|Year : 2019 | Volume
| Issue : 1 | Page : 21-26
Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population - A descriptive study
Pothiraj Pitchai1, Hiral Bipin Dedhia2, Nidhi Bhandari2, Deepa Krishnan2, Nikshita Ria John D'Souza2, Jayesh Mahesh Bellara2
1 Associate Professor, Department of Community Physiotherapy, MGM College of Physiotherapy, Navi Mumbai, Maharashtra, India
2 Physiotherapist, Department of Community Physiotherapy, MGM School of Physiotherapy, MGMIHS, Navi Mumbai, Maharashtra, India
|Date of Web Publication||12-Mar-2019|
Dr. Pothiraj Pitchai
Department of Community Physiotherapy, MGM College of Physiotherapy, Sector 1, Kamothe, Navi Mumbai - 410 209, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Falls is one of the common problems faced by elderly population and in preventing falls in India, research has largely focused on identification and management of risk factors, but the circumstances of the fall and its associated factors are sparsely researched. Objectives: The primary objective is to find the prevalence of fall, investigate risk factors, and its circumstances for falls and level of functional independence in elderly population. The secondary objective is to find out fear of fall (FOF) and its association of demographic factors on elderly population. Methods: This was a cross-sectional study; 2049 elderly population of 60 years and above were recruited by one-stage cluster sampling technique within Mumbai, Panvel, and Thane cities, Maharashtra. Data were collected using a questionnaire, Fall Efficacy Scale-International, Barthel Index, and Kuppuswamy Scale. Obtained responses were analyzed using SPSS software; descriptive statistics and Chi-square test were applied. Results: The prevalence of falls in this study found as 24.98%. Demographic factors such as age group, education, marital status, and socio-economic status had demonstrated a significant association with older adults (P < 0.05); 44.92% of falls occurred in the morning, the majority of falls (65.43%) occurred indoors, 56.45% of the fallers reported to had slips, and 60.55% of the fallers had sustained injuries. From the total participants, 34.70% of the fallers reported FOF, 23.67% of the fallers expressed reduced functional activities, and 18.06% of the fallers demonstrated affection in activities of daily living. Conclusion: This study reveals fall as a significant health problem and provides insight into the influencing risk factors for falls among older adults.
Keywords: Activities of daily living, fear of fall, functional activity, prevalence of falls, risk factors
|How to cite this article:|
Pitchai P, Dedhia HB, Bhandari N, Krishnan D, D'Souza NR, Bellara JM. Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population - A descriptive study. Indian J Public Health 2019;63:21-6
|How to cite this URL:|
Pitchai P, Dedhia HB, Bhandari N, Krishnan D, D'Souza NR, Bellara JM. Prevalence, risk factors, circumstances for falls and level of functional independence among geriatric population - A descriptive study. Indian J Public Health [serial online] 2019 [cited 2020 May 27];63:21-6. Available from: http://www.ijph.in/text.asp?2019/63/1/21/253889
| Introduction|| |
India is the second most populated country in the world, with over 1.21 billion people, and according to the population census in India 2011, the percentage of older adults above the age of 60 is 8.6% of the total population and this population is likely to increase to 198 million in 2030.,, Demographic transition in India has led to an absolute increase in older adult population, which in turn increases the demand on the health-care system to add the quality of life (QOL) to the years lived.
Aging is an irreversible normal phenomenon that takes place at a molecular level, reflecting not only physically but also functionally and psychosocially. Although “geriatric giants” is not uncommon in older adults, falls are regarded as one of the common problems faced by them and also as a significant cause for the increase in morbidity and mortality rate among them.,,,
A fall can be defined as an event results in a person coming to rest inadvertently on the floor, often caused by multifactorial risk factors including intrinsic and extrinsic factors.,, According to the World Health Organization (WHO) global report on falls prevention, people aged 65 years and above fall about 28%–35% in each year and this proportion increases as age and frailty level increase. The prevalence of falls in India, above the age of 60 years, reported to range 14%–53%.
Falls and its consequences are major public health problem because falls have been identified as the second leading cause of unintentional injury morbidity, accounting for 11% unintentional injury mortality rate globally., From the reported 424,000 fall-related deaths in 2004 globally, one-fifth of them took place in India. The consequence of fall can either lead into nontraumatic or traumatic injuries which may vary from no injuries, bruises, and lacerations to dislocations, fractures, and head injuries and in some cases, it may even be fatal.,,,,
Traumatic complications among fallers have increased the rate of hospitalization; also recovery from fall injury is often delayed. A significant proportion of falls, especially nontraumatic injuries, is overlooked often underreported, considering instability in aging is a normal phenomenon., Studies have reported that nontraumatic complication in falls has got a negative impact on the older adults and it sometimes instill fear of fall (FOF) in them.,,, In addition, falls may also lead to a postfall syndrome which includes dependency, loss of autonomy, confusion, immobilization, and depression, which will engender to a further restriction in daily activities., Overall, falls contribute to increase the risk of future fall thus affecting the QOL.
Redundant literatures are available in developed countries on the determinants of health and aging, whereas in developing countries, there is a paucity of these epidemiological data which reflect insufficient attention on fall prevention in some regions., Seventy percentage of the aging population lives in developing countries where prevalence and incidence of fall are increasing at an alarming rate and injury due to fall is considered as inevitable and high in number.
The US Public Health Service has estimated that two-third of the death due to fall are preventable, and the WHO proposed “active aging” which aims at improving QOL for all people as they age., In this respect, perspective on fall need to be widened. In view of preventing falls among older adults in India, research has largely focused on identification and management of risk factors  for falls, but the circumstances of the fall and its associated factors are sparsely researched. The objective of this study is to assess the prevalence of falls, factors, and the circumstances behind falls among the geriatric population and to find out the level of functional independence among them and its association with demographic characteristics.
| Materials and Methods|| |
This is community-based cross-sectional study was conducted between January 2016 and June 2016 in the field practice area of greater Mumbai, Thane and Raigad districts of Konkan division of Maharashtra. Institutional ethical clearance was obtained. Consenting participants of old-age home residents and community dwellers above the age of 60 years of both male and female without fall and with fall in the past 1 year were included and participants with declined cognitive function were carefully excluded from the study. A fall was defined as any unintentional change in position where the person ends up on the floor, ground, or other lower level.
The sample size was calculated using the formula, sample size n = Zα/22 pq/L 2 with 5% level of significance and 95% confidence interval, Zα/2 = 1.96, the prevalence of 53%, and error allowable margin of 5% and it was found to be 1367. Considering the refusal rate of 25%, the required sample was rounded off to 1800.
Participants were recruited by one-stage cluster sampling technique from randomly selected Zone 3 from greater Mumbai, Thane, and Panvel. Initially, one house was randomly selected followed which survey was conducted by the door-to-door method; responses were recorded based on the interview-based method. Participants who missed three scheduled appointments in 1-week interval were considered as nonrespondents; thus, a total of 700 individuals from each cluster were screened.
A face validated, predesigned structured questionnaire was used along with the existing literatures , to record the responses that include history and circumstances of fall, the location of fall, time and nature of fall, activities engaged at the time of fall, and consequences of fall. This questionnaire was piloted, and the necessary corrections were made before applying to the study participants.
FOF was measured using the Fall Efficacy Scale-International, as this scale demonstrated good psychometric properties over Activities-Specific Balance Confidence Scale and the modified survey of activities and FOF in the elderly., It assesses an ongoing concern about falling. It consists of 16 items, the level of concern on each item was measured on a four-point Likert scale (1 = not at all concerned, 2 = somewhat concerned, 3 = fairly concerned, and 4 = very concerned). The maximum possible score is 64 and depending on the number of responses, they were classified as the low concern (16–19), moderate concern (20–27), and high concern (28–64) for falls.
The level of dependence in activities of daily living (ADL) was measured using Barthel Index. It is a 10-item ordinal scale in the domains of personal care and mobility such as self-care, sphincter management, transfers, and locomotion. The components are assigned a minimum of 0 to a maximum of 15, and the total possible score would vary from 0 to 100. The scores between 0 and 20 marked as total dependence in ADL, 20–60 as severe dependence, 60–90 as slight dependence, and 90 - 100 as normal., Influence of socioeconomic status was measured using the revised version of 2014 Kuppuswamy Scale.,
Collected data were entered and analyzed using SPSS statistical software version 17 (SPSS Inc. Chicago, IL, USA). Descriptive statistics, such as frequency, percentage, mean, and standard deviation, were applied for all qualitative as well as quantitative study variables. Association among the fallers and nonfallers with various study factors was assessed by Chi-square test.
| Results|| |
The response rate of this survey was 97.57% where 2049 completed questionnaire was analyzed. The mean age of the participants was 69.69 ± 6.94 years including 53.83% of males and 46.17% of females.
The proportion of falls in this study was found to be 24.98% (n = 512). The mean age of faller's was 71.86 ± 7.49 years. Falls were seen more among the older adults with advancing age, and a significant association was found, P = 0.000. Among the reported fallers, 49.41% of the respondents had sustained falls for more than one time in the past 1 year. Association of demographic factors between fallers and nonfallers is described in [Table 1] and [Table 2] shows the clinical characteristics of fallers based on the self-reported clinical condition present at the time of the survey.
|Table 1: Association of socio-demographic factors elderly subjects with and without history of fall n=2049|
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|Table 2: Morbidity characteristics of the elderly subjects with H/O fall n=512|
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Majority of 44.92% of falls has occurred in the morning, followed by 20.90% in the afternoon, 19.34% in the evening, and 14.84% at night. With respect to the location of fall, 65.43% of falls occurred indoors and 34.57% from outdoors. In indoor, 50.75% falls took place in the bathroom, 18.21% in the hall, and kitchen and bedroom share 11.94%, whereas in outdoor, 41.81% experienced fall in public places, 18.64% in streets, and 13.56% outside the house. Walking, turning, and standing were the most engaged activities at the time of fall that share 43.16%, 12.30%, and 6.84%, respectively. Slip, imbalance, and trip were the most reported nature of falls that account 56.45%, 10.74%, and 6.25%, respectively.
Fallers of 60.55% had sustained injuries after the fall, and physician consultation was obtained. Among them, 39.68% of falls required medical consultation, 35.81% took first aid, and 24.52% necessitate hospital admission. Whereas among 39.45% of noninjured fallers, only 1.49% were reported to a physician. Usage of assistive device among the fallers accounts for 30.86% and 12.89% in nonfallers; moreover, walking cane was commonly used by both the groups.
Over 50.3% of the total study participants reported to be on medication. Among older adults who experienced falls 62.30% of them were under medications. Participants who were under medications (58.3%) had >4 medications/day and 41.7% had <4. Majority of 35.44% were on antihypertensive and 31.23 were on antidiabetic drugs. Concurrently, among nonfallers, only 46.26% were on medication in that 51.1% consumed >4 medication. Significant association was found with respect to number of medications and fallers and nonfallers, χ2 (1n = 1030) =4.653, P = 0.031.
Out of 2049 participants, 34.70% reported FOF which consisted 41.21% of fallers and 58.79% of nonfallers. Among fallers, 34.38% demonstrated low concern of fall, 29.49% demonstrated moderate concern, and 36.13% demonstrated high concern, whereas nonfallers shared 59.15%, 23.88%, and 16.98%, respectively. Pearson Chi-square resulted in a significant association between FOF among older adults with fall and without fall (P = 0.000).
Simultaneously, 23.67% of the entire participants expressed reduced functional activities, including 42.27% of fallers and 57.73% of nonfallers. Among fallers, 23.41% reported reduced functional activities inside the house, 30.24% outside the house, and 46.39% in both; however, nonfallers shared 16.79%, 33.93%, and 49.29%, respectively. A Chi-square test for independence demonstrated a significant association between restricted functional activity among fallers and nonfallers, χ2 (1n = 2049) = 100.021, P = 0.000. The reported normal level of functional independence in basic ADL among fallers was 58.40% and 77.68% among nonfallers, (P = 0.000). Functional independence among older adults with certain variables is shown in [Table 3].
|Table 3: Level of functional independence according to Barthel Index among elderly subjects with respect to certain variables|
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Among the total study participants, 48.90% asserted that falls can be preventable in which 4.34% have made modification in their environment to prevent fall that comprising 8.98% among fallers and 2.80% among nonfallers.
| Discussion|| |
This study assessed the prevalence of falls among older adults, and its proportion was found to be 24.98%; however, various studies conducted in India reported the prevalence to vary from 14% to 53%.,,,
This study has demonstrated no association of gender with fallers and nonfallers, which is similar to the finding of Talarska et al. in 2017. However, Pereira et al. reported that the probability of fall among men was higher provided lean and body fat mass and balance were the same. Similarly, no association found between types of residency with older adults which is in contrast to D'Souza et al. and Johnson, who reported their fallers were more of institutionalized.,
A significant association between socioeconomic status and older adults with fall and without fall was found in this study. The participants of the upper middle class demonstrated a higher incidence of fall as compared to other groups; moreover, these groups reported to have higher concern of fall and decreased functional activities. The prevalence of chronic diseases and leading a sedentary lifestyle were the main cause that was reported by this group. The result of this study is in contrast with earlier studies where low socio-economic group was found to be associated with falls.,,
Majority of fallers had experienced a fall in the morning. This finding is inconsistent with previous studies conducted nationally and globally.,,, This may be due to older adults were more engaged in discharging their duties in a hurried manner in the morning. With respect to the location of fall, a greater number of falls had occurred indoors, especially in bathrooms. This is in agreement with earlier studies where bathroom in the house of older adults considered as a hazardous area.,,, The presence of slippery flooring, inappropriate tiling, inadequate lighting, the absence of grab bar, and anti-skid mat were the possible risk factors in the bathroom that were reported by the participants thus heightened their risk of fall. Modification on the Indian toilet/bathroom by creating awareness on the barrier-free environment may benefit Indian older adults from reducing a risk of falling. Studies on home hazard modification have also shown to decrease the incidence of fall.,
Fallers who had sustained injuries utilized health-care services, including hospital admission. Fall-related injuries have been reported from the previous studies to vary from 34% to 74%.,,, However, this study failed to retrieve information related to types and sites of injuries that they had sustained which led them to visit a physician. Whereas remaining noninjured fallers, very negligible proportion of the respondents were reported to a physician because majority had a slip in the bathroom due to extrinsic factors and those factors were overlooked. Those who had a fall due to intrinsic factors also had a misconception that fall in old age is common phenomenon in spite of demonstrating imbalance and muscle weakness. It clearly indicates that elderly adults are poorly informed about risk factors for fall and they are not aware that even noninjury fall requires medical attention for early identification of risk factors to prevent the future fall.
Mobility aids are commonly adopted by older adults to enhance their functional activities, but it has been identified as one of the risk factors associated with falls.,,, Use of mobility aids might hamper the ability of older adults to recover balance and leading to destabilizing biomechanical effects during balance recovery thus increase the risk of falls., Observation among the study participants, who used mobility aids, has revealed usage of inappropriate mobility aid without professional's prescription and their training, the improper height and worn out mobility aid. Thus, these factors may explain the possibility of fall among the participants and need to sensitize older adults to obtain professional helps to adopt an appropriate mobility aid and insisting its periodic examination.
Among the reported FOF, fallers had demonstrated high concern of FOF as compared to nonfallers. Finding of our study was similar to the previous studies where 33.2% of FOF reported among the older adults., Epidemiological-based studies even demonstrated the prevalence of FOFs among nonfallers. Does this FOF in older adults is the cumulative effect of physiological changes that took place eugenically is something need to explore in larger amplitude although its predisposing factors had been identified. Since FOF influenced dysfunctional and decreased the QOL in older adults, it is mandatory to screen in clinical settings to reduce the future risk of fall and/or nursing home admission.
Participants of fallers and nonfallers with FOF had demonstrated a decreased level of functional independence and is in agreement with previous studies as well.,,,
Majority of the participants had demonstrated normal independence in basic ADL; however, certain risk factors which increase dependency rate remain constant between fallers and nonfallers, such as an increase in age, FOF, use of assistive device, and lower socio-economic group. This finding is in similar agreement with the previous study that has identified the decreased level of independence as a risk factor to increase the risk of fall. Restricted functional activities have been reported to invite deconditioning effect leading to disuse muscle atrophy, decreased aerobic capacity, altered balance, social isolation, depression, increase the risk of fall, and affecting the QOL.,, Physical therapist working closely with older adults, therefore, need to screen for risk factors that restrict functional activities and addressing them in the treatment goal will reduce the risk of fall and improve their QOL.
| Conclusion|| |
The finding of this study reveals fall as a significant health problem faced by older adults and provides insight into the influencing risk factors and circumstances for falls. Factors such as age group, education, marital status, and socio-economic status had demonstrated a significant association with fallers. FOF and restricted functional activities are not uncommon among the older adults either with or without falls and considered as important risk factors for falls, especially as one advance in aging. An identified risk factor in this study can help in effective, comprehensive geriatric assessment to facilitate in adopting multidimensional treatment strategies.
We wish to express our sincere gratitude to all the study participants who actively participated in this study without whom this would not be possible. We would also like to acknowledge AncyPMathew who had actively involved in data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ingle GK, Nath A. Geriatric health in India: Concerns and solutions. Indian J Community Med 2008;33:214-8.
] [Full text]
Agarwalla R, Saikia AM, Pathak R, Islam F, Borah M, Parashar M. A cross sectional study on assessment of falls in community dwelling elderly of Assam. Natl J Community Med 2016;7:368-71.
Kumari Y, Dsouza SA. Comparison of fall risk in rural and urban community-dwelling Indian elderly. Asian J Gerontol Geriatr 2016;11:54-9.
Saikia Ashok M, Das AK, Saikia Anjana M. Prevalence and correlates of falls among community-dwelling elderly of Guwahati city, Assam. Indian J Basic Appl Med Res 2016;5:185-19.
Kumar A, Srivastava DK, Verma A, Kumar S, Singh NP, Kaushik A. The problems of fall, risk factors and their management among geriatric population in India. Indian J Community Health 2013;25:89-94.
Dsouza SA, Rajashekar B, Dsouza HS, Kumar KB. Falls in Indian older adults: A barrier to active ageing. Asian J Gerontol Geriatr 2014;9:33-40.
Stewart Williams J, Kowal P, Hestekin H, O'Driscoll T, Peltzer K, Yawson A, et al.
Prevalence, risk factors and disability associated with fall-related injury in older adults in low- and middle-incomecountries: Results from the WHO study on global AGEing and adult health (SAGE). BMC Med 2015;13:147.
Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? JAMA 2007;297:77-86.
Mitchell-Fearon K, James K, Waldron N, Holder-Nevins D, Willie-Tyndale D, Laws H, et al
. Falls among community-dwelling older adults in Jamaica. SAGE Open 2014;4:1-9.
Mane AB, Sanjana T, Patil PR, Sriniwas T. Prevalence and correlates of fear of falling among elderly population in urban area of Karnataka, India. J Midlife Health 2014;5:150-5.
Rubenstein LZ. Falls in older people: Epidemiology, risk factors and strategies for prevention. Age Ageing 2006;35 Suppl 2:ii37-41.
D'Souza SA, Shringarpure A, Karol J. Circumstances and consequences of falls in Indian older adults. Indian J Occup Ther 2008;1:3-11.
Berg WP, Alessio HM, Mills EM, Tong C. Circumstances and consequences of falls in independent community-dwelling older adults. Age Ageing 1997;26:261-8.
Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C, et al.
Development and initial validation of the falls efficacy scale-international (FES-I). Age Ageing 2005;34:614-9.
Jonasson SB, Nilsson MH, Lexell J. Psychometric properties of four fear of falling rating scales in people with Parkinson's disease. BMC Geriatr 2014;14:66.
Mahoney FI, Barthel DW. Functional evaluation: The barthel index. Md State Med J 1965;14:61-5.
O'Sullivan, Susan B, Schmitz, Thomas J. Physical Rehabilitation. Examination of Functional Status and Activity Level. 5th
ed. Philadelphia: F.A. Davis Company; 2006. p. 385.
Gururaj M. Kuppuswamy's socio-economic status scale – A revision of income parameter for 2014. Int J Recent Trends Sci Technol 2014;11:1-2.
Shaikh Z, Pathak R. Revised Kuppuswamy and Prasad BG socio-economic scales for 2016. Int J Community Med Public Health 2017;4:997-9.
Patil SS, Suryanarayana SP, Dinesh R, Shivraj NS, Murthy NS. Risk factors for falls among elderly: A community-based study. Int J Health Allied Sci 2015;4:135-40. [Full text]
Pereira CL, Baptista F, Infante P. Men older than 50 yrs are more likely to fall than women under similar conditions of health, body composition, and balance. Am J Phys Med Rehabil 2013;92:1095-103.
Johnson SJ. Frequency and nature of falls among older women in India. Asia Pac J Public Health 2006;18:56-61.
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.
Sirohi A, Kaur R, Goswami AK, Mani K, Nongkynrih B, Gupta SK, et al.
A study of falls among elderly persons in a rural area of Haryana. Indian J Public Health 2017;61:99-104.
] [Full text]
Ravindran RM, Kutty VR. Risk factors for fall-related injuries leading to hospitalization among community-dwelling older persons: A Hospital-based case-control study in Thiruvananthapuram, Kerala, India. Asia Pac J Public Health 2016;28:70S-6S.
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.
Rao SS. Prevention of falls in older patients. Am Fam Physician 2005;72:81-8.
Lord SR, Menz HB, Sherrington C. Home environment risk factors for falls in older people and the efficacy of home modifications. Age Ageing 2006;35 Suppl 2:ii55-9.
Charron PM, Kirby RL, MacLeod DA. Epidemiology of walker-related injuries and deaths in the United States. Am J Phys Med Rehabil 1995;74:237-9.
Bateni H, Maki BE. Assistive devices for balance and mobility: Benefits, demands, and adverse consequences. Arch Phys Med Rehabil 2005;86:134-45.
Talarska D, Strugała M, Szewczyczak M, Tobis S, Michalak M, Wróblewska I, et al.
Is independence of older adults safe considering the risk of falls? BMC Geriatr 2017;17:66.
[Table 1], [Table 2], [Table 3]