Factors Contributing to Falls and the Effect of a Multipronged Approach on the Incidence of Falls in the Elderly in an Outpatient Setting

FACTORS CONTRIBUTING TO FALLS

AND THE EFFECT OF A

MULTIPRONGED APPROACH ON THE

INCIDENCE OF FALLS IN THE ELDERLY

IN AN OUTPATIENT SETTING

A dissertation submitted in partial fulfillment of

the rules and regulations for MD Geriatrics examination of

the Tamil Nadu Dr. MGR Medical University, Chennai, to

DECLARATION

This is to declare that this dissertation titled “Factors contributing to falls and the effect of a multipronged approach on the incidence of falls in the elderly in an outpatient setting” is my original work done in partial fulfilment of rules and regulations for MD Geriatrics examination of the Tamil Nadu Dr. MGR Medical University, Chennai to be held in May 2019.

CANDIDATE

CERTIFICATE I

This is to certify that the dissertation titled “Factors contributing to falls and the effect of a multipronged approach on the incidence of falls in the elderly in an outpatient setting”, is the bonafide work of Dr. Jini Chirackel Thomas towards the partial fulfilment of rules and regulations for MD Geriatrics degree examination of the Tamil Nadu Dr. MGR Medical University, to be conducted in May 2019.

GUIDE

Dr. SurekhaViggeswarpu MD (Med), FRCP (Lon), Professor and Head of the Department,

Department of Geriatrics,

CERTIFICATE II

This is to certify that the dissertation titled “Factors contributing to falls and the effect of a multipronged approach on the incidence of falls in the elderly in an outpatient setting”, is the bonafide work of Dr. Jini Chirackel Thomas towards the partial fulfilment of rules and regulations for MD Geriatrics degree examination of the Tamil Nadu Dr. MGR Medical University, to be conducted in May 2019.

PRINCIPAL HEAD OF THE DEPARTMENT

CERTIFICATE III

Plagiarism certificate

This is to certify that this dissertation “Factors contributing to falls and the effect of a multipronged approach on the incidence of falls in the elderly in an outpatient setting” of the candidate, Dr. Jini Chirackel Thomas, with Registration Number 201626051 in the branch of Geriatrics, has been submitted for verification. I personally verified the urkund.com website for the purpose of a plagiarism check. I found that the uploaded dissertation file contains 1% percentage plagiarism from introduction to conclusion.

GUIDE

Dr. SurekhaViggeswarpu MD (Med), FRCP (Lon), Professor and Head of the Department,

Department of Geriatrics,

ACKNOWLEDGEMENTS

First and foremost, I thank the Lord Almighty for His constant presence every step of the way.

I express my deep gratitude to the people who were involved in this dissertation from its conceptualization to completion.

I express my most earnest gratitude to my guide Dr.SurekhaViggeswarpu, Professor and Head of the Department of Geriatrics, who has been a constant source of inspiration, support and encouragement.

I also extend my gratitude to Ms.J Visalakashi and Ms.Tunny Sebastian, Department of Biostatistics, for their valuable contributions.

I am grateful to my teachers – Drs. Prasad Mathews, KG Gopinath, Benny Paul Wilson, and my seniors, Drs.Pranita Harshad Vanjare and Rakesh Mishra, who have guided me in various ways. I also thank our office secretary Mrs. Maheshwari, who has been very supportive and helpful.

I would also like to thank the Occupational and Physiotherapy team members, the dieticians and our social worker for all their help and contributions to the study.

To all my friends and colleagues who were a great source of encouragement and help, especially Drs. Stephen Varghese Samuel, Asha Mathai and Baapi Sheikh.

I acknowledge my family, whose support was immeasurable.

Finally, I also acknowledge the participants of the study, without whom, the study would not have been possible.

Dr.Jini Chirackel Thomas MBBS Post Graduate Registrar

Department of Geriatrics

LIST OF ABBREVIATIONS AND ACRONYMS

ACE Angiotensin Converting Enzyme Inhibitor ARB Angiotensin Receptor Blocker

BZD Benzodiazepine BBT Berg Balance tests

CCB Calcium Channel Blocker CMC Christian Medical College

COPD Chronic Obstructive Pulmonary Disease CVA Cerebrovascular Accident

DM Diabetes Msellitus ECG Electrocardiogram OPD Outpatient Department TUGT Timed Up and go Test

Contents

ABSTRACT

1.INTRODUCTION 1

1.2 COMORBIDITIES IN ELDERLY: 4

2. AIM 7

3.OBJECTIVES 7

4. LITERATURE REVIEW 8

4.1 DEFINITION OF A FALL 8

4.2 EPIDEMIOLOGY OF FALLS 100

4.3 PATHOPHYSIOLOGY 111

4.4 CHANGES IN GAIT IN THE ELDERLY 144

4.5 RISK FACTORS FOR FALLS IN ELDERLY 155

4.6 SITE OF FALL 22

4.7 CLASSIFICATION OF FALLS 23

4.8 CONSEQUENCES OF FALLS 23

4.9 SCREENING THE ELDERLY FOR FALLS RISK 24

4.10 ASSESSING THE RISK FOR FALLS 26

5. INTERVENTIONS FOR FALL PREVENTION 30

6. METHODOLOGY 32

7. SAMPLE SIZE CALCULATION 38

8. RESULTS 41

9. DISCUSSION 76

10. CONCLUSION 82

11. LIMITATIONS 83

12. REFERENCES 84

ABSTRACT

TITLE:

FACTORS CONTRIBUTING TO FALLS AND THE EFFECT OF A MULTIPRONGED APPROACH ON THE INCIDENCE OF FALLS IN THE ELDERLY IN AN OUTPATIENT SETTING

DEPARTMENT : GERIATRICS

NAME OF THE CANDIDATE : JINI CHIRACKEL THOMAS DEGREE AND SUBJECT : MD GERIATRICS

NAME OF GUIDE : DR SUREKHAVIGGESWARPU

OBJECTIVE:

Primary objective: To study the various factors contributing to falls in the elderly who presented to the Geriatric OPD in a tertiary care centre.

Secondary objective: To assess the effect of a multipronged approach on the prevalence of falls in these patients.

METHODS:

Baseline relevant investigations were sent. Based on the above assessments and investigations, an individualized multifactorial falls prevention interventional program was initiated.

The patients were followed up telephonically at one month and three month intervals after their initial OPD visit telephonically to assess drug and intervention compliance and a note was made, if they had fallen. All these results were statistically analyzed.

RESULTS AND CONCLUSION:

In this study, 48.3% had fallen in the past one year, of whom 16.7% were recurrent fallers. Subjects who were on sedatives and antidepressants and those who did not have an eye examination in the past year were found to have a higher risk of falls. These factors were significant on the univariate analysis.

1.

INTRODUCTION

The elderly constitute about 8.5 percent of the total population worldwide (617 million). India, which is the second most populous country in the world, has witnessed a steady rise in the number of elderly. According to the 2011 census, about 8.6% of the total population in India are aged sixty-five years and above (1).

Figure 1: Decadal Growth rate of India

Despite this decrease in decadal growth between 2001 and 2011, there has been a 35.5%increase in the elderly population in India (from 7.66 crores to 10.38 crores) (3). This is true in both the urban and the rural areas.

Figure 2: Population of people aged 60+ years over the decades

The figure shows a steady increase in people over the age of sixty years over consecutive decades.

Figure 3: Graph showing the trend in birth and death rates in India

Figure 4: Population pyramid and age structure of India

Source: https://www.populationpyramid.net/india/2050/

In this figure, which represents the population pyramid and age structure of present day India, we see that the younger generation constitutes the majority of the population. They take care of the elderly who belong to the unorganised sector with no financial or social supports. This is the ideal pyramid which is well balanced and smooth and is hence, a stable one (4). This pyramid may become unstable as the number of older persons increase, and there are fewer younger adults to look after them.

1.2 COMORBIDITIES IN ELDERLY:

As one ages, there is an increase in comorbidities, which may be attributed to a decline in physical activity, or the ageing process itself or the increased prevalence of chronic medical conditions in this age group(5)

Managing multiple comorbidities in the elderly is a challenge faced by physicians worldwide. The medications, drug interactions and impact of adverse reactions affect health outcomes in this age group. Multimorbidity is also associated with a poor functional status, quality of life, disability and ultimately, death. (5)

Falls in the elderly contribute hugely to the morbidity and mortality of the elderly.

Disability Adjusted Life Years (DALYs) is defined as the sum of years of potential life lost due to premature mortality, and the years of productive life lost due to disability.

DALY= YLL + YLD,

(a.) Age group 50-69 years

(b.) Above the age of seventy

2010 Mean Rank DALY (95% UI)

1 Ischemic Heart Disease 1.0 (1-1)

2 Stroke 2.0 (2-2)

3 COPD 3.0 (3-3)

4 Lower respiratory Infections 4.5 (4-6)

5 Diabetes 4.6 (4-6)

6 Low back pain 6.7 (4-9)

7 Alzheimer’s Disease 7.3 (6-9)

8 Lung Cancer 7.3 (6-10)

9 Falls 8.6 (7-10)

10 Hypertensive Heart Disease 10.1 (9-12)

Communicable disorders Non communicable diseases Injuries

Table 1: Global distribution of disability-adjusted life-years (DALYs) ranking in 2010.

Source: Institute for Health Metrics and Evaluation. GBD 2010 Arrow Diagram.

UI: uncertainty interval

2010 MEAN RANK DALYs (95% UI)

1 Ischemic Heart Disease 1.0 (1-1)

2 Stroke 2.0 (2-2)

3 COPD 3.1(3-4)

4 Low back pain 4.3 (3-6)

5 Diabetes 4.9 (4-6)

6 Lung cancer 5.7 (4-6)

7 Cirrhosis 7.9 (7-11)

8 Tuberculosis 8.3 (7-12)

9 Major depressive disorder 9.4 (7-15)

10 Road injury 10.5 (7-15)

Uncertainty interval is the same as the classical confidence interval for the population mean when the uncertainty is dominated by the spread of replicate measurements(6). The term has been used to convey some idea of the uncertainty involved in the estimate.

As seen in the above tables, falls contribute to DALYs in those above the age of seventy. They do not figure in the table which shows the DALYs in the “younger” age group.

2.

AIM

To study the

 factors contributing to falls in the study population

 effect of a multipronged approach on the prevalence of falls in the elderly presenting to the geriatrics outpatient department in a tertiary care hospital

3.

OBJECTIVES

Primary objective: To study the various factors contributing to falls in the

elderly presenting to the Geriatric OPD in a tertiary care centre.

Secondary objective: To assess the effect of a multipronged approach on the

4. LITERATURE REVIEW

4.1 DEFINITION OF A FALL:

The World Health Organisation (WHO) has defined a fall as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (7).

Tinetti et al, in 1988 defined fall as “an unintentional event in which a person comes to rest on the floor or ground that is not caused by loss of consciousness, stroke, seizure, or overwhelming force” (8,9).

A fall is also a marker of declining function and poor health and results in pain, prolonged immobilization and heightened risk of institutionalization. Falls cause injuries and consequently lead to disabilities.

Disability is defined as any continuing condition that restricts everyday activities. The Disability Services Act (1993) defines ‘disability’ as:

 which is attributable to an intellectual, psychiatric, cognitive, neurological, sensory or physical impairment or a combination of those impairments

 which is permanent or likely to be permanent

 which may or may not be of a chronic or episodic nature

Falls increase the care taker burden and are a leading cause of morbidity and mortality in the elderly (11).

Recurrent fallers are individuals who have had more than two falls over a six month period (12). Fear of recurrent falling interferes with the patient’s daily activities. Studies have shown that fear of falling increases the risk of falls in a subject (13). Indian studies enumerating the risk factors for falls are available, but there is a lack of research with respect to interventions to reduce the incidence of falls.

A study done by Dhargave et in India revealed that a past history of falls, poor vision, polypharmacy, use of walking aids and vertigo were the main causes of falls in the elderly (14).

4.2 EPIDEMIOLOGY OF FALLS

In the United States, 30% of individuals aged sixty five years or older fall at least once a year (15). About 28-35% of community dwelling older people above sixty four years of age fall each year. In people who are above seventy, approximately 32%-42% fall each year. Age and frailty increase the frequency of falls. It is also important to note that about 75% of falls are unreported (16).

STUDY COUNTRY TARGET GROUP

(Age group in years)

STUDY DESIGN PERCENTAGE

OF FALLS Prudham, D

(1981)

UK N=2793

(65+) Retrospective study (1 year) 28 Campbell, AJ (1981)

New Zealand N=553

(65+) Retrospective study (1 year) 33 Tinetti, ME (1988)

USA N=326

(70+)

Telephone Interview 32

Blake, AJ (1988)

UK N=1042

(65+) Retrospective study (1 year) 35 Downton, JH (1991)

UK N=203

(75+) Retrospective study (1 year) 42 Stalenhoef, PA (2002)

Netherlands N=311

(70+)

Telephone Interview (1 year)

33

Table 2:Percentage of falls among participants in six studies (17)

In another study done in Karnataka, the prevalence of fear of fall among the elderly population was estimated to be 33.2%. Hence it is important to recognise the complexity and burden of falls in the elderly and provide appropriate falls prevention interventions in patients who are at risk for falls.

4.3 PATHOPHYSIOLOGY:

NORMAL GAIT AND GAIT CYCLE:

A normal gait cycle includes two phases: - A stance phase and a swing phase

 Stance phase: During this phase, the reference foot remains in contact with the ground

 Swing Phase: During this phase, the reference foot is not in contact with the ground (20).

Stance Phase:

- This phase constitutes about 60% of the gait cycle.

- In this phase, the reference foot undergoes five movements:

i. Heel strike: This is the initial contact when the heel of the reference foot touches the ground.

ii. Foot flat: The weight is transferred onto the reference leg.

iii. Mid stance: At this point, the body weight is balanced on the reference foot.

iv. Terminal stance: Here the heel of the reference foot rises while its toes are still in contact with the ground.

v. Pre-swing (toe off): The toes of the reference foot are off the ground and this marks the beginning of the swing phase.

Swing phase:

- This phase contributes to the rest 40% of the gait cycle. - Here the reference foot undergoes:

i. Initial swing: This starts from elevation of the limb to the point of maximal knee flexion.

ii. Mid-swing: Here the ankle dorsiflexors contract to cause foot clearance.

Various factors are involved in a normal gait and balance, such as:

- Musculoskeletal integrity

- Cortical-basal ganglia system

- Sensory inputs (vision, hearing, fine touch and proprioception).(21)

- Cognition

- Normal gait speed is between 1.0 to 1.3 m/sec in the elderly. Both slower (<0.6m/sec) and faster (≥1.3 m/s) gait speeds have been associated with an increase in the risk of falls (22).

Figure 7: Predicted Median Life Expectancy by age and gait speed

Adapted From Gait Speed and Survival in Older Adults. JAMA. 2011 Jan 5;305(1):50–8, Studenski et al

4.4 CHANGES IN GAIT IN THE ELDERLY Many changes occur in gait with aging, such as:

 Decrease in gait velocity  Short step length

 Wider based gait

 Decrease in lower limb strength  Increased reaction time

There is a 20% reduction in gait velocity with increased stance phase in the older population (24). Older people have a cautious and more shuffling gait and often have a forward stoop. These changes effect the elderly especially when they walk on irregular or slippery surfaces (25).

4.5RISK FACTORS FOR FALLS IN ELDERLY

INTRINSIC RISK FACTORS:

There are many independent risk factors which include:

1. Age older than 80 years 9. Decreased muscle strength

2. Female sex 10. Gait impairment and walking

difficulty Eg:Parkinson’s

3. Previous falls 11. Balance impairment

4. Diabetes mellitus 12. Visual impairment 5. Cognitive impairment 13. Arthritis and pain (27) 6. Dizziness or orthostasis 14. Incontinence

7. Depression 15. Polypharmacy (more than 4

medications) or psychoactive drug usage

8. Functional limitations 16. Increase in white matter lesions (28)

Table 3: Intrinsic risk factors and falls in elderly

- _{The risk of falling increases with the number of risk factors: One year risk of} falling doubles with each additional factor, starting from 8% with none, and reaching 78% with 4 risk factors (29).

1. Advancing age:

2. Changes in postural control and other systems:

Listed below are some of the age related changes that increase the risk of falls in elderly.

i. Proprioception: Peripheral neuropathy and loss in proprioception in the lower limbs due to ageing lead to an increased risk of falls (30).

ii. Vestibular system: A loss of labyrinthine hair cells, vestibular ganglion cells, and nerve fibres due to ageing, result in dizziness and disequilibrium. (31).

iii. Brain: There is loss of neurons and depletion of neurotransmitters like dopamine within the basal ganglia, which contributes to -postural instability in elderly (32).

- As the function of the nervous system declines with age, the reaction time in elderly increases. “Choice step reaction time”, defined as the time for a task which requires making choices and a physical response to an unpredictable stimulus, has been shown to be higher in the elderly. This results in a delay in their response to external stimuli and puts them at a greater risk for falls (33). - Cognitive impairment and dementia also add to the risk of falls due to postural

3. Musculoskeletal:

Elderly have lower muscle strength in the lower limbs, when compared to the young (35).

There is a difference in the grouping of muscle activation patterns in the young and elderly while walking.

- The elderly activate the proximal muscles, such as the quadriceps, before the distal muscles, such as the tibialis anterior which causes postural

instability(36)(37).

- The gastronemius muscle gives most of the push-off before the foot lift-off phase. A study done among elderly women comparing muscle activation patterns among fallers and non-fallers showed that fallers had a slower time-to-peak for the gastronemius. There was also increased co-contraction of the proximal rectus and biceps femorii during the stepping phase. This made them unable to step forward rapidly (38).

- Fatty infiltration of muscles has been shown to increase the risk for hip fracture. (39)

- Vitamin D deficiency has been demonstrated to cause increased risk of falls in elderly (40).

4. Visual and hearing impairment:

Impairment is defined by the World Health Organization (1980) as “any loss or abnormality of psychological, physiological or anatomical structure or function”.

As one ages, there is decrease in visual acuity, depth perception and dark adaptation (42).There is a decrease in vision secondary to cataract or retinal changes which include retinopathy and age related macular degeneration. Poor vision has been associated with both falls and hip fracture (43).

The use of bifocal lenses also increase the risk of falls (44). Bifocal lenses impair depth perception and may impair the placement of foot in older people especially while climbing onto/or descending from higher levels and may cause trips and falls (44).

Hearing loss depletes one of the auditory cues and puts them at a higher risk of falling. (45)

5. Medical comorbidities:

Various medical comorbidities have been described to cause a greater risk of falls.

i. Respiratory conditions: Chronic Obstructive Pulmonary Disease (46) ii. Cardiac conditions causing an increased risk of falls include

iii. Neurological conditions:

- Past history of stroke causing impairment in gait - Seizure disorder

- Peripheral neuropathy - Parkinsonism (48)

A study done by Homann et al to assess the relation between neurological conditions and falls showed that fallers belonged to the group with stroke (89%), Parkinson’s disease (77%), dementia (60%), epilepsy (57%) and tinnitus (30%) and headache (28%). They observed that disorders like tinnitus and headache which had no direct influence on gait and balance also increased the risk of falling. This study showed that it was not only the type, but also the number of the neurological diseases that increased the risk of falling(49).

iv. Endocrine abnormalities:

- Type 2 Diabetes Mellitus: Diabetes and its related complications like peripheral neuropathy, diabetic retinopathy and cataracts affecting vision, cerebrovascular accidents, sarcopenia, urinary incontinence, mild cognitive impairment and dementia have been described as underlying causative factors for falls(50).

showed impaired gait patterns in patients with hyper or hypothyroidism (51). Current treatment with thyroxine is also known to increase the risk of fracture (lumbar spine, pelvis, hip, femur, lumbar or thoracic spines, wrist, forearm, shoulder or upper arm) in the elderly. An excess of thyroid hormone levels can affect neuromuscular function and muscle strength and increase risk of arrhythmia and falls(52).

iv. Others: Depression and incontinence are also frequently described in patients with falls.

EXTRINSIC RISK FACTORS: 1. Polypharmacy:

As a person ages, the likelihood of medical problems and resultant

polypharmacy increases, and so does the risk of falling. Studies have shown that ingestion of four or more drugs per day puts one at a greater risk of falls, recurrent falls and injurious falls.(38,39). The various classes of medications shown to increase the risk of falls are:

 Antihypertensives: Diuretics and beta blockers

 Psychotropic agents:

Antidepressants(53), Antipsychotics (55)

 Antiepileptic Agents  Sedatives

 Corticosteroids  Hypoglycemic agents and Insulin  Antiparkinsonian agents  Non-Steroidal Anti-inflammatory

Agents

The mechanism of falls with these drugs varies. Some examples are given below:-

- Some drugs cause giddiness and impair the awareness of the environment.

- Some drugs can impair the renal absorption of calcium and decreases bone mineral density, thereby increasing the risk of osteoporotic fractures (56) - Some cause postural hypotension, dehydration or electrolyte imbalance. - Some drugs impair judgement or interact with other medications.

4.5.7 Environmental Hazards:

A fall usually results from interactions between long or short-term predisposing factors and short-term precipitating factors (such as a trip, an acute illness, or an adverse drug reaction) in a person’s environment. A few of the environmental hazards are enumerated below:

o Bath mats and floor mats in the kitchen etc.

o Clutter on the floor

o Cord cables and wires

o Slippery floors or uneven surfaces

o Poor lighting

4.6 SITE OF FALL:

About 56% of the falls in the elderly occur outside home such as in the compound, street or a public place (11). Within homes, falls are more frequent in the bathrooms (11). A study done in India showed most of the falls to occur on the road (30.5%) or in the bathroom (21.1%) (58) . The figure shown below clearly indicates the incidence of falls in different locations within the house.

Figure 8: Location and the percentage of falls

Data from Slipping and tripping: fall injuries in adults associated with rugs and carpets - Rosen et al (59)

35.7

21.3

15.3

13.5

5.7 _4.8

3.6

0 5 10 15 20 25 30 35 40

BATHROOM BEDROOM KITCHEN HALLWAY LIVING ROOM

PORCH DOORWAY

PE

RC

EN

TAG

E

OF FALL

S

4.7 CLASSIFICATION OF FALLS:

Falls are classified according to their cause:

1. Extrinsic fall: includes slips, trips and due to environmental factors like carpets and rugs

2. Intrinsic fall: due to impairment in balance, mobility, cognitive or sensory function

3. Non-bipedal fall: Falling from the bed 4. Non-classifiable falls (8)

4.8 CONSEQUENCES OF FALLS:

 Injury

 Hospital admissions  Subsequent fear of falling  Loss of functional independence  Depression

 Confusion  Isolation

 Death: In patients with a hip fracture, the one year postoperative mortality was 27.3% (63).

4.9SCREENING THE ELDERLY FOR FALLS RISK:

Different societies have laid down recommendations for screening in the elderly for the risk of falls.

4.9.1 AMERICAN GERIATRIC SOCIETY/ BRITISH GERIATRIC

SOCIETY GUIDELINES:

All older persons should be asked at least once a year about falls, frequency of falling and difficulty in gait or balance.

A multifactorial assessment should be performed on community dwelling older adults who:

- Report recurrent falls

- Report difficulties with gait or balance

The questions asked to assess gait and balance difficulties may include:

 Do you have dizziness or difficulty walking in crowds? (possibly indicating a vestibular disturbance)

 Do you use a walking aid?

 Do you have a prior history of falls and injuries?(65).

4.9.2 CENTRE FOR DISEASE CONTROL RECOMMENDATIONS:

STEADI TOOL KIT: (59),(60)

STEADI (Stopping Elderly Accidents, Deaths, and Injuries) is a Falls Prevention Tool Kit developed by the Centres for Disease Control and

Prevention’s Injury Centre. It is designed to screen older adults who are at an increased falls risk in a clinical setting.

The patient is asked three key questions. A “yes” answer to any of the questions given below determines the need for a multifactorial risk assessment for falls in the patient.

1. Fall in the past year

2. Feels unsteady when standing or walking

4.9.3 US Preventive Services Task Force Recommendation:

The USPSTF recommends that the clinicians ask their elderly patients about falls, gait and balance problems on a yearly basis.

The clinician should identify various factors that increase the risk of falls in community dwelling adults aged sixty five years or older, which include: advancing age, past history of falls and a history of mobility problems. A Timed Up and Go Test identifies those who are at an increased risk for falls.

4.10 ASSESSING THE RISK FOR FALLS

4.10.1 ‘TIMED GET UP AND GO' TEST (TUGT)

The “Get up and Go test” is a good clinical measure of balance in elderly (69). It is used as part of a global assessment of an individual’s fall risk.

Procedure:

 For this test, the patient sits in a straight-backed armed chair with his/her back against the chair.

 The starting position is sitting with hands resting on the arms of the chair.

 On the command “go”, the patient rises from the chair, walks 3 meters at a comfortable and safe pace, then turns, walks back to the chair and sits down

 Patient who use their assistive devices should use them while performing this test.

 Timing (sec): The time is calculated between the command to start till the buttocks touch the chair. The patient should have one practice trial that is not included in the score (71)

Age (years) Mean time (seconds)

60 to 69 8.1 (7.1 to 9.0)

70 to 79 9.2 (8.2 to 10.2)

80 to 99 11.3 (10.0 to 12.7)

Table 4: Reference Values for TUGT test (72)

The time score of TUGT correlates well with log-transformed scores on the Berg Balance Scale, gait speed and Barthel Index of Activities of Daily Living. It also predicts the ability of the subject to go outside alone safely(71). For this study, a cut-off of 13.5 seconds was taken for the TUGT (73). A trial attempt is given that is not timed before the testing. (Refer Appendix-11)

4.10.2 BERG BALANCE SCALE (BBS):

This scale assesses tasks related to position change and balance. It predicts the risk of multiple falls in older patients (74).

It is interpreted based on the scores as low falls risk (41-56), medium fall risk (21-40) and high fall risk (0 –20). The sensitivity of this test is 91% and the specificity is 82% (75).

4.10.3 GAIT SPEED (FOUR METER WALK TEST):

The time taken by a subject to walk four meters is recorded with a stopwatch. The gait speed (in metres/second) is measured by taking the average of two recordings.

The four meter gait speed is a predictor of the lower limb muscle function and mobility (76)(77)(78). A subject with a walking speed of less than 0.8 metres per second is more likely to have recurrent falls.(79)

4.10.4 HAND GRIP STRENGTH:

Hand grip strength is used as a measure for assessing muscle strength. The isometric hand grip strength is related to lower extremity muscle power, cross sectional muscle area and knee extension torque (76)where torque is the force that causes rotation. Hence a low hand grip indicates poor mobility and a low muscle mass.

4.11 BARTHEL INDEX:

The Barthel Index looks at one’s performance in the Activities of Daily Living (ADL). It gives us information about a subject’s functional status and dependency (82).

Wing-chu et al showed that falls have a negative impact on one’s ADLs which showed a decline within one year of a fall (83)

4.12 Mini-Cog:

The “Mini Cog” is a simple scoring to identify cognitive impairment. It consists of a three word recall and a Clock Drawing Test (CDT). The score from the three item recall and Clock Drawing are added together for a total score.

4.13 MINI NUTRITIONAL ASSESSMENT:

The Mini Nutritional Assessment is a screening and assessment tool to identify elderly patients who are malnourished or are at risk for malnutrition (84). It is a rapid tool to assess the nutritional status in elderly (85).

4.14 SCREENING OF VISION: SNELLEN’S CHART:

4.15 HEARING ASSESSMENT: WHISPER TEST

Functional hearing is defined as a way in which a subject uses whatever hearing he or she has(90). The ‘Whisper test’ is used as a screening test to detect hearing loss.

The Whisper test has a sensitivity of 90-100% and specificity of 70-87% for hearing impairment (91).

5. INTERVENTIONS FOR FALL PREVENTION:

5.1 Drug Optimisation

This includes a review of all the medications the patient is on, the number of medications and the class of drugs. A rational drug prescription is given to the patient at the end of the encounter.

5.2 GAIT AND BALANCE TRAINING EXERCISES

Physiotherapy interventions include a battery of lower limb resistance exercises, gait training, prescribing appropriate walking aids and giving advice on falls prevention. Occupational therapists provide patient and family education on transfers, reiterate fall prevention techniques and prescribe adaptive devices and suggest home modification for falls prevention.

5.3 VITAMIN D

Replacement with Vitamin D has shown to improve postural balance and navigational abilities in the elderly (92).

5.4 DIETARY MODIFICATION:

A nutritious diet has been shown to have negative relationship to falls risk and poor physical function in older adults (93). Increased dietary protein improves the musculoskeletal health in older adults(94). The Framingham study showed that adequate dietary protein (mean total protein intake was 69±23.9 g/day) intake prevents falls in the elderly. Another study done showed that diets with sufficient amounts of protein, polyunsaturated fatty acids, Vitamin D and antioxidants improved muscle mass and strength (95).

5.5 APPROPRIATE FOOTWEAR

The MOBILIZE BOSTON study showed that 51.9% of people were barefoot, wearing socks without shoes, or wearing slippers at the time of in-home falls.

Footwear which are worn out, loose and without back straps increase the chances of falling (96). Older people should wear shoes with low heels and firm slip-resistant soles both inside and outside the home. Velcro fasteners help to affix the shoe firmly onto the wearer’s foot (97).

5.6 HOME SAFETY MEASURES:

5.7 OPHTHALMOLOGY REFERRAL

Poor vision affects the balance stability in elderly. An Ophthalmology referral and timely intervention- appropriate spectacles, cataract surgery, etc, improve vision. Studies have shown that post cataract surgery, the risk of falls and rate of fractures in individuals were reduced.(98,99).

5.8 ENT REFERRAL

ENT referrals should be given for those with a history of tinnitus, hearing loss or peripheral vertigo for appropriate interventions (100).

6. METHODOLOGY

1. SETTING

This study was conducted in the Christian Medical College Vellore, a tertiary hospital in South India. The patients who visited the Geriatrics Outpatient department were enrolled into the study, if they fulfilled the inclusion criteria.

2. STUDY DESIGN:

It was an interventional trial done over a period of ten months (Oct 2017 – July 2018). The study and methodology was approved by the Institutional Review Board of Christian Medical College Vellore (IRB MIN NO. 10743)

3. STUDY PARTICIPANTS

INCLUSION CRITERIA-

i. Subjects aged sixty years or older

ii. Attending the Geriatric OPD between October 2017 to July 2018

iii. Willing to participate and should be capable of giving informed consent iv. Subjects who have had a fall or are at a risk for falls as per the STEADI

questionnaire with the answer ‘Yes’ to any one of the following: - Fear of falling

- Imbalance while walking

- History of falls in the past one year

EXCLUSION CRITERIA-

1. Subjects who declined to give consent were excluded from the study.

2. Subjects with:

- A history of unconscious falls/syncope

- Severe cognitive impairment as defined by a score of < 1 on the Mini-cog - Neurodegenerative disorders

- Severe Parkinson’s/Parkinson Plus syndromes

- Neuromuscular illnesses which prevent them from performing the test - Severe peripheral neuropathy

- Severe visual impairment (visual acuity of less than 3/60) - Severe hearing impairment

- Congestive cardiac failure - Decompensated liver disease - End stage renal disease

- Patients with terminal illnesses

4. OBJECTIVES:

 Primary Objective: To study the various factors contributing to falls in patients presenting to the Geriatrics Outpatient department

 Secondary Objective: To assess the effect of a multipronged approach on the incidence of falls in these patients

5. SUBJECT ENROLMENT:

After fulfilling the inclusion and exclusion criteria, the eligible subjects were informed about the nature of study. An informed consent was taken from individuals who were willing to participate in the study. The participants were recruited from the Geriatrics OPD and were followed up the next day for detailed assessment

6. MATERIALS AND METHODS:

The patients presenting with a history of falls, fear of falling or imbalance while walking to the Geriatrics Outpatient department in Christian Medical College Vellore from October 2017 to July 2018 were recruited for the study. Data collected included –

i. HISTORY:

2. Socioeconomic and educational status

3. Social history: Living with whom, place of residence, income if any

4. Are they participating in a regular exercise program?

5. Comorbidities

6. The number and type of medications the study participants were on

7. Past medical and surgical history

8. History of substance abuse- smoking, alcohol, tobacco products if any

9. Urinary complaints: Urgency, nocturia, stress or urge incontinence

10. Screening questions included:

- History of falls in the past year

- Fear of falling

- Imbalance while walking

11. History of falls: The number of falls in the last one year along with the date of the last fall, time and site of fall, prodromal symptoms, direction of

fall(forward or backward) and injuries, if any were documented.

ii. Assessment included –

1. Snellen’s chart was used to test visual acuity. Study participants were asked for a history of vision loss, recent change in vision, eye

2. A hearing assessment was done using the Whisper Test. Subjects were also asked for any hearing loss, use of hearing aids.

3. Examination of the pulse – the rate and rhythm were noted.

4. Baseline blood pressure in the supine position and blood pressures in the standing position at one and three minutes were documented. Orthostatic hypotension was defined as a fall in the systolic blood pressure by 20 mm Hg or more and/or the diastolic blood pressure by 10 mm Hg or more when the patient was upright for three minutes.

5. Mini –Cog (Refer Appendix-7)

6. Functional status was assessed using the Barthel index (Refer Appendix-8).

5. Body mass index – calculated by body weight (kilograms) divided by height squared (meters).

6. Gait and gait speed

7. Mini Nutritional Assessment (Refer Appendix-9)

8. Hand grip was checked using a Jamar Hand dynamometer (Refer Appendix-10).

9. Timed Up and Go Test (Refer Appendix-11)

11. A clinical examination of the central nervous system was done and abnormal findings were documented.

12. Monofilament test: The monofilament test was done to assess peripheral neuropathy. A 10g monofilament was used to check 10 different sites on each foot. It was considered positive if there was loss of sensation in less than 8 sites checked.

13. Blood investigations ordered included Hemoglobin, Mean Corpuscular Volume, blood sugars, Vitamin D and Albumin. A routine ECG was done.

iii. Interventions included:

1. The patient was advised appropriate interventions in the form of gait and balance training exercises, drug optimisation, Vitamin D supplementation, footwear modification, dietary input, ENT and Ophthalmological referrals.

2. Home safety measures were advised (Refer Appendix-16).

iv. Follow up

7. SAMPLE SIZE CALCULATION-

i. Primary outcome:

To study the factors contributing to falls in patients presenting to the Geriatrics OPD

ii.Secondary outcome/s:

To assess the effect of a multipronged approach on the incidence of falls in these subjects

Target Sample size details:

Primary outcomes:

The required sample size to enumerate the factors contributing to falls was found to be 154 adults, with an anticipated odds ratio of 2, incidence of falls was considered to be 19% with 80% power and 5% level of significance.

Regression methods - Multiple logistic regression

Proportion of disease 0.19 0.19 0.19

Anticipated odds ratio 2 1.5 2

Power (1- beta) % 80 80 90

Alpha error (%) 5 5 5

1 or 2 sided 2 2 2

Multiple correlation coefficient of the exposure

variable with the confounders 0.3 0.3 0.3

Required sample size 154 397 201

References: JAMA, January 3, 2007—Vol 297, No. 1

Secondary outcomes:

Based on the study published in JAGS 56:1390–1397, 2008, the incidence of falls at baseline was 31%, while falls at the end of the study was 46%. However, for the purpose of calculation of the sample size, we anticipate that after the intervention, there should be a reduction in the number of falls. Hence we considered 31% as the incidence of ‘at least one fall’ after intervention, and 46% as the incidence of ‘at least one fall’ at baseline.

The required sample size to show that another fall in the follow-up period of one and six months after intervention was found to be 165 adults (above the age of 60), when the proportion of falls at baseline was assumed to be 0.46, and the proportion after the intervention was considered as 0.33, with 80% power and 5% level of significance. It was anticipated there would be 10% non responders in the group. Therefore, the required sample size adjusted for 10% non-response was found to be 183 adults.

This sample size was calculated using McNemar’s test comparing two correlated proportions specifying marginal proportions in STATA 13.0 software whose details are given below.

McNemar’s test comparing two correlated proportions specifying marginal proportions:

Power paired proportions 0.47 0.34, corr (0.3) Performing iteration

Estimated sample size for a two-sample paired-proportions test Large-sample McNemar's test

Ho: p+1 = p1+ versus Ha: p+1 != p1+ Study parameters:

alpha = 0.0500 power = 0.8000

delta = -0.1300 (difference) p1+ = 0.4700

Estimated sample size: N = 165

With 10% non-response N = 183

Therefore, the sample size considered for this study was 183.

This sample size is sufficient to answer primary and secondary outcome

8. RESULTS-

Data Integration and Analysis

A total of sixty study participants were recruited during the study period. The sample size of could not be reached due to logistic reasons. Four of the study participants were lost to follow up and one expired.

Baseline characteristics Number (Percentage)

1. Mean Age in years 68.22 years

2. Gender Male Female 31 (51.7) 29 (48.3) 3. Education Primary school

Secondary or High school Graduate

Postgraduate

16 (26.7) 23 (38.3) 17 (28.3) 4 (6.7) 4. Location West Bengal Jharkhand Bangladesh Andhra Pradesh Bihar Patna Assam Chattisgarh Tamil Nadu Tripura 31 (51.7) 12 (20.0) 7 (11.7) 2 (3.3) 2 (3.3) 2 (3.3) 1 (1.7) 1 (1.7) 1 (1.7) 1 (1.7) 5. Current occupation status

Employed

Retired or homemaker

11 (18.3) 49 (81.7) 6. Current occupation

Bank employee House help

Engineer / Contractor Chemist Clerk 1 (1.67) 1 (1.67) 2 (3.33) 1 (1.67) 2 (3.33) 7. Area of residence

Urban Rural Semi urban 57(95.00) 2(3.33) 1(1.67) 8. Modified Kuppusamy Classification 2018

II Upper Middle - 12 III Lower Middle - 18 IV Upper Lower – 30

12 (20.00) 18 (30.00) 30 (50.00) 9. Living in

Own home Children’s home Other

56 (93.3) 1 (1.7) 3 (5.0) 10. Living with

Alone Spouse

Spouse and/or children Informal care givers

2 (3.3) 5 (8.3) 51 (85.0) 2 (3.3) 11. Co-morbidities

Hypertension

Problems with vision Type 2 Diabetes Mellitus

Chronic obstructive pulmonary disease Severe osteoarthritis

Peripheral neuropathy Problems with hearing Parkinson’s disease Past history of stroke Congestive Cardiac Failure

40 (66.7) 29 (48.3) 26 (43.3) 12(20.0) 12 (20.0) 9(15.0) 6 (10.0) 2 (3.3) 1(1.7) 1 (1.7) 12. Charlson Comorbidity Index

1) Low - 0 2) Medium – 1-2 3) High – 3-4 4) Very high >5

0 (0.0) 20 (33.33) 28 (46.67) 12 (20.00)

DEMOGRAPHIC PROFILE:

1. Age and gender

Figure 9: Age group distribution of the study participants

The mean age of the study population was 68.22 years. Around 70% (n=42) of them were between 61 to 70 years of age, 25% (n=15) were between 71-80 years and 5% (n=3) were above 80 years of age.

Gender

Frequency

Percentage (%)

Male

31

51.7

Female

29

48.3

Total

60

100

Table 6: Gender distribution among the study participants

Of the 60 study participants who were recruited, 51.7% (n=31) were males and 48.3 %( n=29) were females.

70% 25%

5%

DISTRIBUTION OF AGE

2. Education

Figure 10: Literacy status of the study participants

Around 27% (n=16) of the study population had not completed primary school, 38% (n= 23) had attended secondary/high school, 28% (n=17) were graduates and 7% (n=4) were postgraduates.

3. Location

A majority of the study subjects were from West Bengal 31% (n= 51.7). The figure shows the various geographic locations of the study participants.

Figure 11: Geographical location of the study participants

27%

38% 28%

7%

Education

PRIMARY SCHOOL SECONDARY OR HIGH SCHOOL GRADUATE POST GRADUATE

0 10 20 30 40 50

60 51.7

20

11.7

3.3 3.3 3.3 _{1.7 1.7 1.7 1.7}

LOCATION

4. Current Occupation

Figure 12: Present occupation of the study participants

At the time of the study, 81.7% (n=49) were retired or homemakers, and 18.3% (n= 11) were still working.

Figure 13: Various occupations of the study participants

The majority of the study participants who were currently working were agriculturists (40%) and 16% were labourers.

Income Frequency Percentage (%)

No income 21 35.0

18%

82%

OCCUPATION

WORKING RETIRED OR HOMEMAKER

40%

16% 13%

10% 5% 4% 4% 4%

2% 2%

Occupation

35% had no income of their own, whereas 65% had some source of income - like pension and income from lands/rearing of domestic animals.

5. Area of Residence

Figure 14: Areas of residence of the study participants

95% of the study participants belonged to Urban areas. 6. Modified Kuppusamy classification 2018:

Figure 15: Modified Kuppusamy classification of the study participants

According to the Modified Kuppusamy Classification 2018, 50% of our study participants belonged to the Upper Lower class.

95% 3% 2%

Area of Residence

Urban Rural Semi urban

20%

30% 50%

Modified Kuppusamy classification

7. Family and Social Support

Figure 16a –Residential status of the study participants

93.3% of the study population (n=56) were living in their own homes. Two of the subjects lived in their children’s homes (n=1.7) and the rest (5%) were living with other informal caretakers or in residential care facilities (n=3).

Figure 16 b Social support system of the study participants

Of the study subjects, 51 (85%) were living with their spouses and children, five (8.3%) of them were residing with their spouses, two (3.3%) of them stayed alone and two (3.3%) of them were residing with informal carers.

93% 2% 5%

OWN HOME CHILDREN'S HOME OTHERS

3%

9%

85% 3%

LIVING WITH

8. Distribution of Co-Morbidities

Figure 17: Comorbidities of the study participants

Most of the study participants were hypertensives (66.7%), followed by subjects who had visual problems (48.3%). These were closely followed by subjects with Diabetes (43.3%).

Charlson Comorbidity Index Frequency (%)

1) Low – 0 0 (0.0)

2) Medium – 1-2 20 (33.33)

3) High – 3-4 28 (46.67)

4) Very high ≥ 5 12 (20.00)

The Charlson Comorbidity Index predicts the ten year mortality for a patient with a range of co-morbid conditions and is calculated by taking into account the age and various comorbidities of the patient like diabetes, chronic kidney disease, COPD, heart failure etc. (101).

Most of the study subjects belonged to the high risk group 20% (n=12) with a score of >5.

66.7 _48.3 43.3

20 20 ₁₅ 10

3.3

1.7 1.7 1

10 100

BASELINE CHARACTERISTICS:

Characteristic Frequency

(%)

No Falls (%)

Falls (%) P value

1. Exercise Walking Cycling No exercise Others 22 (36.7)

6 (10.0) 29 (48.3)

3 (5.0)

12 (54.5) 3 (50.0) 15 (51.7) 0 10 (45.5) 3 (50.0) 14 (48.3) 3 (100.0) 0.359

2. Number of medications No medications 1-3 drugs ≥ 4 drugs

9 (15.0) 23 (38.3) 28 (46.7) 6 (66.7) 12 (52.2) 12 (42.9) 3(33.3) 11 (47.8) 16 (57.1) 0.446

3. Class of drugs

Oral hypoglycaemic agents Insulin

Antihypertensives, Diuretics Anticholinergics

Sedatives, Antidepressants Antiparkinsons

Calcium and vitamin D Other

23 (38.3) 7 (11.7) 39 (65.0) 9 (15.0) 17 (28.3) 3 (5.0) 9 (15.0) 12 (20.0) 9 (39.1) 2 (28.6) 20(51.3) 2 (22.2) 5 (29.4) 1 (33.3) 4 (44.4) 5 (41.7) 14 (60.9) 5 (71.4) 19 (48.7) 7 (77.8) 12(70.6) 2 (66.7) 5 (55.6) 7 (58.3) 0.184 0.424 0.787 0.145 0.045 >0.999 >0.999 0.519

4. Smoking history Current smoker Ex-smoker Non-smoker

3 (5.0) 17 (28.3) 40 (66.7)

2 (66.7) 10 (58.8) 18 (45.0) 1 (33.3) 7 (41.2) 22 (55.0) 0.532

5. Alcohol use Current

Ex-alcohol consumer Social drinking

3 (5.0) 9 (15.0) 48 (80.0)

1 (33.3) 6 (66.7) 23 (47.9) 2 (66.7) 3 (33.3) 25 (52.1) 0.492

6. Other addictions (Tobacco, paan, khaini)

10 (16.7) 7 (70.0) 3 (30.0) 0.166

7. Past surgical history 30 (50.0) 18 (60.0) 12 (40.0) 0.121

8. Past hospital admission 29 (48.3) 17 (58.6) 12 (41.4) 0.302

9. Urinary complaints Nocturia Urgency Stress incontinence Urge incontinence 34 (56.7) 26 (43.3) 5 ( 8.3) 11 (18.3)

16 (47.1) 18 (52.9) 0.602

Characteristic Frequency (%)

No Falls (%)

Falls (%) P value

11. Walking aids No aid

Has a walking aid

47 (78.33) 13 (21.67) 25 (53.2) 5 (38.5) 22 (46.8) 8 (61.5) 0.347 12. Vision

Recent change in eye vision Eye exam in the past year Spectacles

Cataract surgery One eye Both eyes No surgery Normal Visual acuity

8 (13.33) 28 (46.66) 43 (71.67) 13 (21.67) 12 (20.00) 35 (58.33) 59 (98.33) 2 (25.0) 18 (64.3) 22 (51.2) 9 (69.2) 6 (50.0) 15 (42.9) 30 (50.8) 6 (75.0) 10 (35.7) 21 (48.8) 4 (30.8) 6 (50.0) 20 (57.1) 29 (49.2) 0.254 0.038 0.774 0.267 - 13. Hearing Hearing aids

Able to make out normal functional speech

Abnormal Whisper test

2 (3.33) 60 (100) 6 (10.0) 2 (100) 30 (50.0) 2 (33.3) - 30 (50.0) 4 (66.7) 0.492 - 0.671

14. Orthostatic hypotension 2 (3.3) 1 (50.0) 1 (50.0) - 15. Mini Cog

<3 ≥3 11 (18.33) 49 (81.67) 5 (45.5) 25 (51.0) 6 (54.5) 24 (49.0) 0.739

16. Mini Nutritional Assessment

Normal Nutritional status (10-14) At risk of malnutrition (8-9) Malnourished (0-7) 53(88.33) 7 (11.67) 24 (45.3) 6 (85.7) 29 (54.7) 1 (14.3) 0.103

17. Gait speed (m/sec) <0.8 ≥0.8 47 (78.3) 13 (21.7) 24 (51.1) 6 (46.2) 23 (48.9) 7 (53.8) 0.754

18. Timed up and go test (seconds) <13.5 ≥13.5 32 (53.3) 28 (46.7) 15 (46.9) 15 (53.6) 17 (53.1) 13 (46.4) 0.605

19. Monofilament Test Normal Abnormal 53 (88.3) 7 (11.7) 27 (50.9) 3 (42.9) 26 (49.1) 4 (57.1) >0.99

20. Vitamin D <30 ≥30 41 (69.5) 18 (30.5) 22 (53.7) 7 (38.9) 19 (46.3) 11 (61.1) 0.296 21. ECG Normal Abnormal 35 (58.3) 25 (41.7) 17 (48.6) 13 (52.0) 18 (51.4) 12 (48.0) 0.793

Baseline characteristics of the patients revealed that 51.7% of them followed a regular exercise pattern, which included walking, cycling and yoga. 48.3% of them reported no regular exercises.

Type of Medications:

Figure 18: Frequency and the type of medications

About half the study subjects (46.7%) were on more than four prescription drugs. 65% of them were on antihypertensives, which included diuretics and 28.3% were on sedatives and antidepressants.

Substance Abuse:

65

38.3

28.3

20

15 15 _11.7

5 0

10 20 30 40 50 60 70

Type of medications

5%

28%

67%

5%

15%

80%

5% of the study population were actively smoking or consuming alcohol, and 16.7% were using other tobacco containing products such as khaini or chewed beetle leaf.

Nutritional Status:

Figure 21: Nutritional status among the study participants

53 (88.3%) of the study participants had a normal nutritional status and only one (1.7%) was malnourished, according to the Mini Nutritional Assessment score.

CNS Examination:

Figure 22: Nervous system examination of the study participants

2% _10%

88%

0%

Malnourished At risk of malnutrition Normal

41.7

15

11.7 ₁₀

0 5 10 15 20 25 30 35 40 45

Muscle tone Reflexes Monofilament test Proprioception

Muscle tone on examination was abnormal in 41.7% of the study subjects, proprioception in 10% and reflexes were abnormal in 15%.

The monofilament test done to assess peripheral neuropathy was positive in seven of the subjects (11.7%). These subjects were given education on foot care and appropriate footwear was prescribed.

RESULTS:

The primary objective of the study was to enumerate the factors contributing to falls in elderly.

The STEADI questionnaire was administered to 60 study participants, 48.3% (n=29) presented with the history of fall in the year prior to enrolment in the study. Of those who had fallen, 16.7% reported to have fallen more than three times in the past year.

Number of falls Frequency Percentage

No falls 29 48.3

1-2 falls 21 35.0

>3 falls 10 16.7

Total 60 100.0

Table 9: Falls at baseline

• 29 (48.3%)

Fall in the past

year

• 45 (75%)

Imbalance while

walking

• 52 ( 86.7%)

Frequency (%) Last fall

In the last week In the last one month In the last 2-6 months

5 (16.7) 21 (70.0) 4 (13.3) Time of last fall

AM PM

19 (63.3) 11 (36.7) Location of fall

Inside home Outside home Community 19 (63.3) 9 (30.0) 2(6.7) Direction of fall

Forward Backward Sat down hard Can’t remember

18 (60.0) 6(20.0) 1 (3.3) 5 (16.7) Tripped over something

Yes No

13 (43.3) 17 (56.7) Loss of balance

Yes No

13 (43.3) 17 (56.7) Light-headedness/giddiness 14 (46.67)

Knees gave way 4 (13.33)

Alcohol or medications prior to fall 0

Fell out of bed 1 (3.33)

Unable to give a reason 4 (13.33)

Unable to get up within five minutes 8 (26.67) Needed assistance to get up 15 (50.00)

Among those who had sustained a fall, most of them fell inside their homes and reported falling forward. A majority of the falls occurred during the daytime (63.3%). Only 43.3% of them remembered tripping over something. 50% (n=15) of them had sustained some form of injury following the fall and 26.67% (n=8) needed assistance to get up within five minutes of falling.

FACTORS ASSOCIATED WITH FALLS:

1. GENDER:

Sex of the subject Falls in the past year (%) No history of falls (%)

p= 0.611 Male

14 (45.2) 17 (54.8)

Female

15 (51.7) 14 (48.3)

Table 11: Gender of the study participants and frequency of falls

Of the study participants who presented with a history of falls, 15 (51.7%) were females and 14 (45.2%) were males. In this study, there was no significant association of gender with history of falls.

2. NUMBER OF MEDICATIONS: Number of

medications

Falls in the past year (%) No history of falls (%)

p= 0.387

No medications _{3 (33.3) 6 (66.7)}

1-3 _{10 (43.6) 13 (56.5)}

≥ 4 _{16 (57.1) 12 (42.9)}

Table 12: Number of medications of the study participants and frequency of falls

33.3% (n=3) were not on medications and 43.6% (n=10) were on less than four types of medications.

3. TYPE 2 DIABETES MELLITUS Type 2 Diabetes

Mellitus

Falls in the past year

P= 0.455

Yes (%) No (%)

YES 14 (53.8) 12 (46.2)

NO 15 (44.1) 19 (55.9)

Table 13: Diabetes Mellitus and the frequency of falls

Twenty six (43.33%) of the study participants were diagnosed to have Type 2 Diabetes Mellitus, of whom 53.8% of them had reported falls. This was not statistically significant (p=0.455).

4. SYSTEMIC HYPERTENSION Systemic

Hypertension

Falls in the past year (%) No history of falls (%)

p= 0.465 YES

18 (45.0) 22 (55.0)

NO _{11 (55.5) 9 (45.0)}

Table 14: Systemic Hypertension and the frequency of falls

18 (45%) of the subjects with hypertension had reported a fall in the last one year.

5. PARKINSONS DISEASE Parkinson’s

Disease

Falls in the past year (%) No history of falls (%)

p= 0.962 YES

1 (50.0) 1 (50.0)

Only two (3.33%) of the subjects were diagnosed to have Parkinson’s disease; and one of them had a history of falls in the last one year.

6. PROBLEMS WITH HEARING AND VISION:

Figure 23: Problems with hearing and vision among the study participants *p= 0.931, ** P= 0.611

Among those who had reported falls in the past 1 year, three (50%) of them had problems with hearing and 15 (51.7%) had problems with vision.

7. SEVERE OSTEOARTHRITIS:

Severe Osteoarthritis Falls in the past year (%)

No History Of Falls (%)

p= 0.519

YES _{6 (50) 6 (50.0)}

NO

23 (47.9) 25 (52.1)

Table 16: Severe Osteoarthritis and the frequency of falls

50% of the study participants (n=6) with severe osteoarthritis had fallen in the past year.

46 47 48 49 50 51 52 53

PROBLEMS WITH HEARING*

PROBLEMS WITH VISION**

8. STROKE

Stroke Falls in the past year

p= 0.346

Yes (%) No (%)

YES _{3 (75.0) 1 (25.0)}

NO _{26 (46.4) 30 (53.6)}

TOTAL _{29 (48.3) 31(51.7)}

Table 17: Stroke and the frequency of falls

Three of the subjects (75%) who had suffered from a stroke in the past had reported a fall during the past year (P-0.346).

9. CONGESTIVE CARDIAC FAILURE Congestive

Cardiac Failure

Falls in the past year

p>0.999

Yes (%) No (%)

YES _{0 1 (100)}

NO

29 (49.2) 30 (50.8)

Table 18: Congestive Cardiac Failure and the frequency of falls

Only one study participant suffered from Congestive Cardiac failure and he did not have a fall.

10. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

COPD Falls in the past year

p= 0.605

Yes (%) No (%)

YES _{5 (41.7) 7 (58.3)}

NO _{24 (50.0) 24 (50.0)}

TOTAL _{29 (48.3) 31(51.7)}

11. CHARLSON COMORBIDITY INDEX

Charlson Comorbidity

Index

Fall in the past year

p= 0.261

Yes (%) No (%)

2 _{10 (50.0) 10 (50.0)}

3 _{7 (46.7) 8 (53.3)}

4 _{4 (30.8) 9 (69.2)}

5 _{8 (72.7) 3 (27.3)}

6 _{1(100.0) 0(0)}

Table 20: Charlson comorbidity Index of the study participants and frequency of falls

Most of the study participants had a score of two (which indicates a low comorbidity burden), of whom 50% had reported a fall. This may be because these subjects were more mobile than those with a higher index.

12. ORTHOSTATIC HYPOTENSION:

Orthostatic Hypotension

Falls in the past year (%) No history of falls in the past year (%)

p= 0.962

YES _{1 (50.0) 1 (50.0)}

NO 28 (48.3) 30 (51.7)

Table 21: Orthostatic Hypotension and the frequency of falls

13. MINI COG

MiniCog Fall in the past year

p= 0.7

Yes (%) No (%)

<3 _{6 (54.5) 5 (45.5)}

≥3 _{24 (49.0) 25 (51.0)}

TOTAL _{30 (50.0) 30 (50.0)}

Table 22: Mini-COG and the frequency of falls

Among the study subjects, eleven had a Mini Cog of <3, and six of them had fallen.

14. TIMED UP AND GO TEST

TUGT (sec) Fall in the past year

p= 0.782

Yes (%) No (%)

<13.5 _{16 (50.0) 16 (50.0)}

≥13.5 _{13 (46.4) 15 (53.6)}

TOTAL

29 (48.3) 31 (51.7)

Table 23: TUGT and the frequency of falls

15. GAIT SPEED

Figure 24: Falls percentages among the study participants according to gait speed

Seven of the study subjects (53.8%) who sustained a fall in the past one year had a gait speed of ≥0.8m/sec.

16. BERG BALANCE TEST

Berg balance test Fall in the past year

p= 0.151

Yes (%) No (%)

High risk _{2 (100.0) 0 (0.0)}

Medium risk _{1 (20.0) 4 (80.0)}

Low fall risk _{26 (50.0) 26 (50.0)}

Table 24: Berg Balance test and the frequency of falls

Among those who reported falls, two of them were at high falls risk, one belonged to the medium falls risk category and 26 of them belonged to the low fall risk category, as classified by the Berg Balance Test (p=0.1510).

<0.8m/sec 47% ≥0.8m/sec

53%

Fall

17. MINI NUTRITIONAL ASSESSMENT (MNA) Mini Nutritional

Assessment

Fall in the past year

p= 0.152

Yes (%) No (%)

Malnutrition _{0 (0.0) 1 (100.0%)}

At risk _{1 (16.7) 5 (83.3)}

Normal _{28 (52.8) 25 (47.2)}

Table 25: Mini Nutritional Assessment and the frequency of falls

Of those who had a fall, 52.8% (n=28) belonged to the ‘Normal Nutritional status’ as per the MNA.

18. HEARING AIDS

Hearing Aids Fall in the past year

p= 0.492

Yes (%) No (%)

YES _{0 (0.0) 2 (100.0)}

NO

29 (50.0) 29 (50.0)

TOTAL

29 (48.3) 31(51.7)

Table 26: Hearing aids and the frequency of falls

Among those who used hearing aids (2, 3.33%), none of them reported a history of falls in the past one year.

19. VISUAL ACUITY

Visual Acuity Fall in the past year

p= 0.483

Yes (%) No (%)

NORMAL _{28 (47.5) 31 (52.5)}

ABNORMAL _{1(100.0) 0 (0.0)}

Visual acuity checked showed that 47.5% of the study participants (n=28) had normal visual acuity and yet had sustained a fall. Only one of the participants (1.67%) with poor vision had sustained a fall in the past year.

20. MONOFILAMENT TEST

Monofilament test Fall in the past year

P= 0.702

Yes (%) No (%)

NORMAL 25 (47.2) 28 (52.8)

ABNORMAL _{4 (57.1) 3 (42.9)}

TOTAL _{29 (48.3) 31(51.7)}

Table 28: Monofilament test and the frequency of falls

Among those who had an abnormal Monofilament test, four (57.1%) reported falls in the past one year.

21. VITAMIN D

Vitamin D Fall in the past year

P= 0.223

YES (%) NO (%)

<30 _{18 (43.9) 23 (56.1)}

≥30

11 (61.1) 7 (38.9)

TOTAL _{29 (49.2) 30 (50.8)}

Table 29: Vitamin D and the frequency of falls

INTERVENTIONS SUGGESTED:

Interventions given to subjects included -

Medication review and the doses and formulations of all the drugs were checked and reviewed. The medications which potentially contributed to the risk of falls were deprescribed. The drug optimisation also included addition of Vitamin D supplements in those with a deficiency.

Intervention Frequency (%)

Home safety measures 60 (100%)

Dietary input 58 (96.7%)

Gait and balance training exercises 58 (96.7%)

Drug optimisation 52 (86.7%)

Appropriate footwear prescription 45 (75%) Vitamin D supplementation 45 (75%)

Ophthalmology referral 44 (73.3%)

ENT referral 9 (15%)

Secondary Outcomes:

At follow ups, telephonic calls were made to enquire of the following: 1. Subjective improvement in gait and balance

2. Any episodes of falls 3. Compliance with exercises

4. Any changes to the medications after the last visit FIRST FOLLOW UP AT ONE MONTH:

Figure 25: First follow up