Risk factors for falls among elderly persons living in the community

To study risk factors for falling, we conducted a one-year prospective investigation, using a sample of 336 persons at least 75 years of age who were living in the community. All subjects underwent detailed clinical evaluation, including standardized measures of mental status, strength, reflexes, balance, and gait; in addition, we inspected their homes for environmental hazards. Falls and their circumstances were identified during bimonthly telephone calls. During one year of follow-up, 108 subjects (32 percent) fell at least once; 24 percent of those who fell had serious injuries and 6 percent had fractures. Predisposing factors for falls were identified in linear-logistic models. The adjusted odds ratio for sedative use was 28.3; for cognitive impairment, 5.0; for disability of the lower extremities, 3.8; for palmomental reflex, 3.0; for abnormalities of balance and gait, 1.9; and for foot problems, 1.8; the lower bounds of the 95 percent confidence intervals were 1 or more for all variables. The risk of falling increased linearly with the number of risk factors, from 8 percent with none to 78 percent with four or more risk factors (P less than 0.0001). About 10 percent of the falls occurred during acute illness, 5 percent during hazardous activity, and 44 percent in the presence of environmental hazards. We conclude that falls among older persons living in the community are common and that a simple clinical assessment can identify the elderly persons who are at the greatest risk of falling.     

Risk factors for falls among older adults: A review of the literature

Falls are one of the major causes of mortality and morbidity in older adults. Every year, an estimated 30–40% of patients over the age of 65 will fall at least once. Falls lead to moderate to severe injuries, fear of falling, loss of independence and death in a third of those patients. The direct costs alone from fall related injuries are a staggering 0.1% of all healthcare expenditures in the United States and up to 1.5% of healthcare costs in European countries. This figure does not include the indirect costs of loss of income both to the patient and caregiver, the intangible losses of mobility, confidence, and functional independence. Numerous studies have attempted to define the risk factors for falls in older adults. The present review provides a brief summary and update of the relevant literature, summarizing demographic and modifiable risk factors. The major risk factors identified are impaired balance and gait, polypharmacy, and history of previous falls. Other risk factors include advancing age, female gender, visual impairments, cognitive decline especially attention and executive dysfunction, and environmental factors. Recommendations for the clinician to manage falls in older patients are also summarized.     

Health risk appraisal in older people 1: are older people living alone an ‘at-risk’ group?

BACKGROUND: In the UK, population screening for unmet need has failed to improve the health of older people. Attention is turning to interventions targeted at 'at-risk' groups. Living alone in later life is seen as a potential health risk, and older people living alone are thought to be an at-risk group worthy of further intervention. AIM: To explore the clinical significance of living alone and the epidemiology of lone status as an at-risk category, by investigating associations between lone status and health behaviours, health status, and service use, in non-disabled older people. Design of study: Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal in older people. SETTING: Four group practices in suburban London. METHOD: Sixty per cent of 2641 community-dwelling non-disabled people aged 65 years and over registered at a practice agreed to participate in the study; 84% of these returned completed questionnaires. A third of this group, (n = 860, 33.1%) lived alone and two-thirds (n = 1741, 66.9%) lived with someone else. RESULTS: Those living alone were more likely to report fair or poor health, poor vision, difficulties in instrumental and basic activities of daily living, worse memory and mood, lower physical activity, poorer diet, worsening function, risk of social isolation, hazardous alcohol use, having no emergency carer, and multiple falls in the previous 12 months. After adjustment for age, sex, income, and educational attainment, living alone remained associated with multiple falls, functional impairment, poor diet, smoking status, risk of social isolation, and three self-reported chronic conditions: arthritis and/or rheumatism, glaucoma, and cataracts. CONCLUSION: Clinicians working with independently-living older people living alone should anticipate higher levels of disease and disability in these patients, and higher health and social risks, much of which will be due to older age, lower educational status, and female sex. Living alone itself appears to be associated with higher risks of falling, and constellations of pathologies, including visual loss and joint disorders. Targeted population screening using lone status may be useful in identifying older individuals at high risk of falling.     

Incidence and Risk Factors for Falling in Patients after Total Knee Arthroplasty Compared to Healthy Elderly Individuals

Background

It is possible that patients who have undergone total knee arthroplasty (TKA) are at a high risk of falling. However, there are insufficient data to confirm the incidence and risk factors for falling in patients after TKA compared with healthy elderly counterparts. The purpose of this study was to elucidate the incidence and risk factors for falling in patients after TKA compared to the age- and gender-matched healthy elderly.

Methods

Subjects who underwent TKA consisted of 252 patients over 60 years of age. Controls were 150 healthy elderly individuals over 60 years of age living independently in the community. A self-administered questionnaire was mailed to patients after TKA and a similar questionnaire was distributed to the controls by investigators during the town-sponsored healthy aging program. The questionnaire included questions for ambulatory ability, functional status in daily living, knee pain, other joint pain and information on falls.

Results

Self-administered questionnares were returned by 192 of the 252 patients (76.1%) and 146 of the 150 controls (97.3%). Age and gender matching was performed for respondents between 70 and 80 years of age. There were 81 patients and 80 controls who fulfilled the inclusion criteria, and all of them agreed to participate. In the previous year, 34 of the 81 patients (38.2%) fell. The incidence of falls was significantly higher in patients than controls (23.8%, P = 0.041). In controls, ability to stand up from a chair without using the arms and restriction from joining social activities due to knee pain showed the strongest association with recent falls. In patients, self-reported kyphosis showed the strongest association with recent falls.

Conclusion

Patients after TKA are more likely to fall than the general Japanese population. Kyphosis showed the strongest association with recent falls in patients after TKA, which was different from the results obtained in the healthy elderly.     

Risk Factors for Falls in Older Korean Adults: The 2011 Community Health Survey

Falls are a major health problem for elderly populations worldwide. We analyzed data from the 2011 Korean Community Health Survey to identify potential risk factors for falls in a representative population-based sample of community-dwelling older Korean adults. Risk factors for falls were assessed by multivariate survey logistic regression models. The prevalence of falls was 36.5% in males and 63.5% in females. Age and female sex were associated with a higher risk of falls. Similarly, living alone, living in an urban area, poor self-rated health, and high stress were associated with a high risk of falls. Subjects with diabetes mellitus, stroke, osteoarthritis, osteoporosis, urinary incontinence, cataracts, or depression had a high risk of falls. However, subjects with hypertension were at low risk for falls. In conclusion, age, female sex, marital status, residence location, self-rated health, stress, and several chronic conditions were significantly associated with the risk for falls in the older Korean adults. Our findings suggest that these risk factors should be addressed in public health policies for preventing falls.

Graphical Abstract

     

The relation between suicidal feelings and mental disorders in the elderly: results from the Berlin Aging Study (BASE)

BACKGROUND: The purpose of this study was to demonstrate the influence of several risk factors (particularly physical and mental disorders, loneliness and housing conditions) on the wish to die in the elderly. METHOD: Using data from a population-based sample of 516 senior citizens (70 to 103 years of age) in Berlin (Germany), we compared 54 persons with death wishes with 462 persons without death wishes on several psychosocial risk factors, physical health and psychiatric diagnoses. A logistic regression analysis was also conducted. RESULTS:. The data indicate that the wish to die is strongly associated with the presence of a mental disorder, especially major depression, while higher age, female gender, subjective assessment of physical health and negative living conditions were all only moderately related to death wishes. CONCLUSIONS: Our results emphasize the need for very careful diagnosis of death wishes in the very old and question the view that it is a normal and understandable phenomenon in older age.     

Long-term predictors of outcome in fatigued employees on sick leave: a 4-year follow-up study

BACKGROUND: Persistent fatigue is strongly associated with functional status and can lead to absenteeism and work disability. Despite several prognostic studies on chronic fatigue, little attention has been paid to occupational outcomes. METHOD: A total of 127 fatigued employees on sick leave were followed-up after 4 years to determine long-term predictors of work disability, fatigue caseness and chronic fatigue syndrome (CFS)-like caseness. Measures included fatigue, physical functioning, illness attributions, psychological problems and emotional exhaustion. RESULTS: Thirty-three participants (26%) were receiving work disability benefits at the 4-year follow-up. Older age and lower levels of physical functioning predicted work disability. Weaker psychological attributions and lower levels of physical functioning were predictors of fatigue caseness. CFS-like caseness was predicted by female gender and lower levels of physical functioning. Self-reported physical functioning remained a strong and statistically significant determinant of work disability [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.24-0.87] and CFS-like caseness (OR 0.20, 95% CI 0.09-0.43) after controlling for confounders. CONCLUSIONS: This study suggests that physical functioning plays an important role in the persistence of fatigue complaints and work disability in employees on sick leave. The course of fatigue is a complex process, and exploring temporal relationships between fatigue, functional status and work status in future research could provide valuable information for the improvement of fatigue management.     

心理危机干预热线来电者的特征及咨询内容

目的:分析厦门市心理危机干预热线来电者在不同人群中的分布特征及主要咨询问题。方法:将2009年3月至2011年2月的咨询来电,按照咨询的内容归为5类(家庭问题、恋爱与人际关系问题、工作学习和经济问题、精神疾病问题、其他生活事件),并分别按照性别、职业、年龄、受教育程度和婚姻状况对不同咨询内容进行分组分析;采用单因素和多因素logistic回归分析有无自杀危险因素来电者的相关因素。结果:具有完整信息的首次咨询来电共计1262例,其中家庭问题402例,精神疾病问题327例,恋爱和人际关系问题309例,工作学习和经济问题125例,其他生活事件99例。不同性别、职业、年龄、受教育程度和婚姻状况的咨询问题分布差异均有统计学意义(P0.05)。男性主要咨询精神疾病问题,女性主要咨询家庭问题;学生主要咨询恋爱和人际关系问题;年龄18岁人群主要咨询工作学习和经济问题,18～35岁人群主要咨询恋爱和人际关系问题,36～55岁人群主要咨询家庭问题,≥56岁人群主要咨询精神疾病问题;高中或中专及以下、现婚和离异或丧偶人群主要咨询家庭问题。单因素logistic回归分析显示,有自杀危险因素咨询来电多为女性、有职业人群、18～35岁者和现婚人群;多因素logistic回归分析显示职业和婚姻状况为独立的危险因素,有职业人群、离异或丧偶人群出现自杀的可能性更大。结论:咨询内容与咨询者性别、年龄、职业、受教育程度和婚姻状况等因素有关,提示咨询员须具备良好的知识以及需要重点关注因职业或婚姻状况所引发精神疾病问题的人群。     

Prospective data on sleep complaints and associated risk factors in an older cohort

OBJECTIVE: The purpose of this study is to provide data on the prevalence of insomnia and hypersomnia among older persons, the stability of these sleep complaints over time, and factors associated with disturbed sleep, in particular age. METHOD: Data on symptoms of insomnia and hypersomnia were examined for the 1994 to 1995 cohort of the Alameda County Study. In addition to age, the effects of gender, education, marital status, chronic medical conditions, functional impairment, life events, financial strain, and mood disturbance were examined using multiple logistic analyses. RESULTS: Prevalence in 1994 was 23.4% for insomnia and 6.8% for hypersomnia. There was moderate concordance between sleep complaints in 1994 and 1995 (kappa=.43). There was a tendency for insomnia and hypersomnia to increase with age in 1995, but not in 1994. Only gender, mood disturbance, and chronic health problems predicted insomnia. Life events, mood disturbance, and chronic conditions predicted hypersomnia. Age, net of the effects of other factors, was not associated with risk of either insomnia or hypersomnia. CONCLUSIONS: The results contribute to the expanding body of evidence concerning the important roles of psychological and somatic dysfunction in sleep disturbance. Age in and of itself is not a risk factor for insomnia or hypersomnia. That is, after adjustment for an array of putative risk factors for sleep problems, it seems the association between sleep difficulties and age is primarily due to depressed mood and physical health problems.     

Health risk appraisal in older people 2: the implications for clinicians and commissioners of social isolation risk in older people

BACKGROUND: Social isolation is associated with poorer health, and is seen by the World Health Organisation (WHO) as one of the major issues facing the industrialised world. AIM: To explore the significance of social isolation in the older population for GPs and for service commissioners. DESIGN OF STUDY: Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal. SETTING: A total of 2641 community-dwelling, non-disabled people aged 65 years and over in suburban London. METHOD: Demographic details, social network and risk for social isolation based on the 6-item Lubben Social Network Scale, measures of depressed mood, memory problems, numbers of chronic conditions, medication use, functional ability, self-reported use of medical services. RESULTS: More than 15% of the older age group were at risk of social isolation, and this risk increased with advancing age. In bivariate analyses risk of social isolation was associated with older age, education up to 16 years only, depressed mood and impaired memory, perceived fair or poor health, perceived difficulty with both basic and instrumental activities of daily living, diminishing functional ability, and fear of falling. Despite poorer health status, those at risk of social isolation did not appear to make greater use of medical services, nor were they at greater risk of hospital admission. Half of those who scored as at risk of social isolation lived with others. Multivariate analysis showed significant independent associations between risk of social isolation and depressed mood and living alone, and weak associations with male sex, impaired memory and perceived poor health. CONCLUSION: The risk of social isolation is elevated in older men, older persons who live alone, persons with mood or cognitive problems, but is not associated with greater use of services. These findings would not support population screening for individuals at risk of social isolation with a view to averting service use by timely intervention. Awareness of social isolation should trigger further assessment, and consideration of interventions to alleviate social isolation, treat depression or ameliorate cognitive impairment.     

Changes in depression and physical decline in older adults: a longitudinal perspective

BACKGROUND: The impact of chronicity and changes in depression on physical decline over time in older persons has not been elucidated. METHODS: This prospective cohort study of 2121 community-dwelling persons aged 55-85 years uses two measurement occasions of depression (CES-D scale) over 3 years to distinguish persons with chronic, remitted, or emerging depression and persons who were never depressed. Physical function is assessed by self-reported physical ability as well as by observed performance on a short battery of tests. RESULTS: After adjustment for baseline physical function, health status and sociodemographic factors, chronic depression was associated with significantly greater decline in self-reported physical ability over 3 years when compared to never depressed persons (odds ratio (OR)=2.83, 95% confidence interval (CI)=1.86-4. 30). In the oldest old, but not in the youngest old, chronic depression was also significantly predictive of greater decline in observed physical performance over 3 years (OR=2.22, 95% CI=1.43-3. 79). Comparable effects were found for older persons with emerging depression. Persons with remitted depression did not have greater decline in reported physical ability or observed performance than persons who were never depressed. CONCLUSIONS: Our findings among community-dwelling older persons show that chronicity of depression has a large impact on physical decline over time. Since persons with remitted depression did not have greater physical decline than never depressed persons, these findings suggest that early recognition and treatment of depression in older persons could be protective for subsequent physical decline.     

Antinuclear antibodies in the oldest-old women and men

The aim of this study was to compare the prevalence of antinuclear antibodies (ANA) in very old individuals (>or=86 years of age) with healthy younger (18-68 years) blood donors (n=200) regarding gender, health status, ratio of circulating CD4/CD8 cells and cytomegalovirus (CMV) serology. Frozen plasma was used for ANA detection in two study groups, i.e. 'OCTO' (97 persons aged 86-92 years, 65% women) and 'NONA' (136 persons aged 86-95 years, 70% women). OCTO participants were recruited on the basis that they were healthy or moderately healthy according to a selection protocol. No exclusion criteria regarding health status were applied in the NONA sample. The prevalence of ANA was significantly higher in the oldest-old samples compared to blood donors. There was no association between health status and the presence of ANA in the oldest-old. The difference across age was most pronounced in men, with low levels at younger age, whereas the prevalence among the oldest-old men reached similar levels as in women. There were no associations between the presence of ANA and CD4/CD8 ratio or with CMV status in the oldest-old. Our findings confirm an increased prevalence of ANA in the oldest-old, and emphasize the importance of taking gender and age into consideration when evaluating ANA.     

Predictors of the risk of falls among elderly with chronic atrial fibrillation

OBJECTIVES:

Though elderly persons with chronic atrial fibrillation have more comorbidities that could limit indications for the chronic use of anticoagulants, few studies have focused on the risk of falls within this particular group. To evaluate the predictors of the risk of falls among elderly with chronic atrial fibrillation, a cross-sectional, observational study was performed.

METHODS:

From 295 consecutive patients aged 60 years or older with a history of atrial fibrillation who were enrolled within the last 2 years in the cardiogeriatrics outpatient clinic of the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, 107 took part in this study. Their age was 77.9±6.4 years, and 62 were female. They were divided into two groups: a) no history of falls in the previous year and b) a history of one or more falls in the previous year. Data regarding the history of falls and social, demographic, anthropometric, and clinical information were collected. Multidimensional assessment instruments and questionnaires were applied.

RESULTS:

At least one fall was reported in 55 patients (51.4%). Among them, 27 (49.1%) presented recurrent falls, with body lesions in 90.4% and fractures in 9.1% of the cases. Multivariate logistic regression showed that self-reported difficulty maintaining balance, use of amiodarone, and diabetes were independent variables associated with the risk of falls, with a sensitivity of 92.9% and a specificity of 44.9%.

CONCLUSION:

In a group of elderly patients with chronic atrial fibrillation who were relatively independent and able to attend an outpatient clinic, the occurrence of falls with recurrence and clinical consequences was high. Difficulty maintaining balance, the use of amiodarone and a diagnosis of diabetes mellitus were independent predictors of the risk for falls. Thus, simple clinical data predicted falls better than objective functional tests.     

Aging and HIV Infection: A Comparison Between Older HIV-Infected Persons and the General Population

Abstract

Background: As HIV-infected persons age, the relative contribution of HIV infection, combination antiretroviral therapy (cART), and the normal aging process to the frequent comorbidities is unknown.Methods: We prospectively evaluated comorbidities, cardiovascular risk, cognitive function, and anthropomorphic and laboratory parameters of HIV-infected persons aged 50 years and over in two US urban clinics. Results were compared to controls from the National Health and Nutrition Examination Survey (NHANES) matched 1:1 by age, race, gender, smoking status, and body mass index (BMI).Results: We enrolled 122 HIV-infected persons; median age 55 years, 83% male, 57% Caucasian, 39% current smokers, mean BMI 26 kg/m², and 92% on cART. Compared to controls, HIV-infected persons had a higher prevalence of hypertension (54% vs 38%), hypertriglyceridemia (51% vs 33%), low bone mineral density (BMD) (39% vs 0%), and lipodystrophy and greater receipt of antihypertensive and lipid-lowering medications (all Ps < .05). Groups were similar in prevalence of coronary heart disease, diabetes mellitus, chronic viral hepatitis, non-AIDS-defining malignancies and Framingham Risk and cognitive function scores.Conclusions: Older HIV-infected persons have a higher prevalence of hypertension, hypertriglyceridemia, low BMD, and lipodystrophy than matched controls, suggesting that HIV and treatment-related factors exceed “normal” aging in the development of those problems.     

Child functional independence and maternal psychosocial stress as risk factors threatening adaptation in mothers of physically or sensorially handicapped children

This study investigated the contribution of child functional independence and maternal psychosocial stress to the adaptation of 119 mothers. Each mother had a child, aged 2-18 years, with a physical or sensory disability. Multiple dimensions of each construct were measured through self-report. Child functional independence did not uniquely explain variation in mothers' adaptation. However, maternal stress was uniquely associated with maternal mental health, but not physical health or social functioning, even when controlling for demographic status, disability type, and functional independence. Daily hassles and handicap-related psychosocial stress in particular put mothers at risk for reporting mental health problems.     

Aging with multimorbidity: a systematic review of the literature

A literature search was carried out to summarize the existing scientific evidence concerning occurrence, causes, and consequences of multimorbidity (the coexistence of multiple chronic diseases) in the elderly as well as models and quality of care of persons with multimorbidity. According to pre-established inclusion criteria, and using different search strategies, 41 articles were included (four of these were methodological papers only). Prevalence of multimorbidity in older persons ranges from 55 to 98%. In cross-sectional studies, older age, female gender, and low socioeconomic status are factors associated with multimorbidity, confirmed by longitudinal studies as well. Major consequences of multimorbidity are disability and functional decline, poor quality of life, and high health care costs. Controversial results were found on multimorbidity and mortality risk. Methodological issues in evaluating multimorbidity are discussed as well as future research needs, especially concerning etiological factors, combinations and clustering of chronic diseases, and care models for persons affected by multiple disorders. New insights in this field can lead to the identification of preventive strategies and better treatment of multimorbid patients.     

Functioning status of adult children of depressed parents: a 23-year follow-up

BACKGROUND: We compared adult offspring of depressed or control parents who were followed for 23 years. Comparisons were on depression symptoms, physical functioning and disability, social functioning, and utilization of help and coping. Also examined was whether the parent's course of depression (stably remitted, partially remitted, non-remitted) was associated with offspring functioning. METHOD: Depressed parents successfully followed at 23 years (n=248, 82%) identified 215 adult offspring; 67% returned questionnaires. Matched control parents successfully followed (n=235, 79%) identified 261 adult offspring; 68% completed questionnaires. RESULTS: Adult offspring of depressed parents were more impaired than adult offspring of controls (with gender and education controlled) in the domains of depression and disability, and obtained more help for mental health problems. They also reported more severe recent stressors and relied more on active cognitive coping and seeking alternative rewards to cope. Adult offspring of depressed and control parents were comparable in a number of domains: psychiatric and behavioral problems other than depression, physical functioning and pain, social functioning, and hospitalizations and medication use for depression. Adult offspring of parents with a non-remitted course of depression were the most likely to show impaired functioning compared with controls. CONCLUSIONS: Having a parent with depression is associated with more depression and disability in adulthood, but does not have debilitating effects in other life domains. Nonetheless, it may be important for offspring of depressed parents, particularly offspring of parents with a non-remitting depression course, to recognize their elevated risk of depression and potential need for help.     

Risk for recurrence in depression

Depression is a highly recurrent disorder with significant personal and public health consequences. Prevention of recurrence would be extremely desirable, and thus researchers have begun to identify risk factors that are specific to recurrence, which may be different from risk factors for first onset of depression. Methodological issues in this area of research are briefly reviewed (e.g., the various definitions of "recurrence" and "depression"), followed by a review of studies on specific risk factors, including demographic variables (gender, socio-economic status, and marital status), clinical variables (age at first onset, number of prior episodes, severity of first/index episode, and comorbid psychopathology), family history of psychopathology, and psychosocial and psychological variables (level of psychosocial functioning, cognitions, personality, social support, and stressful life events). In addition, scar theories are evaluated for their potential to explain how these variables and recurrent depression are linked. Our review suggests that recurrent depression reflects an underlying vulnerability that is largely genetic in nature and that may predispose those high in the vulnerability not only to recurrent depressive episodes, but also to the significant psychosocial risk factors that often accompany recurrent depression.     

Psychoactive medication,alcohol use,and falls among older adults

The purposes of this study were to determine: (1) the prevalence of psychoactive medication and alcohol use and (2) the relationship among psychoactive medications, alcohol use, and falls in a sample of 1028 independently living women and men, aged 55 and older. Twenty-six percent of the sample reported falling, 28% were taking one or more psychoactive drugs, and 38% drank alcohol during the past year. Analyses with logistic regression indicate that predictors of falls were psychoactive drug use, age, and number of illnesses. Living alone, frequency of alcohol use, and gender were not significant predictors.This study was supported, in part, by Grant AA0859 from the National Institute of Alcohol Abuse and Alcoholism and by Grant DA05312 from the National Institute on Drug Abuse.     

Age group and health status effects on health behavior change

The authors explored health behavior change during 5 years, considering age/cohort, health status, and gender effects. The authors divided the sample (n = 1,064) into 4 age/cohort groups: young adults (n = 139; 19-42 years), middle-aged adults (n = 386; 43-62 years), young-old adults (n = 296; 63-72 years), and old-old adults (n = 243; 73+ years) and health status: cardiovascular disease and physical disability. Smoking and seat belt behaviors remained stable, whereas alcohol, food consumption, food preparation, physical activity, dental, and medical behaviors showed change. Change in health behaviors differed by age/cohort group and health status for food consumption, food preparation, and medical care, primarily showing negative change for old-old adults and positive change for individuals with cardiovascular disease. Health behavior interventions need to focus on the old-old, individuals with physical disability, and on smoking and seat belt use. These specific populations and behaviors need to be targeted to promote positive health behavior change, to limit future onsets of disability and morbidity, and to prevent the occurrence of premature death.