|Year : 2015 | Volume
| Issue : 3 | Page : 135-140
Risk factors for falls among elderly: A community-based study
Savita S Patil1, SP Suryanarayana2, Rajaram Dinesh2, NS Shivraj2, NS Murthy2
1 Department of Community Medicine, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India
2 Department of M S Ramaiah Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||16-Jul-2015|
Savita S Patil
Department of Community Medicine, BGS Global Institute of Medical Sciences, Uttarahalli Main Road, Kengeri, Bengaluru - 560 056, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Majority of falls are multifactorial and results from a complex interplay of predisposing and precipitating factors. Falls and their sequelae are potentially preventable. Aims: To determine the risk factors for falls among the elderly. Settings and Design: A community-based cross-sectional study in urban part of Bengaluru. Subjects and Methods: Study conducted for a period of 1-year, among elderly population 60 years and above, were residents since 1-year. Complete enumeration by census methodology applied. A pretested semi-structured questionnaire was administered to collect information about falls. Statistical Analysis Used: Univariate and multivariate logistic regression employed using SPSS version 18. Results: Of the 416 elderly persons studied, prevalence of falls rate 29.8%. The rate of fall for medical factors varied 33.3% diabetes mellitus to 71.4% foot problems. Among the people with behavioral factors, higher fall rate seen among those who were underweight 77.7%, abnormal finding in balance test 59.5%, abnormal gait 51.4%, low Mini Mental State Examination score 50%, Obese 50%, those who had difficulty with steps/stairs 45.3%, habit of smoking 45.1%, low activities of daily living score 45.4%, persons with abnormal get up and go test 43.8% and those who were on alcohol 43.1%. Logistic regression analysis revealed elderly with backache, nonsteroidal anti-inflammatory drugs, visual problem, difficulty in getting on/off toilet, smoking, cataract, TCA's loose slipper outside home were at higher risk of fall, was found to be statistically significant. Conclusions: Majority of the falls in the elderly are due to medical, behavioral factors which are predictable and preventable.
Keywords: Elderly, falls, risk factors
|How to cite this article:|
Patil SS, Suryanarayana S P, Dinesh R, Shivraj N S, Murthy N S. Risk factors for falls among elderly: A community-based study. Int J Health Allied Sci 2015;4:135-40
|How to cite this URL:|
Patil SS, Suryanarayana S P, Dinesh R, Shivraj N S, Murthy N S. Risk factors for falls among elderly: A community-based study. Int J Health Allied Sci [serial online] 2015 [cited 2019 Sep 20];4:135-40. Available from: http://www.ijhas.in/text.asp?2015/4/3/135/160867
| Introduction|| |
In India, the number of persons above the age of 60 years is fast growing, 76.6 million people in India at over the age of 60, constituting above 7.7% of total population and is expected to reach 8.9% in 2016.  Health concerns among the elderly are multiple and complex which includes medical and psychosocial problems. Falls are one of the major problems in the elderly and are considered to be one of the "geriatric giants" (falls, confusion, incontinence, impaired homeostasis, iatrogenic disorders) leading to a significant proportion of morbidity.  Falls are commonly defined as "inadvertently coming to rest on the ground, floor or other lower level excluding intentional change in position to rest in furniture, wall or other objects."  About 1/3 rd of the community living elderly fall in a year.  Falls and consequent injuries are major public health problems that often require medical attention. Falls lead to 20-30% of mild to severe injuries and are underlying cause of 10-15% of all emergency department visits.  Most often causes of fall are multifactorial. There is a limited research on healthy ageing in developing countries like India. Hence, it is of utmost importance to know the prevalence rate and risk factors for falls in the elderly in urban communities. This would provide important information on epidemiology of falls as well as designing effective preventive strategies for comprehensive management. Hence, the present study was undertaken to know the prevalence rate of falls and to identify factors influencing the falls among the elderly.
| Subjects and methods|| |
Ethical clearance was taken by the Institutional Ethics Committee before starting the study. Informed consent obtained from study participants.
A community-based cross-sectional study was conducted between April 2009 and March 2010 in urban part of Bengaluru city, Karnataka. The total population of the urban field practice area of M.S. Ramaiah Medical College comprised of about 7000. A total of 513 elderly were enumerated by census; out of them, 416 were taken up for study by simple random technique out of which 16 were included considering nonresponse rate of 4%. The literature review revealed that the prevalence rates of falls were 30%,  with a relative precision of 15% and confidence level of 95%, the estimated sample size worked out to be 400 elderly persons. The study employed was by census, a complete enumeration of all the elderly above 60 years was undertaken by house-to-house survey in the above area. Persons with history of assault/road traffic accident were excluded. The elderly were classified into three age groups: Young old 60-75; old 76-85; and very old >85 years, respectively.  Respondents with history of fall in the previous 6 months were included for detailed information regarding various factors like activities of daily living (ADL) score using Barthel index,  get up and go test,  underlying medical disorders, medication history, and behavioral factors were recorded. Clinical examination including all anthropometric measurements according to the standards used in MONICA project,  body mass index, pulse, blood pressure in supine and standing postures, mini mental state examination (MMSE) using questionnaire score system, neurological examination for power and reflexes, cardiovascular system by auscultation and musculoskeletal system by examination of posture, positioning of joints etc., was conducted.
Prevalence rates by the various confounding variables along with the odds ratios were estimated. Chi-square/Fisher exact test was employed to find the association between two variables for assessment of various factors. The strength of association of the factors was carried out employing case-control methodology/approach, where all the persons who reported falls were considered as cases and the persons who did not have falls were considered as controls. Unadjusted odds ratio (OR) with 95% confidence intervals (CI) were estimated. The OR obtained represents prevalence odds ratios. Further to find out independent determinants associated with the fall, multiple logistic regression methodology was employed. The statistical significance level was fixed at P < 0.05. Data were entered and analyzed using SPSS version 17.0. SPSS Version(17.5,IBM,Armonk,USA).
| Results|| |
Of the total 416 elderly persons studied, 88.4% were in 60-75, 9.2% were between 76% and 85, 2.4% were 85 years of age group, respectively. Further higher proportions of females 64.4% were noted as compared to males 35.6%. Overall prevalence rate of fall was 29.8% (21.1-38.4 at 95% CI). Prevalence of rate fall was higher among the females 31.3% compared to male elderly 27.0%. The prevalence rate of fall was higher among old (76-85 years) 65.7%, 26.3% in young old (60-75 years) and 20% in very old (>85 years) and this difference was found to be significant statistically P < 0.05. There was a significantly higher rate of fall among elderly on medication (43.9%), Tricyclic antidepressants (100%), nonsteroidal anti-inflammatory drugs (NSAIDS) (82.1%), compared to those who were not on any medication. Higher fall rate were also seen among elderly on sedative hypnotics (40%), antihypertensive (43.4%), hypoglycemic (32%), cardiac medication (44.4%), which was not statistically significant [Table 1].
|Table 1: Fall rate (%) based on the intake of medications for various medical conditions|
Click here to view
Among the people with behavioral factors, significantly higher fall rate was seen among elderly who used walking aid/stick (65.7%), elderly who did not use slippers outside the home (63.8%), those who had habit of smoking (45.1%), difficulty with steps/stairs (45.3%), those who consumed alcohol (43.1%), difficulty in getting on/off toilet (42.7%), tobacco users (43.3%), persons without exercise/physical activity as compared to those without above factors [Table 2].
It was observed that the rate of fall among the study subjects with medical factors varied from 33.3% (diabetes mellitus) to 71.4% (foot problem). Statistically significant higher proportion of fall rate was seen in elderly with backache on walking (77.6%), foot problems (71.4%), joint instability (62.5%) and weakness in any part of the body (55.5%), visual problem (45.5%), acute illness of <3 weeks duration (44.5%), those who felt dizzy (41.2%), joint pain (40.6%) as compared to elderly without such problems [Table 3]. Although the persons with history of epilepsy (50%, P = 0.09, OR = 2.43), tingling sensation over feet/palms (40.8%, P = 0.07, OR = 3.21), hearing Problems (40%, P = 0.29, OR = 1.62), diabetes mellitus (33.3%, P = 0.47, OR = 1.22), hypertension (30.9%, P = 0.29, OR = 1.95), cardiac problem (30.9%, P = 0.39, OR = 1.48) had higher fall rate than those without such problems, however the difference was not statistically significant.
Based on clinical examination parameters, higher proportion of fall rate was seen with the elderly who had low ADL score (score 11-15, 37.8%, score <10, 45.4%), low MMSE score (score < 30, 50%), obese (50%) and underweight elderly (77.7%) (P = 0.01), elderly who had abnormal finding in balance test (59.5%), abnormal gait (51.4%), presence of tremor (55.5%), the persons with abnormal get up and go test (43.8%) had higher fall rate compared with their counterparts and the difference was found to be statistically significant. The elderly with Parkinson's disease although had higher fall rate than those without Parkinsons disease (100%, P = 0.12) but it was not found statistically significant [Table 4]. There was no difference of fall rate found between hypotensive, hypertensive, and normotensive. Statistically significant difference was seen with the elderly who had <6 h of sleep (40.1%), than those who had 6-8 h of sleep (22.1%).
|Table 4: Fall rate (%) based on examination parameters of the study subjects|
Click here to view
On multivariate analysis, elderly with backache, those who were on NSAIDS, visual problem, difficulty in getting on/off toilet, smoking, cataract, TCAs, loose slipper outside home, were at higher risk of fall and was found to be statistically significant [Table 5].
|Table 5: Univariate and logistic regression analysis of predictors of fall|
Click here to view
| Discussion|| |
Our study revealed the overall prevalence rate of fall was 29.8%, similar to studies. ,, In India, prevalence rate of fall ranged 14% in multicentric community study  to 51.5% similar study conducted in Chandigarh city of India.  The rate at which the men and women fell was virtually identical which is similar to community-based study in USA,  whereas in other studies, fall rate was higher among females. ,,,, Women develop greater postural sway and imbalance than men and hence greater tendency to fall. The frequency of falls increases with age and frailty level. This is because most falls are associated with age-related conditions such as physical frailty, immobility, and reduced functional capacity well correlates with multicentric community study in India,  and other studies. ,,
It is noted that in the present study, visual impairment was strongly associated with the falls in older adults agrees with the studies in Chennai  and Gujarati Asian elders.  Similar observation made by Blue Mountains eye,  and Suraj and Awasthi study,  where poor visual acuity, visual factors such as reduced visual field, impaired contrast sensitivity, and the presence of cataract may explain this association. Since cataract-induced visual impairment is common in elderly people, this finding could have major public health implications.
There was no association between falls and the use of diuretics, antihypertensive or tranquilizers, but a significant association between falls and the use of antidepressants, , found in our study seemed to resemble study in Nottingham.  Possibly because drugs in this class have significant sedative properties  elderly people may be more sensitive to drugs effects and less efficient at metabolizing medications, leading to adverse events, which in turn lead to falls  and was also explained in a report. 
The low percentage of sedative hypnotics attributed to falls in our study was probably due to less number of patients being treated with these sedative hypnotics similar observation made by in a report by Aruna.  Multiple drugs for the illnesses can also result in dizziness, blackouts, and falls agrees with report quoted in GOI.  The occurrence of fall among smokers in our study might be due to that smoking habit which is most commonly associated with alcohol consumption may explain the association which well agrees with World Health Organization (WHO) report.  Alcohol consumption is related to postural hypotension which is consequently associated with falls.
The significance of wearing loose slippers and inappropriate shoes with the fall in our study may be because of the relatively thick, soft midsoles interfere with positional sense. High heeled shoes, loose slippers impair balance and are associated with an increased risk of falling was in accordance with in Chinese study.  In the present study, difficulty in getting on/off toilet may be due to age-related osteoarthritis of knee joint or cervical or lumbar spondylosis which produces neuropathy and thus it might result in falls. Physical disability or limited activity increased the risk of fall by 2-4 times.  Low back pain and lower extremity arthritis were significant factors associated with the fall in the present study which similar to as stated in WHO report,  GOI.  Abnormal gait, abnormal get up and go test for joint pains which impairs balance and are more prone for falls, agrees with studies in Lucknow,  Singapore.  Incontinence which is leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing, is associated with an increased risk of falling because of frequent ambulation to the bathroom which well states with WHO report on falls. 
It was observed that the rate of fall for medical factors varied from 33.3% (diabetes mellitus) to 71.4% (foot problems). , The findings of our study are in accordance with Amsterdam study.  Although on logistic analysis few factors found significant which is explained above. Cognitive impairment and confusion even at relatively modest levels can increase the risk of falling. Five or more errors on a short mental status questionnaire a score <26 or <24 on the MMSE is associated with increased risk which might be due to short-term memory over the of age 75 years. , Lack of sleep affects coordination can result in an unsteady walking gait in an older person - thereby increasing the risk of a fall.
| Conclusion|| |
Falls in the elderly are significant public health problem. Falls are one of the most common geriatric giants threatening the independence of older persons. Majority of the falls in the elderly are due to medical, behavioral factors which are predictable and hence they are preventable. In order to improve the health status of the elderly population, it is important to carry out more studies in different areas to identify various factors that are related to falls, psychological distress and disability, which should lead to efforts to develop effective programs in disease prevention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sharma OP. Textbook of Geriatrics and Gerontology. 3 rd
ed. viva books: 2005. p. 2-4, 610-4.
WHO. Epidemiology of falls. WHO Global Report on Falls Prevention in Older Age. WHO Press: 2008.
Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. J Epidemiol Community Health 2003;57:740-4.
Todd C, Skelton D. What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls? Health Evidence Network Report Copenhagen WHO Regional Office for Europe; 2005. Available from: http://www.euro.who.int/document/E82552.pdf
. [Last accessed on 2010 Jun 03].
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL index: A reliability study. Int Disabil Stud 1988;10:61-3.
Mathias S, Nayak US, Isaacs B. Balance in elderly patients: The "get-up and go" test. Arch Phys Med Rehabil 1986;67:387-9.
Anu M, Kari K, Susana S. Quality Assessment of Weight and Height Measurements in the WHO MONICA Project 1998; WHO MONICA Project E-publications No. 12. Available from: http://www.thl.fi/publications/monica/bmi/bmiqa
. [Last accessed on 2008 Aug 15].
Gill T, Taylor AW, Pengelly A. A population-based survey of factors relating to the prevalence of falls in older people. Gerontology 2005;51:340-5.
Joshi K, Kumar R, Avasthi A. Morbidity profile and its relationship with disability and psychological distress among elderly people in Northern India. Int J Epidemiol 2003;32:978-87.
Berg WP, Alessio HM, Mills EM, Tong C. Circumstances and consequences of falls in independent community-dwelling older adults. Age Ageing 1997;26:261-8.
Krishnaswamy B, Shanthi GS. Risk factors for falls in elderly. J Indian Acad Geriatr 2005;1:57-60.
Gillespie LD, Gillespie WJ, Robertson MC. Interventions for preventing falls in elderly people. Cochrane Database Syst Rev 2003;4:CD000340. Available from: http: www.ncbi.nlm.nih.gov/pubmed/
. [Last accessed on 2009 Oct 25].
Carlos A, Reyes OS, Kyriakos S. Falls among elderly persons in Latin America and the Caribbean and among elderly Mexican-Americans. Pan Am J Public Health 2005;17:5-6.
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:1701-7.
Ebrahim S, Patel N, Coats M, Greig C, Gilley J, Bangham C, et al.
Prevalence and severity of morbidity among Gujarati Asian elders: A controlled comparison. Fam Pract 1991;8:57-62.
Rebecca Q, Robert G, Mitchell P. Visual impairment and fall in older adults: The blue mountains eye study. J Am Geriatr Soc 1998;46:58-64.
Suraj K, Awasthi GV. Relationship between fear of falling, balance impairment and functional mobility in community dwelling elderly. Ind J Phys Med Rehabil 2008;9:48-52.
Blake AJ, Morgan K, Bendall MJ, Dallosso H, Ebrahim SB, Arie TH, et al.
Falls by elderly people at home: Prevalence and associated factors. Age Ageing 1988;17:365-72.
Laurence ZR. Clinical risk assessment, interventions and services of falls in older people: Epidemiology, risk factors and strategies for prevention. Age Ageing 2006; Available from:
Aruna. Anti-Depressants Could Increase Risk of Fall Among Elderly. Senior Health News, Archives of Internal Medicine 2009. Available from: . [Last accessed on 2010 Feb 17].
Chu LW, Chi I, Chiu AY. Incidence and predictors of falls in the chinese elderly. Ann Acad Med Singapore 2005;34:60-72.
Graafmans WC, Ooms ME, Hofstee MA, Bezemer PD, Bouter LM, Lips P. Falls in the elderly: A prospective study of risk factors and risk profiles. Am J Epidemiol 1996;143:1129-36.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]