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Revista de Saúde Pública

Print version ISSN 0034-8910

Rev. Saúde Pública vol.47 no.2 São Paulo Apr. 2013 

Original Articles

Prevalence of falls among frail elderly adults

Jack Roberto Silva FhonI 

Idiane RossetII 

Cibele Peroni FreitasIII 

Antonia Oliveira SilvaIV 

Jair Lício Ferreira SantosV 

Rosalina Aparecida Partezani RodriguesVI 

IPrograma de Pós-Graduação em Enfermagem Fundamental. Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil

IIDepartamento de Enfermagem. Escola de Enfermagem. Universidade Federal do Rio Grande do Sul. Porto Alegre, RS, Brasil

IIIHospital das Clínicas. Faculdade de Medicina de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil

IVDepartamento de Enfermagem. Centro de Ciências da Saúde. Universidade Federal da Paraíba. João Pessoa, PB, Brasil

VDepartamento de Medicina Preventiva. Faculdade de Medicina de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil

VIDepartamento de Enfermagem Geral e Especializada. Escola de Enfermagem de Ribeirão Preto. Universidade de São Paulo. Ribeirão Preto, SP, Brasil



To measure the prevalence in frail elderly people, their consequences and associated demographic factors.


This was an epidemiological and cross-sectional study with a probabilistic sample composed of 240 elderly people (≥ 60 years) living in Ribeirão Preto, Sao Paulo state. Data were collected between November 2010 and February 2011, through a questionnaire that included socio-demographic data, fall assessment and the Edmonton Frailty Scale. Uni-variate and bivariate analyses were carried out.


The mean age was 73.5 (± 8.4), with higher ages among women; 25% of the interviewees were aged 80 or older; 11.3% presented moderate frailty and 9.6% severe frailty. The prevalence of falls in frail elderly participants corresponded to 38.6%; higher levels were found among women and younger subjects (60 to 79 years old); 26.8% were victims of 1 to 2 falls, 27.1% of which occurred in the bedroom, 84.7% fell from their own height, 55.9% lost their balance, 54.2% suffered scratches and 78% were afraid of suffering a new fall. Higher fall prevalence levels were found in frail elderly 1,973 (1,094-3,556) compared to non-frail.


We highlight the importance of addressing the health of frail elderly people, especially regarding the risk of falls, as well as of increasing investment in prevention strategies of these syndromes and in the formation of train like a virgin ed human resources to better care for this population.

Key words: Aged ; Frail Elderly ; Accidental Falls ; Risk Factors ; Socioeconomic Factors ; Cross-Sectional Studies



Analisar a prevalência de quedas em idosos frágeis, suas consequências e fatores demográficos associados.


Estudo epidemiológico e transversal com amostra probabilística de 240 idosos em Ribeirão Preto, SP. A coleta de dados foi realizada no período de novembro de 2010 a fevereiro de 2011. Foi aplicado questionário que incluiu dados sociodemográficos, avaliação de quedas e a Escala de Fragilidade de Edmonton. Foram realizadas análises uni e bivariada.


A média de idade foi de 73,5 (dp=:8,4) anos, maior no sexo feminino; 25% dos entrevistados tinham idade ≥ 80 anos; 11,3% apresentaram fragilidade moderada e 9,6% fragilidade severa. A prevalência de quedas no idoso frágil foi de 38,6%, maior no sexo feminino e nos idosos mais jovens (60 a 79 anos); 26,8% sofreram de uma a duas quedas, 27,1% ocorreram no dormitório, 84,7% caíram da própria altura, 55,9% apresentaram alteração do equilíbrio, 54,2% sofreram escoriações e 78% apresentaram medo de sofrer nova queda; houve maior chance de queda no idoso frágil 1,973 (1,094;3,556) quando comparado ao não frágil.


É necessária a abordagem da saúde do idoso frágil, principalmente quanto ao risco de quedas, maior investimento nas estratégias de prevenção dessas síndromes e na formação de recursos humanos preparados para melhor atender essa população.

Palavras-Chave: Idoso; Idoso Fragilizado; Acidentes por Quedas; Fatores de Risco; Fatores Socioeconômicos; Estudos Transversais



Analizar la prevalencia de caídas en ancianos frágiles, sus consecuencias y factores demográficos asociados.


Estudio epidemiológico y transversal con muestra probabilística de 240 ancianos en Ribeirao Preto, SP, Brasil. La colección de datos se realizó en el período de noviembre de 2010 a febrero de 2011. Se aplicó cuestionario que incluyó datos sociodemográficos, evaluación de caídas y la escala de fragilidad de Edmonton. Se realizaron análisis uni y bivariado.


El promedio de edad fue de 73,5 (ds =8,4) años, mayor en el sexo femenino; 25% de los entrevistados tenían edad ≥ 80 años; 11,3% presentaron fragilidad moderada y 9,6% fragilidad severa. La prevalencia de caídas en el anciano frágil fue de 38,6%, mayor en el sexo femenino y en ancianos más jóvenes (60 a 79 años); 26,8% sufrieron de una a dos caídas, 27,1% ocurrieron en el dormitorio, 84,7% cayeron de su propia altura, 55,9% presentaron alteración del equilibrio, 54,2% sufrieron escoriaciones y 78% presentaron miedo de sufrir nueva caída; hubo mayor chance de caída en el anciano frágil, 1,973 (1,094; 3,556) con respecto con el no frágil.


Es necesario el abordaje de la salud del anciano frágil, principalmente frente al riesgo de caídas, mayor inversión en las estrategias de prevención de tales síndromes y en la formación de recursos humanos preparados para mejor atender dicha población.


Falls are one of the main causes of elderly people needing medical care, and are a serious public health problem for this population. Falls are considered the second most common cause of death by accidental and non-accidental injury. a

Approximately 28%-35% of those aged over 65 fall each year, with this figure increasing to 32%-42% in those aged over 70 living in the community. 20, 21

In Korea, 15% of elderly people suffer falls. 17 In Brazil, according to Ministry of Health, figures, 30% of elderly people fall each year. bSilva et al 18 assessed 30 elderly people with different levels of frailty and 66.7% reported having fallen in the 12 months preceding the interview. According to these authors, falls can produce a decrease in functional capacity with regards to everyday activities; moreover, developing frailty syndrome may interfere in the elderly’s quality of life.

Frailty syndrome is a consequence of ageing and linked to the process of chronic illness. This syndrome is characterized by being multi-dimensional and means that the elderly person is more vulnerable. There is a decrease in physiological reserves and an increase in functional deficits, associated with physical changes which lead to adverse effects such as falling, increased morbidity, functional incapacity, prolonged hospital and care home stays and death. 8, 12, 22

Rolfson et al 15 consider frailty to be a multi-dimensional, heterogenic and unstable process, making it more difficult to assess. The Canadian proposal, used in this study, views frailty as including biological, psychological, social and environmental factors which interact throughout the course of the person’s life. 2

Frailty associated with falling may bring health problems, categorized as the great geriatric syndromes of the 21st century. This condition affects functional capacity and leads to a loss of independence and capacity to work. There are few national and international studies which assess frailty in old age and associated factors, above all in the community, and which support appropriate public health policies for this population.

This study aimed to analyze the prevalence of falls, their consequences and associated demographic factors in the frail elderly.


This was a cross-sectional study with 240 elderly subjects aged over 60, of both sexes, resident in the urban area of Ribeirão Preto, Southeastern Brazil between November 2010 and February 2011.

The city of Ribeirão Preto had a gross domestic product (GDP) per capitaof R$ 26,083.97 in 2009. It has 978 health care establishments, 95 belonging to the Brazilian Unified Health System (SUS). There is a population of 604,682, of which 12.7% are elderly people aged 60 and over, of whom 58.7% are women. c

A two-stage probabilistic cluster sampling process was used. In the first stage, the census tract was used as the sampling unit, according to population size, and in the second stage, the individual aged ≥ 60 was the sampling unit. Twenty census tracts were drawn (from the 650 which existed).

The sample size was calculated considering a prevalence of 50% for the estimate, with a confidence interval of 95% and accuracy or error of 6.3%. A sample of 240 individuals, 12 per census tract, was calculated. The blocks o each sector and the respective streets were drawn and covered in a clockwise direction. The residences were visited up to three times on different days and at different times if no one answered on the first attempt. If the individual refused to participate, the researcher moved on to the next residence until reaching a total of 12 elderly people fulfilling the inclusion criteria. There was a refusal rate of around 5%.

Inclusion criteria were: being aged ≥ 60 and resident in the urban area of the city. Elderly people in care homes were excluded from the sample.

The data were collected in the subjects’ homes using a structured interview carried out by previously trained undergraduate and post-graduate nursing students.

The questionnaire used included socio-demographic variables (age, sex, marital status, schooling, household income and living arrangements) and variables related to falls and frailty.

The World Health Organization ddefines falling as any involuntary event in which a person loses balance and the body falls onto the floor or any other solid surface. The questionnaire proposed by Schiaveto, ecreated based on a revision of the literature and validated by a judging body made up from experts in health care and geriatrics, was used to evaluate and characterize falls. The questionnaire is made up of 68 questions which describes falls according to the number, location, cause, type of injury and consequences, when the subject responded in the affirmative to the following question: “Have you fallen in the last six months?”

Fragile elderly people are characterized by their vulnerability and low ability to bear stress factors. This results in a greater susceptibility to illness and in the onset of syndromes which create dependence. 4

The evaluation of frailness was carried out using the Edmonton Frail Scale by Rolfson et al 15 (2006), the Portuguese version validated by Fabrício-Wehbe et al. 7 This scale has nine sections and scores vary from 0 to 17 points (0-4: not frail; 5-6: appears vulnerable; 7-8: mild frailty; 9-10: moderate frailty; 11 and over: serious frailty).

The data were dichotomized according to the frailty scores: frail and not frail with a cutoff point of ≥ 5.

In order to create the database, an Excel® spreadsheet was created in which the data was entered in duplicate. The data were imported to the SPSS statistics program, version 17, in order to carry out descriptive analysis. The quantitative variables were analyzed using measures of central tendency (mean and median) and of dispersion (sd = standard deviation), and categorical variables, in absolute and relative frequency, considering 0.05 as the level of significance. The Chi-squared test was used for bivariate analysis between the presence of falls, demographic variables and the presence of frailty.

The research project was approved by the Committee of Ethical Research of the Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo(Protocol no 1169/2010), in accordance with resolution 196/96 of the National Health Council. The subjects taking part signed consent forms.


Of the 240 interviewees, 62.9% were female; 25% were aged 80 and over; the mean age was 73.5 (sd = 8.4), the minimum age was 60 and the maximum age was 94; among the men, married men were predominant (79.8%) and among the women, widows were predominant (41.1%); 29.0% lived with a partner. The greatest proportion of individuals had between on and four years schooling (sd = 5.4) ( Table 1).

Table 1. Sociodemographic profile of the elderly living in the community according to sex, age group, marital status, schooling and living arrangements. Ribeirão Preto, Southeastern Brazil, 2011. (N = 240) 

Variable Mean Sd Median Variation observed Distribution in categories n %
Age (years) 73.5 8.4 73.0 [60;94] 60 to 64 43 17.9
65 to 69 44 18.3
70 to 74 47 19.6
75 to 79 46 19.2
80 and over 60 25.0
Sex Male 89 37.1
Female 15 62.9
Schooling (years) 5.4 5.0 4.0 [0;26] Illiterate 35 14.6
1 to 4 117 48.8
5 to 8 42 17.5
9 to 11 19 7.9
12 and over 27 11.3
Marital status Single 14 5.8
married 138 57.5
Divorced 10 4.2
Separated 2 0.8
Widowed 75 31.3
Don’t know /didn’t respond 1 0.4
Elderly subject’s monthly income 1,271.7 2,008.0 [0;20.000.0] None 27 11.3
< 510.00 6 2.5
510.00 79 32.9
> 510.00 128 53.3
Monthly household income 2,323.5 2,559.6 [0;20.000.0] None 4 1.7
< 510.00 13 5.4
510.00 13 5.4
> 510.00 210 87.5
Living arrangements Alone 33 13.8
  Living with a partner 70 29.2
Living with partner and children 37 15.4
Living with partner children and son or daughter in law 5 2.1
Living with children 14 5.8
Living with children and grandchildren 21 8.8
Living with grandchildren 3 1.3
Other 57 23.8

RP: ratio of prevalence; RCP: radio of prevalence aTest2 bYounger elderly subjects: 60 to 79 cOlder elderly subjects: 80 and over

The mean number of falls in the frail elderly subjects was 1.61 (sd = 0.5). Male and female subjects fell most often between one and two times in the last six months ( Table 2).

Table 2. Falls according to number, location, type, factors and consequences in frail and non-frail elderly subjects living in the community. Ribeirão Preto, Southeastern Brazil, 2011. (N = 153) 

Variable Frail Non frail
n % n %
Number of falls
None 94 58.8 66 41.3
1 to 2 41 68.3 19 31.7
3 to 4 13 86.7 2 13.3
5 or more 5 100.0 0 0.0
Bedroom 16 94.1 1 5.9
Bathroom 15 83.3 3 16.7
Street 15 88.2 2 11.8
Yard 13 100.0 0 0.0
Pavement 9 75.0 3 25.0
Kitchen 24 70.6 10 29.4
Other 11 68.8 5 31.2
Type of fall
From standing height 50 74.6 17 25.4
From the bed 8 88.9 1 11.1
From a chair 1 33.3 2 66.7
Other 74 66.6 37 33.3
Intrinsic factors
Loss of balance 33 82.5 7 17.5
Muscle weakness 23 95.8 1 4.2
Dizziness/vertigo 21 91.3 2 8.7
Difficulty walking 20 100.0 0 0.0
Other 12 92.3 1 7.7
Extrinsic factors
Uneven flooring 14 93.3 1 6.7
Slippery flooring 13 61.9 8 38.1
Step/change in floor level 7 77.8 2 22.2
Rugs 5 83.3 1 16.7
Objects on the floor 3 42.9 4 57.1
Other 35 77.8 10 22.2
Consequences of the falls
Hospital admission 8 80.0 2 20.0
Surgery 2 50.0 2 50.0
Stitches 7 100.0 0 0.0
Closed fracture 2 50.0 2 50.0
Scrapes 32 86.5 5 13.5
Sprain or dislocation 0 0.0 2 100.0
Impaired walking 27 81.8 6 18.2
Dependency in day-to-day actions 12 100.0 0 0.0
Fear of falling again 46 85.2 8 14.8
Other 32 91.4 3 8.6

More than half the falls (75%) occurred in the subject’s own home and 84.7% were from standing height ( Table 2).

More than half (55.9%) of the subjects reported loss of balance as an intrinsic factor causing falling. As regards extrinsic factors, 57.6% mentioned uneven and slippery surfaces as the main causes ( Table 2).

The main consequence of falling was fear of falling again; “post-fall syndrome” ( Table 2).

The rate of prevalence of falling was 33.3%, and was higher among women; 36.3% of the elderly subjects were not frail, whereas 66.7% showed some degree of frailty: 24.6% appeared vulnerable, 18.3% were had mild frailty, 11.3% moderate frailty and 9.6% serious frailty.

The rate of prevalence of falling was greater among those elderly subjects who were frail (p = 0.023) ( Table 3) and was 59% higher among those deemed frail compared with those who were not frail (rp = 1.598).

Table 3. Prevalence of falls in elderly subjects according to the situation of frailty and among frail subjects according to sex and age group. Ribeirão Preto, Southeastern Brazil, 2011. 

Variable Fall (Yes) Fall (No) RP RCP pa
n % n %
Prevalence 59 38.6 94 61.4
Frailty (n = 240)
Frail 59 38.6 94 61.4 1.598 (1.047;2.438) 1.973 (1.094;3.556) 0.023
Non frail 21 24.1 66 75.9
Frail elderly subjects (n = 153)
Male 18 30.5 38 40.4 0.647 (0.324;1.291) 0.760 (0.487;1.188) 0.215
Female 41 69.5 56 59.6
Age group
Younger elderly subjects 35 59.3 64 68.1 0.684 (0.347;1.345) 0.795 (0.533;1.186) 0.270
Older elderly subjects 24 40.7 30 31.9

Among the frail subjects, the prevalence rate of falling was 38.6%; women and the younger subjects (60 to 79 years old) showed a higher number of falls ( Table 3).


There was a predominance of falls among female subjects and those aged 80 and over; this finding is similar to those of other research carried out in Brazil Brasil 13, 18 and in other countries. 10, 22

It was observed that there was a higher proportion of widowed subjects among the females and married subjects among the males. This may be explained by shorter life expectancy in men and by inequality in social and cultural norms in Brazilian society, in which prejudices still exist, mainly when a widow wishes to marry again. The same does not occur in the case of widowers, who tend to remarry and do so to younger women. 3

The majority simply live together. Of those who lived alone, the majority were women. This may be a result of being widowed, of grown children leaving the family home. 11

The rate of prevalence of falls in the elderly population was 33.3%, similar to the rate observed by Siqueira et al 19 (34.8%) in a study carried out in seven Brazilian states with subjects aged 65 and over. Higher rates of prevalence have been found in other national studies. 7, 14

The prevalence of frailty among the elderly living in the community in the United Sates was estimated to be 6.9%, varying from 3.2% among those aged 65 to 70, to 23.1% in those aged over 90, 9 considerably different to the percentage found here (63.7%). However, that study, in contrast to this one, used phenotypic evidence to assess falls.

The rate of prevalence of falls in the frail elderly was 38.6%, a figure which is higher than those found in studies conducted in the United States (20.5% 23 and 14% 5 ).

The mean was 1.61 and the median was two falls in frail subjects, a figure higher than epidemiological data on falls which estimate 0.7 falls/person/year, with and interval of 0.2 to 1.6. 16

Around 39.1% of elderly people are frail and frailty syndrome is more closely related to females. Fried et al 9 linked frailty to different variables such as low household income, suffering from chronic illness and sarcopenia, which are more commonly observed in females. Similar data were observed in research conducted by Varela-Pinedo et al, 22 in Peru, and by Fabricio-Wehbe, fin Brazil.

Ensrud et al, 5 using the rate of the Study of Osteoporosis Fractures (SOF), identified 13% of frail elderly subjects. Woods et al 23 verified that, of those aged between 70 and 79, 61.6% are frail and, of those aged between 65 and 69, this rate is 38.4%.

The frail elderly are more likely to suffer falls. There are few published studies on this topic, as it is only recently that this area of gerontology has become a concern. Veras et al 24 report that the elderly who need more care are those who have the highest degrees of frailty, as well as having a higher probability of falling ill, being admitted to hospital and suffering falls.

Research carried out by Ensrud et al 5 and Galucci et al 10 observed that the occurrence of falls among the elderly was related, in the majority of cases, to frailty syndrome. This caused serious functional incapacity and may increase the risk of the elderly subject ending up in a care home.

Ensrud et al 5 showed that there was a strong association between frailty and the risk of suffering falls, breaking the him, decreasing functional capacity and hospital admission; they also reinforced the concept of frailty as a geriatric syndrome.

Silva et al 18 did not find any significant differences between the degree of frailty and the occurrence of falls, in contrast to the results of this study, in which those elderly subjects who suffered falls had a higher probability of being frail. Longitudinal studies may better explore the relationship between cause and effect and outcomes. Fried et al 9 reported that the elderly had a greater chance of falling.

Frailty and falling may be bi-directionally linked. Thus, just as falling may lead to the elderly person becoming frail, so frailty may lead to falling. This study, however, did not establish causality between these variables, as the data were collected in a transversal manner, i.e., the variables were measured once, simultaneously.

The location of the fall varied. Findings of studies on the topic were similar, suggesting that falls occur predominantly at home, especially in the living room, followed by the bathroom and the kitchen. Similar results were reported by Gai et al, gaccording to whom the main consequence were: serious injury, including fractures and scrapes. Shin et al 17 showed that falls cause fractures and injuries needing stitches, and these were the most serious consequences.

Nunes et al 13 stated that falling may lead to decreased functional capacity. This is related to the interaction of multi-dimensional factors which include aspects interlinked with mental and physical health in the elderly.

Woods et al 23 and Ensrud et al 5 reported that frailty is one of the causes which may lead the elderly to need care in a residential or care home.

Elderly people who fall repeatedly, and who also have a certain degree of frailty, may be considered a group at high risk of falling again, a risk which increases with age. The consequences may or may not be serious, and may generate a high cost to society (cost of hospital admission, treatment and rehabilitation), and significant costs for the family due to the need to change the physical environment, the dependence and care of the elderly by either a family member or a carer.

“Post-fall” syndrome is among the main consequences described 6 and it cited in the research by Carvalhaes et al hinvolving elderly subjects aged between 75 and 84. The authors identified that the difficulties they encountered in carrying out tasks they considered to be complex may create a higher probability of suffering fall. Elderly people with a history of falling and of co-morbidities may find the day to day activities they are able to carry out reduced, which contributes to them becoming frailer. 23 This situation may have a psycho-social impact, such as “post-fall” syndrome”, further limiting their activities.

The results of this study may lead health care professionals to reconsider the importance of these two geriatric syndromes: falling and frailty, which afflict this population, restricting their functional capacity.

One of the limitations of the cross-sectional study and that it is not able to determine frailty as one of the predictors of falling. In order to do this, follow up studies are needed to assess this syndrome.

Health care for the frail elderly, especially bearing in mind greater life expectancy and the diverse syndromes resulting from the ageing process, calls for greater investment in strategies for promoting health and preventing accidents. Among these accidents, evaluating the risk of falls, as well as training human resources to deal with this eventuality, is a fundamental strategy for the health care of this population.


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Received: June 15, 2011; Accepted: September 9, 2012

The authors declare that there are no conflicts of interests.

Correspondence:, Rosalina Aparecida Partezani Rodrigues, Escola de Enfermagem de Ribeirão Preto - USP, Av. Bandeirantes, 3900 Campus USP, 14040-902 Ribeirão Preto, SP, Brasil, E-mail:

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