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Geriatr Gerontol Int 2016; 16: 336–344
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Prevalence of fear of falling in older adults, and its associations with clinical, functional and psychosocial factors: The Frailty in Brazilian Older People-Rio de Janeiro Study Flávia Moura Malini,1 Roberto Alves Lourenço2 and Claudia S Lopes1 1
Department of Epidemiology, Institute of Social Medicine, and 2Department of Internal Medicine, Faculty of Medical Sciences, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
Aim: The present study estimated the prevalence of fear of falling in older adults, and its associations with clinical, functional and psychosocial factors. Methods: Data from the Research Network Frailty in Brazilian Older People, specifically the Rio de Janeiro Study involving participants aged 65 years and older residing in the city of Rio de Janeiro, Brazil, were analyzed. Fear of falling was assessed by the Brazilian version of Falls Efficacy Scale-International. The following variables were assessed: history of falls, fracture after fall, number of comorbidities, number of medications, hospitalization in the previous year, use of walking support device, functional dependency in activities of daily living (including instrumental activities), hearing and visual impairments, hand grip strength, walking speed, self-rated health, depressive symptoms, cognitive impairment, living alone, social support, and activity level. Associations were evaluated by multiple logistic regression. Results: Among the 742 participants, 51.9% had a fear of falling, which was more prevalent in women and older participants. Fear of falling was associated with a history of one to two falls (odds ratio [OR] 2.18; 95% confidence interval [CI] 1.42–3.36), three or more falls (OR 2.72, 95% CI 1.10–6.70), use of seven or more medications (OR 1.70, 95%CI 1.04–2.80), hearing impairment (OR 1.66, 95% CI 1.10–2.49), functional dependence in activities of daily living (OR 1.73, 95% CI 1.07–2.79), diminished gait speed (OR 1.64 95% CI 1.04–2.58), fair self-rated health (OR 1.89, 95% CI, 1.30–2.74), poor/very poor self-rated health (OR 4.92, 95% CI 1.49–16.27) and depressive symptoms (OR 1.68, 95% CI 1.07–2.63). Conclusions: The prevalence of fear of falling was high in this population, and was associated with history of falls, use of seven or more medications, hearing impairment, functional dependency in activities of daily living, diminished walking speed, fair and poor/very poor self-rated health and depressive symptoms. Geriatr Gerontol Int 2015; 16: 336–344. Keywords: cross-sectional study, elderly, falls, fear of falling, prevalence.
Introduction Tinetti and Powell define fear of falling as a constant concern about falling that limits the performance of activities of daily living (ADL).1 It was initially described as a result of falls, and is the central component of post-fall syndrome.2 It is also reported in individuals with no history of falls.3,4
Accepted for publication 30 January 2015. Correspondence: Miss Flávia Moura Malini MsC, Rua São Francisco Xavier, 524, Pavilhão João Lyra Filho, 7° andar/bloco E, UERJ, Maracanã, Rio de Janeiro CEP 20550-013, Brazil. Email: [email protected]
336 |
doi: 10.1111/ggi.12477
Falls and fear of falling share risk factors, and can lead to serious health outcomes in older adults. Affected individuals might show a vicious cycle of functional decline, social isolation, physical deconditioning, changes in balance and gait, and loss of confidence, which consequently increase the risk and fear of falling.5 Most studies on the fear of falling use self-efficacy related to falls as the underlying concept of explanatory models. Such concepts represent a skill set, motivation and confidence, which are essential elements in an elderly person’s perceived ability to prevent falls.6 The prevalence of fear of falling varies between 12% and 65% for independent elderly individuals without a history of falls, and 29% and 92% in those with a history of falls.3 © 2015 Japan Geriatrics Society
Fear of falling: FIBRA-RJ study
Alterations in gait and balance, history of falls in the last year, female sex, low physical activity level, the use of walking aids, the presence of pain and arthritis, visual impairment and age >80 years are associated with a fear of falling.5,7,8 However, many previous studies focused on physical aspects, neglecting psychological and social factors. Few Brazilian studies have assessed fear of falling, and their limitations include the size and type of samples as well as measurement instruments.9,10 Therefore, the objective of the present study was to determine the prevalence of fear of falling, and its associations with socioeconomic, clinical, functional and psychosocial factors among elderly subjects.
Methods Participants The present cross-sectional study used the database of the Research Network Frailty in Brazilian Older People, specifically the Rio de Janeiro (FIBRA-RJ) section. The study population comprised clients of a healthcare plan and welfare foundation covering the state of Rio de Janeiro, including approximately 102 000 older adults. The inclusion criteria were as follows: customer of a health service provider for ≥12 months, age ≥65 years and resident of a district of the North Zone of Rio de Janeiro City. The exclusion criteria were neuropsychiatric activity, Mini-Mental State Examination (MMSE) score 1 year of school education were 18/19 and 24/25 points, respectively.14 The Geriatric Depression Scale was used to determine the presence of depressive symptoms; the cut-off was 6 points. We assessed whether individuals were living alone (yes/no). Social support was assessed by the following two questions: “If you need or will need help performing any of these activities of daily living, do you have anyone to turn to?” and, “Do you have a relative, friend, or neighbor who could take care of you if necessary?” Responses were yes or no. Activity level in the past year was categorized as better/same or worse.
Covariates Fear of falling The fear of falling was assessed using the Brazilian version of the Falls Efficacy Scale International (FES-I© 2015 Japan Geriatrics Society
The following covariates were assessed: sex, age, marital status, education (years of schooling) and individual income in minimum wages. | 337
F Moura Malini et al.
Data analysis
Results
Bivariate analyses were carried out to calculate the absolute and relative frequencies of fear of falling with respect to socioeconomic, demographic, clinical, functional and psychosocial characteristics. The associations were tested using the Pearson χ2-test. Multivariate analyses were carried out using logistic regression, and the crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated as measures of association. Variables with P < 0.25 in the bivariate analysis were selected and included in groups in the following models: model 1, all independent variables; model 2, clinical and functional variables; model 3, psychosocial variables; model 4, clinical, functional variables, and psychosocial variables (final model). All models were adjusted for socioeconomic and demographic variables. All statistical analyses were carried out using SPSS version 19 taking into account the sample weights and survey design. The FIBRA-RJ Study was approved by the ethics research committee of the Pedro Ernesto University Hospital. All participants provided informed consent.
Among the 742 participants analyzed, 521 (70.2%) were women. The mean ± SD age was 76.7 ± 7.03 years; 319 (43%), 330 (44.5%), and 93 (12, 5%) were aged 65–74, 75–84 and ≥85 years, respectively. Furthermore, 43.4% were married or cohabiting. Most older adults (80.3%) had ≥5 years schooling; 342 (48.3%) had an income ≥5.1 times the minimum wage (US$ 232.5; Table 1). Table 1 presents the prevalence of fear of falling according to socioeconomic and demographic variables. The association was significant for sex (women), age (older) and marital status (widowed); therefore, these variables were included in the models as covariates. Table 2 presents the prevalence of fear of falling according to the clinical and functional variables. Only the presence of hospitalization in the past year was not significantly associated with fear of falling. The psychosocial characteristics significantly associated with fear of falling were the presence of depressive symptoms, a lack of welfare support if required and a worse activity level than in the previous year (Table 3).
Table 1 Prevalence of fear of falling according to socioeconomic and demographic characteristics (Frailty in Brazilian Older People, specifically the Rio de Janeiro Study 2010)
Sex Male Female Age 65–74 years 75–84 years ≥85 years Marital status Married or cohabiting Divorced/separated Single Widow Education level Illiterate 1–4 years ≥5 years Income in minimum wages† 0–2 2.1–5 >5.1
n
(%)
Prevalence of fear of falling (%)
P
221 521
(29.8) (70.2)
35.7 59
Geriatr Gerontol Int 2016; 16: 336–344
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Prevalence of fear of falling in older adults, and its associations with clinical, functional and psychosocial factors: The Frailty in Brazilian Older People-Rio de Janeiro Study Flávia Moura Malini,1 Roberto Alves Lourenço2 and Claudia S Lopes1 1
Department of Epidemiology, Institute of Social Medicine, and 2Department of Internal Medicine, Faculty of Medical Sciences, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
Aim: The present study estimated the prevalence of fear of falling in older adults, and its associations with clinical, functional and psychosocial factors. Methods: Data from the Research Network Frailty in Brazilian Older People, specifically the Rio de Janeiro Study involving participants aged 65 years and older residing in the city of Rio de Janeiro, Brazil, were analyzed. Fear of falling was assessed by the Brazilian version of Falls Efficacy Scale-International. The following variables were assessed: history of falls, fracture after fall, number of comorbidities, number of medications, hospitalization in the previous year, use of walking support device, functional dependency in activities of daily living (including instrumental activities), hearing and visual impairments, hand grip strength, walking speed, self-rated health, depressive symptoms, cognitive impairment, living alone, social support, and activity level. Associations were evaluated by multiple logistic regression. Results: Among the 742 participants, 51.9% had a fear of falling, which was more prevalent in women and older participants. Fear of falling was associated with a history of one to two falls (odds ratio [OR] 2.18; 95% confidence interval [CI] 1.42–3.36), three or more falls (OR 2.72, 95% CI 1.10–6.70), use of seven or more medications (OR 1.70, 95%CI 1.04–2.80), hearing impairment (OR 1.66, 95% CI 1.10–2.49), functional dependence in activities of daily living (OR 1.73, 95% CI 1.07–2.79), diminished gait speed (OR 1.64 95% CI 1.04–2.58), fair self-rated health (OR 1.89, 95% CI, 1.30–2.74), poor/very poor self-rated health (OR 4.92, 95% CI 1.49–16.27) and depressive symptoms (OR 1.68, 95% CI 1.07–2.63). Conclusions: The prevalence of fear of falling was high in this population, and was associated with history of falls, use of seven or more medications, hearing impairment, functional dependency in activities of daily living, diminished walking speed, fair and poor/very poor self-rated health and depressive symptoms. Geriatr Gerontol Int 2015; 16: 336–344. Keywords: cross-sectional study, elderly, falls, fear of falling, prevalence.
Introduction Tinetti and Powell define fear of falling as a constant concern about falling that limits the performance of activities of daily living (ADL).1 It was initially described as a result of falls, and is the central component of post-fall syndrome.2 It is also reported in individuals with no history of falls.3,4
Accepted for publication 30 January 2015. Correspondence: Miss Flávia Moura Malini MsC, Rua São Francisco Xavier, 524, Pavilhão João Lyra Filho, 7° andar/bloco E, UERJ, Maracanã, Rio de Janeiro CEP 20550-013, Brazil. Email: [email protected]
336 |
doi: 10.1111/ggi.12477
Falls and fear of falling share risk factors, and can lead to serious health outcomes in older adults. Affected individuals might show a vicious cycle of functional decline, social isolation, physical deconditioning, changes in balance and gait, and loss of confidence, which consequently increase the risk and fear of falling.5 Most studies on the fear of falling use self-efficacy related to falls as the underlying concept of explanatory models. Such concepts represent a skill set, motivation and confidence, which are essential elements in an elderly person’s perceived ability to prevent falls.6 The prevalence of fear of falling varies between 12% and 65% for independent elderly individuals without a history of falls, and 29% and 92% in those with a history of falls.3 © 2015 Japan Geriatrics Society
Fear of falling: FIBRA-RJ study
Alterations in gait and balance, history of falls in the last year, female sex, low physical activity level, the use of walking aids, the presence of pain and arthritis, visual impairment and age >80 years are associated with a fear of falling.5,7,8 However, many previous studies focused on physical aspects, neglecting psychological and social factors. Few Brazilian studies have assessed fear of falling, and their limitations include the size and type of samples as well as measurement instruments.9,10 Therefore, the objective of the present study was to determine the prevalence of fear of falling, and its associations with socioeconomic, clinical, functional and psychosocial factors among elderly subjects.
Methods Participants The present cross-sectional study used the database of the Research Network Frailty in Brazilian Older People, specifically the Rio de Janeiro (FIBRA-RJ) section. The study population comprised clients of a healthcare plan and welfare foundation covering the state of Rio de Janeiro, including approximately 102 000 older adults. The inclusion criteria were as follows: customer of a health service provider for ≥12 months, age ≥65 years and resident of a district of the North Zone of Rio de Janeiro City. The exclusion criteria were neuropsychiatric activity, Mini-Mental State Examination (MMSE) score 1 year of school education were 18/19 and 24/25 points, respectively.14 The Geriatric Depression Scale was used to determine the presence of depressive symptoms; the cut-off was 6 points. We assessed whether individuals were living alone (yes/no). Social support was assessed by the following two questions: “If you need or will need help performing any of these activities of daily living, do you have anyone to turn to?” and, “Do you have a relative, friend, or neighbor who could take care of you if necessary?” Responses were yes or no. Activity level in the past year was categorized as better/same or worse.
Covariates Fear of falling The fear of falling was assessed using the Brazilian version of the Falls Efficacy Scale International (FES-I© 2015 Japan Geriatrics Society
The following covariates were assessed: sex, age, marital status, education (years of schooling) and individual income in minimum wages. | 337
F Moura Malini et al.
Data analysis
Results
Bivariate analyses were carried out to calculate the absolute and relative frequencies of fear of falling with respect to socioeconomic, demographic, clinical, functional and psychosocial characteristics. The associations were tested using the Pearson χ2-test. Multivariate analyses were carried out using logistic regression, and the crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated as measures of association. Variables with P < 0.25 in the bivariate analysis were selected and included in groups in the following models: model 1, all independent variables; model 2, clinical and functional variables; model 3, psychosocial variables; model 4, clinical, functional variables, and psychosocial variables (final model). All models were adjusted for socioeconomic and demographic variables. All statistical analyses were carried out using SPSS version 19 taking into account the sample weights and survey design. The FIBRA-RJ Study was approved by the ethics research committee of the Pedro Ernesto University Hospital. All participants provided informed consent.
Among the 742 participants analyzed, 521 (70.2%) were women. The mean ± SD age was 76.7 ± 7.03 years; 319 (43%), 330 (44.5%), and 93 (12, 5%) were aged 65–74, 75–84 and ≥85 years, respectively. Furthermore, 43.4% were married or cohabiting. Most older adults (80.3%) had ≥5 years schooling; 342 (48.3%) had an income ≥5.1 times the minimum wage (US$ 232.5; Table 1). Table 1 presents the prevalence of fear of falling according to socioeconomic and demographic variables. The association was significant for sex (women), age (older) and marital status (widowed); therefore, these variables were included in the models as covariates. Table 2 presents the prevalence of fear of falling according to the clinical and functional variables. Only the presence of hospitalization in the past year was not significantly associated with fear of falling. The psychosocial characteristics significantly associated with fear of falling were the presence of depressive symptoms, a lack of welfare support if required and a worse activity level than in the previous year (Table 3).
Table 1 Prevalence of fear of falling according to socioeconomic and demographic characteristics (Frailty in Brazilian Older People, specifically the Rio de Janeiro Study 2010)
Sex Male Female Age 65–74 years 75–84 years ≥85 years Marital status Married or cohabiting Divorced/separated Single Widow Education level Illiterate 1–4 years ≥5 years Income in minimum wages† 0–2 2.1–5 >5.1
n
(%)
Prevalence of fear of falling (%)
P
221 521
(29.8) (70.2)
35.7 59
