International Journal of Environmental Research and Public Health Article History of Falls, Dementia, Lower Education Levels, Mobility Limitations, and Aging Are Risk Factors for Falls among the Community-Dwelling Elderly: A Cohort Study Yan-Yuh Lee 1, Chien-Liang Chen 2,3, I-Chen Lee 4, I-Ching Lee 5 and Nai-Ching Chen 6,* 1 Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; [email protected] 2 Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan; [email protected] 3 Department of Medicine, National Yang-Ming University School of Medicine, Taipei 112, Taiwan 4 Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung 807, Taiwan; [email protected] 5 Ever Blessing Clinic, Kaohsiung 804, Taiwan; [email protected] 6 Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan * Correspondence: [email protected]; Tel.: +886-7-731-7123 (ext. 3304); Fax: +886-7-7318762 Abstract: Background: Falling is a serious issue among elderly community dwellers, often resulting in disability. We aimed to investigate the risk factors for falls among elderly community dwellers. Citation: Lee, Y.-Y.; Chen, C.-L.; Methods: We recruited 232 participants from multiple community learning and care centers, who Lee, I.-C.; Lee, I.-C.; Chen, N.-C. provided their information through questionnaires. They were divided into two groups, according to History of Falls, Dementia, Lower their falling events after a 1-year follow-up. Univariate and multivariate logistic regressions were Education Levels, Mobility used for statistical analysis. Results: A total of 64 participants reported a fall at the 1-year follow-up. Limitations, and Aging Are Risk The falling group comprised older and single people with lower education levels, higher rates of Factors for Falls among the dementia, a history of falls, lower scores on the Mini-Mental State Examination, and more disability Community-Dwelling Elderly: A functions when compared to the non-falling group (all p < 0.05). The regression model showed that a Cohort Study. Int. J. Environ. Res. Public Health 2021, 18, 9356. history of falls (OR: 62.011; p < 0.0001), lower education levels (OR: 4.088; p = 0.039), mild dementia https://doi.org/10.3390/ (OR: 20.729; p = 0.028), older age (OR: 1.176; p < 0.0001), walking for 300 m (OR: 4.153; p = 0.030), and ijerph18179356 running for 30 m (OR: 3.402; p = 0.015) were 1-year risk factors for falls. Conclusion: A history of falling, low education levels, aging, mild dementia, and certain mobility limitations were strong risk Academic Editor: Paul B. Tchounwou factors for future falling accidents in elderly Taiwanese community dwellers. Received: 17 July 2021 Keywords: previous falling event; reduced cognition; Alzheimer dementia; elderly; fall Accepted: 2 September 2021 Published: 4 September 2021 Publisher’s Note: MDPI stays neutral 1. Introduction with regard to jurisdictional claims in Falling is a common health threat, with a high prevalence, of approximately 20–45% [1–3]. published maps and institutional affil- The prevalence of falls among the elderly in Taiwan is around 16.3% to 21.3% [4,5], which iations. is similar to that observed in other countries around the world. Moreover, falling is a major cause of disability and death among the elderly and is related to multiple public health problems worldwide [3]. Fall-related injuries, such as hip fractures, traumatic brain injuries, and intracranial hemorrhage, are related to disabilities and complications, Copyright: © 2021 by the authors. including pressure sores and infections, and, eventually, increased morbidity and mortality; Licensee MDPI, Basel, Switzerland. hence, the consequences of falls are serious in the older adult population [6–10]. Therefore, This article is an open access article it is important to identify the risks for falls among the elderly so that they can benefit from distributed under the terms and fall-prevention programs. conditions of the Creative Commons The risks for falls among elderly community dwellers are multifactorial, including Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ the environment, a history of falling, the individual’s psychology, mobility, sensation, 4.0/). cognition, and psychosocial status, as well as polypharmacy [11,12]. In this group of people, Int. J. Environ. Res. Public Health 2021, 18, 9356. https://doi.org/10.3390/ijerph18179356 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 9356 2 of 9 aging is a key factor related to falling, as fall-related mortality rates increase exponentially with age, with the greatest increase after the age of 80 years [3,13]. This is because age- related conditions, including physical frailty, immobility, reduced functional capacity, and medical conditions contribute to the risk of falls [3,13–16]. Therefore, investigating the risk factors for falls among the elderly is often challenging because the complex aging-related conditions and the interaction among the risk factors make it difficult to estimate the extent of the impact of certain risk factors [17]. In elderly community dwellers, decreased and impaired mobility has been noted as a risk factor for falls [18,19]. A similar report investigated a facility and found that impaired mobility was associated with falling [20]. Decreased mobility, poor physical performance, slow gait speed, and increased mortality are common in the elderly; these characteristics are defined as sarcopenia, due to the associated loss of muscle strength and mass [21]. Therefore, it is crucial to evaluate the mobility of elderly community dwellers in order to prevent falls. A self-administered questionnaire was developed in Taiwan [22] to evaluate mobility and fitness. Considering the high prevalence of falls, a user-friendly, self-administrated screening tool for the assessment of risk factors for falls could be used to improve alertness and prevent falling. The aim of this study was to investigate the risk factors for falls among elderly community dwellers on a longitudinal scale and to evaluate the relationship between falling and its risk factors, including mobility limitations, cognitive function, and other demographic factors. 2. Materials and Methods 2.1. Study Design This was an observational cohort study. The study hospital, Kaohsiung Chang Gung Memorial Hospital, is a tertiary medical center in southern Taiwan. This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institu- tional Review Board of Chang Gung Memorial Hospital (CGMH-IRB No 201801933B0C501). All participants provided informed consent. 2.2. Subjects We enrolled participants via advertisements on bulletin boards in community centers, community colleges, and local dementia community centers. A total of 232 participants were recruited for this study. The inclusion criteria were people >55 years of age who were socially active, able to answer the questionnaire, able to complete the examination, and able to provide signed informed consent. The excluded participants had poor functional status (for example, they needed a cane, a walker, or a wheelchair for mobility). 2.3. Demographic Data and Falling Events The demographic data of the patients, including their age, sex, marital status, years of education, and exercise habits, were checked by the case manager using a formal questionnaire. For disease comorbidities, we recorded the patients’ history of systemic diseases, including diabetes mellitus, hypertension, hyperlipidemia, anemia, and stroke. Falling within the past year was recorded as recent fall history. One year after enrollment, the participants were re-evaluated and asked if there were falling events during this period. Exercise habits were defined using our questionnaire. We surveyed exercise habits according to a previous study [23]. The patients were asked the following question during the interview: “Do you practice sports or physical exercise sufficient to produce sweat- ing or shortness of breath?” Those who answered with a “yes” were defined as having exercise habits. They were also divided into two groups according to exercise frequency: <3 per week and ≥3 per week. Int. J. Environ. Res. Public Health 2021, 18, 9356 3 of 9 2.4. Cognitive Testing We used a comprehensive battery of tests to assess participants’ cognitive abilities and the Mini-Mental State Examination (MMSE) [24] to assess their general intellectual function. Cognitive severity was evaluated using the Clinical Dementia Rating (CDR) Scale [25,26]. Both were administered by a trained neuropsychologist at the dementia integrated out- patient clinic. Among all participants, those with mild dementia (defined as CDR 1) or questionable dementia (defined as CDR 0.5) were recruited. Mild dementia indicated that the subject had moderate memory loss, especially for recent events, along with some impairment in other cognitive domains [26]. Subjects with questionable dementia showed slight forgetfulness, along with some slight impairment in other cognitive domains [26]. 2.5. Mobility Limitation Questionnaire The self-administrated questionnaire [22,27] included 10 simple questions about phys- ical limitations by level of difficulty, which were asked by our case manager. They referred to: (1) standing continuously for 15 min; (2) standing continuously for 2 h; (3)