How does the environment in and around the home affect social care and health outcomes for older people? A national longitudinal dynamic cohort study

BackgroundReducing the burden of falls and fall-related admissions to hospital and care homes is an important policy area because falls cause significant injury leading to a reduced quality of life. We investigated the effect of the environment around people's homes on the risk of falls for older people in Wales.MethodsIn this longitudinal cohort study, we created a dynamic national e-cohort of individuals aged 60 years or older living in Wales between Jan 1, 2010, and Dec 31, 2019. Using the Secure Anonymised Information Linkage Databank, we linked routinely collected, anonymised health-data on general practitioner (GP) appointments; hospital and emergency admissions; and longitudinal individual-level demographic data to metrics detailing the built environment and deprivation as determined by the Welsh Index of Multiple Deprivation. Using adjusted cox regression models, we assessed how the risk of a fall changed with sex, age, deprivation quintile, urban or rural classification, household occupancy, care status, frailty, dementia diagnosis, and built environment metrics. Built environments of urban and rural areas are very different, so we stratified our analysis by urbanicity to compare these associations in each setting.FindingsWe analysed 5 536 444 person-years of data from 931 830 individuals (sex: 51·5% female, 48·5% male; age: 69·2% aged 60–64 years, 12·3% aged 65–69 years, 13·3% aged 70–79 years, 4·4% aged 80–89 years, and 0·7% aged ≥90 years). 154 060 (16·5%) had a fall between joining the cohort and Dec 31, 2019. Men had a lower risk of falling than women (adjusted hazard ratio [aHR] 0·736 [0·729–0·742]), and the risk increased with age compared with individuals aged 60–64 years (1·395 [1·378–1·412] for 65–69 years, 1·892 [1·871–1·913] for 70–79 years, 2·668 [2·623–2·713] for 80–89 years, 3·196 [3·063–3·335] for ≥90 years) and with frailty compared with fit individuals (1·609 [1·593–1·624] for mild frailty, 2·263 [2·234–2·293] for moderate frailty, and 2·833 [2·770–2·897] for severe frailty). Those living in rural areas were less likely to fall than those in urban areas (0·711 [0·702–0·720]). All p values were less than 0·0001.InterpretationAlthough preliminary, these results corroborate current knowledge that as we age and become frailer, the risk of falling increases. The effect of urbanicity on risk of fall suggests that the built environment could be associated with fall risk. We only detected falls that caused emergency or hospital admission, leading to potential selection bias. Nevertheless, this research could help guide policy to reduce the incidence of injuries caused by falls in older people.FundingHealth and Care Research Wales