ABSTRACT

OBJECTIVES: To identify the prevalence of accidental falls among elderly persons in their homes, and to evaluate determining factors to that, including intrinsic and extrinsic risk factors, as well as the awareness about falls, assessed by the Falls Risk Awareness Questionnaire (FRAQ-Brazil).
METHOD: It consisted of a quantitative, transversal, and descriptive study, performed with 472 elderly persons through interview. Data were analyzed by the chi-squared test with a confidence interval of 95%.
RESULTS: The average age of the sample was 70.6 years and most of them were female. Among the sample, 55.2% referred previous episodes of fall. The majority of them self-reported having diseases associated with gait disturbance and used medicines that could cause falls. It was observed less falls among elderly with higher level of awareness about risk factors.
CONCLUSION: A high prevalence of accidental falls and exposure of the elderly persons to several independent and concomitant risk factors were observed. Greater awareness level about falls seems to be a preventive factor, presenting a higher association with falls than level of education and income.

Keywords: aged; accidental falls; risk factors; syndrome; health literacy.

RESUMO

OBJETIVOS: Identificar a prevalência de quedas domiciliares em uma amostra de idosos e avaliar os fatores determinantes para esse desfecho, incluindo os riscos intrínsecos e extrínsecos, bem como a percepção sobre quedas, mensurada por meio do questionário Falls Risk Awareness Questionnaire (FRAQ-Brasil).
MÉTODOS: Estudo transversal, descritivo e quantitativo, realizado com 472 idosos por meio de entrevista. Os dados foram analisados segundo teste do qui-quadrado, com intervalo de confiança de 95%.
RESULTADOS: A média de idade foi 70,6 anos, sendo a maior parcela do sexo feminino. Episódios de queda foram relatados por 55,2% dos entrevistados; a maioria tinha diagnóstico autorreferido de doenças que dificultavam a deambulação e fazia uso de medicamentos que favorecem quedas. Observou-se menor ocorrência de quedas entre os indivíduos com maior percepção sobre seus fatores de risco.
CONCLUSÃO: O estudo identificou elevada prevalência de quedas e exposição dos idosos a vários fatores de risco independentes e concomitantes. Maior nível de percepção sobre quedas parece ser um importante fator de prevenção, apresentando maior associação com a prevalência de quedas do que renda e escolaridade.

Palavras-chave: idoso; acidentes por quedas; fatores de risco; síndrome; alfabetização em saúde.

INTRODUCTION

The proportional and absolute growth of the elderly population is sought globally as the focus of a health agenda. The demographic profile of a country is an indicator of the quality of its health and social security services, and is considered as one of the parameters of human development.^1,2 As health care quality increases, pathological and physiological conditions inherent to aging become challenging and new obstacles to be eliminated or mitigated.

Although a number of factors are involved in maintaining the health of people over 60 years of age, accidental falls stand out as avoidable situations and a great factor of morbidity and mortality in these individuals. It is crucial to emphasize that a falling episode is the final event of a syndromic condition involving continuously related intrinsic, extrinsic, and behavioral factors.^3,4

Intrinsic factors are those related to health problems suffered by individual, such as drug use, reduced visual acuity, hearing disorders, slow gait, syncope, and others. Extrinsic are the factors related to the organization of the environment one lives in. One's home is the setting of greater exposure to these risks, and the principal site of accidents in this age group. Behavioral factors include activities that may lead the individual to a falling episode, and the lack of preventive measures such as dysfunctional alcohol consumption, a sedentary lifestyle, improper use of vision and hearing aid devices, the layout of furniture and objects in one's house, and others.³

Although risks have been systematized in this manner, it is often not possible to promote a clear distinction between the factors involved, or to indicate which one is directly responsible for the fall itself. Owing to these particularities, falling is better seen from a broader perspective, as a syndrome that affects mainly elderly people⁵, mostly female and in the domestic environment.^4,6-10

However, in addition to risk factors, the level of awareness elderly have on this issue is crucial to ensure an effective prevention, as individuals aware of the possibilities should, whenever possible, play an active role in the implementation of preventive measures.¹¹

Elderly people's knowledge regarding falls and associated factors has received little attention in the Brazilian literature. In light of that, this study aims at measuring this awareness and evaluate its effect on the occurrence of falls, in comparison to factors such as sociodemographic level, health, lifestyle, and household environment.

METHODS

This is a cross-sectional, descriptive, and quantitative study.¹² The applied research presented is original and was developed in the city of Juiz de Fora (MG), Brazil. Funding for this study was provided by the Universidade Federal de Juiz de Fora as "research aid."

Census tracts at each of the neighborhoods analyzed were selected at random. To locate residents older than 60 years, households were approached directly through-out the months of May and June of 2015.

People over 60 years of age living in Juiz de Fora were included in the sample. Hospitalized individuals, those of unstable overall health, or those with severe sensory hearing, visual or communication impairments that prevented an adequate collection of data were excluded. Questionnaires left incomplete for any reason were treated as sample loss.

Participants were instructed about the objectives and risks of the study and were addressed in a standardized manner by a trained researcher and invited to join the research sample, voluntarily consenting in their participation by signing an informed consent form.

Researchers were trained in a pilot study including 20 participants in order to identify problems in the understanding of the instruments and ensuring the quality of data collection. These interviews were disregarded in the study's analyses in order to maintain the sample's randomness.

One of the instruments adopted was designed to evaluate the presence of 20 extrinsic and behavioral risk factors associated with falls (hereinafter referred to as "household risk factors"), described in the literature as often related to a greater chance of falling among elderly, e.g., inadequate lighting, lack of safety bars, slippery floors, inadequate furniture height, presence of obstacles, clothing of too large a size, and unsafe shoes.^3,4

In order to assess intrinsic risk factors, the same instrument asked about the participant's overall health condition and autonomy regarding self-reported diagnoses of movement-impairing conditions, use of medications associated with falls, and physical activity. In addition, participants were asked about the occurrence of falls at any moment after completing 60 years of age and the family history of these events occurring in this age group. Sociodemographic information was also collected.

The Falls Risk Awareness Questionnaire (FRAQ-Brazil), translated and validated to Brazilian Portuguese,¹¹ was also used to evaluate elderly people's awareness of different aspects of falls. Containing 25 questions, it considers that a higher level of knowledge on falls is reflected on a greater number of correct answers. Its score, ranging from 0 to 32, reflects the amount of correct answers. There is no minimum score to establish an appropriate level of awareness.

For statistical analysis, sociodemographic variables were categorized as follows: age, divided into 75 years or less and above 75 years, when elderly persons are more exposed to severe falls; gender, male and female; self-reported racial or ethnic background, later divided into white and non-white; income, divided into two minimum wages or less and more than two minimum wages; education, divided into incomplete middle school/illiteracy and complete middle/high/superior education. Next, descriptive statistics were calculated using absolute frequencies (n), relative frequencies (%), measures of central tendency (mean), and measures of dispersion (standard deviation).

To analyze responses, 2x2 contingency tables containing absolute (n) and relative (%) frequencies were generated. To determine the association between variables, the chi-square test of independence (uncorrected) was performed. The odds ratio (OR) was used to measure risk, assessed through the relationship between the chance of an individual exposed to falls fitting the condition of interest if compared to those not exposed. The level of significance was set at p ≤ 0.05 for a confidence interval of 95%. Statistical processing and database assembling was done using the Statistical Package for Social Sciences (SPSS), version 15.0^®, 2010 (SPSS Inc., Chicago, Illinois, United States).

Participation in the survey (approved by the Research Ethics Committee of the Universidade Federal de Juiz de Fora, under protocol number 43917915.6.0000.5147) implied minimal risk to participants, i.e., the researcher did not interfere in any physical, psychological, or social aspect of patients' well-being or privacy, in accordance with the parameters of Resolution no. 466/12¹³ of the National Health Council of the Ministry of Health on human research.

RESULTS

Four hundred and seventy-two valid interviews were conducted, from a total of 601 elderly people approached who met the inclusion and exclusion criteria of this study. Refusals comprised 101 participants (a refusal rate of 16.8%), and 28 interviews were considered as sample loss due to an incomplete questionnaire.

The sample ranged from 60 to 95 years of age, with 21.8% (n = 103) of the sample aged over 75 years. The average age of the sample was 70.6 years. Women accounted for 58.4% (n = 276) and white people accounted for 60.3% (n = 285) of the sample.

Around 46.3% (n = 219) of the sample received up to two minimum wages. Of the total number of respondents, 7.8% (n = 37) had higher education; 26.4% (n = 125) had high school-level education; 21.4% (n = 101) had middle school-level education; and the remainder either had incomplete middle school or declared being illiterate. 17.5% (n = 83) of the sample lived in the city's central area.

Previous episodes of household falling occuring after 60 years of age were reported by 55.2% (n = 261) of respondents. 64.3% (n = 304) of respondents reported the occurrence of falls among close family members with more than 60 years of age.

A diagnosis of cardiac, neurological, and musculoskeletal disorders or others conditions that could hamper walking or standing posture was reported by 41.4% (n = 196) of the sample. Of the total number of respondents, 10.1% (n = 48) reported they had no autonomy to perform basic daily tasks and routine personal care. Regular physical exercise was performed by 39.1% (n = 185) of respondents, i.e., the majority was sedentary.

The continuous or recurrent use of medicine that increases the risk of falling, such as psychotropic drugs, hypotensive agents, sedatives, and others, was reported by 78.9% (n = 373) of respondents. The use of devices for hearing and/or visual aid, such as glasses or contact lenses, was present among 78.0% (n = 369) of participants. It is important to highlight that 44.0% (n = 208) of participants reported feeling they were likely to suffer a fall at any time.

A significant portion (35.9%; n = 170) of sample reported never receiving orientation regarding the risk of falling accidents in their age group. In light of this, it was possible to verify that the overall score in the FRAQ-Brazil ranged from 7 to 29 (of a possible maximum of 32), with an average of 19.5 and a median of 19. The presence of household risk factors ranged from 0 to 15 (of a maximum of 20), with an average of 7.8 and a median of 8.

Factors related to the history of falling accidents were analyzed in Table 1, showing that the only sociodemographic variable associated to past falls was an individual's advanced age.

All health conditions analyzed in the study were associated with falls. A statistically significant association between both one's level of awareness (FRAQ-Brazil) and one's fear of falling, and the occurrence of falling episodes itself was found, as seen in Table 2.

DISCUSSION

Epidemiological data suggest that approximately one-third of elderly people suffer, at least, one fall per year.³ This study found a number of accidents higher than the one described by the literature, a difference also observed in other similarly designed studies (in which the time interval of the events was not specified), ranging from 47.8% to 54.0%.^8,14,15 This value is high, but expected among people who are unprotected and exposed to multiple risks, as observed in the sample.

According to the national and the international literature,^16,17 advanced age is a determining factor of higher incidence of falls. In addition to the more obvious factors, the low quality and quantity of information necessary for elderly people to adopt an efficient body posture as age progresses is a key factor.¹⁸ Furthermore, falls are more frequent among individuals with lower visual and auditory acuity. These individuals become less able to identify and avoid obstacles, in addition to having slow reflexes typical of aging.¹⁹

Sensory acuity is reduced in moments of anxiety, which is a factor that contributes to the higher occurrence of falls observed among individuals who reported fearing sudden falls. Young (2015) explains the feeling of fear as a diversion of attention that reduces the reception of stimuli and increases the postural instability. This is further aggravated by poor physical conditioning or difficulties in walking due to comorbidities.²⁰ Pimentel (2015), when analyzing the link between falls and quality of life, revealed that emotional aspects were the only group of factors associated with more falls, reinforcing the need to consider the fear of falling and other subjective aspects as a public health issue among the elderly.²¹

This feeling of constant anxiety also constitutes an important factor of decreased autonomy among the elderly, who become dependent on external aid for basic activities, as physical conditioning worsens.²² Physical activity is associated to a lower risk of falls, and physical activity programs are among the most effective means of prevention.²³

Elderly people also expose themselves to the risk of falling due to the adverse effects of some drugs,^19,24 such as electrolyte imbalance, peripheral vasodilation, and changes in alertness and concentration.²⁵ Such effects increase the risk of falls by sudden loss of consciousness or by modifying one's perception and reaction to household obstacles.^16,22,26

The exposure to household risk factors contributes strongly to falls. Although a higher prevalence of falling was not detected among individuals with a greater number of household risk factors, it is known that the assessment and modification of one's house are important and recommended preventive measures.^1,27 And although this factor also does not change the frequency with which falls occur, these measures may postpone them or make them less severe.

The level of awareness regarding accidents may be an important factor for prevention,²⁸ especially when associated with initiatives aimed at rethinking habits, modifying domestic environments, and increasing the treatment of comorbidities, in accordance with the World Health Organization recommendations regarding elderly health.¹ Though not an eminently clinic action, it involves educational activities and greater social support, highlighting the role of public health services in health education and individual empowerment.^1,29,30

Owing to the cross-sectional nature of the study, it was not possible to demonstrate the cause-and-effect relationship between the awareness of falling risks and the frequency of the event. We suggest the adoption of preventive measures among individuals with higher awareness on the matter, considering their state of vulnerability and the possibility to change it.³¹ It is essential that the elderly people are instructed about the risk factors for falls, so that they may personally play an active role in the adoption of preventive measures.

A limitation of our study was the self-reported character of the data regarding diagnoses and the use of drugs potentially related to falling. Furthermore, by excluding individuals with more severe health conditions and who could not attend the interview, the sampling process may also have influenced the results.

Despite such limitations, the associations found between variables can serve as a basis for further studies, including longitudinal researches, in order to establish causal relationships between factors, and between falling episodes, and elderly awareness of risk factors. We also suggest that caregivers' and family members' level of knowledge of this risk be taken into account, as they are important agents for elderly health promotion.

CONCLUSION

Interviewees were found to be very vulnerable to falling episodes, which were more related to their level of knowledge of their risk factors than to income or education. In addition, it was found that individuals who suffer falls are more clinically fragile, do not adopt the recommended preventive measures, present a severe reduction in autonomy, and have a family history of falling episodes.

ACKNOWLEDGMENTS

The authors are grateful to the Universidade Federal de Juiz de Fora and its research committee for their material and immaterial support during the development of this research. We also thank Mariana Rodarte Freire for her collaboration in conducting the research.

CONFLICT OF INTERESTS

The authors declare no conflict of interests.

REFERENCES

1. Organização Mundial da Saúde. Ageing and Life Course, Family and Community Health. WHO global report on falls prevention in older age. França: World Health Organization; 2007.

2. Brasil. Política Nacional de Saúde da Pessoa Idosa. Portaria n.° 2.528. Brasília; 2006. [citado em 2015 abr. 5]. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/2528%20aprova%20a%20politicayo20nacionaP/o20de/o20saude/o20di/o20pessoi/o20idosa.pdf

3. Sociedade Brasileira de Geriatria e Gerontologia. Quedas em idosos: Prevenção. Projeto Diretrizes. Sociedade Brasileira de Geriatria e Gerontologia; 2008.

4. Santos JDS, Valente JM, Carvalho MA, Galvão KM, Kasse CA. Identificação dos fatores de riscos de quedas em idosos e sua prevenção. Rev Equil Corp Saude. 2013;5(2):53-9.

5. Carlson C, Merel SE, Yukawa M. Geriatric syndromes and geriatric assessment for the generalist. Med Clin North Am. 2015;99(2):263-79.

6. Downton JH, Andrews K. Prevalence, characteristics and factors associated with falls among the elderly living at home. Aging (Milano) 1991;3(3):219-28.

7. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública. 2002;36(6):709-16.

8. Fabrício SCC, Rodrigues RAP, Costa Junior MLD. Causas e consequências de quedas de idosos atendidos em hospital público. Rev Saúde Pública. 2004; 38(1), 93-9.

9. Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saude Publica. 2007;41(5):749-56.

10. Bloch F, Thibaud M, Dugué B, Breque C, Rigaud AS, Kemoun G. Episodes of falling among elderly people: a systematic review and metaanalysis of social and demographic pre-disposing characteristics. Clinics. 2010;65(9):895-903.

11. Lopes AR, Trelha CS. Translation, cultural adaptation and evaluation of the psychometric properties of the Falls Risk Awareness Questionnaire (FRAQ): FRAQ-Brazil. Braz J Phys Ther. 2013;17(6):593-605.

12. Chehuen Neto JA, Lima WG. Pesquisa Quantitativa. In: Chehuen Neto JA (Org.). Metodologia da Pesquisa Científica: da graduação à pós-graduação. Curitiba: CRV; 2012. p. 147-54.

13. Brasil. Conselho Nacional de Saúde. Resolução n° 466. Brasília; 2012. [citado em 2017 fev. 10]. Disponível em: http://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf

14. Silva FC, Trelha CS, Germano JM, Grott MG. Equilíbrio e medo de cair em idosos comunitários. Geriatr Gerontol Aging. 2012;6(4):361-9.

15. Santos RKM, Maciel ACC, Britto HMJS, Lima JCC, Souza TO. Prevalência e fatores associados ao risco de quedas em idosos adscritos a uma Unidade Básica de Saúde do município de Natal, RN, Brasil. Ciên Saúde Colet. 2015;20(12):3753-62.

16. Boelens C, Hekman EEG, Verkerke GJ. Risk factors for falls of older citizens. Technol Health Care. 2013;21(5):521-33.

17. Pereira GN, Morsch P, Lopes DGC, Trevisan MD, Ribeiro A, Navarro JHDN, et al. Fatores socioambientais associados à ocorrência de quedas em idosos. Ciên Saúde Colet. 2013;18(12):3507-14.

18. Almeida ST, Soldera CL, Carli GA, Gomes I, Resende TD. Analysis of extrinsic and intrinsic factors that predispose elderly individuals to fall. Rev Assoc Med Bras. 2012;58(4):427-33.

19. Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013;75(1):51-61.

20. Young WR, Williams AM. How fear of falling can increase fall-risk in older adults: applying psychological theory to practical observations. Gait Posture. 2015;41(1):7-12.

21. Pimentel WRT, Pagotto V, Nakatani AYK, Pereira LV, Menezes RL. Quedas e qualidade de vida de idosos. Geriatr Gerontol Aging. 2015;9(2):42-8.

22. Pfortmueller CA, Lindner G, Exadaktylos AK. Reducing fall risk in the elderly: risk factors and fall prevention, a systematic review. Minerva Med. 2014;105(4):275-81.

23. Shubert TE. Evidence-based exercise prescription for balance and falls prevention: a current review of the literature. J Geriatr Phys Ther. 2011;34(3):100-8.

24. Chehuen Neto JA, Delgado ÁA, Galvão CC, Machado SJM, Bicalho TC, Oliveira TA. Uso de medicamentos por idosos de Juiz de Fora: um olhar sobre a polifarmácia. HU Rev. 2011;37(3):305-13.

25. Rezende CDP, Gaede-Carrillo MRG, Sebastião ECDO. Queda entre idosos no Brasil e sua relação com o uso de medicamentos: revisão sistemática. Cad Saúde Públ. 2012;28(12):2223-35.

26. Fried TR, O'Leary J, Towle V, Goldstein MK, Trentalange M, Martin DK. Health Outcomes Associated with Polypharmacy in Community-Dwelling Older Adults: A Systematic Review. J Am Geriatr Soc. 2014;62(12):2261-72.

27. Kwan E, Straus SE. Assessment and management of falls in older people. CMAJ. 2014;186(16):E610-21.

28. Karlsson MK, Vonschewelov T, Karlsson C, Coster M, Rosengen BE. Prevention of falls in the elderly: a review. Scand J Public Health. 2013;41(5):442-54.

29. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9(11).

30. Alves VS, Guerra VMCO, Pimentel ACFM, Bezerra JF, Paula EMB. Atuação dos profissionais da Estratégia Saúde da Família na prevenção de quedas no idoso. Geriatr Gerontol Aging. 2012;6(1):33-9.

31. Pohl P, Sandlund M, Ahlgren C, Bergvall-Kåreborn B, Lundin-Olsson L, Wikman AM. Fall risk awareness and safety precautions taken by older community-dwelling women and men: a qualitative study using focus group discussions. PloS One. 2015;10(3).

Received in November 18 2016.
Accepted em February 2 2017.