A. J.

BLAKE
Santor Rtfrow Age and Ageing 1988;17:365-372
K. MORGAN
LactuTar
M . J . BO4DALL
Santor Lacturar/Consultam
Ptiyaician
H. DALLOSSO
Raaoarch Fallow

FALLS BY ELDERLY PEOPLE AT

HOME: PREVALENCE AND
ASSOCIATED FACTORS
E.J. BASSEY
Lacturar Department erf Phyitotogy
and Pharmacology

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Activity and Agalng R i m r c h
Group, Madkal School, Quaan'a
Madical Cent™, Nottingham
NQ7 2UH

Summary
Of 1042 individuals aged 65 years and over who were successfully interviewed in a community survey of
health and physical activity, 35% (nc*356) reported one or more falls in the preceding year. Although
the overall ratio of female fallen to male fallers was 2.7:1, this ratio approached unity with advancing,
age. Mobility was significantly impaired in those reporting falls. Asked to provide a reason for their
falls, 53% reported tripping, 8% dizziness and 6% reported blackouts. A further 19% were unable to
give a reason. There was no association between falls and the use of diuretics, antihypertensives or
tranquillizers, but a significant association between falls and the use of hypnotics and antidepressants
was found.
Discriminant analysis of selected medical and anthropometric variables indicated that handgrip
strength in the dominant hand and reported symptoms of arthritis, giddiness and foot difficulties were
most influential in predicting reports of recent falls.

INTRODUCTION
Research evidence suggests that, in any given year, approximately one third of
people over the age of 65 years living at home experience one or more falls, but that
the number requiring medical attention as a direct result of a fall is only about
14—19/1000 among those over the age of 60 years [1,2]. Because of their multifac-
torial aetiology, there is, as yet, no widely accepted classification of falls. However,
broadly speaking, reported falls can be divided into: (a) accidental falls, in which
environmental factors are responsible and which are unlikely to recur; and (b)
pathological falls which are usually recurrent and are more likely to be associated
with one or more factors which affect the control of balance and posture (e.g.
underlying illness, physical disability, drugs, etc.) [3].
Currently available literature on falls in the elderly provides few reports of detailed
community-based studies in which the samples can be regarded as highly representa-
tive, and multivariate analyses of associated risk factors are rare. This report, based
on the results of a community survey of a representative sample of people over the
age of 65 years, examines the prevalence of, and factors associated with, falls in the
elderly, and uses multivariate analysis to investigate the interdependence of these
factors.
•Present appointment: Consultant Physician, Department of Geriatric Medicine Royal Free Hospi-
tal, Pond Street, London NW3 2QG.
366 AGE AND AGEING VOL. 17, NO. 6

Methods
Data were derived from the Activity and Ageing survey, full details of which are presented elsewhere [4,
5]. Briefly, the study was designed to investigate the role of customary physical activity in promoting
and maintaining psychological and physical well-being in old age. Interviews were conducted by trained
personnel between May and September 1985. The survey sample was selected so as to ensure that
certain characteristics (vix. age-sex structure, social class, ethnicity and households with a single elderly
resident) were both locally and nationally representative. The age group 75 years and over was
deliberately over-sampled so that sufficient numbers would be available for present and future statisti-
cal analyses. Mental competence was assessed using the 12-item Information/Orientation (I/O) scale
from the Clifton Assessment Procedures for the Elderly [6]. Scores of 7 and below are associated with
dementia or acute organic brain syndrome. If the respondent failed to achieve a minimum I/O score of 8
and, in the opinion of the interviewer, was unlikely to respond reliably to the remaining questionnaire

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items, the interview was discontinued.
Of 1599 individuals randomly selected from the Nottinghamshire Family Practioner Committee's
records, 1299 were available for interview and, of these, 1042 were interviewed in their own homes (an
80% response rate).
Of the 257 individuals who refused to be interviewed, 108 (42%) returned short postal questionnaires
which had requested information on their marital status, health status, occupation (or husband's
occupation) before retirement, and reasons for refusing. Results from these postal questionnaires
provided no evidence of age or sex bias in the survey sample [5].
Overall, 38 respondents were found to have I/O scores compatible with a diagnosis of dementia [5].
Information on 23 of these respondents was either considered reliable in the opinion of the interviewer,
or was elicited from a reliable informant, and has been included in the analyses which follow.
During the course of the structured interview the respondent provided information on a variety of
topics including customary activity levels, lifestyle, psychological well-being, physical health, falls, and
drug history. Physical health was assessed using a dichotomoualy-rated (present-absent) health pro-
blem check list, which included self-reported poor eyesight, blindness, hearing difficulties, arthritis or
'rheumatism', heart trouble (including previous myocardial infarction, angina, valvular disease and
palpitations), stomach trouble (including heartburn, dyspepsia, wind, constipation, etc), giddiness,
high blood pressure, headaches, foot trouble (including ingrowing toenails, corns, bunions, ulcers,
etc), urinary incontinence, and other long-term limiting disabilities (e.g. stroke). Validation of these
self-reports against clinicians' ratings appears elsewhere [4]. Anthropometric measurements of
handgrip strength, flexibility, stature, and weight were made on completion of the interview. Measure-
ments of handgrip strength were made using a strain gauge handgrip dynamometer insensitive to the
position of force application [7], and shoulder flexibility was measured by means of a Myrin Ob
goniometer. Reported drug use was verified by the interviewer who was instructed to ask for and
examine tangible evidence of prescribed medication (e.g. bottles, cartons, prescriptions, etc.). Only
drugs which were currently prescribed were recorded. A fall was classified as such if it occurred from an
upright position and only those occurring within the preceding year were recorded.
Characteristics of fallen and non-fallers were first compared using the chi-square statistic. To assess
the possible interdependence of factors associated with falls, these characteristics were then combined
in stepwise discriminant function analysis in order to identify that linear combination of variables which
best discriminated fallers from non-fallers. Where the prevalence rates were derived from the entire
sample, the oversampled 75+ age group was appropriately weighted.

RESULTS
Three hundred and fifty-six respondents (34.8%) reported one or more falls in the
year preceding interview (a weighted prevalence of 34.2%). Falls were significantly
associated with age and sex, women being more likely to report falls than men
(^=31.46, df=l,/ > <0.001), and older respondents being more likely to report falls
than younger respondents (^=12.05, df=4, P<0.05) (Table I). However, analyses
 BLAKE ET AL.: FALLS BY ELDERLY PEOPLE AT HOME 367

Table I. Number (percentage) of people reporting one or more falls over the year preceding interview
(total number of sample = 1042)
Age (years)
65-69 70-74 75-79 80-84 85+ Total
No. of men (%) 22 (21.8) 23 (19.3) 30 (28.0) 15 (26.8) 7 (41.2) 97 (24.3)
No. of women (%) 53 (45.7) 64 (38.3) 60 (36.8) 52 (42.6) 30 (54.5) 259(41.6)
Total 75 (34.6) 87 (30.4) 90 (33.3) 67 (37.6) 37 (51.4) 356 (34.8)

of the sexes separately in 5-year age groups failed to show a statistically significant

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increase in the prevalence of falls with age.
Of the respondents who reported falls, 10.7% were housebound compared with
5.2% of the non-fallere (;P<0.002). However, 61.9% reported falling outdoors while
38.1% reported falling indoors. This distribution changed with increasing age and in
those 85 years and over, the proportions were 29.7% and 70.3%, respectively.

Table II. Reasons given for falling by individuals who reported one or more falls
in the previous year: percentage (number) comparison between the
Nottingham study and the Newcastle study [8]
Nottingham study* Newcastle study
Reason (n=278) (n=660)
Don't know 19.3 (53) 21.8(144)
Tripped 53.3 (147) 50.2 (331)
Accident 5.2 (14) —
Dizziness 7.8 (22) 6.4 (42)
Blackout 6.4 (18) 3.9 (26)
Legs giving way — 9.5 (63)
Other 8.0 (24) 8.2 (54)
— Data not reported.
•Data appropriately weighted to compensate for oversampled 75+ age group
(see text).

Table II compares the reasons given for falling with those reported by Prudham
and Evans [8]. The proportion of subjects who were unable to give a reason for their
falls was 19.3%; 53.3% reported falls due to tripping, and 5.2% reported falls due to
an accident (defined as an incident in which another person is also involved); 7.8%
reported dizziness and 6.4% blackouts as a cause of their fall. Various other causes
were given by the remaining 8%. No significant sex difference as to the reason for
falling was found.
Fig. 1 demonstrates that the prevalence of falls increases significantly with increas-
ing overall drug use (^=24.24, df=5, / J <0.001). However, when considering
individual drugs, the only significant association with falls was in the use of hypno-
tics (^=4.39, df=l, P<0.05), and antidepressants (^=7.16, df=l, /><0.01).
Nevertheless, the significant relationship between the prevalence of falls, and overall
368 AGE AND AGEING VOL. 17, NO. 6

(n-21)

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2 3 4
Number of prescribed drugs
currently taken

Figure. Prevalence of falls with increasing drug use.

drug use (Fig- 1) persisted when both these drug categories were removed from th
analysis (^=23.29, df=4, P<0.001). No significant associations were foun<
between falls and the use of antihypertensives, diuretics or tranquillizers (Tabh
III).
In a final analysis, age, sex, anthropometric measurements of dominant handgrip
strength, weight, flexibility and stature, the presence or absence of specific health
problems and drug use (see Table IV) were combined in a stepwise discriminant
function analysis in which fallers and non-fallers formed a grouping criterion. Four
variables were found significantly to discriminate fallers from non-fallers. The most
influential of the discriminant variables was handgrip strength in the dominant
hand, followed by reported giddiness, reported arthritis, and reported foot pro-

Table III. Individuals taking prescribed medication at time of interview: percent-

age (number) comparison between fallers and non-fallers
Fallen Non-fallen X*
Antihypertensives 14.9 (53) 13.8 (92) NS
Diuretics 25.9 (92) 23.0 (153) NS
Hypnotics 20.3 (71) 14.9 (97) P<0.05
Tranquillizers 5.4 (19) 3.5 (23) NS
Antidepressanta 5.9 (21) 2.4 (16) P<0.01
•Significance of x1 value when compared with those not reporting use of particu-
lar drug.
 BLAKE ET AL.: FALLS BY ELDERLY PEOPLE AT HOME 369

Table IV. Variables included in discriminant analysis

Age Headaches
Sex Foot trouble
Poor eyesight Urinary incontinence
Registered blind Other long-term limiting disabilities, e.g. stroke
Hard of hearing Handgrip strength
Arthritis or 'rheumatism' Joint flexibility
Heart trouble Total number of drugs prescribed
Stomach trouble Use of hypnotics
Giddiness Use of antidepressants
High blood pressure

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Table V. Summary of stepwise discriminant function analysis of varia-
bles predicting fallers
Variable entered nn, , , , ,
, ,_ W&u lambda PD
at each step
Dominant handgrip strength 0.95 <0.0001
Reported giddiness 0.93 <0.0001
Reported arthritis 0.92 <0.0001
Reported foot difficulties 0.91 <0.0001
Proportion of cases correctly classified on the basis of these four
variables=62%.
Remaining variables failed to reach a minimum F to enter of 4.0.

blems. On the basis of these four variables, 62% of all respondents could be correctly
classified as fallers or non-fallers (lambda=0.91, P<0.0001; Table V). Thus, fallers
tended to be weaker, and more likely to report symptoms of arthritis, giddiness, and
foot difficulties.

DISCUSSION
To date, the only large community-based study of falls in the elderly comparable to
that described here was reported by Prudham and Evans [8]. While we endorse the
view of these researchers concerning the limitations of questionnaire data, it should
be noted that in the selection of health-related items [4], the training of personnel
[9], and the administration of the questionnaire [5], the present study was designed
to minimize possible sources of error. In addition, pilot studies conducted prior to
our main survey confirmed the reliability and validity of the items and scales
included in the questionnaire [4].
While the prevalence of falls found in the present study (34.8%) is similar to that
reported by Droller [10] and by Sheldon [11] (viz. 35% and 36%, respectively), it is
somewhat higher than the 28% reported by Prudham and Evans [8]. Although our
study confirmed previous findings that falls occur more frequently amongst elderly
women compared with elderly men, the overall ratio being 2.7:1, and that the
frequency of falls increases with age when considering the entire population, we
370 AGE AND AGEING VOL. 17, NO. 6

failed to show a significant increase in the prevalence of falls with age when analysing
the sexes separately. Nevertheless, the prevalence of falls increased considerably
amongst the very old (85 years and over) for both sexes, but particularly in men, a
pattern previously reported by Prudham and Evans [8].
The distribution of reasons for falling, as provided by the respondent at interview,
is also similar to that reported in Prudham and Evans* Newcastle study (Table II).
Further analyses showed a significant relationship between these reasons and the
age-structure of the sample. In particular, where respondents were unable to give a
reason for their falls, there was a marked age gradient, with only 8.2% of those aged
65—69 years unable to give a reason, compared with 32.4% of those 85 years and over.

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The latter may well include many people who fall because of drop attacks which were
not specifically addressed in the present questionnaire. By definition, drop attacks
occur suddenly and without warning and this may explain why elderly people are
unable to give a reason for their falls. Drop attacks are also known to increase in
frequency with increasing age, and are thought to account for between 12% and 25%
of falls [11, 12]. In contrast, tripping given as a cause of falls shows a decrease in
prevalence from 57.5% in those aged 65-69 years to 29.7% in those 85 years and
over. This may be a reflection of the greater degree of mobility in the younger age
groups compared to the older age groups. Dizziness as a cause of falls was reported
twice as frequently in those aged 85 years and over compared to those aged 65—69
years, but the converse applied when looking at blackouts as a cause. No distinction
was made between rotatory and non-rotatory dizziness or vertigo, but Prudham and
Evans [8] distinguished between the two and found the latter to have a much
stronger association with falls. They proposed a possible relationship between non-
rotatory vertigo and postural instability identified by Overstall et al. [12] in elderly
fallen and suggested that this could represent a generalized failure of proprioceptive
mechanisms.
Our study showed that, compared with individual drugs, polypharmacy signifi-
cantly increased the risk of falling. This was also reported by Davie et al. [13] who
investigated the risk of falling in a group of psychogeriatric patients. They found
that, in addition to polypharmacy perse, certain drug combinations were associated
with a significantly increased risk of falling (e.g. a tricyclic antidepressant + any
other hypotension-producing drug). We also showed a significant association
between falls and the use of hypnotic and antidepressant agents. However, studies
examining the relationship between drug use and falls in the elderly have shown
associations between virtually all the drug categories considered in our study and the
occurrence of falls [8, 13]. Nevertheless, it should be emphasized that, when
considered alongside other health-related variables, polypharmacy and the use of
psychotropic drugs failed to contribute significantly to the function discriminating
fallers from non-fallers (Table IV). Clearly, then, the relationship between drug
consumption and falls is complex, involving both the pharmacological action of the
drug and the clinical condition underlying its use. Future studies should attempt to
clarify this relationship and show variations within these drug categories in order to
identify drugs which are less likely to increase the risk of falling. The importance of
the latter was recently highlighted by Ray et al. [14] in their study on the use of
psychotropic drugs and the risk of hip fracture. Their results support the hypothesis
 BLAKE ETAL.: FALLS BY ELDERLY PEOPLE AT HOME 371

that at least in bivariate analysis psychotropic drugs increase the risk of falling and
fractures in the elderly, but the risk was not increased in those using short-acting
hypnotic-anxiolytics.
Dominant handgrip strength emerged as the most important factor which best
distinguished fallere from non-fallers. Muscle strength, particularly of the lower
extremities, decreases with age [15] and Whipple et al. [16] were the first to study the
relationship between muscle strength and falls in the elderly. They found a signifi-
cant reduction in strength in all the muscle groups of the knees and ankles in a group
of elderly fallers compared to non-fallers and hypothesized a relationship between
lower extremity weakness and postural instability in this group of people. Handgrip
strength has been shown to correlate well with general muscle strength, including the

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leg muscles [17]. The value of this parameter as a 'predictor' of falls may have
important implications for the development of exercise programmes aimed at
strengthening or retraining the affected muscle groups. Giddiness has been found to
be associated with postural instability and falls [12] and arthritis and 'foot problems'
may well contribute towards the postural instability and problems with gait in fallers,
although this relationship has not yet been studied in any detail.
The present study emphasizes and clarifies the epidemiology of falls in a large
nationally representative sample of elderly people living at home. Furthermore, we
have identified certain 'predictors' which, if shown to possess significant longitudinal
validity, could usefully be included in screening programmes to identify high-risk
potential fallers.

ACKNOWLEDGEMENT
This research was supported by a grant from the Grand Charity.

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Date accepted 24 January 1988