The association between delirium and falls in older adults in the community: A systematic review and meta-analysis

Falls, defined as ‘‘an unexpected event in which the participants come to rest on the ground, floor, or lower level’’ [1], affect nearly one-third of community-dwelling adults aged 65 years and older each year. This rises to over 50% for those aged 80 and above [2-4]. While most fall-related injuries are minor, in the UK over 223,000 falls in people aged 65 and older resulted in hospital admissions between 2021 and 2022 [5]. This has a personal burden in terms of pain, injury, fear of falling, loss of confidence and independence and higher mortality. Falls in the community are estimated to cost the National Health Service (NHS) over £1.7 billion per year [6, 7].
Delirium is a condition of acute onset, causing altered attention and awareness with additional disturbances in cognition, which may fluctuate due to underlying medical causes [8]. The prevalence of delirium in the community is estimated at 1–2%, increasing to 14% in people aged over 85 years [9, 10]. In long-term care facilities, the prevalence of delirium among people aged 65 years and over is estimated at 10–40% [11]. However, it is often under-detected and underdiagnosed in the community and sometimes misdiagnosed as other conditions including dementia, depression and psychosis [12]. Delirium causes considerable burdens in terms of functional or cognitive decline in individuals and economic burden to the healthcare system due to increased risk of hospitalisation, higher levels of care and institutionalisation [13-15].
Delirium and falls share common risk factors including older age, frailty, prior history of falls, impaired balance and gait, visual and auditory impairment, cognitive impairment, and polypharmacy [16, 17]. The relationship between delirium and falls can be complex and bidirectional.
In hospital settings, there is an increased incidence of falls in patients with delirium and an increased risk of delirium in people who fall. A systematic review [18] reported a higher risk of falls for inpatients with delirium than those without delirium across ten studies (median RR 54.5, range 1.4–12.6). A recent cross-sectional study analysing the association between delirium and falls in a hospital screening program with more than 29,000 patients [19], found those who screened positive for delirium during admission had a significantly increased risk of falling whilst they were an inpatient (adjusted OR 2.81 (95% CI: 2.12, 3.70)). Delirium screening is recommended as a standard part of fall care pathways [18, 19].
However, little is known about the association between delirium and falls in community settings. Given that falls are a common reason for pre-hospital service use and hospital admission, this is important because there is the potential to reduce hospital admissions and healthcare costs [20]. There is no available systematic review considering the relationships between the incidence of falls and the occurrence of delirium in the community. Our objective was to conduct a rigorous systematic review of the association between delirium and falls in community settings.