Assessment of risk of falls in elderly living at home

ABSTRACT Objective: to assess the risk of falls in elderly, by comparing the sociodemographic and cognitive factors, history of falls and self-reported comorbidities. Method: cross-sectional and quantitative study with 240 elderly. Data were collected based on the social profile, through the instrument of risk of falls and assessment of falls, by univariate analysis, bivariate and multiple logistic regression. The Statistical Package for the Social Sciences (SPSS) version 19 was used for statistical analysis. Results: there was a significant association of the risk of falls, as measured by the Fall Risk Score, with sex (<0.001), age (0.054), cognitive status (<0.001) and history of falls (<0.001). All variables were statistically significant and contributed to the occurrence of falls. In logistic regression, the variables that showed association with risk of falls were: fall, with whom they live, hypertension and visual impairment. Conclusion: female gender, older elderly (over 80 years old), with low cognitive status and occurrence of previous falls in the last six months are factors that increase the prevalence of falls. In logistic regression, the variables that were associated with risk of falls were: fall, with whom they live, visual impairment and rheumatologic diseases.


Introduction
The increasing demographic aging observed in different countries is a complex phenomenon of global relevance that reflects in various sectors of society, including healthcare.
Among the impacts and damages to the elderly's health, it was observed that the prevalence of chronic non-communicable diseases and external causes (such as falls and accidents), feature a significant magnitude and are major causes of morbidity and mortality (1) . In this context, it is important to note that the falls reach up to 32% of elderly people aged 65 to 74 years and 51% of elderly people over 85 years (2) . In a recent study, which covered a sample of 6,616 elderly residing in urban areas in 100 municipalities of 23 Brazilian states, it was observed that the prevalence of falls among them was 27.6%, in the 12 months prior to the interview (3) .
In the daily lives of the elderly, many factors can facilitate or promote the occurrence of falls. These factors are divided into two major groups: intrinsic, which are inherent to the person and related to the biological and psychosocial changes associated with aging; and extrinsic, which results from the interaction of the elderly with the environment, for example, quality of flooring and lighting in their residences, access to public transportation and recreational areas, among others. However, for being multifactorial events, these factors are related to the ability to maintain the skills needed to perform basic and instrumental activities of daily living, perceived as a requirement to live with independence and autonomy, so it is often difficult to report them separately (1,(4)(5)(6) .
Thus, the high prevalence of falls can have serious consequences on the quality of life of the elderly, which can result in prolonged hospitalization, institutionalization, restriction of activities and mobility, changes in balance and postural control, social isolation, anxiety and depression (7) . In this way, it is important to know and identify the potentiating and protective factors, in order to adopt preventive measures for these events of falls. Therefore, changes resulting from the population aging have caused a new vision of care, which requires prioritization of the functional independence and autonomy. In this sense, the occurrence of falls interferes with biopsychosocial and economic aspects of the elderly and society, so it is important to prioritize the knowledge of risk factors and the impact of the occurrence of falls, with the aim of establishing preventive measures.
Given the above, the objective of this study was to evaluate the risk of falls among the elderly living at home, residing in the municipality of João Pessoa, Paraíba, Brazil.

Methods
Cross-sectional study with a quantitative approach, Data collection was carried out in three stages.
In the first stage, it was collected information on the identification, social profile and self-reported health problems, including the following variables: age (by age group); sex (male and female); ethnicity (white, brown and black); marital status (single, married, divorced, widowed); with whom the elderly live (with or without a partner, family or non-family); education (illiterate, low educational level -one to four years-, middle -five to eight years-or high -nine or more years); monthly Smith AA, Silva AO, Rodrigues RAP, Moreira MASP, Nogueira JA, Tura LFR. income (no income, a minimum wage, two minimum wages, three to five minimum wages or more than six minimum wage) and morbidities self-reported by the elderly people with their respective medications prescribed by the doctor. For grading the cognitive status of the elderly, the second stage of data collection, the Mini Mental State Examination (MMSE) (8) was used for the assessment of the cognitive status. pace, assessing the way to walk. This scale ranges from zero to eleven points and scores ≥ three points suggest that the elderly has a high risk of falls (10) . Participants were informed about the research development and those who agreed to participate have signed the Informed Consent Form, in two copies, one copy was given to the elderly.

Results
The results show that most interviewees are female (69.6%). The prevalent age group was from 70 to 74 years, which corresponds to 24 Among the variables highlighted in the study, marital status and monthly income were statistically significant.
To assess the risk of falls, such risk was associated with the following variables: gender, age group, cognitive status and occurrence of falls. The relative risk or risk ratio (RR) and prevalence odds ratio or odds ratio (OR) were statistically significant at a p-value <0.05.
All variables were statistically significant, as shown in Table 1.   Other comorbidities were asked during this study; however, it is not emphasized those little reported.    The remaining predictors were statistically significant when evaluated separately, however, they were not statistically significant in logistic regression.

Discussion
Falls are frequent events, however, for being multifactorial, it is difficult to establish a single risk factor for their occurrence. Thus, the risk of falls was associated with demographic and cognitive factors, occurrence of falls and self-reported comorbidities.
In a study on the assessment of the prevalence and factors associated with falls in 2,096 individuals aged over 65 years in various states of Nigeria, it was observed sociodemographic characteristics, visual impairment, chronic physical conditions and insomnia. It was found that the major risk factors for falls were female gender, aged above 80 years, 7-12 years of study and low or medium socioeconomic status (11) .
Other studies have found greater propensity of falls among females compared to males and this difference is explained in terms of the physiological characteristics and bone and muscle structure, hormonal changes associated with menopause, as well as performing multiple tasks (9,(12)(13) .  environmental risks and an erroneous assessment of their own skills (13) . Therefore, a study carried out in the United States (15) with 175 elderly over 65 years old, with high risk of falls and living in a community, assessed whether cognitive deficits increased the risk of falls. The authors concluded that there is an association between cognitive decline and increased risk of these events.
In this context, it is worth noting that the cognitive assessment through the MMSE was based on the same score used by Bertolucci et al (8) , whose study carried out in 1994, has established the following cutoffs: 13 points for illiterate elderly people, 18 points for the elderly with increased reaction time to dangerous situations (16) .
Other factors that may contribute to the falls are the changes in the Central Nervous System (CNS) and the musculoskeletal system disorders that accompany the aging process. These physiological events lead to a reduction in the density of the long bones and spine, with alterations in bone mineral balance and even more severe reductions, which may result in osteopenic and osteoporotic tissues (12) also observed in the present study.
Studies reported in the literature and conducted with individuals in the community, have suggested that elderly patients who experienced previous falls are at increased risk of recurrence of these episodes, especially the elderly aged over 80 years, living alone, with complaints of dizziness, depressive symptoms and arthritis (17)(18) .
Multiple comorbidities may also favor the occurrence of falls as reported in the literature, since the prevalence of chronic diseases increases the possibilities of this event and drug interactions due to the use of multiple drugs (18)(19) . Drug interactions (3 or more per day) or increased doses of psychoactive medications are associated with an increased number of hospitalizations due to falls.
Other factors that may contribute to the risk of falls are depression and change in cognitive status because they reduce the willingness to carry out tasks, which causes muscle weakness and culminates with difficulty of walking (20)(21) . Another author points out that patients with depression need to use medications such as the benzodiazepines, which may also contribute to the occurrence of falls in elderly (9) .
In a study on the factors associated with chronic diseases, with 385 elderly patients attended in the Family Health Strategy in Teófilo Otoni/Minas Gerais, found a significant prevalence of SAH (69.9%).
In addition, 20% of the elderly have reported musculoskeletal problems (22) . Another study evaluating visual impairment, chronic physical conditions and insomnia in 2,096 individuals aged over 65 years in various states of Nigeria, found that the prevalence of falls increased in the following conditions: arthritis, pain in the thoracic and cervical spine and other pains, visual impairment and insomnia (11) . These results are relevant and corroborate the present study.
Articular diseases are common in the elderly and may contribute to immobility, resulting in pain and postural imbalance, favoring the occurrence of falls (19) .
In this study, logistic regression through saturated regression model showed that the variables associated with the risk of falls were: fall, with whom they live, SAH and visual impairment. These findings were corroborated by a study conducted in China, which found a prevalence of 18% of falls and these were associated with the age range between 60 and 70 years old, female gender, decreased physical activity, visual impairment, living alone and with health problems, such as diabetes mellitus (23) .
Although this study has emphasized the sociodemographic characteristics and intrinsic factors of falls (inherent to the individual), the factors related to the environment should also be prioritized, since the occurrence of these events due to environmental inadequacies, can be minimized with the adoption of a small number of measures (24) .

Conclusion
The results of this study lead to the following