Abstract
Background:
The identification of the occurrence of falls is an important step for screening and for rehabilitation processes for the elderly. The methods of monitoring these events are susceptible to recording biases, and the choice of the most accurate method remains challenging.
Objectives:
(i) To investigate the agreement between retrospective self-reporting and prospective monitoring of methods of recording falls, and (ii) to compare the retrospective self-reporting of falls and the prospective monitoring of falls and recurrent falls over a 12-month period among older women at high risk of falls and fractures.
Method:
A total of 118 community-dwelling older women with low bone density were recruited. The incidence of falls was monitored prospectively in 116 older women (2 losses) via monthly phone calls over the course of a year. At the end of this monitoring period, the older women were asked about their recall of falls in the same 12-month period. The agreement between the two methods was analyzed, and the sensitivity and specificity of self-reported previous falls in relation to the prospective monitoring were calculated.
Results:
There was moderate agreement between the prospective monitoring and the retrospective self-reporting of falls in classifying fallers (Kappa=0.595) and recurrent fallers (Kappa=0.589). The limits of agreement were 0.35±1.66 falls. The self-reporting of prior falls had a 67.2% sensitivity and a 94.2% specificity in classifying fallers among older women and a 50% sensitivity and a 98.9% specificity in classifying recurrent fallers.
Conclusion:
Self-reporting of falls over a 12-month period underestimated 32.8% of falls and 50% of recurrent falls. The findings recommend caution if one is considering replacing monthly monitoring with annual retrospective questioning.
aged; bone density; accidental falls; rehabilitation; mental recall
Introduction
Falls are events with a high prevalence among the elderly population, even among
those who are active and healthy, and constitute one of the major preventable
geriatric syndromes11 Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall?
JAMA. 2007;297(1):77-86. http://dx.doi.org/10.1001/jama.297.1.77.
PMid:17200478
http://dx.doi.org/10.1001/jama.297.1.77...
. Among the
community-dwelling elderly, approximately 30% suffer a fall each year, and half
experience recurrent falls22 Cruz DT, Ribeiro LC, Vieira MT, Teixeira MT, Bastos RR, Leite IC.
Prevalência de quedas e fatores associados em idosos. Rev Saude Publica.
2012;46(1):138-46. http://dx.doi.org/10.1590/S0034-89102011005000087.
PMid:22183513
http://dx.doi.org/10.1590/S0034-89102011...
. Elderly women
with osteoporosis and having a high risk of fractures exhibit an even higher
frequency of falls (51.1%)33 Silva RB, Costa-Paiva L, Oshima MM, Morais SS, Pinto-Neto AM.
Frequência de quedas e associação com parâmetros estabilométricos de equilíbrio
em mulheres na pós-menopausa com e sem osteoporose. Rev Bras Ginecol Obstet.
2009;31(10):496-502. http://dx.doi.org/10.1590/S0100-72032009001000005.
PMid:19942997
http://dx.doi.org/10.1590/S0100-72032009...
. A significant
portion of these falls results in injuries (36%)44 Swanenburg J, Bruin ED, Uebelhart D, Mulder T. Falls prediction in
elderly people: a 1-year prospective study. Gait Posture. 2010;31(3):317-21.
http://dx.doi.org/10.1016/j.gaitpost.2009.11.013. PMid:20047833
http://dx.doi.org/10.1016/j.gaitpost.200...
, fractures (3.4% to 19%)22 Cruz DT, Ribeiro LC, Vieira MT, Teixeira MT, Bastos RR, Leite IC.
Prevalência de quedas e fatores associados em idosos. Rev Saude Publica.
2012;46(1):138-46. http://dx.doi.org/10.1590/S0034-89102011005000087.
PMid:22183513
http://dx.doi.org/10.1590/S0034-89102011...
,
44 Swanenburg J, Bruin ED, Uebelhart D, Mulder T. Falls prediction in
elderly people: a 1-year prospective study. Gait Posture. 2010;31(3):317-21.
http://dx.doi.org/10.1016/j.gaitpost.2009.11.013. PMid:20047833
http://dx.doi.org/10.1016/j.gaitpost.200...
,
55 Sai AJ, Gallagher JC, Smith LM, Logsdon S. Fall predictors in the
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Musculoskelet Neuronal Interact. 2010;10(2):142-50.
PMid:20516631, and the need for medical assistance (8 to
19%)44 Swanenburg J, Bruin ED, Uebelhart D, Mulder T. Falls prediction in
elderly people: a 1-year prospective study. Gait Posture. 2010;31(3):317-21.
http://dx.doi.org/10.1016/j.gaitpost.2009.11.013. PMid:20047833
http://dx.doi.org/10.1016/j.gaitpost.200...
,
55 Sai AJ, Gallagher JC, Smith LM, Logsdon S. Fall predictors in the
community dwelling elderly: a cross sectional and prospective cohort study. J
Musculoskelet Neuronal Interact. 2010;10(2):142-50.
PMid:20516631 and affects lifestyle choices, creating a
high socio-economic burden66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
. Additionally,
experiencing one or more falls in the course of one year significantly increases the
chances of the occurrence of new episodes in the following year among the
community-dwelling elderly44 Swanenburg J, Bruin ED, Uebelhart D, Mulder T. Falls prediction in
elderly people: a 1-year prospective study. Gait Posture. 2010;31(3):317-21.
http://dx.doi.org/10.1016/j.gaitpost.2009.11.013. PMid:20047833
http://dx.doi.org/10.1016/j.gaitpost.200...
,
55 Sai AJ, Gallagher JC, Smith LM, Logsdon S. Fall predictors in the
community dwelling elderly: a cross sectional and prospective cohort study. J
Musculoskelet Neuronal Interact. 2010;10(2):142-50.
PMid:20516631 and postmenopausal women11 Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall?
JAMA. 2007;297(1):77-86. http://dx.doi.org/10.1001/jama.297.1.77.
PMid:17200478
http://dx.doi.org/10.1001/jama.297.1.77...
,
77 Ersoy Y, MacWalter RS, Durmus B, Altay ZE, Baysal O. Predictive
effects of different clinical balance measures and the fear of falling on falls
in postmenopausal women aged 50 years and over. Gerontology. 2009;55(6):660-5.
http://dx.doi.org/10.1159/000235652. PMid:19690394
http://dx.doi.org/10.1159/000235652...
.
Thus, the surveillance of falls among the elderly represents a priority health
issue66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
, which is why questioning the
occurrence of previous falls has been used in clinical/scientific decision
making88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
9 Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and
Go Test for screening risk of falls among community-dwelling elderly. Rev Bras
Fisioter. 2012;16(5):381-8. http://dx.doi.org/10.1590/S1413-35552012005000041.
PMid:22858735
http://dx.doi.org/10.1590/S1413-35552012...
-
1010 Perracini MR, Teixeira LF, Ramos JL, Pires RS, Najas MS.
Fall-related factors among less and more active older outpatients. Rev Bras
Fisioter. 2012;16(2):166-72. http://dx.doi.org/10.1590/S1413-35552012005000009.
PMid:22378477
http://dx.doi.org/10.1590/S1413-35552012...
. Several methods have been suggested for
monitoring the occurrence of falls among the community-dwelling elderly, including
questions asking individuals to recall these events at several intervals by means of
telephone, face-to-face or mail interviews, information obtained from medical
records, and/or prospective records using falls calendars or diaries88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
,
99 Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and
Go Test for screening risk of falls among community-dwelling elderly. Rev Bras
Fisioter. 2012;16(5):381-8. http://dx.doi.org/10.1590/S1413-35552012005000041.
PMid:22858735
http://dx.doi.org/10.1590/S1413-35552012...
,
1111 Hauer K, Lamb SE, Jorstad EC, Todd C, Becker C, PROFANE-Group.
Systematic review of definitions and methods of measuring falls in randomised
controlled fall prevention trials. Age Ageing. 2006;35(1):5-10.
http://dx.doi.org/10.1093/ageing/afi218. PMid:16364930
http://dx.doi.org/10.1093/ageing/afi218...
12 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
-
1313 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort
studies of community-dwelling older people: effect of the recall interval. J Am
Geriatr Soc. 2005;53(12):2190-4.
http://dx.doi.org/10.1111/j.1532-5415.2005.00509.x.
PMid:16398908
http://dx.doi.org/10.1111/j.1532-5415.20...
. However, the elderly have difficulties in
accurately recalling the occurrence of falls in previous periods1313 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort
studies of community-dwelling older people: effect of the recall interval. J Am
Geriatr Soc. 2005;53(12):2190-4.
http://dx.doi.org/10.1111/j.1532-5415.2005.00509.x.
PMid:16398908
http://dx.doi.org/10.1111/j.1532-5415.20...
,
1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294., especially non-injurious falls66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
,
1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294., and, in many cases, they need help
completing the information in the calendar1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
.
Thus, a large part of the available data is susceptible to reporting or recording
errors, which under- or overestimates the occurrence of falls66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
,
88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
,
1111 Hauer K, Lamb SE, Jorstad EC, Todd C, Becker C, PROFANE-Group.
Systematic review of definitions and methods of measuring falls in randomised
controlled fall prevention trials. Age Ageing. 2006;35(1):5-10.
http://dx.doi.org/10.1093/ageing/afi218. PMid:16364930
http://dx.doi.org/10.1093/ageing/afi218...
,
1515 Sanders KM, Hayles AL, Kotowicz MA, Nicholson GC. Monitoring falls
in cohort studies of community-dwelling older women. J Am Geriatr Soc.
2009;57(4):733-4. http://dx.doi.org/10.1111/j.1532-5415.2009.02205.x.
PMid:19392967
http://dx.doi.org/10.1111/j.1532-5415.20...
and renders the assessment of these events
in the elderly challenging1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
.
Therefore, the importance of investigating the sensitivity and specificity of
retrospective self-reporting of falls1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
with
respect to different periods88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
,
1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
has been stressed, aiming to assess the
accuracy of this method. In this context, the objectives of the present study were
to (i) investigate the agreement between retrospective self-reporting and
prospective monitoring of falls and (ii) compare retrospective self-reporting and
prospective monitoring of falls and recurrent falls over 12 months among
community-dwelling elderly women at high risk of falls and fractures and within
subgroups of elderly women with and without post-fall injuries.
Method
Study design and ethical issues
This work is an observational and longitudinal study that has been approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais(UFMG), Belo Horizonte, MG, Brazil (CAAE 0370.0.203.013-11). All participants signed the informed consent form. This survey is part of a main study with the objective to evaluate risk factors of falls among elderly women with low bone mineral density (BMD).
Sample
Community-dwelling elderly women presenting with low bone mass density (BMD)
(T-Score < -1.0 DP) in the L1-L4 spinal segments, the
femoral neck, or both in a dual-energy X-ray absorptiometry (DEXA)
assessment1717 Pinto-Neto AM, Soares A, Urbanetz AA, Souza ACA, Ferrari AEM, Amaral
B, et al. Consenso Brasileiro de Osteoporose 2002. Rev Bras Reumatol.
2002;42(6):343-54. were recruited. In this
study, individuals aged 60 years or above were considered as elderly, according
to the definition proposed by the World Health Organization for developing
countries, including Brazil1818 Organização Mundial de Saúde - OMS. Envelhecimento ativo: uma
política de saúde. Brasília; 2005..
Participants were recruited from programs for health care of the elderly in
Ceilândia, Federal District, by convenience sampling. Bedridden or
wheelchair-bound women, those with severe visual impairment, lower limb
amputations or prostheses, sequelae of a cerebrovascular accident, Parkinson's
disease, rheumatoid arthritis, peripheral arterial occlusive disease, a history
of recent fractures in the lower limbs, vestibulopathy and/or recent reports of
vertigo (i.e. within the past month) or musculoskeletal pain at the beginning of
the study and those with poor cognitive performance on the Mini-Mental State
Examination (MMSE) were excluded from the study. Poor cognitive performance was
identified based on the cutoff scores adopted by the multicenter project -
Frailty in Elderly Brazilians (projeto multicêntrico de Fragilidade de Idosos
Brasileiros). Specifically, due to discrepancies among the different cutoff
scores1919 Chaves MLF, Godinho CC, Porto CS, Mansur L, Carthery-Goulart MT,
Yassuda MS, et al. Cognitive, funcitonal and behavioral assessment. Dement
Neuropsychol. 2011;5(3):153-66., the mean values and
standard deviations for each educational level reported in Brucki et al.2020 Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH.
Sugestões para o uso do mini-exame do estado mental no Brasil. Arq
Neuropsiquiatr. 2003;61(3B):777-81.
http://dx.doi.org/10.1590/S0004-282X2003000500014.
PMid:14595482
http://dx.doi.org/10.1590/S0004-282X2003...
were used - with one standard deviation
subtracted from the mean2121 Neri AL, Ongaratto LL, Yassuda MS. Mini-Mental State Examination
sentence writing among community-dwelling elderly adults in Brazil: text fluency
and grammar complexity. Int Psychogeriatr. 2012;24(11):1732-7.
http://dx.doi.org/10.1017/S104161021200097X. PMid:22874587
http://dx.doi.org/10.1017/S1041610212000...
22 Nicolosi GT, Falcão DV, Batistoni SS, Lopes A, Cachioni M, Neri AL,
et al. Depressive symptoms in old age: relations among sociodemographic and
self-reported health variables. Int Psychogeriatr. 2011;23(6):941-9.
http://dx.doi.org/10.1017/S1041610211000627. PMid:21486519
http://dx.doi.org/10.1017/S1041610211000...
-
2323 Yassuda MS, Lopes A, Cachioni M, Falcao DV, Batistoni SS, Guimaraes
VV, et al. Frailty criteria and cognitive performance are related: data from the
FIBRA study in Ermelino Matarazzo, São Paulo, Brazil. J Nutr Health Aging.
2012;16(1):55-61. http://dx.doi.org/10.1007/s12603-012-0003-6.
PMid:22238002
http://dx.doi.org/10.1007/s12603-012-000...
: a total of 17 points for illiterates,
22 for one to four years of schooling, 24 for five to eight years of schooling,
and 26 for nine or more years of schooling. Analyses were performed using
prospective and retrospective information on falls during the 12 months of the
study (12.36 ± 1.02 months) obtained from 116 of the 118 recruited elderly women
because there were two losses due to death (1.7%).
Variables
Descriptive variables
The studied sociodemographic and clinical variables included age, educational
level, bone metabolic diagnosis, cognitive performance in the MMSE, physical
activity level, and medication under continuous use. Cognitive performance was
categorized into three levels according to Hannan et al.1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
: poor (17-23 points), moderate (24-28 points) or high
(29-30 points). The level of physical activity was determined with the adjusted
activity score (AAS) of the Human Activity Profile (HAP)2424 Souza AC, Magalhães LC, Teixeira-Salmela LF. Adaptação transcultural
e análise das propriedades psicométricas da versão brasileira do Perfil de
Atividade Humana. Cad Saude Publica. 2006;22(12):2623-36.
http://dx.doi.org/10.1590/S0102-311X2006001200012.
PMid:17096041
http://dx.doi.org/10.1590/S0102-311X2006...
, classifying participants as inactive (AAS<53),
moderately active (AAS=53-74) or active (AAS>74).
Falls
A variable fall was defined as a non-intentional event which resulted in the
individual changing position to a lower level in relation to his/her initial
position22 Cruz DT, Ribeiro LC, Vieira MT, Teixeira MT, Bastos RR, Leite IC.
Prevalência de quedas e fatores associados em idosos. Rev Saude Publica.
2012;46(1):138-46. http://dx.doi.org/10.1590/S0034-89102011005000087.
PMid:22183513
http://dx.doi.org/10.1590/S0034-89102011...
. High-trauma falls, coming
to rest against a wall or other structure, and falling as a consequence of
sustaining a violent impact, loss of consciousness or sudden onset of paralysis
were not included as falls in this study33 Silva RB, Costa-Paiva L, Oshima MM, Morais SS, Pinto-Neto AM.
Frequência de quedas e associação com parâmetros estabilométricos de equilíbrio
em mulheres na pós-menopausa com e sem osteoporose. Rev Bras Ginecol Obstet.
2009;31(10):496-502. http://dx.doi.org/10.1590/S0100-72032009001000005.
PMid:19942997
http://dx.doi.org/10.1590/S0100-72032009...
,
44 Swanenburg J, Bruin ED, Uebelhart D, Mulder T. Falls prediction in
elderly people: a 1-year prospective study. Gait Posture. 2010;31(3):317-21.
http://dx.doi.org/10.1016/j.gaitpost.2009.11.013. PMid:20047833
http://dx.doi.org/10.1016/j.gaitpost.200...
.
Prospective monitoring of falls
Prospective data regarding falls among the studied sample were collected on a
monthly basis (to reduce the memory bias) over the 12 months of the study by
means of phone calls (10.97±1.20 calls per participant). Participants were asked
"Have you fallen in the past month? If so, how many
times?", and falls were added up at the end of the study. Those
individuals who replied positively were asked further about the (i) location (at
home or outside of the home), (ii) conditions causing the fall (no apparent
circumstances, slipping, stumbling, half-stepping, dizziness, several causes, or
possible effect of medication), and (iii) consequences1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
(no consequences, bruises, excoriations, lacerations,
fractures, pain and/or edema). The prospective data on falls were considered as
the reference standard.
Retrospective self-report of falls
Retrospective data on falls over the same 12 months referred to the same period of time as the falls recorded for the respective prospective data. For retrospective data collection, participants received a single phone call one week after to the last follow-up phone call of the study and were asked "Have you fallen in the past 12 months? If so, how many times?"
General procedures
Data on the monthly assessment of falls over the 12-month period of the study (prospective data) and on the number of falls in the 12 months prior to the end of the study (retrospective data) were obtained by means of phone calls made by a single researcher. During each call, participants received instructions with respect to the definition that was adopted for the event fall.
According to prospective data on occurring falls and retrospective data on previous falls, the sample was categorized as (i) non-fallers (0 falls) or fallers (≥1 fall) and then reclassified as (ii) non-recurrent fallers (≤1 fall) or recurrent fallers (≥2 falls) for different analyses.
Statistical analysis
Data are expressed as the means and standard deviations for continuous variables, and as percentages and frequencies for categorical variables. Normal data distribution was assessed by means of the Kolmogorov-Smirnov test. Agreements between retrospective and prospective data were evaluated with Cohen's Kappa and Bland-Altman limits of agreement. Kappa values above 80% were considered excellent agreement, between 60% and 80% as substantial agreement, between 40% and 60% as moderate agreement, and below 40% as poor agreement2525 Portney LG, Watkins MP. Statistical measures of reliability. In: Portney LG, Watkins MP, editors. Foundations of Clinical Research: applications to practice. 2nd ed. New Jersey: Prentice-Hall; 2000. p. 557-86.. Global agreement was assessed by calculating the ratio of total agreement. Sensitivity and specificity were calculated to compare the retrospective report of falls in the past 12 months and the prospective monthly report on the occurrence of falls during the course of the same period (reference standard).
Sensitivity was defined as the percentage of participants who correctly recalled
having fallen at least once during the past 12 months among those who reported
falls in the prospective monitoring1313 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort
studies of community-dwelling older people: effect of the recall interval. J Am
Geriatr Soc. 2005;53(12):2190-4.
http://dx.doi.org/10.1111/j.1532-5415.2005.00509.x.
PMid:16398908
http://dx.doi.org/10.1111/j.1532-5415.20...
,
1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
. Specificity was defined as the
percentage of participants who correctly recalled not having fallen during the
past 12 months among those who reported no falls during prospective
monitoring1313 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort
studies of community-dwelling older people: effect of the recall interval. J Am
Geriatr Soc. 2005;53(12):2190-4.
http://dx.doi.org/10.1111/j.1532-5415.2005.00509.x.
PMid:16398908
http://dx.doi.org/10.1111/j.1532-5415.20...
,
1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
. The same analyses were performed for
recurrent falls. The level of significance was set at 5%. Analyses were
performed with SPSS 16.0 statistics software (IBM
(c)
, SPSS Inc., Chicago, IL, USA).
Results
Sample characteristics
Most of the elderly women were in their sixties or seventies, active or moderately
active, had a low educational level and moderate or poor cognitive performance1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
(Table
1).
Occurrence of falls in the present sample and their characteristics
In the monthly phone call-based monitoring over the 12 months of the study, 52 (44.8%) participants reported no falls, 40 (34.5%) reported one fall, and 24 (20.7%) reported two to six falls, with a mean of 1.91±1.34 falls among fallers. Most of the falls occurred outside of the home (50.8%) due to slipping (40.7%) or stumbling (32.2%) and resulted in some type of injury (69.8%) (Table 2).
Retrospective self-reporting of falls
As for the retrospective self-report of falls during the past 12 months at the end of the study, 70 (60.3%) participants denied having fallen, 33 (28.5%) mentioned one fall, and 13 (11.2%) reported two to five falls, with a mean of 1.51±0.93 previous falls among fallers.
Agreement and comparison between retrospective self-reporting and prospective monitoring of falls for total sample
Data on the agreement between prospective monitoring and retrospective self-reporting of falls and recurrent falls over a period of 12 months are shown in Table 3. The percentages of global agreement between both methods were 79.31% for falls and 88.79% for recurrent falls. However, chance-corrected agreement produced Kappa indices of 0.595 for falls and 0.589 for recurrent falls, indicating moderate agreement2525 Portney LG, Watkins MP. Statistical measures of reliability. In: Portney LG, Watkins MP, editors. Foundations of Clinical Research: applications to practice. 2nd ed. New Jersey: Prentice-Hall; 2000. p. 557-86. between the above methods.
The difference between the number of falls obtained with prospective monitoring and retrospective self-reporting versus the mean of both measurements is shown in a Bland-Altman plot in Figure 1. In this analysis, the mean of the difference between the above methods was 0.35, with a standard deviation of 0.83. The Bland-Altman limits of agreement were -1.30 to 2.01 (95% limits of agreement).
Bland-Altman diagram: comparison of prospective monthly monitoring over 12 months and annual retrospective self-reporting (previous 12 months) methods. UL = upper limit; LL = Lower Limit; Mean difference = 0.35. SD = 0.83. Limit of agreement = 0.35±1.66.
The evaluations of the sensitivity and specificity of the retrospective self-reporting of falls and recurrent falls are listed in Table 3. The sensitivity and specificity of the retrospective self-reporting of at least one fall in the previous 12 months were 67.2% and 94.2%, respectively. The retrospective self-reporting of two or more falls exhibited 50% sensitivity and 98.9% specificity.
For self-reported falls in the previous 12 months, under-reporting falls and recurrent falls was more common than over-reporting. Of the 64 elderly women who reported falls during the monthly monitoring, 32.8% denied having fallen in the self-reporting of previous falls. Of the 52 participants who reported no falls during the monthly monitoring, 5.76% reported falls in the self-reporting of previous falls. Similarly, of the 24 elderly women who reported recurrent falls during prospective monitoring, 50% denied recurrent falls in the retrospective self-report. Additionally, of the 92 participants who denied having fallen twice or more during prospective monitoring, 1.1% reported recurrent falls in the self-report of the 12 previous months.
However, the ratio of elderly women who incorrectly reported not having fallen in the previous 12 months decreased with the increase in the number of falls during the year of retrospective follow-up: 40% under-reporting among participants who reported one fall, 30.76% among those who reported two falls, 16.6% among those who reported three falls, and no under-reporting among those who had fallen four to six times during the study.
Comparison between retrospective self-reporting and prospective monitoring of falls for sample subgroups
The analyses of the sensitivity and specificity of retrospective self-reporting of falls and recurrent falls with respect to prospective monitoring regarding subgroups of elderly women who may or may not have suffered injurious falls are shown in Table 4. A better recall capacity of falls in the previous 12 months was observed among participants who suffered injurious falls.
Sensitivity and specificity of retrospective self-reporting of falls and of recurrent falls for sample subgroups.
Discussion
This study analyzed the agreement and comparison between retrospective self-reporting, by means of a single phone call at the end of data collection, and the one year prospective monitoring of falls, by means of monthly telephone calls, in a population of elderly women with low BMD who were active, had a low educational level and exhibited no cognitive impairment. The findings included a 32.8% frequency of under-reporting, moderate agreement, and limited accuracy of fall monitoring by means of retrospective self-reports relative to the past 12 months.
The compared methods exhibited moderate agreement and considerable limits of
agreement, indicating a possible divergence of up to 1.66 falls and a range
difference within the limits of agreement of approximately three falls. The analysis
of recurrent falls revealed moderate agreement (k=0.589); however, the wide
confidence interval with a bottom limit of 0.395 was indicative of poor agreement.
These results suggest that the clinical substitution of prospective monitoring of
falls with a retrospective single telephone method recalling falls over the past 12
months might not be reliable. Previous international studies have also investigated
the agreement between retrospective and prospective monitoring of falls; however,
better agreement indices were achieved. The study by Peel66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
investigated the agreement between retrospective questioning
on the occurrence of falls in the previous year and prospective recording with
monthly fall calendars among elderly subjects in their sixties (79% women) with high
incidence of falls (52%) and revealed a better level of chance-corrected agreement
(K=0.70) than the present study. Hannan et al.1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
evaluated the agreement between monthly prospective follow-up using a
fall calendar over three months and retrospective self-reports among elderly
individuals in their seventies (63% women) who were able to walk without assistance
and had no cognitive impairment (56.3% exhibited moderate and 35% high cognitive
performance) and also found a good level of agreement (k=0.74). Kunkel et al.88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
monitored falls among the elderly in their
seventies (67% men) with a history of stroke by means of retrospective self-reports
and a fall diary over a period of 12 months and found substantial agreement for
falls (K=0.65) and moderate agreement for recurrent falls (K=0.51). However, the
authors observed a possible difference of up to five falls between the compared
methods.
In this study, the recall of falls and recurrent falls in the previous year was
highly specific (i.e. a few false positives), although poorly sensitive with respect
to intensive monitoring by monthly phone calls. These findings confirm the important
problem of under-reporting due to the use of retrospective self-reporting when
monitoring falls among the elderly1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
.
International studies on the accuracy of the one-year retrospective self-report66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
,
1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294.
,
1515 Sanders KM, Hayles AL, Kotowicz MA, Nicholson GC. Monitoring falls
in cohort studies of community-dwelling older women. J Am Geriatr Soc.
2009;57(4):733-4. http://dx.doi.org/10.1111/j.1532-5415.2009.02205.x.
PMid:19392967
http://dx.doi.org/10.1111/j.1532-5415.20...
also support the above statement, although
with lower indices of under-reporting66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
,
1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294.
,
1515 Sanders KM, Hayles AL, Kotowicz MA, Nicholson GC. Monitoring falls
in cohort studies of community-dwelling older women. J Am Geriatr Soc.
2009;57(4):733-4. http://dx.doi.org/10.1111/j.1532-5415.2009.02205.x.
PMid:19392967
http://dx.doi.org/10.1111/j.1532-5415.20...
. Hale et al.1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294. compared a retrospective self-report with a weekly
prospective record sent by mail for falls that occurred over a period of 12 months
among community-dwelling elderly subjects (80% women) in their seventies with no
cognitive impairment. The authors observed excellent sensitivity (89%) and
specificity (95%) and an under-reporting frequency of only 11%. In the analysis of
the recall of falls in the past year relative to the self-reporting of falls using a
monthly calendar over the same period of time, Peel66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
found 79.5% sensitivity and 91.4% specificity and an under-reporting
percentage of 20.5%. Sanders et al.1515 Sanders KM, Hayles AL, Kotowicz MA, Nicholson GC. Monitoring falls
in cohort studies of community-dwelling older women. J Am Geriatr Soc.
2009;57(4):733-4. http://dx.doi.org/10.1111/j.1532-5415.2009.02205.x.
PMid:19392967
http://dx.doi.org/10.1111/j.1532-5415.20...
compared the self-reporting of previous falls with the prospective monitoring of
falls using a monthly calendar over a period of 12 months among community-dwelling
elderly women at high risk of falls and fractures and high incidence of falls
(42.8%), observing 77.1% sensitivity, 94.2% specificity, and 22.9% under-reporting.
Additionally, similar to the present study, Mackenzie et al.1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
observed that the ratio of under-reporting previous falls
was reduced with the increased number of falls suffered by the elderly (60.5%
under-reporting one fall and 26.3% under-reporting recurrent falls).
In this context, the following reasons have been suggested for the failure of
self-reports of previous falls1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294.
,
1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
: (i) forgetting events that occurred in
the past, (ii) denial of falls that occurred during the period of monitoring, or
(iii) the telescoping effect1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
, in which
individuals project memorable events to a given period of time that actually
occurred outside this period. However, several methods have aimed to attenuate this
bias in clinical-scientific settings. Specifically, the individual's participation
in the studies themselves delimits the recall period more accurately. Monthly
contacts and records might further contribute to better memorization and, thus, to a
more accurate recall of falls over one year1313 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort
studies of community-dwelling older people: effect of the recall interval. J Am
Geriatr Soc. 2005;53(12):2190-4.
http://dx.doi.org/10.1111/j.1532-5415.2005.00509.x.
PMid:16398908
http://dx.doi.org/10.1111/j.1532-5415.20...
,
1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294.. The use of self-reports relative to
larger time intervals also reduces the chances of possible recall errors1313 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort
studies of community-dwelling older people: effect of the recall interval. J Am
Geriatr Soc. 2005;53(12):2190-4.
http://dx.doi.org/10.1111/j.1532-5415.2005.00509.x.
PMid:16398908
http://dx.doi.org/10.1111/j.1532-5415.20...
,
1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294. because it allows for better
memory-capture than remembrances that are restricted to a shorter period of
time1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
. Additionally, denying falls to
conceal possible signs of frailty might contribute to under-reporting1515 Sanders KM, Hayles AL, Kotowicz MA, Nicholson GC. Monitoring falls
in cohort studies of community-dwelling older women. J Am Geriatr Soc.
2009;57(4):733-4. http://dx.doi.org/10.1111/j.1532-5415.2009.02205.x.
PMid:19392967
http://dx.doi.org/10.1111/j.1532-5415.20...
. However, this phenomenon seems to be more
accentuated when the fall is relatively recent1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294.. Thus, despite the monthly contact by phone, the use of a long
reference period, and a presumably more cautious sample due to a higher fear of
falls and fractures77 Ersoy Y, MacWalter RS, Durmus B, Altay ZE, Baysal O. Predictive
effects of different clinical balance measures and the fear of falling on falls
in postmenopausal women aged 50 years and over. Gerontology. 2009;55(6):660-5.
http://dx.doi.org/10.1159/000235652. PMid:19690394
http://dx.doi.org/10.1159/000235652...
,
2626 Sinaki M, Brey RH, Hughes CA, Larson DR, Kaufman KR. Balance
disorder and increased risk of falls in osteoporosis and kyphosis: significance
of kyphotic posture and muscle strength. Osteoporos Int. 2005;16(8):1004-10.
http://dx.doi.org/10.1007/s00198-004-1791-2. PMid:15549266
http://dx.doi.org/10.1007/s00198-004-179...
,
2727 Arnold CM, Busch AJ, Schachter CL, Harrison L, Olszynski W. The
relationship of intrinsic fall risk factors to a recent history of falling in
older women with osteoporosis. J Orthop Sports Phys Ther. 2005;35(7):452-60.
http://dx.doi.org/10.2519/jospt.2005.35.7.452. PMid:16108586
http://dx.doi.org/10.2519/jospt.2005.35....
, the results of the present study showed a
lower index of agreement between the compared methods, reduced accuracy of
retrospective self-reporting with respect to prospective monitoring, and significant
under-reporting of falls compared to international studies66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
,
88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
,
1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
. These findings might be due to a poorer
cognitive performance (there was a low cognitive performance1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
in 43.2% of the sample)1313 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort
studies of community-dwelling older people: effect of the recall interval. J Am
Geriatr Soc. 2005;53(12):2190-4.
http://dx.doi.org/10.1111/j.1532-5415.2005.00509.x.
PMid:16398908
http://dx.doi.org/10.1111/j.1532-5415.20...
and to the possibility that some participants of the present sample
did not count the falls as legitimate due to their tendency to attribute them to
external factors1515 Sanders KM, Hayles AL, Kotowicz MA, Nicholson GC. Monitoring falls
in cohort studies of community-dwelling older women. J Am Geriatr Soc.
2009;57(4):733-4. http://dx.doi.org/10.1111/j.1532-5415.2009.02205.x.
PMid:19392967
http://dx.doi.org/10.1111/j.1532-5415.20...
. Additionally, the use of
diaries and calendars for prospective monitoring of falls might have contributed to
better memorization in the international studies66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
,
88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
,
1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
,
1515 Sanders KM, Hayles AL, Kotowicz MA, Nicholson GC. Monitoring falls
in cohort studies of community-dwelling older women. J Am Geriatr Soc.
2009;57(4):733-4. http://dx.doi.org/10.1111/j.1532-5415.2009.02205.x.
PMid:19392967
http://dx.doi.org/10.1111/j.1532-5415.20...
,
1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
.
Some authors66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
,
1313 Ganz DA, Higashi T, Rubenstein LZ. Monitoring falls in cohort
studies of community-dwelling older people: effect of the recall interval. J Am
Geriatr Soc. 2005;53(12):2190-4.
http://dx.doi.org/10.1111/j.1532-5415.2005.00509.x.
PMid:16398908
http://dx.doi.org/10.1111/j.1532-5415.20...
,
1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294. have found that the recollection of
previous falls was more accurate when the episodes were accompanied by injuries,
with 87%66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
and 100%1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294.sensitivity for subgroups with injurious falls, as opposed to
62%66 Peel N. Validating recall of falls by older people. Accid Anal Prev.
2000;32(3):371-2. http://dx.doi.org/10.1016/S0001-4575(99)00066-4 .
PMid:10776852
http://dx.doi.org/10.1016/S0001-4575(99)...
and 78%1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294. sensitivity in subgroups with non-injurious falls. The
present study also detected higher sensitivity for self-reported falls in the
previous 12 months within the subgroup that reported injurious falls (68.2%)
compared to the subgroup that denied the occurrence of injuries (63.1%). The small
difference might be because the consequences of the reported injuries were
minimal.
In this study, the characterization of the cognitive profiles and educational levels of all participants, the low rate of sample loss, the implementation of both studied self-reporting methods within the same sample, and the 100% availability of prospective and retrospective data reinforce the obtained results.
However, the restricted inclusion of women with osteopenia or osteoporosis, the
exclusion of individuals with cognitive impairment, and the active profile of the
sample limit the generalization of the obtained results. A further significant
limitation of this study was the use of phone calls to monitor the occurrence of
falls, thus not allowing for the generalization of the findings to other methods.
When using this method, it is important to note that even monthly prospective
monitoring of falls by telephone, used as the reference standard, exhibited
limitations. As for any form of self-reporting of falls, the monthly telephone call
is susceptible to forgetfulness, denial or the telescoping effect1616 Mackenzie L, Byles J, D'Este C. Validation of self-reported fall
events in intervention studies. Clin Rehabil. 2006;20(4):331-9.
http://dx.doi.org/10.1191/0269215506cr947oa. PMid:16719031
http://dx.doi.org/10.1191/0269215506cr94...
. Furthermore, the discussion of this study's
findings in comparison to previous studies was limited by the heterogeneity of the
definition of the event fall. While information on the economic cost of telephone
calls and human resources might be useful for the future comparison of potential
costs between different methods of monitoring the occurrence of falls, it was not
recorded in the present study.
According to the findings on comparisons and agreement between retrospective
self-reporting of falls and prospective monitoring, the replacement of monthly
monitoring with retrospective questioning for the 12 previous months would only be
reasonable in a population where the main interest lies in the reduction of false
negatives. Thus, the authors of this study considered prospective monthly data
collection methods as the ideal for longitudinal surveys on elderly individuals with
the occurance of falls as the main outcome of the study88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
,
1212 Hannan MT, Gagnon MM, Aneja J, Jones RN, Cupples LA, Lipsitz LA, et
al. Optimizing the tracking of falls in studies of older participants:
comparison of quarterly telephone recall with monthly falls calendars in the
MOBILIZE Boston Study. Am J Epidemiol. 2010;171(9):1031-6.
http://dx.doi.org/10.1093/aje/kwq024. PMid:20360242
http://dx.doi.org/10.1093/aje/kwq024...
. In the clinical environment, this
combination of daily records by the patient and the monthly monitoring by the staff
might be very expensive88 Kunkel D, Pickering RM, Ashburn AM. Comparison of retrospective
interviews and prospective diaries to facilitate fall reports among people with
stroke. Age Ageing. 2011;40(2):277-80. http://dx.doi.org/10.1093/ageing/afq177.
PMid:21242191
http://dx.doi.org/10.1093/ageing/afq177...
, thus justifying the
careful use of retrospective interviews. In Brazil, the low educational level and
reduced digital inclusion among the elderly hampered the use of either diaries or
electronic media for the surveillance of falls. The authors of this study suggest
increasing the awareness of this problem1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294.,
training elder-healthcare professionals to ensure proper records of the events in
the Elderly Health Handbook (Caderneta de Saúde da Pessoa Idosa) and to investigate
the accuracy of this tool in future studies. The authors of this study further
recommend a more simple definition of falls to allow for a broader
understanding1111 Hauer K, Lamb SE, Jorstad EC, Todd C, Becker C, PROFANE-Group.
Systematic review of definitions and methods of measuring falls in randomised
controlled fall prevention trials. Age Ageing. 2006;35(1):5-10.
http://dx.doi.org/10.1093/ageing/afi218. PMid:16364930
http://dx.doi.org/10.1093/ageing/afi218...
allowing more attention to
be paid to the correct understanding of the definition by patients. Thus, the proper
recognition of the patient's history of falls would allow clinicians and researchers
to develop strategies to reduce the incidence of falls and injuries and to preserve
mobility among elderly patients1414 Hale WA, Delaney MJ, Cable T. Accuracy of patient recall and chart
documentation of falls. J Am Board Fam Pract. 1993;6(3):239-42.
PMid:8503294., especially
among those at high risk of falls and fractures.
Conclusion
The method of retrospective self-reporting of falls in the previous 12 months exhibited moderate agreement and limited accuracy with respect to the method of prospective monitoring of falls among elderly women at high risk of falls and fractures. The retrospective self-reporting of falls was more sensitive with respect to prospective monitoring among women with injurious falls than among those with no post-fall injuries. These findings call for caution when substituting monthly monitoring with retrospective questioning and indicate the importance of including associated clinical-functional information for decision-making in clinical-scientific settings.
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Publication Dates
-
Publication in this collection
12 June 2015 -
Date of issue
May-Jun 2015
History
-
Received
20 June 2014 -
Reviewed
09 Sept 2014 -
Accepted
04 Feb 2015