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Falls in older community-dwelling women and men: risk factors and safety strategies. Fall risk awareness, fear of falling, and preferred exercise properties from a gender perspective.
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Falls are the leading cause for non-fatal injuries in older community-dwelling people. Compared to men, women fall more often, experience more fall-related injuries, and report fear of falling (FoF) more often. Falls may be prevented with specific exercises, but adherence is often low in long-term. One aim of the thesis was to gain a deeper understanding of the risk factors previous falls, FoF, and gender. Another aim was to explore safety strategies in older community-dwelling people in terms of fall risk awareness and actions taken to protect from falls, and to identify motives for exercising and preferred exercise properties. A gender perspective was used throughout the thesis.

Methods To determine the impact of the risk factors on future falls and injurious falls, a cross-sectional design was used combined with longitudinal data. Baseline data from 230 community-dwelling people over 75 years were collected with questionnaires and performance-based tests. FoF was measured with the single item question “Are you afraid of falling?”. Monthly fall calendars were collected for one year (monitoring year). Based on status on falls, participants were classified as those with i) no falls (n=119), ii) 1 non-injurious fall (n=51), iii) ≥2 non-injurious falls (n=40), and iv) ≥1 injurious fall (n=20). These data were linked to data from an injury database (IDB) with respect to registered injurious falls for a period of about 5 years (long term follow-up). Andersen-Gill method of Cox regression for multiple events was used to estimate the risk of future injurious fall events. To find relationships between FoF, gender, and falls (defined as two or more falls), a general log-linear analysis was performed. Associations between FoF and the components of the International Classification of Functioning (ICF) were explored with a structural equation model. To explore fall risk awareness and safety strategies, and to identify motives and preferred exercise properties, qualitative study design was used. Multistage focus groups were held with 18 community-dwelling people (10 women and 8 men) between 70 and 80 years. Transcriptions were analysed with qualitative content analysis.

Results Fourty-eight per cent of the 230 participants fell at least once during the monitoring year, and 23% experienced recurrent falls. Compared to men, women reported FoF more often, but did not experience more recurrent falls, and no more injurious falls. FoF was significantly associated with the ICF components Activity/Participation and Personal Factors in women and men both; but in opposite directions for women and men on Personal Factors. During the long-term follow-up, 91 injurious falls were registered in 70 participants (30%). Those with injurious falls during the monitoring year were at significant risk of experiencing new injurious falls in long-term (HR 2.78; 95% CI 1.40-5.50), compared to those with no falls. Women experienced a higher rate of fractures than did men. Analyses from the multistage focus groups resulted in three categories: Facing various feelings; Recognizing one’s fall risk; and Taking precautions. A comprehensive theme tied them together: Safety precautions through fall risk awareness. Analyses also resulted in six categories identifying preferred exercise properties in the context of falls prevention: Motives to start exercise; Barriers to start exercise; Exercise characteristics; Confirmation; Spirit lifters; and Maintenance tricks. All categories included sub-categories. Both studies revealed greater variations among women and among men than between women and men.

Conclusion Community-dwelling people over 75 years who have experienced an injurious fall are at high risk of sustaining new injurious falls the forthcoming five years, and should be offered multifactorial fall risk assessments with targeted interventions to optimize the prevention of future falls. The single item question “Are you afraid of falling?” has no predictive value for future falls, and the answer may be strongly gendered. The questions should therefore be avoided in clinical practice and research in community settings. The participants of the qualitative studies implicity and explicitly described how they had become aware of fall risks in everyday life, and both women and men took precautionary actions. Raised fall risk awareness was achieved by several channels including the media, and by meeting with peers and professionals with expertise in falls prevention. A wide variety of preferred exercise properties in the context of falls prevention were identified among the older community-dwelling people. The variations of the requests were greater among women and among men than between women and men. The results should be taken into consideration when offering exercise-based falls prevention interventions to older people. The results from this thesis indicated that measures can be taken on a broad front in order to reduce the damage from injurious falls in older community-dwelling people. A gender perspective is warranted for in clinical practice and future research. Adopting a gender perspective may broaden the understanding of gender differences and similarities when implementing falls prevention activities.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2015. , 88 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1692
Keyword [en]
Older people, Community-dwelling, Falls, Fall-related injuries, Fear of falling, ICF, Gender, Exercise preferences, Fall risk awareness, Falls prevention, Safety precautions, Qualitative research
National Category
Physiotherapy
Identifiers
URN: urn:nbn:se:umu:diva-98369ISBN: 978-91-7601-184-3 (print)OAI: oai:DiVA.org:umu-98369DiVA: diva2:782389
Public defence
2015-02-13, Vårdvetarhuset, Aulan, Norrlands universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2015-01-23 Created: 2015-01-21 Last updated: 2015-03-27Bibliographically approved
List of papers
1. Gender perspective on fear of falling using the classification of functioning as the model
Open this publication in new window or tab >>Gender perspective on fear of falling using the classification of functioning as the model
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2015 (English)In: Disability and Rehabilitation, ISSN 0963-8288, E-ISSN 1464-5165, Vol. 37, no 3, 214-222 p.Article in journal (Refereed) Published
Abstract [en]

Abstract Purpose: To investigate associations between fear of falling (FOF) and recurrent falls among women and men, and gender differences in FOF with respect to International Classification of Functioning (ICF). Methods: Community-dwelling people (n = 230, 75-93 years, 72% women) were included and followed 1 year regarding falls. Data collection included self-reported demographics, questionnaires, and physical performance-based tests. FOF was assessed with the question "Are you afraid of falling?". Results were discussed with a gender relational approach. Results: At baseline 55% women (n = 92) and 22% men (n = 14) reported FOF. During the follow-up 21% women (n = 35) and 30% men (n = 19) experienced recurrent falls. There was an association between gender and FOF (p = 0.001), but not between FOF and recurrent falls (p = 0.79), or between gender and recurrent falls (p = 0.32). FOF was related to Personal factors and Activity and Participation. The relationship between FOF and Personal factors was in opposite directions for women and men. Conclusions: Results did not support the prevailing paradigm that FOF increases rate of recurrent falls in community-dwelling people, and indicated that the answer to "Are you afraid of falling?" might be highly influenced by gendered patterns.

Implications for Rehabilitation

The question "Are you afraid of falling?" has no predictive value when screening for the risk of falling in independent community-dwelling women or men over 75 years of age.

Gendered patterns might influence the answer to the question "Are you afraid of falling?" Healthcare personnel are recommended to be aware of this when asking older women and men about fear of falling.

Place, publisher, year, edition, pages
Informa Healthcare, 2015
Keyword
Falls, fear, gender, ICF, older people
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-96717 (URN)10.3109/09638288.2014.914584 (DOI)000348789500004 ()24786969 (PubMedID)
Available from: 2014-11-27 Created: 2014-11-27 Last updated: 2017-12-05Bibliographically approved
2. Community-dwelling older people with an injurious fall are likely to sustain new injurious falls within 5 years: a prospective long-term follow-up study
Open this publication in new window or tab >>Community-dwelling older people with an injurious fall are likely to sustain new injurious falls within 5 years: a prospective long-term follow-up study
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2014 (English)In: BMC Geriatrics, ISSN 1471-2318, E-ISSN 1471-2318, Vol. 14, no 1, 120- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Fall-related injuries in older people are a leading cause of morbidity and mortality. Self-reported fall events in the last year is often used to estimate fall risk in older people. However, it remains to be investigated if the fall frequency and the consequences of the falls have an impact on the risk for subsequent injurious falls in the long term. The objective of this study was to investigate if a history of one single non-injurious fall, at least two non-injurious falls, or at least one injurious fall within 12 months increases the risk of sustaining future injurious falls.

METHODS: Community-dwelling individuals 75-93 years of age (n = 230) were initially followed prospectively with monthly calendars reporting falls over a period of 12 months. The participants were classified into four groups based on the number and type of falls (0, 1, ≥2 non-injurious falls, and ≥1 injurious fall severe enough to cause a visit to a hospital emergency department). The participants were then followed for several years (mean time 5.0 years ±1.1) regarding injurious falls requiring a visit to the emergency department. The Andersen-Gill method of Cox regression for multiple events was used to estimate the risk of injurious falls.

RESULTS: During the long-term follow-up period, thirty per cent of the participants suffered from at least one injurious fall. Those with a self-reported history of at least one injurious fall during the initial 12 months follow-up period showed a significantly higher risk for sustaining subsequent injurious falls in the long term (hazard ratio 2.78; 95% CI, 1.40-5.50) compared to those with no falls. No other group showed an increased risk.

CONCLUSIONS: In community-dwelling people over 75 years of age, a history of at least one self-reported injurious fall severe enough to cause a visit to the emergency department within a period of 12 months implies an increased risk of sustaining future injurious falls. Our results support the recommendations to offer a multifactorial fall-risk assessment coupled with adequate interventions to community-dwelling people over 75 years who present to the ED due to an injurious fall.

Place, publisher, year, edition, pages
BioMed Central, 2014
Keyword
accidental falls,  older adults,  risk factors,  community-dwelling,  fall prediction
National Category
Physiotherapy Geriatrics
Identifiers
urn:nbn:se:umu:diva-96716 (URN)10.1186/1471-2318-14-120 (DOI)000346030500005 ()25407714 (PubMedID)
External cooperation:
Available from: 2014-11-27 Created: 2014-11-27 Last updated: 2017-12-05Bibliographically approved
3. Fall risk awareness and safety precautions taken by older community-dwelling women and men: a qualitative study using focus group discussions
Open this publication in new window or tab >>Fall risk awareness and safety precautions taken by older community-dwelling women and men: a qualitative study using focus group discussions
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2015 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 3, e0119630Article in journal (Refereed) Published
Abstract [en]

Introduction Daily life requires frequent estimations of the risk of falling and the ability to avoid a fall. The objective of this study was to explore older women's and men's understanding of fall risk and their experiences with safety precautions taken to prevent falls.

Methods A qualitative study with focus group discussions was conducted. Eighteen community-dwelling people [10 women and 8 men] with and without a history of falls were purposively recruited. Participants were divided into two groups, and each group met four times. A participatory and appreciative action and reflection approach was used to guide the discussions. All discussions were audio recorded and transcribed verbatim. Data were analysed by qualitative content analysis, and categories were determined inductively.

Findings Three categories describing the process of becoming aware of fall risks in everyday life were identified: 1] Facing various feelings, 2] Recognizing one's fall risk, and 3] Taking precautions. Each category comprised several subcategories. The comprehensive theme derived from the categories was "Safety precautions through fall risk awareness". Three strategies of ignoring [continuing a risky activity], gaining insight [realizing the danger in a certain situation], and anticipating [thinking ahead and acting in advance] were related to all choices of actions and could fluctuate in the same person in different contexts.

Conclusions The fall risk awareness process might be initiated for various reasons and can involve different feelings and precautions as well as different strategies. This finding highlights that there are many possible channels to reach older people with information about fall risk and fall prevention, including the media and their peers. The findings offer a deeper understanding of older peoples' conceptualizations about fall risk awareness and make an important contribution to the development and implementation of fall prevention programmes.

Keyword
Older people, Fall risk awareness, Safety precautions, Community-dwelling, Qualitative research
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-98404 (URN)10.1371/journal.pone.0119630 (DOI)000351284600078 ()25781181 (PubMedID)
Available from: 2015-01-22 Created: 2015-01-22 Last updated: 2017-12-05Bibliographically approved
4. Gender Perspective on Older People’s Preferences for Exercises in the Context of Falls Prevention: A qualitative study
Open this publication in new window or tab >>Gender Perspective on Older People’s Preferences for Exercises in the Context of Falls Prevention: A qualitative study
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

The aim with this study was to explore the preferences of community-dwelling older women and men regarding exercise characteristics in the context of preventing falls. Multistage focus group discussions were conducted with 18 older community-dwelling people with or without a history of falls. Participants were purposively sampled, and divided into two groups. Each group met six times. Participatory and Appreciative Action and Reflection methodology was used to guide the discussions. A qualitative content analysis approach was used in the analysis. Six categories emerged from the analysis. Two categories were related to motives and barriers for uptake, and four categories were related to adherence and maintenance: exercise characteristics; confirmation; spirit lifters and maintenance tricks. Small differences and many similarities in what women and men perceived as motivating factors in an exercise situation were displayed. To conclude, older people have many diverse preferences regarding exercise in the context of preventing falls, and the individual differences within genders seem to be greater than the differences between men and women. Exercise interventions to prevent falls should be individually tailored based on the specific needs and preferences of the older participant. In order to encourage internalization and intrinsic motivation for exercises, autonomy-supportive approaches may be applied and accompanied by competence strengthening confirmations, energizing spirit lifters and practical tips for exercise maintenance

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-98406 (URN)
Available from: 2016-02-13 Created: 2015-01-22 Last updated: 2015-01-22

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