Prevalence of falls among frail elderly adults

Abstracts

OBJECTIVE

To measure the prevalence in frail elderly people, their consequences and associated demographic factors.

METHODS

This was an epidemiological and cross-sectional study with a probabilistic sample composed of 240 elderly people (≥ 60 years) living in Ribeirão Preto, Sao Paulo state. Data were collected between November 2010 and February 2011, through a questionnaire that included socio-demographic data, fall assessment and the Edmonton Frailty Scale. Uni-variate and bivariate analyses were carried out.

RESULTS

The mean age was 73.5 (± 8.4), with higher ages among women; 25% of the interviewees were aged 80 or older; 11.3% presented moderate frailty and 9.6% severe frailty. The prevalence of falls in frail elderly participants corresponded to 38.6%; higher levels were found among women and younger subjects (60 to 79 years old); 26.8% were victims of 1 to 2 falls, 27.1% of which occurred in the bedroom, 84.7% fell from their own height, 55.9% lost their balance, 54.2% suffered scratches and 78% were afraid of suffering a new fall. Higher fall prevalence levels were found in frail elderly 1,973 (1,094-3,556) compared to non-frail.

CONCLUSIONS

We highlight the importance of addressing the health of frail elderly people, especially regarding the risk of falls, as well as of increasing investment in prevention strategies of these syndromes and in the formation of train like a virgin ed human resources to better care for this population.

Aged ; Frail Elderly ; Accidental Falls ; Risk Factors ; Socioeconomic Factors ; Cross-Sectional Studies

OBJETIVO:

Analisar a prevalência de quedas em idosos frágeis, suas consequências e fatores demográficos associados.

MÉTODOS:

Estudo epidemiológico e transversal com amostra probabilística de 240 idosos em Ribeirão Preto, SP. A coleta de dados foi realizada no período de novembro de 2010 a fevereiro de 2011. Foi aplicado questionário que incluiu dados sociodemográficos, avaliação de quedas e a Escala de Fragilidade de Edmonton. Foram realizadas análises uni e bivariada.

RESULTADOS:

A média de idade foi de 73,5 (dp=:8,4) anos, maior no sexo feminino; 25% dos entrevistados tinham idade ≥ 80 anos; 11,3% apresentaram fragilidade moderada e 9,6% fragilidade severa. A prevalência de quedas no idoso frágil foi de 38,6%, maior no sexo feminino e nos idosos mais jovens (60 a 79 anos); 26,8% sofreram de uma a duas quedas, 27,1% ocorreram no dormitório, 84,7% caíram da própria altura, 55,9% apresentaram alteração do equilíbrio, 54,2% sofreram escoriações e 78% apresentaram medo de sofrer nova queda; houve maior chance de queda no idoso frágil 1,973 (1,094;3,556) quando comparado ao não frágil.

CONCLUSÕES:

É necessária a abordagem da saúde do idoso frágil, principalmente quanto ao risco de quedas, maior investimento nas estratégias de prevenção dessas síndromes e na formação de recursos humanos preparados para melhor atender essa população.

Idoso; Idoso Fragilizado; Acidentes por Quedas; Fatores de Risco; Fatores Socioeconômicos; Estudos Transversais

OBJETIVO:

Analizar la prevalencia de caídas en ancianos frágiles, sus consecuencias y factores demográficos asociados.

MÉTODOS:

Estudio epidemiológico y transversal con muestra probabilística de 240 ancianos en Ribeirao Preto, SP, Brasil. La colección de datos se realizó en el período de noviembre de 2010 a febrero de 2011. Se aplicó cuestionario que incluyó datos sociodemográficos, evaluación de caídas y la escala de fragilidad de Edmonton. Se realizaron análisis uni y bivariado.

RESULTADOS:

El promedio de edad fue de 73,5 (ds =8,4) años, mayor en el sexo femenino; 25% de los entrevistados tenían edad ≥ 80 años; 11,3% presentaron fragilidad moderada y 9,6% fragilidad severa. La prevalencia de caídas en el anciano frágil fue de 38,6%, mayor en el sexo femenino y en ancianos más jóvenes (60 a 79 años); 26,8% sufrieron de una a dos caídas, 27,1% ocurrieron en el dormitorio, 84,7% cayeron de su propia altura, 55,9% presentaron alteración del equilibrio, 54,2% sufrieron escoriaciones y 78% presentaron miedo de sufrir nueva caída; hubo mayor chance de caída en el anciano frágil, 1,973 (1,094; 3,556) con respecto con el no frágil.

CONCLUSIONES:

Es necesario el abordaje de la salud del anciano frágil, principalmente frente al riesgo de caídas, mayor inversión en las estrategias de prevención de tales síndromes y en la formación de recursos humanos preparados para mejor atender dicha población.

INTRODUCTION

Falls are one of the main causes of elderly people needing medical care, and are a serious public health problem for this population. Falls are considered the second most common cause of death by accidental and non-accidental injury. ^a

Approximately 28%-35% of those aged over 65 fall each year, with this figure increasing to 32%-42% in those aged over 70 living in the community.²⁰, ²¹

In Korea, 15% of elderly people suffer falls.¹⁷ In Brazil, according to Ministry of Health, figures, 30% of elderly people fall each year. ^bSilva et al¹⁸ assessed 30 elderly people with different levels of frailty and 66.7% reported having fallen in the 12 months preceding the interview. According to these authors, falls can produce a decrease in functional capacity with regards to everyday activities; moreover, developing frailty syndrome may interfere in the elderly’s quality of life.

Frailty syndrome is a consequence of ageing and linked to the process of chronic illness. This syndrome is characterized by being multi-dimensional and means that the elderly person is more vulnerable. There is a decrease in physiological reserves and an increase in functional deficits, associated with physical changes which lead to adverse effects such as falling, increased morbidity, functional incapacity, prolonged hospital and care home stays and death.⁸, ¹², ²²

Rolfson et al¹⁵ consider frailty to be a multi-dimensional, heterogenic and unstable process, making it more difficult to assess. The Canadian proposal, used in this study, views frailty as including biological, psychological, social and environmental factors which interact throughout the course of the person’s life.²

Frailty associated with falling may bring health problems, categorized as the great geriatric syndromes of the 21^st century. This condition affects functional capacity and leads to a loss of independence and capacity to work. There are few national and international studies which assess frailty in old age and associated factors, above all in the community, and which support appropriate public health policies for this population.

This study aimed to analyze the prevalence of falls, their consequences and associated demographic factors in the frail elderly.

METHODS

This was a cross-sectional study with 240 elderly subjects aged over 60, of both sexes, resident in the urban area of Ribeirão Preto, Southeastern Brazil between November 2010 and February 2011.

The city of Ribeirão Preto had a gross domestic product (GDP) per capitaof R$ 26,083.97 in 2009. It has 978 health care establishments, 95 belonging to the Brazilian Unified Health System (SUS). There is a population of 604,682, of which 12.7% are elderly people aged 60 and over, of whom 58.7% are women. ^c

A two-stage probabilistic cluster sampling process was used. In the first stage, the census tract was used as the sampling unit, according to population size, and in the second stage, the individual aged ≥ 60 was the sampling unit. Twenty census tracts were drawn (from the 650 which existed).

The sample size was calculated considering a prevalence of 50% for the estimate, with a confidence interval of 95% and accuracy or error of 6.3%. A sample of 240 individuals, 12 per census tract, was calculated. The blocks o each sector and the respective streets were drawn and covered in a clockwise direction. The residences were visited up to three times on different days and at different times if no one answered on the first attempt. If the individual refused to participate, the researcher moved on to the next residence until reaching a total of 12 elderly people fulfilling the inclusion criteria. There was a refusal rate of around 5%.

Inclusion criteria were: being aged ≥ 60 and resident in the urban area of the city. Elderly people in care homes were excluded from the sample.

The data were collected in the subjects’ homes using a structured interview carried out by previously trained undergraduate and post-graduate nursing students.

The questionnaire used included socio-demographic variables (age, sex, marital status, schooling, household income and living arrangements) and variables related to falls and frailty.

The World Health Organization ^ddefines falling as any involuntary event in which a person loses balance and the body falls onto the floor or any other solid surface. The questionnaire proposed by Schiaveto, ^ecreated based on a revision of the literature and validated by a judging body made up from experts in health care and geriatrics, was used to evaluate and characterize falls. The questionnaire is made up of 68 questions which describes falls according to the number, location, cause, type of injury and consequences, when the subject responded in the affirmative to the following question: “Have you fallen in the last six months?”

Fragile elderly people are characterized by their vulnerability and low ability to bear stress factors. This results in a greater susceptibility to illness and in the onset of syndromes which create dependence.⁴

The evaluation of frailness was carried out using the Edmonton Frail Scale by Rolfson et al¹⁵ (2006), the Portuguese version validated by Fabrício-Wehbe et al.⁷ This scale has nine sections and scores vary from 0 to 17 points (0-4: not frail; 5-6: appears vulnerable; 7-8: mild frailty; 9-10: moderate frailty; 11 and over: serious frailty).

The data were dichotomized according to the frailty scores: frail and not frail with a cutoff point of ≥ 5.

In order to create the database, an Excel^® spreadsheet was created in which the data was entered in duplicate. The data were imported to the SPSS statistics program, version 17, in order to carry out descriptive analysis. The quantitative variables were analyzed using measures of central tendency (mean and median) and of dispersion (sd = standard deviation), and categorical variables, in absolute and relative frequency, considering 0.05 as the level of significance. The Chi-squared test was used for bivariate analysis between the presence of falls, demographic variables and the presence of frailty.

The research project was approved by the Committee of Ethical Research of the Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo(Protocol n^o 1169/2010), in accordance with resolution 196/96 of the National Health Council. The subjects taking part signed consent forms.

RESULTS

Of the 240 interviewees, 62.9% were female; 25% were aged 80 and over; the mean age was 73.5 (sd = 8.4), the minimum age was 60 and the maximum age was 94; among the men, married men were predominant (79.8%) and among the women, widows were predominant (41.1%); 29.0% lived with a partner. The greatest proportion of individuals had between on and four years schooling (sd = 5.4) ( Table 1).

Table 1.
Sociodemographic profile of the elderly living in the community according to sex, age group, marital status, schooling and living arrangements. Ribeirão Preto, Southeastern Brazil, 2011. (N = 240)

Variable	Mean	Sd	Median	Variation observed	Distribution in categories	n	%
Age (years)	73.5	8.4	73.0	[60;94]	60 to 64	43	17.9
					65 to 69	44	18.3
					70 to 74	47	19.6
					75 to 79	46	19.2
					80 and over	60	25.0
Sex					Male	89	37.1
					Female	15	62.9
Schooling (years)	5.4	5.0	4.0	[0;26]	Illiterate	35	14.6
					1 to 4	117	48.8
					5 to 8	42	17.5
					9 to 11	19	7.9
					12 and over	27	11.3
Marital status					Single	14	5.8
					married	138	57.5
					Divorced	10	4.2
					Separated	2	0.8
					Widowed	75	31.3
					Don’t know /didn’t respond	1	0.4
Elderly subject’s monthly income	1,271.7	2,008.0		[0;20.000.0]	None	27	11.3
					< 510.00	6	2.5
					510.00	79	32.9
					> 510.00	128	53.3
Monthly household income	2,323.5	2,559.6		[0;20.000.0]	None	4	1.7
					< 510.00	13	5.4
					510.00	13	5.4
					> 510.00	210	87.5
Living arrangements					Alone	33	13.8
					Living with a partner	70	29.2
					Living with partner and children	37	15.4
					Living with partner children and son or daughter in law	5	2.1
					Living with children	14	5.8
					Living with children and grandchildren	21	8.8
					Living with grandchildren	3	1.3
					Other	57	23.8

• RP: ratio of prevalence; RCP: radio of prevalence ^aTest^{2 b}Younger elderly subjects: 60 to 79 ^cOlder elderly subjects: 80 and over

The mean number of falls in the frail elderly subjects was 1.61 (sd = 0.5). Male and female subjects fell most often between one and two times in the last six months ( Table 2).

Table 2.
Falls according to number, location, type, factors and consequences in frail and non-frail elderly subjects living in the community. Ribeirão Preto, Southeastern Brazil, 2011. (N = 153)

Variable		Frail		Non frail
		n	%	n	%
Number of falls
	None	94	58.8	66	41.3
Falls
	1 to 2	41	68.3	19	31.7
	3 to 4	13	86.7	2	13.3
	5 or more	5	100.0	0	0.0
Location
	Bedroom	16	94.1	1	5.9
	Bathroom	15	83.3	3	16.7
	Street	15	88.2	2	11.8
	Yard	13	100.0	0	0.0
	Pavement	9	75.0	3	25.0
	Kitchen	24	70.6	10	29.4
	Other	11	68.8	5	31.2
Type of fall
	From standing height	50	74.6	17	25.4
	From the bed	8	88.9	1	11.1
	From a chair	1	33.3	2	66.7
	Other	74	66.6	37	33.3
Intrinsic factors
	Loss of balance	33	82.5	7	17.5
	Muscle weakness	23	95.8	1	4.2
	Dizziness/vertigo	21	91.3	2	8.7
	Difficulty walking	20	100.0	0	0.0
	Other	12	92.3	1	7.7
Extrinsic factors
	Uneven flooring	14	93.3	1	6.7
	Slippery flooring	13	61.9	8	38.1
	Step/change in floor level	7	77.8	2	22.2
	Rugs	5	83.3	1	16.7
	Objects on the floor	3	42.9	4	57.1
	Other	35	77.8	10	22.2
Consequences of the falls
	Hospital admission	8	80.0	2	20.0
	Surgery	2	50.0	2	50.0
	Stitches	7	100.0	0	0.0
	Closed fracture	2	50.0	2	50.0
	Scrapes	32	86.5	5	13.5
	Sprain or dislocation	0	0.0	2	100.0
	Impaired walking	27	81.8	6	18.2
	Dependency in day-to-day actions	12	100.0	0	0.0
	Fear of falling again	46	85.2	8	14.8
	Other	32	91.4	3	8.6

More than half the falls (75%) occurred in the subject’s own home and 84.7% were from standing height ( Table 2).

More than half (55.9%) of the subjects reported loss of balance as an intrinsic factor causing falling. As regards extrinsic factors, 57.6% mentioned uneven and slippery surfaces as the main causes ( Table 2).

The main consequence of falling was fear of falling again; “post-fall syndrome” ( Table 2).

The rate of prevalence of falling was 33.3%, and was higher among women; 36.3% of the elderly subjects were not frail, whereas 66.7% showed some degree of frailty: 24.6% appeared vulnerable, 18.3% were had mild frailty, 11.3% moderate frailty and 9.6% serious frailty.

The rate of prevalence of falling was greater among those elderly subjects who were frail (p = 0.023) ( Table 3) and was 59% higher among those deemed frail compared with those who were not frail (rp = 1.598).

Table 3.
Prevalence of falls in elderly subjects according to the situation of frailty and among frail subjects according to sex and age group. Ribeirão Preto, Southeastern Brazil, 2011.

Variable		Fall (Yes)		Fall (No)		RP	RCP	pa
		n	%	n	%
Prevalence		59	38.6	94	61.4
Frailty (n = 240)
	Frail	59	38.6	94	61.4	1.598 (1.047;2.438)	1.973 (1.094;3.556)	0.023
	Non frail	21	24.1	66	75.9
	Frail elderly subjects (n = 153)
Sex
	Male	18	30.5	38	40.4	0.647 (0.324;1.291)	0.760 (0.487;1.188)	0.215
	Female	41	69.5	56	59.6
Age group
	Younger elderly subjects	35	59.3	64	68.1	0.684 (0.347;1.345)	0.795 (0.533;1.186)	0.270
	Older elderly subjects	24	40.7	30	31.9

Among the frail subjects, the prevalence rate of falling was 38.6%; women and the younger subjects (60 to 79 years old) showed a higher number of falls ( Table 3).

DISCUSSION

There was a predominance of falls among female subjects and those aged 80 and over; this finding is similar to those of other research carried out in Brazil Brasil¹³, ¹⁸ and in other countries.¹⁰, ²²

It was observed that there was a higher proportion of widowed subjects among the females and married subjects among the males. This may be explained by shorter life expectancy in men and by inequality in social and cultural norms in Brazilian society, in which prejudices still exist, mainly when a widow wishes to marry again. The same does not occur in the case of widowers, who tend to remarry and do so to younger women.³

The majority simply live together. Of those who lived alone, the majority were women. This may be a result of being widowed, of grown children leaving the family home.¹¹

The rate of prevalence of falls in the elderly population was 33.3%, similar to the rate observed by Siqueira et al¹⁹ (34.8%) in a study carried out in seven Brazilian states with subjects aged 65 and over. Higher rates of prevalence have been found in other national studies.⁷, ¹⁴

The prevalence of frailty among the elderly living in the community in the United Sates was estimated to be 6.9%, varying from 3.2% among those aged 65 to 70, to 23.1% in those aged over 90,⁹ considerably different to the percentage found here (63.7%). However, that study, in contrast to this one, used phenotypic evidence to assess falls.

The rate of prevalence of falls in the frail elderly was 38.6%, a figure which is higher than those found in studies conducted in the United States (20.5%²³ and 14%⁵).

The mean was 1.61 and the median was two falls in frail subjects, a figure higher than epidemiological data on falls which estimate 0.7 falls/person/year, with and interval of 0.2 to 1.6.¹⁶

Around 39.1% of elderly people are frail and frailty syndrome is more closely related to females. Fried et al⁹ linked frailty to different variables such as low household income, suffering from chronic illness and sarcopenia, which are more commonly observed in females. Similar data were observed in research conducted by Varela-Pinedo et al,²² in Peru, and by Fabricio-Wehbe, ^fin Brazil.

Ensrud et al,⁵ using the rate of the Study of Osteoporosis Fractures (SOF), identified 13% of frail elderly subjects. Woods et al²³ verified that, of those aged between 70 and 79, 61.6% are frail and, of those aged between 65 and 69, this rate is 38.4%.

The frail elderly are more likely to suffer falls. There are few published studies on this topic, as it is only recently that this area of gerontology has become a concern. Veras et al²⁴ report that the elderly who need more care are those who have the highest degrees of frailty, as well as having a higher probability of falling ill, being admitted to hospital and suffering falls.

Research carried out by Ensrud et al⁵ and Galucci et al¹⁰ observed that the occurrence of falls among the elderly was related, in the majority of cases, to frailty syndrome. This caused serious functional incapacity and may increase the risk of the elderly subject ending up in a care home.

Ensrud et al⁵ showed that there was a strong association between frailty and the risk of suffering falls, breaking the him, decreasing functional capacity and hospital admission; they also reinforced the concept of frailty as a geriatric syndrome.

Silva et al¹⁸ did not find any significant differences between the degree of frailty and the occurrence of falls, in contrast to the results of this study, in which those elderly subjects who suffered falls had a higher probability of being frail. Longitudinal studies may better explore the relationship between cause and effect and outcomes. Fried et al⁹ reported that the elderly had a greater chance of falling.

Frailty and falling may be bi-directionally linked. Thus, just as falling may lead to the elderly person becoming frail, so frailty may lead to falling. This study, however, did not establish causality between these variables, as the data were collected in a transversal manner, i.e., the variables were measured once, simultaneously.

The location of the fall varied. Findings of studies on the topic were similar, suggesting that falls occur predominantly at home, especially in the living room, followed by the bathroom and the kitchen. Similar results were reported by Gai et al, ^gaccording to whom the main consequence were: serious injury, including fractures and scrapes. Shin et al¹⁷ showed that falls cause fractures and injuries needing stitches, and these were the most serious consequences.

Nunes et al¹³ stated that falling may lead to decreased functional capacity. This is related to the interaction of multi-dimensional factors which include aspects interlinked with mental and physical health in the elderly.

Woods et al²³ and Ensrud et al⁵ reported that frailty is one of the causes which may lead the elderly to need care in a residential or care home.

Elderly people who fall repeatedly, and who also have a certain degree of frailty, may be considered a group at high risk of falling again, a risk which increases with age. The consequences may or may not be serious, and may generate a high cost to society (cost of hospital admission, treatment and rehabilitation), and significant costs for the family due to the need to change the physical environment, the dependence and care of the elderly by either a family member or a carer.

“Post-fall” syndrome is among the main consequences described⁶ and it cited in the research by Carvalhaes et al ^hinvolving elderly subjects aged between 75 and 84. The authors identified that the difficulties they encountered in carrying out tasks they considered to be complex may create a higher probability of suffering fall. Elderly people with a history of falling and of co-morbidities may find the day to day activities they are able to carry out reduced, which contributes to them becoming frailer.²³ This situation may have a psycho-social impact, such as “post-fall” syndrome”, further limiting their activities.

The results of this study may lead health care professionals to reconsider the importance of these two geriatric syndromes: falling and frailty, which afflict this population, restricting their functional capacity.

One of the limitations of the cross-sectional study and that it is not able to determine frailty as one of the predictors of falling. In order to do this, follow up studies are needed to assess this syndrome.

Health care for the frail elderly, especially bearing in mind greater life expectancy and the diverse syndromes resulting from the ageing process, calls for greater investment in strategies for promoting health and preventing accidents. Among these accidents, evaluating the risk of falls, as well as training human resources to deal with this eventuality, is a fundamental strategy for the health care of this population.

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Publication Dates

• Publication in this collection
  June 2013

History

• Received
  15 June 2011
• Accepted
  9 Sept 2012