Fall and its association with the frailty syndrome in the elderly: systematic review with meta-analysis

Fhon, Jack Roberto Silva; Rodrigues, Rosalina Aparecida Partezani; Neira, Wilmer Fuentes; Huayta, Violeta Magdalena Rojas; Robazzi, Maria Lucia do Carmo Cruz

doi:10.1590/S0080-623420160000700018

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REVIEW • Rev. esc. enferm. USP 50 (06) • Nov-Dec 2016 • https://doi.org/10.1590/S0080-623420160000700018 copy

Fall and its association with the frailty syndrome in the elderly: systematic review with meta-analysis

Caída y su asociación con el síndrome de la fragilidad en el adulto mayor: revisión sistemática con metaanálisis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

OBJECTIVE

To analyze the prevalence of falls and frailty syndrome and the association between these two syndromes in the elderly population.

METHOD

Systematic review, without restriction of dates, in English, Portuguese and Spanish languages, in the databases PubMed, CINAHL, LILACS and in the SciElo virtual library. The association between both variables was extracted from the studies (Odds Ratio and 95% Confidence Intervals).

RESULTS

The review included 19 studies published between 2001 and 2015. The prevalence of falls in the frail elderly population was between 6.7% and 44%; in the pre-frail, between 10.0% and 52.0%, and in the non-frail, between 7.6% and 90.4%. The association between both variables presented a value of OR 1.80 (95% CI 1.51-2.13).

CONCLUSION

There is evidence that falls are associated to the frailty in the elderly. Other factors may influence this association, such as age, sex, data collection instrument of the studies, place where they live and the process of senescence.

Descriptors
Aged; Accidental Falls; Frail Elderly; Geriatric Nursing; Review

Author, year	Population	Age, sex	Method	Instruments	Prevalence
NORTH AMERICA
Puts et al. (2013)²⁰20 Puts MTE, Monette J, Girre V, Wolfson C, Monette M, Batist G, et al. The fall rate of older community-dwelling cancer patients. Support Care Cancer. 2013; 21(3):775-83.	112 hospitalized elderly	≥ 65 years Women 69,6%	Longitudinal Prospective	Self-report fall Markers proposed by Edmonton Frail Scale	Fall: 19% Frailty: 2.3
Samper-Ternent et al. (2012)²⁴24 Samper-Ternent R, Karmarkar A, Graham J, Reistetter T, Ottenbacher K. Frailty as a predictor of falls in older Mexican Americans. J Aging Health. 2012;24(4): 641-53.	847 community- dwelling elderly	≥ 65 years Women 64,7%	Longitudinal retrospective	Self-report fall CHS Index	Fall: 46.2%; Frailty: 12.3%
León et al. (2012)²⁵25 León GED, Tamez PHE, Gutiérrez HH, Cedillo RJA, Torres G. Fragilidad y su asociación con mortalidad, hospitalizaciones y dependencia funcional en mexicanos de 60 años o más. Med Clin. 2012;138(11):468-74.	4.068 community-dwelling elderly	≥ 60 years Men 54,7%	Longitudinal Prospective	Self-report fall FRAIL index	Fall: 794 participants during follow-up; Frailty: 33.0%
Xue et al. (2011)³¹31 Xue QL, Walston JD, Fried LP, Beaner BA. Prediction of risk of falling, physical disability and frailty by rate of decline in grip strength: the women’s health and aging study. Arch Intern Med. 2011;171(12):1119-21.	352 community-dwelling elderly women	≥ 65 years Research with Women	Longitudinal Prospective	Self-report of fall Gripping force	Fall: 20.0%; Frailty: 3.0%
Ensrud et al. (2009)³⁶36 Ensrud KE, Ewing SK, Cawthon PM, Fink HA, Taylor BC, Cauley JA, et al. A comparison of frailty indexes for the prediction of falls, disability, fractures and mortality in older men. J Am Geriatr Soc. 2009;57(3):492-8.	3.132 community-dwelling elderly	≥ 65 years Research with Men	Longitudinal Prospective	Self-report of fall SOF Index CHS Index	Fall: 14.0%; Frailty: CHS Index 14.0% frailty and SOF Index 13.0% frailty.
Ensrud et al. (2008)³⁷37 Ensrud KE, Ewing SK, Taylor BC, Fink HA, Cawthon PM, Stone KL, et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures and death in older women. Arch Intern Med. 2008;168(4):382-9.	6.701 community-dwelling elderly women	≥ 65 years Research with Women	Longitudinal Prospective	Self-report fall SOF Index CHS Index	Fall: 11.0%; Frailty: SOF Index 17.0% frailty e CHS Index 16.0% frailty
Ensrud et al, (2007)³³33 Ensrud KE, Ewing SK, Taylor BC, Fink HA, Stone KL, Cauley JA, et al. Frailty and risk of falls, fracture and mortality in older women: the study of osteoporotic fractures. J Gerontol A Biol Sci Med Sci. 2007;62(7):744-51.	6.724 community-dwelling elderly women	≥ 65 years Research with Women	Longitudinal Prospective	Self-report fall CHS Index	Fall: 11.0%; Frailty: CHS Index 16.3% frailty
Nelson et al. (2007)³⁴34 Nelson JM, Dufraux K, Cook PF. The relationship between glycemic control and falls in older adults. J Am Geriatr Soc. 2007;55(12):2041-4.	111 community-dwelling elderly	≥ 75 years Men 50,5%	Longitudinal Retrospective	Self-report fall Vulnerable Elders Survey - VES 13 for frailty	Fall: 50.0%; VES13: 51.4% frailty
Fried et al. (2001)⁷7 Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.	5.317 community-dwelling elderly	≥ 65 years of both genders most were female	Longitudinal Prospective	Self-report fall CHS Index	Frailty CHS Index 6.92%
EUROPE
Joosten et al. (2014)²⁸28 Joosten E, Demuynck M, Detroyer E, Milisen K. Prevalence of frailty and its ability to predict in hospital delirium, falls and 6-month mortality in hospitalized older patients. BMC Geriatr. 2014;14:1. doi: 10.1186/1471-2318-14-1. https://doi.org/10.1186/1471-2318-14-1....	220 hospitalized elderly	≥ 70 years Women 57,3%	Longitudinal Prospective	Report of fall in hospital by nurse CHS Index SOF Index	Fall: 8.2%; Frailty: CHS Index 40.0% frailty e SOF Index 32.5% frailty
Crehan et al. (2013)²¹21 Crehan F, O´Shea D, Ryan JM, Horgan F. A profile of elderly fallers referred for physiotherapy in the emergency department of a Dublin teaching hospital. Ir Med J. 2013;106(6):173-6.	40 hospitalized elderly	≥ 65 years Women 77,5%	Longitudinal Prospective	Self-report fall CHS Index	Fall: 62.5%; Frailty: 75.0%
De Vries et al. (2013)²²22 de Vries OJ, Peeters GMEE, Lips P, Deeg JH. Does frailty predict increased risk of falls and fratures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.	2.310 community-dwelling elderly	≥ 65 Women 51,8%	Longitudinal Prospective	Self-report fall LASA Frailty Instrument	Fall: 32,2%; Frailty: 20,7%
Sheehan et al. (2013)²³23 Sheehan KJ, O’Connell MDL, Cunningham C, Crosby L, Kenny RA. The relationship between increased body mass index and frailty on falls in community dwelling older adults. BMC Geriatr. 2013;13:132. doi: 10.1186/1471-2318-13-132. https://doi.org/10.1186/1471-2318-13-132...	546 clinic elderly	≥ 60 years Women 68,6%	Longitudinal Prospective	Self-report fall CHS Index	Fall: 346 events in 148 participants; Frailty: 8.1%
Bilotta et al. (2012)²⁶26 Bilotta C, Nicolini P, Casè A, Pina G, Rossi S, Vergani C. Frailty syndrome diagnosed according to the study of osteoporotic fractures (SOF) criteria and adverse health outcomes among community-dwelling older outpatients in Italy. A one-year prospective cohort study. Arch Gerontol Geriatr. 2012;54(2):23-8.	265 geriatrics elderly clinic	≥ 65 years Women 71,0%	Longitudinal Prospective	Self-report fall SOF Index	Fall: 226 in one year follow-up; Frailty: 37,0%
Forti et al. (2012)²⁷27 Forti P, Rietti E, Pisacane N, Olivelli V, Maltoni B, Ravaglia G. A comparison of frailty indexes for prediction of adverse health outcomes in an elderly cohort. Arch Gerontol Geriatr. 2012;54(1):16-20.	1.007 community-dwelling elderly	≥ 65 years Women 55,4%	Longitudinal Prospective	Self-report of fall CSBA Index SOF Index	Fall: 1.462 during follow-up; Frailty: CSBA Index 37.6% frail e SOF Index 11.6% frail
Bravell et al. (2011)³²32 Bravell ME, Westerlind B, Midlov P, Ostgren CJ, Borgquist L, Lannering C, et al. How to assess frailty and the need for care? Report from the study of health and drugs in the elderly (SHADES) in community dwelling in Sweden. Arch Gerontol Geriatr. 2011;53(1):40-5.	315 community-dwelling elderly	≥ 65 years Women 71,4%	Longitudinal Prospective	The Downton fall risk index (DFRI) SNAC instrument measure frailty	Fall: 93.0% risk of Fall; Frailty: mean 58.8%.
ASIA / AUSTRALIA
Woo et al. (2015)³⁵35 Woo J, Yu R, MPhil MW, Yeung F, Wong M, Lum C. Frailty screening in the community using the FRAIL scale. J Am Med Dir Assoc. 2015;16(5):412-9.	815 community-dwelling elderly	≥ 65 years Women 85,4%	Longitudinal retrospective	Self-report of fall FRAIL index	Fall: 56 events during follow-up; Frailty 12.5%
Fairhall et al. (2014)²⁹29 Fairhall N, Sherrington C, Lord SR, Kurrle SE, Langron C, Lockwood K, et al. Effect of a multifactorial, interdisciplinary intervention on risk factors for falls and fall rate in frail older people: a randomized controlled trial. Age Ageing. 2014;43(5):616-22.	241 rehabilitation services elderly	≥ 70 years Control group: 78% Women Intervention group: 77% Women	Randomized controlled trial	Self-report of fall CHS Index	Fall: 361 events in follow-up. In both the control and intervention groups, the elderly were frail.
Bennet et al. (2014)³⁰30 Bennet A, Gnjidic D, Gillett M, Carroll P, Matthews S, Johnell K, et al. Prevalence and impact of fall-risk-increasing drugs, polypharmacy and drugs-drug interactions in robust versus frail hospitalized falls patients: a prospective cohort study. Drugs Aging. 2014;31(3):225-32.	204 hospitalized elderly	≥ 60 years Women 65,0%	Longitudinal retrospective	Self-report of fall Edmonton Frail Scale	Fall: 22.0%; Frailty: 50.5%

		Fall
Authors	Instrument	Frail		Pre-frail		Non-frail
		Nº	%	Nº	%	Nº	%
Woo et al. (2015)³⁵35 Woo J, Yu R, MPhil MW, Yeung F, Wong M, Lum C. Frailty screening in the community using the FRAIL scale. J Am Med Dir Assoc. 2015;16(5):412-9.	FRAIL Scale	41	19.6	16	35.6	-	-
Bennet et al. (2014)³⁰30 Bennet A, Gnjidic D, Gillett M, Carroll P, Matthews S, Johnell K, et al. Prevalence and impact of fall-risk-increasing drugs, polypharmacy and drugs-drug interactions in robust versus frail hospitalized falls patients: a prospective cohort study. Drugs Aging. 2014;31(3):225-32.	EFS	32	31.0	-	-	12	12.0
Joosten et al. (2014)²⁸28 Joosten E, Demuynck M, Detroyer E, Milisen K. Prevalence of frailty and its ability to predict in hospital delirium, falls and 6-month mortality in hospitalized older patients. BMC Geriatr. 2014;14:1. doi: 10.1186/1471-2318-14-1. https://doi.org/10.1186/1471-2318-14-1....	CHS Index	8	9.1	-	-	10	7.6
	SOF Index	5	7.6	-	-	12	11.3
Sheehan et al. (2013)²³23 Sheehan KJ, O’Connell MDL, Cunningham C, Crosby L, Kenny RA. The relationship between increased body mass index and frailty on falls in community dwelling older adults. BMC Geriatr. 2013;13:132. doi: 10.1186/1471-2318-13-132. https://doi.org/10.1186/1471-2318-13-132...	CHS Index	5	6.7	35	43.3	40	50.0
Forti et al. (2012)²⁷27 Forti P, Rietti E, Pisacane N, Olivelli V, Maltoni B, Ravaglia G. A comparison of frailty indexes for prediction of adverse health outcomes in an elderly cohort. Arch Gerontol Geriatr. 2012;54(1):16-20.	CSBA Index	287	38.7	-	-	454	61.3
	SOF Index	69	9.6	-	-	652	90.4
León et al. (2012)²⁵25 León GED, Tamez PHE, Gutiérrez HH, Cedillo RJA, Torres G. Fragilidad y su asociación con mortalidad, hospitalizaciones y dependencia funcional en mexicanos de 60 años o más. Med Clin. 2012;138(11):468-74.	FRAIL Index	236	32.3	361	29.0	197	26.5
Samper-Ternent et al. (2012)²⁴24 Samper-Ternent R, Karmarkar A, Graham J, Reistetter T, Ottenbacher K. Frailty as a predictor of falls in older Mexican Americans. J Aging Health. 2012;24(4): 641-53.	CHS Index	57	14.5	204	52.0	131	33.4
Bilotta et al. (2012)²⁶26 Bilotta C, Nicolini P, Casè A, Pina G, Rossi S, Vergani C. Frailty syndrome diagnosed according to the study of osteoporotic fractures (SOF) criteria and adverse health outcomes among community-dwelling older outpatients in Italy. A one-year prospective cohort study. Arch Gerontol Geriatr. 2012;54(2):23-8.	SOF Index	57	44.0	36	29.0	26	18.0
Ensrud et al. (2009)³⁶36 Ensrud KE, Ewing SK, Cawthon PM, Fink HA, Taylor BC, Cauley JA, et al. A comparison of frailty indexes for the prediction of falls, disability, fractures and mortality in older men. J Am Geriatr Soc. 2009;57(3):492-8.	CHS Index	122	28.0	233	14.0	86	9.0
	SOF Index	111	27.0	197	15.0	133	10.0
Ensrud et al. (2008)³⁷37 Ensrud KE, Ewing SK, Taylor BC, Fink HA, Cawthon PM, Stone KL, et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures and death in older women. Arch Intern Med. 2008;168(4):382-9.	CHS Index	211	20.0	323	10.0	200	8.0
	SOF Index	215	19.0	268	11.0	251	8.0
Ensrud et al. (2007)³³33 Ensrud KE, Ewing SK, Taylor BC, Fink HA, Stone KL, Cauley JA, et al. Frailty and risk of falls, fracture and mortality in older women: the study of osteoporotic fractures. J Gerontol A Biol Sci Med Sci. 2007;62(7):744-51.	CHS Index	450	41.0	949	30.0	641	26.0
Nelson et al. (2007)³⁴34 Nelson JM, Dufraux K, Cook PF. The relationship between glycemic control and falls in older adults. J Am Geriatr Soc. 2007;55(12):2041-4.	VES - 13	20	35.1	-	-	7	13.0
Fried et al. (2001)⁷7 Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.	CHS Index	143	41.0	818	33.0	667	27.0

Authors	Instrument	Type of analysis	p-value
Crehan et al. (2013)²¹21 Crehan F, O´Shea D, Ryan JM, Horgan F. A profile of elderly fallers referred for physiotherapy in the emergency department of a Dublin teaching hospital. Ir Med J. 2013;106(6):173-6.	Markers of frailty	t test	0.809
Bravell et al. (2011)³²32 Bravell ME, Westerlind B, Midlov P, Ostgren CJ, Borgquist L, Lannering C, et al. How to assess frailty and the need for care? Report from the study of health and drugs in the elderly (SHADES) in community dwelling in Sweden. Arch Gerontol Geriatr. 2011;53(1):40-5.	CNS questions	Regression analysis	0.12^* * p < 0.01
Nelson et al. (2007)³⁴34 Nelson JM, Dufraux K, Cook PF. The relationship between glycemic control and falls in older adults. J Am Geriatr Soc. 2007;55(12):2041-4.	VES-13	Correlation coeficient	0.001

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E-mail: reeusp@usp.br

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[1] Corresponding author: Jack Roberto Silva Fhon. Rua Machado de Assis 971, Bairro Vila Tibério, CEP 14050-490 - Ribeirão Preto, SP, Brazil. beto_fhon@hotmail.com