Falls An Issue Among Elderly Women

About one third of community-based seniors fall each year, with the rate increasing to forty percent among those over the age of eighty. Most seniors that fall do not experience physical injury; however, these falls often lead to serious psychological and social consequences. Older women not only experience higher falls rates than men, but are also more likely to experience serious soft-tissue injuries and fractures. Given that falls represent a high cost to the individual and to society, preventing falls among those at greatest risk, women of advanced age, is essential.

Magnitude of the Problem

It has been estimated that approximately one third of community-based seniors over the age of sixty-five fall each year. Prudham and Evans report that this rate increases to forty percent for seniors over the age of eighty. Josephson et al. estimated that the annual rate of falls in community surveys of seniors living at home was between 0.2 and 0.8 falls per person. Analysis of data from the National Population Health Survey calculated a prevalence rate for falls of 4.94 for Canadian seniors; however, tabulating separate scores for males and females revealed some discrepancy. The prevalence rates for females and males was 6.29 and 3.21, respectively, indicating the occurrence of a larger proportion of falls among females.

Falling is the leading cause of injury and the sixth leading cause of death in individuals over the age of sixty-five. For example, Riley11 reported that accidental falls accounted for 65% of all accident-related hospital separations (a separation form is completed whenever a patient is discharged or if a patient dies within the hospital), 72% of accident-related days of hospital care, and 56% of accidental deaths for individuals over the age of 65. More recently, Health Canada reports that falls represent 65% of all injuries among Canadian seniors annually. In short, falls among seniors represent a frequent cause of high injury severity and mortality. Seniors that do survive from falling often experience a number of complications, including restricted activity, soft-tissue injuries or fractures. For example, Tideiksaar1 and Kane et al. report that individuals may acquire impaired mobility from injury, fear, lack of selfconfidence, or restriction of ambulation, that is either self-imposed or imposed by family members, to prevent subsequent falls. The serious nature and consequence of non-injurious falls, such as fear of falling or lack of self-confidence, should not be underestimated. For example, Nevitt et al. found that one third of seniors that had fallen reported reduced participation in social activities, while 16% of fallers reported limiting their usual activities because they feared subsequent falls. Further, Tinetti et al. found that approximately half of seniors that fell reported fear of falling, while onequarter reported restricting their activity after a fall.

With respect to fractures and soft tissue injuries, approximately five percent of fall episodes result in fractures, while an additional five percent cause serious soft tissue injuries within community-based samples. Both of these injuries may require hospitalization or immobilization for extended periods of time. Further, elderly women not only experience higher fall rates than men, but they are also more likely to sustain fall-related fractures. Approximately, one in forty seniors are hospitalized as a result of their falls. Gryfe et al.14 and Josephson et al. contend that approximately 50% of elderly individuals admitted to a hospital after a fall are alive one year later. Additionally, repeated falls are one of the factors that often lead to institutionalization of previously independent seniors. Sattin et al. report that approximately 50% of fall injury events that occurred within the home and required hospital admission resulted in nursing home placement upon discharge. Kiel et al. report that one-time fallers, and more specifically repeated fallers (2 or more falls in the past year), were at increased risk of subsequent hospitalization, admission into nursing homes, and frequent contact with a physician than non-fallers, after controlling for the following: age, gender, perceived health status, and difficulties with activities of daily living. Josephson et al. and Rubenstein et al. contend that the problem associated with falls and the elderly is not simply their high incidence, since young children and athletes incur higher incidence of falls than all age groups, with the exception of the frailest, older individuals. Rather, it is the combination of the high incidence of falling, with the high susceptibility to injury among seniors that accounts for the problem. This proclivity for injury is associated with a high prevalence of clinical disease (e.g., osteoporosis) and age-related changes (e.g., slowed protective reflexes) that make even a seemingly mild fall dangerous. Given the high incidence of falls and the potential serious outcomes of falls, it would seem imperative to provide accurate information pertaining to the risk factors and preventative strategies available to reduce falls among those at greatest risk - women.

Potential Risk Factors For Falls

Given that the exact cause of falling is frequently difficult to pinpoint or to predict, specifically with seniors that have multiple, identifiable age-related changes and/or medical conditions that often precipitate falls, identifying and treating (or modifying) relevant risk factors for falls is an alternative approach in the study and prevention of falls. Although several studies have been conducted to determine risk factors for falls among the various elderly segments of the population, few studies completed analyses separately for women. Further, several of the studies failed to complete multivariate analyses and have only reported univariate and bivariate information for falls. Despite these limitations, risk factors identified within the literature will be reviewed, and where appropriate, information pertaining to women will be provided.

Potential Risk Factors for Falls Among the Community-Based

Several risk factors have been consistently identified within the literature for community-based elderly. Having a history of previous falls, multiple stumbles, and being physiologically or functionally impaired have repeatedly been implicated as risk factors for falling. Similarly, the socio-demographic variables of age, the female gender and living alone have also been found to increase seniors susceptibility to falls. Further, the need for support services were predictive of falling for women.

Another noteworthy risk factor for falls is the use of various drugs among the community-based, specifically alcohol, diuretics, sedatives and tranquilizers, vasodilators, psychotropics (women only) and anti-inflammatories. Further, Campbell et al. found that fall risk increased for women as medication number increased.

Specific conditions or diseases were also associated with an increased risk of falling, namely cardiovascular disease, history of hypertension (women only for Yasumura et al.), decreased vision (women only for Campbell et al.), podiatric problems, joint disease, and arthritis. Individuals with cognitive impairments, dementia and depression have also been found to be more susceptible to falling.

Risk factors for falls that are associated with balance, and may contribute to instability in seniors include abnormal reflexes, disability of the lower extremities, and impairments in balance and gait. Other risk factors that have been reported among the community-based involve the type of activity being completed and various environmental hazards that seniors were confronted with at the time the fall occurred (see, for example, women only for Campbell et al.)

Multivariate analysis of data from the 1995 National Population Health Survey revealed the following factors to increase women's risk of falling: receiving homecare services (O.R.=2.58), arthritis (O.R.=1.59), diabetes (O.R.=2.09), urinary problems (O.R. =2.77), visual impairments (O.R.=3.39), and use of analgesics (O.R.=1.78), while social support was associated with a decreased risk (O.R.=0.77). Further, analysis of data from the Survey of Ageing and Independence, which examined injuries that were most likely attributable to women falling, found advanced age (O.R.=1.59), poor health (O.R.=1.46), home in need of repairs (O.R.=2.80), receiving support (O.R.= 2.89), and dissatisfaction with life (1.45) to increase fall risk. Conversely, not smoking (O.R.=0.66), obtaining adequate rest (O.R.=0.68) and not having a health limitation (O.R.=0.46) protected against fall risk (unpublished results from author).

Fall Intervention Programs

Hornbrook et al. and Sattin note that although a number of risk factors for falls have been identified within the falls literature, relatively fewer studies have tested the effectiveness of proposed prevention interventions for falls. Additionally, a large portion of the literature pertaining to falls prevention has been mainly descriptive in nature. For example, after determining risk factors for falls with a specific population, suggestions were then made as to possible prevention strategies for falls (see, for example, DeVito et al.); however the majority of these strategies are not tested for their effectiveness. Thus, the extent to which these prevention strategies actually prevent falls is questionable and limit the potential generalizability of the methods and results to other settings. Further, few interventions have focused specifically on the prevention of falls for women. A review of a few of the more promising communitybased intervention strategies will be discussed.

MacRae et al. initiated a study to determine the effects of a 1 year-low intensity exercise program in the prevention of falls for community-based women, and to determine the effects of the exercises on several physical performance risk factors (e. g., poor balance, lower extremity muscular weakness, gait abnormalities) associated with falling. At the end of the intervention, there were no significant differences for falls between the control and experimental group, although the control group did experience significant declines in isometric strength of the knee extensors and ankle dorsiflexors within the year. MacRae et al. concluded that the exercise program was not of sufficient intensity or specific enough to affect gait performance in relatively healthy women. A study by Hornbrook et al. concluded similar results concerning the inadequacy of the intervention dose after a randomized trial of a fall prevention program that addressed home safety, exercise and behaviour risk factors, which also failed to produce a marked protective effect in seniors' risk of falling. As well, Reinsch et al. did not find any effect on fall rate or secondary outcome measures (e.g., strength, balance, fear of falling, perceived health) after a one year "stand-up/step-up" exercise program, and they also attributed these effects to inadequate exercise intensity.

A ten week balance control exercise intervention for the prevention of falls revealed that the experimental group experienced less falls, fractures, hospitalizations and deaths than the control group. Further, the experimental group significantly improved their balance and balance confidence scores (unpublished results available from author). Another exercise prevention program found that the experimental group participating in the exercise intervention improved their reaction time, neuromuscular control and body sway, with no improvements within the control group; however, there were no significant differences in the proportion of fallers between the exercise and control groups, although there was some evidence to suggest the trend of fall frequency and adherence to the exercise program.

Gallagher and Brunt conducted the Falls Intervention Trials (FIT) Project, a randomized clinical trial of a program developed with the intent of reducing falls and the resulting complications among 100 individuals over the age of 60. Seniors in the intervention group received a comprehensive risk assessment, individualized feedback about any risks that had been identified, and a video and booklet (“Head Over Heels”), while the control group received no intervention. Statistical analysis revealed no significant effect of the intervention program on the main outcome measures, namely, fall incidence, falls self-efficacy, fear of falling, health service utilization, quality of life, and social functioning. The authors suggested that a lack of statistical power, and the fact that only 50% of the recommendations for reducing falls were completed by the seniors, may in part explain the absence of an effect of the intervention program.

Although some of the aforementioned intervention efforts may have been successful, as with other interventions not described, one of the more promising fall prevention programs include the FICSIT trials in the United States. For example, Tinetti et al. conducted a randomized trail comparing the effectiveness of usual care plus social visits, versus a multifactorial, targeted risk abatement intervention strategy in reducing falls among community-based seniors at risk of falling. Community-based men and women (n=301) who were 70 years of age or older, and who possessed one of the following risk factors for falling: (1) postural hypotension, (2) use of sedatives, (3) use of at least four prescription medications, and (4) impairments in the arm, in leg strength, in range of motion, in balance, in the ability to move safely from the bed to a chair, or in gait, were studied. The control group received their usual health care visits, plus social visits from the researching staff. The experimental group were given adjustments in their medications, behavioral instructions to prevent falls, and exercise programs aimed at modifying their individual risks for falls. At the end of the one year intervention, the multiple-risk factor intervention strategy resulted in a significant reduction in the risk of falling among the elderly. Further, the proportion of seniors with targeted risk factors for falling was reduced in the intervention group, as compared to the control group. Tinetti et al. concluded that the reduction of falls found in the experimental group may be partly explained by the strategy utilized, given that the risk factors that also contributed to immobility and functional decline were improved. Other efforts from the FICSIT trials have also shown effectiveness in reducing fall risk. As stated by Tinetti and Williams “falling represents one of the few health conditions meeting all the criteria for prevention - high frequency, evidence of preventability, and heavy burden of morbidity” (p. M118). As such, implementing strategies to reduce falls and fall injuries which have the potential to affect seniors’ quality of life and the health care cost associated with falling should be a priority issue.

Clinical Implications Of Falling as a Health Issue for Women

Two of the more relevant issues concerning women and falls, namely, use of psychotropics, and osteoporosis, deserve further attention. Psychotropic use not only increases risk of falling (women only for Campbell et al.) but has also been associated with fractures. Campbell et al. contend that the use of psychotropic drugs contribute to increased fall risk in women compared to men, and is maintained even after controlling for factors such as depression and dementia. Further, osteoporosis occurs more frequently in women, and has been associated with higher incidence rates of fractures among females of advanced age. Given the frequency of osteoporosis and psychotropic use among women, the management of these conditions by health practitioners, and the effect they exert on falls and fractures, is essential.

Limitations

Although several limitations exist in the falls research that contribute to the lack of knowledge concerning women and their risk of falling, only the major issues will be discussed. One of the greatest limitations facing falls research is the lack of a standard, universal definition and classification system of falls. Lach et al. contend that the multiplicity of risk factors for falls may obscure the different risk factors for different types of falls, and their relative contribution of risk may also differ. Retrospective and cross-sectional designs further limit the conclusions drawn from studies. Retrospective studies depend upon the quality of documentation of health professionals and the memory of past fallers to determine the relationship between the risk factors identified and the fall episode, while cross-sectional designs do not allow for the establishment of a temporal order for factors associated with the fall event. Additionally, studies that do not approach the fall event from a multidisciplinary perspective may overlook significant risk factors for falling or misinterpret inappropriately confounding explanations for some factors associated with falling. Lastly, the lack of multivariate statistical analyses and failure to examine risk factors for males and females separately also contribute to limitations within the literature. For example, univariate and bivariate results fail to control for potentially confounding risk factors for falls, while analyses for men and women may fail to account for risk factors that are significant for each gender separately.

Concluding Remarks: Why Study Falls Among Elderly Women?

Undeniably falls and their potential ramifications constitute a considerable health and economic cost to society and may be an issue of greater significance to elderly women than men. Evidence exists that fall prevention is possible. As such, new research must provide accurate information about specific risk factors and prevention programs from a multidisciplinary perspective for falls focusing on women. Further, longitudinal studies are needed to evaluate different prevention programs for women, dealing with areas affecting the health of women (e.g., For example, do dietary supplements of vitamin D and calcium reduce fractures among women? Does the reduction of psychotropics decrease falls and fractures among women?). Additionally, efforts that approach prevention from a multidisciplinary perspective, as in the FICSIT trials, should be continued and expanded upon, in order to obtain a better understanding of fall prevention. This area needs to be expanded in other settings, such as long term care, chronic care and acute care facilities, a relatively under-researched area in comparison to community-settings.