Falls and concomitant injuries are common problems among large groups of the elderly population, leading to immobility and mortality. These problems are even more pronounced among people suffering from dementia. This thesis targets fall risk factors for people with dementia in institutions. The overall aim of this thesis was to investigate risk factors for falls, predisposing as well as related to circumstances surrounding falls, and to do this as efficiently as possible. In a prospective cohort study including residents of residential care facilities with and without dementia, the fall rate was higher for those with dementia, the crude incidence rate ratio (IRR) was 2.55 (95% CI 1.60–4.08) and the adjusted IRR was 3.79 (95% CI 1.95–7.36). In the group of people suffering from dementia, including 103 residents, a total of 197 falls resulted in 11 fractures during the 6-months follow-up period. From the same baseline measurements 26% and 55%, respectively, of the variation in falls could be explained in the group of residents with and without dementia. Fall predictors significantly and independently associated with an increased risk of falls in the group of people suffering from dementia were the category “man walking with an aid” and the use of more than four drugs. In a prospective cohort study, including 204 patients in a psychogeriatric ward, a total of 244 falls resulted in 14 fractures. Fall predictors significantly and independently associated with an increased risk of falls were male sex, failure to copy a design, use of clomethiazole, and walking difficulties. Treatment with statins was associated with a reduced risk of falls. With these fall predictors in the negative binomial regression (Nbreg) model, 48% of the variation in falls was explained. The data from the psychogeriatric ward were also analysed with the use of partial least squares regression (PLS) and regression tree to be compared with the results of the Nbreg analysis. PLS and regression tree are techniques based on combinations of variables. They both showed similar patterns, that a combination of a more severe level of dementia, behavioral complications and medication related to these complications is associated with an increased fall rate. Thirty-two percent and 38%, respectively, of the variation in fall rate were explained in the PLS and regression tree analysis. The circumstances surrounding the falls in the psychogeriatric ward were analysed. It was found that the fall rate was equally high during the night and the day. A large proportion of the falls was sustained in the patients’ own room and a small proportion of the falls was witnessed by the staff. This pattern was even more pronounced during the night. The proportion of diurnal rhythm disturbances and activity disturbances was higher for falls at night than for falls during the day. Circumstances associated with an increased risk of falls, as shown by a short time to first fall, were anxiety, darkness, not wearing any shoes and, for women, urinary tract infection. The proportion of urinary tract infection was also higher in connection to falls sustained by women than to falls sustained by men. This thesis confirms that people suffering from dementia are prone to fall. Walking difficulties, male sex and impaired visual perception are factors that should be considered in the work of reducing falls among people suffering from dementia. Furthermore, falls at night, behavioral complications and medication related to these complications should also be considered in this work, especially as the dementia disease progresses. A larger portion of the variation of the outcome variable was explained by the Nbreg model than the regression tree and PLS. However, these statistical methods, based on combinations of variables, gave a complementary perspective on how the fall predictors were related to falls.

Abstract Becoming involved in war is an experience that has the potential to shape later-life health. The aim of the present study was to explore Finnish Second World War veterans’ health status and the determinants of self-rated health (SRH) and functional capacity, especially the ability to walk, and to identify risk factors and their combinations that predict late-life mortality among veterans. The study population comprised Finnish Second World War veterans who participated in the Veteran 1992 and Veteran 2004 Project surveys. In 1992, a postal questionnaire was sent to all 242,720 war veterans living in Finland. The follow-up survey, the Veteran 2004 Project, was conducted with a randomized sample of veterans who participated in the Veteran 1992 Project. The total number of participants in the baseline survey was 177,989 men and 48,745 women, and in the follow-up survey, 4,348 men and 651 women. The response rate was high in both surveys: 93% in 1992 and 87% in 2004. All analyses were conducted separately for men without disability, men with disability and women. In a cross-sectional study, SRH and functional capacity was found to be better among 80–84-year-old Finnish war veterans in 2004 compared with 1992, although the prevalence of many diseases increased during the follow-up. Among the 4,999 veterans who participated in both surveys, the majority rated their health as improved or unchanged during the follow-up. Walking difficulties and cardiovascular (CVD), musculoskeletal and neurological diseases were found to be predictors of declined SRH. When exploring functional capacity among veterans, neurological and musculoskeletal diseases, but especially walking difficulties, predicted veterans’ future functional impairment as many as 12 years in advance, and worsening of these conditions was associated with impaired activities of daily living. During an average 9.9-year follow-up, walking difficulties alone or together with multimorbidity and/or with a third risk factor was the most important risk factor for total and for CVD mortality among all veteran groups. In conclusion, the majority of veterans rated their SRH as improved or unchanged during the follow-up. The importance of walking difficulties as a determinant of SRH and functional capacity and as a predictor of mortality was confirmed. / Tiivistelmä Tutkimuksen tarkoituksena oli arvioida suomalaisten toisen maailmansodan veteraanien terveydentilaa ja tutkia, mitkä tekijät vaikuttavat veteraanien itsearvioituun terveyteen ja toimintakykyyn (erityisesti kävelykykyyn) sekä tunnistaa ne riskitekijät ja tekijäyhdistelmät, jotka ennustavat kuolleisuutta. Tutkimuspopulaationa käytettiin Veteraaniprojekti 1992 ja Veteraaniprojekti 2004 -tutkimuksiin osallistuneita veteraaneja. Vuonna 1992 kysely lähetettiin postitse jokaiselle Suomessa tuolloin asuneelle 242 720 veteraanille. Seurantatutkimukseen valittiin 5 750 veteraanin satunnaisotos vuoden 1992 tutkimukseen osallistuneista. Veteraaniprojekti 1992 -tutkimukseen osallistui 177 989 miestä ja 48 745 naista ja seurantatutkimukseen 4 348 miestä ja 651 naista. Osallistumisprosentti oli 93 % (1992) ja 87 % (2004). Analyysit tehtiin erikseen veteraanimiehille joilla ei ollut invaliditeettia, invalidimiehille ja naisille. Poikkileikkaustutkimuksessa tarkasteltiin 80–84-vuotiaiden veteraanien terveyttä ja toimintakykyä vuosina 1992 ja 2004. Vuonna 2004 veteraanit arvioivat terveytensä ja toimintakykynsä paremmiksi kuin samanikäiset veteraanit vuonna 1992, vaikka monet sairaudet yleistyivät seuranta-aikana. Suurin osa molempiin kyselyihin vastanneista 4 999 veteraanista arvioi terveytensä joko parantuneen tai pysyneen ennallaan seuranta-aikana. Veteraanien kokemat kävelyvaikeudet, sydän- ja verisuonisairaudet, tuki-ja liikuntaelinsairaudet sekä neurologiset sairaudet ennustivat itsearvioidun terveyden heikkenemistä. Sydän- ja verisuonisairauksia lukuun ottamatta edellä mainitut tekijät ennustivat myös toimintakyvyn laskua jopa 12 vuotta etukäteen. Myös kävelykyvyn heikkeneminen ja sairauksien paheneminen seuranta-aikana ennustivat toimintakyvyn laskua. Kävelyvaikeudet joko yksin tai yhdessä multimorbiditeetin ja/tai jonkin kolmannen riskitekijän kanssa oli tärkein sekä kokonaiskuolleisuutta että sydän- ja verisuonitautikuolleisuutta ennustava tekijä kaikissa veteraaniryhmissä keskimäärin 9,9 vuoden seuranta-aikana. Yhteenvetona voidaan todeta, että enemmistö tutkimukseen osallistuneista veteraaneista arvioi terveytensä joko parantuneen tai pysyneen ennallaan seuranta-aikana. Koetut kävelyvaikeudet ovat erittäin tärkeä itsearvioitua terveyttä, toimintakykyä ja kuolleisuutta ennustava tekijä.