Fall Risk Factors in Community-Dwelling Elderly Depending on Their Physical Function, Cognitive Status and Symptoms of Depression

Int. J. Environ. Res. Public Health 2015, 12, 3406-3416; doi:10.3390/ijerph120403406
International Journal of
Environmental Research and
Public Health
ISSN 1660-4601
www.mdpi.com/journal/ijerph
Article
Fall Risk Factors in Community-Dwelling Elderly Depending
on Their Physical Function, Cognitive Status and Symptoms
of Depression
Magdalena Sylwia Kamińska 1,
*, Jacek Brodowski 1 and Beata Karakiewicz 2
1 Department of Primary Health Care, Faculty of Health Sciences, Pomeranian Medical University in
Szczecin, 48 Żołnierska St., 71-210 Szczecin, Poland; E-Mail: [e-mail]
2 Public Health Department, Faculty of Health Sciences, Pomeranian Medical University in Szczecin,
48 Żołnierska St., 71-210 Szczecin, Poland; E-Mail: [e-mail]
* Author to whom correspondence should be addressed; E-Mail: [e-mail];
Tel.: [phone].
Academic Editor: Paul B. Tchounwou
Received: 3 November 2014 / Accepted: 11 March 2015 / Published: 24 March 2015
Abstract: Falls are the leading cause of unintentional injuries and injury-related disability,
morbidity and mortality in the geriatric population. Therefore, they may also lower quality
of life. The aim of this study was to analyze the fall risk factors in the community-dwelling
elderly depending on their physical function, cognitive status and symptoms of depression.
The study involved 304 individuals aged 65–100 years with a mean age of 78.6 ± 7.4.
This survey-based study was conducted using the Geriatric Environmental Inquiry,
the Barthel Scale (BS), the Abbreviated Mental Test Score (AMTS), the Geriatric Depression
Scale (GDS) and the Tinetti Test (TT). There was a statistically significant correlation
between the BS, the TT and the incidence of falls (p < 0.05). The number of falls
correlated significantly with the results of the BS (R = −0.39), the GDS (R = 0.18),
and the TT (R = −0.40). A statistically significant correlation was also noted between the
TT results and the results of the BS (R = 0.77), the AMTS (R = 0.40) and the GDS
(R = −0.37). The incidence of falls may significantly increase in people with a lower
functional status, which may be related to cognitive process disturbances and lower
affective functioning. A comprehensive geriatric assessment, related to all aspects of
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Int. J. Environ. Res. Public Health 2015, 12 3407
advanced-age patients’ efficiency, is recommended. Fall prevention strategies should
include actions undertaken to evaluate and treat depression and cognitive disturbances.
Keywords: elderly falls; functional state; cognitive function; depression
1. Introduction
According to the definition accepted for the purpose of epidemiological research, a fall is an event
which results in a person coming to rest inadvertently on the ground or floor or other lower level [1].
Epidemiological statistics indicate that every year falls happen to about 30% of adults aged over 65
and living in their own homes. However, about 50% of them don’t talk about their falls either to their
caregivers or medical staff. What is more, elderly people staying in residential homes experience falls
more often than those living in their own homes. Every year, falls happen to about 45% of people
provided with long-term care, out of whom 40% experience multiple falls [1–3].
Among older adults, falls are the leading cause of both fatal and nonfatal injuries. The consequences of
fall-related injuries among over 65-year-olds include: long-lasting disability, loss of autonomy,
lower quality of life, and problems with organizing professional and non-professional care for this
group of patients. Falls are the main cause of injury-related disability, morbidity and mortality in
geriatric people [1–6].
In member countries of the European Union, the problem of injuries affects about 105,000 people.
Furthermore, nearly 40,000 elderly people are pronounced dead due to falls. The rate of fall-related
fatal injuries among those aged 60 or older is 36.8 per 100,000 in the United States, whereas in Canada
it is 9.4 per 10,000 in the same age group [1].
In 2013, over 2,000,000 non-fatal injuries were treated in emergency departments, and more than
700,000 of them required hospitalization [4]. The hospital admission rate for injuries caused by falls
among people over 60 and older in Australia, Canada, the United Kingdom of Great Britain and
Northern Ireland is 1.6–3.0 per 10,000 citizens. In Western Australia and Great Britain, it is as high as
5.5–8.9 per 10,000 people. The most common fall-related causes of admission to hospital are hip joint
fractures, traumatic brain injuries, and injuries to the upper extremities. It is also worth emphasizing
that, in the case of the elderly, the period of hospitalization due to falls is considerably longer than
hospitalization for other reasons [1].
Moreover, fall-related injuries among over 65-year-olds generate high costs for the health care and
welfare sectors. In 2012, the direct medical costs of injuries caused by falls among people over 65 years
of age, adjusted for inflation, was 30 billion dollars [1–7].
The incidence of falls rises with age and the worsening of general fitness. Regardless of the reasons,
falls in advanced age have serious physical, mental, and socio-economic consequences. Falls usually
result from the interaction and interference of factors categorized in four domains: biological,
behavioral, environmental, and socio-economic [1].
Biological fall risk factors include fixed factors, such as age, gender, and race, and are closely related to
involution changes and morbidity, which impair the functioning of the “postural control system” defined
as internal causes of falls. External causes include behavioral, environmental, and socioeconomic

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factors. Behavioral fall risk factors are potentially modifiable, and include such issues as alcohol
abuse, using inappropriate shoes, as well as physical inactivity. Behavioral factors also include
polypharmacotherapy, and not taking into account the differences in drug pharmacokinetics and
pharmacodynamics in the organism of an old person. Environmental factors refer to the development of
private and public spaces (uneven terrain, architectural obstacles, and problems with transport).
Socio-economic issues are: low income, low standard of living, limited access to health and
social services, and the lack of social support [1].
Identification of the main fall risk factors may contribute to the implementation of preventive
actions reducing the incidence of falls. These actions should form a part of an interdisciplinary process
aiming at compensation of deficits in all spheres of human functioning. The specificity of geriatrics
necessitates the provision of an overall solution to the problems of advanced-age patients. Therefore,
the therapeutic and nursing management in the case of the elderly should be based on a comprehensive
geriatric assessment (CGA). The literature describes a number of functional tests used to assess the
risk of falls in people of advanced age. Their availability, the short time required for their execution,
and the possibility of using them in any conditions, mean that they can be also applied on an outpatient
basis [8]. The aim of this study was to analyze the fall risk factors in the community-dwelling elderly
depending on their physical function, cognitive status and symptoms of depression.
2. Materials and Methods
2.1. Ethics Statement
All subjects gave their informed consent for inclusion before they participated in the study.
The study was conducted in accordance with the Declaration of Helsinki, and the protocol was
approved by the Ethics Committee of the Pomeranian Medical University in Szczecin, Poland
(KB-0080/141/09).
2.2. Sample Size
The study involved 304 people aged 65–100 years, using outpatient health services provided by
The Regional Centre of Occupational Medicine - West Pomeranian Prevention and Therapy Centre
in Szczecin, North West Poland. Women constituted 77.3% of those analyzed, men −22.7%. The mean
age was 78.6 ± 7.4.
2.3. Participants and Recruitment
Principal criteria for the selection of participants were: the availability of the patients at the moment
of carrying out the study, no symptoms of the exacerbation of the co-existing diseases or other health
problems, the mental condition of the patients making them able to cooperate during the study and
understand the orders of the researcher, the ability of the surveyed to move without assistance,
as well as conscious and voluntary consent to participate in the research. All subjects who met the
above mentioned criteria were included in the study. All patients were acquainted with the nature,
goals, and course of the study, and informed that their participation in the study was voluntary and
they were free to resign at any stage. The examination time per patient was approximately 90–120 min

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and was adjusted to the individual needs of the patient. During the study the researchers applied the
principles of effective interpersonal communication.
2.4. Data Collection
The study was conducted in conditions which guaranteed the accuracy of the measurement and
elimination of interfering factors. The specificity of the research situation, as well as the characteristics
of the participants and their health status were taken into account. The place where the participants
were examined was suitable for people of advanced age. The study was conducted with respect for the
patients’ dignity, intimacy, comfort and feelings of safety.
The study was based on a diagnostics survey, conducted using the technique of an oral, open,
individual categorized interview. The interview was conducted directly with the patients or indirectly
with their professional or non-professional caregivers. Instruments employed in the study included the
original Geriatric Environmental Inquiry. The questionnaire concerned the general assessment of
socio-environmental and economic situation, as well as the health evaluation and circumstances of falls
in the past. Additionally, observations were conducted using a non-standard, occasional, direct and
spontaneous technique as a supplementary method. Another instrument used in the study was the
Barthel Scale (BS) for measuring the ability to perform activities of daily living. This test enables the
identification of three groups of patients depending on their self-reliance level. Individuals with scores
of 0–20, 21–85, 86–100 points were classified as “very dependent”, “moderately dependent”,
and “independent”, respectively. The Abbreviated Mental Test Score (AMTS) was applied to assess
cognitive functions. This test enables the identification of three groups of patients: a group with
seriously disturbed cognitive function (0–3 points), a group with moderate disability (4–6 points),
and a group with normal mental efficiency (>6 points). The short version of the Geriatric Depression
Scale (GDS) was used to assess the severity of depressive symptoms. Individuals with scores of
11–15 points are regarded as having severe depressive disorders, patients with scores of 6–10—moderate
depression, and those with the score of 0–5 - no depressive symptoms. The Tinetti Test (TT) was
employed to evaluate patients’ ability to walk and maintain balance. The TT enables the division of
patients into three groups depending on the level of their dependence and the risk of falls. The group at
the highest risk obtains the lowest scores (≤18). The group at moderate risk consists of people with
scores of 19–23 points, which reflects moderate dependence and fall risk. The group at minimal risk is
the one with scores of ≥24 points.
The last stage of the study involved the analysis of the documentation. The authors analyzed medical
documents filled in by those taking care of a given patient (family doctor, family nurse, doctors of different
specialties, physiotherapists) in order to verify information about health and nursing problems obtained
during medical interview. The study was performed using a standard technique. The research instruments
of choice were: the history of disease, the documentation of the nursing process, the results of consultation
and diagnostic tests and hospital treatment information charts.
2.5. Data Analysis
The research material was verified in terms of its completeness, reliability, and the correctness of
its collection. Then, a statistical grouping was conducted in order to organize and systematize