Memory Loss and Missteps: Investigating Fall Risks in Alzheimer's and Dementia Patients

doi:10.21203/rs.3.rs-4921780/v1

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Memory Loss and Missteps: Investigating Fall Risks in Alzheimer's and Dementia Patients

https://doi.org/10.21203/rs.3.rs-4921780/v1

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Background: Degenerative diseases such as Alzheimer's disease and dementia are significant health concerns among older adults in the United States, contributing substantially to the high incidence of falls in this population. This study aims to investigate the incidence and prevalence of falls among older adults diagnosed with Alzheimer's disease and dementia and explore the association between these conditions and the occurrence of traumatic brain injuries (TBIs).

Methods: A retrospective cohort study was conducted using data from 17,000 older adults aged 65 and above, arrived to the hospital with fall related injuries, obtained from the TriNetX network at Virginia Commonwealth University Health System (VCUHS) between January 1, 2019, and December 31, 2023. Data included demographic information, diagnosis codes (ICD-10), and details on falls, Alzheimer's disease, dementia, and TBIs. Descriptive statistics and logistic regression analyses were performed using TriNetX analytical tools.

Results: The study revealed that older adults with Alzheimer's disease (incidence proportion: 3.11%, prevalence: 4.81%) and dementia (incidence proportion: 12.46%, prevalence: 17.06%) had a significantly higher incidence of falls compared to those without these conditions. Females showed a slightly higher incidence of falls than males. Logistic regression analysis indicated that patients with Alzheimer's disease had a reduced risk of TBIs (OR=0.765, 95% CI: 0.588-0.996, p=0.047), while those with unspecified dementia had an increased risk (OR=1.161, 95% CI: 1.002-1.346, p=0.047).

Conclusions: Our study reveals a higher risk of falls and traumatic brain injuries (TBIs) in older adults with dementia compared to Alzheimer's disease. These findings underscore the need for targeted fall prevention strategies and educational programs for caregivers. Refining risk assessment tools and implementing evidence-based interventions can enhance patient safety and improve outcomes for older adults with cognitive impairments.

Geriatrics & Gerontology

Alzheimer's disease

dementia

falls

older adults

traumatic brain injury (TBI)

epidemiology

prevention.

Annually, one in four older adults experiences a fall, leading to approximately 3 million emergency department visits (CDC, 2024a; The National Council on Aging (NCOA), 2023). The risk of falls escalates with advancing age, with individuals aged 85 and older being at the highest risk (Bergen, 2016; Prevention et al., 1992). Degenerative diseases, including Alzheimer's disease and dementia, are significant contributors to the high incidence of falls among older adults (Baniasadi, 2023; Fernando et al., 2017; Kehrer-Dunlap et al., 2024).

Cognitive impairments associated with Alzheimer's disease affect an individual's ability to recognize hazards and respond appropriately to environmental challenges. Additionally, motor deficits and balance issues commonly seen in Alzheimer's patients further elevate the risk of falling (National Institute on Aging NIH, 2023). Studies have shown that individuals with Alzheimer's disease are twice as likely to experience falls compared to those without the disease (Minta et al., 2023).

Similarly, dementia, which encompasses a range of cognitive impairments including Alzheimer's disease, is strongly linked to an increased risk of falls (NHS, 2023). Dementia and Alzheimer’s affects approximately 6.9 million adults aged 65 and older in the United States (“2024 Alzheimer’s Disease Facts and Figures,” 2024). The cognitive deficits associated with dementia, including impaired executive function and attention, can significantly increase the risk of major nervous system injuries (Emmady et al., 2024). These deficits hinder an individual's ability to navigate their environment safely, making them more susceptible to falls and other accidents that can result in severe injuries to the nervous system, such as traumatic brain injuries (Luukinen et al., 2005; Petersen et al., 2018).

The outcomes of TBIs in older adults can be devastating, leading to prolonged hospitalizations, increased morbidity, and higher mortality rates (Thompson et al., 2006). The CDC reports that falls are the leading cause of TBI in older adults, accounting for approximately 60% of all TBI-related hospitalizations in this age group (CDC, 2024b).

The economic burden of neurodegenerative and cognitive disorders is staggering on both a global and national scale. The global cost of traumatic brain injury (TBI) is estimated to be $400 billion annually, which is 0.5% of the world's annual output (Fatuki et al., 2020). The total lifetime cost of care for a person living with dementia is estimated at almost $400,000, with seventy percent of these costs borne by family caregivers (National Conuncil on Aging, 2023). Alzheimer's disease alone costs the U.S. economy an estimated $321 billion in 2022, in addition to approximately $271 billion in unpaid caregiving (Skaria, 2022, p. 3). Hence, comprehending the relationship between falls, degenerative diseases, and TBIs is essential for formulating effective prevention and intervention strategies to reduce these risks.

The current study aims to investigate the incidence and prevalence of falls among older adults diagnosed with Alzheimer's disease and dementia and to explore the association between these conditions and the occurrence of TBIs.

Study Design and Population. This retrospective cohort study utilizes a dataset of 17,000 older adults above 65 years old, and have experienced falls, as identified through their medical records. The study period spans from January 1, 2019, to December 31, 2023.

Data Collection. Data were extracted from the electronic health records (EHRs) available in the TriNetX network at Virginia Commonwealth University Health System (VCUHS). The dataset includes detailed demographic information (age, sex, race, and ethnicity), diagnosis codes (ICD−10), and information on fall incidents, Alzheimer's disease, dementia, and traumatic brain injuries (TBIs). Additional data on comorbidities, medications, and previous fall history were also included to account for potential confounders.

The EHR data encompass comprehensive patient records, capturing a wide range of clinical variables essential for robust epidemiological analysis. Diagnosis codes were based on the International Classification of Diseases, 10th Revision (ICD−10), ensuring standardized and accurate identification of medical conditions. Data extraction was facilitated by the informatics team at Virginia Commonwealth University's (VCU). Kenneth and Dianne Wright Center for Clinical and Translational Research. Their support ensured the accuracy and completeness of the dataset, enabling detailed analysis of patient outcomes.

The observational informatics program at VCUHS provided secure access to the TriNetX database, adhering to stringent data governance protocols designed to protect patient privacy and comply with regulatory standards. This program ensured that all data handling processes met ethical and legal requirements, guaranteeing the integrity and confidentiality of patient information.

Statistical Analysis. Our analysis was conducted on the TriNetX platform. We employed descriptive statistics to summarize the demographic characteristics of the study population. Continuous variables such as age were expressed as means and standard deviations, while categorical variables including sex, race, and ethnicity were reported as frequencies and percentages.

Univariate analysis was performed using Chi-square tests and T-tests to explore the data further. We calculated the incidence and prevalence of falls, Alzheimer's disease, dementia, and traumatic brain injuries (TBIs), and these were stratified by demographic variables.

Logistic regression analyses were utilized to assess the associations between Alzheimer's disease, dementia, and the risk of TBIs. This analysis was conducted using both univariate and multivariable models. The multivariable models provided estimates of crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs), adjusting for potential confounders such as age, sex, comorbidities, medications, and previous fall history.

Incidence rates were calculated as the number of new cases per person-day, providing a measure of the risk of developing Alzheimer's disease, dementia, or TBIs over the study period. Additionally, we computed the incidence proportion and prevalence for each condition

Software and Tools. Data analysis was conducted using the analytical tools available within the TriNetX network. These tools facilitated the processing and analysis of large datasets, enabling comprehensive statistical evaluations and visualizations.

Descriptive analysis. The dataset encompasses a diverse group of 17,000 older adults aged 65 and above, who have experienced falls, spanning a wide range of ages from 65 to 89 years, with an average age of 78 years and a standard deviation of 8 years. The demographic breakdown reveals a predominant female representation at approximately 59.29%, compared to 40.70% male, and a minimal percentage (0.05%) with unspecified sex. Ethnically, the majority are non-Hispanic or Latino (96.64%), with a small representation of Hispanic or Latino individuals (0.52%). Racial demographics show a significant portion of White individuals (61.70%), followed by Black or African American (33.58%). Other racial categories include Asian (0.52%), American Indian or Alaskan Native (0.11%), and Native Hawaiian or Other Pacific Islander (0.05%), with a small percentage of patients identified as other races (2.58%) or unknown (1.58%).

Table 1

Demographic Description of Fall related injury
Variable	Category	Percentage	Count
Total Patients		100%	17,000
Age	Minimum Age		65 years
	Maximum Age		90 years
	Mean Age		78 years
	Standard Deviation		8 years
Sex	Female	59.29%	10,079
	Male	40.70%	6,919
	Unknown	0.05%	9
Ethnicity	Not Hispanic or Latino	96.64%	16,429
	Hispanic or Latino	0.52%	88
	Unknown Ethnicity	2.88%	490
Race	White	61.70%	10,489
	Black or African American	33.58%	5,709
	Asian	0.52%	88
	American Indian or Alaskan Native	0.11%	19
	Native Hawaiian or Other Pacific Islander	0.05%	9
	Other Race	2.58%	439
	Unknown Race	1.58%	269

The demographic distribution of Alzheimer’s Disease among older adults over a five-year period reveals notable trends in incidence and prevalence. Incidence begins at 1.85% for those aged 65–69 and increases to 6.83% for individuals aged 85 and older. Prevalence similarly rises from 2.57–11.83% across the same age groups.

Gender analysis shows that females have a slightly higher incidence proportion (3.41%) and prevalence (5.02%) compared to males, who have an incidence proportion of 2.85% and a prevalence of 4.49%. The incidence rates per person-day are 0.0000267 for females and 0.0000240 for males.

Racially, Asian individuals have the highest incidence proportion at 12.5%, with a corresponding prevalence and incidence rate of 0.0001039 cases per person-day. White individuals have an incidence proportion of 3.14%, a prevalence of 4.74%, and an incidence rate of 0.0000257 cases per person-day.

In terms of ethnicity, Hispanic or Latino individuals exhibit a significantly higher incidence proportion at 16.67%, with the same prevalence and an incidence rate of 0.0003091 cases per person-day. Non-Hispanic or Latino individuals show an incidence proportion of 3.07%, a prevalence of 4.83%, and an incidence rate of 0.0000246 cases per person-day.

Table 2

Incidence and Prevalence of Falls in Older Adults with Alzheimer Over Five Years
Demographic	Category	Incidence Proportion	Prevalence	Incidence Rate (cases/person-day)
Age	65–69 years	1.85%	2.57%	0.000014
	70–74 years	3.16%	3.92%	0.000024
	75–79 years	4.02%	6.37%	0.000033
	80–84 years	6.49%	10.00%	0.000056
	85 and older	6.83%	11.83%	0.000069
Sex	Female	3.41%	5.02%	0.0000267
	Male	2.85%	4.49%	0.0000240
Race	White	3.14%	4.74%	0.0000257
	Black or African American	3.08%	4.97%	0.0000234
	Asian	12.5%	12.5%	0.0001039
	Other Race	5.56%	5.56%	0.0000539
	Unknown Race	4.35%	8.70%	0.0000546
	American Indian or Alaska Native	0.0%	0.0%	0.0
	Native Hawaiian or Other Pacific Islander	NaN	NaN	NaN
Ethnicity	Hispanic or Latino	16.67%	16.67%	0.0003091
	Not Hispanic or Latino	3.07%	4.83%	0.0000246
	Unknown Ethnicity	0.05%	0.05%	0.0000468

Similarly, the analysis of falls among older adults with dementia reveals significant demographic patterns. Among age groups, individuals aged 85 and older exhibit the highest incidence proportion at 28.08%, with a prevalence of 37.87% and an incidence rate of 0.0003058 cases per person-day. In contrast, those aged 65–69 years have the lowest incidence proportion at 7.58%, with a prevalence of 10.29% and an incidence rate of 0.0000585 cases per person-day. This trend highlights the increasing risk of falls with advancing age among individuals with dementia.

Gender analysis indicates that females have an incidence proportion of 12.28%, with a prevalence of 17.20% and an incidence rate of 0.0000989 cases per person-day. Males show a slightly higher incidence proportion at 12.75%, with a prevalence of 16.82% and an incidence rate of 0.0001107 cases per person-day.

Racially, Black or African American individuals have a notable incidence proportion of 13.92% and a prevalence of 19.87%, with an incidence rate of 0.0001095 cases per person-day. White individuals show an incidence proportion of 11.80%, a prevalence of 15.66%, and an incidence rate of 0.0000993 cases per person-day. Asian individuals have an incidence proportion and prevalence of 12.5%, with an incidence rate of 0.0001109 cases per person-day, while other races display varied incidence rates.

In terms of ethnicity, Hispanic or Latino individuals have a significantly high incidence proportion of 33.33%, with the same prevalence and an incidence rate of 0.0006996 cases per person-day. Non-Hispanic or Latino individuals show an incidence proportion of 12.43%, a prevalence of 17.19%, and an incidence rate of 0.0001024 cases per person-day.

Table 3

Incidence and Prevalence of Falls in Older Adults with Dementia Over Five Years
Demographic	Category	Incidence Proportion	Prevalence	Incidence Rate (cases/person-day)
Age	65–69 years	7.58%	10.29%	0.0000585
	70–74 years	11.43%	14.90%	0.0000904
	75–79 years	16.15%	21.08%	0.0001410
	80–84 years	22.07%	29.38%	0.0002025
	85 and older	28.08%	37.87%	0.0003058
Sex	Female	12.28%	17.20%	0.0000989
	Male	12.75%	16.82%	0.0001107
Race	White	11.80%	15.66%	0.0000993
	Black or African American	13.92%	19.87%	0.0001095
	Asian	12.5%	12.5%	0.0001109
	American Indian or Alaska Native	0.5%	0.5%	0.0004033
	Native Hawaiian or Other Pacific Islander	NaN	NaN	NaN
	Other Race	11.76%	16.67%	0.0001133
	Unknown Race	13.64%	17.39%	0.0001744
Ethnicity	Hispanic or Latino	33.33%	33.33%	0.0006996
	Not Hispanic or Latino	12.43%	17.19%	0.0001024
	Unknown Ethnicity	0.1%	0.12%	0.0000963

Alzheimer's Disease Vs Dementia−5 Year Fall Analysis. The five-year fall analysis highlights significant differences in the incidence and prevalence of falls among older adults with Alzheimer's disease and dementia. Alzheimer's disease shows an incidence proportion of 3.11% and a prevalence of 4.81%, with an incidence rate of 0.0000251 cases per person-day related to falls. In contrast, dementia exhibits a much higher incidence proportion at 12.46% and a prevalence of 17.06%, with an incidence rate of 0.0001033 cases per person-day related to falls.

This indicates that dementia is associated with a higher risk of falls and has a greater overall impact and risk for injury in the older adult population compared to Alzheimer's disease. Specifically, the incidence proportion of falls in individuals with dementia is approximately four times higher than in those with Alzheimer's disease (12.46% vs. 3.11%). Similarly, the prevalence of falls is about 3.5 times higher in individuals with dementia compared to those with Alzheimer's disease (17.06% vs. 4.81%).

Table 4

Incidence and Prevalence of Falls in Alzheimer and Dementia Over Five Years
Measure	Alzheimer	Dementia
Incidence Proportion	3.11%	12.46%
Prevalence	4.81%	17.06%
Incidence Rate (cases/person-day)	0.0000251	0.0001033

The logistic regression analysis reveals significant differences in the relationship between Alzheimer's disease, dementia, and the occurrence of diffuse traumatic brain injury (TBI) with a loss of consciousness lasting between 6 and 24 hours in patients aged 65 years and older. Patients presenting with a fall and Alzheimer's disease (390 out of 910) are 23.5% less likely to suffer from this type of brain injury, with a crude odds ratio of 0.765 (95% CI: 0.588–0.996, p = 0.047), which remains consistent after adjusting for potential confounding factors. In contrast, patients presenting with a fall and dementia (1,210 out of 3,080) are 16.1% more likely to experience diffuse traumatic brain injury, with a crude odds ratio of 1.161 (95% CI: 1.002–1.346, p = 0.047), also consistent after adjustment. These findings indicate that Alzheimer's disease is associated with a significantly lower risk of TBI, while dementia is associated with a significantly higher risk of TBI as a consequence of fall injuries. The statistical significance of both results is supported by p-values of 0.047, indicating that the associations observed are unlikely to be due to chance. Notably, dementia shows a more significant association with the risk of TBI compared to Alzheimer's disease.

Table 5

Comparison of Logistic Regression Results for Alzheimer's Disease and Dementia
Condition	Odds Ratio (Univariate)	95% Confidence Interval	p-value
Alzheimer's	0.765	0.588–0.996	*0.047
Dementia	1.161	1.002–1.346	*0.047

A retrospective study provides significant insights into the incidence and prevalence of falls among older adults diagnosed with Alzheimer's disease and dementia and their association with traumatic brain injuries (TBIs). The results underscore the heightened vulnerability of this population to falls and the severe injuries that can arise, such as TBIs.

Our study confirms the results found by the CDC, indicating that the risk of falls increases with advanced age. Additionally, our study confirms that this trend is also evident among Alzheimer’s and dementia patients who come to the emergency department with fall-related injuries (Bergen, 2016; Prevention et al., 1992). The female cohort had a slightly higher incidence of falls than the male cohort. This finding is consistent with previous research indicating that older women are more prone to falls with injury due to factors such as lower bone density and muscle mass (Asavamongkolkul et al., 2024; Gale et al., 2016). Hewson et al., reported high fall rates among Asians compared with other racial groups (Wehner-Hewson et al., 2022). Our study confirms these findings, indicating that the incidence of falls among Alzheimer's and dementia patients varies significantly across racial and ethnic groups. Asian individuals exhibited the highest incidence of falls related to Alzheimer's disease, while Black or African American individuals showed the highest incidence of falls related to dementia. These demographic alignments served as a key motivator for us to develop risk level assessment tools (low, medium, and high risk) in the neurological assessment section to enroll cognitive disorder patients in targeted interventions. By categorizing patients based on their risk levels, we can implement caregiver intervention strategies to mitigate fall risks effectively at the family level.

Having analyzed the demographic data on the incidence and prevalence of falls among older adults with Alzheimer's disease and dementia, we now shift our focus to contextualize these findings within the broader landscape of existing research. The analysis revealed that individuals with dementia exhibit a four times higher risk of falls compared to those with Alzheimer's disease. To better understand these outcomes, we compare our study's results with relevant literature, examining how our findings align with or diverge from previous research on fall risks associated with cognitive impairments. The individuals with dementia have been reported to have a substantially higher risk of falls and fall-related injuries (Emmady et al., 2024; Luukinen et al., 2005; NHS, 2023). For instance, studies have shown that seniors with dementia are up to three times more likely to suffer hip fractures compared to those without cognitive impairments, highlighting the profound impact of cognitive decline on physical stability (Friedman et al., 2010).

While TBI is associated with cognitive diseases (Shively et al., 2012), the association between Alzheimer's disease and a reduced risk of TBIs observed in this study was unexpected. The logistic regression analysis indicated that patients with Alzheimer's disease are less likely to suffer from TBIs with loss of consciousness lasting between 6 and 24 hours. This finding could be influenced by several factors, including the severity of Alzheimer's disease and the level of care provided to these patients, which may include measures to prevent severe injuries. However, this area requires further investigation to understand the underlying mechanisms and to validate these results.

Conversely, the study found that individuals with unspecified dementia had an increased risk of TBIs, highlighting the need for targeted interventions in this group. The cognitive and physical impairments associated with dementia, such as poor coordination and balance, likely contribute to this elevated risk. This finding emphasizes the importance of comprehensive fall prevention programs that address both cognitive and physical health in dementia patients.

The findings from our study can significantly enhance the development of risk assessment tools for older adults with cognitive impairments. By demonstrating that individuals with dementia have a markedly higher risk of falls compared to those with Alzheimer's disease, our team has revised the scoring system to focus on interventions targeting caregivers. This approach will enable investigators to implement more effective education programs for caregivers of cognitive patients. By incorporating tailored fall prevention strategies, we aim to ultimately improve patient safety and outcomes. This ensures that the research assessment tools are evidence-based and have high validity.

Strengths. The study boasts several strengths. The large sample size of 17,000 older adults provides robust statistical power, enhancing the reliability of our findings. The use of standardized ICD-10 codes ensures consistent and accurate identification of medical conditions. Furthermore, the comprehensive demographic and clinical data allow for detailed analyses and stratification by various factors, enriching our understanding of fall risks in older adults with cognitive impairments.

Limitations. One key limitation of our study is its retrospective nature, which relies on previously collected data and may be subject to incomplete or inaccurate electronic health records (EHR). Additionally, the use of de-identified data prevents us from conducting follow-up assessments or validating the accuracy of recorded diagnoses and fall incidents. Furthermore, the study's setting within the Virginia Commonwealth University Health System (VCUHS) may limit the generalizability of the findings to other populations or healthcare settings, as practices and patient demographics can vary widely.

In conclusion, our study highlights the significant risk of falls and traumatic brain injuries (TBIs) among older adults with Alzheimer's disease and dementia. The findings underscore the markedly higher incidence and prevalence of falls in individuals with dementia compared to those with Alzheimer's disease. This differential risk emphasizes the need for targeted fall prevention strategies and educational programs tailored to caregivers of dementia patients. By refining risk assessment tools and implementing evidence-based interventions, researchers and program interventionists can improve patient safety and outcomes, ultimately enhancing the quality of life for older adults with cognitive impairments. Our results provide a solid foundation for future research aimed at developing more effective fall prevention programs and exploring the underlying mechanisms of fall-related injuries in this vulnerable population.

Acknowledgement and Funding Statement

We extend our gratitude to the informatics team at Virginia Commonwealth University's (VCU) C. Kenneth and Dianne Wright Center for Clinical and Translational Research, especially Dr. Tamas Gal and his team members, Evan French and Patrick Shi, for their invaluable support in data extraction through TriNetX platform. This work was supported by the Wright Center under the Clinical and Translational Science Award (CTSA) Grant number UM1TR004360.

Data Availability Statement

The datasets generated and/or analyzed during the current study were extracted from the TriNetX database and are available upon request from the corresponding author due to privacy and ethical restrictions.

Ethics Approval Statement

Ethical approval for this study was obtained from the Institutional Review Board (IRB) at Virginia Commonwealth University, classified as a non-human subject submission to ensure adherence to ethical guidelines and patient confidentiality. Access to the TriNetX database was secured through the observational informatics program at Virginia Commonwealth University’s C. Kenneth and Dianne Wright Center for Clinical and Translational Research, following strict data governance protocols to protect patient privacy and comply with regulatory standards.

Patient Consent Statement

Patient consent was not required for this retrospective study using de-identified data.

Conflict of Interest

Each author has completed and submitted the Conflict-of-Interest Disclosure Form and has declared that:
• Financial conflicts: None of the authors have financial relationships with any entities that have an interest in the information in the submitted work. There are no affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this publication.
• Personal conflicts: There are no personal relationships or direct engagements that could influence or appear to influence the submitted work.

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The authors declare no competing interests.

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