Skip to main content
NCBI home page
American Journal of Alzheimer's Disease and Other Dementias logoLink to American Journal of Alzheimer's Disease and Other Dementias
. 2013 May 22;28(4):403–407. doi: 10.1177/1533317513488921

The Effects of Sleep Quality, Physical Activity, and Environmental Quality on the Risk of Falls in Dementia

Sima Ataollahi Eshkoor 1, Tengku Aizan Hamid 1,✉, Siti Sa’adiah Hassan Nudin 2, Chan Yoke Mun 1
PMCID: PMC10852720  PMID: 23698600

Abstract

Objectives:

This study aimed to identify the effects of sleep quality, physical activity, environmental quality, age, ethnicity, sex differences, marital status, and educational level on the risk of falls in the elderly individuals with dementia.

Methodology:

Data were derived from a group of 1210 Malaysian elderly individuals who were noninstitutionalized and demented. The multiple logistic regression model was applied to estimate the risk of falls in respondents.

Results:

Approximately the prevalence of falls was 17% among the individuals. The results of multiple logistic regression analysis revealed that age (odds ratio [OR] = 1.03), ethnicity (OR = 1.76), sleep quality (OR = 1.46), and environmental quality (OR = 0.62) significantly affected the risk of falls in individuals (P < .05). Furthermore, sex differences, marital status, educational level, and physical activity were not significant predictors of falls in samples (P > .05).

Conclusion:

It was found that age, ethnic non-Malay, and sleep disruption increased the risk of falls in respondents, but high environmental quality reduced the risk of falls.

Keywords: dementia, elderly, environment, falls, physical activity, sleep quality

Introduction

Falls are common among the elderly individuals 1,2 which cause substantial costs to both individuals and society. 3 Advanced age increases falls due to age-related changes in muscular strength, flexibility, balance control, and walking stability. 4 Dementia aggravates the risk of falls in the elderly individuals 5 because of malnutrition, cognitive decline, behavioral disorders, visuospatial impairment, motor apraxia, gait and balance disturbances, adverse effects of medications, and fear of falling. 6 It has been well documented that the risk of falls in elderly individuals associates with cognition, 7 physical activity, 8 sleep problems, 3 and environmental factors. 6,7,9 -12

Sleep disruption could increase the risk of falls in the elderly individuals 13 via the negative effects on cognitive functions. 3,14 Physical activities could also reduce the risk of falls by increasing cognitive abilities, 8 delaying age-related changes as well as maintaining and/or improving physical health. 4 Apparently, environmental hazards increase the risk of falls in elderly individuals with dementia due to a change in adaptation to their environments. 6,12 Environmental properties along with medications and comorbid conditions increase confusion and disorientation in dementia, which elevate the risk of falls. 15

However, environmental variables are able to affect the condition in a varying degree to modify the outcome. The management of falls in the elderly individuals with dementia seems to be a difficult task due to many intrinsic and extrinsic factors. 16 It is expected that a good knowledge of details and a coordinated effort can play important roles to improve the condition in those patients. This study tried to determine the prevalence of falls among the community Malaysian elderly individuals with demetia as well as to determine the effects of sleep quality, physical activity, environmental quality, and sociodemographic factors on the risk of falls among the mentioned group of individuals.

Methodology

This project was registered in the National Medical Research Register (Project Code: NMRR-09-443-4148). Approval and permission for conducting the study were received from the ethical committee of the Ministry of Health. It was a national cross-sectional survey titled “Determinants of Health Status among Older Malaysians” and carried out in cooperation with the Institute for Health Behavioral Research, National Institute of Health, Ministry of Health, and Institute of Gerontology, University Putra Malaysia.

The research participants included 1210 Malaysian elderly individuals with dementia who were of age 60 years and older, living in noninstitutional places. The elderly patients residing in institutions and bedridden patients were excluded. The data were collected by trained interviewers who had prior experiences as interviewers in projects conducted by the Institute of Gerontology. The average duration of interview was about 60 minutes. The samples represented the Malaysian population in terms of age and were collected from Peninsular Malaysia, which was divided into 4 zones of North, South, West, and Central.

This study evaluated the effects of age, ethnicity, sex differences, educational level, marital status, sleep quality, physical activity, and environmental quality on the risk of falls in respondents. Score of less than 26 in the Mini-Mental State Examination (MMSE) indicated the presence of dementia. 17 In this study, falls were defined according to the International Classification of Diseases, Ninth Revision 18 that excluded falls due to silent blow, loss of consciousness, epileptic seizure, and sudden onset of paralysis such as stroke. History of falls was referred to having at least 1 fall, at day or night time, during the past 6 months. Sleep quality was operationalized by asking, “ Do you feel fresh and relax after waking up in the morning,” 19 and the response was (1) Yes and (0) No. The short form of International Physical Activity Questionnaire (IPAQ) was used to measure physical activity in patients. 20 The respondents were divided into 2 groups based on their physical activity level: (1) respondents with low physical activity and (2) respondents with moderate to high physical activity. Environmental quality was related to the quality of living places 6,15 that was measured using 5 housing quality parameters of strength, lighting, ventilation, noise, cleanliness, and sanitation. This variable was recoded into (1) low quality and (2) high quality. In addition, the patients were divided into 2 groups based on age: (1) included patients less than 70 years old and (2) included patients aged 70 years and older.

Statistical Analysis

The prevalence of falls was computed for total samples wih regard to their age, ethnicity, sex differences, marital status, educational level, sleep quality, environmental quality, and physical activity. Bivariate analysis was carried out using a series of chi-square (χ2) tests to examine the association of each variable with the risk of falls. The multivariate logistic regression analysis was used to estimate the predictability of falls by focusing on age, ethnicity, sex differences, marital status, educational level, sleep quality, environmental quality, and physical activity among the respondents. Odds ratios (OR) with 95% confidence intervals (95% CIs) were computed. The critical level for rejection of the null hypothesis was considered to be a P value of 5%, 2-tailed. All analyses were performed using the Statistical Package for the Social Sciences (SPSS) software version 20.0 (IBM, Chicago, Illinois).

Results

Analysis was performed on the data collected from 1210 respondents who were Malaysian elderly patients with dementia. The prevalence of falls was approximately 17% (95% CI: 15.01-19.24) in samples (Table 1). The proportion of falls was 20.2% in the subjects with sleep disturbances and 14.9% in those without sleep disturbances. A higher percentage of falls was found in the samples with low physical activity (18.3%) compared to those with moderate to high physical activity (15.4%). Furthermore, the findings showed that the risk of falls in the environments with low quality (23.6%) was greater than that in the environments with high quality (15.1%). It was found that the risk of falls in females (18.3%) was higher than that in males (14.8%). Moreover, the prevalence of falls was 18.5% in the respondents with no education and 14.7% in those with education. The results showed that the subjects aged 70 years and older (20.5%) have further risk of falls compared to those aged less than 70 years (13%). The percentage of falls was found to be as high as 19.4% for single individuals and 14.2% for married individuals.

Table 1.

Prevalence of Falls Among 1210 Elderly Patients With Dementia.

Character N n (%) 95% CI
Falls
 No 1004 83 80.76-84.99
 Yes 206 17 15.01-19.24
Open in a new tab

Abbreviation: CI, confidence interval.

Bivariate analysis showed that the risk of falls was significantly (P < .05) associated with age (χ2 = 12.00, P = .001), ethnicity (χ2 = 10.20, P = .001), marital status (χ2 = 5.75, P = .010), sleep quality (χ2 = 5.85, P = .010), and environmental quality (χ2 = 11.05, P = .001). Further results indicated that physical activity, sex differences, and educational level were variables unrelated to the risk of falls (Table 2).

Table 2.

Prevalence of Falls and Associations With Sociodemographic Factors.

n n% 95% CI χ2 P Valuea
Sleep disruption
 No 106 14.9 12.4-17.7 5.85 .010
 Yes 100 20.2 16.9-23.9
Environmental quality
 <5 (Low)* 66 23.6 19-28.9 11.05 .001
 ≥5 (High) 140 15.1 12.9-17.5
Physical activity
 Low 123 18.3 15.6-21.4 1.75 .106
 Moderate to high 83 15.4 12.6-18.7
Sex differences
 Male 65 14.8 11.8-18.5 2.32 .074
 Female 141 18.3 15.7-21.1
Marital status
 Nonmarried 129 19.4 16.6-22.6 5.75 .010
 Married 77 14.2 11.5-17.4
Ethnicity
 Malays* 73 13.3 10.7-16.4 10.20 .001
 Non-Malays 133 20.2 17.3-23.5
Educational level
 No 143 18.5 15.9-21.3 2.82 .054
 Yes 63 14.7 11.6-18.3
Age
 <70 years oldb 72 13 10.43-16.02 12.00 .001
 ≥70 years old 134 20.5 17.57-23.75
Open in a new tab

Abbreviations: CI, confidence interval; χ2, chi-square.

a Significant at the .05 level using the chi-square test.

* Reference group.

The multiple logistic regression analysis revealed that age (P = .009), ethnicity (P = .001), sleep quality (P = .022), and environmental quality (P = .006) significantly affected the risk of falls among the respondents (P < .05). The findings indicated that non-Malay ethnicity (OR = 1.73, 95% CI: 1.25-2.40), sleep disruption (OR = 1.44, 95% CI: 1.05-1.97), and age 70 or older (OR = 1.58, 95% CI: 1.12-2.21) significantly increased the risk of falls among subjects. Moreover, the results revealed that high environmental quality (OR = 0.63, 95% CI: 0.45-0.88) significantly decreased the risk of falls. It was found that sex differences, marital status, educational level, and physical activity had no significant effects on the risk of falls among samples (P > .05). Among all variables, ethnicity (OR = 1.73) was the most significant parameter to predict a higher risk of falls (Table 3).

Table 3.

Prevalence of Falls and Associations Derived by Logistic Regression Analysis.a

B SE P Valueb OR 95% CI for OR
Lower Upper
Physical activity −0.05 0.16 .752 0.95 0.69 1.31
Environment quality −0.47 0.17 .006 0.63 0.45 0.88
Sleep quality 0.36 0.16 .022 1.44 1.05 1.97
Sex differences 0.19 0.18 .303 1.21 0.85 1.72
Educational level −0.05 0.10 .622 0.95 0.78 1.16
Marital status −0.16 0.18 .376 0.86 0.60 1.21
Ethnicity 0.55 0.17 .001 1.73 1.25 2.40
Age 0.46 0.17 .009 1.58 1.12 2.21
Open in a new tab

Abbreviations: CI, confidence interval; OR, odds ratio; SE, standard error; χ2, chi-square.

a Hosmer-Lemeshow test: χ2(8) =1.14, P = .997.

b Significant at the .05 level using the logistic regression analysis.

Discussion

Falls are major health problems in the elderly patients with dementia. 21 The age-related changes in the body systems, 4 sleep quality, physical activity, and environmental quality could affect the risk of falls in the elderly patients with dementia. Such effect is related to the influences of these factors on cognitive decline. 7,22 As falls aggravate burden and cost in both patients and caregivers, 14,23 the assessment of risk factors seems to be an important issue in further investigations. In this study, the effects of age, ethnicity, sex differences, marital status, educational level, physical activity, environmental quality, and sleep quality on the risk of falls were evaluated in the Malaysian elderly with dementia. The results showed that age, ethnicity, environmental quality, and sleep quality were the significant predictors of the likelihood of falls in the respondents. This study confirmed several previous research, 3,13,14 which indicated further risk of falls via sleep problems in the elderly individuals and in individuals with dementia. Such effect potentially occurs due to physical, psychological, and cognitive changes. 24 It sounds that the negative impacts of sleep disturbances on attention, cognition, mood, and motor performances 3 could increase the risk of falls in older adults with dementia.

The findings showed that the subjects surrounded by the high environmental quality had decreased risk of falls. It seems that an appropriate environmental quality helps to overcome deficits in physical fitness and cognitive abilities posed by dementia 6,12 and therefore reduces the risk of falls in elderly patients with dementia.

Although there are several studies 8,25 -28 indicating a direct link between physical activity and the risk of falls, but in our study we could not find a similar result. Such differences could be related to the choice of sample population as well as the amount and type of activities. 25 In addition, marital status, income, educational level, sex differences, 29 sleep problems, and the environmental quality are all possible confounding factors to interact between physical activity and cognition when considering the risk of falls in the respondents.

In spite of many reports 30 -32 that did not establish a relation between ethnicity and the risk of falls, our study showed a link supporting other findings. 5,7,33 This discrepancy is possibly due to differences in predisposition, lifestyle, and cultures 34 as well as the rate of comorbidities such as hypertension, ischemic heart disease, and stroke. 35 This study was consistent with other findings, 5,10,36,37 establishing a link between age and the likelihood of falls. Apparently, age-related changes in physiological mechanisms, vision, gait, memory, and strength 7,9,33,38 predispose elderly patients with dementia to the further risk of falls. Several research studies 5,7,39 show differences between sexes in relation to the risk of falls. However, our finding that is in support of a finding by Bueno-Cavanillas and colleagues 16 shows the same risk of falls for both sexes with dementia. In addition, marital status 5 and educational level 5,7,38,40 had been previously reported to influence the risk of falls in the elderly individuals, a correlation found unlikely in our research among the elderly with dementia. Nevertheless, differences in findings suggest that confounding factors such as income, 41 supplement intake, 7 social supports, 42 sleep quality, and environmental stimuli probably affect the outcomes.

Conclusion

We concluded that sleep disruption and environmental attributes were among parameters that could affect, influence, and increase the risk of falls in the elderly with dementia. Accordingly, our findings did not support the increased risk of falls in samples due to the levels of physical activity. As falls increase burden, morbidity, and mortality in elderly patients with dementia, thereby, it is warranted to assume that more investigations are needed to identify the potential risk factors in order to prevent or reduce the risk of falls in the old people with dementia. Although there are many attempts to study the predisposing factors of falls in the elderly patients with dementia, some parameters limit these studies. One of those factors can be difficulty in communication and collecting accurate self-reported data from the patients. In addition, the high prevalence of comorbidities prevents to identify the certain causes of falls in those patients. Moreover, the effect of cognitive function on the risk of falls is another aspect that needs more intervention.

Acknowledgment

The authors gratefully acknowledge the cooperation of all volunteers who participated in this study. In addition, the authors also thank all staff in their efforts on data collection.

Footnotes

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors wish to acknowledge the financial support from the Ministry of Health for this study.

References

  • 1. Biderman A, Cwikel J, Fried A, Galinsky D. Depression and falls among community dwelling elderly people: a search for common risk factors. J Epidemiol Community Health. 2002;56(8):631–636. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Kannus P, Sievãnen H, Palvanen M, Jãrvinen T, Parkkari J. Prevention of falls and consequent injuries in elderly people. Lancet. 2005;366(9500):1885–1893. [DOI] [PubMed] [Google Scholar]
  • 3. Teo JSH, Briffa NK, Devine A, Dhaliwal SS, Prince RL. Do sleep problems or urinary incontinence predict falls in elderly women? Aust J Physiother. 2006;52(1):19–24. [DOI] [PubMed] [Google Scholar]
  • 4. Schleicher MM, Wedam L, Wu G. Review of Tai Chi as an effective exercise on falls prevention in elderly. Res Sports Med. 2012;20(1):37–58. [DOI] [PubMed] [Google Scholar]
  • 5. Van Doorn C, Gruber-Baldini AL, Zimmerman S, et al. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc. 2003;51(9):1213–1218. [DOI] [PubMed] [Google Scholar]
  • 6. Van Hoof J, Kort H, Duijnstee M, Rutten P, Hensen J. The indoor environment and the integrated design of homes for older people with dementia. Build Environ. 2010;45(5):1244–1261. [Google Scholar]
  • 7. Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006;90(5):807–824. [DOI] [PubMed] [Google Scholar]
  • 8. Ahlskog J, Geda Y, Graff-Radford N, Petersen R. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011;86(9):876–884. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9. Akyol A. Falls in the elderly: what can be done? Int Nurs Rev. 2007;54(2):191–196. [DOI] [PubMed] [Google Scholar]
  • 10. Anderson K. Falls in the elderly. J R Coll Physicians Edinb. 2008;38:138–143. [Google Scholar]
  • 11. Lord SR, Menz HB, Sherrington C. Home environment risk factors for falls in older people and the efficacy of home modifications. Age Ageing. 2006;35(suppl 2):ii55–ii59. [DOI] [PubMed] [Google Scholar]
  • 12. Phair L, Heath H. Environments and older people with dementia. Ment Health Pract. 2001;4(9):32–38. [Google Scholar]
  • 13. Roepke SK, Ancoli-Israel S. Sleep disorders in the elderly. Indian J Med Res. 2010;131:302–310. [PubMed] [Google Scholar]
  • 14. McCall WV. Sleep in the elderly: burden, diagnosis, and treatment. Prim Care Companion J Clin Psychiatry. 2004;6(1):9–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15. Teresi JA, Holmes D, Ory MG. The therapeutic design of environments for people with dementia. Gerontologist. 2000;40(4):417–421. [DOI] [PubMed] [Google Scholar]
  • 16. Bueno-Cavanillas A, Padilla-Ruiz F, Jimenez-Moleon JJ, Peinado-Alonso CA, Galvez-Vargas R. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. Eur J Epidemiol. 2000;16(9):849–859. [DOI] [PubMed] [Google Scholar]
  • 17. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198. [DOI] [PubMed] [Google Scholar]
  • 18. Masud T, Morris RO. Epidemiology of falls. Age Ageing. 2001;30(suppl 4):3–7. [DOI] [PubMed] [Google Scholar]
  • 19. Dewald JF, Meijer AM, Oort FJ, Kerkhof GA, Bogels SM. The influence of sleep quality, sleep duration and sleepiness on school performance in children and adolescents: a meta-analytic review. Sleep Med Rev. 2010;14(3):179–189. [DOI] [PubMed] [Google Scholar]
  • 20. Craig CL, Marshall A, Sjostrom M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35(8):1381–1395. [DOI] [PubMed] [Google Scholar]
  • 21. Ballard C, Cream J. Drugs used to relieve behavioral symptoms in people with dementia or an unacceptable chemical cosh? Int Psychogeriatr. 2005;17(1):4–12. [DOI] [PubMed] [Google Scholar]
  • 22. Chen YM, Hwang SJ, Chen LK, Chen DY, Lan CF. Risk factors for falls among elderly men in a veterans home. J Chin Med Assoc. 2008;71(4):180–185. [DOI] [PubMed] [Google Scholar]
  • 23. Wu CY, Su TP, Fang CL, Yeh Chang M. Sleep quality among community-dwelling elderly people and its demographic, mental, and physical correlates. J Chin Med Assoc. 2012;75(2):75–80. [DOI] [PubMed] [Google Scholar]
  • 24. Cole C, Richards K. Sleep disruption in older adults: Harmful and by no means inevitable, it should be assessed for and treated. Am J Nurs. 2007;107(5):40–49; quiz 50. [DOI] [PubMed] [Google Scholar]
  • 25. Teri L, Logsdon RG, McCurry SM. Exercise interventions for dementia and cognitive impairment: the Seattle Protocols. J Nutr Health Aging. 2008;12(6):391–394. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26. Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomised controlled trial. Age Ageing. 2003;32(4):407–414. [DOI] [PubMed] [Google Scholar]
  • 27. Stevens J, Killeen M. A randomised controlled trial testing the impact of exercise on cognitive symptoms and disability of residents with dementia. Contemp Nurse. 2006;21(1):32–40. [DOI] [PubMed] [Google Scholar]
  • 28. Miu D, Szeto S, Mak Y. A randomised controlled trial on the effect of exercise on physical, cognitive and affective function in dementia subjects. Asian J Gerontol Geriatr. 2008;3:8–16. [Google Scholar]
  • 29. Rolland Y, Abellan van Kan G, Vellas B. Physical activity and Alzheimer's disease: from prevention to therapeutic perspectives. J Am Med Dir Assoc. 2008;9(6):390–405. [DOI] [PubMed] [Google Scholar]
  • 30. Faulkner KA, Cauley JA, Zmuda JM, et al. Ethnic differences in the frequency and circumstances of falling in older community-dwelling women. J Am Geriatr Soc. 2005;53(10):1774–1779. [DOI] [PubMed] [Google Scholar]
  • 31. Means KM, O'Sullivan PS, Rodell DE. Balance, mobility, and falls among elderly African American women. Am J Phys Med Rehabil. 2000;79(1):30–39. [DOI] [PubMed] [Google Scholar]
  • 32. Hanlon JT, Landerman LR, Fillenbaum GG, Studenski S. Falls in African American and white community-dwelling elderly residents. J Gerontol A Biol Sci Med Sci. 2002;57(7):M473–M478. [DOI] [PubMed] [Google Scholar]
  • 33. Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159–2168. [PubMed] [Google Scholar]
  • 34. Jean-Louis G, Magai C, Cohen C, et al. Ethnic differences in self-reported sleep problems in older adults. Sleep. 2001;24(8):926–936. [DOI] [PubMed] [Google Scholar]
  • 35. Krishnaswamy S, Kadir K, Ali RA, Sidi H, Mathews S. Prevalence of dementia among elderly Malays in an urban settlement in Malaysia. Neurol J Southeast Asia. 1997;2:159–162. [Google Scholar]
  • 36. Riefkohl EZ, Bieber H, Burlingame M, Lowenthal D. Medications and falls in the elderly: a review of the evidence and practical considerations. P&T. 2003;28(11):724–733. [Google Scholar]
  • 37. Stevens M, Holman CDAJ, Bennett N, De Klerk N. Preventing falls in older people: outcome evaluation of a randomized controlled trial. J Am Geriatr Soc. 2002;49(11):1448–1455. [DOI] [PubMed] [Google Scholar]
  • 38. Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing. 2006;35(suppl 2):ii37–ii41. [DOI] [PubMed] [Google Scholar]
  • 39. Al-Aama T. Falls in the elderly Spectrum and prevention. Can Fam Physician. 2011;57(7):771–776. [PMC free article] [PubMed] [Google Scholar]
  • 40. Ness KK, Gurney JG, Ice GH. Screening, education, and associated behavioral responses to reduce risk for falls among people over age 65 years attending a community health fair. Phys Ther. 2003;83(7):631–637. [PubMed] [Google Scholar]
  • 41. Mukamal K, Mittleman MA, Longstreth WT, Jr, Newman A, Fried L, Siscovick D. Self-reported alcohol consumption and falls in older adults: cross-sectional and longitudinal analyses of the cardiovascular health study. J Am Geriatr Soc. 2004;52(7):1174–1179. [DOI] [PubMed] [Google Scholar]
  • 42. Faulkner KA, Cauley JA, Zmuda JM, Griffin JM, Nevitt MC. Is social integration associated with the risk of falling in older community-dwelling women? J Gerontol A Biol Sci Med Sci. 2003;58(10):M954–M959. [DOI] [PubMed] [Google Scholar]

Articles from American Journal of Alzheimer's Disease and Other Dementias are provided here courtesy of SAGE Publications

RESOURCES