Abstract
Purpose
Falls in older age are the result of the interaction of several modifiable and nonmodifiable risk factors. Risk factors for falls may vary in frequency not only in different economic and cultural contexts but also in different forms of care services among the older population. The aim of the present cross-sectional descriptive observational study was to assess the prevalence of risk factors for falls among older ambulant patients on a chronic inpatient ward in Hungary.
Material/Methods
Data associated with risk factors for falls, such as age, sex, chronic physical and mental illness, acute illness, incontinence, history of falls, balance and gait disorder, and visual impairment, were collected from 82 participants. The frequency of these risk factors in our sample was compared with their prevalence in the elderly population living at home — based on data available in the literature and statistical databases — using chi-square tests.
Results
Our results show that the prevalence of hypertension, cerebrovascular events, dementia and diabetes are significantly higher in the elderly population in chronic inpatient care than in the elderly population living at home. There is also a significantly higher prevalence of balance disorders and the use of sedatives/sleeping pills/neuroleptics in the studied population. Cardiovascular diseases, osteoporosis, and Parkinson's disease are equally prevalent in both populations.
Conclusions
In the case of many of the patients admitted to chronic inpatient care, there is a real chance that their physical condition will improve or stabilise to the point where they can return to their own homes or be moved to a nursing home. This kind of rehabilitation approach to chronic inpatient care would require many more qualified nurses, physiotherapists, occupational therapists, dietitians and social workers than are currently available.
Introduction
In economically developed countries, including Hungary, the age distribution of the population is changing. In Hungary, the proportion of people aged 65 and over was 18.3% of the total population in 1975 and almost 20% in 2000, and is estimated to rise to more than 36% by 2050 [1]. As people get older, the prevalence of falls increases. In geriatric medicine, a fall is defined as “an unexpected event in which the participants come to rest on the ground, floor, or lower level” [2, 3].
According to the international literature, approximately 30% of people aged 65 and over living at home, and 50% of institutionalised older people, fall at least once a year [4]. Similar figures apply to Hungary. In a survey conducted among 314 elderly people living alone in their homes in a county in Southern Transdanubia, 37% (116) responded that they had fallen during the previous three months [5]. Another study measured the incidence of falls among residents of two nursing homes during a one-year prospective follow-up period [6]. A total of 1,013 falls occurred among the 1,016 residents. The study did not investigate multiple falls, thus the proportion of elderly people who suffered a fall is not known.
Almost one-third of falls result in some kind of injury. In one survey of older people living at home, 47% of those who had had a fall were injured: 6% suffered a fracture and 34% some kind of soft tissue injury [5]. Similar figures have been found among institutionalised older people: 4% suffered a fracture and 34% a soft tissue injury as a result of a fall [6].
Besides physical injuries, falls also have psychological consequences. Whether or not they have experienced an earlier fall, elderly people tend to be afraid of falling [7, 8]. Fear of falling is a condition in which an older person constantly thinks about falling, or about the risk of falling, causing them to restrict their daily activities [9]. This can lead to the weakening of muscles and a functional decline in the balance control system, thus increasing the risk of a fall in the future. This process jeopardises an elderly person's ability to live independently and increases the likelihood of long-term institutional care [8–10].
Falls in older age result from the interaction of several risk factors. Fabre grouped the risk factors identified earlier in retrospective research as either nonmodifiable or modifiable [11]. According to this classification, age, female sex, and physical and mental chronic diseases in old age are nonmodifiable risk factors. However, the most important risk factors in terms of prevention are those that are partially or completely modifiable with appropriate intervention. These include acute illnesses, incontinence, previous falls, balance and gait problems, visual impairment, taking more than three medications, inappropriate footwear, and hazards in the physical environment [11].
The frequency of risk factors for falls may vary not only in different economic and cultural contexts but also in different forms of care services among the older population. Walk-in patients in chronic inpatient wards typically return to their own homes or move to a nursing home that provides long-term care.
The aim of our cross-sectional descriptive observational study was to assess the prevalence of risk factors for falls among ambulant elderly patients on a chronic inpatient ward in Hungary, for which no scientifically collected data previously existed. We then compared the prevalence in our sample with the prevalence among the elderly population in Hungary (Table 1) [12].
Prevalence of chronic diseases in the elderly population in Hungary
| Disease | Prevalence |
| Osteoporosis | 21.6% |
| Alzheimer's disease | 6.9% |
| Cerebrovascular | 26.4% |
| Cardiovascular | 48.9% |
| Hypertension | 92.0% |
| Parkinson's disease | 2.0% |
Compiled by the authors based on data from the Hungarian Central Statistical Office.
For the prevalence of dementia, diabetes, balance and gait problems, and regular use of sedatives/sleeping pills/neuroleptics, we relied on data published in the Hungarian literature. The prevalence of dementia of various origins (e.g., Alzheimer's disease, vascular dementia) in the population aged 65 years and over is 30.7% [13]. In a public health survey conducted in 2014, almost one in five people aged 65 and over reported having diabetes [14]. Data for gait disorders among older people in Hungary were collected in a 2010 survey, in which 43% of people aged 65 and over reported being barely able to walk 500 m on flat ground without a walking aid or help from another person [15].
We hypothesised that the prevalence of risk factors for falls among older ambulant patients on the investigated chronic inpatient ward would not differ significantly from the data found in the Hungarian literature for older people living at home.
Methods
Participants
Our study was conducted on a general medical ward for patients with chronic conditions, with the approval of the management of the institution. The average age of the patients was over 80 years: the youngest participant was 57 and the oldest was 97 years old. Slightly more than half the samples were women. Participation was voluntary, and anonymity was ensured. The study included patients who were cared for on the ward between 1 September 2019 and 30 June 2020 and who were independently mobile with or without a walking aid. From among the 235 patients, we were able to include 82 people based on this criteria.
Data collection
Data on what are considered risk factors for falls, such as age, sex, chronic physical and mental illness, acute illness, incontinence, a history of falls, balance and gait disorders, and visual impairment were collected from the medical records of the selected patients (medical charts, previous discharge summaries, fever charts, nursing records, nursing discharge summaries).
Statistical analysis
Descriptive statistics for the sample included mean (standard deviation), absolute and relative frequencies (%), based on data quality. The frequencies of the risk factors for falls in our sample were compared with the frequencies reported in the literature and statistical databases using chi-square tests. Results were considered significant below a P value of 0.05. The statistical calculations were performed using PASW Statistics for Windows, Version 18.0 statistical software (Released 2009. Chicago: SPSS Inc.).
Results
A total of 82 older patients were included in the study. The members of the sample group had been living in the institution for various periods of time, ranging from 52 months to one month, with an average stay of 13.5 months. The demographic characteristics of the sample are summarised in Table 2.
Characteristics of the sample (n = 82)
| Participants | Values |
| Age (years), mean (standard deviation) | 80.3 (9.3) |
| Sex, female, n (%) | 57 (69.5) |
| BMIa (cm kg−2), mean (standard deviation) | 25.2 (4.26) |
| Duration of institutionalisation (months), mean (standard deviation) | 13.6 (10.8) |
| Family status | |
| Married, n (%) | 8 (9.8) |
| Widowed, n (%) | 40 (48.8) |
| Divorced, n (%) | 7 (8.5) |
| Single, n (%) | 27 (32.9) |
a) BMI: body mass index.
Polypragmasy was found to be frequent among patients on the investigated ward (Table 3). The most commonly taken drugs were antihypertensives and anticoagulants. The former were taken regularly by more than 70% of the patients, and the latter by almost 60%. The proportion of patients taking diuretics and sedatives/sleeping pills/neuroleptics was close to 40%. More than a quarter of sample members took antidepressants regularly. On average, the patients in the sample took more than six medications, while the proportion taking more than three medications was over 80%.
Use of medications that are a risk factor for falls
| Medication | Values |
| Antihypertensives, n (%) | 58 (70.7) |
| Anticoagulants, n (%) | 47 (57.3) |
| Diuretics, n (%) | 38 (40.3) |
| Sedatives/sleeping pills/neuroleptics, n (%) | 32 (39.0) |
| Antidepressants, n (%) | 21 (25.6) |
| Antiparkinson agents, n (%) | 2 (2.4) |
| Medications per capita, mean (standard deviation) | 6.6 (3.1) |
| Taking more than three medicines, n (%) | 67 (81.7) |
Among the chronic diseases and conditions that become more common in older age, hypertension and post-cerebrovascular disease state had the highest prevalence, at around 80% (Table 4). More than half the survey participants had cardiac disease and dementia. Diabetes and lower-limb osteoarthritis affected more than one-third of the sample, and osteoporosis almost a quarter. Balance and gait disorders were present in nearly 80% of the patients. The prevalence of incontinence in the sample was over 70%, with similar proportions by sex: 40 of the 57 female participants (70%) and 18 of the 25 male participants (72%) suffered from incontinence. Nearly 80% of the sample used some form of walking aid: most used a walker or cane, although some used wheeled walkers and wheelchairs. In our sample, 12% used no walking aid, even in cases where it would have been necessary.
Physical and mental attributes that increase the risk of falls
| Attributes | Values |
| Chronic illnesses | |
| Hypertension, n (%) | 66 (80.5) |
| Cerebrovascular disease, n (%) | 65 (79.3) |
| Cardiac disease, n (%) | 48 (59.8) |
| Dementia, n (%) | 46 (56.1) |
| Diabetes, n (%) | 28 (34.1) |
| Lower-limb osteoarthritis, n (%) | 27 (32.9) |
| Osteoporosis, n (%) | 18 (22.0) |
| Parkinson's disease, n (%) | 4 (4.9) |
| Other disorders | |
| Balance disorder, n (%) | 65 (78.0) |
| Incontinence, n (%) | 58 (70.7) |
| Hearing impairment, n (%) | 13 (15.9) |
| Wearing glasses | |
| No glasses, n (%) | 21 (26.6) |
| Only for reading, n (%) | 58 (70.7) |
| Only for watching TV, n (%) | 1 (1.2) |
| Continuously, n (%) | 2 (2.4) |
| Walking aid | |
| No walking aid, n (%) | 29 (35.4) |
| One cane, n (%) | 12 (14.6) |
| Walker, n (%) | 25 (30.5) |
| Wheeled walker, n (%) | 1 (1.2) |
| Wheelchair, n (%) | 5 (6.1) |
| Not using a walking aid but should be, n (%) | 10 (12.2) |
The physical and mental attributes associated with the risk of falling for which a benchmark specific to older people living at home or in institutions was found in the literature or databases were further analysed.
The prevalence of hypertension in our sample (80.5%) was significantly higher than the published figure of 60% for the population aged 65 years and over (χ2 = 10.954, P = 0.002). Symptoms and dysfunction following a brain event were significantly more prevalent in our sample (n = 65, 79.3%) than the figure of 26% given in the literature for the elderly population in general (χ2 = 56.167, P < 0.001). The proportion of people with cardiac disease (n = 49, 59.8%) was not significantly different from the proportion reported among the elderly population in general practice (48.9%) (χ2 = 2.394, P = 0.121). A diagnosis of dementia was found in significantly more elderly people in our sample (n = 46, 56.1%) than the estimated prevalence of 30.7% given in the literature, based on data from a survey of patients over 60 years of age in general practice in Hungary (χ2 = 56.167, P < 0.001). The prevalence of diabetes was also significantly higher in our sample (n = 28, 34.1%) than the 12% prevalence found in the literature (χ2 = 14.071, P < 0.001). The proportion of patients with osteoporosis (n = 18, 22%) corresponded to the 21% estimated in the literature based on data from general practice in Hungary for people aged 65 years and over (χ2 = 0.029, P = 0.863). Also, the proportion of people with Parkinson's disease in our sample (n = 4, 4.9%) did not differ significantly from the 2% rate among older people living at home (χ2 = 1.263, P = 0.261).
Significantly more people in the sample were taking sedatives/sleeping pills/neuroleptics (n = 32, 39%) than the 15% estimated in the literature (χ2 = 14.610, P < 0.001). There was a significantly higher prevalence of balance or gait disorders in our sample (n = 65, 78%) compared to the estimated prevalence in the elderly population living at home (43%) (χ2 = 25.630, P < 0.001).
In the 12 months prior to the survey, 41.5% of our sample (n = 34) had fallen at least once. This frequency is higher than the 30% rate for older people living at home, although the significance of the difference is marginal (χ2 = 2.880, P = 0.081). Among those who had had a fall, 17 (50%) suffered a fracture, which is a significantly higher proportion than in both the international literature for older people living at home (6%, χ2 = 48.015, P < 0.001) and the Hungarian data for older people living in nursing homes (4%, χ2 = 53.067, P < 0.001). Twenty-four people in our sample (70.6%) had suffered a fracture or soft tissue injury requiring medical attention.
Discussion
In our descriptive study, based on a sample of older people being cared for on a chronic inpatient ward, we investigated the prevalence of risk factors for falls that are also characteristic of elderly people living at home. We compared the frequency of those risk factors found in the sample, for which we also found data in the literature, with their prevalence in the elderly population living at home. Our results show that the prevalence of hypertension, cerebrovascular events, dementia and diabetes were significantly higher in the elderly population in chronic inpatient care than in the elderly population living at home. There was also a significantly higher prevalence of balance disorders and of the use of sedatives/sleeping pills/neuroleptics in the studied population. Cardiovascular diseases, osteoporosis, and Parkinson's disease were equally prevalent in both populations.
The prevalence of falls in the 12-month period preceding the survey was almost the same in the sample and in the elderly population living at home, although the severity of the falls was significantly higher in the sample.
According to the National Health Insurance Fund of Hungary, “Chronic care is defined as care designed to stabilise, maintain, or restore health. The duration or termination of care is usually unplanned, and care is typically of long duration” [16]. Chronic inpatient units can thus realistically aim to prepare elderly patients to participate as actively as possible in the basic activities of self-care once they have returned to their own home or moved into a nursing home. An essential element in this process is to reduce the risk of falls. The presence of risk factors for falls should be taken into account when designing effective preventive measures — in other words, the impact of nonmodifiable risk factors can be reduced only by reducing the modifiable risk factors [11].
In the literature, chronic physical and mental illnesses are classified among nonmodifiable risk factors, together with age and sex. Modifiable risk factors include acute illnesses, incontinence, previous falls, balance and gait problems, visual impairment, medication, footwear, and the physical environment [11].
Chronic diseases
In the context of cardiovascular disease, one of the most common diseases among older people is hypertension. According to professional guidelines, the prevalence of hypertension is estimated at between 30% and 45% of the adult population, and its prevalence increases progressively with age [17]. Although the prevalence among people aged 60 years and above is over 60% in the general population, in our sample it was significantly higher. Hypertension increases the risk of falls, partly due to the increased incidence of orthostatic hypotension and partly due to the side effects of medication [18]. The existence of other risk factors for falls should thus be carefully explored and addressed where possible. Partly because of possible fluctuations in blood pressure and partly because of the mechanism of drug action, cardiovascular diseases increase not only the risk but also the severity of falls [11, 19, 20]. The risk of falls rises by 60% when using antiarrhythmic calcium channel blockers; by 20% when taking drugs containing digoxin; and by 10% when taking diuretics [15, 21]. Based on our sample data and data for the elderly population living at home, it can be stated that one in two elderly people suffer from cardiovascular disease [22].
The incidence of ischaemic stroke in Hungary is remarkably high, at double the rates in Finland and Italy (43.3/100,000 inhabitants) [23]. Stroke is the third leading cause of death in Hungary. The incidence of the disease increases with advancing age, the over 65s being the most affected age group [24, 25].
An elderly person with declining cognitive function is at twice the risk of falling compared to an elderly person with intact cognitive ability. Dementia causes structural and neurochemical changes in the brain that negatively affect gait and balance control [26]. It may also be associated with impaired judgement, visual perception or orientation [27]. In our sample, the prevalence of people with dementia was significantly higher compared to the data for older people living at home.
The prevalence of diabetes also increases with advancing age. Almost 13% of people aged between 51 and 60 have diabetes. The proportion rises to 19% among people aged between 61 and 70, and to 20% among people aged 71 and over, meaning that one in five people aged 60 and above have diabetes. In 2014, more than 60% of people with type 2 diabetes were over 60 years of age [14]. Diabetes also leads to an increased risk of falls due to its impact on balance control (cerebrovascular consequences, peripheral neuropathy, retinopathy, and sensory impairments) [28].
The proportion of people with osteoporosis was equally high in our sample and among the elderly population living at home. Not only do older people with osteoporosis suffer more serious injuries in falls, but there is also evidence that they fall more often [29, 30]. One reason for this is their fear of falling, which, by triggering the cycle described above, increases the likelihood of a fall. Another reason for the high prevalence of falls may be that vertebral compression, even if painless, increases kyphosis, which alters the balance of the body [29, 30]. This is associated with a weakening of the muscles in the trunk and lower limbs.
There was no significant difference between the prevalence of Parkinson's disease in the sample and the prevalence in the elderly population living at home. Prevalence increases with advancing age [31]. It is of paramount importance to maintain physical function for as long as possible with appropriate medication and regular exercise.
Lower-limb osteoarthritis increases the risk of falls as it causes difficulty in walking and muscle weakness [4]. Between 60 and 69 years of age, 10% of men and 14% of women suffer from osteoarthritis of the knee joint; between the ages of 70 and 79 this increases to 15% and 24% respectively; while over the age of 80, the prevalence exceeds 20% in men and 30% in women. In our sample, we did not differentiate the prevalence of lower-limb osteoarthritis according to sex and age group, although overall we recorded a prevalence of almost 33%. The impact of lower-limb osteoarthritis on falls in old age is illustrated by the following data: where osteoarthritis is present in a single joint there is a 53% higher risk of falling; where it is present in two joints there is a 74% higher risk; and where three to four joints are affected, there is an 85% higher risk of falling compared to those with no disorder in the lower-limb joints [32]. Balance and gait problems increase the risk of falling by almost three times [4].
In a survey in Hungary, 43% of people over the age of 65 reported finding it difficult or barely manageable to walk 500 m on flat ground without a walking aid or help. Among patients in chronic inpatient care, 78% experience a degree of imbalance that makes walking significantly more difficult [15].
In this context, individually selected walking aids for patients are particularly important, as a poorly adjusted or incorrectly used walking aid increases the risk of falls by 2.6 times [4]. The literature suggests that 75% of people living in nursing homes and 20% of people living in non-institutionalised settings require the use of a walking aid [15]. Poorly chosen footwear is a common problem that does not receive sufficient attention. The risk of falling is 45% higher when wearing shoes with high heels or slippery soles, slippers, or footwear that does not fit properly [33, 34]. One review recommends the wearing of low-heeled, non-slip, well-fitting footwear both indoors and outdoors [35].
Although the incidence of falls in the 12 months prior to the survey was higher among the older people in chronic inpatient care, the difference showed borderline significance. However, the prevalence of serious consequences was significantly higher in the sample compared to the data published in the literature [5, 6].
The number of medications taken regularly, regardless of the type of medication, is associated with the risk of falls. Those taking more than three medications are at double the risk of falling [36]. There is evidence of an increased risk of falling if certain medications are taken regularly. This increased risk is due partly to the side effects of the drugs and partly to drug interactions. The risk of falling is 66% higher when taking psychoactive drugs [21, 22, 37]. In terms of medication, the most common cause of falls is the regular use of antidepressants: serotonin reuptake inhibitors in particular increase the risk of falls [38]. Benzodiazepines and tranquillisers, which are taken regularly by 15% of older people, increase the risk of falls by 8% [21, 37, 38]. Drugs that affect the central nervous system, such as those used to treat Parkinson's disease, as well as narcotic painkillers, also increase the risk of falls.
The results of our study highlight the importance of assessing risk factors for falls among older people who have a realistic chance of returning to their own homes in the near future and including them in a targeted falls prevention programme.
Limitations of the research
The present study has certain limitations. Firstly, all the data for the study were collected retrospectively, which means that no causal relationships can be identified between the variables. A further limitation of our research is that the sample is neither complete nor representative. Nevertheless, since admission to chronic inpatient wards generally takes place in a similar way (by a referral from a general practitioner, from the elderly person's own home, or from an active ward) and for the same reasons (the patients are unable to care for themselves safely and require continuous supervision) throughout the country, and since there are no significant differences in terms of the staffing and facilities on such wards, the results of our study are applicable to other elderly patients admitted to chronic inpatient wards.
Conclusions
The provision of health and social care for an increasingly elderly population, and the financing of these services, are challenging tasks for society and will become even more difficult in the future. In the case of many of the patients admitted to chronic inpatient care, there is a realistic chance that their condition will improve or stabilise to the point where they can return to their own home or be moved to a nursing home. Such a rehabilitation approach to chronic inpatient care would require many more qualified nurses, physiotherapists, occupational therapists, dietitians and social workers than there are at present, whose work would enable members of the older generation to enjoy a better quality of life.
Authors' contributions
ISW and ÉK summarised the scientific background to the paper; ISW and PKK collected the data; ISW, ÉK and ZSGY carried out the statistical analyses; ZSGY, AK and SZB finalised the text.
Ethical approval
This study was conducted in accordance with the 2008 revision of the 1975 Declaration of Helsinki.
Conflicts of interest
The authors declare no conflict of interest.
Acknowledgements
We would like to thank the Department of Chronic Internal Medicine at the Károlyi Sándor Hospital for enabling and supporting the research. We would also like to thank the staff of the hospital for their help in data collection, which has enabled us to contribute to the health of the elderly population and of future generations.
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