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Nursing diagnosis Risk for Falls in the elderly in primary health care

Diagnóstico de enfermería de Riesgo de Caídas en los ancianos en atención primaria

ABSTRACT

Objective:

to evaluate the Nursing Diagnosis (ND) Risk for Falls in elderly subjects in primary health care in the Federal District.

Methods:

a descriptive, quantitative, cross-sectional study conducted in two basic health units. Data collection included blood collection, nursing consultation and physical evaluation of 156 elderly subjects with chronic diseases.

Results:

the most prevalent intrinsic risk factors of NANDA-I were visual impairment (73.7%), impaired mobility (70.5%) and history of falls (69.9%); and extrinsic factors were the use of insufficient material in the bathroom (60.3%) and loose carpets (58.3%). The intrinsic factors that increased the risk for falls were the use of assistive devices (OR 3.50; p=0.030), impaired walking (OR 2.84; p=0.019) and cognitive impairment (OR 1.26; p=0.019); and the extrinsic factor was the use of loose rugs (OR 1.59; p=0.041).

Conclusion:

this ND has proved to be a valuable instrument for the identification of risk factors for falls in elderly subjects in primary care.

Descriptors:
Elderly; Accidents by Falls; Risk factors; Nursing Diagnosis; Primary Health Care

RESUMEN

Objetivo:

evaluar el Diagnóstico de Enfermería (ND) de Riesgo de Caídas en ancianos en atención primaria de salud en Distrito Federal.

Métodos:

investigación descriptiva, cuantitativa, transversal realizada en dos unidades básicas de salud. La recolección de datos incluyó recolección de sangre, consulta de enfermería y evaluación física de 156 ancianos con enfermedades crónicas.

Resultados:

los factores de riesgo intrínsecos más prevalentes de NANDA-I fueron la discapacidad visual (73.7%), movilidad disminuida (70.5%) y antecedentes de caídas (69.9%); y los factores extrínsecos fueron el uso insuficiente de material en el baño (60.3%) y alfombras sueltas (58.3%). Los factores intrínsecos que aumentaron el riesgo de caídas fueron el uso de dispositivos de asistencia (OR 3.50; p=0.030), dificultades de la marcha (OR 2.84; p=0.019) y deterioro cognitivo (OR 1.26; p=0,019); y el factor extrínseco fue el uso de alfombras sueltas (OR 1.59; p=0.041).

Conclusión:

este ND ha demostrado ser una herramienta valiosa para identificar factores de riesgo de caídas en ancianos en atención primaria de salud.

Descriptores:
Anciano; Accidentes por caídas; Factores de riesgo; Diagnóstico de Enfermería; Atención Primaria de Salud

RESUMO

Objetivo:

avaliar o Diagnóstico de Enfermagem (DE) de Risco de Quedas em idosos da atenção primária do Distrito Federal.

Métodos:

estudo descritivo, quantitativo, transversal, realizado em duas unidades básicas de saúde. A coleta de dados compreendeu coleta de sangue, consulta de enfermagem e avaliação física de 156 idosos com doenças crônicas.

Resultados:

os fatores de risco intrínsecos da NANDA-I mais prevalentes foram deficiência visual (73,7%), mobilidade prejudicada (70,5%) e história de quedas (69,9%) e os fatores extrínsecos foram uso de material insuficiente no banheiro (60,3%) e tapetes soltos (58,3%). Os fatores intrínsecos que aumentaram o risco de quedas foram uso de dispositivos auxiliares (OR 3,50; p=0,030), dificuldades na marcha (OR 2,84; p=0,019) e alteração na função cognitiva (OR 1,26; p=0,019); e o extrínseco foi o uso de tapetes soltos (OR 1,59; p=0,041).

Conclusão:

esse DE se revelou uma ferramenta valiosa na identificação dos fatores de risco para quedas em idosos da atenção primária.

Descritores:
Idoso; Acidentes por Quedas; Fatores de Risco; Diagnóstico de Enfermagem; Atenção Primária à Saúde

INTRODUCTION

The trend of population aging observed in recent decades, especially in developing countries, results from the demographic transition phenomenon consolidated with the reduction in mortality and fertility rates. In this scenario, the World Health Organization (WHO) estimates a world population of 1.2 billion people over 60 years of age in 2025 and 2 billion in 2050. By 2025, Brazil can be the sixth largest country in number of seniors, totaling about 32 million elderly in its population(11 World Health Organization - WHO. Envelhecimento ativo: uma política de saúde[Internet]. Brasília: Organização Pan-Americana da Saúde; 2005. 62 p. Available from: http://dms.ufpel.edu.br/ares/bitstream/handle/123456789/232/52005envelhecimento_ativo.pdf?sequence=1
http://dms.ufpel.edu.br/ares/bitstream/h...
-22 Cavalcanti CL, Gonçalves MCR, Asciutti LSR, Cavalcanti AL. Envelhecimento e obesidade: um grande desafio no século XXI. Rev Bras Ciênc Saúde [Internet]. 2011[cited 2017 Dec 14];14(2):87-92. Available from: http://www.periodicos.ufpb.br/ojs/index.php/rbcs/article/view/7230/5318
http://www.periodicos.ufpb.br/ojs/index....
).

The higher number of elderly individuals also brings a significant increase in noncommunicable chronic diseases (NCDs), such as systemic arterial hypertension (SAH), diabetes mellitus (DM) and obesity. NCDs are considered a major public health problem and the leading cause of mortality worldwide. The scenario is also alarming in Brazil, since these diseases account for 71% of death causes(33 Ministério da Saúde (BR). Secretaria de Vigilância em Saúde, Departamento de Análise de Situações de Saúde. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas não Transmissíveis (DCNT) no Brasil 2011-2022. [Internet]. Brasília; 2011[cited 2017 Dec 14]. 148 p. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/plano_acoes_enfrent_dcnt_2011.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
).

The morphological and physiological changes resulting from aging, associated with NCDs, predispose the elderly to episodes of falls. These are concerning events because of their high incidence, mortality and morbidity, in addition to social and economic costs resulting from falls. There is evidence of a high prevalence of falls among the elderly, which can result in serious consequences such as fractures, soft tissue injuries and death(44 Falsarella GR, Gasparotto LPR, Coimbra AMV. Quedas: conceitos, frequências e aplicações à assistência ao idoso. Revisão da literatura. Rev Bras Geriatr e Gerontol [Internet]. 2014 [cited 2017 Dec 14];17(4):897-910. Available from: http://www.scielo.br/pdf/rbgg/v17n4/1809-9823-rbgg-17-04-00897.pdf
http://www.scielo.br/pdf/rbgg/v17n4/1809...
).

Falls are events of multifactorial causes that can be intrinsic and extrinsic factors. Intrinsic factors include sociodemographic, cognitive, physiological and lifestyle aspects. Extrinsic factors include environmental aspects that contribute to episodes of falls. Identifying these risk factors is essential, since many of them are preventable(55 Gauterio DP, Zortea B, Santos SS, Tarouco BS, Lopes MJ, Fonseca CJ. Risk factors for new accidental falls in elderly patients at Traumatology Ambulatory Center. Invest Educ Enferm [Internet]. 2015 [cited 2018 Aug 6];33(1):35-43. Available from: http://www.scielo.org.co/pdf/iee/v33n1/v33n1a05.pdf
http://www.scielo.org.co/pdf/iee/v33n1/v...
).

Among the instruments available for identifying the risk for falls in the elderly, the Nursing Diagnosis (ND) Risk for Falls is defined by the North American Nursing Diagnosis Association (NANDA) Taxonomy II as “vulnerability to increased susceptibility for falls, which can cause physical damage and compromise health”(66 NANDA International. NANDA International nursing diagnoses: definitions and classification 2015-2017. Herdman TH, Kamitsuru S, organizadores. Porto Alegre: Artmed; 2015.).

Although the literature has studies assessing the Risk for Falls ND in various health care contexts(77 Luzia MF, Victor MAG, Lucena AF. Nursing Diagnosis Risk for falls: prevalence and clinical profile of hospitalized patients. Rev Latino-Am Enfermagem [Internet]. 2014 [cited 2017 Nov 29];22(2):262-8. Available from: http://www.scielo.br/pdf/rlae/v22n2/0104-1169-rlae-22-02-00262.pdf
http://www.scielo.br/pdf/rlae/v22n2/0104...
-88 Reis KMC, Jesus CAC. Relação da polifarmácia e polipatologia com a queda de idosos institucionalizados. Texto Contexto Enferm [Internet]. 2017 [cited 2018 Apr];26(2). Available from: http://www.scielo.br/pdf/tce/v26n2/pt_0104-0707-tce-26-02-e03040015.pdf
http://www.scielo.br/pdf/tce/v26n2/pt_01...
), there is a gap of studies on the use of this ND in primary health care with community elderly. A larger number of studies was developed with institutionalized elderly.

Therefore, the present study is justified by the impact of the fall event on elderly individuals’ health, especially those affected by NCDs, and by the need to improve the identification of risk factors for the occurrence of falls in community elderly. Given the relevant role of nursing in the promotion of self-care and prevention of health problems(99 Bezerra F, Lemos STM, Sousa AC, Carvalho SML, Fernandes CMC, Alves AFS, Dalva M. Promoção da saúde: a qualidade de vida nas práticas da enfermagem. Enferm Glob [Internet]. 2013 [cited 2018 Apr 10];23:270-9. Available from: http://scielo.isciii.es/pdf/eg/v12n32/pt_ensayos2.pdf
http://scielo.isciii.es/pdf/eg/v12n32/pt...
), the application of the Risk for Falls ND can contribute both to the precise identification of factors that contribute to falls in the elderly, and to the prevention of these events.

OBJECTIVE

To evaluate the Nursing Diagnosis Risk for Falls in the elderly of primary health care in the administrative region of Ceilândia - Federal District.

METHODS

Ethical aspects

This project is part of a larger project called “Approach to chronic noncommunicable conditions in primary health care”, approved by the Research Ethics Committee of the Fundação de Ensino e Pesquisa em Ciências da Saúde (FEPECS). All participants signed the Informed Consent form (IC).

Design, place of study and period

Descriptive, quantitative, cross-sectional study based on part of the master’s dissertation of one of the authors. The study was conducted in two Basic Health Units (Portuguese acronym: UBS) of Ceilândia, which is considered the largest administrative region of the Federal District. The data collection period was between February and July 2017.

Population or sample: inclusion and exclusion criteria

Random sampling was performed through a draw of elderly subjects registered in the Diabetic and Hypertensive groups of the health unit. For sample calculation, were considered a sampling error of 6.0%, a confidence interval of 95% and a population size of 1,600, resulting in 196 elderly. For the selection of study participants, were considered the following inclusion criteria: age ≥ 60 years, both sexes, with DM and/or SAH. Thirty elderly people were excluded because they met the criterion of inability to perform physical tests to assess the risk for falls, such as being in a wheelchair. In addition, ten elderly subjects did not agree to participate in the study, hence the final sample comprised 156 elderly individuals. The sample loss was 20%, which is considered within the normal range.

Study protocol

The elderly selected were approached during the group meeting at the health unit. At this time, they were instructed to come to the health unit at a previously scheduled day and time, in a 12-hour fast. Upon arrival at the unit, they were advised on the study protocol and those who agreed to participate as volunteers signed the informed consent form. Initially, blood was drawn from the elderly for a complete blood count and blood glucose in order to identify risk factors related to changes in blood glucose level and anemia. Samples were obtained with puncture, preferably in the cubital vein, using vacuum tubes, and were sent for analysis in a private laboratory partner of the research group. Fasting glucose levels considered low were ≤70mg/dl, and those considered high were ≥126 mg/dl(1010 Sociedade Brasileira de Diabetes - SBD. Diretrizes da Sociedade Brasileira de Diabetes 2015-2016. [Internet] 2015 [cited 2018 Mar 18]. Available from: http://www.diabetes.org.br/profissionais/images/docs/DIRETRIZES-SBD-2015-2016.pdf
http://www.diabetes.org.br/profissionais...
). Hemoglobin values were considered altered when below 12 g/dl for women and below 13 g/dl for men(1111 World Health Organization - WHO. Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers[Internet]. 2001 [cited 2018 Mar 18]. Available at: http://pesquisa.bvsalud.org/portal/resource/pt/who-66914
http://pesquisa.bvsalud.org/portal/resou...
).

After blood collection, the elderly received breakfast and were referred to the nursing consultation that consisted of data collection for characterization of subjects, cognitive assessment and assessment of the Risk for Falls ND with duration of approximately 50 minutes. Consultations were held in the offices by nurses and nursing students (members of the study group), who were previously trained by researchers for the collection of data and performance of assessments. Consultations were performed with the sole purpose of collecting data for the study.

The instrument of characterization of elderly subjects included sociodemographic, clinical and lifestyle characteristics. The Anatomical Therapeutic Chemical (ATC) Classification, composed of thirteen classes of medications, was adopted to assess the use of medications. Cognitive assessment was performed by applying the Mini Mental State Examination (MMSE). The cutoff points used to identify cognitive changes, considering education, were: illiterate, 18 points; from 1 to 3 years of schooling, 21 points; 4-7 years of schooling, 24 points; more than 7 years of schooling, 26 points(1212 Melo DM, Barbosa AJG. O uso do Mini-Exame do Estado Mental em pesquisas com idosos no Brasil: uma revisão sistemática. Cienc Saude Colet [Internet]. 2015 [cited 2018 Mar 11];20(12):3865-76. Available from: http://www.scielo.br/pdf/csc/v20n12/1413-8123-csc-20-12-3865.pdf
http://www.scielo.br/pdf/csc/v20n12/1413...
).

For the assessment of the Risk for Falls ND, was built a checklist instrument containing the risk factors for falls involving the elderly, according to NANDA-I (2015-2017). Although in NANDA, the risk factors for falls are grouped into the categories “In adults”, “In children”, “Cognitive”, “Environmental”, “Pharmacological agents” and “Physiological”, in this study, we chose to group them into intrinsic or extrinsic factors, as used in another study on this theme(1313 Chaves ECL, Cordeiro LAM, Goyatá SLT, Godinho MLSC, Meirelles VC, Nascimento AM. Identificação do diagnóstico risco de quedas em idosos atendidos pelo Programa de Atenção ao Idoso. Rev Enferm UFPE [Internet]. 2011 [cited 2018 Apr 8];5(10):2507-2514 p. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/download/6971/6220
https://periodicos.ufpe.br/revistas/revi...
).

In the grouping of risk factors, the category of child-related risk factors was not considered(66 NANDA International. NANDA International nursing diagnoses: definitions and classification 2015-2017. Herdman TH, Kamitsuru S, organizadores. Porto Alegre: Artmed; 2015.). Risk factors in categories “In adults”, “Cognitive”, “Pharmacological agents” and “Physiological” were classified as intrinsic risk factors, while the “Environmental” category comprised extrinsic risk factors. The identification of risk factors for the Risk for Falls ND occurred through elderly subjects’ self-reports, observation of the elderly by the evaluator, physical evaluation and laboratory parameters.

At the end of the nursing consultation, elderly individuals were directed to the external area of the health unit to assess the risk for falls through application of an instrument/physical tests, and to track peripheral neuropathy. This step lasted 30 minutes on average.

The following methods were used to identify the risk for falls: 1) The Fall Risk Score has a score ranging from 0 to 11 points. In this case, scores greater than or equal to 3 indicate a high risk for falls(1414 Reis LA, Rocha TS, Duarte SFP. Quedas: risco e fatores associados em idosos institucionalizados. Rev Baiana Enferm [Internet]. 2014 [cited 2018 Mar 11];28(3):225-34. Available from: https://portalseer.ufba.br/index.php/enfermagem/article/viewFile/12303/8982
https://portalseer.ufba.br/index.php/enf...
); 2) The Berg Balance Scale (BBS) has a maximum score of 56 points. In this case, the lower the score achieved the higher the risk for falls; scores below 45 points indicate a high risk for falls and scores between 46 and 53 indicate low to moderate risk for falls(1515 Miyamoto ST, Lombardi Jr I, Berg KO, Ramos LR, Natour J. Brazilian version of the Berg balance scale. Brazilian J Med Biol Res [Internet]. 2004 [cited 2018 Mar 11];37(9):1411-21. Available from: http://www.scielo.br/pdf/bjmbr/v37n9/5292.pdf
http://www.scielo.br/pdf/bjmbr/v37n9/529...
); 3) The Timed Up-and-Go (TUG) is a test quantified in seconds, according to which the execution time up to 10 seconds is considered normal, 11-20 seconds indicates partial independence and low risk for falls, and a time greater than 20 seconds indicates significant physical mobility deficit and risk for falls(1616 Karuka AH, Silva JAMG, Navega MT. Analysis of agreement of assessment tools of body balance in the elderly. Rev Bras Fisioter [Internet]. 2011 [cited 2018 Mar 11];15(6):460-6. Available from: http://www.scielo.br/pdf/rbfis/v15n6/en_v15n6a06.pdf
http://www.scielo.br/pdf/rbfis/v15n6/en_...
).

Screening for peripheral neuropathy consisted of investigating the loss of protective sensation (LPS) by the 10g monofilament test and neurological tests (deep painful sensation, vibration sensation and Achilles reflex). To complete the diagnosis of loss of sensation, in addition to the absence of protective sensation, the patient should present one or more altered neurological tests(1717 Pedrosa HC. Polineuropatia Diabética: novas estratégias para diagnóstico e intervenção terapêutica precoces - Diretrizes NeurALAD. Argentina; 2010 [cited 2018 Apr 4]. Available from: http://www.anad.org.br/wp-content/uploads/2015/07/Highlight_CODHy_Buenos_Aires_Dra_Hermelinda_Pedrosa_7505.pdf
http://www.anad.org.br/wp-content/upload...
).

Analysis of results and statistics

For data analysis, was built a database with the Statistical Package for the Social Sciences (SPSS®), version 20.0. As for data related to the sample characterization, descriptive statistical analysis was performed using absolute, relative frequencies and dispersion measures (mean, standard deviation, minimum and maximum). Normal distribution was assessed by the Kolmogorov-Smirnov test. To compare means between the two groups, was performed the t-test. Risk factors were associated with the likelihood of occurrence of falls by calculating the Odds Ratio, its 95% confidence interval (CI) and the p-value. The significance level considered in this study was p<0.05.

RESULTS

In total, were evaluated 156 elderly, most of which were female (79.5%), mean age of 67.9 ± 5.8 years. Elderly individuals aged 60 to 64 years corresponded to 34.0%, followed by those aged 65 to 69 years (31.4%), of mixed race (52.6%), married (51.3%) and inactive (41.7 %). Only 39.1% were retired (Table 1).

Table 1
Sociodemographic characteristics of elderly subjects with chronic diseases (N=156), Brasília, Brazil, 2018

Regarding education, the sample showed elderly people with few years of education, and 33.3% had from one to four years of schooling. Low income was prevalent among the elderly, who reported receiving less than or equal to one minimum wage (52.6%). Regarding the number of residents in the house, 11.5% of the elderly lived alone, while the majority (29.5%) lived with three people in the house (Table 1).

Most elderly subjects declared themselves non-smokers (92.3%), non-alcoholics (94.2%) and practitioners of physical activities (73.7%). Regarding sleep habits, 44.9% reported changes in sleep (Table 2). Regarding comorbidities, 80.8% had hypertension, 59.6% had DM and 48.1% had both comorbidities (SAH and DM). Among diabetics, 10.9% used insulin. Regarding inflammatory diseases, 8.3% of the elderly said they had some diagnosis, and arthrosis and arthritis were the most common (Table 2). The majority used medication related to the cardiovascular system (84.6%), followed by alimentary tract and metabolism drugs (64.1%) (Table2).

Table 2
Clinical characteristics and lifestyle habits of elderly subjects (N=156), Brasília, Brazil, 2018

In this study, 71.2% of the elderly reported a history of falls. Regarding sex, females had a higher prevalence of falls, accounting for 83.5% of total falls. When analyzing the history of falls according to the age of elderly individuals, the age group with the highest prevalence of falls was that of 75 to 79 years old (75.0%), followed by the group of 66 to 69 years old (73.5%), 70 to 74 years old (70.6%), 60 to 65 years old (66.0%), and lastly, those over 80 years old (62.5%).

In the analysis of the number of the risk factors for the Risk for Falls ND according to the elderly’s history of falls, a higher mean of risk factors (mean = 8.7) was observed in elderly who had already fallen compared to the elderly with no history of falls (mean = 6.8) (p <0.000).

When investigating the Risk for Falls ND, the risk factors of elderly with chronic diseases were presented as intrinsic and extrinsic. The most prevalent intrinsic factors in elderly subjects of the “In adults” category, were history of falls (69.9%) and age ≥ 65 years (66.0%). In the “Cognitive” category, 54.5% of the elderly had some cognitive impairment, either mild or moderate. In the category “Pharmacological agents”, medications for the cardiovascular system were the most used by elderly subjects (84.6%) (Table 3).

Table 3
Association between intrinsic risk factors and the occurrence of falls and no falls in elderly subjects with chronic diseases, odds ratio (OR) and confidence interval (95% CI), Brasília, Brazil 2018

Regarding the category “Physiological”, the most highlighted risk factors were visual impairment (73.7%), impaired mobility (70.5%) and sleep deprivation (47.4%). The occurrence of falls was related to intrinsic risk factors, which demonstrates the significant association between the use of assistive devices such as walking stick, cognitive impairment, anemia and impaired walking, and the risk for falls (Table 3).

Regarding the category “In adults”, the use of assistive devices by the elderly was related to the occurrence of falls, since 87.5% of elderly users of these devices had a history of falls. Furthermore, the use of the assistive device increases the risk for falls by 3.50 times (p=0.030). In the category “Cognitive”, elderly with cognitive impairment had a higher prevalence of falls (62.4%). This risk factor increases by 1.26 times an elderly person’s chance of fall (p = 0.030) (Table 3).

In the “Physiological” category, was observed an interesting fact in the anemia risk factor, since most anemic elderly people did not experience falls (71.4%), thereby demonstrating a 2.5 times greater chance of not having episodes of falls (p=0.026). Still in this category, impaired walking was higher in elderly people with a history of falls (84.2%), thus increasing the risk for falls by 2.84 times (p=0.019) (Table 3).

When considering extrinsic risk factors, in the “Environmental” category, the most prevalent factors were the use of insufficient non-slip material in the bathroom (60.3%), followed by use of loose carpets in the house (58.3%). Elderly subjects who reported using loose carpets in their homes had a higher prevalence of falls (75.8%), increasing by 1.59 times the chance of a fall event (p=0.041) (Table 4).

Table 4
Association between extrinsic risk factors and the occurrence of falls and no falls in elderly subjects with chronic diseases, odds ratio (OR) and confidence interval (95% CI), Brasília, Brazil, 2018

DISCUSSION

The results presented show the magnitude of the problem of falls in the elderly in the primary health care context and the high prevalence of history of falls. In addition, they demonstrate that using the Risk for Falls ND in conjunction with assessments and additional instruments represents an important strategy to identify intrinsic and extrinsic factors contributing to the occurrence of falls in this population in specific contexts.

When analyzing the sociodemographic characteristics of elderly subjects in this study, was observed a prevalence of females, older people of the younger age group, married, mixed race, who do not work, with few years of schooling, low income and who do not live alone. Similar results were found in a study conducted by the Center for Elderly Care of the Universidade Federal de Pernambuco with 150 diabetic elderly subjects attended in outpatient service(1818 Borba AKOT, Marques APO, Ramos VP, Leal MCC, Arruda IKG, Ramos RSPS, et al. Factors associated with elderly diabetic adherence to treatment in primary health care. Cienc Saude Colet [Internet]. 2018 [cited 2018 Apr 6];23(3):953-61. Available from: http://www.scielo.br/pdf/csc/v23n3/en_1413-8123-csc-23-03-0953.pdf
http://www.scielo.br/pdf/csc/v23n3/en_14...
).

The higher prevalence of females in these studies corroborates data from the National Household Sample Survey (Portuguese acronym: PNAD-2012) of the Brazilian Institute of Geography and Statistics (Portuguese acronym: IBGE)(99 Bezerra F, Lemos STM, Sousa AC, Carvalho SML, Fernandes CMC, Alves AFS, Dalva M. Promoção da saúde: a qualidade de vida nas práticas da enfermagem. Enferm Glob [Internet]. 2013 [cited 2018 Apr 10];23:270-9. Available from: http://scielo.isciii.es/pdf/eg/v12n32/pt_ensayos2.pdf
http://scielo.isciii.es/pdf/eg/v12n32/pt...
) and may be related to the fact of women being more careful with their health, which reflects greater access to health services and lower mortality(2020 Gavasso WC, Beltrame V. Functional capacity and reported morbidities: a comparative analysis in the elderly. Rev Bras Geriatr e Gerontol [Internet]. 2017 [cited 2018 Apr 6];20(3):398-408. Available from: http://www.scielo.br/pdf/rbgg/v20n3/1809-9823-rbgg-20-03-00398.pdf
http://www.scielo.br/pdf/rbgg/v20n3/1809...
).

The low educational level of elderly subjects drew attention. In a study conducted with elderly people from Pelotas, Rio Grande do Sul, low education was inversely associated with the risk for falls. The impact of low education on elderly subjects’ health may be related to a greater difficulty with accessing health services and a lower ability of understanding and taking advantage of information provided by health professionals regarding self-care and disease prevention, including falls(2121 Vieira LS, Gomes AP, Bierhals IO, Farías-Antúnez S, Ribeiro CG, Miranda VIA, et al. Falls among older adults in the South of Brazil: prevalence and determinants. Rev Saude Publica [Internet]. 2018 [cited 2018 Apr 9];52:22. Available from: http://www.revistas.usp.br/rsp/article/view/143831/138461
http://www.revistas.usp.br/rsp/article/v...
).

Regarding inappropriate life behaviors, the elderly presented disturbed sleep. In a study of elderly people from Singapore, Asia, in the context of primary health care, were evaluated the determinants of poor sleep quality in elderly people with cardiometabolic risk factors (DM, SAH, and hyperlipidemia). Nocturia was the only variable associated with a higher risk of poor sleep quality in participants(2222 Chiang GSH, Sim BLH, Lee JJM, Quah JHM. Determinants of poor sleep quality in elderly patients with diabetes mellitus, hyperlipidemia and hypertension in Singapore. Prim Health Care Res Dev [Internet]. 2018 [cited 2018 Apr 6];1-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29580302
http://www.ncbi.nlm.nih.gov/pubmed/29580...
).

In this study, was identified a high prevalence of history of falls in the elderly. In a study of 724 elderly in Uberaba, Minas Gerais, was found a prevalence of falls of 28.3%, lower than that observed in this study, more frequent in females and elderly over 80 years old, who had more than two comorbidities and used five or more medications. The high prevalence of history of falls found in this study can be explained by the inclusion of elderly people with NCDs in the sample. When associated with functional decline resulting from aging, these diseases may increase vulnerability or propensity for falls, especially with recurrent episodes(2323 Nascimento JS, Tavares DMS. Prevalence and factors associated with falls in the elderly. Texto Contexto Enferm [Internet]. 2016 [cited 2017 Dec 14];25(2). Available from: http://www.scielo.br/pdf/tce/v25n2/en_0104-0707-tce-25-02-0360015.pdf
http://www.scielo.br/pdf/tce/v25n2/en_01...
).

The occurrence of falls has multifactorial causes and increases linearly according to the number of risk factors. An investigation of 464 seniors in Natal, Rio Grande do Norte found that elderly people with no risk factors were 8% likely to fall, while those with four or more risk factors had a 78% chance of experiencing falls(2424 Santos RKM, Maciel ACC, Britto HMJS, Lima JCC, Souza TO. Prevalência e fatores associados ao risco de quedas em idosos adscritos a uma Unidade Básica de Saúde do município de Natal, RN, Brasil. Cienc Saude Colet [Internet]. 2015 [cited 2018 Apr 7];20(12):3753-62. Available from: http://www.scielo.br/pdf/csc/v20n12/1413-8123-csc-20-12-3753.pdf
http://www.scielo.br/pdf/csc/v20n12/1413...
). These results corroborate the findings of the present study.

In this study, the most prevalent intrinsic risk factors were history of falls, age ≥ 65 years, cognitive impairment, visual impairment, impaired mobility and sleep deprivation. Extrinsic factors were the use of insufficient non-slip material in the bathroom and the use of loose carpets at home. In a study conducted in Alfenas, Minas Gerais, with 114 medical records of elderly subjects attended in the Elderly Care Program, was investigated the Risk for Falls ND. The study demonstrated a higher frequency of intrinsic factors, namely; age ≥ 65 years, use of medications, impaired walking and history of falls, and also revealed 62% of extrinsic factors(1313 Chaves ECL, Cordeiro LAM, Goyatá SLT, Godinho MLSC, Meirelles VC, Nascimento AM. Identificação do diagnóstico risco de quedas em idosos atendidos pelo Programa de Atenção ao Idoso. Rev Enferm UFPE [Internet]. 2011 [cited 2018 Apr 8];5(10):2507-2514 p. Available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/download/6971/6220
https://periodicos.ufpe.br/revistas/revi...
).

A systematic review identified risk factors for fall in community-dwelling elderly according to NANDA-I Taxonomy II. Sixty-two articles were evaluated, in which the most prevalent intrinsic risk factors were pharmacological agents, gait modifications, impaired balance and visual deficit. Extrinsic factors included disorganized environment and use of insufficient non-slip material in the bathroom(2525 Sousa LMM, Marques-Vieira CMA, Caldevilla MNGN, Henriques CMAD, Severino SSP, Caldeira SMA. Risco de quedas em idosos residentes na comunidade: revisão sistemática da literatura. Rev Gaúcha Enferm [Internet]. 2016 [cited 2018 Apr 7];37(4). Available from: http://www.scielo.br/pdf/rgenf/v37n4/en_0102-6933-rgenf-1983-144720160455030.pdf
http://www.scielo.br/pdf/rgenf/v37n4/en_...
).

A study conducted in Brasilia, Federal District, evaluated 271 institutionalized elderly and identified a prevalence of falls of 41%. Among the risk factors present in NANDA-I Taxonomy II, foot problems and the gait were strongly correlated with falls in the elderly(2626 Reis KMC. Avaliação de risco de queda em população idosa institucionalizada[Internet]. 2014 [cited 2018 Apr 9]. Available from: http://www.repositorio.unb.br/handle/10482/16848
http://www.repositorio.unb.br/handle/104...
). Gait modifications may be a strategy for increasing stability. With aging, the elderly person tends to modify the gait pattern and assume a decrease in normal arm balance, gait speed, step length, single foot support time, and an exaggerated external rotation of feet(2727 Silva TL, Martinez EZ, Junior APS, Manço ARX, Arruda MF. A associação entre a ocorrência de quedas e a alteração de equilíbrio e marcha em idosos. Rev Saúde Pesqui [Internet]. 2014 [cited 2018 Apr 8];7(1). Available from: http://periodicos.unicesumar.edu.br/index.php/saudpesq/article/view/3169/2206
http://periodicos.unicesumar.edu.br/inde...
).

Regarding cognitive function, in a study conducted in Juiz de Fora, Minas Gerais, was also found an association between cognitive impairment and falls, since the frequency of falls in the group with cognitive impairment was 42%(2828 Teles Da Cruz D, Moreira Da Cruz F, Ribeiro AL, Lagrotta C, Veiga D, Cristina I, et al. Associação entre capacidade cognitiva e ocorrência de quedas em idosos [Internet]. 2015 [cited 2018 Apr 8];23(4):386-93. Available from: http://www.scielo.br/pdf/cadsc/v23n4/1414-462X-cadsc-23-4-386.pdf
http://www.scielo.br/pdf/cadsc/v23n4/141...
). The association of cognitive impairment with falls in the elderly can be explained by the fact that motor and sensory systems are linked by neurological processes, which are related to the needed cognition for motor planning, dual-task attention and responses to environmental circumstances. Thus, elderly subjects with cognitive impairment may have impaired mobility and slower reaction to imbalances, and these aspects favor falls(2929 Bortoli CG, Piovezan MR, Piovesan EJ, Zonta MB. Balance, falls and functionality among elderly persons with cognitive function impairment. Rev Bras Geriatr Gerontol [Internet]. 2015 [cited 2018 Apr 7];18(3):587-97. Available from: http://www.scielo.br/pdf/rbgg/v18n3/en_1809-9823-rbgg-18-03-00587.pdf
http://www.scielo.br/pdf/rbgg/v18n3/en_1...
).

Although in NANDA anemia is considered a physiological risk factor for falls, an interesting fact observed in this study was that anemic elderly were less likely to experience falls. However, were found no studies to corroborate this finding. Only seven elderly had anemia, and just two out of them reported episodes of fall.

The extrinsic factor that increased the risk for falls in the elderly in this study was the use of loose carpets. A study conducted in Foz do Iguaçu, Paraná with a sample of 350 elderly, also identified a statistically significant association between the occurrence of falls and the use of non-slip loose rugs in the kitchen and bedroom(3030 Pereira SG, Santos CB, Doring M, Portella MR, Portella MR. Prevalence of household falls in long-lived adults and association with extrinsic factors. Rev Latino-Am Enfermagem [Internet]. 2017 [cited 2017 Dec 14];25(0):e2900-. Available from: http://www.scielo.br/pdf/rlae/v25/0104-1169-rlae-25-e2900.pdf
http://www.scielo.br/pdf/rlae/v25/0104-1...
). Another study conducted in the Federal District evaluated the homes of 191 elderly and highlighted the following among environmental risk factors for falls in the elderly: lack of support for entering/leaving the bathroom and insufficient use of non-slip mats in the bathroom(3131 Lourenço TS, Lima LR, Santos WS, Souza JMO, Funghetto SS, Karnikowski MGO, et al. Environmental risk factors for falls in the elderly residents of Ceilândia-DF. Rev Mov [Internet]. 2013 [cited 2018 Mar 18];6(2):1984-4298. Available from: http://www.nee.ueg.br/seer/index.php/movimenta/article/viewFile/670/507
http://www.nee.ueg.br/seer/index.php/mov...
).

The Risk for Falls ND has been poorly studied in the context of primary health care. However, results from other studies demonstrate the use of this ND in the scenario of hospitalized(77 Luzia MF, Victor MAG, Lucena AF. Nursing Diagnosis Risk for falls: prevalence and clinical profile of hospitalized patients. Rev Latino-Am Enfermagem [Internet]. 2014 [cited 2017 Nov 29];22(2):262-8. Available from: http://www.scielo.br/pdf/rlae/v22n2/0104-1169-rlae-22-02-00262.pdf
http://www.scielo.br/pdf/rlae/v22n2/0104...
), institutionalized elderly(88 Reis KMC, Jesus CAC. Relação da polifarmácia e polipatologia com a queda de idosos institucionalizados. Texto Contexto Enferm [Internet]. 2017 [cited 2018 Apr];26(2). Available from: http://www.scielo.br/pdf/tce/v26n2/pt_0104-0707-tce-26-02-e03040015.pdf
http://www.scielo.br/pdf/tce/v26n2/pt_01...
) or those in specific conditions, such as in patients with stroke(3232 Morais HCC, Holanda GF, Oliveira ARS, Costa AGS, Ximenes CMB, Araujo TL. Identificação do diagnóstico de enfermagem risco de quedas em idosos com acidente vascular cerebral. Rev Gaúcha Enferm [Internet]. 2012 [cited 2018 Apr 7];33(2):117-24. Available from: http://www.scielo.br/pdf/rgenf/v33n2/17.pdf
http://www.scielo.br/pdf/rgenf/v33n2/17....
) or unstable angina(3333 Vitor AF, Lopes MVO, Araujo TL. Diagnóstico de enfermagem risco de quedas em pacientes com angina instável. Rev Rene [Internet]. 2010 [cited 2018 Mar 18];11(1). Available from: http://periodicos.ufc.br/rene/article/view/4484/3392
http://periodicos.ufc.br/rene/article/vi...
).

Study limitations

The limitation of the study was the absence of home visits to identify environmental risk factors in the elderly’s home. For future studies, is recommended an assessment of these aspects together with elderly subjects’ self-reports of environmental factors.

Contributions to the nursing area, health or public policy

The present study contributed to fill a gap existing to date, of studies evaluating the Risk for Falls ND in the elderly in the context of primary health care. The results showed the importance of using this ND in primary care, especially in the elderly population, preferably in conjunction with additional instruments. The application of this ND in primary care will assist nurses in the initial assessment of risk for falls and guide the decision making in view of the identified risk factors, aiming at the prescription and implementation of specific and appropriate nursing interventions to the needs of every individual.

Considering that the studied sample presented high indices of history of falls and a high number of risk factors, mainly intrinsic, the role of nurses in the integral evaluation of the elderly is critical. These professionals should be aware of the inherent changes to the aging process and focus on the promotion of self-care and education of the elderly and their families regarding the risk for falls and damage prevention strategies. When addressing extrinsic risk factors, nurses and other members of the Family Health Strategy team have a key role in the observation of the home environment for identifying problems and promoting the safety of elderly subjects in their environments.

CONCLUSION

The study identified a high prevalence of history of falls in the elderly. In NANDA-I, the eight intrinsic risk factors related to history of falls were: age ≥ 65 years, cognitive impairment, visual impairment, impaired mobility, sleep deprivation, impaired balance, and neuropathy. The extrinsic risk factors related to the history of falls were the use of insufficient non-slip material in the bathroom and the use of loose carpets in the house.

The intrinsic risk factors of NANDA-I that increased the risk for falls in the elderly with chronic diseases were: use of assistive devices, impaired walking, cognitive impairment and anemia. Regarding the extrinsic factor that increased the risk for falls in the elderly in this study, we highlight the use of loose carpets.

  • FUNDING
    Fundação de Apoio a Pesquisa do Distrito Federal (FAP-DF). Conselho Nacional de Desenvolvimento Cientifico e Tecnológico (CNPq).

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Edited by

EDITOR IN CHIEF: Dulce Barbosa
ASSOCIATE EDITOR: Marcos Brandão

Publication Dates

  • Publication in this collection
    08 July 2020
  • Date of issue
    2020

History

  • Received
    22 Oct 2018
  • Accepted
    19 Aug 2019
Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br