Capstone Fall Prevention Program Project Literature Review

Indian Journal of Gerontology

2015, Vol. 29, No. 2, pp. 187–197

Prevalence of Falls and Fall Risk Assessment in an Urban Elderly Population of Ludhiana

Shilpa Accamma Philip, Paramita Sengupta,and Anoop Ivan Benjamin

Department of Community Medicine,

Christian Medical College, Ludhiana – 141008 (Punjab)

ABSTRACT

Falls are one of the major problems in the elderly. With the increasing elderly population in India, falls in the elderly are expected to be an increasingly significant and preventable public health problem. The present cross-sectional study was conducted amongst the elderly (>60 years old) residents of an urban field practice area of the Department of Community Medicine, Christian Medical College, Ludhiana, to assess the various risk factors associated with falls in the study population. A systematic random sample of 170 consenting elderly was studied and the respondents were visited in their homes. Socio-demographic infor- mation was obtained on a pre-tested questionnaire incorporated with the standard and validated “Falls Risk for Older People – Community setting” (FROP-COM) questionnaire. Falls Risk was assessed using FROP-COM Falls Risk Assessment Guidelines. The prevalence of falls in the studied elderly was found to be 28.2 per cent with an average of 0.2 falls per person per year. Increasing age (P = 0.002) and lower socio-economic status (P = 0.039) were observed to have a significantly higher risk of falls in the elderly. No statistically significant association was found for both the prevalence of falls as well as the falls risk score, and sex, age, educa- tional status, marital status, employment status and type of family. Several promising strategies such as exercise programmes,

environmental modifications and other educational opportunities for preventing falls and fractures can considerably decrease the risk of falls and limit impairment.

Key words: Falls, Elderly, Community-based, FROP-COM.

Falls are one of the major problems in the elderly and are considered one of the “Geriatric giants” (immobility, instability, incontinence and impaired intellect/memory) (Kumar, et al.,2013). Koski, et al., (1998) defines “fall” as a sudden, unintended loss of balance leaving the individual in contact with the floor or another surface such as a step or chair. WHO (2008) reports that about 4,24,000 fall-related deaths occurred globally in 2004 and about one fifth of them (95,000 deaths) took place in India. Falls are the second leading cause of unintentional injury mortality and they account for 11 per cent of all unintentional injury deaths worldwide. About a third of community-dwelling people >65 years fall each year, and the incidence increases with age (Gillespie, et al., 2012). Forty five percent elderly in a south (Gutta, et al., 2013) and 51.5 per cent in a north (Joshi, et al., 2003) Indian population have been reported to have a history of fall.

Risk factors strongly associated with falling in the elderly include muscle weakness, a history of falls, impairments in gait or balance, visual impairment, arthritis, depression, age >80 years, functional limitation, and use of psychotropic medications. (Rubenstein and Powers 2002). According to the National Center for Injury Prevention and Control (2008), the major underlying causes for fall-related hospital admissions are hip fractures, traumatic brain injuries and upper limb injuries. Healthcare impacts and costs of falls in older age are increasing all over the world.

Increasing awareness about fall risk factors and ways to reduce fall risk is crucial in helping older adults and their families to effectively prevent falls, emphasizing the importance of health education as an important component in fall prevention programs (WHO, 2007). People should also be made to understand that falls are preventable and need not be a part of normal ageing (Gutta, et al., 2013).

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Objectives

To assess the various risk factors associated with falls in an elderly population in Ludhiana.

Method

This Cross-sectional, descriptive study was planned by the Department of Community Medicine, Christian Medical College, Ludhiana and was conducted in the period from June 2014 to August 2014

Study Population: 361 elderly (>60 years of age) residents of Jamalpur, (field practice area of the Department of Community Medicine), which has a total population of 8300 (status as on 31.12.2013: Source: Annual Report 2013, Department of Community Medicine, Christian Medical College, and Ludhiana.). This population is covered for healthcare in a beat visit manner by two MPHWs (F) (female multipurpose health workers), along with medical interns and nursing students.

Sample: Taking 51.5 per cent as the prevalence of falls in the elderly in a North Indian population (Joshi, 2003), and using the formula n = [DEFF*Np(1-p)]/[(d2/Z21-a/2*(N-1)+p*(1-p)] (Dean, 2011), the minimum sample size required at 95 per cent confidence interval and 5 per cent absolute precision, with finite population correction for a population of 361, was 167. The sample for study was obtained by systematic random sampling technique. Family folders were screened and a line-list of all the elderly was made. By dividing the total number of elderly by the minimum sample size required, the sampling interval obtained in this study was 361/167=2.16 (say 2). A random number was chosen (using the last three digits in a 100 rupee note). The first respondent to participate in the study was selected from the line-list by this random number. The sampling interval was then used as the constant difference between subjects. Thus every alternate elderly was included in the study. Out of 180 respondents, 10 met the exclusion criteria. Hence, 170 respondents were studied.

Exclusion Criteria: Bed-ridden elderly patients, those who had suffered a paralysis, those who did not consent to participate in the study and those who could not be contacted on two consecutive visits were excluded.

Prevalence of Falls and Fall Risk Assessment in an Urban Elderly 189

Data Collection: The respondents were visited in their homes by the student investigator, assisted by the MPHWs to assist in communi- cating with the respondents in the local language (Hindi/Punjabi). After obtaining signed informed consent from the respondent, socio-demographic information was obtained on a pretested question- naire incorporated with the standardized and validated “Falls Risk for Older People-Community setting” (FROP-COM) questionnaire. The FROP-COM Falls Risk Assessment Guidelines has been developed by the National Ageing Research Institute (2010). The falls risk is graded according to the score as mild (score 0-11), moderate (score 12–18) and high (score 19–60), on a scale with a maximum score 60.

The respondents were assessed and graded for fall risk and, based on the assessment, were advised on prevention and management of falls at the household level. They were referred to the Health Centre for medical management and advice if required. The Socio-economic status was calculated and graded using modified BG Prasad’s Scale (Bhalwar, et al., 2009).

Statistical Analysis: The data was analyzed using Epi-Info version-6 software. Statistical analysis was done using simple propor- tions and percentages. Odds Ratio with 95 per cent confidence limits was calculated, and the Chi square test was applied where appropriate.

Results

Table 1 Frequency of Falls in the Elderly

No of falls after 60 years

Frequency Number of falls in the past 12 months

Frequency

0 122 (71.8) 0 144 (84.7)

1 27 (15.9) 1 19 (11.2)

2 10 (5.9) 2 5 (2.9)

3 and more 11 (6.5) 3 2 (1.2)

Table-1: Out of 170 elderly respondents, 48 (28.2%) had history of fall after age 60, 21 (12.3%) fell more than once. Hence the prevalence of falls among elderly was found to be 28.2 per cent . Out of the 170 elderly 26 (15.3%) had history of at least one fall, 19 (11.2%) fell once, 5

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(2.9%) fell twice and 2 (1.2%) fell three or more times in the past twelve months, averaging 0.2 falls per person per year.

Table 2 Association of Falls with Socio-demographic Characteristics in the Elderly

Variables Fell Did not fall

Total OR (95% CI) P-value

Sex

Female 31 (30.7) 70 (69.3) 101 (59.4) 1.35 (0.64-2.87) 0.390

Male 17 (24.6) 52 (75.4) 69 (40.6) 1 (Reference)

Age Group

61-70 years 22 (19.5) 91 (80.5) 113 (66.5) 1 (Reference) 0.002

71-80 years 21 (46.7) 24 (53.3) 45 (26.5) 3.62 (1.61-8.20)

>80 years 5 (41.7) 7 (58.3) 12 (7.0) 2.95 (0.73-11.78)

Education

Illiterate 20 (27.8) 52 (72.2) 72 (42.4) 1 (Reference) 0.994

Literate 28 (28.6) 70 (71.4) 98 (32.9)

Marital Status

Married 33 (26.6) 91 (73.4) 124 (72.9) 1 (Reference) 0.440

Single/Widowed 15 (32.6) 31 (67.4) 46 (27.1) 1.33 (0.60-2.95)

Occupation

Employed 3 (15.0) 17 (85.0) 20 (11.8) 1 (Reference) 0.162

Not gainfully employed 45 (30.0) 105 (70.0) 150 (88.2) 2.43 (0.63-11.00)

Type of Family

Joint 23 (25.8) 66 (74.2) 89 (52.4) 1 (Reference) 0.468

Nuclear 25 (30.9) 56 (69.1) 81 (47.6) 1.28 (0.62-2.64)

Socio-Economic Status

I-Upper 2 (9.1) 20 (90.9) 22 (12.9) 1 (Reference) 0.039

II-Upper Middle 22 (25.3) 65 (74.7) 87 (51.2) 3.38 (0.68-22.80)

III-Lower Middle 17 (41.5) 24 (58.5) 41 (24.1) 7.08 (1.31-50.48)

IV-Upper Lower 7 (35.0) 13 (65.0) 20(11.8) 5.38 (0.81-44.94)

Total 48 122 170

Table-2: Increasing age (P = 0.002) and lower socio-economic status (P = 0.039) were observed to have a significantly higher risk of falls in the elderly

Prevalence of Falls and Fall Risk Assessment in an Urban Elderly 191

Table 3 Falls Risk and Number of Falls After 60 Years in the Elderly

No. of Falls Mild Falls Risk Moderate/Severe Falls Risk Total

0 116 (74.4) 6 (42.9.0) 122 (71.8)

1 22 (14.1) 3 (35.7) 27 (15.9)

2 or more 18 (11.5) 3 (21.4) 21 (12.3)

Total 156 (100.0) (91.8) 14 (100.0) (8.2) 170

�2=3.42, df=2, p=0.181

Table-3: Out of all the individuals who had mild fall risk (risk score 0-11) 74.4 per cent did not fall after 60 years of age, 14.1 per cent fell once after 60 years of age, 6.4 per cent fell twice and 5.1 per cent fell 3 times or more after 60 years of age. Out of the individuals who had moderate fall risk (risk score 12-18) 60 per cent did not fall beyond 60 years of age, 30 per cent fell once and 10 per cent fell 3 times or more beyond 60 years of age. Among those who were at Severe fall risk (risk score 19-60) 50 per cent had one fall after 60 years of age and 50 per cent fell down 3 times or more. These findings are statistically signif- icant.

Discussion

Out of the 170 community dwelling elderly studied, 48 had a fall, and hence the prevalence of falls in the elderly in the present study was found to be 28.2 per cent , averaging 0.2 falls per person per year. Prospective studies have reported that 30 per cent to 60 per cent of community dwelling elderly fall each year, with approximately half of them experiencing recurrent falls. Rubenstein, et al., (2002) and Kerse et al., (2008) reported the prevalence of falls as 24.1 per cent among community dwelling elderly in Australia. A WHO report (2004) showed 28-35 per cent of people aged 65 years and above fall each year. Krishnaswamy and Usha (2005), while observing the distribution of history of falls among elderly people over 60 years found that 51.5 per cent of the subjects had fallen. Banker et al., (2011) found the frequency of falls among elders aged 60 years and above as 7.7 per cent. This low prevalence of falls among these elderly may be attributed to the fact that reduced risk of falls was due to better housing conditions, as the study was done on the inmates of old age homes.

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21 (12.4%) of the elderly in the present study gave history of recurrent falls after the age of 60 years with 2.4 per cent of them having more than 4 falls. Chu, et al., (2005) found 24.5 per cent of the ambulatory Chinese elderly had recurrent falls with 1.3 per cent of the fallers having 4 or more falls. However, prospective studies done in the developed countries have shown that approximately half of those who fall, experience recurrent falls (Joshi, et al., 2003). In a study conducted in Vellore, 45 per cent elderly were found to have fallen more than once and one third having fallen 4 or more times with 77 per cent of falls occurring between 60 and 70 years of age. (Gutta, et al., 2013)

More females (30.7%) than males (24.6%) amongst the study respondents had a fall. Dandona, et al., (2010) reported the annual incidence of non-fatal fall related injury based on a 3 month recall as 3.30 per cent for men and 9.22 per cent for women with the incidence increasing with age. Large scale robust epidemiological studies of falls related injuries have demonstrated that women have more falls injuries than men, with more attendant suffering, morbidity and mortality (Stevens, and Sogolow 2005). Another study on Saudi community dwelling older people also reported the proportion of those who fell in the previous 12 months to be 37.5 per cent for males and 62.5 per cent for females (El-Sobsky, 2011).

The present study showed a statistically significant (P=0.002) relationship between age-group and incidence of falls. The significance of falls among elderly people, is that, the number of falls increases with age but the injury rate is highest among the oldest old subjects (>80 years) subjects with the history of falling more than twice (WHO, 2007). Johnson, et al., (2006) in his study found 45 per cent of community dwelling participants suffered a fall in the previous year. Overall of those who fell, 74 per cent reported an injury. The incidence of falls (History of a single fall in the last 6 months) was found to be 14 per cent in 10 states across India (Johnson, et al., 2006).

No significant relationship was observed between educational status of the elderly respondents and falls. A study conducted among elderly in Cambridge city showed higher incidence of falls among people with higher education level, significantly high among non-manual social class (Fleming, et al., 2008). Hanlon et al., (2002)

Prevalence of Falls and Fall Risk Assessment in an Urban Elderly 193

also suggested that greater level of education is associated with higher falls risk.

The single (unmarried or widowed) as well as those staying in a nuclear family were found to have more chances of experiencing a fall, though the associations was not found to be statistically significant. Cultural practices such as family caregiving, and family values around and support for independent living of elders, for example, might impact on fall frequency, as might government legislation and policies (for example in relation to accessibility of public facilities).

In the present study, a statistically significant relationship has been found between socio-economic class and falls in the elderly, with those belonging to the lower class having more falls. West, et al., (2004) also observed a 10 per cent higher admission for falls amongst the most deprived which can be explained in terms of the possibility that a minor fall has bigger impact on an individual with multiple co-morbidities and/or poor living environment than it would on someone who has good health, social and financial resources.

The number of falls increased with increasing falls risk score, but the falls risk score was not found to be influenced by sex, age, educa- tional status, marital status, employment status, type of family and socio-economic status in the present study. Falls are not an inevitable consequence of aging, but falls do occur more often among older adults because fall risk factors increase with age and are usually associated with health and aging conditions. Usually two or more risk factors interact to cause a fall (such as poor balance and low vision, which can cause a trip and fall going up a single step). Falls can negatively affect the lives of older adults, even when they do not result in significant injuries (Schuffham, et al., 2003). Home or environ- mental risk factors play a role in about half of all falls. Understanding these risk factors is a very important step which helps in reducing older adult falls.

The FROP-COM Falls Risk Assessment Guidelines developed by the National Ageing Research Institute (2010) recommend the following actions for the elderly according to their falls risk: mild falls risk: implement actions for identified individual risk factors and recommend health promotion behavior to minimize future ongoing risk (e.g., increased physical activity, good nutrition); moderate falls

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risk: implement actions for identified individual falls risk factors; high falls risk: implement actions for identified individual risk factors and implement additional actions for high falls risk (e.g., refer to a specialist Falls Clinic).

Conclusions

The prevalence of falls in the elderly in the present study was found to be 28.2 per cent, with the older elderly having higher preva- lence of falls as well as recurrent falls. The prevalence of falls in the elderly was significantly higher in those belonging to the lower socio-economic classes as compared to those of the upper class. The prevalence of falls was not observed to be influenced by sex, educa- tional status, marital status, employment status and type of family. The number of falls increased with increasing falls risk score, but the falls risk score was not found to be influenced by sex, age, educational status, marital status, employment status, type of family and socio-economic status.

Recommendations

Several promising strategies such as exercise programmes, environmental modifications and other educational opportunities for preventing falls and fractures can considerably decrease the risk of further falls and limit impairment. People should also be made to understand that falls are preventable and need not be a part of normal ageing. Health professionals should be more careful to identify the causes of falls, inform the family about the cause and then prescribe effective interventions. Follow up of these individuals should be done to monitor compliance. Community-based fall registries and surveil- lance systems can be set up.

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