versión impresa ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.2 São Paulo abr. 2012
Assessing the risk of falls for the elderly in Basic Health Units*
Evaluación del riesgo de caídas en ancianos atendidos en Centros Básicos de Salud
Tatyana Ataíde Melo de PinhoI; Antonia Oliveira SilvaII; Luiz Fernando Rangel TuraIII; Maria Adelaide Silva P. MoreiraIV; Sandra Nagaumi GurgelV; Adriana de Azevedo Freitas SmithVI; Valeria Peixoto BezerraVII
IPhysical Therapist. Master by the Nursing Graduate Program, Universidade Federal da Paraíba. Member of the Grupo Internacional de Estudos e Pesquisa em Envelhecimento e Representações Sociais (International Group for Studies and Research on Aging and Social Representations). João Pessoa, PB, Brazil. email@example.com
IIPh.D., Professor of the Nursing Graduate Program, Universidade Federal da Paraíba. Head of the Grupo Internacional de Estudos e Pesquisa em Envelhecimento e Representações Sociais. Paraíba, PB, Brazil. firstname.lastname@example.org
IIIPh.D., Professor, Universidade Federal do Rio de Janeiro. Member of the Grupo Internacional de Estudos e Pesquisa em Envelhecimento e Representações Sociais. Rio de Janeiro, RJ, Brazil. email@example.com
IVPhysical Therapist. Professor, Universidade Estadual do Sudoeste da Bahia. Member of the Grupo Internacional de Estudos e Pesquisa em Envelhecimento e Representações Sociais, Universidade Federal da Paraíba. Jequié, BA, Brazil. firstname.lastname@example.org
VPhysical Therapist. Member of the Grupo Internacional de Estudos e Pesquisa em Envelhecimento e Representações Sociais, Universidade Federal da Paraíba. João Pessoa, PB, Brazil. email@example.com
VIPhysical Therapist. Master student of the Nursing Graduate Program, Universidade Federal da Paraíba. Member of the Grupo Internacional de Estudos e Pesquisa em Envelhecimento e Representações Sociais. João Pessoa, PB, Brazil. firstname.lastname@example.org
VIIPh.D. Professor, Universidade Federal da Paraíba. Member of the Grupo Internacional de Estudos e Pesquisa em Envelhecimento e Representações Sociais. João Pessoa, PB, Brazil. email@example.com
The world population is aging rapidly, which poses a greater challenge for the institutions involved which, in turn, require new public health policies that include the prevention of falls. The objective of this study was to assess the risk of falls in the elderly. This epidemiological, cross-sectional study was performed at a family health unit, using a quantitative approach. The sample consisted of 150 elderly individuals evaluated from January to April 2009. Data were collected using the Fall Risk Score, which was analyzed using SPSS 17.0. Of all seniors evaluated, 58.8% did not suffer falls. However, 63 seniors did suffer falls, 71.4% of this total experienced 1 to 2 falls, and the main intrinsic cause they reported was dizziness/vertigo, whereas the extrinsic cause was wet or slippery floors. Therefore, it is concluded that it is important to assess the risk of falls among the elderly so that preventive measures can be taken, with a view to maximizing their quality of life.
Descriptors: Aged; Aging; Accidental falls; Geriatric nursing
La población mundial envejece abruptamente, lo que representa un gran desafío para los órganos competentes, necesitándose nuevas políticas sanitarias públicas, incluso en la prevención de caídas. Se objetivó evaluar el riesgo de caídas en ancianos. Estudio epidemiológico transversal con abordaje cuantitativo, realizado en unidad de salud de la familia. La muestra se compuso de 150 ancianos evaluados entre enero y abril de 2009. Para recolección de datos se utilizó el Fall Risk Score, que fue analizado mediante SPSS 17,0. De los ancianos evaluados, 58,8% no sufrieron caídas, resultando que, de los que sí las sufrieron (63 ancianos), 71,4% experimentaron de 1 a 2 caídas, siendo la principal causa intrínseca el mareo/vértigo, mientras que la extrínseca fueron pisos patinosos o mojados. Por lo tanto, resulta altamente relevante evaluar el riesgo de caídas en ancianos, para generar medidas preventivas, apuntando a maximizar la calidad de vida.
Descriptores: Anciano; Envejecimiento; Accidentes por caídas; Enfermería geriátrica
Studying the problem of falls affecting elderly individuals is a relevant and challenging theme, contributing to the promotion of the well-being of this specific population in Brazil, as well as in most developed countries, because aging is a collective concern. One of the main challenges in elderly health care is to help them rediscover the possibility of living a quality life with autonomy and independence. These possibilities increase as society recognizes the potential and value of these individuals.
Globally, the 21st century is being marked by significant changes in socioeconomic and health conditions, and, consequently, in the demographic structure. The world population is experiencing a transition process that has repercussions on society as well as on the healthcare system, particularly in developing countries, which are often unprepared to deal with the aging of their population.
By 2025, Brazil will be ranked as the sixth highest country in terms of numbers of elderly individuals, which represents about 32 million people, accounting for a 15-fold increase in this specific population, while the general population is expected to increase only five-fold in the same period of time. The state of Paraíba ranks as third in elderly population in Brazil, and as first in the Northeast region. In João Pessoa, the elderly account for 7.36% of the population, or 40,446 people(1).
The changes due to the process of aging, evidenced by a reduced muscular strength, range of motion, speed of muscular contraction, diminished sight and hearing, and by posture alterations affect one's functional mobility and causes impaired balance, all of which can be related to the musculoskeletal, neuromuscular, and sensorial systems. These alterations can pose problems for the elderly, such as an increased fall risk and a reduction in their functional independence level, thus reducing their quality of life(2). Therefore, the first step is to maintain the elderly's functional independence in order to have a positive effect on their quality of life(3).
Studies show that dependence for performing activities of daily living tends to increase from about 5% in the 60's age group to about 50% in the 90's age group. Currently, falls are considered to be a public health problem, considering the high incidence, mortality, morbidity and the social and economic costs they incur. Falls occur frequently in aged individuals. They can be caused by intrinsic as well as extrinsic factors, and are one of the main causes of injury, incapacity and death in this specific population. The prevention of falls is a great challenge for the individuals, their families and health care professionals(4).
Falling is a common event and is feared by most aged individuals due to the disastrous consequences associated with falls. Falls are defined as an unintentional event that results in a change in the individual's initial position to a lower level. Events associated with loss of consciousness, acute cerebrovascular lesions (stroke), accidents occurring during the process of providing care, vigorous recreational activity or violence are often excluded from the definition of falls in the elderly(5).
Most fractures result from falls at home, which occur during common daily activities such as ascending and descending stairs, going to the bathroom or working in the kitchen. The North American health system spends about 10 billion dollars every year on patients who have sustained hip fractures(6).
In Western countries, about 30% of the elderly who are 65 years of age or older fall at least once a year, and about half of them fall two or more times. This frequency is less in Eastern countries, where approximately 15% of the elderly fall once per year and only 7.2% have recurrent falls. This event is the sixth cause of death among people greater than 65 years of age, and the non-fatal results include physical injuries, the fear of falling again, functional incapacity and institutionalization. In Brazil, a São Paulo study found a 32.7% falls rate in the elderly and a 13.9% rate for recurrent falls(7).
Some authors(6-7) state there is a higher incidence of falls among women aged 75 years or younger and that, after this age, the risk of falling is similar in both genders. This fact remains unclear in the literature, and the suggested causes of falls are women's greater physical fragility compared to men, as well as a higher prevalence of chronic diseases and greater exposure to domestic activities, thus increasing the possibility of falls.
According to the Ministry of Health, in February 2000 the hospital mortality rate due to falls was 2.6%. Studies show there is an increase of about 50% in the mortality of elderly individuals who have a second fall within one year from the first(8).
Some authors (9-10) state that half the elderly who suffer a hip fracture due to falls become incapacitated, and 25% of them die in less than six months. This shows the negative impact that this problem has on the survival and quality of life of this population. It is necessary to identify the risks involved in falls so that preventive measures can be quickly established with a view to correcting the factors that can be changed, and thus reduce the occurrence of falls and the subsequent limitations (11).
The main intrinsic factors include the physical and mental changes associated with aging, a reduced functional capacity, the occurrence of chronic diseases, changes in balance, osteoarticular diseases, inactivity, changes in sight and hearing and vertigo. Another big problem is associated with the loss of muscular strength, considering that sarcopenia and muscular weakening are universal characteristics of aging. Studies (12-14) show that muscular weakening is referred to as one of the main causes of functional incapacity in this community, predisposing the elderly to falls and functional limitations. The most common extrinsic factors are those related to the environment, such as stairs, steps, bad lighting, irregular surfaces, rugs, slippery floors, inappropriate footwear and bathrooms without adaptations.
In this sense, the objectives of the present study were to evaluate the fall risk of the elderly cared for at Viver Bem Family Health Unit, and to perform a systemized survey of the causal factors in the management of the elderly.
This epidemiological, cross-sectional study was performed within the area covered by the Viver Bem Family Health Unit, located in João Pessoa/Paraíba-Brazil. This unit was chosen because it is located in an area of very irregular surface, with many slopes, crooked floors, no sidewalks, some unpaved streets with no pavement, open sewers, poor public lighting and no public transportation. These factors can all contribute to increasing the risk of falls among the elderly.
The present study population was estimated considering the number of families living in the referred area. We performed a survey on the Primary Care Information System to identify the population. We found that the unit followed 3,028 families, or approximately 11,125 people, and estimated that approximately 1,093 would be seniors, considering the prevalence of people aged 60 years or older, thus reaching a percentage of 9.8%. Considering this population, 150 senior participants would be necessary to guarantee a 95% reliability in estimating the 50% prevalence of falls, with an error of 7.5%.
The inclusion criteria were: having the physical and mental capability of participating in an interview. The data collection period was from January to April 2009.
The fall risk was evaluated using Downtown's Fall Risk Score. The Fall Risk Score has been validated for the Portuguese language and its sensitivity and specificity has been estimated(8). The study data were stored using Microsoft Excel 2003 and analyzed using the SPSS 17.0 statistical package.
The project was approved by the Research Ethics Committee of the Health Sciences Center, Universidade Federal da Paraíba (protocol 0597), and all participants provided written consent.
In the present study, the age of the elderly subjects ranged between 60 and 96 years, with a mean age of 71 years and standard deviation of 9.8 years, observing that females account for 70.7% of the sample. Of all subjects, 68.2% of the men and 53.8% of the women reported never having experienced a fall. Among the elderly participants, the prevalent number of falls was one to two times, accounting for 30% (Table 1).
Most falls (90.5%) occurred from the participant's own height. The most frequent locations where the falls occurred were: street/avenue (25.4%); patio/backyard (22.0%); bathroom (16.9%) and entrance hall (13.6%).
The total number of seniors who experienced falls (63 individuals) stated they had not consumed any alcoholic beverages before the fall, but 15.9% had taken medications.
Regarding the factors that contributed to the falls, extrinsic factors were more frequent than intrinsic factors. The most common extrinsic factors were: wet or slippery floors (42.6%); floors that were uneven or had holes (35.2%); high steps and/or uneven tiles (16.7%) and stairways without a handrail (5.6%). The most frequent intrinsic factors were: dizziness/vertigo (61.1%); loss of balance (47.2%); muscular weakness (36.1%) and difficulty in walking (16.1%).
To evaluate the quality of the Fall Risk Score, a ROC curve (Figure 1) was used, and its area under the curve estimates 63.1% accuracy. The best cut-off score was three points with 79.4% sensitivity and 63.2% specificity, and the accuracy in the study was 70%. Patients were considered to be at a high risk for falls if their score was >= three.
It is observed that, as age advances, the fall risk increases (Table 2), in which logistic regression was used to evaluate the importance of the variables: gender, age group, who you live with, and fall risk.
The mean relative risk or prevalence rate (RR) and odds ratio (OR) were considered significant for p-value< 0.20, and the results were: 0.104; 0.672; 0.037 and 0.033, respectively. Age group was the only variable that was not significant, with a p-value = 0.672.
It is observed in Table 3 that being male increases the prevalence of falls (68.8%), while the prevalence for individuals 85 years of age of older is 33.8% higher than those in the age group of 60 to 64 years. Living alone also increases the fall risk (75.6%). Furthermore, having a fall risk increases the prevalence of falls (64.8%).
In Table 4 the predictors gender, who you live with and fall risk were evaluated for the occurrence of falls. The fall risk was the only variable that presented an association with the occurrence of falls over the last 12 months, showing statistical significance (p = 0.047 < 0.05). The prevalence of high fall risk was two-fold higher than that of low risk, i.e., OR = 2.18 and CI95% (1.01 4.72). Therefore, the logistic regression confirms the effectiveness of the scales used in this study to evaluate the risk of falls.
Regarding the other predictors, despite their showing statistical significance when evaluated alone, none of them were statistically significant when logistic regression was used.
The predominance of females over males in the present study, accounting for 70.7% of the sample, is confirmed by some studies(15-16) that point to a process of feminization of aging, which demonstrates that the female population increases faster than the male population, most likely due to the higher mortality rate among men and the higher life expectancy among women. One study(19) analyzed the changes in the life conditions of Brazilian elderly women, according to the Demographic Census of the year 2000, and reported that 55% of the Brazilian population older than 60 years consists of women, and when considering individuals older than 80 years, the rate increases to 60.1%.
Considering all of the present study participants, the prevalent number of falls was one to two times, accounting for 30% (Table 1). Most falls (90.5%) occurred from the participant's own height. Among the seniors who fell, 71.4% fell once or twice over the last 12 months, and most fell from their own height. These data are ratified by a study performed with 515 seniors from Ribeirão Preto, a city in the state of São Paulo(8), which found that the prevalence of falls was 24.1%, and that 72.6% of those fell only once, and usually from their own height. Another study(17), found that the prevalence of falls among the elderly was 34.8%, and 55% of those who fell over the last 12 months reported having fallen only once.
The most frequent settings where the falls occurred were similar to the findings of other studies(6,11), which found that falls usually took place near or within the seniors' homes, in their backyard, bedroom, bathroom and kitchen, thus confirming previous findings(8).
Studies regarding domestic accidents among the elderly aged 70 years or more, performed with 425 seniors, found that 110 of the participants had suffered some kind of accident. Of that total, 50.5% reported falls. The locations with the highest number of accidents were: outside the home (i.e., yard), followed by the kitchen (17%) and the bedroom (15%). Seniors who had more than five risk situations in the domestic environment and who also used some kind of support for walking (i.e., walker or cane) experienced at least one fall (18).
Elderly individuals who are healthy tend to fall during the performance of instrumental activities outside the home, while frail seniors tend to fall at home while performing common activities that do not require too much balance.
A study(15) performed with 50 seniors of both genders in Ribeirão Preto, who had been cared for in two units of a public hospital found that a high number of the participants had fallen at home (66%), and that most falls occurred due to an inappropriate physical environment (54%), which is similar to the present study findings.
In the present study, 74.6% of the falls occurred in the individual's home, and approximately 36% were due to problems related to the environment, which demonstrates the importance of adapting the house to prevent falls. A similar finding was obtained, but with variation of the places according to gender and age(19).
In this context, specific intervention programs must be implemented with the objective to mitigate risk factors related to functional incapacity and, consequently, reduce the risk of falls(3).
Some studies show an association between the occurrence of falls and the use of multiple medications(8,20). In the present study, the seniors reported they took many medications before the fall, and it was not observed that gender is a determinant of that use (Table 1), which differs from the reported studies in which over half the participants used medications. The use of four or more drugs (polypharmacy) can increase the risk of falls in the elderly. This can occur due to the association between drugs (drug interactions) or to the fact that polypharmacy may be related to functional debilitation and a poor health condition. The relationship between drug use and falls can be related to the use of inappropriate doses, adverse effects or drug interactions. Therefore, it is important that health professionals make a careful evaluation regarding the need for prescribed drugs and make appropriate dose adjustments, thus reducing the risk of falls(20).
Regarding the causes of the falls, extrinsic factors were more prevalent than intrinsic factors. These data confirm a study(8) that showed that extrinsic factors prevailed in falls among the elderly.
There is no single cause for falls. What exists is a combination of intrinsic and extrinsic factors, and one important causal factor for falls is inadequacies in the environment. Furthermore, minimizing domestic hazards, combined with controlling the intrinsic factors of the elderly, could reduce fall risks.
A large number of seniors fell at home (66%), mostly because of an inappropriate physical environment (54%)(12). These data could be explained by the time that the elderly spend at home. This occurs because, despite their familiarity with the environment, they often encounter insecure situations, like steps, rugs, or wet floors. Because their alertness is reduced due to their self-confidence regarding the environment they live in (and possibly due to medications they take), as is their attention because they are performing common everyday activities, accidents that could be avoided become the cause of reduced mobility or functional capacity.
The data presented in Table 4 contradict those of the referenced literature, as they stress that women have a 1.71 times greater fall risk than men. Women are more exposed to outdoor activities, use a number of drugs including psychotropic medications, and have a reduced grip strength(22).
The present study sought to evaluate the risk of falls of elderly people cared for at the Viver Bem health unit in João Pessoa - Paraíba, Brazil, who experienced falls over the last 12 months, based on the validation of the content and by determining the accuracy indicators of the Fall Risk Score, estimating the proportion of elderly individuals that are at a high risk for falls.
It was verified that most elderly participants did not fall; those who did fall, fell from their own height. The falls were mostly caused by extrinsic factors. It was verified that the incidence of falls increases with age.
The importance of evaluating the risk for falls is essential to implementing preventive measures. However, it is necessary to build the awareness of the population so that this common event is not only addressed after it happens, but before-- we must work together to implement preventive actions, thus providing a better quality of life for the elderly and reducing the expenses associated with treatment due to falls.
1. World Health Organization (WHO). Global Forum for Health Research: The Report on Health Research. Genebra, 2000 [citado em 2008 mai 2005] [ Links ].
2. Pickles B. Fisioterapia na terceira Idade. São Paulo: Reichmann; 2000. [ Links ]
3. Ferreira OGL, Maciel SC, Silva AO, Santos WS, Moreira MASP. O envelhecimento ativo sob o olhar de idosos funcionalmente independentes. Rev Esc Enferm USP. 2010;44(4):1065-9. [ Links ]
4. Carter ND, Kannus P, Khan KM. Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. Sports Med. 2001;31(6):427-38. [ Links ]
5. Ganança FF, Gazzola, JM, Aratani MC, Perracini MR, Ganança MM. Circunstâncias e consequências de quedas em idosos com vestibulopatia crônica. Rev Bras Otorrinolaringol. 2006;72(3):388-93. [ Links ]
6. Tinetti ME. Clinical practice: preventing falls in elderly persons. N Engl J Med. 2003;348(1):42-9. [ Links ]
7. Perracini M, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública. 2002;36(6):709-16. [ Links ]
8. Schiaveto FV. Avaliação do risco de quedas em idosos na comunidade [dissertação]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 2008. [ Links ]
9. Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159-68, 2173-4. [ Links ]
10. Kelly KD, Pickett W, Yiannakoulias N, Rowe BH, Schopflocher DP, Svenson L, et al Medication use and falls in community-dwelling older persons. Age Ageing. 2003;32(5)503-9. [ Links ]
11. Vassalo M, Stockdale R, Sharma JC, Briggs R, Allen S. A comparative study of the use of four falls risk assessment tools on acute medical wards. J Am Geriatr Soc. 2005;53(6):1034-8. [ Links ]
12. Fabrício SCC. Quedas com Idosos Atendidos em um Hospital Governamental do Interior Paulista: causas e consequências [dissertação]. São Paulo: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto; 2002. [ Links ]
13. Honeycutt PH, Ramsey P. Factors contributing to falls in elderly men living in the community. Geriatric Nursing. 2002;23(5):250-7. [ Links ]
14. Messias MG, Neves RF. A influência de fatores comportamentais e ambientais domésticos nas quedas em idosos. Rev Bras Geriatr Gerontol. 2009;12(2):275- 82. [ Links ]
15. Camarano AA. Mulher idosa: suporte familiar ou agente de mudança? Estudos Avançados. 2003;17(49):35-63. [ Links ]
16. Freitas EV, Py L, Cançado AX, Gorzoni ML. Tratado de geriatria e gerontologia. Rio de Janeiro: Guanabara-Koogan; 2006. p. 900-9. [ Links ]
17. Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saúde Pública. 2007; 41(5):749-56. [ Links ]
18. Carter SE, Campbell EM, Sanson-Fisher RW, Gillesple WJ. Accidents in older people living at home: a community based study assessing prevalence, type, location and injuries. Austr NZJ. Public Health. 2000;24(6):633-6. [ Links ]
19. Coutinho ES, Bloch KV, Rodrigues LC. Characteristics and circumstances of falls leading to severe fractures in elderly people in Rio de Janeiro, Brazil. Cad Saúde Pública. 2009;25(2):455-9. [ Links ]
20. Ribeiro AP, Souza ER, Atie S, Souza AC, Schilithz AO. A influência das quedas na qualidade de vida de idosos. Ciênc Saúde Coletiva. 2008;13(4):1265-73. [ Links ]
21. Fabrício SCC, Rodrigues RAP, Costa Júnior ML. Causas e consequências de quedas em idosos atendidos em hospital público. Rev Saúde Pública. 2004;38(1): 93-9. [ Links ]
22. Dyer CA, Watkins CL, Gould C, Rowe J. Risk-factor assessment for falls: from a written checklist to the penless clinic. Age Ageing. 1998;27(5):569-72. [ Links ]
* Extracted from the dissertation "Avaliação do risco de quedas em idosos na perspectiva das representações sociais", Nursing Graduate Program, Federal University of Paraiba, 2010
* Extracted from the dissertation "Avaliação do risco de quedas em idosos na perspectiva das representações sociais", Nursing Graduate Program, Federal University of Paraiba, 2010