Risk for falls among community-dwelling older people: systematic literature review

Luís Manuel Mota Sousa Cristina Maria Alves Marques-Vieira Maria Nilza Guimarães Nogueira de Caldevilla Cristina Maria Alves Dias Henriques Sandy Silva Pedro Severino Sílvia Maria Alves Caldeira About the authors

RESUMO

Objetivo

Identificar fatores de risco de queda em idosos residentes na comunidade para atualização da taxonomia II da NANDA Internacional.

Método

Revisão sistemática da literatura, com pesquisa na plataforma EBSCOHost®, na CINAHL e MEDLINE, no período de dezembro de 2010 a dezembro de 2014. Utilizaram-se os descritores (Fall* OR Accidental Fall) AND (Community Dwelling OR Community Health Services OR Primary health care) AND (Risk OR Risk Assessment OR Fall Risk Factors) AND (Fall* OR Accidental Fall) AND (Community Dwelling OR older) AND Nurs* AND Fall Risk Factors.

Resultados

Obteve-se uma amostra de 62 estudos e um total de 50 fatores de risco, dos quais, apenas 38 estão presentes na classificação.

Conclusões

São propostas duas novas categorias de fatores: os psicológicos e socioeconômicos. Foram identificados novos fatores de risco de queda dos idosos residentes na comunidade, o que contribui para a atualização deste diagnóstico na taxonomia II da NANDA Internacional.

Acidentes por quedas; Fatores de risco; Diagnóstico de enfermagem; Idoso

RESUMEN

Objetivo

Identificar los factores de riesgo de caídas en los ancianos residentes en la comunidad.

Método

Revisión sistemática de la literatura. La búsqueda fue realizada en plataforma EBSCOHost®, en CINAHL y MEDLINE, entre diciembre de 2010 y diciembre de 2014. Los descriptores utilizados fueron (Fall* OR Accidental Fall) AND (Community Dwelling OR Community Health Services OR Primary health care) AND (Risk OR Risk Assessment OR Fall Risk Factors) AND (Fall* OR Accidental Fall) AND (Community Dwelling OR older) AND (Nurs*) AND (Fall Risk Factors).

Resultados

Fueron seleccionados 62 artículos en los cuales se identificaron 50 factores de riesgo, de los que apenas 38 están presentes en la NANDA Internacional.

Conclusiones

Se proponen dos nuevas categorías de factores: los psicológicos y los socioeconómicos. Se identificaron nuevos factores de riesgo de caídas en los ancianos residentes en la comunidad, lo que contribuyó para la actualización de la taxonomía II NANDA Internacional.

Accidentes por caídas; Factores de riesgo; Diagnóstico de enfermería; Anciano

ABSTRACT

Objective

To identify the risk factors for falls of the community-dwelling elderly in order to update the Taxonomy II of NANDA International.

Method

A systematic literature review based on research using the following platforms: EBSCOHost®, CINAHL and MEDLINE, from December 2010 to December 2014. The descriptors used were (Fall* OR Accidental Fall) AND (Community Dwelling OR Community Health Services OR Primary health care) AND (Risk OR Risk Assessment OR Fall Risk Factors) AND (Fall* OR Accidental Fall) AND (Community Dwelling OR older) AND Nurs* AND Fall Risk Factors.

Results

The sample comprised 62 studies and 50 risk factors have been identified. Of these risk factors, only 38 are already listed in the classification.

Conclusions

Two new categories of risk factors are proposed: psychological and socio-economical. New fall risk factors for the community-dwelling elderly have been identified, which can contribute to the updating of this nursing diagnosis of the Taxonomy II of NANDA International.

Accidental falls; Risk factors; Nursing diagnosis; Aged

INTRODUCTION

A fall is an unexpected event, in which a person moves from a higher level to a lower level of the floor(11. Caldevilla M, Costa M, Teles P, Ferreira PM. Evaluation and cross-cultural adaptation of the Hendrich II Fall Risk Model to Portuguese. Scand J Caring Sci. 2013 Jun 1;27(2):468-74.). Preventing the injuries associated with this event is crucial, especially among the elderly(22. Miake-Lye EM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158 (5 Pt 2):390-6.) due to the morbidity and mortality that this event brings, and because it is one of the leading causes of hospitalisation among this population(33. Ministério da Saúde (PT). Despacho nº 1400-A/2015. Plano Nacional para a Segurança dos Doentes (PNSD) 2015-2020. Diário da República, 2ª série. 2015 fev 10 (28):3882(2-10).). The global annual fall rate among people over 65 years of age is between 28% and 35%, and 32% to 42% in people over 70 years of age(33. Ministério da Saúde (PT). Despacho nº 1400-A/2015. Plano Nacional para a Segurança dos Doentes (PNSD) 2015-2020. Diário da República, 2ª série. 2015 fev 10 (28):3882(2-10).). Therefore, the risk for falls should be the focus of nursing care for community-dwelling older people.

The ability to establish the nursing diagnosis risk of falls requires knowledge on the multifactorial nature of falls, namely, the risk factors for falls that contributed to the event. The fall history, medication, and deficits in mobility, muscle strength, gait and balance, have been described in the literature as frequent fall risk factors(44. Sturnieks DL, George R, Lord SR. Balance disorders in the elderly. Neurophysiol Clin. 2008;38:467-78.-55. Baixinho C, Dixe MA. Monitoramento de episódios de quedas em instituição para idosos. Rev Eletr Enf. 2014;16(1):28-34.), and they are included in NANDA International (NANDA-I) as risk factors for the nursing diagnosis risk for falls (00155).

The nursing diagnosis “Risk for falls” (00155) is defined as “increased susceptibility to falling that may cause physical harm”(6, p. 384). This means that the susceptibility of the elderly to falls depends on the risk factors they may have. For adults, the risk factors listed in the NANDA-I are: age greater than or equal to 65 years, history of falls, living alone, lower limb prosthesis, and use of assistive devices. The environmental factors are: cluttered environment, exposure to conditions of insecurity related to weather conditions (e.g., wet floor, ice), dimly-lit room, no anti-slip material in bath and/or shower, unfamiliar room, restraints, throw/scatter rugs. The pharmacologic agents listed as risk factors are alcohol use and drugs. The physiological factors are acute illness, blood sugar changes, anaemia, arthritis, foot problems, decreased lower extremity strength, diarrhoea, difficulty with gait, faintness when extending the neck, faintness when turning the neck, hearing difficulties, impaired balance, impaired physical mobility, incontinence, neoplasms, neuropathy, orthostatic hypotension, postoperative conditions, proprioceptive deficits, insomnia, urinary urgency, vascular disease, and visual difficulties. Finally the cognitive factors are related to changes in cognitive function(66. Herdman TH, Kamitsuru S, editors. NANDA International Nursing Diagnoses: definitions and classification 2015-2017. Oxford: Wiley-Blackwell; 2014.).

For the clinical practice of community nursing, it is essential to assess the risk for falls based on the multifactorial nature of the event. The use of standard classifications and languages that represent current knowledge is also desirable. When nurses are provided with the right information to an accurate diagnosis they can intervene appropriately and obtain positive outcomes in the health of the elderly. Moreover, in-depth reviews on the reported concepts of diagnosis and its elements, and clinical research that provides clinical evidence can essentially improve the basis of this clinical practice.

Consequently, we based the systematic literature review (SLR) on the following research question: What are the risk factors for falls of community-dwelling older people?

The SLR can be used to obtain an accurate assessment and a summary of the scientific evidence with minimal biases that can be reproduced(77. Bettany-Saltikov, J. How to do a systematic literature review in Nursing: a step-by-step guide. Berkshire: McGraw-Hill International; 2012.). Systematic methods are specifically used to identify, select, critically evaluate, and synthesize research evidence that can be used to solve a particular problem of clinical practice(88. Grove SK, Burns N, Gray JR. The practice of nursing research: appraisal, synthesis and generation of evidence. 7th ed. St. Louis: Elsevier Saunders; 2013.).

METHODOLOGY

The historical review of the NANDA-I nursing diagnosis risk for falls was used to extract information on the inclusion date (2000)(99. North American Diagnosis Association, organizador. Diagnósticos de enfermagem da NANDA: definições e classificação 2001-2002. Porto Alegre: Artmed; 2002. 288 p.) and review date (2013) of the diagnosis. Based on these data and on the evidence that is currently available on this phenomenon, a SLR has been considered the most adequate method, as itonly included the original research studies.

The review question and inclusion criteria has been based on JBI guidelines of the Joanna Briggs Institute (JBI)(1010. The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011.)and the research questions were created according to the PICo format, which considered Population (P), the elderly; Interest Area/Intervention (I), fall risk factors; Context (Co), community.

In this study, we used the seven stages recommended for the SLR(1111. Galvão CM, Sawada NO, Trevizan MA. Revisão sistemática: recurso que proporciona a incorporação das evidências na prática da enfermagem. Rev Latino-Am Enfermagem. 2004; 12(3):549-56.): construction of the protocol; adaptation of the question; studies search; selection; critical evaluation of the studies; data collection; and summary of findings. The steps were: collection of scientific evidence on the fall risk of community-dwelling older people, and related risk factors; identification of types of research and methodological procedures; description and critical analysis of the results, and, finally, synthesis of the results.

The online search was performed in January 2015 via the EBSCOHost® platform and in the databases CINAHL and Complete and MEDLINE Complete. The search terms were: (Fall* OR Accidental Fall) AND (Community Dwelling OR Community Health Services OR Primary health care) AND (Risk OR Risk Assessment OR Fall Risk Factors) AND (Fall* OR Accidental Fall) AND (Community Dwelling OR older) AND Nurs* AND Fall Risk Factors. The searches were based on the presence of these terms in the abstract.

In addition to the criteria defined by the question and PICo format, only studies with the full text available in Portuguese, English or Spanish, published between December 2010 and December 2014, and with an experimental, quasi-experimental, cohort or quantitative descriptive design have been included. Studies that referred to institutionalized older people were excluded from the research.

Research was independently conducted by two reviewers to ensure the accuracy of the method and the accuracy of the results. The articles included in the sample were selected using the sequence: reading of the title, reading of the abstract, and reading of the full text. In case the reviewers disagreed, the articles were included in the stage that followed analysis.

The guidelines of the JBI(1010. The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011.) and the Registered Nurses` Association of Ontario(1212. Registered Nurses’ Association of Ontario (CA). Falls prevention: building the foundations for patient safety: a self learning package. Toronto: RNAO; 2007.) were applied to classify the levels of evidence (LE).

Finally, we applied the JBI tables related to controlled and random clinical trials; cohort studies/case control studies; descriptive studies/case series studies, economic evaluation studies(1010. The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011.)and systematic reviews(1313. Bugalho A, Carneiro AV. Intervenções para aumentar a adesão terapêutica em patologias crónicas. Lisboa: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina; 2004.) to assess the feasibility, appropriateness, significance and effectiveness of the articles for the SLR. At this stage, 4 studies that did not meet at least 75% of these criteria were excluded(1010. The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011., 1313. Bugalho A, Carneiro AV. Intervenções para aumentar a adesão terapêutica em patologias crónicas. Lisboa: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina; 2004.)(Figure 1).

Figure 1
– Mapping of article identification, analysis, and selection

All the new terms in English related to risk factors for falls in this review and the risk factors in the NANDA-I were translated into European Portuguese by two independent translators.

A table was used for the full reading of the articles to systematize the information and to help process and interpret the data.

Since the aim of this study was the articles, intellectual property was observed by fully and accurately citing the authors of all the articles used as the sample of this study(1414. Nunes L. Considerações éticas a atender nos trabalhos de investigação académica de enfermagem. Setubal: Instituto Politécnico de Setubal, Escola Superior de Saúde, Departamento de Enfermagem; 2013.-1515. Polit DF, Beck CT. Fundamentos de pesquisa em enfermagem: avaliação de evidências para a prática da enfermagem. Porto Alegre: Artmed; 2011.).

RESULTS

Of the 62 articles included in this review, 60% were published in 2012 (16-34) and 2013 (3535. de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.

36. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.

37. Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8.

38. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.

39. Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.

40. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.

41. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62.

42. Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.

43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.

44. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.

45. Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7.

46. Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.

47. Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.

48. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.

49. Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5.

50. Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053.

51. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.
-5252. Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.). The articles are from 15 different countries, but especially from the United States of America(1818. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.-1919. Elliott SJ, Ivanescu A, Leland NE, Fogo J, Painter JA, Trujillo LG. Feasibility of interdisciplinary community-based fall risk screening. Am J Occup Ther. 2012;66(2):161-8.,2424. Kelsey JL, Procter-Gray E, Berry SD, Hannan M, Kiel DP, Lipsitz LA, et al. Reevaluating the implications of recurrent falls in older adults: location changes the inference. J Am Geriatr Soc. 2012;60(3):517-24.-2525. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.,3030. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.,3333. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.,3939. Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.,5353. Buracchio TJ, Mattek NC, Dodge HH, Hayes TL, Pavel M, Howieson DB, et al. Executive function predicts risk of falls in older adults without balance impairment. BMC Geriatr. 2011;11:74.

54. Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85

55. Fischer BL, Gleason CE, Gangnon RE, Janczewski J, Shea T, Mahoney JE. Declining cognition and falls: role of risky performance of everyday mobility activities. Phys Ther. 2014;94(3):355-62.

56. Gangavati A, Hajjar I, Quach L, Jones RL, Kiely DK, Gagnon P, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59(3):383-9.

57. Honaker JA, Shepard NT. Use of the Dynamic Visual Acuity Test as a screener for community-dwelling older adults who fall. J Vestib Res. 2011;21(5):267-6.

58. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R, et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(12):815-25.

59. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31

60. Quach L, Galica AM, Jones RN, Procter-Gray E, Manor B, Hannan MT, et al. The nonlinear relationship between gait speed and falls: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc. 2011;59(6):1069-73.
-6161. Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.)and Australia(1717. Currin ML, Comans TA, Heathcote K, Haines TP. Staying safe at home: home environmental audit recommendations and uptake in an older population at high risk of falling. Australas J Ageing. 2012;31(2):90-5.,2828. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.,3232. Taylor ME, Ketels MM, Delbaere K, Lord SR, Mikolaizak AS, Close JC. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators. Age Ageing. 2012;41(5):665-9.,3434. Zheng JJ, Lord SR, Close JC, Sachdev PS, Wen W, Delbaere K, et al. Brain white matter hyperintensities, executive dysfunction, instability, and falls in older people: a prospective cohort study. J Gerontol. 2012;67(10):1085-91.,3636. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.,4242. Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.,4444. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.,4646. Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.-4747. Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.,5252. Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.,6262. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci. 2011;66(6):674-80.

63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.
-6464. Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.), with 16 and 13 studies, respectively. The other countries with most articles were Canada(2323. Jenkyn KB, Hoch JS, Speechley M. How much are we willing to pay to prevent a fall? Cost-effectiveness of a multifactorial falls prevention program for community-dwelling older adults. Can J Aging. 2012;31(2):121-37., 2929. Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age Ageing. 2012;41(3):299-308., 4040. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46., 6565. Arnold CM, Faulkner RA, Gyurcsik NC. The relationship between falls efficacy and improvement in fall risk factors following an exercise plus educational intervention for older adults with hip osteoarthritis. Physiother Can. 2011;63(4):410-20.

66. Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.

67. Hsu CL, Voss MW, Handy TC, Davis JC, Nagamatsu LS, Chan A, et al. Disruptions in brain networks of older fallers are associated with subsequent cognitive decline: a 12-month prospective exploratory study. PloS One. 2014;9(4): e93673.
-6868. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.)with seven, Netherlands(2020. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5., 3131. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65., 3535. de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403., 5151. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286., 6969. Peeters GM, Heymans MW, de Vries OJ, Bouter LM, Lips P, van Tulder MW. Multifactorial evaluation and treatment of persons with a high risk of recurrent falling was not cost-effective. Osteoporos Int. 2011;22(7):2187-96.)with five, and United Kingdom(4848. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70., 7070. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.

71. Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. J Am Geriatr Soc. 2011;59(1):26-33.
-7272. Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.)with four. Then came China(2626. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51., 5050. Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053., 7373. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.), France(4545. Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7., 4949. Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5., 7474. Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.) and Sweden (3737. Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8.-3838. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.,4141. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62.), with two, Ireland (7575. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14.-7676. O’Halloran AM, Pénard N, Galli A, Fan CW, Robertson IH, Kenny RA. Falls and falls efficacy: the role of sustained attention in older adults. BMC Geriatr. 2011;11:85.)with one, and Germany(2121. Freiberger E, Häberle L, Spirduso WW, Zijlstra GA. Long-term effects of three multicomponent exercise interventions on physical performance and fall-related psychological outcomes in community-dwelling older adults: a randomized controlled trial. J Am Geriatr Soc. 2012;60(3):437-46.), Brazil(1616. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.), Korea(2626. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.), Spain(7777. Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.), Japan(2222. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.), and Thailand(4343. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.).

Six of the selected studies are secondary (systematic literature reviews) and the remaining 56 are primary studies based on quantitative methodology, i.e. seven random controlled clinical trials, two quasi-experimental studies, 20 cohort studies, and 27 descriptive studies. Of the analysed studies, six were SLR with a la level of evidence(2929. Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age Ageing. 2012;41(3):299-308., 4141. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62., 4545. Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7., 5858. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R, et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(12):815-25., 6363. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53., 7575. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14.)and seven were randomized clinical trials with a Ib level of evidence(2121. Freiberger E, Häberle L, Spirduso WW, Zijlstra GA. Long-term effects of three multicomponent exercise interventions on physical performance and fall-related psychological outcomes in community-dwelling older adults: a randomized controlled trial. J Am Geriatr Soc. 2012;60(3):437-46., 2323. Jenkyn KB, Hoch JS, Speechley M. How much are we willing to pay to prevent a fall? Cost-effectiveness of a multifactorial falls prevention program for community-dwelling older adults. Can J Aging. 2012;31(2):121-37., 3737. Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8., 5555. Fischer BL, Gleason CE, Gangnon RE, Janczewski J, Shea T, Mahoney JE. Declining cognition and falls: role of risky performance of everyday mobility activities. Phys Ther. 2014;94(3):355-62., 6565. Arnold CM, Faulkner RA, Gyurcsik NC. The relationship between falls efficacy and improvement in fall risk factors following an exercise plus educational intervention for older adults with hip osteoarthritis. Physiother Can. 2011;63(4):410-20., 6969. Peeters GM, Heymans MW, de Vries OJ, Bouter LM, Lips P, van Tulder MW. Multifactorial evaluation and treatment of persons with a high risk of recurrent falling was not cost-effective. Osteoporos Int. 2011;22(7):2187-96., 7171. Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. J Am Geriatr Soc. 2011;59(1):26-33.). The quasi-experimental studies were two, one with a IIa(1717. Currin ML, Comans TA, Heathcote K, Haines TP. Staying safe at home: home environmental audit recommendations and uptake in an older population at high risk of falling. Australas J Ageing. 2012;31(2):90-5.)level of evidence and one with a IIb level of evidence. Finally, 47 of the studies had a III level of evidence(1616. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.,1818. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.,2020. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.,2222. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.,2424. Kelsey JL, Procter-Gray E, Berry SD, Hannan M, Kiel DP, Lipsitz LA, et al. Reevaluating the implications of recurrent falls in older adults: location changes the inference. J Am Geriatr Soc. 2012;60(3):517-24.

25. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.

26. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.

27. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.
-2828. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.,3030. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.

31. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.

32. Taylor ME, Ketels MM, Delbaere K, Lord SR, Mikolaizak AS, Close JC. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators. Age Ageing. 2012;41(5):665-9.

33. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.

34. Zheng JJ, Lord SR, Close JC, Sachdev PS, Wen W, Delbaere K, et al. Brain white matter hyperintensities, executive dysfunction, instability, and falls in older people: a prospective cohort study. J Gerontol. 2012;67(10):1085-91.

35. de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.
-3636. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.,3838. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.

39. Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.
-4040. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.,4242. Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.

43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.
-4444. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.,4646. Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.

47. Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.

48. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.

49. Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5.
-5050. Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053.,5252. Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.,5454. Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85,5757. Honaker JA, Shepard NT. Use of the Dynamic Visual Acuity Test as a screener for community-dwelling older adults who fall. J Vestib Res. 2011;21(5):267-6.,5959. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31

60. Quach L, Galica AM, Jones RN, Procter-Gray E, Manor B, Hannan MT, et al. The nonlinear relationship between gait speed and falls: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc. 2011;59(6):1069-73.
-6161. Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.,6363. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.-6464. Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.,6666. Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.

67. Hsu CL, Voss MW, Handy TC, Davis JC, Nagamatsu LS, Chan A, et al. Disruptions in brain networks of older fallers are associated with subsequent cognitive decline: a 12-month prospective exploratory study. PloS One. 2014;9(4): e93673.
-6868. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.,7070. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.,7272. Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.

73. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.
-7474. Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.,7676. O’Halloran AM, Pénard N, Galli A, Fan CW, Robertson IH, Kenny RA. Falls and falls efficacy: the role of sustained attention in older adults. BMC Geriatr. 2011;11:85.-7777. Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.), with 20 cohort studies(2222. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.,2424. Kelsey JL, Procter-Gray E, Berry SD, Hannan M, Kiel DP, Lipsitz LA, et al. Reevaluating the implications of recurrent falls in older adults: location changes the inference. J Am Geriatr Soc. 2012;60(3):517-24.-2525. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.,2828. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.,3131. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.-3232. Taylor ME, Ketels MM, Delbaere K, Lord SR, Mikolaizak AS, Close JC. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators. Age Ageing. 2012;41(5):665-9.,3434. Zheng JJ, Lord SR, Close JC, Sachdev PS, Wen W, Delbaere K, et al. Brain white matter hyperintensities, executive dysfunction, instability, and falls in older people: a prospective cohort study. J Gerontol. 2012;67(10):1085-91.,4040. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.,4242. Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.

43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.
-4444. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.,4646. Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.-4747. Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.,5151. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.

52. Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.
-5353. Buracchio TJ, Mattek NC, Dodge HH, Hayes TL, Pavel M, Howieson DB, et al. Executive function predicts risk of falls in older adults without balance impairment. BMC Geriatr. 2011;11:74.,5959. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31-6060. Quach L, Galica AM, Jones RN, Procter-Gray E, Manor B, Hannan MT, et al. The nonlinear relationship between gait speed and falls: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc. 2011;59(6):1069-73.,7070. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.,7777. Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.)and 27 descriptive and correlational studies(1616. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.,1818. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.,2020. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.,2626. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.-2727. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.,3030. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.,3333. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.,3535. de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.-3636. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.,3838. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.-3939. Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.,4848. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.

49. Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5.
-5050. Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053.,5454. Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85,5757. Honaker JA, Shepard NT. Use of the Dynamic Visual Acuity Test as a screener for community-dwelling older adults who fall. J Vestib Res. 2011;21(5):267-6.,6161. Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.-6262. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci. 2011;66(6):674-80.,6464. Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.,6666. Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.

67. Hsu CL, Voss MW, Handy TC, Davis JC, Nagamatsu LS, Chan A, et al. Disruptions in brain networks of older fallers are associated with subsequent cognitive decline: a 12-month prospective exploratory study. PloS One. 2014;9(4): e93673.
-6868. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.,7272. Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.

73. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.
-7474. Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.,7676. O’Halloran AM, Pénard N, Galli A, Fan CW, Robertson IH, Kenny RA. Falls and falls efficacy: the role of sustained attention in older adults. BMC Geriatr. 2011;11:85.)

The samples in the primary studies ranged from 27(4848. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.) to 21,020(2020. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.)community-dwelling elderly participants.

In this SLR, only one study was conducted in the field of nursing. The aim of the study was to determine housing, environment, and health factors in Korean women who fall at home, and recurrent falls in the community(2727. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.).

A total of 50 risk factors for falls were identified in this review, and organised according to the NANDA-I categories (Chart 1).

Table 1
– Comparative synthesis of factors found in the SLR and the factors classified in the NANDA-I. Lisbon, 2015.

With regard to adults and as mentioned above, NANDA-I presents the risk indicators in six categories. However, this SLR allowed the addition of two categories that were named, by common agreement, psychological factors and socio-economic factors. In the personal factors (adult), the most prevalent risk factors in relation to the NANDA-I were history of falls (n = 7), old age (n = 6), and female (n = 8).

In the category of environmental factors, the identified risk for falls were: cluttered environment (n = 4), no anti-slip material on bath/shower (n = 4), and dimly lit room (n = 3). However, two additional risk factors for falls were referenced, namely, access to external areas without grab bars and handrails/obstacle of the doorway (n = 3), and toilets without grab bars (n = 1).

In the pharmacological agents group, there was a reference to drugs in general (n = 14), poly-medication (n = 11), antihypertensive agents (n = 2), and benzodiazepines (n = 2). The studied antihypertensive agents were diuretics, angiotensin converting enzyme inhibitors, calcium channel blockers, beta-adrenergic blockers(5353. Buracchio TJ, Mattek NC, Dodge HH, Hayes TL, Pavel M, Howieson DB, et al. Executive function predicts risk of falls in older adults without balance impairment. BMC Geriatr. 2011;11:74., 6363. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.).

The category of cognitive factors consists of one identified NANDA-I factor: change in cognitive function (n = 8). However, another factor was identified in this review: diminished executive functions (n = 3).

The category of physiological factors consists of 23 risk factors in NANDA-I. The most frequently identified factors in this category were: difficulty with gait (n = 13), impaired balance (n = 13), visual difficulties (n = 10), orthostatic hypotension (n = 5), decreased lower extremity strength (n = 4), blood sugar changes (n = 3), limited mobility (n = 3), vascular disease (n = 3), insomnia (n = 2), arthritis (n = 2), urinary incontinence (n = 1), and urinary urgency (n = 1). Other fall risk factors were confirmed for community-dwelling older people, especially the decline of basic activities of daily living (n = 10), associated comorbidity/chronic disease (n = 6), chronic pain (n = 5), decline of instrumental activities of daily living (n = 4), and arterial hypertension (n = 4). Additional factors were detected and presented in the table. The comorbidities were cardiopulmonary diseases, metabolic diseases, neurological diseases, sensory diseases, stroke, and cancer (1717. Currin ML, Comans TA, Heathcote K, Haines TP. Staying safe at home: home environmental audit recommendations and uptake in an older population at high risk of falling. Australas J Ageing. 2012;31(2):90-5.,4343. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.,6464. Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.). With respect to chronic diseases, the studies referred to hypertension, arthritis, visual difficulties, COPD, diabetes, and heart disease (2727. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.-2828. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.,6868. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.). Metabolic syndrome corresponds to the presence of abdominal obesity, hypertriglyceridemia, hypertension, and impaired glucose tolerance (2626. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.).

In the category of psychological factors, the studies confirmed the fear of falling (n = 14) as one of the most important risk factors for falls in community-dwelling older people. This fear of falling is associated with the activities of daily living (basic and instrumental), such as hygiene, getting dressed/undressed, using the toilet, going up and down stairs, using public transportation, and shopping. The symptoms of depression/depression (n = 8) were confirmed as risk factors for falls in community-dwelling older people. The depressive symptoms were more prevalent in older people with recurring falls (44.7% versus 25%)(6161. Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.). Anxiety (n = 2) was also confirmed as a risk factor. Finally, the socio-economic factors consist of low education (n = 1), low family income (n = 1), and black/ethnic minority group (n = 1), all listed in a single study.

DISCUSSION

The discussion of results should focus on the implications of the presented evidence regarding decisions for the clinical practice. This, and the guiding question, revealed that the risk factors for falls that are not listed in the NANDA-I are female (women are more prone to falls in the community)(2020. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.,3838. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.,4040. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.,5959. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31,6363. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.,7373. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.-7474. Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.,7777. Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.), compromised activities of daily living (basic and instrumental)(1616. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.,2222. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.,2525. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.,3131. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.,3333. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.,5454. Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85-5555. Fischer BL, Gleason CE, Gangnon RE, Janczewski J, Shea T, Mahoney JE. Declining cognition and falls: role of risky performance of everyday mobility activities. Phys Ther. 2014;94(3):355-62.,6363. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.,7070. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.,7373. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.), the fear of falling(3030. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.,3636. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.

37. Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8.
-3838. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.,4444. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.,5151. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.,5959. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31,6262. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci. 2011;66(6):674-80.-6363. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.,6666. Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.,7070. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.

71. Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. J Am Geriatr Soc. 2011;59(1):26-33.
-7272. Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.), symptoms of depression/depression (1818. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7., 3030. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76., 4343. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15., 4545. Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7., 5151. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286., 5959. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31, 6363. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.), and lastly, low education(7070. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.), low family income(7070. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.), and ethnic minorities(7070. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.). As for the level of evidence of these risk factors, we found that symptoms of depression/depression and female are mentioned in at least two papers , and compromised activities of daily living and fear of falling are mentioned in at least three random clinical trials (Ib evidence). However, the other risk factors are described in level III studies. Regarding the recommendation for the clinical practice and additions to the NANDA-I, there is evidence of recommendations in the nursing diagnosis of the fall risk factors symptoms of depression/depression, female, compromised activities of daily living, and fear of falling.

Based on the results of the SLR and the proposal of NANDA-I for risk factors for falls in community-dwelling older people, we confirmed the multifactorial nature of risk factors that requires comprehensive, interdisciplinary, and multifactorial/multicomponent interventions(4141. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62., 6969. Peeters GM, Heymans MW, de Vries OJ, Bouter LM, Lips P, van Tulder MW. Multifactorial evaluation and treatment of persons with a high risk of recurrent falling was not cost-effective. Osteoporos Int. 2011;22(7):2187-96.).

Thus, our SLR contributes to the knowledge of nurses by transferring these findings to the clinical practice, which supports the provision of evidence-based nursing care.

Recent studies with the elderly population indicate that the risk of falling increases with the number of risk factors, and each year the risk of falling of the elderly doubles with each additional risk factor(7878. Al-Aama, T. Falls in the elderly: spectrum and prevention. Can Fam Physician. 2011;57(7):771-6.).

Therefore, it is important to understand the multiple risk factors involved in this event in order to make appropriate assessments that target the older people who live in the community. The risk factors for falls of community-dwelling older people include environmental risk factors, pharmacologic agents, cognitive risk factors, physiological risk factors, psychological risk factors, and socio-economic risk factors.

CONCLUSIONS

This SLR identified risk factors associated with the nursing diagnosis risk for falls in community-dwelling older people. Some of these factors are already listed in NANDA-I and others were not. Therefore, one of the purposes of this review was the submission of these results to the commission for the development of diagnostics of NANDA-I.

Moreover, the implication of this SLR for the clinical practice of community nursing is the addition of the fall risk factors symptoms of depression/depression, female, compromised activities of daily living, and fear of falling in the diagnosis.

For nursing education, this SLR reveals the need to offer further training in this area, and consequently, the need for increasing the scientific production in nursing. In fact, only one of the studies that integrated the SLR was conducted by nurses. Therefore, we suggest further studies, especially those that aim to clinically validate nursing diagnoses.

The limitation of this study was the criterion to only include papers with full text available.

Finally, more importantly than reporting findings, we believe that incorporating the information presented here to the daily clinical practice can improve the quality of community nursing care.

The classifications and standard languages should represent the clinical practice, and they must be functional and comprehensive since they also represent nursing knowledge. Thus, studies such as this one do not only enhance the practice, but also the education of new nurses.

References

  • 1
    Caldevilla M, Costa M, Teles P, Ferreira PM. Evaluation and cross-cultural adaptation of the Hendrich II Fall Risk Model to Portuguese. Scand J Caring Sci. 2013 Jun 1;27(2):468-74.
  • 2
    Miake-Lye EM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158 (5 Pt 2):390-6.
  • 3
    Ministério da Saúde (PT). Despacho nº 1400-A/2015. Plano Nacional para a Segurança dos Doentes (PNSD) 2015-2020. Diário da República, 2ª série. 2015 fev 10 (28):3882(2-10).
  • 4
    Sturnieks DL, George R, Lord SR. Balance disorders in the elderly. Neurophysiol Clin. 2008;38:467-78.
  • 5
    Baixinho C, Dixe MA. Monitoramento de episódios de quedas em instituição para idosos. Rev Eletr Enf. 2014;16(1):28-34.
  • 6
    Herdman TH, Kamitsuru S, editors. NANDA International Nursing Diagnoses: definitions and classification 2015-2017. Oxford: Wiley-Blackwell; 2014.
  • 7
    Bettany-Saltikov, J. How to do a systematic literature review in Nursing: a step-by-step guide. Berkshire: McGraw-Hill International; 2012.
  • 8
    Grove SK, Burns N, Gray JR. The practice of nursing research: appraisal, synthesis and generation of evidence. 7th ed. St. Louis: Elsevier Saunders; 2013.
  • 9
    North American Diagnosis Association, organizador. Diagnósticos de enfermagem da NANDA: definições e classificação 2001-2002. Porto Alegre: Artmed; 2002. 288 p.
  • 10
    The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011.
  • 11
    Galvão CM, Sawada NO, Trevizan MA. Revisão sistemática: recurso que proporciona a incorporação das evidências na prática da enfermagem. Rev Latino-Am Enfermagem. 2004; 12(3):549-56.
  • 12
    Registered Nurses’ Association of Ontario (CA). Falls prevention: building the foundations for patient safety: a self learning package. Toronto: RNAO; 2007.
  • 13
    Bugalho A, Carneiro AV. Intervenções para aumentar a adesão terapêutica em patologias crónicas. Lisboa: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina; 2004.
  • 14
    Nunes L. Considerações éticas a atender nos trabalhos de investigação académica de enfermagem. Setubal: Instituto Politécnico de Setubal, Escola Superior de Saúde, Departamento de Enfermagem; 2013.
  • 15
    Polit DF, Beck CT. Fundamentos de pesquisa em enfermagem: avaliação de evidências para a prática da enfermagem. Porto Alegre: Artmed; 2011.
  • 16
    Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.
  • 17
    Currin ML, Comans TA, Heathcote K, Haines TP. Staying safe at home: home environmental audit recommendations and uptake in an older population at high risk of falling. Australas J Ageing. 2012;31(2):90-5.
  • 18
    Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.
  • 19
    Elliott SJ, Ivanescu A, Leland NE, Fogo J, Painter JA, Trujillo LG. Feasibility of interdisciplinary community-based fall risk screening. Am J Occup Ther. 2012;66(2):161-8.
  • 20
    Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.
  • 21
    Freiberger E, Häberle L, Spirduso WW, Zijlstra GA. Long-term effects of three multicomponent exercise interventions on physical performance and fall-related psychological outcomes in community-dwelling older adults: a randomized controlled trial. J Am Geriatr Soc. 2012;60(3):437-46.
  • 22
    Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.
  • 23
    Jenkyn KB, Hoch JS, Speechley M. How much are we willing to pay to prevent a fall? Cost-effectiveness of a multifactorial falls prevention program for community-dwelling older adults. Can J Aging. 2012;31(2):121-37.
  • 24
    Kelsey JL, Procter-Gray E, Berry SD, Hannan M, Kiel DP, Lipsitz LA, et al. Reevaluating the implications of recurrent falls in older adults: location changes the inference. J Am Geriatr Soc. 2012;60(3):517-24.
  • 25
    Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.
  • 26
    Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.
  • 27
    Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.
  • 28
    Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.
  • 29
    Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age Ageing. 2012;41(3):299-308.
  • 30
    Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.
  • 31
    Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.
  • 32
    Taylor ME, Ketels MM, Delbaere K, Lord SR, Mikolaizak AS, Close JC. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators. Age Ageing. 2012;41(5):665-9.
  • 33
    Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.
  • 34
    Zheng JJ, Lord SR, Close JC, Sachdev PS, Wen W, Delbaere K, et al. Brain white matter hyperintensities, executive dysfunction, instability, and falls in older people: a prospective cohort study. J Gerontol. 2012;67(10):1085-91.
  • 35
    de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.
  • 36
    Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.
  • 37
    Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8.
  • 38
    Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.
  • 39
    Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.
  • 40
    Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.
  • 41
    Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62.
  • 42
    Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.
  • 43
    Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.
  • 44
    Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.
  • 45
    Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7.
  • 46
    Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.
  • 47
    Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.
  • 48
    Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.
  • 49
    Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5.
  • 50
    Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053.
  • 51
    Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.
  • 52
    Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.
  • 53
    Buracchio TJ, Mattek NC, Dodge HH, Hayes TL, Pavel M, Howieson DB, et al. Executive function predicts risk of falls in older adults without balance impairment. BMC Geriatr. 2011;11:74.
  • 54
    Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85
  • 55
    Fischer BL, Gleason CE, Gangnon RE, Janczewski J, Shea T, Mahoney JE. Declining cognition and falls: role of risky performance of everyday mobility activities. Phys Ther. 2014;94(3):355-62.
  • 56
    Gangavati A, Hajjar I, Quach L, Jones RL, Kiely DK, Gagnon P, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59(3):383-9.
  • 57
    Honaker JA, Shepard NT. Use of the Dynamic Visual Acuity Test as a screener for community-dwelling older adults who fall. J Vestib Res. 2011;21(5):267-6.
  • 58
    Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R, et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(12):815-25.
  • 59
    Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31
  • 60
    Quach L, Galica AM, Jones RN, Procter-Gray E, Manor B, Hannan MT, et al. The nonlinear relationship between gait speed and falls: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc. 2011;59(6):1069-73.
  • 61
    Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.
  • 62
    Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci. 2011;66(6):674-80.
  • 63
    Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.
  • 64
    Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.
  • 65
    Arnold CM, Faulkner RA, Gyurcsik NC. The relationship between falls efficacy and improvement in fall risk factors following an exercise plus educational intervention for older adults with hip osteoarthritis. Physiother Can. 2011;63(4):410-20.
  • 66
    Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.
  • 67
    Hsu CL, Voss MW, Handy TC, Davis JC, Nagamatsu LS, Chan A, et al. Disruptions in brain networks of older fallers are associated with subsequent cognitive decline: a 12-month prospective exploratory study. PloS One. 2014;9(4): e93673.
  • 68
    Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.
  • 69
    Peeters GM, Heymans MW, de Vries OJ, Bouter LM, Lips P, van Tulder MW. Multifactorial evaluation and treatment of persons with a high risk of recurrent falling was not cost-effective. Osteoporos Int. 2011;22(7):2187-96.
  • 70
    Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.
  • 71
    Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. J Am Geriatr Soc. 2011;59(1):26-33.
  • 72
    Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.
  • 73
    Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.
  • 74
    Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.
  • 75
    Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14.
  • 76
    O’Halloran AM, Pénard N, Galli A, Fan CW, Robertson IH, Kenny RA. Falls and falls efficacy: the role of sustained attention in older adults. BMC Geriatr. 2011;11:85.
  • 77
    Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.
  • 78
    Al-Aama, T. Falls in the elderly: spectrum and prevention. Can Fam Physician. 2011;57(7):771-6.

Publication Dates

  • Publication in this collection
    2016

History

  • Received
    23 Apr 2015
  • Accepted
    17 Oct 2016
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