Despite a lack of consistency in the definition of falls within studies, leading to uncertainty in what contributed to a fall, epidemiological studies have generated
significant data. In the case of falls, epidemiologic studies have identified the population most at risk being adults over the age of 65 years (Ambrose et al., 2013; Callis, 2016;
Close, Lord, Hylton, Menz & Sherrington, 2005; Dickinson et al., 2011; Gelbard et al., 2014; Tuunainen et al., 2014; Sherrington & Tiedemann, 2015). Adults over the age of 65 years, experience the greatest number of fatal falls, making falls the second largest cause of unintentional injury death following road traffic collision worldwide, and the fifth largest cause of death overall in the United States (WHO, 2018b). The number of people aged 65 years and above is estimated to rise to by over 40 per cent to more than 16 million in the next 17 years (Office for National Statistics, 2015), with 30 per cent falling once a year (NICE, 2013). For those aged 80 years an above, it is 50 per cent (NICE, 2013). Comparatively, in the UK, 30 per cent of people aged 65 years and above fall at least once a year, with 50 per cent aged 80 years and above falling at least once a year (NICE, 2013).
Epidemiological studies have also contributed to knowledge regarding consequences related to falling (e.g. recovery, injury, disability, mortality). By using this data, the greatest problems for the health service can be identified (Bonita, Beaglehole &
Kjellström, 2006). One consequence of falls is injury. Injuries related to falls have been prioritised by the health service worldwide as a public health concern due to the
implications of the health needs of an ageing population (WHO, 2007). For example, as
the population ages, if effective falls prevention strategies are not implemented, the number of falls necessarily will rise. Annual incidence rates for injury due to falls are high in Western Australia and the UK with a rate of 5.5 to 8.9 per 10,000 population total; countries such as Australia, Canada and the UK have high rate of hospitalisation due to a fall in people over the age of 60 years, yielding 1.6 to 3.0 per 10,000 population total (WHO, 2018b).
To gather significant data on falls as above, it is important to find out the most
appropriate method of data collection. Falls epidemiology is examined by calculating falls incidence. It has been recommended that the preferred method of recording falls is by using prospective daily recording and a notification system with a minimum of monthly reporting, with missing data being chased via telephone or face-to-face interview (Lamb, Jørstad-Stein, Hauer & Becker, 2005). Using rigorous data collection methods,
epidemiologic information can help with falls prevention planning (Bonita et al., 2006).
For example, the greatest population at risk can be identified, as well as where the risk is most burdensome for the health service with causal associations often evident (Landers, Oscar, Sasaoka & Vaughn, 2016). Overall, there is a need for consistency of the use of falls definitions among epidemiological studies in order to compare them.
Risk factors for falling
Although increasing age is a risk factor for falling, people do not fall just because they get older. In fact, there may be multiple underlying risk factors involved (Bath & Morgan, 1999; Campbell, Reinken, Allan & Martinez, 1981; Campbell, Borrie & Spears, 1989;
Lord et al., 2007; O’Laughlin, Robitaille, Boivin & Suissa, 1993; Prudham & Grimley-Evans, 1981; Wu et al., 2013). Understanding the causes, or at least the risk factors for falling is a pre-requisite for a fall prevention intervention. Falls usually result from a combination of several associated factors, so prevention strategies need to be directed at more than one factor (Bonita et al., 2006). To reduce the risk of falls, risk factors need to be modifiable. However, not all risk factors are modifiable, and those that are might not be conducive to an exercise programme. Thus, remains the question, which modifiable falls risk factors are suitable to consider when developing a falls prevention exercise programme? Table 1 below presents a list of both non-modifiable and
modifiable risk factors from multiple sources. Modifiable risk factors which may be reduced through exercise are asterisked, most of which are discussed above.
Table 1 Evidence table for fall risk factors in the general population
Campbell et al.(1981); Campbell and Borrie (1989); Campbell and
Matthews (2010); Chu, Chi & Chiu (2005); Graafmans (1996);
Kamińska et al. (2015); Lamb et al.
(2003); Mackintosh et al. (2004);
Morrison et al. ( 2011); Murphy et al. (2013); Nyberg and Gustafson (1997); Horak et al. (2006);
O’Laughlin et al. (1993); Olsson, Lofgren, Gustafson and Nyberg (2005); Rabaldi (2008); Rubenstein et al. (2006); Stapleton, Ashburn and Stack (2001); Teasell (2002);
Wallman (2009);
Fear of falling* 70 per cent of fallers develop fear of falling.
Fear of falling is
associated with balance impairment.
Batchelor et al. (2012); Campbell and Matthews (2010); Chen et al.
(2011); Cho, Yu and Rhee (2015);
Chu et al. (2005); Dionyssiotis (2012); Dueñas et al. (2016);
Gazibara et al. (2016); Jalayondeja, Sullivan and Pichaiyongwongdee (2014); Kumar et al. (2014); Lord, Sherrington, Menz and Close (2007);
Mackintosh, Goldie and Hill (2004);
Pang and Eng (2008); Schmid and Rittman (2009); Wallmann (2009) Poor vision Contributes to balance
impairment.
Dionyssiotis (2012); Kamińska et al.
(2015) Depression* Geriatric patients with
depression are three times more likely to fall than those without depression; causation is unclear because
Biderman et al. (2002); Tinetti, Baker and McVay (1995); Friedman et al. (2002); Kojima et al. (2015);
Kvelde et al. (2014); Sheeran et al.
(2004); Sjösten, Vaapio and Kivelä (2008); Turcu et al. (2004);
depression may cause a
Medications Some researchers argue it is not depression but depression medication greater odds for falling.
Bloch et al. (2011); Czemuszenko and Czlonkowska (2009);
Dionyssiotis (2012); Kamińska et al.
(2015); Martin (2011); Schmid et al.
(2010)
around an unstable joint
Batchelor et al. (2012); Cho, Yu and Rhee (2015); Dionyssiotis, 2012;
Gazibara et al. 2016); Jaylondeja et al. 2014; Mackintosh et al. (2004);
Schmid et al. (2013) Falls efficacy* Low perceived confidence
in ability to avoid a fall;
associated with balance four or more risk factors for falls.
Dionyssitosis (2012)
Non-modifiable risk factors
Comment Authors
Advanced Age Older people are more at risk of falling due to muscle weakness, poor vision and chronic conditions.
Bird (2013); Chang and Do, (2014);
Chu et al. (2005); Dionyssiotis (2012); Grundstrom, Guse and Layde (2012)
(Female) Gender Women are at most risk of sustaining an injury following a fall due to osteoporosis.
Dionyssiotis (2012); Gazibara et al.
(2016); Grundstrom et al. (2012)
History of falls Once a person has fallen, if the causes have not been addressed, they are likely to fall again.
Chu et al. (2005); Kamińska et al.
(2015); Mackintosh et al. (2004)
A fall prevention exercise programme may improve balance and reduce falls multi-fold by addressing multiple falls risk factors because according Gillespie et al. (2012), falls are multifactorial. Older people who fall may develop a fear of falling and thus
experience unnecessary activity restrictions (Gazibara et al., 2016; Wallmann, 2009), increasing the risk of future falls (Chu, Chi & Chiu, 2005; Dionyssiotis, 2012). Among the general population who fall, up to 70 per cent develop a fear of falling (Dionyssiotis,
2012). According to Dueñas, Bernat, del Horno, Aguilar-Rodríguez and Alcántara (2016), the number of fallers who develop a fear of falling is 73 per cent within the previous year. Fear of falling can increase fall-risk in older adults (Young & Williams, 2014) and can be defined as “low perceived self-efficacy” (Tinetti, Richman & Powell, 1990) about balance (Pang & Eng, 2008). “Self-efficacy is the belief and confidence in one’s ability to avoid a fall” (Hadjistavropoulos, Delbaere, & Fitzgerald, 2011), a concept based on the strong theoretical assumption of Bandura (1977) about the cognitive process which underlies emotions.
Another definition of fear of falling is ‘an ongoing concern about falling that ultimately limits the performance of daily activities’ (Lord et al., 2007). Fear of falling is associated with previous falls, poor health status, functional decline and frailty, and has been correlated to restriction and avoidance of activity, reduced quality of life, depression and social isolation (Lord et al., 2007). Fear of falling has been associated with balance impairment (Kumar, Carpenter, Morris, Iliffe & Kendrick, 2014). Balance impairment is a risk factor for falls (Campbell et al., 1981; Campbell et al., 1989; Campbell & Matthews, 2010; Chu et al., 2005; Graafmans, 1996; Horak, 2006; Kamińska, Brodowski, &
Karakiewicz., 2015; Lamb, Ferrucci, Volapto, Fried & Guralnik, 2013; Morrison et al., 2011; Murphy, Dubin & Gill, 2003; O’Loughlin et al., 1993; Rubenstein, 2006; Wallmann, 2009). However, Morrison et al. (2011) found that impaired balance as a risk factor was not consistent across rehabilitation settings. The authors reported that balance
impairment was not significantly associated with falls for those receiving inpatient rehabilitation. The authors acknowledged that this may be due to hospital procedures protocols in place to prevent falls in those who at high-risk. Balance impairment may be due to the inability to control balance and posture, which in turn leads to falling in the elderly (Wallmann, 2009). According to Horak (2006), balance impairment is caused by different things in different people, for example dizziness and muscle weakness.
Therefore, Horak (2006) suggests that to improve balance, treatment must target the cause.
According to Biderman, Cwikel, Fried & Galinsky (2002), depression is associated with falls among the elderly. Some studies have demonstrated that depression in the general population, aged above 64 years, is a risk factor for falls (Friedman, Munoz, West, Rubin
& Fried, 2002; Kvelde et al., 2013; Kojima et al., 2015; Sjösten, Vaapio & Kivelä, 2008;
Turcu et al., 2004). Sheeren, Brown, Nassisi & Bruce (2004) found that geriatric patients with depression were nearly three times more likely to have a fall than those without depression. Tinetti, Doucette, Claus and Marottoli (1995) found a high score on
depression, one of four predisposing factors for falls. However, the order of causation is
unclear because depression may precede a fall, and vice versa. Biderman et al. (2002) suggest that a third factor may be involved and found that depression and falls are related to chronic medical conditions, particularly functional disability.
Kamińska et al. (2015) found that other researchers suggest that depression is not a risk of falls itself, but the administration of antidepressants that is the cause of falling.
Indeed, a meta-analysis by Bloch, Thubaud, Dugué, Brèque and Kemoun (2011)
confirms the association between psychotropic drugs and falls. Dionyssiotis (2012) also suggests that benzodiazepines and psychotropics increase the risk of falls, as well as diuretics and sedatives. The author also highlighted the use of digoxin and anti-arrhythmic drugs as contributing factors. The risk of falling further increases if four or more medications are taken (Dionyssiotis, 2012).
Figure 1 below highlights fall risk factors in the general population. Falls are often multifactorial (Gillespie et al., 2012) with the rate of falling increasing from 27 per cent for those with zero or one risk factor to 78 per cent for older people with four or more risk factors (Dionyssiotis, 2012). It is interesting to note that some of the risk factors shown in Figure 1 are linked. For example, some risk factors are associated with balance impairment and have been discussed above. How these risk factors are linked to stroke is shown in Figure 2.
Exposure to the environment plays an important part in falling (see Figure 1 and Figure 2) because it has been shown that between 30 per cent and 50 percent of falls are due to home hazards (Dionyssiotis, 2012). This means that if home hazards are reduced, the risk of falling has been greatly reduced. Fall risk can be reduced even further by
addressing the remaining modifiable falls risk factors. Encountering home hazards often occur when individuals are performing ADLs. Exposure to ADLs is associated with falls, whether the individual experiences a deterioration or improvement in performing them (Stenhagen, Ekström, Nordell & Elmståhl, 2013).
Avoidance of ADLs may be due to fear of falling. In order to understand and reduce fear of falling, fear of falling needs to be measured. Falls efficacy is associated with and is a measurement of fear of falling (see Fig. 1 & 2) (Lord et al., 2007; Tinetti et al., 1990;).
Falls efficacy has been defined as ‘low perceived self-efficacy of avoiding falls during essential, non-hazardous activities of daily living’ (Tinetti et al., 1990). Therefore, in order to find out if an exercise programme to reduce fear of falling reduces the risk due to this fall risk factor, falls efficacy needs to be measured.
GENERAL
POPULATION Exposure
Advanced age
Chronic conditions
Muscle weakness
Gender
Lack of physical
activity
Balance
Poor vision
Medications
ADLs
Time Home
hazards (History of)
falls
Fear of Falling Falls efficacy
Depression
Figure 1 Fall risk factors in the general population