Mortalidade por quedas em idosos no Distrito Federal: características e tendência temporal no período 1996-2017

Resumo Objetivo Descrever e analisar a tendência temporal dos óbitos por quedas em idosos no Distrito Federal, Brasil, no período de 1996 a 2017. Métodos Estudo descritivo, a partir de dados sobre óbitos por quedas do Sistema de Informações sobre Mortalidade, da base de dados do Departamento de Informática do Sistema Único de Saúde do Brasil. Foram investigadas variáveis demográficas, socioeconômicas, tipo de queda e local de ocorrência do óbito. Realizou-se regressão linear segmentada para analisar a variação percentual anual (VPA), adotando-se p≤0,05. Resultados Foram analisados os dados de 2.828 óbitos por quedas em idosos (mulheres, 54,2%; homens, 45,8%). Observou-se aumento do número de óbitos por quedas entre idosos com 80 anos ou mais (VPA=3,0; p<0,001). Conclusão Houve tendência crescente de mortalidade por quedas em idosos ≥80 anos. São necessárias estratégias para redução dos óbitos por quedas, principalmente entre os idosos com idade mais avançada.


INTRODUCTION
Occurrence of falls among the elderly represents a serious public health problem, given the frequency with which it occurs and its consequences, such as femur and hip fractures, which can generate social and economic costs for the elderly, their caregivers and health services. 1,2me 28% to 35% of elderly people suffer an episode of falling per year, with a higher proportion of these accidents, 32% to 42%, after the age of 70. 3 In Brazil, in 2018, there were around 12,000 deaths from falls in people over 60 years of age, 84% of whom were over 70 years of age. 4 In the same period as that covered by this study (1996-2017), there were 118,233 deaths from falls among the elderly in Brazil.The Federal District accounted for 2.4% of deaths due to falls among the elderly, considering the entire Brazilian territory.This is the second highest percentage in the country's Midwest region (27%), coming only behind the state of Goiás (42%). 5nitoring deaths from falls among the elderly is a relevant action for taking measures to prevent and control these accidents, as well as for formulating targeted public policies, with possible repercussions of importance for the health system and society in general.
The objective of this study was to describe the characteristics and analyze the temporal trend of deaths from falls in the elderly, in the Federal District, Brazil, from 1996 to 2017.

METHODS
This was a descriptive study of the temporal trend of deaths from falls among the elderly in the Federal District from 1996 to 2017.
The study site, the Federal District, is located in the Midwest region of the Brazil and occupies an area of 5,779.999km², inhabited by 447,957 elderly people (≥60 years old). 6 analyzed the records of deaths of elderly people living in the Federal District and which were recorded according to Chapter XX of the International Statistical Classification of Diseases and Related Health Problems -Tenth Revision (ICD-10), corresponding to the 'Falls' category and codes W00 to W19. 7 According to this classification, falls can occur on the same level as the victim or involve different levels, such as falling from steps, ladders or chairs.

Main results
Data from 2,828 deaths due to falls among the elderly (female= 54.2%; male = 45.8%).There was an increase in mortality due to falls in the elderly aged 80 years and older.

Implications for services
The occurrence of falls among the elderly represents a major public health problem, due to the frequency with which it happens and its consequences, which may generate social and economic costs for the elderly, caregivers and health services.

Perspectives
Monitoring deaths due to falls among the elderly is relevant for prevention and control measures, as well as the development of public policies, important for the health system and society.
Epidemiologia e Serviços de Saúde, Brasília, 31(1):e2021681, 2022 Technology Department (DATASUS) of the Brazilian National Health System, taking the records for each year studied (1996 to 2017). 5The standard document used to input information to the Mortality Information System is the Declaration of Death.It is a standardized document with three copies and is provided by the Ministry of Health for use throughout the entire country.The Declaration of Death is filled out by the physician or, in his/ her absence, by two qualified persons who witnessed or verified the death.The Declarations of Death are collected by the municipal or state Health Department from the health facility, and the data are input to the Mortality Information System with the objective of informing strategies for public policy monitoring and design in Brazil.
In order to analyze the death time series, we used the records of deaths due to falls, by age group as the dependent variable; while the independent variable was the year in which the deaths occurred.
We calculated the annual rates of death from falls.First we calculated the crude rates (number of deaths from falls among the elderly in the area of interest in the specific year, divided by the population according to age group, in the same area and year, multiplied by 100,000).Then we calculated age-adjusted death rates in order to estimate mortality trends.We used Joinpoint version 4.7 to calculate segmented linear regression in order estimate annual percentage change (APC) in mortality and identify points where there was a change in the trend.
The study project was not submitted for approval by a research ethics committee with regard to data collection, analysis and publication of the results, since the study used public domain data.

RESULTS
There were 2,828 records of deaths from falls in the elderly during the study period, and none were excluded.Among these, 54.2% were female and 45.8% were male, with a predominance of those aged 80 years or older (58.0%), those of white race/skin color (54.6%), widowed (39.6%) and with 1 to 7 years of schooling (41.5%).Regarding cause of death, we found a higher prevalence of the following categories: 'W18 -Other fall on same level' (70-79 years, 47.2%; ≥80 years, 52.1%) and 'W19 -Unspecified fall' (60-69 years, 35.4%) (Table 1).
Analysis of deaths from falls among the elderly, according to year and place of occurrence, revealed that hospitals were the main place of death (94.8%), followed by deaths at home (4.1%), in all years of the time series (Table 2).
Analysis of the trend of deaths from falls, according to the age groups defined (60-69, 70-79 and ≥80 years), showed statistically significant positive inflection points in the trend curve only for the population aged 80 years and older (APC=3.0;95%CI 1.2; 4.9; p<0.001).We found a decrease (60-69 years) and an increase (70-79 years) in the trend of deaths from falls, although these results were not statistically significant (Table 3).

DISCUSSION
Between 1996 and 2017, deaths from falls in the Federal District increased as age increased, being more frequent in the elderly aged 80 or over, compared to those who were 60 to 69 years old.There was a higher proportion of deaths due to falls among female sex, those who were older, widowed and had low schooling.The hospital setting was the most frequent location of reported cases of deaths from falls, with 'Other fall on same level' being the most frequent type of fall.In the period studied (1996-2017), there was an increasing trend of deaths from falls among the elderly aged 80 or over.This research was based on secondary data and was, therefore, subject to typing and recording errors.However, because it is official national data, which is required to be filled out in all health services, we believe that the information is reliable and enabled the proposed objectives to be achieved.10] Higher occurrence of deaths in older elderly people may be related to physiological changes resulting from advancing age, characterized by decreased bone and muscle mass and increased fat tissue, these being processes that can compromise the functioning of the musculoskeletal system, 11 as well as being related to use of psychotropic medications, such as antipsychotics and antidepressants, 12 and polypharmacy (use of five or more medications). 13aths from falls occurred mainly among widowed elderly people, corroborating data in the literature.National population-based and longitudinal studies on factors associated with falls indicate that living with a partner may result in mutual care and lower occurrence of these events. 14,15Based on 17 longitudinal and crosssectional studies, with samples ranging from 200 to 43,367 elderly people, published between 2003 and 2019, a systematic review demonstrated that loneliness, social isolation and living alone were factors significantly associated with falls among the elderly. 16currence of deaths from falls in the elderly was higher among those who, although they were literate, had low levels of schooling (1 to 7 years), and who, in most cases, have lower income and only basic living and health conditions.[19] Falls leading to death in the hospital environment accounted for approximately 95% of cases.However, this information is not enough in the context of fall prevention, because it is important to know where the falls occurred in order to achieve better targeting of strategies to modify environments.[22] Other falls on the same level were the most frequent type of fall, accounting for about half of the deaths from falls.This coincides with data found in the literature. 20,23This type of fall can occur due to intrinsic factors (prior history of falls, advancing age, use of medications, presence of metabolic, neurological or osteoarticular diseases, visual impairment, functional dependence) and extrinsic factors (inadequate lighting, slippery surfaces, obstacles, rugs, steps, absence of handrails). 24We found a high number of deaths from falls that were not properly specified, possibly resulting from shortcomings in the quality of information recorded on the Declarations of Death.
][27][28] A national ecological study, conducted between 1996 and 2012, found a 200% increase in the elderly mortality rate due to falls in Brazilian state capitals. 25 study conducted using data from the Brazilian Hospital Information System (1998-2015), found an increasing trend in hospitalization, mortality and case fatality rates due to falls among the elderly (4.5%). 26 conclusion, we found an increasing trend in mortality from falls in the elderly aged 80 and over in the Federal District between 1996 and 2017.This increase may reflect changes in demographic, socioeconomic and behavioral profiles, associated with population aging.Strategies are needed to reduce deaths from falls, especially among older adults, such as use of the Elderly Person's Health Booklet, a record and guidance document used by the Brazilian National Health System that allows identification of risk of falls and offers guidance on self-care.