Gender and the risk of falling: a sociological approach

AIM: This paper reports a grounded theory study of the influence of gender on older people's perceptions of their risk of falling and their actions to prevent future falls. BACKGROUND: The incidence and rates of falls among older people, including injurious falls, are of much international concern. The risk of falling remains a major concern for older people since it increases with age, with those aged 85 years and over at greatest risk. However, research using a sociological approach to the topic is limited. METHODS: An exploratory design, with grounded theory analysis, was used. Data were collected during 2001 through in-depth interviews with a convenience sample of 40 older people living in south east of England. FINDINGS: Two core categories emerged: gendered meanings of risk and gendered responsibility. The social construction of the meaning of the risk of falling and of participants' actions was gendered. Older men and women had specific ways of talking about their 'risk' and identifying the risk factors for falling. Older men perceived themselves as 'responsible' and 'rational' individuals who expected to reduce their own risk of falling. Older women's expectations of themselves and of their peers explained their tendency to blame themselves or others for their falls. These perceptions influenced the actions they took to prevent future falls. CONCLUSION: Nurses and other healthcare professionals need to take account of the gendered meanings attached to falling by older men and women when carrying out risk assessments and giving advice on fall prevention.     

The risk factors related to falling in elderly females

The purpose of this study was to explore the relationship between muscle strength and functional mobility and falls in women aged 65 and over. Thirty-one female subjects with a mean age of 69.57 +/- 4.89 years (65-78) were enrolled in the study. Demographic properties, body mass index, comorbid medical conditions, smoking, the number of medications taken, and fall characteristics were recorded. Knee flexor and extensor strength of the dominant extremity was measured by Biodex isokinetic system, and physical capacity was assessed with a 6-minute walk test. Cognitive status was evaluated by the Mini-Mental State Examination, and disability in daily activities was determined with the Barthel Index. Twelve subjects (38.7%) reported experiencing a fall in the previous year. Eight (25.8%) had experienced a fall outside the home and 4 (12.9%) inside the home. Nine subjects had fallen once, 2 subjects twice, and 1 subject had fallen 3 times. Six (19.4%) subjects reported a fracture after falling. Muscle strength of the knee extensors and flexors and work capacity was similar between those who had fallen and those who had not. The risk factors related to falling were evaluated, but no related factor was determined. Fear of falling was found to be high in patients who had fallen in the previous year. In conclusion, knee extensor and flexor strength are not significant factors in falls or the risk of falling for elderly women, particularly those who are able to function independently. Balance tests in current use are not effective predictors of falls in older adults who live independently and who do not have any significant health problem. These results suggest that there may be a significant interactive effect of the many causal factors that we need to address. Further study is needed to develop new assessment tools for active elderly people to help prevent falls and fall-related injuries.     

Psychosocial consequences of falling: the perspective of older Hong Kong Chinese who had experienced recent falls

AIM OF THE STUDY: The study's aim was to explore the psychosocial consequences of falling with a group of older Chinese who had recently fallen. BACKGROUND: Older people fall more frequently. Thus, the consequences of these falls and their influence on health outcomes need to be determined. One important outcome, namely the psychosocial consequence of falling, has not been extensively studied. As a result, this study explored the psychosocial consequences of falling with a group of older Chinese who had recently experienced a fall. RESEARCH APPROACH: An explorative qualitative approach with semi-structured interviews was used in this study. SAMPLE: Twenty informants, with recent fall experiences either in the community or hospital setting, were interviewed in two elder care wards in an acute care hospital. FINDINGS: Three major categories of psychosocial consequences of falling emerged from the interview data: powerlessness, fear and seeking care. Powerlessness was also exemplified in three subcategories: lack of control, self-comforting and lack of emotion. Informants perceived falls as unpredictable and not preventable, expressing fears that falling could result in dependence on others and becoming a care burden. The interview data also showed that there is a need by older Chinese to seek care and advice from relatives and health care professionals. CONCLUSIONS: Findings from this study have provided insights into the psychosocial consequences of falling for older Chinese. These insights suggest nursing interventions should promote a sense of mastery in prevention of falls, facilitate supportive social interactions with relatives and give empathetic responses to those who have fallen.     

A pilot study of falls risk and vestibular dysfunction in older fallers presenting to hospital emergency departments

PURPOSE: To compare falls risk in older fallers and non-fallers, with an emphasis on dizziness and signs of vestibular dysfunction. METHOD: The fallers had presented to the Emergency Department of the Royal Melbourne Hospital, Australia following a fall and were discharged directly home (n = 20) (75% female, mean age 78 years). The non-fallers were an age and gender matched group, who had not fallen in the past 12 months (n = 20). All clients received a home-based assessment, which involved a comprehensive assessment of falls risk. RESULTS: Over three-quarters of the fallers took four or more medications, had balance impairments, and used a gait aid in the community. The fallers had a significantly higher falls risk score (P < 0.001), demonstrated significantly poorer balance (P < 0.001) and walked significantly more slowly (P < 0.001) than the non-fallers. There was no significant difference between the groups in their reports of dizziness (P = 0.68), although static balance testing (CTSIB condition 5) suggested a greater degree of underlying vestibular dysfunction in the group of fallers (P < 0.001). CONCLUSION: Older people discharged home from the ED following a fall are at high risk of falling in the future and have a greater level of vestibular dysfunction based on simple clinical testing. Additional clinically applicable tests of vestibular function are required to further investigate the relationship between vestibular dysfunction and falling in older people.     

Iatrogenesis in the elderly. Contributors to falls

Persons who are susceptible to falls can be identified before a fall occurs. A risk prediction tool must be evaluated for its usefulness; if a tool is not feasible, elderly persons who have fallen once are at high risk of falling again. Once high risk has been identified, strategies must be planned to prevent subsequent falls. One of the most important strategies is to communicate to all staff which patients are at high risk and the general circumstances surrounding any patient fall. Few interventions have been shown through rigorous clinical studies to be effective. Passive interventions, such as alarms, are usually more reliable than active interventions that staff must administer. Interventions must be individualized, based on the patient's deficits.     

A single home visit by an occupational therapist reduces the risk of falling after hip fracture in elderly women: a quasi-randomized controlled trial.

OBJECTIVE: To assess the effectiveness of a single home visit by an occupational therapist in the reduction of fall risk after hip fracture in elderly women. DESIGN: Quasi-randomized controlled trial. PARTICIPANTS: Ninety-five women aged 60 years or older, living in the community, who sustained a fall-related hip fracture. METHODS: The women were allocated alternately to intervention or control groups. All the women underwent a multidisciplinary programme targeted at fall prevention during in-patient rehabilitation. Additionally, the intervention group received a home visit by an occupational therapist a median of 20 days after discharge. Falls were recorded at a 6-month follow-up. RESULTS: Thirteen of the 50 women in the control group sustained 20 falls during 9231 days, whereas 6 of the 45 women in the intervention group sustained 9 falls during 8970 days. After adjustment for observation periods, Barthel Index scores, and body height, a significantly lower proportion of fallers was found in the intervention group: the odds ratio was 0.275 (95% confidence interval 0.081-0.937, p=0.039). CONCLUSION: A single home visit by an occupational therapist after discharge from a rehabilitation hospital significantly reduced the risk of falling in a sample of elderly women following hip fracture.     

Older women with diabetes have a higher risk of falls: a prospective study

OBJECTIVE: To determine whether older women with diabetes have an increased risk of falls and whether known risk factors for falls account for any increased risk. RESEARCH DESIGN AND METHODS: This prospective cohort study included 9,249 women > or =67 years of age enrolled in the Study of Osteoporotic Fractures. Diabetes was determined by questionnaire at baseline. Physical performance was measured at the second examination. Subsequently, falls were ascertained every 4 months by postcard. RESULTS: A total of 629 (6.8%) women had diabetes, including 99 who used insulin. During an average of 7.2 years, 1,640 women (18%) fell more than once a year. Diabetes, stratified by insulin use, was associated with an increased risk of falling more than once a year (age-adjusted odds ratio [OR] 1.68 [95% CI 1.37-2.07] for non-insulin-treated diabetes; age-adjusted OR 2.78 [1.82-4.24] for insulin-treated diabetes). In the first 2 years of follow-up, women with diabetes were not more likely to fall than women without diabetes (44 vs. 42%; P = 0.26), but they had more falls (3.1 vs. 2.4; P < 0.01). Women with diabetes were more likely to have other risk factors for falls, which appeared to account for the increased risk of falls associated with non-insulin-treated diabetes (adjusted OR 1.18 [0.87-1.60]) but not insulin-treated diabetes (adjusted OR 2.76 [1.52-5.01]). CONCLUSIONS: Older women with diabetes have an increased risk of falling, partly because of the increased rates of known fall risk factors, and may benefit from interventions to prevent falls. Further research is needed to determine whether diabetes treatment reduces fall risk.     

Recurrent elderly fallers.

Factors associated with recurrent falling during a one-year period were analysed among elderly Finns (65 yrs and more) seeking medical treatment due to a fall. Recurrent falling in men was independently related to a lesser amount of depressive symptoms and to less severe injury due to the first fall. In women, recurrent falling was independently related to the non-occurrence of a fear of falling. Furthermore, recurrent falling, amount of daily movement, mental capacity, and falling during the previous year were related variables. Here the risk of recurrent falling was high among persons with poor mental capacity, who moved about a large amount daily, and who had had at least one accident during the previous year. In addition, there was an association between poor health and recurrent falling women. Demented women moving about daily, frail women, and incautious men and women seemed to be the main risk groups for repeated falling. What could general practitioners do to prevent repeated falls in the elderly? First, the overall health status and functional capacities of frail elderly women should be improved. Second, all elderly persons, especially those who have fallen, should be informed about how to minimize the risks of falls. Prevention is not easy among the demented population, however.     

Recurrent Elderly Fallers

Factors associated with recurrent failing during a one-year period were analysed among elderly Finns (65 yrs and more) seeking medical treatment due to a fall. Recurrent falling in men was independently related to a lesser amount of depressive symptoms and to less severe injury due to the first fall.

In women, recurrent falling was independently related to the non-occurrence of a fear of falling. Furthermore, recurrent falling, amount of daily movement, mental capacity, and falling during the previous year were related variables. Here the risk of recurrent falling was high among persons with poor mental capacity, who moved about a large amount daily, and who had had at least one accident during the previous year. In addition, there was an association between poor health and recurrent falling in women.

Demented women moving about daily, frail women, and incautious men and women seemed to be the main risk groups for repeated falling. What could general practitioners do to prevent repeated falls in the elderly? First, the overall health status and functional capacities of frail elderly women should be improved. Second, all elderly persons, especially those who have fallen, should be informed about how to minimize the risks of falls. Prevention is not easy among the demented population, however.     

Patients' perspectives of falling while in an acute care hospital and suggestions for prevention

Patient falls and falls with injury are the largest category of reportable incidents and a significant problem in hospitals. Patients are an important part of fall prevention; therefore, we asked patients who have fallen about reason for fall and how falls could be prevented. There were two categories for falls: the need to toilet coupled with loss of balance and unexpected weakness. Patients asked to be included in fall risk communication and asked to be part of the team to prevent them from falling. Nurses need to share a consistent and clear message that they are there for patient safety.     

Perceptions of older people living in the community about their fear of falling

Purpose. A fear of falls is widespread amongst older Australians. It increases the risk of falls and can lead to restriction of activity. The aim of this study was to gain insight into the precursors of a fear of falls and the experiences associated with this fear.

Methods. Using a qualitative, phenomenological method, individual, semi-structured interviews were conducted with 9 community-based participants who reported moderate to high levels of fear of falling.

Results. Most participants did not fear falling until they had experienced a fall themselves. The fear of falls was described as a negative experience, often linked with incapacitation, fear of dependence and having to leave their home. Participants chose to avoid falls by ‘taking care’. Five themes emerged from data analysis: activity levels; view of the future; perceptions of fall experiences; fall avoidance; and development of fear of falls.

Conclusions. The results indicated that factors other than a fear of falling resulted in a restriction of activities for these participants; therefore, it cannot be assumed that a fear of falls alone results in reduction of activity. Fear of falls, in combination with other potential issues that could restrict activities, should be taken into account in the development of fall-prevention programs in order to ensure clients' needs are being met.     

The association of nocturia with incident falls in an elderly community‐dwelling cohort

Objective: The aim of this study was to examine the association of nocturia with incident falls in a population‐based sample of community‐dwelling elderly persons. Methods: The University of Alabama at Birmingham Study of Aging is a prospective cohort study of 1000 community‐dwelling older adults in the USA designed to examine factors associated with impaired mobility. Subjects were recruited from a stratified, random sample of Medicare beneficiaries to include equal numbers of black women, black men, white women and white men. Nocturia was assessed at baseline and falls were assessed at baseline and every 6 months for a total of 36 months of follow‐up. Results: A total of 692 individuals (mean age 74.5 ± 6.2, 48% female, 52% black) did not fall in the 12 months prior to baseline. Of these 692, 214 (30.9%) reported falling at least once during the subsequent 3 years. In unadjusted analysis, three or more nightly episodes of nocturia were associated with an incident fall [RR = 1.27, 95% CI (1.01–1.60)]. After multivariable logistic regression, three or more episodes of nocturia were associated with an increased risk of falling [RR = 1.28, (1.02–1.59)]. Discussion: In a racially diverse, community‐based sample of older men and women who had not fallen in the previous year, nocturia three or more times a night was associated in multivariable analysis with a 28% increased risk of an incident fall within 3 years. While this study has several advantages over previous reports (longitudinal follow‐up, performance‐based measures of function, population‐based sampling), causality cannot be ascertained. Further research is needed to ascertain the impact of treatments to reduce nocturia as part of a multi‐component programme to reduce fall risk.     

Predicting which patient will fall again… and again

In order to compare the characteristics, preventive interventions and outcomes of single and multiple fallers, a retrospective cross-sectional study was conducted in a 680-bed acute-care hospital in Western Australia Fifty patients falling more than once (multiple fallers) were randomly selected from all patients reported to have fallen between 1 July 1989 and 31 December 1989, and age–sex matched with 50 patients falling once in the trial period (single fallers) In total, 382 in-patients were reported to have sustained 578 falls in the 6-month trial period Fifty-two per cent of these falls involved multiple fallers An analysis of the 100 single and multiple fallers showed that single fallers were more likely to have fallen from their bed, be discharged home from hospital, and be clinically deteriorating at the time of the fall Multiple fallers were more likely to be transferred to a long-term nursing facility after discharge from hospital, suffer blindness/poor vision, be sedated post fall, be ordered to be restrained following a fall, and be hospitalized for longer periods There was also a tendency for multiple fallers to repeat the type and location of the fall on successive falls Stepwise logistic regression showed that falling from the bed on the first fall predicted remaining a single faller Being ordered to be restrained following the first fall and hospitalized for longer periods predicted the patient would fall repeatedly Further analytical research incorporating an expanded number of independent variables is needed to allow confident assertions of causality To test the effectiveness of preventive measures, a prospective longitudinal study is required.     

A fall prevention program for the home environment

Falls are the leading cause of injury, death, and disability among people older than 65. When elders fall, they sustain such injuries as hip, spine, hand, and/or pelvic fractures. The prognosis after such a fall is poor--only half of older adults hospitalized for hip fractures are able to return home or live independently again. Even without injury, falls cause a loss of confidence that results in reduced physical activity, increased dependency, and social withdrawal. As a home care agency dealing with a geriatric population, our goal was to develop a user-friendly fall prevention program that would promote multidisciplinary assessment and intervention. We have developed a preventive approach through which clinicians and patients can collaborate on preventing falls in the home and maintaining our patients' first priority: quality of life.     

Facteurs prédictifs de la chute chez l''hémiplégique vasculaire en centre de médecine physique

OBJECTIVES: To determine factors predicting falls by patients with vascular hemiplegia to establish a program aimed at preventing falls in this population. METHODS: A comparative prospective study performed over 19 months with 44 patients older than 16 years who had had a cerebral vascular accident (CVA, stroke) and were consequently admitted to the Centre Richelie. The exclusion criteria were represented by CVA history, evidence of another form of encephalic lesion, and subsequent admission to hospital after hemiplegia or for follow-up. Assessment consisted of taking note of the mechanism of the fall, possible lesions, and number of falls and analyzing follow-up after the return home. Also included for all patients was information on 20 variables that could be risk factors for fall. RESULTS: The patients' average age was 60.43+/-13.43 years and 20 had had at least one fall (mean 2.2), which allowed us to determine a "falling" group and a control group. Statistical analysis revealed the following factors considered to predict falls: large amount of time prior to hospitalization and lengthy hospitalization, low functional independence measure for entering and leaving, the existence of sensitivity disorders, spatial neglect, failed seated and standing equilibrium, and sedative treatment. In most cases, whatever their nature, falls occurred during transfers (68% of cases). Most often, the post-fall lesions were minor. However, in one case, a femur neck fracture necessitated osteosynthesis. One-third of the patients had a fall at home (as opposed to 5% of the control group). CONCLUSION: Our results confirm those in the literature. The predictive factors for falls in patients with hemiplegia are therefore well established and essentially correlate with the CVA. This consideration must lead to implementation of a prevention program including material-based as well as human measures.     

Characteristics of individuals who fell while receiving home health services

BACKGROUND AND PURPOSE: Many patients receiving home health services are at risk for falling, but fall risk factors have not been previously investigated in this population. A retrospective record review was used to describe individuals who fell while being served by a home health agency. SUBJECTS: The 98 individuals who fell while receiving home health services were compared with a random sample of 98 subjects served by the home health agency during the same period who did not report falling. METHODS: Subjects were compared by age, sex, days of receiving home health services, number of falls prior to admission to the home health agency, diagnosis, medication category, home health services received, and type of health care coverage. In the group with falls, causes of falls and interventions were described. RESULTS: The group with falls had comorbidities of neurological and cardiovascular impairment, took more medications associated with increased risk of falling, and had almost 3 times the number of falls prior to admission than the group without falls. DISCUSSION AND CONCLUSION: Home care providers should consider medical history, medication usage, and fall history as risk factors for falls in the home environment.     

Falls and fear of falling among elderly persons living in the community: occupational therapy interventions

Each year, about one third of the population over 65 years of age experiences at least one fall (Perry, 1982). Assessment of the incidence of falls and the prevalence, intensity, and covariates of fear of falling among community-based elderly persons was conducted through interviews of 115 residents in a housing development (mean age = 78 years). Fifty-three percent reported having fallen in recent years, 32% in the last year. Fear of falling ranked first when compared with other common fears. In a logistic regression model predicting limitation of activity independent of risk factors for falling, fear of falling was marginally significant (p = .06). The results of the study show that falls are frequent and fear of falling prevalent among the community-based elderly. A comprehensive program designed to reduce the risk of falls is presented.     

Falls in the elderly

A substantial number of elderly persons living at home fall each year. Falling can lead to both physical and psychological harm, causing some to place unwarranted restrictions on themselves based on their fear of falling again. There are many causes of falls, including age-related changes in physical status, certain pathological states and environmental hazards. Thorough assessment of the patient who has fallen includes both a detailed history and a physical examination aimed at determining the extent of injury as well as the cause of the fall. Armed with this information, the nurse practitioner can design a fall-prevention educational program that fits the patient's specific needs. Fall-prevention education is appropriate for all elderly patients, not only those who have a history of falling.