protocol paper for the i-FOCIS randomised controlled trial

BACKGROUND

The rate of falls in community dwelling older people with cognitive impairment (CI) is twice that of a cognitively intact population, with almost two thirds of people with CI falling annually. Studies indicate that exercise involving balance and/or a home hazard reduction program are effective in preventing falls in cognitively intact older people. However the potential benefit of these interventions in reducing falls in people with CI has not been established.This randomised controlled trial will determine whether a tailored exercise and home hazard reduction program can reduce the rate of falls in community dwelling older people with CI. We will determine whether the intervention has beneficial effects on a range of physical and psychological outcome measures as well as quality of life of participants and their carers. A health economic analysis examining the cost and potential benefits of the program will also be undertaken.

METHODS AND DESIGN

Three hundred and sixty people aged 65 years or older living in the community with CI will be recruited to participate in the trial. Each will have an identifiable carer with a minimum of 3.5 hours of face to face contact each week.Participants will undergo an assessment at baseline with retests at 6 and 12 months. Participants allocated to the intervention group will participate in an exercise and home hazard reduction program tailored to their cognitive and physical abilities.The primary outcome measure will be the rate of falls which will be measured using monthly falls calendars. Secondary outcome measures will include the risk of falling, quality of life, measures of physical and cognitive function, fear of falling and planned and unplanned use of health services. Carers will be followed up to determine carer burden, coping strategies and quality of life.

DISCUSSION

The study will determine the impact of this tailored intervention in reducing the rate of falls in community dwelling older people with CI as well as the cost-effectiveness and adherence to the program. The results will have direct implications for the design and implementation of interventions for this high-risk group of older people.

TRIAL REGISTRATION

The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry - ACTRN12614000603617.

How can you prevent falls and subsequent fractures?

Over the years, a number of strategies have been investigated to prevent falls in older people in a number of settings. Over 200 randomised controlled trials now exist, and the challenge for the discerning clinician is to read and interpret the existing literature so as to be able to implement effective strategies, targeting the right individual with the right intervention. This chapter reviews the current literature and attempts to simplify what has become an enormously complex area. Interventions are reviewed in three main settings - community, hospital and care facilities and based on the type of approach - single, multiple or multifactorial interventions. It also considers the reality in which we practise and provides some 'best bets' to consider at this point in time.

Dementia and hip fractures: development of a pathogenic framework for understanding and studying risk

Dementia and hip fractures are 2 conditions that are seen primarily in older adults, and both are associated with substantial morbidity and mortality. An individual with dementia is up to 3 times more likely than a cognitively intact older adult to sustain a hip fracture. This may occur via several mechanisms, including (1) risk factors that are common to both outcomes; (2) the presence of dementia increasing hip fracture incidence via intermediate risk factors, such as falls, osteoporosis, and vitamin D; and (3) treatment of dementia causing side effects that increase hip fracture risk. We describe a model that applies these 3 mechanisms to explain the relationship between dementia and hip fractures. Comprehensive understanding of these pathways and their relative influence on the outcome of hip fracture will guide the development of effective interventions and potentially improve prevention efforts.

Physiological fall risk factors in cognitively impaired older people: a one-year prospective study

BACKGROUND/AIMS

Cognitively impaired older people are at twice the risk of falls compared to cognitively intact, with approximately 60% falling once or more per year. This study aimed to investigate sensorimotor and balance risk factors for falls in cognitively impaired older people.

METHODS

177 community-dwelling older people with mild to moderate cognitive impairment (Mini-Mental State Examination < 24, Addenbrooke's Cognitive Examination-Revised < 83) were assessed using the Physiological Profile Assessment (PPA). Falls were recorded prospectively for 12 months using monthly calendars with the assistance of carers.

RESULTS

Seventy-one participants (43%) fell ≥2 times in the follow-up period. Impaired simple reaction time, postural sway, leaning balance and increased PPA fall risk score were significantly associated with multiple falls. The area under the receiver-operating characteristic curve for the PPA model including tests of vision, proprioception, knee extension strength, reaction time, postural sway and leaning balance was 0.75 (95% confidence interval: 0.68-0.83).

CONCLUSION

These findings indicate poor performance on physiological fall risk factors, particularly balance, increases the risk of falls in older cognitively impaired people.

Fall-related hip fracture hospitalisations and the prevalence of dementia within older people in New South Wales, Australia: an analysis of linked data

INTRODUCTION

Dementia and fall-related hip fractures both contribute significantly to the burden of illness within elderly populations in Australia and elsewhere. The research presented here uses a large probabilistically linked dataset from NSW, Australia to estimate the prevalence of dementia within hip fracture patients and investigate the impact of dementia on hospitalisation length of stay (LOS) and survival.

METHOD

The cases considered were NSW residents aged 65 years and above who experienced a fall related hip fracture between 1 July 2000 and 30 June 2009. The prevalence of dementia was calculated for the incident hip fracture using two methods to infer dementia status. Cox proportional hazards regression modelling was used to estimate the relative rate of discharge from a hospitalisation episode, and the relative mortality rate of hip fracture patients suffering dementia versus those who were cognitively intact. Additional covariates used in the models included sex, age group at admission, the Charlson Comorbidity Index and separation mode.

RESULTS

Of the 44,143 fall-related incident hip fracture cases considered, between 24% (observed diagnosis) to 29% (inferred diagnosis) of these people had dementia. The median LOS for patients with dementia was shorter than those without dementia, but there was a strong interaction with age. The rate of discharge from the fracture-related hospitalisation episode of the cases with dementia was 40% greater (95% CI 1.4-1.5) than the non-demented group. Similarly, the relative mortality rate of those with dementia was greater (2.4, 95% CI 2.3-2.6) than the non-demented group. Both Cox analyses indicated evidence for main effects of age at admission and comorbidity, as well as interaction effects between age group and dementia status.

CONCLUSION

The use of linked datasets with tens of thousands of cases enables the calculation of precise estimates of various parameters. People with dementia constitute a significant proportion of the total population of elderly hip fracture patients in hospitals (up to 29%). Their mortality rate is greater than those without a diagnosis of dementia and their hospital length of stay is shorter, particularly if they are discharged to a residential aged care facility.

Fall determinants in older long-term care residents with dementia: a systematic review

BACKGROUND

Persons with dementia are two to three times more likely to fall compared to persons without dementia. In long-term care settings, the dementia prevalence is highest. Therefore, older long-term care residents with dementia can be considered a high-risk group for falls. Nevertheless, no systematic evaluation of fall determinants in this population was found. The purpose of this study was to identify fall determinants among older long-term care residents with dementia or cognitively impaired persons in long-term care, by conducting a systematic literature review.

METHODS

We searched English, French, Dutch, and German articles listed in: CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, and Web of Science. Additionally, references of included articles were screened. Studies were included if determinants or circumstances of falls in older persons with dementia living in long-term care were assessed.

RESULTS

Eight studies met the inclusion criteria. Three studies were excluded from detailed analysis because of insufficient quality. Use of psychotropic drugs, a "fair or poor" general health, gait impairments, and age were associated with an increased fall risk. Also trunk restraints were associated with an increased number of falls while full bedrails and wandering behavior were protective against falls.

CONCLUSIONS

Fall risk factors known from other populations, e.g. use of psychotropic drugs, physical restraints, and health conditions, are found in long-term care residents with dementia as well. Due to the limited evidence available, future studies with adequate sample sizes and prospective designs are required to determine specific fall risk factors and verify existing results in this population.

Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators

OBJECTIVES

to explore the associations between spatiotemporal gait parameters and falls in cognitively impaired older people and to investigate whether sensorimotor and neuropsychological factors mediate the association between gait performance and falls.

DESIGN

prospective cohort study with a 1 year follow-up.

SETTING

community-dwelling sample.

PARTICIPANTS

sixty-four participants (62-96 years of age) with cognitive impairment.

MEASUREMENTS

gait analysis and sensorimotor and neuropsychological functions were assessed in all participants. Falls were identified prospectively for 1 year.

RESULTS

multiple fallers (≥2 falls) had significantly slower gait velocity, shorter stride length, greater double support time and increased step length variability in univariate analyses. Multivariate logistic regression indicated that the relationship between gait and falls was mediated primarily by sensorimotor function and to a lesser extent by neuropsychological performance.

CONCLUSION

the findings indicate that slow and variable gait patterns increase the risk of falls in cognitively impaired older adults. Further, the association between gait and falls seems to be mediated in large by reduced sensorimotor functioning. Further research is needed to investigate whether interventions aimed at improving gait and/or sensorimotor fall risk factors, such as strength and balance, can prevent falls in cognitively impaired older adults.

Characteristics of falls in mild and moderate Alzheimer's disease

The occurrence of falls in AD patients is frequent, and their consequences are cognitive decline, fractures and loss of independence. Many studies have addressed fall risk factors in order to establish effective prevention strategies.

Objectives

We describe the frequency and characteristics of falls in a sample of AD patients and their main risk factors.

Methods

We evaluated 40 subjects without cognitive impairment, and 45 AD patients, graded as CDR 1 and CDR 2.

Results

Environmental hazard risks were the most frequent cause associated with falls in CDR 1 (41.4%) and CDR 2 (46.7%). Instability (31%) and dizziness (17.2%) were frequent causes of falls in the CDR 1 group, and this group showed the highest rate of recurrence (28%). In both groups of AD patients, indoors falls predominated (70.3 and 80% respectively for CDR 1 and 2). In our sample, the remaining factors studied were not associated with increasing risk for falls.

Conclusions

These results reinforce the hypothesis that falls in AD are mutifactorial and that their risk factors are highly interconnected. Preventative strategies considering all aspects should be implemented most crucially eliminating environmental risks, maintaining constant presence of caregivers, and providing physical and functional stimulation, both in mild and moderate AD.

Executive function and gait in older adults with cognitive impairment

BACKGROUND

Cognitive impairment has been shown to predict falls risk in older adults. The ability to step accurately is necessary to safely traverse challenging terrain conditions such as uneven or slippery surfaces. However, it is unclear how well persons with cognitive impairment can step accurately to avoid such hazards and what specific aspects of cognition predict stepping ability in different patient populations.

METHODS

Healthy older adults (NC), patients with Mild Cognitive Impairment with only memory impairment (MCI-EF) or memory and executive function impairments (MCI+EF) and early Alzheimer's patients (AD) were timed as they performed a stepping accuracy test with increasing cognitive demand (Walking Trail-Making Test; W-TMT), which required stepping on instrumented targets with either increasing sequential numbers (W-TMT A) or alternating sequential numbers and letters (W-TMT B).

RESULTS

After accounting for age and baseline walking speed, the AD and MCI+EF groups were significantly slower than the NC and MCI-EF groups on the task with the highest cognitive demand, W-TMT B (interaction effect F = 6.781, p <.0001). No group differences were noted on the W-TMT A task that was less cognitively demanding. Neuropsychological measures of executive functioning were associated with slower W-TMT B performance, whereas memory, visual attention and visual spatial skills were not (adjusted R(2) = 0.42).

CONCLUSIONS

Executive function is important for stepping performance, particularly under more complex environmental conditions.

The "posture second" strategy: a review of wrong priorities in Parkinson's disease

Falls are common in Parkinson's disease. It remains difficult to predict these falls, presumably because clinical balance tests assess single components of postural control, whereas everyday fall mechanisms are typically more complicated. A substantial proportion of everyday falls appears to occur while Parkinson patients attempt to perform multiple tasks at the same time. Furthermore, little attention is generally paid to the possible contribution of cognitive impairments to falls. The importance of mental dysfunction is supported by the fact that cognitive loading while walking or balancing can lead to marked deteriorations in postural performance, and there is some evidence to suggest that such "dual tasking" is particularly difficult for elderly persons with dementia or depression. We examined what strategies Parkinson patients used when a basic walking task became increasingly challenging by adding additional tasks (both motor and cognitive). Most patients could perform a simple "dual task" test: simultaneously walking and answering simple questions. However, as the walking task became more complex, patients' performance began to deteriorate. Interestingly, this was reflected not only by failure to answer questions, but also by an increasing number of blocks in motor performance (walking and balancing). This behaviour was different from that of both young and elderly controls, who appeared to sacrifice performance on the cognitive task in order to optimise their gait and balance ("posture first" strategy). Preliminary evidence suggest that impaired multiple task performance is associated with a two-fold increased risk of sustaining falls in daily life. We conclude that Parkinson patients are less inclined than healthy persons to maintain a safe gait. Instead, Parkinson patients use a "posture second" strategy and treat all elements of a complex task with equal priority, which in daily life may go at the expense of maintaining balance and lead to falls.

Psychiatric illness and subsequent traumatic brain injury: a case control study

OBJECTIVE

To determine whether psychiatric illness is a risk factor for subsequent traumatic brain injury (TBI).

METHODS

Case control study in a large staff model health maintenance organisation in western Washington State. Patients with TBI, determined by International classification of diseases, 9th revision, clinical modification (ICD-9-CM) diagnoses, were 1440 health plan members who had TBI diagnosed in 1993 and who had been enrolled in the previous year, during which no TBI was ascertained. Three health plan members were randomly selected as control subjects, matched by age, sex, and reference date. Psychiatric illness in the year before the TBI reference date was determined by using computerised records of ICD-9-CM diagnoses, psychiatric medication prescriptions, and utilisation of a psychiatric service.

RESULTS

For those with a psychiatric diagnosis in the year before the reference date, the adjusted relative risk for TBI was 1.7 (95% confidence interval (CI) 1.4 to 2.0) compared with those without a psychiatric diagnosis. Patients who had filled a psychiatric medication prescription had an adjusted relative risk for TBI of 1.6 (95% CI 1.2 to 2.1) compared with those who had not filled a psychiatric medication prescription. Patients who had utilised psychiatric services had an adjusted relative risk for TBI of 1.3 (95% CI 1.0 to 1.6) compared with those who had not utilised psychiatric services. The adjusted relative risk for TBI for patients with psychiatric illness determined by any of the three psychiatric indicators was 1.6 (95% CI 1.4 to 1.9) compared with those without any psychiatric indicator.

CONCLUSION

Psychiatric illness appears to be associated with an increased risk for TBI.

Vertical impact increase in middle age may explain idiopathic weight-bearing joint osteoarthritis

OBJECTIVE

To test the hypothesis that ground reaction force increases when a standard stepping task is performed in late middle age.

DESIGN

Consecutive sample.

SETTING

Internal medicine practice.

PARTICIPANTS

Thirty-six male patients (age range, 17-72yr) from an internal medicine practice.

INTERVENTION

Subjects performed 20 consecutive footfall impacts onto a force platform while barefoot and while wearing shoes.

MAIN OUTCOME MEASURES

Ground reaction forces were recorded for each footfall.

RESULTS

Impact is positively related to age both when barefoot (r = .84, p < .001) and when wearing shoes (r = .71, p < .001). Impact remains constant until age 50, after which it increases by 13.3% for barefoot subjects. Barefoot impact was significantly lower and less variable than impact when shod (barefoot = 1.18 body weight [BW]; shod = 1.22 BW; F(1,5) = 169.91, p < .001).

CONCLUSION

An increase in impact force during locomotion was identified that occurs in late middle age, when stability declines and idiopathic weight-bearing joint osteoarthritis develops. Because impact is negatively related to stability, the impact rise is probably caused by postural adjustments to instability resulting from irreversible neurologic decline. This heightened impact may account for the accelerated rate of weight-bearing joint osteoarthritis that begins in late-middle age.

[Dementia, depression and activity of daily living as risk factors for falls in elderly patients]

OBJECTIVES

Falls among elderly are a well-recognised public health problem. The purpose of the present study was to explore the relation between dementia, number of depressive symptoms, activities of daily living, setting, and risk of falling.

METHODS

Data for the analysis came from a cross-sectional study about dementia, depression, and disabilities, carried out 1995/96 in Zurich and Geneva. The random sample stratified, by age and gender consisted of 921 subjects aged 65 and more. The interview was conducted by means of the Canberra interview for the Elderly, extended by short questionnaire. The subject was classified as a faller if the subject and/or the informant had reported a fall within the last 12 months prior to the interview. Logistic-regression analysis was used to determine the independent impact of dementia, depressive symptoms, and ADL-score on risk of falling.

RESULTS

The stepwise logistic regression analysis has revealed a statistically significant association between dementia (OR 2.14, 95% CI 1.15-3.96), two resp. three depressive symptoms (OR 1.64, 95% CI 1.04-2.60) as well as four or more depressive symptoms (OR 2.64, 95% CI 1.39-5.02) and the risk of falling. There was no statistically significant relationship between studied risk factors and the risk of being one-time faller. However, we found a strong positive association between dementia (OR 3.92, 95% CI 1.75-8.79), four or more depressive symptoms (OR 3.90, 95% CI 1.55-9.83) and the risk of being recurrent faller. Moreover, residents of nursing homes (OR 8.50, 95% CI 2.18-33.22) and elderly aged 85 or more (OR 2.29, 95% CI 1.08-4.87) were under statistically significant higher risk of sustaining recurrent falls.

CONCLUSIONS

The results of the present study confirm that dementia and depression substantially increase the risk of falling.

Physical restraint use and falls in nursing home residents

OBJECTIVE

To examine the relationship between restraint use and falls while controlling for the effect of psychoactive drug use among nursing home residents, including subgroups of nursing home residents with high rates of restraint use and/or falls.

DESIGN

Secondary analysis of data from a longitudinal clinical trial designed to reduce restraint use.

SETTING

Three nursing homes.

PARTICIPANTS

Subjects (n = 322) were either restrained (n = 119) or never restrained (n = 203) at each observation point during a 9.5-month data collection period that preceded the intervention phase of the clinical trial.

MEASUREMENTS

We evaluated restraint status (independent variable) three times during the data collection period by direct observation over a 72-hour period. Incident reports documenting falls and fall-related injuries (dependent variables) were reviewed. Cognitive status was measured using the Folstein Mini-Mental State Exam and functional status (including ambulation status) by the Psychogeriatric Dependency Rating Scale. Psychoactive drug use profile was obtained through record review.

MAIN RESULTS

Using multiple logistic regression, we compared the effect of restraint use on fall risk between a confused ambulatory subgroup and the remaining sample and found a significant difference in the odds ratio for falls and recurrent falls (P = .02; chi-square = 5.24, df = 1; P = .003, chi-square = 9.12, df = 1). In the confused ambulatory subgroup, restraint use was associated with increased falls (odds ratio: 1.65, 95% CI: 0.69, 3.98) as well as recurrent fall risk (odds ratio: 2.46, 95% CI: 1.03, 5.88). Increased falls and recurrent fall risk was not observed in the remaining sample (falls odds ratio: 0.49, 95% CI: 0.28, 0.87; recurrent falls odds ratio: 0.42, 95% CI: 0.20, 0.91). One subgroup, the nonconfused ambulatory residents, were never restrained; after removing this subgroup, the confused ambulatory continued to be associated, though not significantly, with a higher risk of falls and injuries. Only nonconfused nonambulatory restraints were associated with a lower risk of all three outcomes: falls (odds ratio: 0.28, 95% CI: 0.05, 1.58), recurrent falls (odds ratio: 0.48, 95% CI: 0.05, 4.72), and injurious falls (odds ratio:0.42, 95% CI: 0.04, 4.01); these results, however, were not statistically significant. There was no evidence that the effect of restraint use on fall risk depended upon the use of psychoactive drugs (chi square = 4.43; df = 2, P = .11).

CONCLUSION

Restraints were not associated with a significantly lower risk of falls or injuries in subgroups of residents likely to be restrained. These findings support individualized assessment of fall risk rather than routine use of physical restraints for fall prevention. Researchers and clinicians should continue to focus efforts on developing a variety of approaches that reduce risk of falls and injuries and promote mobility rather than immobility.

Acute health status and its relationship to falls in the nursing home

1. Falls represent a major health threat to the elderly, often resulting in injury, disability and/or death. 2. A significant association between acute changes in health status and falling was revealed in this study over 1-month, 2-month and alternating time periods. 3. Nurses' fall prevention efforts should be more attuned to the more relevant predictor of changing health status and functioning capability of residents.

Home hazards and falls in the elderly: the role of health and functional status

OBJECTIVES

This study was undertaken to determine whether vigorous and frail older people who identify environmental hazards in their homes have an increased risk for falls.

METHODS

A 1-year prospective study was conducted among 266 female and 59 male community-dwelling volunteers aged 60 to 93 years who had fallen at least once during the previous year. Composite measures of home safety and of frailty were derived using principal components analysis. Participants were divided into vigorous and frail groups, and associations between baseline home safety measures and falls at home over the follow-up year were compared between the two groups.

RESULTS

Frail individuals were more than twice as likely as vigorous individuals to fall during follow-up (rate ratio [RR] = 2.24; 95% confidence interval [CI] = 1.54, 3.27). In the study group as a whole, falls were not strongly associated with the presence of home hazards. However, when compared with vigorous older persons living with fewer home hazards, vigorous older persons living with more home hazards were more likely to fall. The increased risk for falls among vigorous elderly was limited to falls where home hazards were present. By contrast, living with more home hazards was not associated with increased likelihood of falls among frail older persons.

CONCLUSIONS

While frail older persons experience higher overall fall rates, vigorous older persons should not be overlooked in fall prevention projects.

Prodromal falls among older nursing home residents

Although numerous studies have identified medical antecedents of falls among the elderly (premonitory), few have examined falls as a possible predictor of subsequent disease onset (prodromal falling). This study compared disease incidence (up to 12 months after the first fall) among fallers (n = 42) and nonfallers (n = 20) selected from 236 admissions to the health care center of a nursing home. Data collected on up to five new falls per resident (total of 102 falls) included (a) predictors of falls, (b) circumstance of falls, and (c) postfall events. Results showed that although faller and nonfaller groups were similar on admission in both numbers and types of medical diseases, fallers showed greater frequency of developing new medical problems in the 12-month postfall follow-up period. However, no particular medical diseases were found to singularly account for the greater number of medical problems evident among fallers. Additionally, fallers tended to be more impaired on admission in ambulation and daily living abilities than nonfallers.

Agitation and falls in institutionalized elderly persons

The occurrence of falls and the manifestations of three dimensions of agitation (aggressive behaviors, physically nonaggressive behaviors, verbal behaviors) were recorded in 408 nursing home residents during each of the three nursing shifts. Falls occurred most frequently during the busiest shift (the day shift) and least frequently during the night shift when most residents were sleeping and nursing staff were not as busy, a result that confirms previous reports. In comparison to residents who did not fall, residents who fell manifested significantly more physically nonaggressive behaviors, more aggressive behaviors, more verbally agitated behaviors, and overall, a greater total number of agitated behaviors.