Accid. Anal. & Pro. Vol. 24, No. 5, pp. 521-537, Printed in Great Britain.
ml-4575192 0 1992 Pergamon
1992
FALLS IN 84- TO 85-YEAR-OLD AT HOME
s5.w + .oo Press Ltd.
PEOPLE LIVING
MARIE-LOUISE SVENSSON, AKE RUNDGREN, and STEN LANDAHL Department
of Geriatric and Long-Term Care Medicine, University of Gothenburg, Hospital, 411 33 Gothenburg, Sweden
Vasa
(Received 3 April 1991; in revised form 30 July 1991) Abstract-The present study is a part of the Swedish longitudinal population study “70-yearold people in Gothenburg”. The aim of the present study was to analyse retrospectively incidence, circumstances, and consequences of falls during one year among 741 home-living people aged 84-85. A comparison of social and medical characteristics of failers and non-fallers aged 85 was performed. Information was collected by interviews and clinical examinations. In 1986/1987,732 home-living people (244 men and 488 women), aged 85 gave information about falls during the last year. Three hundred and one (41%). 97 men and 204 women. had fallen at least once durine the iast year, mainly indoors. No sex ‘difference was found in incidence. The most dominant triggering causes of falls were stumbling, dizziness, and feebleness. In 80% of the falls an injury occurred, of which every fourth was a fracture. A multivariate regression procedure showed that dizziness, vertigo and unsteadiness, transient ischemic attacks, antidepressant drugs, and poor subjectively experienced health characterized the failers. Mortality rate of those between 85 and 88 years of age showed no association with falls.
INTRODUCTION
Falls among home-living as well as institutionalized elderly above 65 years of age are common, as has been reported in many studies (Campell et al. 1990; Colling and Park 1983; DeVito et al. 1988; Wickham et al. 1989; Sjdgren and Bjornstig 1989; UdCn 1985). Causes of falls are explained both by external environmental and individual factors (Boucher 1959; Lowry 1990; Meiring 1986; Parsons and Levy 1987; Rubenstein et al. 1988; Svensson et al., 1991; Tinetti, Speechley, and Ginter 1988). The falls often result in injuries with hospitalization and high medical costs (Edna 1983; Haddon and Baker 1981; Hedlund, Ahlborm, and Lindgren 1986; Pentland et al. 1986; Roy, Pentland, and Miller 1986; Sjogren and Bjornstig 1989). Consequences of falls include anxiety of falling again, restrictions in activities and mobility, and an increased need of assistance (Escher et al. 1989; Vellas et al. 1987). Furthermore, falls are the leading cause of accidental death among persons above age 65 in Sweden as well as in other countries (Campell et al 1990; Escher, O’Dell, and Gambert 1989; Parson and Levy 1987; Sjogren and Bjiirnstig 1989; Svensson et al. 1991; Tideiksaar 1986; Tideiksaar 1989). Within the frame of the longitudinal population study “70-year-old people in Gothenburg”, (Rinder et al. 1975), the incidence of, circumstances around, and consequences of falls occurring to people between 84-85 years of age have been carefully investigated. As far as we know falls have not previously been analysed in such a large group of people at this advanced age. The aim of this study was to describe retrospectively the incidence, locality, causes, and consequences of falls in individuals living at home between 84-85 years of age and who were still alive and living in their-own homes at the age of 85. A comparison of social and medical characteristics of fallers and nonfallers at age 85 was also performed. STUDY
POPULATION
AND
METHODS
The longitudinal population study “70-year-old people in Gothenburg” started in 1971/ 1972 with an invitation of 1,148 persons, a 30%) systematically chosen sample of 70-year-old people living in Gothenburg (Rinder et al. 1975). The participation rate was 85%, comprising 449 men and 524 women. This cohort was reexamined at ages 75, 79, 81, and 83. The participation rates at these occasions were 92%, 92%, 87% and 81%) respectively. 527
528
M.-L. SVENSSONet al.
At age 85 those still living in the original population sample, including all previous nonresponders, were invited together with the rest of the 85year-old population in Gothenburg (N = 1,512). The participation rate was 64%, comprising 974 persons (302 men and 672 women). This retrospective interview study, performed in 1986/1987 deals with 741 subjects, 85 years old, who were living in their own homes at the time of the investigation. Two men and seven women did not give information about falls. The population studied thus comprised 732 subjects (244 men and 488 women), born in 1901 and 1902. Those who reported one or more falls during the year preceding the investigation were defined as failers and those who denied having falling as nonfallers. The latter served as a comparison group. The fallers were interviewed about frequency, locality, causes, and consequences of falls. All subjects were examined with respect to social conditions including marital status, home living conditions, activities, smoking habits, interests, loneliness, and need of community service. Furthermore the elderly were interviewed about previous diseases and symptoms, dizziness, quality of night-time sleep, natural functions, well-being and tiredness. Additional data from the total group comprised visual and hearing functions, heart rate and blood pressure (supine, after five minutes rest and standing, after one and three minutes), neurological and general medical examination, and laboratory tests. The neurological examination involved a balance test (Romberg’s test), which assesses balance on five levels: (i) ability to rise from a chair with closed eyes, (ii) ability to stand with eyes closed and feet together, (iii) ability to stand with feet together and eyes open, (iv) ability to stand with feet apart and eyes open, and (v) inability to do any of the above. The elderly were also investigated in activity of daily living (ADL), physical capability, and activity. Nursing load was assessed and based on a model previously used at Vasa Hospital (Hulten et al. 1969). The scale comprised mobility, dressing, feeding, personal hygiene, urinary and fecal continence, and disturbing behaviour. The score varied from 0 to 39 points, where 0 indicates no help. Mobility was graded according to the method of Gillner et al. 1969. The optimal score was zero and the maximum negative value was -32 points, meaning a bedridden person with total immobility. A systematically chosen sample of the total investigated population (50%), was examined by a psychiatrist for presence of dementia. The state of mental orientation was tested by the Mini Mental Test (Folstein, Folstein, and McHugh 1975). In a randomly chosen sample of lo%, information was collected about earlier and actual consumption of alcohol, both by interviews with the subjects and through contacts with the Temperance Board register. Statistical methods Fisher’s permutation test, including Fisher’s exact test as a special case, was used to test the hypothesis that there was no difference between the fallers and the nonfallers, and p < 0.05, two-sided test, was considered statistically significant. Finally, a stepwise logistic multivariate regression model was used, including all statistically significant parameters, in order to establish characteristics for people who had fallen at the age of 84-85. Results A total of 301 persons, 97 men (32%) and 204 women (68%), reported falls at 8485 years of age. The comparison group of nonfallers amounted to 431, 147 men (34%) and 284 women (66%). No statistically significant differences were found in distribution of sexes and marital status between the two groups. Forty-one percent of the investigated population had had one or more falls during the last year (Table 1). Among the fallers, men reported an average number of 2.87 falls and women 2.95 falls (n.s.). Women more often than men had falls indoors, (53% and 41%, respectively, p < 0.05). The predominant causes of falls were stumbling, dizziness, and feebleness (Table 2). Falls during nights were unusual, less than 1% of all falls. Eighty percent of the fallers suffered some type of injury: 60 (25%) received fractures, 176 (73%) soft tissue injuries, 4 (2%) concussion of the brain or sprains. No statistical difference with respect to type of injuries
529
Falls in 84- to 85year-old people living at home Table 1. Number of falls at 84-85 years of age Women (n = 488)
Men (n = 244) n
(%)
n
147 40
(69
285
1 2 3 45 26
25 17 3 6 6
{::I 1;;
z: 2:
Number of falls 0
(%)
$1 ii; (4)
between men and women could be found. The injured subjects had to consult a physician in 52% of the cases. Living conditions and functional abilities
There were no statistically significant differences between the groups in type of residence, level of floor, presence of elevators, or part of the city in which they lived. Over 90% in both groups felt secure in the housing area and were content with their housing. Seventy percent of the investigated population lived alone, and 31% experienced feelings of loneliness. Seventy three percent (534) had or had had children, and the majority of them (76%) reported a good relationship. Daily contacts with other people were registered in 55%, and 73% of them had a close relationship with someone. No statistically significant differences in these social conditions were found between the two groups. Forty one percent of both the groups were active members of some kind of association. One difference between the two groups was that 53% of the fallers did not devote themselves to earlier interests compared with 45% of the nonfallers, p < 0.05. Among the fallers, 7% were smokers and 8% had been reported to the Temperance Board register because of alcohol abuse. Eight percent of the nonfallers smoked, and 13% had a registration of alcohol abuse. No statistically significant differences were found between the two groups. Fallers reported more frequent urination (less than two-hourly in 12% compared with 7% of the nonfallers (p < 0.05). Urinary incontinence was reported for 84 (28%) fallers and 103 (24%) nonfallers (n.s). This condition was registered as a handicap in daily living in 32% for both the fallers and the nonfallers. Among the fallers 44% consumed prescribed and not prescribed laxatives compared with the nonfallers’ 34%, (p < 0.01). Irregular defecations were reported in 49% of the fallers compared with 32% of the nonfallers (p < 0.001). Quality of nighttime sleep was reported unsatisfactory in 44% of the fallers and in 31% of the nonfallers (p < 0.01). The fallers also used to rest or to sleep more often than nonfallers during the day (77% and 69%, respectively, p < 0.05). Feelings of tiredness were also more prevalent among the fallers (49%) than in the comparison group (36%) p < 0.01). The fallers used walking
Table 2. Triggering causes of falls Women (n = 204)
Men (n = 97) n Stumbling Dizziness Feebleness Other reasons
60 8
n
(%) (62)
(%)
126
:;
Fisher’s exact test, men against women. **p 2 0.01.
(3) (14)
530
M.-L. SVENSON
et al.
aids (primarily canes), more often (48%) then the nonfallers (38%), (p < 0.05). Eight percent of the failers needed human assistance when moving compared to 4% of the nonfallers, and 1% in both groups were wheelchair-bound. Thirty two percent of the failers reported difficulties when walking around indoors compared with 21% of the nonfallers, (p < 0.01). Fourteen percent in the comparison group needed living assistance when walking outdoors compared to 21% among the fatlers, (p < 0.05). Only 22% of the fallers took a daily walk while 33% of the nonfallers did so, (p < 0.01). The main reason for not going out was due to “disease or handicap”, given by 37% among the fallers and by 28% for the comparison group, (p < 0.05). The mobility score was - 1.2, 2 1.9 (M t SD) for the failers and - 0.9, -t 2.2 (M + SD) for the nonfallers (p < 0.05). The fallers had a higher score of nursing load 1.5, + 3.2 (M rf: SD) compared with the nonfallers’ 1.0 , t 2.6 (M 2 SD), (p < 0.05). From Table 3 it might be concluded that the failers needed more help in their daily activities than those in the comparison group. No statistically significant differences were found between the two groups in utilizing social and medical home help. The only difference found was in using special transportation-70% of the fallers received this service compared with 58% of the nonfallers (p < 0.01). Low physical and mental energy was reported by 38% of the fallers and by 23% of the nonfallers (p < 0.001). Dizziness, vertigo, impaired balance, and unsteadiness were reported in 57% of the failers and in 44% of the nonfallers (p < 0.001). Th e main sensation of dizziness was a feeling of unsteadiness, which was experienced more often by the fallers (Table 4). Syncope was also more common among the fallers. Different triggering situations for dizziness are presented in Table 5. Symptoms of dizziness that had lasted for more than six months were reported in 89% of fallers and in 86% in the comparison group. In 16% of the cases, dizziness had lasted for more than 10 years. Dizziness was reported as a problem in activities of daily living for 26% of the fallers and in 16% of the nonfallers (p < 0.001). Tremor and hypokinesia were more frequent among the failers, as seen in Table 6. The test of balance (Rombergs) showed that balance was impaired among the fallers compared with the nonfallers, (p < 0.05). Seventy-two percent of the nonfallers managed to rise from a chair with closed eyes compared with 65% of the fallers. Visual ability (binocular, visus test r 0.5) with or without correction by lenses was satisfactory in 64% of the fallers and in 68% of the nonfallers (ns). Hearing ability tested without hearing aids showed no difference between the two groups. Ninety-two percent in both samples were judged completely lucid and mentally oriented to time, place, and person. Mini Mental Test score showed no differences in variables of mental orientation between fallers and nonfallers. A detailed investigation of dementia showed symptoms of different types of dementia in 13% of the fallers and in 12% of the elderly nonfallers. Medication, Morbidity, and Mortality In both groups, 90% consumed one or more drugs and on the average, fallers had a higher regular drug consumption; 4.1 ? 3.0 (M f SD) compared with 3.6 + 2.8 (M + SD) of the nonfallers (p < 0.05). Table 7 shows the groups of drugs prescribed most often and those with statistically significant differences in pre~ription frequency between the fallers and nonfallers, There were no statisti~lly signi~cant differences in consumption of hypnotic, sedative, analgesic or cardiovascular drugs between fallers and nonfallers. The failers estimated their own health as bad or extremely bad in 20% compared to 11% in nonfallers (p < 0.001). Previous transient ischemic attacks (TIA) was reported by 5% of the fallers vs. 2% of the nonfallers (p c 0.05). Eighteen percent of the fallers suffered from dyspnoea compared to 12% in the comparison group, (p < 0.05) Apart from these differences, cardiovascular disease was not more prevalent among the fallers. Eleven percent of the fallers and seven percent of the nonfallers had had a cataract operation (p < 0.05). Previous fractures were reported in 9% of the fallers and in 6% of the nonfallers (n.s). Joint problems were reported from 40% of the fallers and from 33% of the nonfallers (p < 0.05). Bone mineral content examined by an osteometer (participation rate 69%) and osteoporosis of the vertebral column examined with X-ray (participation rate 59%) showed no statistical differences between the two groups. No
Ability to: Rise from a bed Rise from a chair Dress/Undress Eat Use the toilet Use the bathtub or shower
240 226 237 290 257 1%
n
Self
(80) (75) g;
(a)
:;
7:
(13) (10)
z
n
‘i:;
(%)
:!3 “:
fi
I:; (3) (2) (251
(2)
(“ro) 385 374 376 420 396 328
n
(76)
(87) g{
(%I
22
33 3:
fi
(5)
(ii] $1
(9)
(%)
With difficulty
Self
With difficulty
With assistance
Nonfallers (n = 431)
Failers (n = 301)
Table 3. ADL capacity among failers and nonfallers
81
zi 22 I:
fz
(5) (3) (1) (19)
(“ro)
With assistance
0.006 0.003 0.021 0.691 0.040 0.000
P-value
Fisher’s exact test against the nonfallers. ‘p -=z0.05.
Unsteadiness and impaired balance Rotation of head Syncope Rotation environment Black-out Feeling of unreality
n (%)
Men (n = 51) n
(%)
n (%)
n
(%)
Men (n = 56) n
(%)
(n = 133)
Women
Total (n = 171)
Women (n = 120)
Non failers
Failers
Table 4. Sensations of dizziness among those with postural disturbances
n
C%)
Total (n = 189)
Falls in 84- to 85-year-old people living at home
533
Table 5. Triggering situations for those with dizziness Nonfallers
Failers Men (n = 51) n Rising from lying to standing Walking Turning one’s head Tilting one’s head back Sitting Lying
35 24 7 11 8 3
Women (n = 120)
Women (n = 133)
Men (n = 56)
(%)
n
(%)
n
(%)
n
(%)
{Zj (14)*
: ;;
{:zj (23)
:: ;
I::]
z
i:q
“,;i
;A
I::; (6)
16 10
I::; (8)
[:$ (8) (4)
6 1
Fisher’s exact test against the nonfallers. *p < 0.05.
other statistical differences were found in morbidity incidence between the two groups. History of previous diseases is shown in Table 8. No differences in pulse rate and blood pressure (supine and standing) were evident between the two groups. After one minute’s standing the systolic blood pressure among both the fallers and the nonfallers had fallen 20 mm Hg or more in 81% of the subjects. After three minutes’ postural position, the same conditions were registered. The values of laboratory tests of B-haemoglobin, serum vitamin, B-12, serum and blood folates, Bglucose, S-sodium, S-potassium, and S-calcium did not differ statistically between the two groups. One year after the investigation, 23 (7%) of the fallers were deceased compared to 31 (7%) of the nonfallers. Three years after the investigation, 76% in the nonfalling group were still alive compared to 77% in the falling group. The stepwise logistic regression procedure showed that such factors as postural disturbances, subjectively experienced poor health, antidepressant drugs, and transient ischemic attacks were more common among people who had fallen (Table 9). DISCUSSION
In the present retrospective study the incidence of falls for 84- to 85year-olds during one year was 41% . The fallers had on average experienced nearly three falls during one year. Other studies have reported an annual incidence of from 30% to 85% for falls in people over 65 years old with an age-related increase in incidence (Campell et al. 1981; Perry 1982; Prudham and Grimley 1981; Sjogren and Bjornstig 1989; Tinetti et al. 1988). The findings here are thus in agreement with earlier studies. Falls very often are underreported (DeVito et al. 1988; Hindmarsch and Estes 1989; Roy et al. 1986; Tinetti et al. 1988), which is why such figures must be interpreted cautiously. Despite the state of high mental lucidness in this population, falls not producing an injury could be difficult to remember for such a long period as one year. No sex differences in the incidence of falls were found, which agrees with findings in other investigations (Campell et al. 1990; Pentland et al. 1986). However, one Swedish (Sjogren and Bjornstig 1989) and an English study (Livesley 1988) reported that women more often than men were exposed to falls in old age. Every fourth subject suffered a fracture in connection with the fall. The prevalence of osteoporosis was not different between the groups in our study in contrast to some other studies (Alffram 1964; Buhr and Cooke 1959; Nilsson and Westling 1977; Zetterberg and Andersson 1982). In the age group studied, low bone mineral content and osteoporosis is an almost general finding and therefore other risk factors like balance disturbances are probably of greater importance. In this study, the reported incidence of previous fractures was very low, compared to incidence in our earlier study of institutionalized elderly (Svensson et al. 1991). One explanation might be that these homeliving elderly had really had only a few previous fractures or that they had forgotten to report the true incidence. Another explanation could be that individuals with serious
13 21 14 3
I::;* (22)* (3)
(%) :: 35 4
n
*p 9 0.05.
(2) (5)
(%)
Women (n = Zaz)
Fisher’s exact test against the flonfailers,
Hypokinesia Tremor Paraesthesias Rigidity
n
Men (n = 97)
Failers
2;
n
(8) (2)
(%)
Total (n = 301)
97
n
(n
(%)
Men = 147)
Table 6. Prevalence of neurological symptoms
n
“,:; (2) (4)
(o/o)
Women (n = 284)
Nonfallers
15 51 ;;
n
(%)
Total (n = 431)
Falls in 84- to S-year-old
535
people living at home
Table 7. The most commonly prescribed groups of drugs and statistical prescription differences between groups Falters (n = 301) n Antipyretic analgesics Diuretics Hypnotics, sedatives Laxatives Heart glycosides Vascular dilatators Antiarrhtythmies Thyroid drugs Antidepressants Parkinsonian drugs
138 114 102 E 57 36 18 18 1
(%) {zz] I;; (22) r:;; (6)* (6)* (
ml-4575192 0 1992 Pergamon
1992
FALLS IN 84- TO 85-YEAR-OLD AT HOME
s5.w + .oo Press Ltd.
PEOPLE LIVING
MARIE-LOUISE SVENSSON, AKE RUNDGREN, and STEN LANDAHL Department
of Geriatric and Long-Term Care Medicine, University of Gothenburg, Hospital, 411 33 Gothenburg, Sweden
Vasa
(Received 3 April 1991; in revised form 30 July 1991) Abstract-The present study is a part of the Swedish longitudinal population study “70-yearold people in Gothenburg”. The aim of the present study was to analyse retrospectively incidence, circumstances, and consequences of falls during one year among 741 home-living people aged 84-85. A comparison of social and medical characteristics of failers and non-fallers aged 85 was performed. Information was collected by interviews and clinical examinations. In 1986/1987,732 home-living people (244 men and 488 women), aged 85 gave information about falls during the last year. Three hundred and one (41%). 97 men and 204 women. had fallen at least once durine the iast year, mainly indoors. No sex ‘difference was found in incidence. The most dominant triggering causes of falls were stumbling, dizziness, and feebleness. In 80% of the falls an injury occurred, of which every fourth was a fracture. A multivariate regression procedure showed that dizziness, vertigo and unsteadiness, transient ischemic attacks, antidepressant drugs, and poor subjectively experienced health characterized the failers. Mortality rate of those between 85 and 88 years of age showed no association with falls.
INTRODUCTION
Falls among home-living as well as institutionalized elderly above 65 years of age are common, as has been reported in many studies (Campell et al. 1990; Colling and Park 1983; DeVito et al. 1988; Wickham et al. 1989; Sjdgren and Bjornstig 1989; UdCn 1985). Causes of falls are explained both by external environmental and individual factors (Boucher 1959; Lowry 1990; Meiring 1986; Parsons and Levy 1987; Rubenstein et al. 1988; Svensson et al., 1991; Tinetti, Speechley, and Ginter 1988). The falls often result in injuries with hospitalization and high medical costs (Edna 1983; Haddon and Baker 1981; Hedlund, Ahlborm, and Lindgren 1986; Pentland et al. 1986; Roy, Pentland, and Miller 1986; Sjogren and Bjornstig 1989). Consequences of falls include anxiety of falling again, restrictions in activities and mobility, and an increased need of assistance (Escher et al. 1989; Vellas et al. 1987). Furthermore, falls are the leading cause of accidental death among persons above age 65 in Sweden as well as in other countries (Campell et al 1990; Escher, O’Dell, and Gambert 1989; Parson and Levy 1987; Sjogren and Bjiirnstig 1989; Svensson et al. 1991; Tideiksaar 1986; Tideiksaar 1989). Within the frame of the longitudinal population study “70-year-old people in Gothenburg”, (Rinder et al. 1975), the incidence of, circumstances around, and consequences of falls occurring to people between 84-85 years of age have been carefully investigated. As far as we know falls have not previously been analysed in such a large group of people at this advanced age. The aim of this study was to describe retrospectively the incidence, locality, causes, and consequences of falls in individuals living at home between 84-85 years of age and who were still alive and living in their-own homes at the age of 85. A comparison of social and medical characteristics of fallers and nonfallers at age 85 was also performed. STUDY
POPULATION
AND
METHODS
The longitudinal population study “70-year-old people in Gothenburg” started in 1971/ 1972 with an invitation of 1,148 persons, a 30%) systematically chosen sample of 70-year-old people living in Gothenburg (Rinder et al. 1975). The participation rate was 85%, comprising 449 men and 524 women. This cohort was reexamined at ages 75, 79, 81, and 83. The participation rates at these occasions were 92%, 92%, 87% and 81%) respectively. 527
528
M.-L. SVENSSONet al.
At age 85 those still living in the original population sample, including all previous nonresponders, were invited together with the rest of the 85year-old population in Gothenburg (N = 1,512). The participation rate was 64%, comprising 974 persons (302 men and 672 women). This retrospective interview study, performed in 1986/1987 deals with 741 subjects, 85 years old, who were living in their own homes at the time of the investigation. Two men and seven women did not give information about falls. The population studied thus comprised 732 subjects (244 men and 488 women), born in 1901 and 1902. Those who reported one or more falls during the year preceding the investigation were defined as failers and those who denied having falling as nonfallers. The latter served as a comparison group. The fallers were interviewed about frequency, locality, causes, and consequences of falls. All subjects were examined with respect to social conditions including marital status, home living conditions, activities, smoking habits, interests, loneliness, and need of community service. Furthermore the elderly were interviewed about previous diseases and symptoms, dizziness, quality of night-time sleep, natural functions, well-being and tiredness. Additional data from the total group comprised visual and hearing functions, heart rate and blood pressure (supine, after five minutes rest and standing, after one and three minutes), neurological and general medical examination, and laboratory tests. The neurological examination involved a balance test (Romberg’s test), which assesses balance on five levels: (i) ability to rise from a chair with closed eyes, (ii) ability to stand with eyes closed and feet together, (iii) ability to stand with feet together and eyes open, (iv) ability to stand with feet apart and eyes open, and (v) inability to do any of the above. The elderly were also investigated in activity of daily living (ADL), physical capability, and activity. Nursing load was assessed and based on a model previously used at Vasa Hospital (Hulten et al. 1969). The scale comprised mobility, dressing, feeding, personal hygiene, urinary and fecal continence, and disturbing behaviour. The score varied from 0 to 39 points, where 0 indicates no help. Mobility was graded according to the method of Gillner et al. 1969. The optimal score was zero and the maximum negative value was -32 points, meaning a bedridden person with total immobility. A systematically chosen sample of the total investigated population (50%), was examined by a psychiatrist for presence of dementia. The state of mental orientation was tested by the Mini Mental Test (Folstein, Folstein, and McHugh 1975). In a randomly chosen sample of lo%, information was collected about earlier and actual consumption of alcohol, both by interviews with the subjects and through contacts with the Temperance Board register. Statistical methods Fisher’s permutation test, including Fisher’s exact test as a special case, was used to test the hypothesis that there was no difference between the fallers and the nonfallers, and p < 0.05, two-sided test, was considered statistically significant. Finally, a stepwise logistic multivariate regression model was used, including all statistically significant parameters, in order to establish characteristics for people who had fallen at the age of 84-85. Results A total of 301 persons, 97 men (32%) and 204 women (68%), reported falls at 8485 years of age. The comparison group of nonfallers amounted to 431, 147 men (34%) and 284 women (66%). No statistically significant differences were found in distribution of sexes and marital status between the two groups. Forty-one percent of the investigated population had had one or more falls during the last year (Table 1). Among the fallers, men reported an average number of 2.87 falls and women 2.95 falls (n.s.). Women more often than men had falls indoors, (53% and 41%, respectively, p < 0.05). The predominant causes of falls were stumbling, dizziness, and feebleness (Table 2). Falls during nights were unusual, less than 1% of all falls. Eighty percent of the fallers suffered some type of injury: 60 (25%) received fractures, 176 (73%) soft tissue injuries, 4 (2%) concussion of the brain or sprains. No statistical difference with respect to type of injuries
529
Falls in 84- to 85year-old people living at home Table 1. Number of falls at 84-85 years of age Women (n = 488)
Men (n = 244) n
(%)
n
147 40
(69
285
1 2 3 45 26
25 17 3 6 6
{::I 1;;
z: 2:
Number of falls 0
(%)
$1 ii; (4)
between men and women could be found. The injured subjects had to consult a physician in 52% of the cases. Living conditions and functional abilities
There were no statistically significant differences between the groups in type of residence, level of floor, presence of elevators, or part of the city in which they lived. Over 90% in both groups felt secure in the housing area and were content with their housing. Seventy percent of the investigated population lived alone, and 31% experienced feelings of loneliness. Seventy three percent (534) had or had had children, and the majority of them (76%) reported a good relationship. Daily contacts with other people were registered in 55%, and 73% of them had a close relationship with someone. No statistically significant differences in these social conditions were found between the two groups. Forty one percent of both the groups were active members of some kind of association. One difference between the two groups was that 53% of the fallers did not devote themselves to earlier interests compared with 45% of the nonfallers, p < 0.05. Among the fallers, 7% were smokers and 8% had been reported to the Temperance Board register because of alcohol abuse. Eight percent of the nonfallers smoked, and 13% had a registration of alcohol abuse. No statistically significant differences were found between the two groups. Fallers reported more frequent urination (less than two-hourly in 12% compared with 7% of the nonfallers (p < 0.05). Urinary incontinence was reported for 84 (28%) fallers and 103 (24%) nonfallers (n.s). This condition was registered as a handicap in daily living in 32% for both the fallers and the nonfallers. Among the fallers 44% consumed prescribed and not prescribed laxatives compared with the nonfallers’ 34%, (p < 0.01). Irregular defecations were reported in 49% of the fallers compared with 32% of the nonfallers (p < 0.001). Quality of nighttime sleep was reported unsatisfactory in 44% of the fallers and in 31% of the nonfallers (p < 0.01). The fallers also used to rest or to sleep more often than nonfallers during the day (77% and 69%, respectively, p < 0.05). Feelings of tiredness were also more prevalent among the fallers (49%) than in the comparison group (36%) p < 0.01). The fallers used walking
Table 2. Triggering causes of falls Women (n = 204)
Men (n = 97) n Stumbling Dizziness Feebleness Other reasons
60 8
n
(%) (62)
(%)
126
:;
Fisher’s exact test, men against women. **p 2 0.01.
(3) (14)
530
M.-L. SVENSON
et al.
aids (primarily canes), more often (48%) then the nonfallers (38%), (p < 0.05). Eight percent of the failers needed human assistance when moving compared to 4% of the nonfallers, and 1% in both groups were wheelchair-bound. Thirty two percent of the failers reported difficulties when walking around indoors compared with 21% of the nonfallers, (p < 0.01). Fourteen percent in the comparison group needed living assistance when walking outdoors compared to 21% among the fatlers, (p < 0.05). Only 22% of the fallers took a daily walk while 33% of the nonfallers did so, (p < 0.01). The main reason for not going out was due to “disease or handicap”, given by 37% among the fallers and by 28% for the comparison group, (p < 0.05). The mobility score was - 1.2, 2 1.9 (M t SD) for the failers and - 0.9, -t 2.2 (M + SD) for the nonfallers (p < 0.05). The fallers had a higher score of nursing load 1.5, + 3.2 (M rf: SD) compared with the nonfallers’ 1.0 , t 2.6 (M 2 SD), (p < 0.05). From Table 3 it might be concluded that the failers needed more help in their daily activities than those in the comparison group. No statistically significant differences were found between the two groups in utilizing social and medical home help. The only difference found was in using special transportation-70% of the fallers received this service compared with 58% of the nonfallers (p < 0.01). Low physical and mental energy was reported by 38% of the fallers and by 23% of the nonfallers (p < 0.001). Dizziness, vertigo, impaired balance, and unsteadiness were reported in 57% of the failers and in 44% of the nonfallers (p < 0.001). Th e main sensation of dizziness was a feeling of unsteadiness, which was experienced more often by the fallers (Table 4). Syncope was also more common among the fallers. Different triggering situations for dizziness are presented in Table 5. Symptoms of dizziness that had lasted for more than six months were reported in 89% of fallers and in 86% in the comparison group. In 16% of the cases, dizziness had lasted for more than 10 years. Dizziness was reported as a problem in activities of daily living for 26% of the fallers and in 16% of the nonfallers (p < 0.001). Tremor and hypokinesia were more frequent among the failers, as seen in Table 6. The test of balance (Rombergs) showed that balance was impaired among the fallers compared with the nonfallers, (p < 0.05). Seventy-two percent of the nonfallers managed to rise from a chair with closed eyes compared with 65% of the fallers. Visual ability (binocular, visus test r 0.5) with or without correction by lenses was satisfactory in 64% of the fallers and in 68% of the nonfallers (ns). Hearing ability tested without hearing aids showed no difference between the two groups. Ninety-two percent in both samples were judged completely lucid and mentally oriented to time, place, and person. Mini Mental Test score showed no differences in variables of mental orientation between fallers and nonfallers. A detailed investigation of dementia showed symptoms of different types of dementia in 13% of the fallers and in 12% of the elderly nonfallers. Medication, Morbidity, and Mortality In both groups, 90% consumed one or more drugs and on the average, fallers had a higher regular drug consumption; 4.1 ? 3.0 (M f SD) compared with 3.6 + 2.8 (M + SD) of the nonfallers (p < 0.05). Table 7 shows the groups of drugs prescribed most often and those with statistically significant differences in pre~ription frequency between the fallers and nonfallers, There were no statisti~lly signi~cant differences in consumption of hypnotic, sedative, analgesic or cardiovascular drugs between fallers and nonfallers. The failers estimated their own health as bad or extremely bad in 20% compared to 11% in nonfallers (p < 0.001). Previous transient ischemic attacks (TIA) was reported by 5% of the fallers vs. 2% of the nonfallers (p c 0.05). Eighteen percent of the fallers suffered from dyspnoea compared to 12% in the comparison group, (p < 0.05) Apart from these differences, cardiovascular disease was not more prevalent among the fallers. Eleven percent of the fallers and seven percent of the nonfallers had had a cataract operation (p < 0.05). Previous fractures were reported in 9% of the fallers and in 6% of the nonfallers (n.s). Joint problems were reported from 40% of the fallers and from 33% of the nonfallers (p < 0.05). Bone mineral content examined by an osteometer (participation rate 69%) and osteoporosis of the vertebral column examined with X-ray (participation rate 59%) showed no statistical differences between the two groups. No
Ability to: Rise from a bed Rise from a chair Dress/Undress Eat Use the toilet Use the bathtub or shower
240 226 237 290 257 1%
n
Self
(80) (75) g;
(a)
:;
7:
(13) (10)
z
n
‘i:;
(%)
:!3 “:
fi
I:; (3) (2) (251
(2)
(“ro) 385 374 376 420 396 328
n
(76)
(87) g{
(%I
22
33 3:
fi
(5)
(ii] $1
(9)
(%)
With difficulty
Self
With difficulty
With assistance
Nonfallers (n = 431)
Failers (n = 301)
Table 3. ADL capacity among failers and nonfallers
81
zi 22 I:
fz
(5) (3) (1) (19)
(“ro)
With assistance
0.006 0.003 0.021 0.691 0.040 0.000
P-value
Fisher’s exact test against the nonfallers. ‘p -=z0.05.
Unsteadiness and impaired balance Rotation of head Syncope Rotation environment Black-out Feeling of unreality
n (%)
Men (n = 51) n
(%)
n (%)
n
(%)
Men (n = 56) n
(%)
(n = 133)
Women
Total (n = 171)
Women (n = 120)
Non failers
Failers
Table 4. Sensations of dizziness among those with postural disturbances
n
C%)
Total (n = 189)
Falls in 84- to 85-year-old people living at home
533
Table 5. Triggering situations for those with dizziness Nonfallers
Failers Men (n = 51) n Rising from lying to standing Walking Turning one’s head Tilting one’s head back Sitting Lying
35 24 7 11 8 3
Women (n = 120)
Women (n = 133)
Men (n = 56)
(%)
n
(%)
n
(%)
n
(%)
{Zj (14)*
: ;;
{:zj (23)
:: ;
I::]
z
i:q
“,;i
;A
I::; (6)
16 10
I::; (8)
[:$ (8) (4)
6 1
Fisher’s exact test against the nonfallers. *p < 0.05.
other statistical differences were found in morbidity incidence between the two groups. History of previous diseases is shown in Table 8. No differences in pulse rate and blood pressure (supine and standing) were evident between the two groups. After one minute’s standing the systolic blood pressure among both the fallers and the nonfallers had fallen 20 mm Hg or more in 81% of the subjects. After three minutes’ postural position, the same conditions were registered. The values of laboratory tests of B-haemoglobin, serum vitamin, B-12, serum and blood folates, Bglucose, S-sodium, S-potassium, and S-calcium did not differ statistically between the two groups. One year after the investigation, 23 (7%) of the fallers were deceased compared to 31 (7%) of the nonfallers. Three years after the investigation, 76% in the nonfalling group were still alive compared to 77% in the falling group. The stepwise logistic regression procedure showed that such factors as postural disturbances, subjectively experienced poor health, antidepressant drugs, and transient ischemic attacks were more common among people who had fallen (Table 9). DISCUSSION
In the present retrospective study the incidence of falls for 84- to 85year-olds during one year was 41% . The fallers had on average experienced nearly three falls during one year. Other studies have reported an annual incidence of from 30% to 85% for falls in people over 65 years old with an age-related increase in incidence (Campell et al. 1981; Perry 1982; Prudham and Grimley 1981; Sjogren and Bjornstig 1989; Tinetti et al. 1988). The findings here are thus in agreement with earlier studies. Falls very often are underreported (DeVito et al. 1988; Hindmarsch and Estes 1989; Roy et al. 1986; Tinetti et al. 1988), which is why such figures must be interpreted cautiously. Despite the state of high mental lucidness in this population, falls not producing an injury could be difficult to remember for such a long period as one year. No sex differences in the incidence of falls were found, which agrees with findings in other investigations (Campell et al. 1990; Pentland et al. 1986). However, one Swedish (Sjogren and Bjornstig 1989) and an English study (Livesley 1988) reported that women more often than men were exposed to falls in old age. Every fourth subject suffered a fracture in connection with the fall. The prevalence of osteoporosis was not different between the groups in our study in contrast to some other studies (Alffram 1964; Buhr and Cooke 1959; Nilsson and Westling 1977; Zetterberg and Andersson 1982). In the age group studied, low bone mineral content and osteoporosis is an almost general finding and therefore other risk factors like balance disturbances are probably of greater importance. In this study, the reported incidence of previous fractures was very low, compared to incidence in our earlier study of institutionalized elderly (Svensson et al. 1991). One explanation might be that these homeliving elderly had really had only a few previous fractures or that they had forgotten to report the true incidence. Another explanation could be that individuals with serious
13 21 14 3
I::;* (22)* (3)
(%) :: 35 4
n
*p 9 0.05.
(2) (5)
(%)
Women (n = Zaz)
Fisher’s exact test against the flonfailers,
Hypokinesia Tremor Paraesthesias Rigidity
n
Men (n = 97)
Failers
2;
n
(8) (2)
(%)
Total (n = 301)
97
n
(n
(%)
Men = 147)
Table 6. Prevalence of neurological symptoms
n
“,:; (2) (4)
(o/o)
Women (n = 284)
Nonfallers
15 51 ;;
n
(%)
Total (n = 431)
Falls in 84- to S-year-old
535
people living at home
Table 7. The most commonly prescribed groups of drugs and statistical prescription differences between groups Falters (n = 301) n Antipyretic analgesics Diuretics Hypnotics, sedatives Laxatives Heart glycosides Vascular dilatators Antiarrhtythmies Thyroid drugs Antidepressants Parkinsonian drugs
138 114 102 E 57 36 18 18 1
(%) {zz] I;; (22) r:;; (6)* (6)* (
