Association Between Falls and Chronic Health Conditions Among Adults in Residential Care Facilities: Analysis of the National Survey of Residential Care Facilities (NSRCF) Data

in that of can be associated with ABSTRACT Objective: This study attempts to examine the effects of stroke, heart disease, Alzheimer/dementia, Chronic Obstructive Pulmonary Disease (COPD), age, gender, and Medicaid status on falls for adults in residential care facilities. Methods: Univariate analysis was conducted to examine the distribution of resident demographic characteristics, health conditions, and Medicaid status for the entire sample. Bivariate analyses (Chi-square test of independence) were also conducted to determine if there were any statistically significant associations between independent and dependent variables. Finally, multivariable logistic regression analyses were conducted to determine the effects of stroke, heart disease, Alzheimer/dementia,

functional decline and falls as well as quality of life [4]. In addition, when elderly transition to long-term care 30% of the elderlies report they are more likely to reduce physical activity [5]. Due to the fact that most residential care facilities do not have the ability to hire sufficient care-givers that allows to assist each resident enough physical exercise, more than 80% of the time was spent sitting or lying down [6]. Fall rates can vary from 3 to 20 per 1000 bed-days among hospitalized patients [2]. For instance, the association between elderly with other chronic health conditions such as antidepressants with falls, and other risk of falls factors varies from each individual [7]. Another common chronic health issue among elderly is progression of dementia, more than a quarter of older people will have dementia or related symptoms and they are eightfold higher to be at risk of falling compared to those without dementia [8]. Reducing fall rates for adults in residential care facilities has been a priority among healthcare lawmakers due to associated risks related to prolonged hospitalization. Moreover, other studies have shown that those who transition to nursing homes have approximate 20% to 24% fatal falls with approximately 1.5 falls occurring per nursing home bed per year [9,10].
The statistical results have provided large amounts of evidence that there are more fall risk tools that need to be addressed. A large and growing body of literature has identified risk factors that can increase the incidence of hospitalizations among residents with congestive heart failure (CHF), circulatory or respiratory problems adjusting for age and gender [4]. Although many studies have examined hospitalizations among older adults (aged 65 years and older), fewer studies have investigated the relationship between falls and hospitalizations risk factors among younger and older residents in assisted living and other residential care facilities.
The purpose of this study was to examine the prevalence of falls in younger and older adults in residential care facilities from the 2010 National Survey of Residential Care Facilities (NSRCF) data.
This study attempts to examine the effects of stroke, heart disease, Alzheimer/dementia, Chronic Obstructive Pulmonary Disease (COPD), age, gender, and Medicaid status on falls for adults in residential care facilities.

Study Design & Data Source
In 2010, the National Center for Health Statistics collected data on U.S. residents living in residential care settings by conducting proxy interviews with facility administrators. This study utilized a cross-sectional study design from the 2010 National Survey of Residential Care Facilities (NSRCF). Data were collected via inperson interviews with the facility directors or designated staff and not directly with the residents. Data collected on residents included residents' demographics, living arrangements, activities, health conditions (both physical and mental), cognitive and physical functioning, as well as services received. Detailed information about the design and data collection procedures can be found elsewhere [5]. The sample included around 8,094 residents.

Measures
The variable selection of the independent variables based on previous literature about risk factors for falls, then we grouped the variables into these categories: demographic characteristics, chronic health conditions, and Medicaid coverage for residents [2,11,12,13]. Independent variables for the analysis included demographic characteristics such as age (≤64, 65-84, and >85), and gender (male and female). Other independent variables included chronic health conditions (presence or absence of stroke, heart disease, Alzheimer/dementia, and COPD) and Medicaid coverage for residents. Chronic health condition assessments were done by asking facility administrators the following question: "As far as you know, has a doctor or other health professional ever diagnosed the resident with any of the following conditions?" Our key outcome variable was whether residents experienced falls in the past 12 months based on two survey questions that result from either hip fracture or other injury.

Statistical Analyses
Univariate analysis was conducted to examine the distribution of resident demographic characteristics, health conditions, and Medicaid status for the entire sample. Bivariate analyses (Chisquare test of independence) were also conducted to determine if there were any statistically significant associations between independent and dependent variables. Finally, multivariable logistic regression analyses were conducted to determine the effects of stroke, heart disease, Alzheimer/dementia, and COPD, age, gender, and Medicaid status on the likelihood of any falls in the past year among adult residents in residential care facilities. Odds ratios and 95% confidence intervals were computed using STATA, version 13 (Stata Corporation, College Station, TX). For all inferential statistics, an alpha value of 0.05 was used.   Table 2 shows the association between falls versus resident characteristics and falls versus chronic medical conditions. There was a statistically significant association between falls and age (categorical data with three levels) for residents' age less than or equal to 64 years old, age between 65 to 84 years old, and greater than equal to 85 years old with a p-value < 0.001. Residents aged greater than or equal to 85 years old were more likely to experience falls (58.49%) compared to younger aged residents.

Bivariate Analyses
There was a statistically significant association between falls and gender (p-value < 0.001) as female residents were more likely to experience falls (76.9%) compared to male residents (23.08%).
Thirdly, there was a statistically significant association between falls and Alzheimer's disease or dementia with a p-value < 0.001.
Residents with Alzheimer's disease were more likely to experience falls (51.09%) compared to those without Alzheimer's diseases or dementia (48.91%). Lastly, there was a statistically significant association between falls and heart disease (p-value = 0.001).
Residents with heart disease were more likely to experience falls (37%) relative to those without heart disease (63%). However,   Table 3 shows that all seven predictor variables are categorical variables. Age has two outputs since residents' age level < 65 were used as a reference group. Binary logistic regression results showed that residents' age between 65-84 had 1.52 times odds of experiencing falls (or 52% increased odds) than the aged ≤ 64 group with statistical significance (p-value <0.001). Residents aged ≥ 85 had 1.89 times odds of experiencing falls (or 89% increased odds) than residents who aged ≤64 group with statistical significance (p-value <0.001). We see that as age levels rise, the odds of falls also rises. Female residents had 1.47 times odds (or 47% increased odds) of experiencing falls than male residents with statistical significance (p-value <0.001). Residents with heart disease had 1.19 times odds (or 19% increased odds) of experiencing falls than residents without heart disease with statistical significance  COPD and stroke were a not-statistically significant predictor of falls.

Discussion
This study provides evidence from a nationally representative survey that residents' age, gender, heart disease, Alzheimer's/ Dementia, and Medicaid coverage status were significantly predicting the likelihood of falls among younger and older adults in residential care facilities. These results suggest that efforts by residential care facility administrators to reduce falls through careful monitoring of residents as well as to identify residents at higher risk of falls will improve the quality of life and prevent prolonged hospitalization [4]. Our results corroborate findings from other studies. According to Iinattiniemi et al study, the rate of fall injuries for adults 85 and older were almost four times higher than adults between 65 and 74 in the U.S. Our study findings mirror previous studies that examined the association between falls and gender.
Women at or over the age of 70 years were reported to be 58% more likely than men to have a fall injury [9]. As aforementioned, age, gender, residents with heart disease, circulatory, or respiratory problems are risk factors that can increase hospitalizations and falls incidence among older adults [4].
The most interesting finding was that COPD was a notstatistically significant predictor of falls. COPD is a chronic health condition that can limit the patient's activity. It was hypothesized that older patients with a history of COPD could have an increased risk of falling compared to their healthy peers [14]. Although we hypothesized that stroke would be an essential predictor for falls, we did not find significant results. A possible explanation for this result is possibly due to only 11% of residents having reported having a stroke. Although these results differ from another published study, they found that among 170 individuals 80 adults with a mean age of 67.6 (who experienced a stroke and recently discharged home) are at higher risk of falling than individuals without stroke [15].
However, a possible explanation for this variance in our findings with this previously published study might be due to the location of their research, which took place at patients' homes. These findings have important implications for health policy to develop plans to prevent the incidence of falls among younger and older adults in residential care facilities. Residential care facilities and assisted living administrators should make every effort to reduce falls rate among younger and older adults. Considering the high rate of falls among adults in residential care facilities and the lack of evidencebased guidelines to prevent falls, additional guideline development studies on falls at residential care facilities are necessary [16].
Moreover, there is a need to investigate continually whether the available evidence-based guidelines are actually conveyed to practice and to assess its effectiveness.
Appropriate assessments immediately after admission, physical safety enhancements, and careful monitoring of residents who are at higher risk of incurring a fall should be implemented to prevent falls in residential care facilities [4]. Appropriate assessments can help to identify those residents who have an increased risk of falls. Assessment should include the underlying causes and plans to reduce the negative impact of falls in older adults.