A study on the perception of fall as a health problem in elderly patients attending a Family Medicine Specialist Clinic

Loretta K P Lai 黎潔萍, Soe-tjhoen Lam 林樹春, Kwai-wing Wong 黃桂榮, J T N Chung 鍾子能

HK Pract 2007;29:391-397

Summary

Fall is common and associated with considerable mortality and morbidity in elderly patients. Our study was designed to explore the perception of fall as a health problem and the knowledge of fall-related risk factors in local elderly population. In our study, more than half of the subjects identified the fall related risk factors with polypharmacy being least recognized. 79.4% of subjects thought that doctors did not provide adequate information about falls. With the ageing population and increasing life expectancy, fall will become an increasing burden to the health care system. As a primary care physician, we should better equip ourselves to promote fall prevention and manage fall in our daily practice.

摘要

老人跌倒很常見，與他們患病與死亡有相當密切的關繫。本研究探討本地老人對於跌倒本身是一個健康問題和跌倒有關危險因素的認知。 我們發現逾半數受訪者能夠辨別跌倒相關危險因素，但對於複方藥劑的危險認識最少。79.4%受訪者以為醫生未能提供足夠相關資料。 伴隨人口增加，壽命延長，跌倒將為醫療服務帶來更大的負擔。基層醫療的醫生應當更好裝備自己，在日常工作中， 更好地推廣預防跌倒和處理這類病人。

Introduction

Falls are among the most common problems that elders are facing. In a local cross-sectional study of 2032 community dwelling elderly Chinese, 18% reported history of falls during the past 12 months.¹ A follow-up prospective cohort study showed that about 22% from this elderly population fell during a period of nine months.² In Western countries, a higher fall prevalence rate was found. Approximately one third of elders aged 65 years or above suffered falls each year.³ Falls are associated with considerable mortality, morbidity, reduced functioning and premature nursing home admissions.^4-7

Falls generally result from an interaction of multiple intrinsic and extrinsic risk factors,^8-11 many of which are correctable. Frequently, elders neither recognize their risks of falls nor report falls to their primary care physicians until after preventable injuries and disabilities have occurred.¹² The effectiveness of multi-factorial fall intervention programmes is established by current evidence. It incorporates exercise programme for muscle strengthening, gait and balance training, medication review, environmental modifications, education about fall prevention and risk factors reduction.^13,14

Studies of fall related knowledge, concern and attitudes¹⁵ among local elderly population are lacking despite falls are prevalent, potentially harmful and known to have identified risk factors and preventable measures.¹⁶ Our study was designed to explore the perception of fall as a health problem and the knowledge of fall-related risk factors in local elderly population in order to provide a basis for fall prevention strategies.

Method

Subjects

Chinese elderly patients aged 65 or above attending the Family Medicine Specialist Clinic of United Christian Hospital in May 2006 were randomly selected. The clinic provides medical care for patients with chronic medical conditions. The source of referrals is from Specialist Out-patient Clinics of the Hospital. The clinic has a daily attendance of more than 200 patients. A list of patients attending the clinic was generated from the clinical management system daily. The list of patients was numbered chronologically and a random list of numbers was generated by using an on-line computer programme called Research Randomizer by Geoffrey C Urbaniak and Scott Plous, webmaster of Social Psychology Network 1997-2007. The patients were then selected according to the list of random numbers. Patients who were wheelchair bound or immobile and those with communication problems were excluded.

Sample size planning and data collection

Sample size was determined by using computer software PASS. Prevalence of fall was assumed to be 18% according to a local study.1 A sample size of 227 subjects was required with precision of 0.05 and 95% confidence level. Assuming 90% response rate, a sample size of 253 subjects would be required.

A 34-item questionnaire in Chinese was developed for use in this study. Verbal consent was obtained. Face to face interviews were performed with trained interviewers, using a standardized questioning technique.

Fall is defined as an unexpected event where a person falls to the ground from an upper level or the same level, not as a result of sudden illness or major hazard (e.g. traffic accident).¹⁷ Questions were incorporated into 4 sections:

1. Subjects' demographic data and general health issues,
2. Fall history of the subjects,
3. Subjects' perception of fall as a health concern,
4. Subjects' understanding of fall related risks.

The understanding on fall risks were assessed in 4 areas: environmental, lifestyle, physical and psychological factors which were literature-based.^18,19

Statistical analysis

All statistical analyses were performed with SPSS for Windows, version 13.0. Descriptive statistics including means, standard deviations and ranges were used to characterize the study population. Analysis of the baseline characteristics of the two groups, perceivers and non perceivers of fall being more important than other health concerns, was based on t-test for continuous data. Differences in proportions were analyzed using Chi-square test or, where appropriate, Fisher's Exact test. ANOVA was used to test the differences among several means for significance. A p value equal to or less than 0.05 was considered statistically significant.

Results

289 subjects were randomly selected during the study period. 32 patients were excluded from the study because of communication problem (n=15), chair-bound status (n=9) and default of appointment (n=8). As a result, 257 eligible subjects were recruited. 141 subjects were male and 116 subjects were female. The response rate was 100%. The socio-demographic characteristics of the study sample were reported in Table 1. The mean age was 74.6 years old (SD 6.2, range 65-89). Over one third of the subjects received no formal education (37.4%). Those subjects who walked with aids (stick, quadripod & frame) (34.3%, 23/67) reported more occurrence of fall in the past one year than those who walked unaided (15.3%, 29/190). Higher proportion of female subjects (25.9%) reported history of falls than male subjects (15.6%).

20.2% (52/257) subjects reported falls in the past one year. Among these fallers, 17.3% (9/52) experienced injurious falls resulting in fracture. The prevalence of falls was highest among those subjects older than 85 years old (45% or 9/20). 36.5% (19/52) of the subjects reported history of falls more than once in the past one year. Among the subjects who reported history of falls, only 38.5% (20/52) sought medical advice after falls.

More than half of the subjects (58.8% or 151/257) considered that something could be done to prevent fall. Moreover, the vast majority of the subjects considered falls as a serious health problem (95.3% or 245/257) (Table 2). Compared with other health concerns, however, fall was only considered as a more important health problem by 17.9% (46/257) subjects. (Table 3) The perception of fall being a more important health concern was found to be associated with the mobility and Barthel Index of the subjects. (Table 4) Higher proportion of elderly who walked with aids (30.0% or 20/67) considered fall being more important than those who walked unaided (13.7% or 26/190). In subjects with Barthel Index less than 100, 35% (13/37) of them considered fall being more important. Compared with those having Barthel Index equal to 100, only 18% (33/220) of subjects will have the same perception.

All listed risk factors, except polypharmacy, were considered by more than half of the subjects to be fall-related risk factors. (Table 5) 52.9% (136/257) of the subjects were using four or more chronic drugs. However, only 49.5% (55/136) of these subjects considered use of multiple drugs as a risk factor of fall.

Over half of the subjects (63.8% or 164/257) considered themselves to have adequate or very adequate knowledge about fall. Among those subjects (36.2% or 93/257) who considered themselves to have inadequate knowledge about fall, 48 subjects reported that they had never thought of this problem. 79.4% (204/257) of subjects thought that doctor did not provide adequate information about fall to them.

Discussion

In our study, the prevalence of fall (20.2%) is comparable to that from a local large-scale population-based study on fall in the Chinese elderly population.² Increased risk of fall in older age and in female is in concordance with the findings in other international studies.²⁰

Fall was considered as a preventable and serious health problem by more than half of the subjects though less than one-fifth of the subjects considered fall as a more important health issue when compared with other health concerns. Higher proportion of elderly who walked with aids consider fall as more important and at the same time, they reported more occurrence of fall in past year. Therefore, majority of the elderly who never experienced fall may actually underestimate their fall risk. Nearly all the listed risk factors were perceived as fall related risk factors by more than half of subjects, suggesting that there was reasonably adequate understanding of fall related risk factors in our elderly population.

Among all the listed risk factors, polypharmacy is least recognized as a contributing factor to fall. We found that there were few elders using four or more chronic medications considered polypharmacy as a risk factor of fall. In a meta-analysis of 29 studies, subjects reporting usage of more than three or four medications of any type were at increased risk of recurrent falls.²¹ Detailed questioning into the drug history, monitoring of drug side effects and patient education are paramount to reduce iatrogenic, medication-related falls.

Large number (approximately 80%) of subjects thought that doctors did not provide adequate information about fall. As a clinical syndrome, fall is difficult to tackle especially in primary care setting because of its multi-factorial nature. The lack of awareness, knowledge, skill and time may be the reasons that hinder family physicians from working on fall prevention. However, in view of our rapidly ageing local population,²² fall will become an increasing burden to the health care system. Fall prevention should therefore be instilled into all family physicians' daily practice who would expect to encounter substantial number of elderly at risk for fall. Family physician is in a good position to educate our elderly population, increase their awareness, and carry out an initial fall risk assessment. This would help formulate individualized plans for each elderly patient so as to minimize the risk of fall and improve quality of life.

According to the latest guideline for the prevention of falls in older persons by the American Geriatrics Society, all elderly patients who are under the care of a health professional should be asked at least annually about falls.²³ An elderly patient reporting a single fall should be observed for gait and balance deficits. "Get up & Go" test is one of the simple screening tool.²⁴ Those demonstrating gait and balance problem should have a comprehensive fall evaluation, which may necessitate referral to a specialist (e.g., geriatrician).

This study has several limitations. Firstly, the subjects were recruited from a Family Medicine Specialist Clinic. Generalization of the results to other population should be made with caution. Secondly, patients with chair-bound status or having communication problems were excluded from the studies which may lead to selection bias. Yet this only contributes 8.5% (24/281) of the total number of subjects. Thirdly, the fall related risk factors in this study may not be exhaustive. Finally, the data were based on a retrospective, cross-sectional study. As in all other cross-sectional studies, it is unable to discriminate the causal relationships of variables. Recall bias is also an important limitation, especially among those elderly subjects who tend to have poor memory.²⁵ A prospective study is needed to identify convincingly the incidence, the relationship between perceptions of falls as a health problem, the knowledge on fall-related risk factors and the risk of fall.

Conclusions

With the ageing population and increasing life expectancy, fall is prevalent in our population and becomes a very important public health issue. In our study, elderly patients attending our clinic consider fall to be a serious and preventable health problem. They have an adequate knowledge on fall related risk factors but the perceived personal risk of falling may be underestimated. As family physicians, it is our role to promote the concept of fall as a preventable and important health problem, to help improve understanding of the full scope of fall-related risk factors and to include fall risk screening in geriatric assessment.

Acknowledgement

We would like to thank Dr David Chao for his valuable assistance and comments.

Key messages
In comparing general practitioners with and without higher qualification, those with higher qualification are more likely to:

1. Falls are prevalent, associated with significant morbidity and mortality and known to have identified risk factors and preventable measures.
2. Polypharmacy is the least recognised fall related risk factor in our study. Medication review and patient education are paramount to reduce iatrogenic, medication-related falls. 3. As family physicians, we should promote fall prevention, educate elderly patients on fall-related risk factors and include fall risk screening in geriatric assessment.