|Year : 2017 | Volume
| Issue : 2 | Page : 99-104
A study of falls among elderly persons in a rural area of Haryana
Aniket Sirohi1, Ravneet Kaur2, Anil Kumar Goswami2, Kalaivani Mani3, Baridalyne Nongkynrih4, Sanjeev Kumar Gupta4
1 Junior Resident, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Assistant Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
3 Scientist II, Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
4 Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||2-Jun-2017|
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Falls are a common, disabling, and frequently fatal health concern among elderly persons. Assessment of the prevalence of falls and associated factors can lead to the identification of corrective measures, which can help in preventing falls and their consequent effects on health and well-being of the elderly. Objectives: The objective is to determine the prevalence of falls among elderly persons in a rural area and to study the association of falls with sociodemographic variables and selected health conditions. Methods: In a community-based, cross-sectional study conducted among 456 elderly persons in a rural area, information regarding sociodemographic details, selected health conditions, and history of falls in the past 12 months was recorded. Univariate analysis followed by stepwise multivariate logistic regression analysis was carried out. The effect of sociodemographic and various health conditions on falls was analyzed using logistic regression analysis. Results: Among the 456 study participants, the prevalence of falls in the past 12 months was 36.6% (95% confidence interval [CI] =32.1–40.0). The prevalence among women was 40.6% (95% CI = 34.5–46.7) and among men was 31.5% (95% CI = 25.0–37.9). Low socioeconomic status, urgency of micturition, knee pain, visual impairment, hearing impairment, functional disability, and depression were significantly associated with falls. Conclusions: Falls are common among elderly persons. Health programs for the elderly must include prevention of falls and rehabilitation of fall-related injuries.
Keywords: Elderly, falls, injury, older persons, rural
|How to cite this article:|
Sirohi A, Kaur R, Goswami AK, Mani K, Nongkynrih B, Gupta SK. A study of falls among elderly persons in a rural area of Haryana. Indian J Public Health 2017;61:99-104
|How to cite this URL:|
Sirohi A, Kaur R, Goswami AK, Mani K, Nongkynrih B, Gupta SK. A study of falls among elderly persons in a rural area of Haryana. Indian J Public Health [serial online] 2017 [cited 2019 Oct 17];61:99-104. Available from: http://www.ijph.in/text.asp?2017/61/2/99/207399
| Introduction|| |
India houses the world's second largest geriatric population, which is about 1/8th of the total geriatric population of the globe. As per the Census 2011, 103.2 million people in India were of the age 60 years or more, accounting for 8.6% of the total population. Elderly persons are one of the most vulnerable groups of the society. In India, the elderly face a dual burden of communicable and noncommunicable diseases as well as various social and economic challenges. Among many health issues that are faced by the elderly, falls are an important concern.
Fall is defined as “inadvertently coming to rest on the ground, floor, or other lower level, excluding intentional change in position to rest.”
The elderly are vulnerable to falls because, with aging, many normal reactions of an individual start fading. Vision, hearing, locomotor abilities, ability to respond, and reflex actions begin to decline. The vulnerability to injuries increases due to the fragility of organs, and time to recover is long due to the slow recovery process.
Falls are one of the leading causes of death in elderly persons. Falls are responsible for 20%–30% of injuries among the elderly age group and are responsible for 10%–15% of all emergency department visits. They are also responsible for 50% of injury-related hospitalization among people of 65 years and above., Falls, thus, result in a considerable economic burden to the person as well as the family.
In majority of the cases, falls are preventable. Determination of the prevalence of falls and identification of associated factors will help in understanding their causal relationship and hence planning the preventive measures.
This study was conducted in a rural community to determine the prevalence of falls and to identify factors associated with falls among elderly persons in a rural area.
| Materials and Methods|| |
It was a community-based, cross-sectional study conducted in the rural field practice area of the research institute. The field practice area consists of 28 villages, having a population of nearly 95,000 in Ballabgarh block of Faridabad district of Haryana. There is a computerized health management information system, which is a database of all the individuals residing in the area. This database is regularly updated annually.
The study was conducted among persons aged 60 years and above residing in the villages under field practice area for at least past 12 months. A pretested semi-structured interview schedule in Hindi was administered to the participants. Socioeconomic status was assessed using Uday Pareek scale. Information regarding self-reported or physician-diagnosed chronic health conditions, medication use, and current use of alcohol or tobacco was recorded. To elicit medication use, the participants were asked to show the medicines or blister packs. Medical records, if available, were also seen.
History of falls in the past 12 months was asked. Details regarding fall such as time and place of fall, severity, resulting injury, part of the body injured, disability, hospitalization, and treatment were recorded.
Assessment of vision, hearing, body mass index (BMI), functional disability, and balance was done. For assessment of vision, Snellen chart was used. For hearing assessment, the WHO grades of hearing impairment were used and Grades 2, 3, and 4 were considered as hearing impairment. BMI was calculated as weight/(arm span)2 expressed in kg/m 2, as arm span has been reported to be a more valid indicator of height among the elderly.,, Functional disability was assessed by Barthel's activities of daily living (ADL) questionnaire., For assessment of gait, get up and go test was used  while body balance was assessed by Romberg's test.
The Hindi-mini-mental state examination (HMSE) was used for the assessment of cognitive status. For screening of depression, Hindi version of the Geriatric Depression Scale (GDS-H) was used. Both HMSE and GDS-H have been validated in earlier studies at Ballabgarh.,
An event that results in a person coming to rest inadvertently on the ground or floor or other lower level. Falls due to assault and intentional self-harm were not included in this study. Falls from animals, burning buildings, and transport vehicles and falls into the fire, water, and machinery were also excluded from this study.
Consumption of substance (alcohol/tobacco product) was currently for at least 3 days in a week.
Current knee pain or physician-diagnosed osteoarthritis in the knee joint.
Chronic respiratory morbidity
Self-reported presence of shortness of breath or long-standing cough, i.e., cough on most days for 3 consecutive months or more during the year for the past 2 years or more or physician-diagnosed chronic obstructive pulmonary disease from which participant was currently suffering.
Inability or limitation in performing socially defined activity and roles expected of individuals within a social and physical environment. It included any impairment, activity limitation, and participation restriction.
Injury was taken as any recallable self-perceived damage to the body due to fall.
Sample size was calculated using the prevalence of 31% as reported in a previous study. Taking a relative precision of 15%, the calculated sample size was 396.
Assuming a nonresponse rate of 20%, the final sample size was calculated as 495 elderly individuals. From the computerized database, a list of all the individuals aged 60 years and above was obtained, and 495 persons were selected by simple random sampling. Persons who were bedridden for more than 1 year were excluded from the study.
Data collection was undertaken from May to July 2015. House-to-house visit was done for all 495 participants. In case a participant was not found at home despite three visits, he/she was categorized as a nonrespondent. All the participants found during the visit were told about the purpose of the visit. Data were collected by a single trained investigator. Training was given to the investigator by the Faculty of Ophthalmology and ENT for the assessment of vision and hearing, respectively.
Data were entered and managed in MS Excel 2013, and statistical analysis was carried out using Stata 11(Stata Corp LLC 4905, Lakeway Drive College Station, Texas, USA). Mean (standard deviation [SD]) and frequency (percentage) was reported for continuous and categorical variables, respectively. The prevalence of fall was reported as a percentage with 95% confidence interval (CI). Contingency table analysis was performed using Chi-square results. The association of sociodemographic and various health conditions with falls was analyzed using logistic regression analysis. Univariate analysis followed by stepwise multivariate logistic regression analysis was carried out. In the stepwise analysis, variable selection was performed by keeping probability of removal and entry at 0.25 and 0.05, respectively. The results were presented as odds ratio (OR) with 95% CI. P < 0.05 was considered as statistically significant.
Ethical approval for this study was obtained from the Ethics Committee of the All India Institute of Medical Sciences, New Delhi, India. Written informed consent was obtained from all the participants. Results of examinations were communicated to the participants. All information collected was kept confidential. The participants identified as having visually impairment, hearing impairment, and other disorders were referred to the appropriate outpatient department at the nearest health center.
| Results|| |
Of the 495 randomly selected individuals, eight were found to be dead, and one was excluded as he was bedridden due to fall for more than 1 year. Of the remaining 486 individuals, 26 could not be contacted despite three visits and four refused to participate. Thus, out of 495 persons, 456 participated in the study, giving a response rate of 92.1%. The response rates for men and women were 89.6% and 94.1%, respectively.
Out of 456 participants, 256 (56%) were women. Mean age was 69.4 years (SD = 6.7), being 69.6 years (SD = 7.3) for men and 69.2 (SD = 6.2) for women. Half of the participants (51%) were in the age group of 60–69 years, 173 (37.9%) in the age group of 70–79 years, while 50 (11%) in the age group of 80 years and above. Three hundred and twenty-seven participants (71.7%) were currently married, and 129 (28.3%) were widows/widowers.
Most of the participants (98.4%) were living with family or spouse. Approximately 60% of the participants were illiterate. Regarding socioeconomic status, the participants in upper middle were included in upper, and those in lower middle were included in lower socioeconomic status. There were 169 participants (37.1%) in lower, 152 (33.3%) in middle, and 135 (29.6%) in upper socioeconomic status. Most of the participants (72.3%) had a monthly self-income of ≤ Rs. 1200, which was the amount of old age pension by the government. Only 6.1% of the elderly persons had income more than Rs. 1200.
Forty-eight percent of the participants reported substance use. Among these, 99.5% were using some form of tobacco such as bidi, hukka, or chewable tobacco. Alcohol use was reported by 10% of the participants. None of the women reported alcohol use.
[Table 1] shows clinical characteristics of the participants. Out of 456 participants, 270 (59.2%) reported to have knee pain. Urgency of micturition was reported by 119 (26%) while 110 (24.1%) had hypertension and 47 (10.3%) had chronic respiratory morbidity. Diabetes mellitus was reported by 36 (7.9%) of the participants while four reported seizure disorder.
Majority (60.3%) of the participants were not using any medication. Out of 181 participants who were using medication, nearly half (51.3%) were using one medication while 48.6% were using more than one medication. Among those using medication, 55.8% were taking antihypertensive drugs, followed by bronchodilators (40.8%) and antidiabetics (18.2%). Some participants (13.8%) were taking analgesics and antiallergic drugs (12.1%).
Visual impairment was present in 39.7% of the participants while hearing impairment was found in 24.3%.
According to Barthel's ADL score, 39.7% of the participants were found to have some functional disability. It was more common in women (47.3%) as compared to men (30%).
Abnormal body balance was found in 10.3% of the participants and 22.6% had abnormal gait. Low BMI was present in 30.9% while high BMI (>25) was present in 11.6% of the participants; cognitive impairment was found in 11.4% of the participants. When screened for depression, 27.8% screened positive.
In this study, the prevalence of fall in the past 12 months was found to be 36.6% (95% CI = 32.1–40). It was more in women (40.6%) as compared to men (31.5%). Among these, 77.2% of the participants had a single fall, 9.6% had two falls, while 13.2% reported more than two falls. In most (59.3%) of the cases, place of fall was home, followed by road (20.4%), fields (13.2%), and workplace (7.2%). Most (38.9%) of the falls occurred during the afternoon. Majority (71.3%) of the participants were engaged in routine activities such as bathing, urination, or defecation at the time of fall. In 64 (38.3%) individuals, the cause of fall was dizziness. Fifty-four participants (32.3%) had slipped on the road, 35 (21%) tripped on the road, 6 (3.6%) did not remember the cause of the fall, while 3 (1.8%) of the participants did not see the lying object.
Among 167 participants who suffered a fall, 105 (62.9%) of them sustained injuries.
[Table 2] shows the details of the injuries sustained. Lower extremity was the most common site of injury. Majority (86.7%) of the injured sustained minor injuries such as cuts and abrasions. Fractures were sustained by 9.5% of the participants.
Association of falls with sociodemographic variables and selected chronic conditions is shown in [Table 3]. In univariate analysis, it was found that higher age, female gender, being a widow/widower, illiteracy, and low socioeconomic status were associated with falls. The use of more than one medication and tobacco use were also found to be associated with falls in univariate analysis (P < 0.001, OR = 2.3 [1.6–3.5]) and (P = 0.004, OR = 1.8 [1.2–2.6]), respectively. However, these were nonsignificant in multivariate analysis.
|Table 3: Association of falls in the past 12 months with sociodemographic characteristics and selected chronic health conditions|
Click here to view
In univariate analysis, it was found that urgency during micturition, hypertension, chronic respiratory morbidity, knee pain, visual impairment, hearing impairment, abnormal body balance, abnormal gait, low BMI, impaired cognition, depression, and functional disability were associated with falls.
Following univariate analysis, stepwise multivariate logistic regression was carried out. [Figure 1] shows the association of sociodemographic variables and various health conditions with falls as analyzed using logistic regression analysis. It was found that lower socioeconomic status (P = 0.03, OR = 1.9 [1.1–3.5]), urgency of micturition (P = 0.006, OR = 2 [1.2–3.3]), presence of osteoarthritis (P = 0.005, OR = 2 [1.2–3.5]), visual impairment (P = 0.049, OR = 1.6 [1.1–2.6]), hearing impairment (P = 0.04, OR = 1.7 [1.0–3.0]), depression (P = 0.03, OR = 2.2 [1.3–3.7]), and functional disability (P = 0.003, OR = 2.1 [1.2–3.3]) were significantly associated with falls.
|Figure 1: Forest plot showing association of falls with the socioeconomic status and selected chronic health conditions.|
Click here to view
| Discussion|| |
This study describes the prevalence of falls among elderly persons in a rural area and its association with sociodemographic variables and chronic health conditions.
In our study, the prevalence of falls was found to be 36.6% (95% CI = 32.1–40.0). In various studies conducted in India and abroad, the prevalence of falls ranged from 18.8% to 53%.,,,,,, Tripathy et al. conducted a community-based study among elderly in rural, urban, and slum areas of Chandigarh and reported the prevalence of falls to be 31%. D'souza, in a study conducted among community-dwelling elders and old age home residents in Karnataka, reported the prevalence of falls to be 38% in the past 2 years. In a cross-sectional study in rural, urban, and slum areas of northern India, Joshi et al. reported that 51.5% of elderly had a history of fall. The differences may be due to different study settings. Furthermore, the time span considered for fall history was different in various studies. D'souza reported falls in the past 2 years while Joshi et al. recorded “history of fall” in their study., Some studies have reported the 6-month prevalence of falls.
In the present study, 62.9% of those with a history of fall sustained injuries. It is similar to Tripathy et al. who reported 67% of injury. Other studies have reported injuries in the range of 34%–74%.,,, In our study, fractures occurred in 9.5% of the participants. D'souza reported fractures in 15.8% of the falls while Joshi et al. reported 21.3% of fractures., The reason for lesser proportion of fractures in our study might be the rural settings as floors and roads are usually kutcha in rural areas. The other studies had an urban component, with pucca floors and roads.
As reported in earlier studies, most of the falls did not result in serious injuries., However, falls do have an impact on functionality among the elderly. In the present study, 13.3% of the participants reported to have some sort of disability after the fall. This is similar to the findings of a study conducted by Tripathy et al. where it was reported that 14% of the participants experienced restricted mobility and self-care issues.
Home was found to be the most common place of fall and majority of falls occurred while being engaged in daily activities. This is in accordance with the previous studies conducted in India and abroad.,,
Among sociodemographic factors, higher age and female gender have been reported to be significantly associated with falls in the previous studies. In the present study, none of these factors was found to be associated with falls. As in earlier studies, low socioeconomic status was found to be associated with falls.,, Low socioeconomic status may be associated with fall as it could lead to poor household environment. It may also be associated with untreated health conditions, for example, hypertension.
In this study, falls were found to be significantly associated with urgency of micturition, presence of osteoarthritis, visual impairment, hearing impairment, functional disability, and depression. Earlier studies have also reported that musculoskeletal disorders, functional disability, visual impairment, and urinary incontinence are associated with falls.,,,,,,
In previous studies, gait and balance abnormalities have been shown to be associated with falls.,,, However, in our study, these were not found to be significantly associated with falls. It may be due to community-based nature of the study, where ideal testing conditions cannot be created. Furthermore, the balance test did not assess the ability to sit and rise from floor, which is a common activity in rural areas.
The study has few limitations. Due to a period of 1 year, some participants might not remember minor falls, leading to an underestimate of the prevalence of falls. Moreover, individuals who might have died due to fall cannot be considered in such studies. In case of participants with impaired cognition and severe hearing impairment (WHO Grades 3 and 4), history was elicited from close relatives. This could have led to an underestimation in the prevalence of falls.
Temporal association of falls with chronic health conditions cannot be established due to the cross-sectional type of the study design. Although home was found to be the most common place of fall, assessment of home environment was not done in this study.
However, community-based nature of the study and high response rates are some of the strengths of the present study. The study corroborates the factors associated with falls as shown in earlier studies. Identification of these factors and appropriate corrective measures can help in preventing the falls and their consequent effects on the health and well-being of the elderly persons. It has been shown that environmental modifications, community awareness, and exercise programs reduce the rate of falls as well as injuries related to falls. Prevention of falls has been identified as one of the measures, which extends healthy life expectancy and improve the quality of life among the elderly.
A comprehensive fall risk assessment tool for easier screening can be developed for Indian settings, and fall prevention must be emphasized in the health programs for the elderly people.
| Conclusion|| |
Falls are common among the elderly, and are associated with co-morbid conditions like visual impairment, hearing impairment, depression, urgency of micturition and functional disability. Identification of factors associated with falls and their prevention must be included in health programs for the elderly.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Registrar General of India. Census 2011. Ministry of Home Affairs; 2011. Available from: http://www.censusindia.net
. [Last accessed on 2016 Jan 15].
Centers for Disease Control and Prevention (CDC). Fatalities and injuries from falls among older adults – United States, 1993-2003 and 2001-2005. MMWR Morb Mortal Wkly Rep 2006;55:1221-4.
Scuffham P, Chaplin S, Legood R. Incidence and costs of unintentional falls in older people in the United Kingdom. J Epidemiol Community Health 2003;57:740-4.
Guru Raj MS, Shilpa S, Maheshwaran R. Revised socio-economic status scales for urban and rural India-revision for 2015. Socioeconomica 2015;4:167-74.
Rabe B, Thamrin MH, Gross R, Solomons NW, Schultink W. Body mass index of the elderly derived from height and from armspan. Asia Pac J Clin Nutr 1996;5:79-83.
Manonai J, Khanacharoen A, Theppisai U, Chittacharoen A. Relationship between height and arm span in women of different age groups. J Obstet Gynaecol Res 2001;27:325-7.
de Lucia E, Lemma F, Tesfaye F, Demisse T, Ismail S. The use of armspan measurement to assess the nutritional status of adults in four Ethiopian ethnic groups. Eur J Clin Nutr 2002;56:91-5.
Mahoney FI, Barthel DW. Functional evaluation: The Barthel Index. Md State Med J 1965;14:61-5.
Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: A reliability study. Int Disabil Stud 1988;10:61-3.
Podsiadlo D, Richardson S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142-8.
Khasnis A, Gokula RM. Romberg's test. J Postgrad Med 2003;49:169-72.
] [Full text]
Pandav R, Fillenbaum G, Ratcliff G, Dodge H, Ganguli M. Sensitivity and specificity of cognitive and functional screening instruments for dementia: The Indo-U.S. Dementia Epidemiology Study. J Am Geriatr Soc 2002;50:554-61.
Ganguli M, Dube S, Johnston JM, Pandav R, Chandra V, Dodge HH. Depressive symptoms, cognitive impairment and functional impairment in a rural elderly population in India: A Hindi version of the geriatric depression scale (GDS-H). Int J Geriatr Psychiatry 1999;14:807-20.
World Health Organization. International classification of impairment, disabilities, handicaps. Geneva: World Health Organization; 1980.
Tripathy NK, Jagnoor J, Patro BK, Dhillon MS, Kumar R. Epidemiology of falls among older adults: A cross sectional study from Chandigarh, India. Injury 2015;46:1801-5.
D'Souza AJ. Health of the elderly in rural Dakshina Kannada. Indian J Gerontol 2011;25:329-44.
Joshi K, Kumar R, Avasthi A. Morbidity profile and its relationship with disability and psychological distress among elderly people in Northern India. Int J Epidemiol 2003;32:978-87.
Fhon JR, Fabrício-Wehbe SC, Vendruscolo TR, Stackfleth R, Marques S, Rodrigues RA. Accidental falls in the elderly and their relation with functional capacity. Rev Lat Am Enfermagem 2012;20:927-34.
Mizukami S, Arima K, Abe Y, Kanagae M, Kusano Y, Niino N, et al.
Falls are associated with stroke, arthritis and multiple medications among community-dwelling elderly persons in Japan. Tohoku J Exp Med 2013;231:299-303.
Johnson SJ. Frequency and nature of falls among older women in India. Asia Pac J Public Health 2006;18:56-61.
Ranaweera AD, Fonseka P, PattiyaArachchi A, Siribaddana SH. Incidence and risk factors of falls among the elderly in the District of Colombo. Ceylon Med J 2013;58:100-6.
Cardona M, Joshi R, Ivers RQ, Iyengar S, Chow CK, Colman S, et al.
The burden of fatal and non-fatal injury in rural India. Inj Prev 2008;14:232-7.
Padubidri A, Al Snih S, Samper-Ternent R, Markides KS, Ottenbacher KJ, Raji MA. Falls and cognitive decline in Mexican Americans 75 years and older. Clin Interv Aging 2014;9:719-26.
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;60:230-7.
Chiarelli PE, Mackenzie LA, Osmotherly PG. Urinary incontinence is associated with an increase in falls: A systematic review. Aust J Physiother 2009;55:89-95.
[Table 1], [Table 2], [Table 3]