A Population-Based Study Examining Injury in Older Adults with and without Dementia

Association of first anti-seizure medication choice with injuries in older adults with newly diagnosed epilepsy

BACKGROUND

Epilepsy incidence increases exponentially in older adults, who are also at higher risk of adverse drug effects. Anti-seizure medications (ASM) may be associated with sedation and injuries, but discontinuation can result in seizures. We sought to determine whether there was an association between prescribing non-guideline concordant ASM and subsequent injury as this could inform care models.

METHODS

Retrospective cohort study of adults 50 years or older with newly-diagnosed epilepsy in 2015-16, sampled from the MarketScan Databases. The outcome of interest was injury within 1-year of ASM prescription (e.g., burns, falls) and the exposure of interest was ASM category (recommended vs. not recommended by clinical guidelines). Descriptive statistics characterized covariates and a multivariable Cox-regression model was built to examine the association between ASM category and subsequent injury.

RESULTS

5,931 people with newly diagnosed epilepsy were prescribed an ASM within 1-year. The three most common ASMs were: levetiracetam (62.86%), gabapentin (11.73%), and phenytoin (4.45%). Multivariable Cox-regression found that medication category was not associated with injury; however, older age (adjusted hazard ratio (AHR) 1.01/year), history of prior injury (AHR 1.77), traumatic brain injury (AHR 1.55) and ASM polypharmacy (AHR 1.32) were associated with increased hazard of injury.

CONCLUSIONS

Most older adults appear to be getting appropriate first prescriptions for epilepsy. However, a substantial proportion still receives medication that guidelines suggest avoiding. In addition, we show that ASM polypharmacy is associated with an increased hazard of injury within 1- year. Efforts to improve prescribing in older adults with epilepsy should consider how to reduce. both polypharmacy and exposure to medications that guidelines recommend avoiding.

Injury-related emergency department use among assisted living residents with Alzheimer's disease and related dementias

BACKGROUND

Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL.

METHODS

Using Medicare claims, we identified a cohort of fee-for-service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site-specific information on memory care designation (n = 116,754). Outcomes included all injury-related ED visits and injury-related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury-related ED visits.

RESULTS

The adjusted risk of injury-related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury-related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury-related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL.

CONCLUSIONS

Injury-related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD.

Association Between Young-Onset Dementia and Risk of Hospitalization for Motor Vehicle Crash Injury in Taiwan

IMPORTANCE

Several studies have suggested that older-onset dementia is associated with an increased risk of motor vehicle crash injury (MVCI). However, evidence of an association between young-onset dementia and the risk of MVCI is insufficient, particularly in Asia.

OBJECTIVE

To investigate the association between young-onset dementia and MVCI-related hospitalization in Taiwan.

DESIGN, SETTING, AND PARTICIPANTS

In this nationwide, population-based cohort study in Taiwan, a cohort of 39 344 patients aged 40 to 64 years with incident dementia diagnosed between 2006 and 2012 was matched 1:1 with a cohort of participants without dementia by age, sex, and index year (initial diagnosis of dementia). Participants were identified from Taiwan's National Health Insurance Research Database (NHIRD). Data were analyzed between March 25 and October 22, 2021.

EXPOSURES

Dementia, defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes.

MAIN OUTCOMES AND MEASURES

Hospitalization for MVCI, determined using linked data from Taiwan's Police-Reported Traffic Accident Registry and the NHIRD from January 1, 2003, to December 31, 2015. Hazard ratios (HRs) for MVCI-related hospitalization were estimated using Cox proportional hazards regression models adjusted for sex, age, salary-based insurance premium, urbanization level, and comorbidities.

RESULTS

Of the 78 688 participants, 47 034 (59.8%) were male; the mean (SD) age was 54.5 (7.4) years. During the 10-year follow-up period, the incidence density of MVCI-related hospitalization was 45.58 per 10 000 person-years (95% CI, 42.77-48.39 per 10 000 person-years) among participants with dementia and 24.10 per 10 000 person-years (95% CI, 22.22-25.99 per 10 000 person-years) among participants without dementia. Compared with participants without dementia, patients with young-onset dementia were at higher risk of MVCI-related hospitalization (adjusted HR [aHR], 1.83; 95% CI, 1.63-2.06), especially those in younger age groups (aged 40-44 years: aHR, 3.54; 95% CI, 2.48-5.07) and within a shorter period (within 1 year of follow-up: aHR, 3.53; 95% CI, 2.50-4.98) after dementia was diagnosed. Patients with young-onset dementia also had a higher risk of being a pedestrian when the crash occurred (aHR, 2.89; 95% CI, 2.04-4.11), having an intracranial or internal injury (aHR, 2.44; 95% CI, 2.02-2.94), and having a severe injury (aHR, 2.90; 95% CI, 2.16-3.89).

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, patients in Taiwan with a diagnosis of young-onset dementia had a higher risk of MVCI-related hospitalization than did individuals without dementia and the risk varied by age, disease duration, transport mode, injury type, and injury severity. These findings suggest a need for the planning of strategies to prevent transportation crashes among patients with young-onset dementia.

Nurse-led home modification interventions for community-dwelling older adults with dementia and their impact on falls prevention

This quasi-experimental study aimed to investigate the effects of nurse-led home modification interventions on the family members of home-dwelling older adults with dementia. The sample consisted of 42 older adults diagnosed with dementia and their family members. A number of validated tools were used. Three home visits were undertaken, a training package with family members was instigated, and the patients were followed up for a 6-month period. It was determined that there was a decrease in falls in the first 3-month period (p=0.002). The number of falls in the second 3-month period was lower in the older adults who had their homes modified (p=0.000). Family-centred, nurse-led home-modification interventions can be effective in the prevention and reducing of falls in older adults with dementia.

Differences in the risk of severe falls between patients aged <65 years and patients aged ≥65 years at a psychiatric hospital based on 12-year incident reports

PURPOSE

This study compared age differences in risk factors for falls requiring treatment in psychiatric patients.

DESIGN AND METHODS

An incident database was used to compare fall incidents in patients aged less than 65 years and those aged greater than or equal to 65 years.

FINDINGS

Approximately 30% of fallers were less than 65 years. Mental status and medication were the main risk factors. Decreased activities of daily living were associated with the most falls in patients greater than or equal to 65 years.

PRACTICE IMPLICATIONS

Fall risk differed between the two age groups. Medication may play a major role in falls among patients less than 65 years.

Typology of Technology-Supported Dementia Care Interventions From an In-Home Telehealth Trial

Identifying the needs of dementia caregivers is critical for supporting dementia home care. This study identified a typology of expert interventions delivered to dementia caregivers during an innovative telehealth trial that used in-home video recordings to directly observe care challenges. Qualitative content analysis was used to analyze narrative notes describing interventions that were developed based on video data submitted by 33 caregiver-care recipient dyads. Two major themes emerged: education and skills for dementia care and caregiver support. Ten subthemes included education and skills related to: behavioral and psychological symptoms of dementia, disease expectations, safety, activities of daily living, medical care optimization, and medication utilization and caregiver support related to: respite, positive reinforcement, social and financial support, and self-care. Families providing in-home dementia care experience a wide range of care challenges. By using video data, dementia care experts were able to witness and evaluate challenging care situations and provide individualized feedback.

Randomised Controlled Trial Of The Effect Of Tai Chi On Postural Balance Of People With Dementia

Purpose

To investigate the effect of Tai Chi exercise on postural balance among people with dementia (PWD) and the feasibility of a definitive trial on falls prevention.

Patients and methods

Dyads, comprising community-dwelling PWD and their informal carer (N=85), were randomised to usual care (n=43) or usual care plus weekly Tai Chi classes and home practice for 20 weeks (n=42). The primary outcome was the timed up and go test. All outcomes for PWD and their carers were assessed six months post-baseline, except for falls, which were collected prospectively over the six-month follow-up period.

Results

For PWD, there was no significant difference at follow-up on the timed up and go test (mean difference [MD] = 0.82, 95% confidence interval [CI] = -2.17, 3.81). At follow-up, PWD in the Tai Chi group had significantly higher quality of life (MD = 0.051, 95% CI = 0.002, 0.100, standardised effect size [ES] = 0.51) and a significantly lower rate of falls (rate ratio = 0.35, 95% CI =0.15, 0.81), which was no longer significant when an outlier was removed. Carers in the Tai Chi group at follow-up were significantly worse on the timed up and go test (MD = 1.83, 95% CI = 0.12, 3.53, ES = 0.61). The remaining secondary outcomes were not significant. No serious adverse events were related to participation in Tai Chi.

Conclusion

With refinement, this Tai Chi intervention has potential to reduce the incidence of falls and improve quality of life among community-dwelling PWD [Trial registration: NCT02864056].

Impact of Social Network on the Risk and Consequences of Injurious Falls in Older Adults

OBJECTIVES

A smaller social network is associated with worse health-related outcomes in older people. We examined the impact of social connections and social support on the risk of injurious fall and on fall-related functional decline and mortality.

DESIGN

Prospective study with 6-year follow-up.

SETTING

Community.

PARTICIPANTS

A total of 2630 participants (aged ≥60 years) from the Swedish National Study on Aging and Care in Kungsholmen.

MEASUREMENTS

Social connections (social network size and contact frequency) and social support (social resource perception and satisfaction) were assessed through validated questionnaires. Data on injurious falls (falls requiring inpatient or outpatient care) and mortality came from official registers. We defined injurious falls as severe if they caused fracture and/or intracranial injury and as multiple if two or more occurred during the 6-year follow-up. Functional decline was defined as the loss of ability to perform one or more activities of daily living during the follow-up.

RESULTS

During the follow-up, 322 participants experienced injurious falls. After adjusting for potential confounders, the hazard ratio of injurious falls was 1.7 (95% confidence interval [CI] = 1.1-2.4) for people with poor social connections and 1.5 (95% CI = 1.1-2.1) for people with moderate social connections (reference: rich social connections). Social support was not associated with fall risk. The odds of functional decline among those with severe/multiple falls and (1) poor social connections (odds ratio [OR] = 5.2 [95% CI = 2.1-12.9]) or (2) poor social support (OR = 4.5 [95% CI = 1.7-12.0]) was up to twice as high as among those with severe/multiple falls and (3) rich social connections (OR = 2.5 [95% CI = .9-6.6]) or (4) rich social support (OR = 2.7 [95% CI = 1.2-6.3]). Similar but more attenuated results emerged for mortality.

CONCLUSIONS

Social network may influence fall risk and fall-related functional decline and mortality. J Am Geriatr Soc 67:1851-1858, 2019.

The Association Between Central Nervous System-Active Medication Use and Fall-Related Injury in Community-Dwelling Older Adults with Dementia

OBJECTIVES

To examine the association between central nervous system (CNS)-active medication use and the risk of fall-related injury in community-dwelling older adults following dementia onset. Further, to evaluate increased risk at higher doses or with a greater number of CNS-active medication classes.

METHODS

Participants included community-dwelling older adults aged 65 years and older with a dementia diagnosis participating in the Adult Changes in Thought Study. From automated pharmacy data, a time-varying composite measure of CNS-active medication use was created. Central nervous system-active medication use was classified as current (use within prior 30 days), recent (prior 31-90 days), past (prior 91-365 days), and nonuse (no exposure in prior year). For current users, standardized daily doses (SDDs) were calculated for each CNS-active medication and summed across medications, and the number of CNS-active medication classes used was also measured. The outcome was fall-related injury based on emergency department, inpatient, and outpatient International Classification of Diseases, Ninth Revision (ICD-9) and external cause of injury (E) codes.

RESULTS

Among 793 subjects, 303 fall-related injuries occurred over a mean follow-up of 3.7 years (2907 total person-years). Relative to nonuse, fall risk was significantly higher for current use (adjusted hazard ratio [HR] 1.59, 95% confidence internal [CI] 1.19-2.12) but not for past or recent use. Among current users, increased risk was seen across SDD levels: HRs (95% CI): 1.77 (1.19-2.62), 1.79 (1.25-2.56), and 1.35 (0.96-1.92) for less than 1 SDD, 1 to less than 2 SDDs, and 2 or more SDDs, respectively (trend test, p=0.14). A trend was seen for increasing risk with a greater number of CNS-active medication classes; however, this was not statistically significant (trend test, p=0.084).

CONCLUSIONS

Current use of CNS-active medications was associated with fall-related injury in community-dwelling older adults followed from time of dementia onset, with increased risk even with use of low doses.

Falls resulting in health care among older people with intellectual disability in comparison with the general population

BACKGROUND

Falls are common among older people with intellectual disability (ID) and are also a major contributor to injuries in this population. Yet, fall characteristics have only been sparsely studied, and the results are inconsistent. The aim of the present study was to investigate type of falls, places where they occurred and activities that caused them, as well as health outcomes and health utilisation patterns after falls, among older people with ID in comparison with their age peers in the general population.

METHODS

We established an administrative cohort of people with ID aged 55 years, or more, and alive at the end of 2012 (ID cohort; n = 7936). A cohort from the general population, one-to-one matched by sex and year of birth, was used as referents. Data regarding fall-induced health care episodes in inpatient and outpatient specialist care were collected from the National Patient Register for the period 2002-2012.

RESULTS

With the exception of falls from one level to another (i.e. fall on and from stairs and steps, ladder and scaffolding; fall from, out of or through building or structure; fall from tree or cliff and diving or jumping into water; or other fall from one level to another), people in the ID cohort were more likely to fall and fall more often than those in the general population cohort. Falls during a vital activity (e.g. attending to personal hygiene or eating) were twice as common among people with ID compared with the general population. When falling, people with ID were more likely to injure their head and legs but less likely to sustain injuries to the thorax and elbow/forearm. They were more likely to have superficial injuries, open wounds and fractures but less likely to have dislocations, sprain and strains. Fall-related health care visits among people with ID were more likely to be in inpatient care and be unplanned. People with ID were also more likely than those in the general population to have a readmission within 30 days.

CONCLUSIONS

People with ID are more likely to require specialist care after a fall and also more likely to obtain injuries to the head, compared with the general population. This is important to consider when taking preventive measures to reduce falls and fall-related injuries.

The Effects and Meanings of Receiving a Diagnosis of Mild Cognitive Impairment or Alzheimer's Disease When One Lives Alone

BACKGROUND

One third of older adults with cognitive impairment live alone and are at high risk for poor health outcomes. Little is known about how older adults who live alone experience the process of receiving a diagnosis of mild cognitive impairment (MCI) or Alzheimer's disease (AD).

OBJECTIVE

The aim of this study was to understand the effects and meanings of receiving a diagnosis of MCI or AD on the lived experience of older adults living alone.

METHODS

This is a qualitative study of adults age 65 and over living alone with cognitive impairment. Participants' lived experiences were elicited through ethnographic interviews and participant observation in their homes. Using a qualitative content analysis approach, interview transcripts and fieldnotes were analyzed to identify codes and themes.

RESULTS

Twenty-nine older adults and 6 members of their social circles completed 114 ethnographic interviews. Core themes included: relief, distress, ambiguous recollections, and not knowing what to do. Participants sometimes felt uplifted and relieved by the diagnostic process. Some participants did not mention having received a diagnosis or had only partial recollections about it. Participants reported that, as time passed, they did not know what to do with regard to the treatment of their condition. Sometimes they also did not know how to prepare for a likely worsening of their condition, which they would experience while living alone.

CONCLUSION

Findings suggest the need for more tailored care and follow-up as soon as MCI or AD is diagnosed in persons living alone.

Anticoagulation Therapy for Atrial Fibrillation in Patients With Alzheimer's Disease

Background and Purpose- Direct oral anticoagulants (DOACs) are safer, at least equally efficacious, and cost-effective compared to warfarin for stroke prevention in atrial fibrillation (AF) but they remain underused, particularly in demented patients. We estimated the cost-effectiveness of DOACs compared with warfarin in patients with AF and Alzheimer's disease (AD). Methods- We constructed a microsimulation model to estimate the lifetime costs, quality-adjusted life-years (QALYs), and cost-effectiveness of anticoagulation therapy (adjusted-dose warfarin and various DOACs) in 70-year-old patients with AF and AD from a US societal perspective. We stratified patient cohorts based on stage of AD and care setting. Model parameters were estimated from secondary sources. Health benefits were measured in the number of acute health events, life-years, and QALYs gained. We classified alternatives as cost-effective using a willingness-to-pay threshold of $100 000 per QALY gained. Results- For patients with AF and AD, compared with warfarin, DOACs increase costs but also increase QALYs by reducing the risk of stroke. For mild-AD patients living in the community, edoxaban increased lifetime costs by $6603 and increased QALYs by 0.076 compared to warfarin, yielding an incremental cost-effectiveness ratio of $86 882/QALY gained. Even though DOACs increased QALYs compared with warfarin for all patient groups (ranging from 0.019 to 0.085 additional QALYs), no DOAC treatment alternative had an incremental cost-effectiveness ratio <$150 000/QALY gained for patients with moderate to severe AD. For patients living in a long-term care facility with mild AD, the DOAC with the lowest incremental cost-effectiveness ratio (rivaroxaban) costs $150 169 per QALY gained; for patients with more severe AD, the incremental cost-effectiveness ratios were higher. Conclusions- For patients with AF and mild AD living in the community, edoxaban is cost-effective compared with warfarin. Even though patients with moderate and severe AD living in the community and patients with any stage of AD living in a long-term care setting may obtain positive clinical benefits from anticoagulation treatment, DOACs are not cost-effective compared with warfarin for these populations. Compared to aspirin, no oral anticoagulation (warfarin or any DOAC) is cost effective in patients with AF and AD.

Analysis of the risk and risk factors for injury in people with and without dementia: a 14-year, retrospective, matched cohort study

BACKGROUND

Most previous studies on dementia and injuries have focused on a particular type of injury, and few studies have investigated overall injury in people with dementia. In this study, we investigated the risk factors and risk of overall injury, including the diagnosis, cause, and intentionality of injury, in people with and without dementia in Taiwan.

METHODS

We collected relevant data between 2000 and 2013 from the National Health Insurance Research Database (NHIRD). Overall, 455,630 cases, consisting of 91,126 people with dementia and 364,504 people without dementia, were included in this study and we performed subgroup analysis. A multivariate Cox proportional hazards regression analysis was used to determine the risk of injuries.

RESULTS

The 14-year follow-up data showed that people with dementia had a higher risk of injury-related hospitalization than did people without dementia (19.92% vs 18.86%, hazard ratio (HR) = 1.070, p < 0.001). Regarding the cause of injury, people with dementia were more likely to be hospitalized due to suffocation (HR = 2.301, p < 0.001), accidental drug poisoning (HR = 1.485, p < 0.001), or falls (HR = 1.076, p < 0.001), and were less likely to be hospitalized due to suicide or self-inflicted injury (HR = 0.670, p < 0.001) or a traffic accident (HR = 0.510, p < 0.001) than were people without dementia. Subgroup analysis showed that people with dementia with any of the three subtypes of dementia were at a higher risk of homicide or abuse than were people without dementia (vascular dementia, HR = 2.079, p < 0.001; Alzheimer's disease, HR = 1.156, p < 0.001; other dementia, HR = 1.421, p < 0.001). The risk factors for overall injury included dementia diagnosis, female gender, age 65-74 years, and seeking medical attention for an injury within the past year.

CONCLUSION

People with dementia are at a higher risk of injury-related hospitalization than people without dementia. The results of this study provide a reference for preventing suffocation, drug poisoning, and falls in people with dementia. In addition, government agencies should pay attention to and intervene in cases of abuse suffered by people with dementia.

Cognitive enhancers associated with decreased risk of injury in patients with dementia: a nationwide cohort study in Taiwan

This study aimed to investigate the associations among dementia, psychotropic medications and the risk of overall injuries. In this nationwide matched cohort study, a total of 144 008 enrolled patients ≥age of 50, with 36 002 study subjects who suffered from dementia and 108 006 controls matched for sex and age, from the Inpatient Dataset, for the period 2000-2010 in Taiwan were selected from the National Health Insurance Research Database, according to International Classification of Diseases, 9th Revision, Clinical Modification. When adjusting for the confounding factors, a Cox proportional hazards analysis was used to compare the risk of developing psychiatric disorders during the 10 years of follow-up. Of the study subjects, 6701 (18.61%) suffered injury when compared with 20 919 (19.37%) in the control group. The Cox regression analysis revealed that the study subjects were more likely to develop an injury (HR: 2.294, 95% CI=2.229 to 2.361, P<0.001) after adjusting for sex, age, monthly income, urbanization level, geographic region, and comorbidities. Psychotropic medications in the subjects with dementia were associated with the risk of injury (adjusted HR=0.217, 95% CI: 0.206 to 0.228, P<0.001). Cognitive enhancers, including acetylcholinesterase inhibitors and memantine, were associated with the risk of injury in the study subjects after being adjusted for all comorbidities and medications (adjusted HR=0.712(95% CI=0.512 to 0.925, P<0.01)). In conclusion, patients who suffered dementia had a higher risk of developing injury, and the cognitive enhancers were associated with the decreased risk of injury.