© Borgis - New Medicine 4/2003, s. 130-132
Marek Zak1, Magdalena Namysl2
Assessment of potential risk factors for falls in the frail elderly versus individual mobility considerations
1 Faculty of Clinical Rehabilitation Academy of Physical Education, Cracow, Poland
Head: prof. Krzysztof Spodaryk, MD, PhD
2 Nursing home, Sportowe 9, Cracow, Poland
Background: The frequency of falls in the elderly breaks down as 33% amongst outpatients, 20% in hospitalised patients, and 45% in nursing home residents. Both the frail elderly and their relatively fit peers are equally exposed to a potential risk of fall.
Materials and methods: The study group comprised 78 nursing home residents (aged 65-94). A timed „Up-and-Go” test was applied in order to assess individual mobility. All assessments were pursued in compliance with the Pilet and Swine method. Group I comprised subjects who scored 12 seconds or more (50 subjects – 41 women, 9 men; mean age 81 years), whereas Group II comprised those who scored 8 seconds or less (28 subjects – 17 women, 11 men; mean age 77 years).
Results: There were no statistically significant differences in the risk of fall assessment. In Group I (where the subjects scored worse in the timed „Up-and-Go” test), a high risk of fall was reported in 84% of subjects, whereas in Group II (better test scores) it was about 71%. The subjects proved most at risk when attempting to change posture, or when assessed for their individual sense of balance.
Conclusions: We cannot conclude that better locomotive capabilities in the elderly reduce the individual risk of an accidental fall. Paradoxically, the highest risk correlated with executing the apparently simple tasks of daily life.
The frequency of falls in the elderly breaks down as 33% amongst outpatients, 20% in hospitalised patients, and 45% in nursing home residents (1, 2, 3). Data regarding the actual frequency of falls often misrepresent the facts, as most falls do not usually result in severe complications. However enough facilitate development of a post-fall syndrome and – in due course – a perceptible deterioration of patient´s overall mobility, effectively making them even more prone to the falls (3, 4, 5).
Around 10-15% of falls result in serious life-threatening trauma. Immobilisation of a patient in the wake of a serious fall brings about a threat of venous thrombosis, pulmonary embolism, dehydration, muscular contracture, and bed sores (4, 5). Consequently, more frequent and prolonged hospitalisation is required, a patient becoming steadily more care-dependent. By far the most frequent consequences of falls are bone fractures (50%). Those within the upper femoral bone area being the most serious (6). Mortality from post-fall complications tends to increase significantly with every decade of age.
As may be seen from observations, the vast majority of falls are sustained during simple activities of daily living, such as getting out of bed, change of posture (e.g. bending down to pick something up), or just walking, whereas only 5% are reported to occur when potentially dangerous tasks are being attempted, e.g. climbing a ladder. Minimising the risk of accidental falls and any attendant complications invariably depends upon gaining a good insight into the accompanying circumstances, with a view to establishing the nature of potential risks to which patients are exposed, and ultimately developing a series of effective preventive measures.
The authors therefore aimed to gain a detailed insight into the circumstances of such events, to identify and categorise the principal risk factors. Given the fact that both the frail elderly, usually suffering from multiple ailments, and their relatively fit peers are equally exposed to a potential risk of fall, the authors set out to assess the risk factors, considerating individual mobility with the following questions in the study:
Can it be unequivocally established that nursing home residents with relatively unimpaired mobility are exposed to a lesser risk of sustaining an accidental fall?
During which activities of daily living do the nursing home residents run the highest risk of an accidental fall?
MATERIALS AND METHODS
The study group comprised 78 nursing home residents (aged 65-94) from two nursing homes in Krakow. Each of them was reported to have sustained at least one fall prior to the commencement of the study.
The largest part of the study group (41%) was subjects whose principal ailments were related to circulatory disorders, impaired mobility in 31%, whereas disorders of the nervous system accounted for 28% of the entire group.
The following inclusion criteria were applied in admitting the patients into the study:
1. Patient´s informed written consent for participation in the study
2. At least one fall sustained within a 6-month period immediately preceding the commencement of the study
3. Overall fitness allowing for the execution of test procedures
4. Mental condition allowing written consent to participation in the study
The inclusion criteria required that each patient should have sustained at least one accidental fall in the period preceding the actual study (pursued in 2000-2001). Out of 160 residents, 78 were eventually enrolled as fully compliant.
At first, a timed „Up-and-Go” test was applied in order to assess individual mobility amongst the subjects (7). Subsequently, the subjects were split into two groups depending on results. Group I was subjects who scored 12 seconds or more (50 subjects – 41 women, 9 men; mean age 81 years), whereas Group II was those who scored 8 seconds or less (28 subjects – 17 women, 11 men; mean age 77 years). The „Up-and-Go” test was carried out on each subject three times and the best score was considered for allocation to a group.
The study focused principally upon assessing the risk of accidental falls and individual functional abilities, pursued in full compliance with the method put forward by Pilet and Swine (8).
The study consisted of two parts. The first focused on assessing the risk of fall during routine daily activities, and the second concerned ability to cope effectively after sustaining a fall.
In assessment of individual risk of fall, there were no statistically significant differences between the groups. In Group I (where the subjects scored worse in the timed „Up-and-Go” test), a high risk of fall was reported in 84% of subjects, whereas in Group II (better test scores) it remained around the 71% mark (Graph 1).
However, there were substantial differences in the circumstances and sites of falls. In Group II the subjects turned out to be at the highest risk when attempting to climb up or down stairs, (Graphs 2, 3).
In Group I the highest risk was associated with a change of posture, e.g. climbing out of bed, or when assessed for individual sense of balance (Graphs 4, 5).
The parameters were assessed with the 0-2 scale, and a non-parametric Wilcoxon test was used to compare the paired variables, to determine the significance of any differences. All data were subsequently processed by the Statgraphic for Windows v. 3.1. software package.
Numerous reports on the subject, as well as research observations, give ample grounds for believing that the highest risk of an accidental fall is run by the nursing home residents (3, 9). It should be noted that about 40% of the elderly eventually end up as nursing home residents as a result of having become victims of such events, which usually leave them permanently incapacitated or disabled. The authors therefore set out to gain a detailed insight into the accompanying circumstances of such events, with a view to identifying and categorising the principal risk factors.
Graph 1. Results of the test assessing risk of fall in Group I and Group II.
In Group I high risk 84%, medium risk 12%, minimum risk 4%
In Group II high risk 71%, medium risk 15%, minimum risk 14%
P-Value = 0.008
Graph 2. Results of the test assessing high risk of fall (Climbing up the stairs).
in Group I (32%) high risk was observed
in Group II (68%) high risk was observed
P-Value = 0.008
Graph 3. Results of the test assessing high risk of fall (Coming down the stairs).
in Group I (32%) high risk was observed
in Group II (68%) high risk was observed
P-Value = 0.008
Graph 4. Results of the test assessing high risk of fall (Regaining a fully upright position from a prone position).
in Group I (78%) high risk was observed
in Group II (22%) high risk was observed
P-Value = 0.007
Graph 5. Results of the test assessing high risk of fall, (Lifting an object off the floor).
in Group I (88%) high risk was observed
in Group II (15%) high risk was observed
P-Value = 0.03
As may be readily inferred from many reports, the highest risk is usually associated with executing the simple tasks of daily living, e.g. change of posture from sitting down at a table to a fully upright position. However, it is far from clear which factors proved instrumental in causing adverse events, as the available records did not cover pharmacotherapy, nor indeed the majority of commonly recognised risk factors (9, 10, 11).
Lord et al. (6) and Tinetti et al. (12), who studied similar – sized populations, subscribe to the view that the factors most likely contribute to such events are associated with age-related degenerative changes in the locomotive system, impaired eyesight, and dependence upon specific medication. The same also seems to hold true for the relatively fit elderly, who – although well capable of carrying out their routine daily tasks unassisted – are by no means less prone to falls.
Other reports by Tinetti et al. (9) reveal that almost 50% of falls take place during activities requiring only a slight displacement of one´s centre of gravity, e.g. changing from a sitting position to a fully upright position, irrespective of whether it be the frail and incapacitated elderly, or their relatively fit and self-reliant peers. This is very much in keeping with the findings of Studenski et al. (13), who allocated to a high risk group all subjects with geriatric gait and/or experiencing difficulties with about-turns, also clearly reflected in the results of this study.
It is estimated that ca. 80% of the elderly experience a need for urination during the night, which in turn exposes them to a substantially increased risk of an accidental fall on the way to a toilet (4).
Studies comprehensively addressing the issue of accidental falls in the elderly and the attendant medical cost to the public health system are still very scarce in Poland, although the problem definitely merits further studies and an in-depth investigation, especially in consideration of the on-going restructuring within the country´s medical service sector (14).
We cannot conclude that better locomotive capabilities in the elderly reduce the individual risk of an accidental fall. Paradoxically, the highest risk correlated with carrying out the apparently simple tasks of daily life.
1. Rigler S.K.: Preventing falls in older adults. Hospit. Pract.1999; 34: 8-12. 2. Simpson J.M.: Eldery people at risk of falling: the role of muscle weakness. Physiother. 1993; 79:12-18. 3. Thornby M.A.: Balance and falls in the frail older person: a review of the literature. Top. Ger. Rehbil.1995; 11:35-43. 4. Galus K., Kocemba J. (Red.): MSD Podręcznik Geriatrii. Wydawnictwo Urban & Partner, Wrocław 1999; p. 70-84. 5. Żak M.: Ocena ryzyka upadków u osób starszych i możliwości prewencji. Gerontol. Pol. 2000; 8:18-21. 6. Lord S.R. et al.: Physiological factors associated with injurious falls in older people living in the comunnity. Gerontol. 1992; 38:338-46. 7. Mathias S. et al.: Balance in the elderly patient: The „Get-up and Go” test. Arch. Phys. Med. Rehabil. 1986; 67:387-9. 8. Pilet J.M., Swine Ch.: Kinesitherapie geriatrique et prevention des risques de chute. Temp. Med.1998; 6:11-6. 9. Tinetti M.E. et al.: A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N. Engl. J. Med. 1994; 331:821-7. 10. Campbell A.J. et al.: Fall prevention over two years: a randomised controlled trial in women 80 years and older. Age Ageing 1999; 28:513-18. 11. Campbell A.J. et al.: Randomized controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. Br. Med. J. 1997; 315:1065-9. 12. Tinetti M.E. et al.: Falls risk index for elderly patients based on number of chronic disabilites. Am. J. Med. 1986; 80: 429-34. 13. Studenski S. et al.: Predicting falls: the role of mobility and nonphysical factors. J. Am. Geriatr. Soc. 1994; 42:297-302. 14. Żak M.: Upadki osób starszych – analiza zagrożeń na podstawie obserwacji prowadzonych w latach 1994-2001. Przegl. Lek. 2002; 59:304-7.