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Artigo de revisão

Epidemiology of falls in older adults in Brazil: an integrative literature review

Epidemiologia das quedas entre idosos no Brasil: uma revisão integrativa de literatura

Sarah Musy Leitãoa,b; Samily Cordeiro de Oliveirac; Luciana Ramalho Rolimb; Raquel Pessoa de Carvalhob; João Macêdo Coelho Filhoa,c; Arnaldo Aires Peixoto Juniora,b,c

DOI: 10.5327/Z2447-211520181800030

ABSTRACT

OBJECTIVE: To conduct an integrative literature review on epidemiology of falls in older adults in Brazil, seeking to identify occurrence rate, recurrence, and potentially modifiable factors associated with these events.
METHOD: This literature review consisted of searching the Medical Literature Analysis and Retrieval System Online (MEDLINE), Scientific Electronic Library Online (SciELO), and Latin American and Caribbean Center on Health Sciences Information (LILACS) databases for scientific articles on November 14, 2017. The following keywords were used for finding articles: “accidental falls,” AND/OR “elderly,” AND/OR “Brazil.” Epidemiological data were collected from primary studies and then compared.
RESULTS: Thirty-five studies were selected. Most of them were performed in the Brazilian Southeast (15) and South (11) regions. The occurrence rate of falls ranged from 10.7 to 59.3%. The most common setting for falls was the home during daytime. The most commonly described circumstances were tripping, slipping, dizziness, and uneven flooring, resulting in falling from one's own height. The factors most frequently associated with falls were female sex, age greater than 80 years, cognitive impairment, and depressive symptoms. The reported consequences were fractures and fear of falling again.
CONCLUSION: As some factors associated with falls in older adults in Brazil are modifiable, fall prevention may reduce morbidity and mortality in this population.

Keywords: accidental falls; aged; Brazil; epidemiology.

RESUMO

OBJETIVO: Realizar revisão integrativa de literatura sobre epidemiologia de quedas entre idosos no Brasil, buscando identificar taxa de ocorrência, recorrência e fatores potencialmente modificávies associados a esses episódios.
MÉTODO: Foi efetuada revisão de literatura, consistindo na busca de artigos científicos das bases de dados Literatura Internacional em Ciências da Saúde (MEDLINE), Scientific Electronic Library Online (SciELO) e Centro Latino-Americano e do Caribe de Informação em Ciências da Saúde (LILACS) em 14 de novembro de 2017. Os artigos foram selecionados a partir das seguintes palavras-chave: “Acidentes por quedas” E/OU “Idoso” E/OU “Brasil”. Dados epidemiológicos foram extraídos dos estudos primários e comparados.
RESULTADOS: Foram selecionados 35 artigos. A maioria dos estudos foi realizada nas regiões Sudeste (15) e Sul (11). A taxa de ocorrência de quedas variou entre 10,7 e 59,3%. O domicílio, no período diurno, é o cenário mais frequente de quedas. As circunstâncias mais comumente descritas são tropeço, escorregão, tontura e existência de desnível, ocasionando tombo da própria altura. Os fatores mais frequentemente associados às quedas foram sexo feminino, idade maior que 80 anos, déficit cognitivo e sintomas depressivos. As consequências identificadas foram fraturas e o medo de cair novamente.
CONCLUSÃO: Alguns fatores associados aos tombos em idosos no Brasil são modificáveis e prevenir as quedas pode possibilitar a redução da morbimortalidade nessa população.

Palavras-chave: acidentes por quedas; idoso; Brasil; epidemiologia.

INTRODUCTION

Falls have been found to be the main external cause of morbidity and mortality in older adults worldwide.1 They are also considered an important indicator of poorer quality of life in this age group, as well as of poorer quality of health care services providing for them.2

The occurrence rate of falls in older people varies according to the method used for investigating the phenomenon.3 In 2011, a Brazilian study assessed prevalence, risk factors, and consequences of falls in older adults.4 Despite the nationwide nature of this study, regional investigations have reported different data regarding prevalence and other aspects of falls in older age.

Thus, the present study aims to present an integrative literature review of the epidemiology of falls in older adults in Brazil, including institutionalized patients, seeking to identify potentially modifiable factors associated with these events.

 

METHOD

This integrative review examined the published literature on epidemiology of falls in older adults in Brazil. The following steps were conducted to elaborate this review, according to the integrative method: reflecting and formulating guiding questions; selecting and searching for articles; defining data to be collected from the selected studies; critically assessing the selected studies; discussing the results; and presenting the integrative review.

Guiding questions

The first step was formulating the following guiding questions: “What is the prevalence of falls in older adults in Brazil?,” “What are the circumstances of falls in older adults in Brazil?,” and “Which factors are associated with falls in older adults in Brazil?”

Search strategy and article selection

Medical Literature Analysis and Retrieval System Online (MEDLINE), Scientific Electronic Library Online (SciELO), and Latin American and Caribbean Center on Health Sciences Information (LILACS) databases were searched for scientific articles on November 14, 2017. The following keywords indexed in Health Sciences Descriptors (DeCS) were used for finding articles: “accidental falls,” “elderly,” and “Brazil.” The Boolean operators “AND” and “OR” were used for searching all possible combinations of keywords. A reference management software (EndNote X7 for Windows, Thomson Reuters, 2013) was used for bibliographic search and screening.

Original articles in English and Portuguese were eligible for inclusion in the review.

Inclusion and exclusion criteria

After searching the databases according to the described strategy, original articles were selected using the following inclusion criteria:

• purpose of evaluating falls in older adults in Brazil;

• presence of quantitative data on prevalence or incidence, risk factors, and/or circumstances of falls.

Exclusion criteria were as follows:

• literature reviews;

• case reports;

• repeated studies on databases;

• failure to meet the inclusion criteria.

Collected data

The data collected from primary studies and included in this review were the following:

• number of older adults evaluated;

• age;

• sex;

• data collection method;

• prevalence of falls;

• recurrence of falls;

• Brazilian region where older adults lived;

• place of residence;

• place where they fell;

• time of falls;

• circumstances of falls;

• risk factors for falls;

• comorbidities, if present.

Critical assessment of selected studies

The original articles were read once for overall comprehension and identification of type of article and method used in the study. Then, in a second round of reading, relevant data from the studies were analyzed.

Chart 1 was designed to make data easier to understand and included the following: author, year of publication, study design, number of patients, mean age, sex, prevalence of falls in previous year, recurrence of falls, Brazilian region, place of residence, place of falls, time of falls, circumstances, and risk factors. These data are arranged in order of year of publication.

 

 

The studies assessing prevalence of falls in older adults living in Brazil are listed in Table 1. Other seven studies included samples of older adults in which all participants had necessarily fell previously, in addition to living in Brazil. These are not listed in the table, but their findings are discussed in the present review. Studies including older adults living in the community or in long-term care facilities (LTCFs) were assessed.

 

RESULTS

Database search resulted in 88 articles from MEDLINE, 58 articles from SciELO, and 163 articles from LILACS, with a total of 309 articles published between 1997 and 2017. Manuscript titles and abstracts were analyzed in order to determine whether the studies were potentially eligible for inclusion.

Then, 274 articles were considered ineligible according to inclusion and exclusion criteria. The other 35 articles were thoroughly analyzed and included in this review (Figure 1).

 


Figure 1 Flowchart showing the course of article selection. Fortaleza (CE), Brazil, 2017.

 

Most studies included in this review were cross-sectional, two were case-control studies, and one was a prospective cohort study. The majority of studies were conducted in the Brazilian Southeast and South regions. Only five studies analyzed data exclusively from the North and Northeast regions. Female sex was predominant in most samples of the selected articles.

Place of residence

Of all studies selected for review, 30 included community-dwelling older adults, while five included institutionalized patients.

Occurrence rate of falls in older adults

Of the selected articles, 23 were based on cross-sectional studies of community-dwelling older adults, which allowed the identification of occurrence rate of falls in non-institutionalized older adults. Possibly due to the use of different methods for data collection (face-to-face interview, telephone call, or consulting medical records), the occurrence of falls in community-dwelling older adults in the previous 12 months ranged from 10.7% in the state of Rio Grande do Sul (59 cities) to 59.3% in the city of Belo Horizonte (MG).2,5

Regarding recurrence of falls, data variation is even greater, also because of differences in the methods used for calculating the percentages. In some studies, the calculation is based on the ratio between number of patients who fell twice or more and total number of older adults evaluated (index), while others divide the number of patients who fell twice or more by the total number of patients who fell (coefficient or rate). The recurrence of falls in community-dwelling older adults ranged from 8.7 to 64.1%.2,6 However, several articles do not specify the formula used for calculation, preventing an accurate analysis of these data.

In the single prospective cohort study of community-dwelling older adults addressing the Brazilian population and selected for review, the incidence of falls was 30.9%. Recurrence was 10.8%.7

In the studies of older patients living in LTCFs, all cross-sectional, the occurrence of falls ranged from 32.5 to 66.7%.8,9 Two or more recurrent falls were found in 57.7% in a study of institutionalized older people and in 80% in a study of older adults living in LTCFs who had already fell.8,10

Place, time, and circumstances of falls in community-dwelling older adults

Two studies showed that the bedroom is where community-dwelling older adults most often fall.2,11 Other common places for falls include bathroom, yard, and other external areas.2,9,12 The home, therefore, is the primary setting for falls in community-dwelling older adults, indicating that it must as safe and equipped as possible to prevent such events.2,11-17

Four studies that evaluated time of falls in community-dwelling older adults showed that they most often occur during daytime (morning and afternoon).11,17-19 Some studies also identified the circumstances associated with falls in this population. Tripping, slipping, change in floor level, and slippery or uneven flooring contributed to falling from one’s own height while walking.11-13,16,17,20

The bedroom was also the most commonly reported place for falls in institutionalized older adults, followed by yard (external area) and living room.8-10,21,22 Only one of these studies reported time of falls, which were more frequent during daytime. The same study was also the only one that investigated the circumstances of falls in this specific population, which were associated with slipping and dizziness.8

Risk factors and conditions associated with falls in older adults

Risk factors for falls in older Brazilians with strong scientific evidence

None of the selected articles showed that being male is a risk factor for falling. Nonetheless, 15 studies demonstrated that female sex is associated with falls in community-dwelling older adults.4-7,12,14,15,20,23-29 Other relevant risk associations for falls in older people living in the community are age greater than 80 years (7 articles),4-6,15,26,28,30 cognitive impairment (3 articles),2,3,28 and depressive symptoms (3 articles).3,6,26

Risk factors for falls in older Brazilians with moderate or weak scientific evidence

The following characteristics were identified as risk factors for falls in only two of the 25 studies of community-dwelling older adults: not having a partner,7,28 living alone,4,28 osteoporosis,3,15 low educational level,5,7 frailty syndrome,12,31 sedentary lifestyle,4,30 use of mobility aids,5,15 poor self-perceived health,20,30 and being dependent for basic activities of daily living (BADLs).7,32

The following clinical conditions were associated with falls in community-dwelling older adults in one study each: chronic pain for more than two years,3 osteoarthritis,3 osteo-articular diseases,25 urinary incontinence,3 cataract,3 visual impairment,7 hearing impairment,6 daytime napping,26 alcohol consumption greater than four drinks per day,33 previous fracture,7 previous hospitalization,6 obesity,4 having more than eight associated diseases,6 being black,16 polypharmacy,30 presence of caregiver,27 winter season,29 poor sleep quality,34 low muscle strength,34 and use of benzodiazepines and antidepressants.35

In the studies of institutionalized older adults, the factors associated with falls differed considerably from those of the studies of older people living in the community. For instance, white skin color was associated with falls in two of the studies of patients living in LTCF.21,22 Other conditions associated with falls in this population were hypertension,9 back pain,21 use of psychotropic drugs,8 polypharmacy,22 depressive symptoms22, and being separated or divorced.22

Consequences of falls in community-dwelling older adults

Falls are the main external cause of morbidity and mortality in older adults, while in younger people this is attributed to traffic accidents. Older adults who are younger and more active are more often involved in traffic accidents than in falls.17

In one study of community-dwelling older adults, fear of falling was reported by 70.4% as a consequence of having fallen.13 Another study reported that bone fractures occurred in 30.6% of community-dwelling older adults who fell.29 In a study with similar characteristics, femur fracture occurred in 68.6%.13

A single selected study including a group of institutionalized older patients who fell evaluated bone fractures because of falls. It found an incidence of 40% of fractures secondary to these events.10

Antes et al.36 related fear of recurrent falls, found in 57.1% of the study participants, with female sex, less interaction with friends, spine disease, and limitations for BADLs after falling. Falling depends on a number of factors, and since many of them are preventable or modifiable, relatively simple changes may reduce the risk of falls as well as morbidity and mortality in the older population.3,5,11

 

DISCUSSION

Falling in older age is a public health issue that may lead to increased health expenses and reduced quality of life. To prevent it, a comprehensive epidemiological knowledge of the current context is important.

In the selected studies, the prevalence of falls was higher among women and those aged over 80 years.4-7,12,14,15,20,23-30 These data are consistent with the findings of another Brazilian study conducted by Pimentel et al.,37 who found an association between falls and quality of life in community-dwelling older adults. Faller older adults had a lower mean score in the emotional domain of the 36-Item Short Form Health Survey (SF-36) quality of life measure, with development of negative feelings and fear of falling again.37

Fear of falling may significantly reduce the functionality of older adults, who may remain bedbound and subjected to the onset of immobility syndrome. Such fear must be addressed by health professionals as part of the approach to fall prevention, with special attention to immobility and functional loss.13,36,37

Investigating the history of falls as well as their risk factors and consequences must be included, therefore, in the anamnesis performed by Brazilian Family Health Program professionals and in the health care of older patients in any context because of the importance and prevalence of falls.6

The occurrence rate of falls ranged from 10.7 to 59.3% in older adults living in the community,2,5 and from 32.5 to 66.7% in older adults living in LTCF.8,9 The recurrence rate of falls in community-dwelling older adults ranged from 8.7 to 64.1%.2,6 However, the formula used for calculating the recurrence rate is unclear in several articles, which may have influenced its significantly broad range.

When the present results are compared with those of the international literature, heterogeneous data emerge from different countries. Sandoval et al.38 conducted a literature review on the occurrence of falls in community-dwelling older adults and included studies from Brazil, the United States, Spain, Italy, Nigeria, Turkey, and China. The occurrence rate ranged from 15.9 to 56.3%, with median of 28.5%.38 Despite this great variation, falls in older adults were fairly common in different countries, with different social, economic, and cultural characteristics.

A systematic review of studies investigating falls in older adults in Southeast Asian countries found prevalence rates ranging from 10.4% in Thailand to 53.6% in the Philippines. Most risk factors identified in this review were similar to those of the Brazilian studies. However, unlike studies conducted in Brazil and other countries, this review identified as fall-related risk factors sedentary lifestyle and being dependent on family members in multigenerational environments.39

A meta-analysis examined the incidence of fall-related injuries in older people in mainland China. A moderate incidence was found; overall incidence in those older than 60 years was 54.95 per 100,000 population, and women were more affected than men. In addition, the number of injuries increased proportionally to age.40

Silva Gama et al.41 conducted another systematic review to identify incidence, risk factors, and consequences of falls in older adults in Spain. The reported annual incidence rate of falls was 30 to 35% in older adults living in the community, and 40% in those living in LTCF. Risk factors included antipsychotic drugs, benzodiazepines, comorbidities, decreased physical strength, female sex, and previous falls. The major fall-related consequences were fractures and fear of falling. These findings were similar to those of Brazilian studies.

A limitation of the present study is the relative lack of data on falls in older adults from Brazilian North, Northeast, and Mid-west regions. Additionally, because of the predominance of cross-sectional studies, the heterogeneity of data collection methods, and the identification of a single prospective cohort study on the topic, determining the true risk factors for falls is a difficult task. Nonetheless, a comprehensive review of studies on falls in older adults in Brazil was conducted and allowed the identification of potentially modifiable risk factors in this population.

 

CONCLUSION

The occurrence of falls in older adults varied widely, being more common in institutionalized persons. Few studies have described the risk factors associated with this phenomenon in older adults living in LTCF.

For older adults living in the community, the most common setting for falls is the home during daytime. Fall-related circumstances include tripping, slipping, and change in floor level, resulting in falling from one’s own height. Fractures and fear of falling again were identified as consequences and may lead to immobility syndrome.

Prevention is a key measure to manage falls in this population. In community-dwelling older people, several fall-associated factors are modifiable or preventable through simple interventions. Prospective studies will be useful to confirm the present results and evaluate potential interventions.

 

CONFLICT OF INTERESTS

The authors declare no conflict of interests.

 

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Received in June 6 2018.
Accepted em August 2 2018.


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