C International Psychogeriatric Association 2014 International Psychogeriatrics (2014), 26:9, 1511–1519 doi:10.1017/S104161021400074X
Depressive symptoms are independently associated with recurrent falls in community-dwelling older adults ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Sébastien Grenier,1 Marie-Christine Payette,1,2 Francis Langlois,3,4 Thien Tuong Minh Vu4,5 and Louis Bherer1,6 1
Centre de recherche, Institut universitaire de gériatrie de Montréal (CRIUGM), Montréal, Québec, Canada Université du Québec à Montréal (UQAM), Montréal, Québec, Canada 3 Institut universitaire de gériatrie de Sherbrooke (IUGS), Montréal, Québec, Canada 4 Institut universitaire de gériatrie de Montréal (IUGM), Montréal, Québec, Canada 5 Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada 6 PERFORM Centre, Concordia University, Montréal, Québec, Canada 2
ABSTRACT
Background: Falls and depression are two major public health problems that affect millions of older people each year. Several factors associated with falls are also related to depressive symptoms such as medical conditions, sleep quality, use of medications, cognitive functioning, and physical capacities. To date, studies that investigated the association between falls and depressive symptoms did not control for all these shared factors. The current study addresses this issue by examining the relationship between falls and depression symptoms after controlling for several confounders. Methods: Eighty-two community-dwelling older adults were enrolled in this study. The Geriatric Depression Scale (GDS-30) was used to evaluate the presence of depressive symptoms, and the following question was used to assess falls: “Did you fall in the last 12 months, and if so, how many times?” Results: Univariate analyses indicated that the number of falls was significantly correlated with gender (women), fractures, asthma, physical inactivity, presence of depressive symptoms, complaints about quality of sleep, use of antidepressant drugs, and low functional capacities. Multivariate analyses revealed that depressive symptoms were significantly and independently linked to recurrent falls after controlling for confounders. Conclusions: Results of the present study highlight the importance of assessing depressive symptoms during a fall risk assessment. Key words: older adults, depressive symptoms, recurrent falls, sleep quality, cognitive functioning, physical capacities
Introduction More than one-third of community-dwelling older adults (aged 65+ years) fall each year, half of fallers fall more than twice a year, and 10–15% of them are seriously injured (e.g., fractures, severe tissue damages, etc.) (Tinetti et al., 1995; Tinetti et al., 1988; Rubenstein and Josephson, 2002; Iaboni and Flint, 2013). This places falls as a leading cause of injury-related deaths in this age group (Batra et al., 2012). In order to prevent severe consequences caused by falls, one strategy is to identify risk factors and to
Correspondence should be addressed to: Dr. Sébastien Grenier, Centre de recherche, Institut universitaire de gériatrie de Montréal (CRIUGM), 4565, Queen-Mary Road, Montréal (Québec) H3W 1W5, Canada. Phone: +1-514-340-3540, Ext. 4782; Fax: +1-514-340-2801. Email: [email protected]. Received 21 Oct 2013; revision requested 30 Dec 2013; revised version received 23 Jan 2014; accepted 23 Mar 2014. First published online 23 April 2014.
act on those that are modifiable. Results of previous studies suggested that older people (Oosterink et al., 2009; Deandrea et al., 2010; Rossat et al., 2011; Grundstrom et al., 2012), females (Biderman et al., 2002; Bloch et al., 2010; Deandrea et al., 2010; Fabre et al., 2010; Rossat et al., 2011; Ferrer et al., 2012; Launay et al., 2013), and less educated (Fabre et al., 2010) were associated with a higher occurrence of falls. Various medical conditions have also been linked to falls, such as osteoporosis (Lynn et al., 1997; Sinaki et al., 2005), rheumatoid arthritis (Stanmore et al., 2013; Armstrong et al., 2005; Laylor et al., 2003; Hayashibara et al., 2010), cardiovascular diseases and associated conditions (e.g., diabetes) (Carey and Potter, 2001; Laylor et al., 2003; Deandrea et al., 2010; Mayne et al., 2010), pulmonary diseases (Laylor et al., 2003; Roig et al., 2011), poor vision (Delbaere et al., 2006; Fabre et al., 2010; Salonen and Kivela, 2012; Reed-Jones
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et al., 2013), number of medications (Woolcott et al., 2009; Al-Aama, 2011; Launay et al., 2013), and use of benzodiazepine (Laylor et al., 2003; Pariente et al., 2008; Rossat et al., 2011). Other studies have further shown that falls are related to older people’s physical capacities. Indeed, a prospective study conducted over 12 months on community-dwelling older adults found that a low score on the Physical Performance Test (PPT), followed by decreased maximal handgrip strength were the strongest predictors of subsequent falls, although variables from different categories (e.g., medical, psychological, sensory, physical, and postural) were also significant (Delbaere et al., 2006). Results of previous studies also revealed that slow walking speed (Muraki et al., 2013), irregular gait pattern (Deandrea et al., 2010), and low level of mobility (measured by the Timed Up and Go test (TUG); Beauchet et al., 2011) significantly increased the likelihood of falling among older people. It has also been suggested that unhealthy life habits, such as drinking, smoking, and physical inactivity (i.e., sedentary lifestyle), were associated with falls in elderly adults (mainly because of decreasing muscle mass and contributing to the development of osteoporosis; Law and Hackshaw, 1997; Todd and Skelton, 2004; Kanis et al., 2005; Cawthon et al., 2006). Moreover, a recent systematic review and metaanalysis, including 27 studies, concluded that both global cognitive impairments (often based on the Mini-Mental State Examination (MMSE) scores) and executive function impairments (often measured by the Trail Making test, part B) were significantly associated with an increased risk of fall in community- and institution-dwelling older adults (Muir et al., 2012). Taken together, these results suggest that several socio-demographic, medical, physical, and cognitive factors are associated with falls in older people. However, the fall risk assessment remains incomplete without considering the presence of depressive symptoms (i.e., symptoms of depression not meeting full Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for a specific mood disorder), a psychological state frequently associated with falls in literature (Biderman et al., 2002; Deandrea et al., 2010; Launay et al., 2013). Similar to falls, depressive symptoms are also frequently reported by community-dwelling older adults, affecting up to one-third of them (Heun et al., 2000; Blazer, 2003). The nature of the relationship between depressive symptoms and falls remains somewhat unclear, as the many factors they share in common may provide confounding information (Iaboni and Flint, 2013). Indeed,
many studies suggest that depression is significantly related to factors that may also be associated with falls such as deficits in cognitive functioning (Austin et al., 2001; Kizilbash et al., 2002; Baune et al., 2007) and decline in physical performance among older adults (Penninx et al., 1998; Stuck et al., 1999; Everson-Rose et al., 2005). Moreover, the use of antidepressant drugs and the presence of sleep problems, two conditions often related to depression, are further associated with falls in older population (Leipzig et al., 1999; Brassington et al., 2000; Laylor et al., 2003; Hill et al., 2007; Kerse et al., 2008; Stone et al., 2008). To date, no study has examined the independent association between depressive symptoms and recurrent falls after controlling for all these shared factors. Therefore, this study aimed to determine if depressive symptoms are independently associated with recurrent falls in older people.
Methods Recruitment and assessment procedure This is a secondary analysis of a clinical trial that involved comprehensive medical assessment prior to physical exercise intervention in sedentary and frail older adults (Langlois et al., 2013). Eighty-two community-dwelling older adults were enrolled in this study. They were 79.2% women and had a mean age of 72.13 ± 6.11 years (range: 61 to 89 years). Participants were recruited via advertisements placed in newspapers and posted at locations near the research center where the study took place (e.g., pharmacies, banks, and hospitals). All participants signed a consent form approved by the ethical committee of the research center. Participants were assessed in three different sessions. The occurrence of falls (in the last 12 months), the presence of medical conditions or life habits (e.g., physical inactivity) potentially associated with falls, and the use of medications were assessed by a geriatrician (session 1). Participants’ physical capacities were evaluated by a kinesiologist (session 2). Finally, cognitive functioning, presence of depressive symptoms, and sleep quality were assessed by a neuropsychologist (session 3). Patients were given at least one day of rest between each session and were excluded if they showed signs of dementia (scores
Depressive symptoms are independently associated with recurrent falls in community-dwelling older adults ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Sébastien Grenier,1 Marie-Christine Payette,1,2 Francis Langlois,3,4 Thien Tuong Minh Vu4,5 and Louis Bherer1,6 1
Centre de recherche, Institut universitaire de gériatrie de Montréal (CRIUGM), Montréal, Québec, Canada Université du Québec à Montréal (UQAM), Montréal, Québec, Canada 3 Institut universitaire de gériatrie de Sherbrooke (IUGS), Montréal, Québec, Canada 4 Institut universitaire de gériatrie de Montréal (IUGM), Montréal, Québec, Canada 5 Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada 6 PERFORM Centre, Concordia University, Montréal, Québec, Canada 2
ABSTRACT
Background: Falls and depression are two major public health problems that affect millions of older people each year. Several factors associated with falls are also related to depressive symptoms such as medical conditions, sleep quality, use of medications, cognitive functioning, and physical capacities. To date, studies that investigated the association between falls and depressive symptoms did not control for all these shared factors. The current study addresses this issue by examining the relationship between falls and depression symptoms after controlling for several confounders. Methods: Eighty-two community-dwelling older adults were enrolled in this study. The Geriatric Depression Scale (GDS-30) was used to evaluate the presence of depressive symptoms, and the following question was used to assess falls: “Did you fall in the last 12 months, and if so, how many times?” Results: Univariate analyses indicated that the number of falls was significantly correlated with gender (women), fractures, asthma, physical inactivity, presence of depressive symptoms, complaints about quality of sleep, use of antidepressant drugs, and low functional capacities. Multivariate analyses revealed that depressive symptoms were significantly and independently linked to recurrent falls after controlling for confounders. Conclusions: Results of the present study highlight the importance of assessing depressive symptoms during a fall risk assessment. Key words: older adults, depressive symptoms, recurrent falls, sleep quality, cognitive functioning, physical capacities
Introduction More than one-third of community-dwelling older adults (aged 65+ years) fall each year, half of fallers fall more than twice a year, and 10–15% of them are seriously injured (e.g., fractures, severe tissue damages, etc.) (Tinetti et al., 1995; Tinetti et al., 1988; Rubenstein and Josephson, 2002; Iaboni and Flint, 2013). This places falls as a leading cause of injury-related deaths in this age group (Batra et al., 2012). In order to prevent severe consequences caused by falls, one strategy is to identify risk factors and to
Correspondence should be addressed to: Dr. Sébastien Grenier, Centre de recherche, Institut universitaire de gériatrie de Montréal (CRIUGM), 4565, Queen-Mary Road, Montréal (Québec) H3W 1W5, Canada. Phone: +1-514-340-3540, Ext. 4782; Fax: +1-514-340-2801. Email: [email protected]. Received 21 Oct 2013; revision requested 30 Dec 2013; revised version received 23 Jan 2014; accepted 23 Mar 2014. First published online 23 April 2014.
act on those that are modifiable. Results of previous studies suggested that older people (Oosterink et al., 2009; Deandrea et al., 2010; Rossat et al., 2011; Grundstrom et al., 2012), females (Biderman et al., 2002; Bloch et al., 2010; Deandrea et al., 2010; Fabre et al., 2010; Rossat et al., 2011; Ferrer et al., 2012; Launay et al., 2013), and less educated (Fabre et al., 2010) were associated with a higher occurrence of falls. Various medical conditions have also been linked to falls, such as osteoporosis (Lynn et al., 1997; Sinaki et al., 2005), rheumatoid arthritis (Stanmore et al., 2013; Armstrong et al., 2005; Laylor et al., 2003; Hayashibara et al., 2010), cardiovascular diseases and associated conditions (e.g., diabetes) (Carey and Potter, 2001; Laylor et al., 2003; Deandrea et al., 2010; Mayne et al., 2010), pulmonary diseases (Laylor et al., 2003; Roig et al., 2011), poor vision (Delbaere et al., 2006; Fabre et al., 2010; Salonen and Kivela, 2012; Reed-Jones
1512
S. Grenier et al.
et al., 2013), number of medications (Woolcott et al., 2009; Al-Aama, 2011; Launay et al., 2013), and use of benzodiazepine (Laylor et al., 2003; Pariente et al., 2008; Rossat et al., 2011). Other studies have further shown that falls are related to older people’s physical capacities. Indeed, a prospective study conducted over 12 months on community-dwelling older adults found that a low score on the Physical Performance Test (PPT), followed by decreased maximal handgrip strength were the strongest predictors of subsequent falls, although variables from different categories (e.g., medical, psychological, sensory, physical, and postural) were also significant (Delbaere et al., 2006). Results of previous studies also revealed that slow walking speed (Muraki et al., 2013), irregular gait pattern (Deandrea et al., 2010), and low level of mobility (measured by the Timed Up and Go test (TUG); Beauchet et al., 2011) significantly increased the likelihood of falling among older people. It has also been suggested that unhealthy life habits, such as drinking, smoking, and physical inactivity (i.e., sedentary lifestyle), were associated with falls in elderly adults (mainly because of decreasing muscle mass and contributing to the development of osteoporosis; Law and Hackshaw, 1997; Todd and Skelton, 2004; Kanis et al., 2005; Cawthon et al., 2006). Moreover, a recent systematic review and metaanalysis, including 27 studies, concluded that both global cognitive impairments (often based on the Mini-Mental State Examination (MMSE) scores) and executive function impairments (often measured by the Trail Making test, part B) were significantly associated with an increased risk of fall in community- and institution-dwelling older adults (Muir et al., 2012). Taken together, these results suggest that several socio-demographic, medical, physical, and cognitive factors are associated with falls in older people. However, the fall risk assessment remains incomplete without considering the presence of depressive symptoms (i.e., symptoms of depression not meeting full Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for a specific mood disorder), a psychological state frequently associated with falls in literature (Biderman et al., 2002; Deandrea et al., 2010; Launay et al., 2013). Similar to falls, depressive symptoms are also frequently reported by community-dwelling older adults, affecting up to one-third of them (Heun et al., 2000; Blazer, 2003). The nature of the relationship between depressive symptoms and falls remains somewhat unclear, as the many factors they share in common may provide confounding information (Iaboni and Flint, 2013). Indeed,
many studies suggest that depression is significantly related to factors that may also be associated with falls such as deficits in cognitive functioning (Austin et al., 2001; Kizilbash et al., 2002; Baune et al., 2007) and decline in physical performance among older adults (Penninx et al., 1998; Stuck et al., 1999; Everson-Rose et al., 2005). Moreover, the use of antidepressant drugs and the presence of sleep problems, two conditions often related to depression, are further associated with falls in older population (Leipzig et al., 1999; Brassington et al., 2000; Laylor et al., 2003; Hill et al., 2007; Kerse et al., 2008; Stone et al., 2008). To date, no study has examined the independent association between depressive symptoms and recurrent falls after controlling for all these shared factors. Therefore, this study aimed to determine if depressive symptoms are independently associated with recurrent falls in older people.
Methods Recruitment and assessment procedure This is a secondary analysis of a clinical trial that involved comprehensive medical assessment prior to physical exercise intervention in sedentary and frail older adults (Langlois et al., 2013). Eighty-two community-dwelling older adults were enrolled in this study. They were 79.2% women and had a mean age of 72.13 ± 6.11 years (range: 61 to 89 years). Participants were recruited via advertisements placed in newspapers and posted at locations near the research center where the study took place (e.g., pharmacies, banks, and hospitals). All participants signed a consent form approved by the ethical committee of the research center. Participants were assessed in three different sessions. The occurrence of falls (in the last 12 months), the presence of medical conditions or life habits (e.g., physical inactivity) potentially associated with falls, and the use of medications were assessed by a geriatrician (session 1). Participants’ physical capacities were evaluated by a kinesiologist (session 2). Finally, cognitive functioning, presence of depressive symptoms, and sleep quality were assessed by a neuropsychologist (session 3). Patients were given at least one day of rest between each session and were excluded if they showed signs of dementia (scores
