Archives of Gerontology and Geriatrics 52 (2011) e1–e10

A systematic review of accidental injury from fire, wandering and medicationself-administration errors for older adults with and without dementia

Alison Douglas *, Lori Letts, Julie Richardson

McMaster University, School of Rehabilitation Science, Faculty of Health Sciences, 1400 Main St W.- IAHS Bldg. Rm 402, Hamilton, ON, Canada L8S 1C7

A R T I C L E I N F O

Article history:

Received 14 September 2009

Received in revised form 18 February 2010

Accepted 23 February 2010

Available online 23 March 2010

Keywords:

Systematic review

Accidental injury

Older adults

Assessment of safety

A B S T R A C T

The assessment of risk of injury in the home is important for older adults when considering whether they

are able to live independently. The purpose of this systematic review is to determine the frequency of

injury for persons with dementia and the general older adult population, from three sources: fires/burns,

medication self-administration errors and wandering. Relevant articles (n = 74) were screened and 16

studies were retained for independent review. The studies, although subject to selection and information

bias, showed low proportions of morbidity and mortality from the three sources of injury. Data did not

allow direct comparison of morbidity and mortality for persons with dementia and the general older

adult population; however, data trends suggested greater event frequencies with medication self-

administration and wandering for persons with dementia. Assessment targeting these sources of injury

should have less emphasis in the general older adult population compared to persons with dementia.

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1. Introduction

The home is regarded as a place of safety and security for manyolder adults (Rioux, 2005). Older adults and their families oftenrely on community services to promote independence and safety athome. Health policy agendas of ‘‘Aging at Home’’ and ‘‘Aging inPlace’’ promote provision of environmental, social, and economicsupports to promote healthy and safe homes so individuals canstay in their own homes (Ministry of Health and Long Term Care,2002; National Institutes of Health, 2006). Health services arerequested to provide recommendations for injury prevention inthe home. Clinical assessment of older adults at home includesobservation of independence and safety in ability to carry outactivities of daily living such as cooking and bathing (Beghe, 2004;Byles et al., 2000). Recommendations often include measures forthe prevention of falls, fires, or errors in self-administration ofmedication. Currently, many recommendations are based onperceptions of risk by care providers (‘‘common sense’’) ratherthan evidence of the incidence of injury (Horvath et al., 2005).Professionals and family members may be motivated by a desire toprevent injury and the perception of risk may be higher than theactual risk. The purpose of this systematic review is to describe theepidemiology of morbidity and mortality from fires/burns,medication self-administration errors and wandering for adultswith dementia and the general older adult population. Evidence

* Corresponding author. Tel.: +1 905 525 9140x26410; fax: +1 905 524 0069.

E-mail address: douglaam@mcmaster.ca (A. Douglas).

0167-4943/$ – see front matter � 2010 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.archger.2010.02.014

regarding the prevalence of injury is important for informing theassessment of risk, however it is important to note that it is not theonly consideration in assessment of risk. Severity of injury, ethicsassociated with autonomy of decision-making about living aloneand caregiver concern must also contribute to determination ofoverall risk. This paper examines the epidemiology of injury as animportant but not the sole factor for assessment of risk.

Multiple sources of injury are commonly addressed in theprocess of home assessment (Rowe and Fehrenbach, 2004). It iswell known in the literature that falls are the most common sourceof in-home accidents leading to morbidity (Raina et al., 1999;Runyan et al., 2005b) and mortality (Cooper, 1981; Hogue, 1982;Waller, 1985; Lilley et al., 1995; Sikron et al., 2004; StatisticsCanada, 2004; Fletcher and Hirdes, 2005; Runyan et al., 2005a).Falls are also the leading source of in-home injury in dementia(Lach et al., 1995). Therefore, the need to assess risk for falls is wellestablished. Intervention strategies for falls prevention have beensystematically reviewed (Beghe, 2004; Gillespie et al., 2006). Thehome safety literature has largely focused on falls prevention (Langand Edwards, 2006; Lyons et al., 2006).

Other sources of injury are also part of home safety assess-ments. Potential injury from fires and burns, medication self-administration errors and wandering are assessed as items inhome safety assessment tools such as the SAFER tool (Oliver et al.,1993), the Safe at Home (Robnett et al., 2002), and safetyassessment scale (Poulin de Courval et al., 2006). The content ofthese scales was developed with expert panels and the likelihoodof injury from each source was not reported. A health care providerwho is requested to make recommendations for the safety of an

A. Douglas et al. / Archives of Gerontology and Geriatrics 52 (2011) e1–e10e2

older adult at home thereby relies on a checklist withoutsupporting evidence as to the likelihood of injury from fires,medication self-administration or wandering.

Safety of older adults at home has been defined in terms ofsecurity, or, dependable physical, social, and interpersonalresources (Parmelee and Lawton, 1990). The clinical assessmentof safety also must include the autonomy and decision-makingcapacity of the individual to accept a certain level of risk (Parmeleeand Lawton, 1990; Moats and Doble, 2006). Effective assessment ofsafety at home contributes to ethical and cost effective health careby identifying those most in need of support, and at greatest risk ofinjury. The theoretical understanding of the definition of safety hasbeen described as being comprised of two factors: intrinsic andextrinsic (Beghe, 2004). Intrinsic factors are elements of theindividual which may contribute to risk such as decreasedcognition, medication use, and decreased vision. Extrinsic factorsare environmental hazards such as older electrical wiring in thehome or twist off caps on medication bottles. The focus of thispaper is to understand the frequency of injury from various sourcesand examines populations with and without the intrinsic factor ofdementia. This factor has been chosen because it is important tounderstand if populations with dementia have different safetyconcerns than older adults who have not been diagnosed withdementia.

Dementia is characterized by a gradual decline in cognitivefunction which is associated with a decline in the ability to carryout daily living tasks such as self-care (Patterson et al., 2001).Approximately one in 13 Canadians over age 65 has Alzheimerdisease or a related dementia (Alzheimer’s Society of Canada,2008). Safety concerns for older adults may reflect physical orsensory deficits in the ability to carry out daily tasks such ascooking or getting in and out of the bath tub. For persons withdementia, safety concerns are compounded because cognitivedeficits may cause a person to forget items on the stove, or takemedications too frequently or infrequently. Wandering is also asafety issue in persons with dementia and is defined as beingmobile with concomitant spatial disorientation and/or elopingbehavior (Algase, 2006). In addition, a lack of awareness of unsafesituations such as poorly placed power cords may increase the riskof accidental injury.

This systematic review focuses on three risk sources of injury:fires/burns, wandering and medication self-administration errors.The rationale for choosing these three sources of injury is based onliterature and clinical relevance. The selected risk factors areimportant with this population (Lach et al., 1995; Lilley et al.,1995), and are more frequently assessed by clinicians. Moreoverthey are modifiable in that the likelihood of injury from each ofthese sources can potentially be reduced with intervention.Evidence is required that links the exposure (fire/burns, medica-tion self-administration or wandering) to injury. The literaturesearch sought evidence that gave frequency of morbidity ormortality associated with each source of injury. Evidence was alsosought that linked the exposure to each source to injury. A reviewof literature rather than review of specific databases in one countryenabled comparison of data from multiple countries and multipledatabases.

Mortality and morbidity statistics are described as ‘‘measures offrequency’’ (Rothman and Greenland, 1998). They provideinformation about the proportion of injury or death attributedto a certain source. They do not examine whether the person wasexposed to factors which may increase the likelihood of morbidityor mortality. It is assumed that all persons in the study population(denominator) are at equal risk of morbidity or mortality(numerator). However, this may not be the case as certain intrinsicfactors (e.g., multiple comorbidities) or extrinsic factors (olderwiring in house, lack of smoke alarm) may increase the likelihood

of injury for an individual. Measures of frequency provide basicevidence about morbidity or mortality from a certain exposure, butdo not demonstrate the link between the exposure and theoutcome. These studies therefore do not reflect individual risk forthe outcome, but can inform recommendations for individuals bydemonstrating that the frequency of injury in the population ishigh or low. For example, if an individual with dementia iswandering, and measures of frequency show that morbidityassociated with wandering is high in a dementia population, thereis evidence to be concerned about the safety of the individual.

Causation evidence, in addition to noting the frequency ofinjury, demonstrates a direct causal link between the exposure andinjury (Rothman and Greenland, 1998), for example by demon-strating that fire causes not only property damage but personalinjury, that errors in medication self-administration lead directlyto harm, or that wandering directly causes fractures. In order todemonstrate causation, evidence must fulfill the following criteria:(a) clearly defined groups of persons exposed and not exposed, (b)outcomes measured similarly in both groups, (c) follow-up ofgroups, (d) exposure precedes the onset of the outcome, (e) dose–response gradient, (f) positive evidence from a ‘‘dechallenge-rechallenge’’ study (outcome is measured after the person isremoved from exposure then re-exposed), (g) association isconsistent from study to study and (h) the association is plausible(Levine et al., 1994).

Data on harm from fires/burns, wandering and errors inmedication self-administration are important for decision-makingabout home safety and have not been summarized in the literature.It is important to understand whether persons who are exposed tothese sources are at risk, or whether the level of risk differs forpersons with dementia and the general older adult population.

2. Methods

A systematic review of the literature was undertaken to searchfor evidence linking injury and exposure to three sources: fires andburns, wandering and medication self-administration. The reviewwas conducted following guidelines for systematic reviews ofobservational studies (Stroup et al., 2000). An overview of thereview method is shown in Fig. 1. The following databases weresearched to 2008 (week 1) by the first author: Cochrane library,Medline 1996–2008 (week 1), EMBASE, CINAHL, Ageline andPsychINFO for studies in English. The research question was: whatis the morbidity and mortality for persons with dementia and thegeneral older adult population associated with fire, errors inmedication self-administration or wandering? The search termswere adjusted for each database and verified by a professionallibrarian (NB). The Medline search strategy included the followingMeSH headings which were exploded then a limit applied forEnglish language and ‘‘all aged (>65)’’: ‘‘accidents, home’’ OR‘‘patient admission’’ OR ‘‘patient readmission’’ OR ‘‘hospitaliza-tion’’ OR ‘‘emergency service’’; ‘‘dementia’’; ‘‘fires’’ OR ‘‘burns’’;‘‘wander$’’; ‘‘prescriptions, drug’’ OR polypharmacy’’ OR ‘‘drugtherapy’’; ‘‘self-administration.’’ Detailed tables of the searchstrategy for each database can be obtained by request from the firstauthor.

Relevant articles were chosen based on the abstract (n = 74).Inclusion and exclusion criteria were then applied to select articlesfor review (n = 12). The inclusion criteria were (a) the studypopulation resided in the community and included persons olderthan age 65 or with dementia and (b) outcomes included mortality,patient admissions to hospital or injuries related to fire, medica-tion self-administration, and wandering. Sources were excluded ifthey reported single case studies or the results for older adultswere not reported separately from other age groups. Duplicateswere excluded and the reference list of each article was searched

Fig. 1. Overview of the systematic review.

A. Douglas et al. / Archives of Gerontology and Geriatrics 52 (2011) e1–e10 e3

for additional sources (n = 4). Non-English language articles werereviewed by reading the English abstract and no articles met theinclusion criteria. A total of 16 articles were retained for detailedreview.

Two reviewers (AD and LL) independently reviewed the studiesthat met the inclusion and exclusion criteria. The study design wasclassified according to definitions from the Cochrane collaborationSTROBE initiative (Vandenbroucke et al., 2007) which are based onthe definitions provided by Rothman and Greenland (1998). Forthe purposes of this review, the definitions of study designs weretaken from Rothman and Greenland (1998), including theclassification of proportional mortality studies as case controlstudies. Studies were reviewed using guidelines for evaluatingprevalence studies (Boyle, 1998) (Appendix A). No articles metcriteria for a study examining causation (Levine et al., 1994).Evaluation of the validity of each article followed an eight pointrating scale with one point allocated to each of the following: (1)Was the target population defined by clear inclusion and exclusioncriteria? (2) Was probability sampling used to identify potentialrespondents (or the whole population approached)? (3) Didcharacteristics of respondents match the target population, i.e.,was the response rate �80% or appropriate analysis includedcomparing responders and non-responders? (4) Were datacollection methods standardized? (5) Was the survey instrumentvalid? (6) Was the survey instrument reliable? (7) Were features ofsampling design accounted for in the analysis, through appropriateweighting of the data (or the whole population approached)? (8)Do the reports include confidence intervals (or was the wholepopulation approached)?

Data extraction included the sample size, duration of observa-tion time of the study, and proportion of morbidity or mortality.The results of validity ratings and data extraction were discussedand disagreements resolved by consensus. In studies for whichdata were presented only in figures without specific numbers (e.g.,bar graphs), the first author was contacted to request raw data,however in all cases the authors were not able to supply the rawdata. These studies are identified in Table 3 and values wereestimated from the figures. None of the reviewed articles reportedthe standard error (SE) or 95% confidence interval (CI), thereforethese were calculated in a Microsoft Excel spreadsheet followingthe formulas shown on the data extraction form (Appendix A). Thestudies were heterogeneous regarding sample, age range, design(Tables 1 and 2), and duration of observation (Tables 3 and 4), andtherefore meta-analyses could not be performed (Egger et al.,1998). Results were synthesized in tables comparing design,sample, validity scores and calculations of likelihood of outcomes.Synthesis of the results followed Cochrane Collaboration STROBEguidelines for reporting outcome studies (Vandenbroucke et al.,2007).

3. Results

The studies (n = 12) that met the inclusion criteria for fires andburns are described in Table 1. Studies regarding wandering (n = 3)and medication self-administration errors (n = 1) are described inTable 2. Few studies were found that examined a sample of personswith dementia. Overall, the majority of studies (11/16) sampled anolder adult population and reported on fires and burns. All studies

Table 1Evaluation of studies of injuries from fires and burns in persons with dementia and general adult population.

Study Population and outcome

(morbidity or mortality)

Description of sample Age range Design Evaluation criteria for studies

Defined pop Sampling Representative Standardized Valid

tool

Reliable

tool

Analysis Con.

Intervals

Total

score

1 Dementia: morbidity Caregiver interviews, consecutive

patients of Alzheimer’s centre, US

Not

specified

Case series U X X U X X X X 2

2 *Adults: morbidity National databases, UK 65+ Case control U U U U X X U U 6

3 *Adults: morbidity National health surveys, 1 yr, US 65+ Case control U U X U X X U U 5

4 *Adults: morbidity National hospital and mortality

databases, 1 yr, Italy

65+ Case control U U U U X X U U 6

5 *Adults: morbidity Hospital, ambulance, fire and

coroner databases, 1 yr London, UK

65+ Case control U U U U X X U U 6

6 *Adults: morbidity Cluster random sampling,

interviews, Greece

60+ Cross-sectional U U U U X X X U 5

7 *Adults: morbidity Interviews in emergency,

31 shifts, Hong Kong

65+ Prospective cohort X X X U X X X X 1

8 *Adults: mortality National Statistics system, 8 yr, US 60+ Case control U U U U X X U U 6

9 *Adults: mortality National Mortality tapes, 1 yr, US 65+ Case control U U U U X X U U 6

10 *Adults: mortality Mortality tapes, 4 yr, US 60+ Case control U U U U X X U U 6

11 *Adults: mortality Fire and coroner records, 10 yr,

Scotland

60+ Retrospective case series U U U X X X U U 5

12 *Adults: mortality State fire Marshal records 6 yr, US 60+ Retrospective case series U U U U X X U U 6

1. Oleske et al. (1995); 2. Lilley et al. (1995); 3. Runyan et al. (2005b); 4. Farchi et al. (2006); 5. DiGuiseppi et al. (2000); 6. Evci et al. (2006); 7. Lee et al. (1999); 8. Runyan et al. (2005a); 9. Gulaid et al. (1989); 10. Centers for Disease

Control and Prevention [CDC, 1998]; 11. Elder et al. (1996); 12. McGwin et al. (1999).* Adult populations may include persons with dementia.

Table 2Evaluation of studies of injuries from wandering and medication self-administration in persons with dementia and general adult population.

Defined

pop

Sampling Representative Standardized Valid

tool

Reliable

tool

Analysis Con.

Intervals

Total

score

Wandering

13 Dementia: morbidity 3 hospitals’ medical records, 2 yr, US 40+ Retrospective case series U U X U X X U U 5

14 Dementia: mortality Reviewed 93 newspaper articles, US Not specified Retrospective case series U X X U X X X X 2

15 Dementia: mortality Case reports from a national

wandering registry, US

Not specified Prospective cohort U U X U X X X X 3

Medication self-administration

16 Dementia: morbidity Referral by MD or community agency,

medical records, Canada

65+ Prospective cohort U X X U X X X X 2

13. Rowe and Fehrenbach (2004); 14. Rowe and Bennett (2003); 15. Rowe and Glover (2001); 16. Tierney et al. (2004).

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Table 3Proportion morbidity or mortality: fires and burns.

Study Population and outcome

(morbidity or mortality)

Sample N Duration of observation Proportion

n events/n SE 95% CI

1 Dementia: morbidity 281 persons 6 months 0.0036% .355% 0.0–1.05%

2 *Adults: morbidity Per 1,000,000 population Average annual rate 0.00053% 0.0001% 0.0–0.0002%

3 *Adults: morbidity Per 100,000 population 1 yr Reported negligible n/a n/a

4 *Adults: morbidity Per 100,000 population 1 yr 0.045%+ 0.0067% 0.032–0.058%

5 *Adults: morbidity Per 100,000 population 1 yr 0.060%+ 0.0077% 0.045–0.075%

6 *Adults: morbidity 3277 persons 1 yr 5.56% 0.4003% 4.78–6.34%

7 *Adults: morbidity 100 persons 31 shifts 3.00% 1.7059% 0.0–6.34%

8 *Adults: mortality Per 100,000 population Average annual rate over 8 years 0.003% 0.0017% 0.0–0.006%

9 *Adults: mortality Per 100,000 population 1 yr 0.005% 0.0022% 0.00051–0.009%

10 *Adults: mortality Per 100,000 population Average annual rate over 4 yr 0.006%+ 0.0024% 0.0012–0.011%

11 *Adults: mortality Not reported 10 yr 547/n sample n/a n/a

12 *Adults: mortality Not reported 6 yr 251/n sample n/a n/a

* Adult populations may include persons with dementia.+ Estimated from figure.

Table 4Proportion morbidity or mortality: wandering and medication self-administration.

Study Population and outcome (morbidity or mortality) Sample N Duration of observation Proportion

n events/n SE 95% CI

Wandering

13 Dementia: morbidity 153 persons 2 yr 0.650% 0.65% 0.0–1.92%

14 Dementia: mortality Not reported 4 yr 93/n sample n/a n/a

15 Dementia: mortality 617 deaths 1 yr 0.648% 0.32% 0.015–1.28%

Medication self-administration

16 Dementia: morbidity 139 persons 18 months 2.200% 1.24% 0.0–4.64%

A. Douglas et al. / Archives of Gerontology and Geriatrics 52 (2011) e1–e10 e5

of the dementia population were clinically based samples, that is,participants were sampled from persons receiving clinical services.Clinical populations do not demonstrate that they are representa-tive of the population as a whole (Boyle, 1998). This designapproach resulted in lower total score ratings for the quality of thestudies in dementia.

3.1. Evaluation criteria scores

No study received full rating for quality and therefore all datawere subject to sources of bias in observation studies (Egger et al.,1998; Jepsen et al., 2004). These sources of bias can over- orunderestimate the association between the exposure (fire/burns,wandering and medication self-administration) and morbidity ormortality (Jepsen et al., 2004).

Fire and burns studies comprised the majority of studies thatmet the inclusion criteria (12/16). Many of these studies were casecontrol studies. Case control design does not allow a follow-upperiod, and samples were compared to a ‘‘control’’ group of personswho had died from other causes (Lilley et al., 1995; Runyan et al.,2005a). Mortality rates from fire were compared between agegroups (Elder et al., 1996), and persons of differing socio-economicstatus (Gulaid et al., 1989; McGwin et al., 1999).

Population mortality studies (Table 1, studies 8, 9 and 10)received the highest scores because they sampled an entirepopulation, the sample was representative of the population andthe sampling method representative. However, no populationmortality study demonstrated reliability and validity of the deathcertificate data. Although death certificate data are collected in astandardized way and may be expected to be reliable and validthey were found to be subject to both selection and informationbias. Only those deaths within 30 days of the original exposure arerecorded (Lilley et al., 1995; Runyan et al., 2005b) and a third factorsuch as socio-economic status in the region may affect mortalityrates (Runyan et al., 2005a). This creates selection bias that maylead to under-estimation of the number of deaths from a particular

exposure. Death certificate data are also subject to informationbias for two reasons. It is not known whether all persons in eachsample were exposed. If persons in the sample are not exposed, thefrequency of mortality is underestimated. Secondly, the codingsystems on death certificates introduce information bias becausedeaths from fires or burns may have been coded as pneumonia orcardiac arrest thereby underestimating mortality from fires(Runyan et al., 2005a).

Population morbidity studies (Table 1, studies 2, 4, 5) alsoreceived high scores. These studies employed rigorous samplingmethods and analyses; however they were subject to bias becausethey did not demonstrate the validity or reliability of measurementtools. Samples from emergency records may under-represent therates of morbidity and mortality because persons with burns maybe triaged directly to burn units (Runyan et al., 2005a) and becauseregional factors such as socio-economic status may influencemorbidity. The location of injury was not reported in most cases,thereby introducing information bias which may have under-estimated the rates of home injury.

For wandering, only three studies met the inclusion criteria(Table 2) as many studies on wandering did not report injuries ordeaths. Studies examining injuries or deaths from wanderingscored lower on the evaluation criteria (mean total score = 3.3)compared to studies of fires and burns (mean total score = 5.0).They were subject to selection bias because they did notdemonstrate representative sampling. Measurement tools werenot examined for reliability and may be a source of informationbias. For example, data obtained from interviews were self-reported and morbidity or mortality from wandering may havebeen coded under falls. This may significantly underestimate themortality and morbidity rates from wandering.

For medication self-administration, one study met the inclusioncriteria (Table 2). This study was a prospective cohort withstandardized measures but did not demonstrate reliability orvalidity of measurement tools or report confidence intervals for themorbidity data. Although studies were found that reported rates of

A. Douglas et al. / Archives of Gerontology and Geriatrics 52 (2011) e1–e10e6

polypharmacy or use of particular classes of medication, thesecould not be included because they did not report errors from self-administration of medication. Difficulties resulting from medica-tion self-administration may have been coded as poisoning or mayhave resulted in falls and been coded as a fall. Medication self-administration errors may have higher incidence than the datademonstrate because of data coding and the difficulty ofidentifying when these incidents have occurred.

3.2. Morbidity and mortality

The differences and similarities in morbidity and mortality canbe examined with consideration of the sources of bias (Egger et al.,1998). The population, sample and duration of observation periodwere tabulated (Tables 3 and 4). Differences in proportions wereexamined for each source of injury: fires/burns (Table 3),wandering and medication self-administration errors (Table 4).It was not possible to determine exposed and non-exposed groupsand risk ratios could not be calculated.

For fires and burns, the proportion of injuries or deaths was<6%in all studies. In studies that met the inclusion criteria, fires were thesecond highest cause of accidental death at home (Lilley et al., 1995;Runyan et al., 2005a) and the third highest cause of accidental injuryat home (Runyan et al., 2005b). As anticipated, studies that met theinclusion criteria reported that the leading accidental source of bothmorbidity and mortality in older adults was falls (Lilley et al., 1995;Rowe and Fehrenbach, 2004; Fletcher and Hirdes, 2005; Runyanet al., 2005a,b). Studies that obtained information from interviewsrather than databases reported higher incidences of injury from firesand burns. Evci et al. (2006) reported 5.56% and Lee et al. (1999)reported 3% injury from fires and burns which was higher than allother studies of morbidity and mortality. This may have beenbecause the interviewers obtained data on injuries for whichpersons had not sought medical care, highlighting that informationin the reported databases may underestimate rates of injury. In thestudy with a sample of people with dementia (Oleske et al., 1995),the incidence of injury from fires or burns (0.3%) was low comparedto the incidence of injury from falls (43.8%). A second study with adementia sample could not be included as it reported damage toproperty from fire (likelihood proportion = 7.2e�3) but no incidentsof personal injury (Tierney et al., 2004).

Wandering studies that met the inclusion criteria showed ahigher mortality (Rowe and Glover, 2001) but lower morbidity(Rowe and Fehrenbach, 2004) compared to fires and burns. All thestudies on wandering that met the inclusion criteria sampledpersons with dementia. In the dementia population, injuries fromfalls (Rowe and Fehrenbach, 2004) or failure to eat (Tierney et al.,2004) predominated but accidental injuries from wandering werethe ranked third (Rowe and Fehrenbach, 2004). Compared with theresults from another sample with dementia (Oleske et al., 1995),accidental injuries from wandering appeared to occur with greaterfrequency than fires and burns. However, because of heterogeneityof sampling and measurement of outcomes, the results from thetwo studies cannot be directly compared. Although the exposure ofpersons with dementia to the source of injury was not noted, thisindicates a preliminary finding that, for persons with dementia, thefrequency of injury associated with wandering may be greater thanfor fires and burns.

Wandering injuries or deaths were not reported in general olderadult samples. This may be because the risk of injury fromwandering may be negligible in the general adult population andhigher for persons with dementia; however direct statisticalcomparison of the likelihood of injury or death from fires,wandering or medication self-administration could not be madebetween persons with dementia and the general adult populationfrom the data in this review.

The incidence of harm from errors in medication self-administration was reported in one study that sampled personswith dementia (Tierney et al., 2004) (Table 4). In this study, injuryfrom medication self-administration was noted as the fifth highestsource of harm with the leading sources being failure to eat anddrink, and failure to report a medical condition. Again, because ofheterogeneity of sampling and outcome measurement, the relativerisk of injury from medication self-administration could not bedirectly compared, but the trend shows a likelihood of injury frommedication self-administration is higher than from both fires andwandering.

The results indicate that persons with dementia were at greaterrisk of injury from wandering and medication self-administrationthan persons without dementia. However this is noted as a trendsince direct comparison of rates between persons with andwithout dementia was not available. Studies that focused onpersons with dementia were fewer and had smaller sample sizesthan studies of the general older adult population. Studies whichfocussed on dementia samples did not include comparison groupswithout dementia, nor were persons with dementia reportedseparately in general older adult samples.

4. Discussion

Studies describing rates of morbidity and mortality for sourcesof in-home accidental injuries were reported. Each source of injuryis discussed separately. Comparison is drawn between studiessampling persons with dementia and the general older adultpopulation.

4.1. Fires and burns

Amongst the older adult population, fires were reported to bethe second highest source of in-home accidental mortality afterfalls, and third highest source of in-home accidental morbidityafter falls and traffic accidents. In the general population, rates ofinjury and death from fires and burns were consistently found tobe highest for older adults and young children (Lilley et al., 1995;Elder et al., 1996; McGwin et al., 1999; Warda et al., 1999;DiGuiseppi et al., 2000; Runyan et al., 2005a). The types and causesof fires differed between younger adults and older adults. The latterwere less likely to be smoking or have alcohol prior to the fire, andmore likely to have a smoke detector, mobility limitations and tobe incorrectly using electrical appliances such as electric blankets(Elder et al., 1996). Among older adults, although the frequency ofharm from fires is higher than in younger populations, the overallfrequency of harm associated with fire was found to be low,particularly when compared to frequency of harm associated withfalls.

Overall, the morbidity and mortality rates associated with firesand burns were low. Although morbidity rates were second highestafter falls, in studies which reported on both falls and burns, fallrates were two times (Runyan et al., 2005a), five times (Lilley et al.,1995) or negligible (Runyan et al., 2005b) compared to burn rates.This was not expected since vigilance is applied in the clinicalsetting to reduce the risk of fires at home (Oliver et al., 1993;Robnett et al., 2002; Poulin de Courval et al., 2006).

Two factors may have influenced the finding of low morbidityand mortality from fires and burns. First, as previously noted,reviewed studies are affected by selection and information biaswhich can lead to under-reporting of incidents. Second, vigilancewith fire prevention may reduce the exposure to the source ofinjury. The literature did not note differences in injury frequencybetween exposed and non-exposed groups (for example, personswho have stopped using the stove versus persons who use thestove). Causation of burn injuries was not demonstrated which

A. Douglas et al. / Archives of Gerontology and Geriatrics 52 (2011) e1–e10 e7

places limitations on the ability to plan prevention programs.Considering this limitation, the finding that the overall rates werelow for fires and burns remains relevant in examining the processof assessment for risk in the general older adult population.

Although the data did not directly compare samples of personswith and without dementia, studies sampling persons withdementia reported greater morbidity from fires or burns thanstudies sampling the general older adult population. In a studyexamining risk factors for fire-related death, dementia was foundto increase the risk, although numbers of injuries were notreported (Warda et al., 1999). The circumstances of burn injuries inpersons with dementia have been described by Alden et al. (2005)who found that the majority of persons were unsupervised at thetime of injury (67%) and were burned while performing routineactivities of daily living (51%) (e.g., cooking, eating, bathing). Thecauses were predominantly bathroom or kitchen scalding (44%)and flame burns (36%). This suggests that prevention of burninjuries in persons with dementia needs to address routine cookingand bathroom activities when the individual is alone.

Studies that obtained information from interviews rather thandatabases reported greater numbers of injured persons (Lee et al.,1999; Evci et al., 2006). This may have been because the interviewersobtained data on injuries for which persons had not sought medicalcare, highlighting that information in the databases may under-estimate the true rates of injury. In addition, the databases did notseparate burns from scalds versus fires and no studies that met theinclusion criteria reported number of events associated with scalds.Scalds comprised up to 40% of all burns (Boufous and Finch, 2005).Older adults are also at greater risk of scald injuries than youngeradults possibly due to decreased sensation or skin thickness(Boufous and Finch, 2005). The number of injuries from fires maybe higher than hospital records indicate. This trend was noted in astudy of older adults in Canada which found that numerous minorinjuries were reported in interviews and although persons had notsought medical care, these injuries were of sufficient severity toprevent them from being able to perform daily activities (Raina et al.,1999). The data reported in this review show low mortality andmorbidity from fires and burns but may underestimate the rates ofburn injuries due to biases in observational studies.

The majority of studies that met the inclusion criteria reportedfires and burns (Tables 1 and 2) whereas fewer studies reportedinjury from wandering or medication self-administration. Thistrend may reflect the greater ease of determining the source ofinjury in the case of fires and burns and therefore more inclusiveand definitive reporting in databases.

4.2. Wandering

Studies that examined direct causation between wandering andinjury were not found in the review. Few studies were found thatreported on wandering. This may reflect databases that do notrecord the location of death, or record the cause of death ashypothermia, or hyperthermia rather than becoming lost orwandering. Many pedestrian accidents may be a result ofwandering and pedestrian accidents were reported in one studyto be the leading cause of accidental mortality (Lilley et al., 1995).Wandering has been reported to increase the risk of falls (Rowe andBennett, 2003). It may be that the effects of wandering arecumulative over a period of time making it more difficult todetermine a causal link between wandering and injury. The resultsof this review may underestimate the numbers of injuries as aresult of wandering and further research is needed into therelationship between wandering and injury. The likelihood ofinjury from wandering was found in this review to be low whencompared to falls, but in a population with dementia, there was atrend for wandering to be a greater risk than fires and burns.

Studies have shown the prevalence of wandering amongpopulations with dementia to be between 38% (Cohen-Mansfieldand Wirtz, 2007) and 80% (Hope et al., 2001). Prevalence ratesdepend on the definition of wandering and the severity (Lai andArthur, 2003). Wandering has been cited as the most commonsafety problem reported by caregivers of people with dementia(Rabins et al., 1982; Lach et al., 1995) and increased wandering isassociated with increased caregiver distress (Logsdon et al., 1998).Although few studies linked wandering to the incidence of injury,wandering has been associated with increased risk for accidents(Rowe and Bennett, 2003) and institutionalization (McShane et al.,1998; Rolland et al., 2007). However, after adjustment for baselinecharacteristics, wanderers were not at greater risk for death thannon-wanderers (Rolland et al., 2007). Persons who wander are atgreater risk of falling (Cesari et al., 2002; French et al., 2007) andmore likely to have lower cognitive status (Logsdon et al., 1998).Studies on wandering have been characterized as being in theexploratory phase to determine the patterns of wandering andconcerns of caregivers (Peatfield et al., 2002). Further, there are nodata to support the effectiveness of interventions for wandering(Siders et al., 2004; Robinson et al., 2006). These additional studiesinform the review data by demonstrating that even though the rateof injury from wandering is comparatively low, it remains asignificant source of stress for caregivers and may precipitateadmission to hospital or long-term care without having causeddirect injury to the wanderer. This may be because the perceptionof risk in wandering is unnecessarily high, or because wanderinghas other consequences which are seen as intolerable such asdecreasing sleep of the caregiver or inability to care for a personwho becomes lost.

4.3. Errors in medication self-administration

The studies that met the inclusion criteria indicated a trend thataccidental injuries from errors in medication self-administrationare more likely than injury from fires/burns and wandering forpeople with dementia.

Data on the likelihood of injury from errors in medication self-administration were not found for the general older adultpopulation. This may be because the difficulty of attributingcausation of the injury to error in medication self-administration.Studies reported an association between medications and falls;however it is difficult to determine direct causation because ofgradual and cumulative effects of medication errors and thedifficulty distinguishing between the underlying disease andeffects of the medications (Lilley et al., 1995).

The paucity of studies that sampled the general older adultpopulation may also be because the number of events is negligible.However, a number of studies have examined the effects of takingmultiple medications (polypharmacy) and adverse drug reactions.Adverse drug reactions have been linked to hospital admissions(Pouyanne et al., 2000; Walker et al., 2005) and to falls (Wilkins,1999). The number of drugs being taken was reported as the mostimportant predictor of hospital admissions (Onder et al., 2002) andfalls (Paniagua et al., 2006; Russell et al., 2006). The ability to self-manage medications is predicted by cognition, and medicationregimen complexity (Maddigan et al., 2003). One study found thatthe majority of self-medication errors leading to adverse drugreactions occurred in administering the medication (31.8%),modifying the medication regimen (41.9%), or not followingclinical advice about medication use (21.7%) (Field et al., 2007).These were related to cognitive deficits, sensory or physicalproblems with dispensers, or the complexity of the regimen (Fieldet al., 2007). Although the morbidity or mortality associated witherrors in medication self-administration is not well known, thiscumulative evidence on adverse drug reactions indicates that

A. Douglas et al. / Archives of Gerontology and Geriatrics 52 (2011) e1–e10e8

medication self-management may be an important source of harmfor persons with complex drug regimens and cognitive deficits.

4.4. Comparison of persons with and without dementia

There were no studies that directly compared frequency ofinjury or death in a dementia sample to the general older adultpopulation. In studies sampling either group, falls were the mostsignificant cause of in-home injury in persons with dementia andthe general older adult population. Moreover, decreased cognitionwas noted to be associated with increased risk for falls (Paniaguaet al., 2006). As well, decreased cognition was associated withincreased risk for burns (Lilley et al., 1995), wandering (Cesariet al., 2002) and adverse drug events (Maddigan et al., 2003). Datadiscussed in this review on dementia, while unable to be directlycompared to older adult populations, indicated that falls, errors inmedication self-administration, and wandering occur withincreased frequency in dementia samples. The data indicates thatcognitive deficits may contribute to increased risk for persons withdementia compared to persons in the general older adultpopulation from all three sources of injury. For persons withdementia, the preliminary indication was that the risk ofmedication self-administration errors was greatest, followed bywandering then fires or burns. These findings are preliminarybecause of the methodological quality of the studies. It is notknown if persons with dementia have had modifications to theenvironment that reduce their exposure to injury. Reduction ofexposure would lead to under-estimation of the risk of injury indementia. Further research is required to determine if thefrequency of accidental morbidity and mortality is higher forpersons with dementia than the general older adult population.

Caregivers reported that wandering was the most commonsafety problem (Lach et al., 1995). A qualitative study, whichdescribed caregivers’ perceptions of behaviors that lead toaccidents (Horvath et al., 2005) found the most prevalent risktaking behaviors reported by caregivers of persons with dementiawere wandering, cooking with the stove, taking medication, andwalking. It is interesting to note that the data on larger populationsamples in this current systematic review would not support theseperceptions because of the low frequency of injuries from thesesources compared to falls.

When considering overall home safety, multiple factors asidefrom the risk of personal injury may take precedence. Theperception of risk may affect caregiver workload and be thecrucial factor on which determinations of independent living aremade. The likelihood of property damage may also take precedenceover the risk for personal injury. Risks to property affect otherswith whom an older adult lives or shares a building and althoughthe older adult may be willing to accept certain personal risks, therisks to others may be deemed to be untenable. For example, onestudy stated that caregivers were motivated to seek help or makechanges after events such as burning a pot on the stove (Horvathet al., 2005) when injury to the individual had not necessarilyoccurred. Finally, in persons with dementia, unlike in the generalolder adult population, behavior problems such as wandering andagitation have been reported to be the main cause of emergencyadmission for persons with dementia (Nourhashemi et al., 2001).Education about the factors that increase risk of injury, such aswandering leading to risk of falls, may help to ease caregiver stress.

4.5. Limitations of this review

Other sources of injury not examined in this review may beimportant in the determination of home safety, such as failure toeat or use ambulation aids. This review noted that falls are thegreatest source of accidental injury in older adults and examined

three other sources of injury based on factors that are commonlyaddressed in home assessments in this population. Other sourcesof injury were noted in the literature for persons with dementia. Astudy (n = 139) by Tierney et al. (2007) reported the mostfrequently occurring reason for harm was failure to eat and drink(n = 9). This was followed by failure to: use prescribed assistivedevices (resulted in bruises, fractures) (n = 5), report a medicalcondition (n = 5), maintain personal hygiene (n = 4), use medica-tions properly (n = 3), recognize a familiar environment (n = 2),turn off electrical appliances (n = 1), and judge fraudulent activities(n = 1). This indicates that self-neglect behaviors as well asaccidental injuries are important sources of harm in persons withdementia. Future research is required which samples older adultpopulations and identifies persons with and without dementia todetermine the most prevalent sources of injury.

Sources of bias and heterogeneity of data in this systematicreview prevented comparison of the morbidity or mortalityamongst studies. Data to demonstrate the causal associationbetween exposure and injury were not found. Information wasassembled at the level of association. Data were found reportingthe number of injuries after a fire/burn, wandering, or error inmedication self-administration but causal association was notdemonstrated. These sources of injury are important to caregiversand are included in health care safety assessments, and therefore,future population-based studies are required which compare therates of injury or death from falls, medication self-administrationand wandering in samples that identify persons with and withoutdementia.

5. Conclusions

The results can be used to understand the frequency of injuryfor the general older adult population and persons with dementia.In the general older adult population, the morbidity and mortalityis low for injury from fires/burns, wandering, or medication self-administration. In persons with dementia, although also low,trends in the data indicated that the morbidity and mortality isslightly higher from wandering and medication self-administra-tion. Rates of falls are also higher in dementia as reported in thebackground literature. The observation that the frequency of injurywas low may be an indication of success in reducing the exposurein the environment. Nonetheless, the low proportions of injuriesindicate that the primary emphasis of home safety assessment forolder adults with and without dementia should be placed on fallsprevention. Wandering and errors in medication self-administra-tion may contribute to falls and should be examined as theycontribute to increasing the risk for falls. Additional assessmentshould be undertaken for persons with suspected dementia.Although not conclusive, the background literature indicated thatpersons with dementia are at greater risk than the general olderadult population of injury or death from falls, not eating ordrinking, medication self-administration errors, wandering andfires or burns.

The data from this review are intended to inform assessmentsto screen for persons at greatest risk for accidents at home. Currentstandardized safety assessment instruments require data tosupport their ability to predict injury. Whether the approachesto determine safety actually decrease the frequency of injury isunknown. Current practice however is reliant on therapists’ andcaregivers’ perceptions of risk and checklists. Families andclinicians may perceive risk of injury from these three sources,which may lead them to advise premature placement in long-termcare. The high numbers of injuries and mortality from fallsreported in the literature must be considered when determiningthe overall risk of the older adult living at home. The current stateof the evidence is not sufficient to demonstrate causation of injury

A. Douglas et al. / Archives of Gerontology and Geriatrics 52 (2011) e1–e10 e9

from fires/burns, wandering and medication self-administrationerrors, and therefore is insufficient to support safety assessmentfor injury prevention. Future studies are needed which sample thegeneral older adult population, identify persons with and withoutdementia, and report rates attributable home-accidental morbid-ity or mortality.

Home safety intervention programs require the application of amodel of care and a recent review found that there is a lack ofmodel development for home safety (Lang and Edwards, 2006).There is an identified need to develop a model for home safetyassessment that is supported by evidence about the level ofattributable risk associated with various sources of injury.

Admission to hospital or long-term care depends on a numberof factors including the risk to the individual older adult. However,when describing the risk for injury to older adults and theircaregivers, it is important to emphasize that individuals are morelikely to become injured from a fall. If an individual is suspected ofhaving dementia, the risk of injury from falls is higher than for thegeneral adult population, measures need to be put into place toprevent falls, and prevention measures for injury from medicationself-administration, wandering and fires/burns must also beconsidered.

Conflict of interest statement

None.

Acknowledgements

We thank Neera Bhatnagar, reference librarian, for verifying thedatabase searches and Dr. Kevin Eva for reviewing the manuscript.The first author was supported by a Canadian Institutes of HealthResearch Doctoral Scholarship.

Appendix A. Data extraction form

Part 1: Checklist for evaluating prevalence studies (Boyle, 1998)

Research question: What accidental home injuries happen topersons older than age 65 and persons with dementia?

i.e. What is the prevalence of injuries related to fires,medication self-administration and wandering?

Score 1 point for each criterion present(1) Was the target population defined by clear inclusion andexclusion criteria?

(2) Was probability sampling used to identify potential respondents(or the whole population approached)?

(3) Did characteristics of respondents match the target population,i.e., was the response rate �80% or appropriate analysis includedcomparing responders and non-responders?

(4) Were data collection methods standardized?

(5) Was the survey instrument valid?

(6) Was the survey instrument reliable?

(7) Were features of sampling design accounted for in the analysis,through appropriate weighting of the data, or the whole populationapproached?

(8) Do the reports include confidence intervals or was the wholepopulation approached?

Total points________

Part 2: Calculation of proportions

Reference: Centre for Evidence Based Medicine (2008)Clinical Measure:

Proportion where:

the number of patients = n

the proportion of these patients who experience the event = p

n from evidence:

p from evidence:

Standard Error (SE):ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffifp� ð1� pÞ=ng

p

where p is proportion and n is number of patients

Typical Calculation of CI:

If p = 24/60 = 0.4 (or 40%) and n = 60

SE ¼ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffif0:4� ð1� 0:4Þ=60g

p

=0.063 (or 6.3%)

95% CI is 40% � 1.96 � 6.3%

or 27.6% to 52.4%

SE: ____________

95% CI: ________

References

Alden, N.E., Rabbitts, A., Yurt, R.W., 2005. Burn injury in patients with dementia: Animpetus for prevention... including commentary by silverstein P. J. Burn CareRehabil. 26 (3), 267–271 266.

Algase, D.L., 2006. What’s new about wandering behaviour? An assessment ofrecent studies. Int. J. Older People Nurs. 1, 226–234.

Alzheimer’s Society of Canada, 2008. Statistics on Alzheimer’s disease. Available at:http://www.alzheimer.ca/english/disease/stats-people.htm (approached May1, 2008).

Beghe, C., 2004. Review: interventions targeting intrinsic and environmental riskfactors reduce falls in older persons. ACP J. Club 141, 17.

Boufous, S., Finch, C., 2005. Epidemiology of scalds in vulnerable groups in NewSouth Wales, 1998/1999 to 2002/2003. J. Burn Care Rehabil. 26, 320–326.

Boyle, M.H., 1998. Guidelines for evaluating prevalence studies. Evid. Based Ment.Health 1, 37–39.

Byles, J., Higginbotham, N., MacKenzie, L., 2000. Designing the home falls andaccident screening tool (HOMEFAST): selecting the items. Br. J. Occup. Ther.63, 260–269.

Center for Evidence Based Medicine, Toronto, 2008. Critical appraisal worksheets(prognosis). Available at: http://www.cebm.utoronto.ca/teach/materials/caworksheets.htm (approached March 18, 2008).

Centers for Disease Control and Prevention (CDC), 1998. Deaths resulting fromresidential fires and the prevalence of smoke alarms – United States, 1991–1995. Morb. Mortal. Wkly. Rep. 47, 803–806.

Cesari, M., Landi, F., Torre, S., Onder, G., Lattanzio, F., Bernabei, R., 2002. Prevalenceand risk factors for falls in an older community-dwelling population. J. Gerontol.A: Biol. Sci. Med. Sci. 57, M722–M726.

Cohen-Mansfield, J., Wirtz, P.W., 2007. Characteristics of adult day care participantswho enter a nursing home. Psychol. Aging 22, 354–360.

Cooper, S., 1981. Accidents and older adults. Geriatr. Nurs. 2, 287–290.DiGuiseppi, C., Edwards, P., Godward, C., Roberts, I., Wade, A., 2000. Urban resi-

dential fire and flame injuries: a population-based study. Inj. Prev. 6, 250–254.Egger, M., Schneider, M., Smith, G.D., 1998. Meta-analysis: spurious precision?

Meta-analysis of observational studies. Br. Med. J. 316, 140–144.Elder, A.T., Squires, T., Busuttil, A., 1996. Fire fatalities in elderly people. Age Ageing

25, 214–216.Evci, E.D., Ergin, F., Beser, E., 2006. Home accidents in the elderly in Turkey. Tohoku J.

Exp. Med. 209, 291–301.Farchi, S., Giorgi Rossi, P., Chini, F., Camilloni, L., Di Giorgio, M., Guasticchi, G., Borgia,

P., 2006. Unintentional home injuries reported by an emergency-based sur-veillance system: incidence, hospitalisation rate and mortality. Accid. Anal.Prev. 38, 843–853.

Field, T.S., Mazor, K.M., Briesacher, B., Debellis, K.R., Gurwitz, J.H., 2007. Adversedrug events resulting from patient errors in older adults. J. Am. Geriatr. Soc. 55,271–276.

A. Douglas et al. / Archives of Gerontology and Geriatrics 52 (2011) e1–e10e10

Fletcher, P.C., Hirdes, J.P., 2005. Risk factor for accidental injuries within seniorcitizens’ homes: analysis of the Canadian survey on ageing and independence. J.Gerontol. Nurs. 31, 49–57.

French, D.D., Werner, D.C., Campbell, R.R., Powell-Cope, G.M., Nelson, A.L., Ruben-stein, L.Z., Bulat, T., Spehar, A.M., 2007. A multivariate fall risk assessment modelfor VHA nursing homes using the minimum data set. J. Am. Med. Dir. Ass. 8,115–122.

Gillespie, L.D., Gillespie, W.J., Robertson, M.C., Lamb, S.E., Cumming, R.G., Rowe, B.H.,2006. Interventions for preventing falls in elderly people. The Cochrane Library, 1.

Gulaid, J.A., Sacks, J.J., Sattin, R.W., 1989. Deaths from residential fires among olderpeople, United States, 1984. J. Am. Geriatr. Soc. 37, 331–334.

Hogue, C.C., 1982. Injury in late life. Part I. Epidemiology. J. Am. Geriatr. Soc. 30,183–190.

Hope, T., Keene, J., McShane, R.H., Fairburn, C.G., Gedling, K., Jacoby, R., 2001.Wandering in dementia: a longitudinal study. Int. Psychogeriatr. 13, 137–147.

Horvath, K.J., Hurley, A.C., Duffy, M.E., Gauthier, M.A., Harvey, R.M., Trudeau, S.A.,Cipolloni, P.B., Smith, S.J., 2005. Caregiver competence to prevent home injuryto the care recipient with dementia. Rehabil. Nurs. 30, 189–196.

Jepsen, P., Johnsen, S.P., Gillman, M.W., Sørensen, H.T., 2004. Interpretation ofobservational studies. Heart. Aug 90 (8), 956–960.

Lach, H.W., Reed, T., Smith, L.J., Carr, D.B., 1995. Alzheimer’s disease: assessingsafety problems in the home. Geriatr. Nurs. 16, 160–164.

Lai, C.K.Y., Arthur, D.G., 2003. Wandering behaviour in people with dementia. J. Adv.Nurs. 44, 173–182.

Lang, A., Edwards, M., 2006. Safety in come care: a background paper for roundtablediscussion: Canadian Patient Safety Institute. Available at: http://www.patient-safetyinstitute.ca/resources/publications_new.html (approached October 30,2006).

Lee, V.M., Wong, T.W., Lau, C.C., 1999. Home accidents in elderly patients presentingto an emergency department. Accid. Emerg. Nurs. 7, 96–102.

Levine, M., Walter, S., Lee, H., Haines, T., Holbrook, A., Moyer, V., 1994. Users’ guidesto the medical literature: how to use an article about harm. Ev medicineworking group. J. Am. Med. Ass. 271, 1615–1619.

Lilley, J.M., Arie, T., Chilvers, C.E., 1995. Accidents involving older people: a review ofthe literature. Age Ageing 24, 346–365.

Logsdon, R.G., Teri, L., McCurry, S.M., Gibbons, L.E., Kukull, W.A., Larson, E.B., 1998.Wandering: a significant problem among community-residing individuals withAlzheimer’s disease. J. Gerontol. B: Psychol. Sci. Soc. Sci. 53, P294–P299.

Lyons, R.A., Sander, L.V., Weightman, A.L., Patterson, J., Jones, S.A., Lannon, S., Rolfe,B., Kemp, A., Johansen, A., 2006. Modification of the home environment for thereduction of injuries. Cochrane Library, 4.

Maddigan, S.L., Farris, K.B., Keating, N., Wiens, C.A., Johnson, J.A., 2003. Predictors ofolder adults’ capacity for medication management in a self-medication pro-gram: a retrospective chart review. J. Aging Health 15, 332–352.

McGwin Jr., G., Chapman, V., Curtis, J., Rousculp, M., 1999. Fire fatalities in olderpeople. J. Am. Geriatr. Soc. 47, 1307–1311.

McShane, R., Gedling, K., Keene, J., Fairburn, C., Jacoby, R., Hope, T., 1998. Getting lostin dementia: a longitudinal study of a behavioural symptom. Int. Psychogeriatr.10, 253–260.

Ministry of Health and Long Term Care, Ontario, 2002. Aging at home strategy.Available at: http://www.health.gov.on.ca/english/public/program/ltc/34_stra-tegy_qa.html (approached May 2, 2008).

Moats, G., Doble, S., 2006. Discharge planning with older adults: toward a nego-tiated model of decision making. Can. J. Occup. Ther. 73, 303–311.

National Institutes of Health, 2006. National Institute on Aging 2006 strategic plan.Available at: http://www.ncmhd.nih.gov/strategicmock/our_programs/strate-gic/pubs/NIA Rev.pdf (approached May 2, 2008).

Nourhashemi, F., Andrieu, S., Sastres, N., Ducasse, J.L., Lauque, D., Sinclair, A.J.,Albarede, J.L., Vellas, B.J., 2001. Descriptive analysis of emergency hospitaladmissions of patients with Alzheimer disease. Alzheimer Dis. Assoc. Disord.15, 21–25.

Oleske, D.M., Wilson, R.S., Bernard, B.A., Evans, D.A., Terman, E.W., 1995. Epide-miology of injury in people with Alzheimer’s disease. J. Am. Geriatr. Soc. 43,741–746.

Oliver, R., Blathwayt, J., Brackley, C., Tamaki, T., 1993. Development of the SafetyAssessment of Function and the Environment for Rehabilitation (SAFER) tool.Can. J. Occup. Ther. 60, 78–82.

Onder, G., Pedone, C., Landi, F., Cesari, M., Della Vedova, C., Bernabei, R., Gambassi,G., 2002. Adverse drug reactions as cause of hospital admissions: results fromthe Italian group of pharmacoepidemiology in the elderly (GIFA). J. Am. Geriatr.Soc. 50, 1962–1968.

Paniagua, M.A., Malphurs, J.E., Phelan, E.A., 2006. Older patients presenting to acounty hospital ED after a fall: missed opportunities for prevention. Am. J.Emerg. Med. 24, 413–417.

Parmelee, P.A., Lawton, M.P., 1990. The design of special environments for the aged.In: Birren, J.E., Schaie, K.W. (Eds.), Handbook of the Psychology of Aging. 3rd ed.Academic Press Inc., New York, pp. 464–488.

Patterson, C., Gauthier, S., Bergman, H., Cohen, C., Feightner, J.W., Feldman, H., Grek,A., Hogan, D.B., 2001. The recognition, assessment and management of dement-ing disorders: conclusions from the Canadian consensus conference on demen-tia. Can. J. Neurol. Sci. 28 (Suppl 1), S3–S16.

Peatfield, J.G., Futrell, M., Cox, C.L., 2002. Wandering: an integrative review. J.Gerontol. Nurs. 28, 44–50.

Poulin de Courval, L., Gelinas, I., Gauthier, S., Dayton, D., Liu, L., Rossignol, M.,Sampalis, J., Dastoor, D., 2006. Reliability and validity of the safety assessmentscale for people with dementia living at home. Can. J. Occup. Ther. 73, 67–75.

Pouyanne, P., Haramburu, F., Imbs, J.L., Begaud, B., 2000. Admissions to hospitalcaused by adverse drug reactions: cross-sectional incidence study. Br. Med. J.320, 1036.

Rabins, P.V., Mace, N.L., Lucas, M.J., 1982. The impact of dementia on the family. J.Am. Med. Assoc. 248, 333–335.

Raina, P., Dukeshire, S., Wong, M., Scanlan, A., Chambers, L., Lindsay, J., 1999.Patterns of self-reported health care use in injured and uninjured older adults.Age Ageing 28, 316–318.

Rioux, L., 2005. The well-being of aging people living in their own homes. J. Environ.Psychol. 25, 231–243.

Robinson, L., Hutchings, D., Corner, L., Beyer, F., Dickinson, H., Vanoli, A., Finch, T.,Hughes, J., Ballard, C., May, C., Bond, J., 2006. A systematic literature review ofthe effectiveness of non-pharmacological interventions to prevent wanderingin dementia and evaluation of the ethical implications and acceptability of theiruse. Health Technol. Assess. 10, 1–108.

Robnett, R.H., Hopkins, V., Kimball, J.G., 2002. The SAFE AT HOME: a quick homesafety assessment. Phys. Occup. Ther. Geriatr. 20, 77–101.

Rolland, Y., Andrieu, S., Cantet, C., Morley, J.E., Thomas, D., Nourhashemi, F., Vellas,B., 2007. Wandering behaviour and Alzheimer disease. The REAL-FR prospectivestudy. Alzheimer Dis. Assoc. Disord. 21, 31–38.

Rothman, K.J., Greenland, S. (Eds.), 1998. Modern Epidemiology. Little, Brown &Company, New York.

Rowe, M.A., Bennett, V., 2003. Look at deaths occurring in persons with dementialost in the community. Am. J. Alzheimers Dis. Other Demen. 18, 343–348.

Rowe, M.A., Fehrenbach, N., 2004. Injuries sustained by community-dwellingindividuals with dementia. Clin. Nurs. Res. 13, 98–110.

Rowe, M.A., Glover, J.C., 2001. Antecedents, descriptions and consequences ofwandering in cognitively-impaired adults and the safe return (SR) program.Am. J. Alzheimers Dis. Other Demen. 16, 344–352.

Runyan, C.W., Casteel, C., Perkis, D., Black, C., Marshall, S.W., Johnson, R.M., Coyne-Beasley, T., Waller, A.E., Viswanathan, S., 2005a. Unintentional injuries in thehome in the United States. Part I. Mortality. Am. J. Prev. Med. 28, 73–79.

Runyan, C.W., Perkis, D., Marshall, S.W., Johnson, R.M., Coyne-Beasley, T., Waller,A.E., Viswanathan, S., 2005b. Unintentional injuries in the home in the UnitedStates. Part II. Morbidity. Am. J. Prev. Med. 28, 80–87.

Russell, M.A., Hill, K.D., Blackberry, I., Day, L.L., Dharmage, S.C., 2006. Falls risk andfunctional decline in older fallers discharged directly from emergency depart-ments. J. Gerontol. A: Biol. Sci. Med. Sci. 61, M1090–M1095.

Siders, C., Nelson, A., Brown, L.M., Joseph, I., Algase, D., Beattie, E., Verbosky-Cadena,S., 2004. Evidence for implementing nonpharmacological interventions forwandering. Rehabil. Nurs. 29, 195–206.

Sikron, F., Giveon, A., Aharonson-Daniel, L., Peleg, K., 2004. My home is my castle! Oris it? Hospitalizations following home injury in Israel, 1997–2001. Israel Med.Assoc. J. 6, 332–335.

Stroup, D.F., Berlin, J.A., Morton, S.C., Olkin, I., Williamson, G.D., Rennie, D., Moher,D., Becker, B.J., Stipe, T.A., Thacker, S.B., 2000. Meta-analysis of observationalstudies in epidemiology: a proposal for reporting. Meta-analysis of observa-tional studies in epidemiology (MOOSE) group. J. Am. Med. Assoc. 283, 2008–2012.

Tierney, M.C., Charles, J., Naglie, G., Jaglal, S., Kiss, A., Fisher, R.H., 2004. Risk factorsfor harm in cognitively impaired seniors who live alone: a prospective study. J.Am. Geriatr. Soc. 52, 1435–1441.

Tierney, M.C., Snow, W.G., Charles, J., Moineddin, R., Kiss, A., 2007. Neuropsycho-logical predictors of self-neglect in cognitively impaired older people who livealone. Am. J. Geriatr. Psychiatry 15 (2), 140–148.

Vandenbroucke, J.P., von Elm, E., Altman, D.G., Gøtzsche, P.C., Mulrow, C.D., Pocock,S.J., Poole, C., Schlesselman, J.J., Egger, M., 2007. STROBE initiative. Strengthen-ing the Reporting of Observational Studies in Epidemiology (STROBE): explana-tion and elaboration. PloS Med. 4, e297 1628–1654.

Walker, L., Jamrozik, K., Wingfield, D., 2005. Sherbrooke questionnaire predicts useof emergency services. Age Ageing 34, 233–237.

Waller, J.A., 1985. Unintentional injury among the medically impaired and elderly.Public Health Rep. 100, 577–579.

Warda, L., Tenenbein, M., Moffatt, M.E., 1999. House fire injury prevention update.Part I. A review of risk factors for fatal and non-fatal house fire injury. Inj. Prev. 5,145–150.

Wilkins, K., 1999. Medications and fall-related fractures in the elderly. Health Rep.11, 45–53.