Falls in Older Community-Dwelling Women and Men: Risk Factors and Safety Strategies
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Falls in older community-dwelling women and men: risk factors and safety strategies Fall risk awareness, fear of falling, and preferred exercise properties from a gender perspective Petra Pohl Department of Community Medicine and Rehabilitation, Physiotherapy Umeå 2015 Responsible publisher under Swedish law: the Dean of the Medical Faculty This work is protected by the Swedish Copyright Legislation (Act 1960:729) ISBN: 978-91-7601-184-3 ISSN: 0346-6612 Frontpage: Logotype for the project ‘Safe Step’, illustrated by Anna Johnsson Electronic version available from 2016-02-13 at http://umu.diva-portal.org/ Printed by: Print & Media Umeå, Sweden 2015 In loving memory Christine Pohl It takes a child one year to acquire independent movement and ten years to acquire independent mobility. An old person can lose both in one day. Bernard Isaacs, The Challenge of Geriatric Medicine, 1992 Contents Abstract i Svensk populärvetenskaplig sammanfattning iii Abbreviations vi Definitions vii Original papers ix Preface xi Introduction 1 Incidence of falls 1 Definitions of falls and fall-related injuries 3 Consequences of falls 4 Risk factors for falls and fall-related injuries 5 Previous falls 8 Fear of falling 8 Gender 10 Falls prevention interventions and strategies 10 Building fall risk awareness 10 Evidence-based exercise interventions 11 Smart technology for fall risk prediction and falls prevention 12 Theoretical framework 13 Dynamic systems theory 13 Postural control 15 The model of ICF 15 Gender perspective 16 Self-determination theory 17 Rationale for this thesis 18 Aims of the thesis 20 Specific aims 20 Methods 21 Procedures in studies on fall risk factors 22 Settings and participants 23 Data collections 23 One-year follow-up on self-reported falls 23 Long-term follow-up on registered injurious falls 24 Withdrawals 25 Statistical analysis (study I) 25 Statistical analysis (study II) 26 Procedures in studies on fall risk awareness and exercise preferences 32 Settings and participants 32 Data collections 33 Data analysis (study III and IV) 37 Ethical approvals 38 Results 39 Impact of previous falls on future injurious falls (study I) 39 Fear of falling, recurrent falls, and the ICF (study II) 41 Fall risk awareness and safety precautions (study III) 43 Exercise preferences in the context of falls prevention (study IV) 47 Discussion 51 Previous falls as risk factor for injurious falls 51 Gender and fear of falling as risk factors 54 Emergence of fall risk awareness and safety precautions taken 56 Preferred exercise properties in the context of falls prevention 58 Methodological considerations 60 Ethical considerations 60 Validity 61 Strengths and limitations 62 Clinical implications 66 Implications for future research 68 Conclusions 69 Acknowledgements 70 References 72 Dissertations written by physiotherapists, Umeå University 1989–2014 84 Abstract Background Falls are the leading cause for non-fatal injuries in older com- munity-dwelling people. Compared to men, women fall more often, experi- ence more fall-related injuries, and report fear of falling (FoF) more often. Falls may be prevented with specific exercises, but adherence is often low in long-term. One aim of the thesis was to gain a deeper understanding of the risk factors previous falls, FoF, and gender. Another aim was to explore safe- ty strategies in older community-dwelling people in terms of fall risk aware- ness and actions taken to protect from falls, and to identify motives for exer- cising and preferred exercise properties. A gender perspective was used throughout the thesis. Methods To determine the impact of the risk factors on future falls and injurious falls, a cross-sectional design was used combined with longitudinal data. Baseline data from 230 community-dwelling people over 75 years were collected with questionnaires and performance-based tests. FoF was measu- red with the single item question “Are you afraid of falling?”. Monthly fall calendars were collected for one year (monitoring year). Based on status on falls, participants were classified as those with i) no falls (n=119), ii) 1 non- injurious fall (n=51), iii) ≥2 non-injurious falls (n=40), and iv) ≥1 injurious fall (n=20). These data were linked to data from an injury database (IDB) with respect to registered injurious falls for a period of about 5 years (long- term follow-up). Andersen-Gill method of Cox regression for multiple events was used to estimate the risk of future injurious fall events. To find relation- ships between FoF, gender, and falls (defined as two or more falls), a general log-linear analysis was performed. Associations between FoF and the compo- nents of the International Classification of Functioning (ICF) were explored with a structural equation model. To explore fall risk awareness and safety strategies, and to identify motives and preferred exercise properties, qualita- tive study design was used. Multistage focus groups were held with 18 com- munity-dwelling people (10 women and 8 men) between 70 and 80 years. Transcriptions were analysed with qualitative content analysis. Results Fourty-eight per cent of the 230 participants fell at least once du- ring the monitoring year, and 23% experienced recurrent falls. Compared to men, women reported FoF more often, but did not experience more recur- rent falls, and no more injurious falls. FoF was significantly associated with the ICF components Activity/Participation and Personal Factors in women and men both; but in opposite directions for women and men on Personal Factors. During the long-term follow-up, 91 injurious falls were registered in 70 participants (30%). Those with injurious falls during the monitoring year were at significant risk of experiencing new injurious falls in long-term i (HR 2.78; 95% CI 1.40-5.50), compared to those with no falls. Women expe- rienced a higher rate of fractures than did men. Analyses from the multistage focus groups resulted in three categories: Facing various feelings; Recogni- zing one’s fall risk; and Taking precautions. A comprehensive theme tied them together: Safety precautions through fall risk awareness. Analyses also resulted in six categories identifying preferred exercise properties in the context of falls prevention: Motives to start exercise; Barriers to start exer- cise; Exercise characteristics; Confirmation; Spirit lifters; and Maintenance tricks. All categories included sub-categories. Both studies revealed greater variations among women and among men than between women and men. Conclusion Community-dwelling people over 75 years who have experien- ced an injurious fall are at high risk of sustaining new injurious falls the forthcoming five years, and should be offered multifactorial fall risk assess- ments with targeted interventions to optimize the prevention of future falls. The single item question “Are you afraid of falling?” has no predictive value for future falls, and the answer may be strongly gendered. The questions should therefore be avoided in clinical practice and research in community settings. The participants of the qualitative studies implicity and explicitly described how they had become aware of fall risks in everyday life, and both women and men took precautionary actions. Raised fall risk awareness was achieved by several channels including the media, and by meeting with peers and professionals with expertise in falls prevention. A wide variety of prefer- red exercise properties in the context of falls prevention were identified among the older community-dwelling people. The variations of the requests were greater among women and among men than between women and men. The results should be taken into consideration when offering exercise-based falls prevention interventions to older people. The results from this thesis in- dicated that measures can be taken on a broad front in order to reduce the damage from injurious falls in older community-dwelling people. A gender perspective is warranted for in clinical practice and future research. Adopting a gender perspective may broaden the understanding of gender differences and similarities when implementing falls prevention activities. ii Svensk populärvetenskaplig sammanfattning En fallhändelse – att oavsiktligt hamna på golvet eller marken – är den van- ligaste orsaken till att äldre kvinnor och män skadar sig. Äldre personer i Västerbottens län är särskilt drabbade av skadefall. Det är vanligare att kvin- nor skadar sig, men män avlider oftare än kvinnor av sviterna efter ett fall. Det finns indikationer på att äldre som faller ofta, med eller utan skador som följd, är mer drabbade av skadefall än de som inte faller, men det saknas idag specifika kunskaper om detta. Förutom skador kan fall också leda till fall- rädsla. En viss grad av försiktighet skyddar mot fall, men en överdriven räds- la kan leda till att normala vardagsaktiviteter undviks. Man riskerar då att bli fysiskt inaktiv, vilket på sikt kan leda till muskelsvaghet, försämrad livskva- litet och ökad fallrisk. Tidigare studier har visat att kvinnor både faller och rapporterar fallrädsla oftare än män. Dessa samband ses ofta som normala och blir sällan ifrågasatta eller betraktade utifrån ett genusperspektiv. Det är oklart varför kvinnor är särskilt drabbade av fallrädsla och fall. Det övergri- pande syftet med denna avhandling var att få en fördjupad kunskap om fall- riskfaktorer och säkerhetsstrategier hos äldre kvinnor och män i ordinärt bo- ende, med särskilt fokus på tidigare fall, fallrädsla, fallriskmedvetenhet, och träningspreferenser.