Journal of Gerontological Nursing

DOES GENDER MAKE A DIFFERENCE THE RISK OF FALLS? A Japanese Study

Mizue Suzuki, RN, PHD; Yoskiko Shimamoto, RN, PHD; Irene Kawamura, RN, MS, MPH; Hideto Takahasi, MS

Abstract

The number of elderly people in the world is increasing at a remarkable rate and the rate of aging in Japan is die world's highest. According to a statistical survey done in 1994, people over 65 years of age constitute 14.1% of the Japanese population. In addition, the Japanese average life expectancy in 1991 was the highest in the world, reaching 76.1 years for men and 82.1 years for women. A prominent health problem among elderly people is immobility which can result in elderly patients becoming bedridden (Eto, 1992). Recently, the problem of falls among the frail elderly has received increased interest. Although fall mortality in the Japanese elderly was not as high as those of France or the United States (Rockett & Smith, 1989), falls lead to deterioration in the health and physical status of the elderly.

If falls could be reduced among the elderly, many of the health problems attributed to immobility among the Japanese elderly would be reduced. Some falls have a single and obvious cause, but most appear to result from several factors. With better knowledge of the causes and risk factors for falls among the elderly, effective preventive measures can be instituted (Tinetti, Speechley, & Ginter, 1988 ; Ryynanen, 1994; Teno, Kiel, & Mor 1990).

There are few studies concerning falls among the institutionalized elderly (Haga, Shibata, Shichida, Matsuzaki, & Hatano, 1986) and communitydwelling elderly in Japan (Yasumura et al., 1994; Niino et al., 1995; Suzuki et al., 1991, 1992; Suzuki, Yamada, Takahashi, & Tsuchiya, 1991; Suzuki, Yamada, & Tsuchiya, 1993). The purpose of this study was to investigate falls among the elderly, selected at random, who live in Koga, a city in eastern Japan.

LITERATURE REVIEW

The frail elderly are especially prone to falls and in western countries approximately 30% to 50% of the elderly fall at least once a year (Droller, 1955; Gryfe, Amies, & Ashley, 1977; Tmetti, Inouye, Gill, & Doucette, 1995). Early studies of falls among the elderly in western countries were carried out by gerontologists or public health researchers. Sheldon (1948), Tmetti (1986), Tinetti, Speechley, and Ginter (1988), Isaacs (1985) and Ring, Nayak, and Isaacs (1988) carried out communitybased studies and medical examinations of the elderly in laboratories. They reported risk factors for falls, such as use of sedatives, cognitive impairment, disability and increased body sway. Janken (1986), Gross, Simamoto, Rose, and Frank (1990) and Roberts (1989, 1993) pointed out cerebrovascular disease, incontinence, lower-extremity disability and mental status such as confusion, depression or cognitive impairment as other risk factors for falls. Nurses also realize that falls are one of the main causes of accidents in hospitals, and that they should be studied to enable timely and useful nursing intervention. Nursing studies concerning falls among the elderly can be classified into three types: 1) identification of risk factors among elderly patients; 2) evaluation of risk management programs; and 3) development of new nursing aids.

Falling is the most serious accident in geriatric units or hospitals because it is related to high morbidity and mortality. Risk management programs, like nursing care plans, are one of the strategies that nurses use to identify the elderly who exhibit many risk factors for falls. These strategies are currently in use (Innes & Turman, 1983; Kilpack, Boehm, Smith, & Mudge, 1991). Other research studies include ones aimed at the development of new devices (Widder, 1985) or assessment tools, such as balance scales, to identify those prone to falling (Roberts, 1989, 1993; Roberts & Mueller, 1987).

Although studies in hospitals are carried out to identify the risk factors for falls among elderly patients, the studies in communities…

The number of elderly people in the world is increasing at a remarkable rate and the rate of aging in Japan is die world's highest. According to a statistical survey done in 1994, people over 65 years of age constitute 14.1% of the Japanese population. In addition, the Japanese average life expectancy in 1991 was the highest in the world, reaching 76.1 years for men and 82.1 years for women. A prominent health problem among elderly people is immobility which can result in elderly patients becoming bedridden (Eto, 1992). Recently, the problem of falls among the frail elderly has received increased interest. Although fall mortality in the Japanese elderly was not as high as those of France or the United States (Rockett & Smith, 1989), falls lead to deterioration in the health and physical status of the elderly.

If falls could be reduced among the elderly, many of the health problems attributed to immobility among the Japanese elderly would be reduced. Some falls have a single and obvious cause, but most appear to result from several factors. With better knowledge of the causes and risk factors for falls among the elderly, effective preventive measures can be instituted (Tinetti, Speechley, & Ginter, 1988 ; Ryynanen, 1994; Teno, Kiel, & Mor 1990).

There are few studies concerning falls among the institutionalized elderly (Haga, Shibata, Shichida, Matsuzaki, & Hatano, 1986) and communitydwelling elderly in Japan (Yasumura et al., 1994; Niino et al., 1995; Suzuki et al., 1991, 1992; Suzuki, Yamada, Takahashi, & Tsuchiya, 1991; Suzuki, Yamada, & Tsuchiya, 1993). The purpose of this study was to investigate falls among the elderly, selected at random, who live in Koga, a city in eastern Japan.

LITERATURE REVIEW

The frail elderly are especially prone to falls and in western countries approximately 30% to 50% of the elderly fall at least once a year (Droller, 1955; Gryfe, Amies, & Ashley, 1977; Tmetti, Inouye, Gill, & Doucette, 1995). Early studies of falls among the elderly in western countries were carried out by gerontologists or public health researchers. Sheldon (1948), Tmetti (1986), Tinetti, Speechley, and Ginter (1988), Isaacs (1985) and Ring, Nayak, and Isaacs (1988) carried out communitybased studies and medical examinations of the elderly in laboratories. They reported risk factors for falls, such as use of sedatives, cognitive impairment, disability and increased body sway. Janken (1986), Gross, Simamoto, Rose, and Frank (1990) and Roberts (1989, 1993) pointed out cerebrovascular disease, incontinence, lower-extremity disability and mental status such as confusion, depression or cognitive impairment as other risk factors for falls. Nurses also realize that falls are one of the main causes of accidents in hospitals, and that they should be studied to enable timely and useful nursing intervention. Nursing studies concerning falls among the elderly can be classified into three types: 1) identification of risk factors among elderly patients; 2) evaluation of risk management programs; and 3) development of new nursing aids.

Falling is the most serious accident in geriatric units or hospitals because it is related to high morbidity and mortality. Risk management programs, like nursing care plans, are one of the strategies that nurses use to identify the elderly who exhibit many risk factors for falls. These strategies are currently in use (Innes & Turman, 1983; Kilpack, Boehm, Smith, & Mudge, 1991). Other research studies include ones aimed at the development of new devices (Widder, 1985) or assessment tools, such as balance scales, to identify those prone to falling (Roberts, 1989, 1993; Roberts & Mueller, 1987).

Although studies in hospitals are carried out to identify the risk factors for falls among elderly patients, the studies in communities also need to clarify the risk factors. The falls among the elderly living in the community are related to serious health problems. Implementation of nursing care plans is important to prevent physical impairment and to reduce morbidity and mortality in both hospitals and communities, due to falls.

Tinetti, Speechley, and Ginter (1988) and OToughlin, Robitaille, Boivin, and Suissa (1993) studied risk factors for falls, but did not analyze gender differences. Campbell and colleagues (1990) and Yasumura and colleagues (1994) reported that among elderly living in the community, women are more likely than men to fall. We postulated that there are some differences in the physical status and the mechanisms of falling between men and women, and therefore examined differences by gender among Japanese elderly living in Koga with the ultimate goal of aiding nursing intervention.

PURPOSE OF THE STUDY

The purpose of this study was to identify by gender the risk factors for falls in a random sample of elderly persons living in a community in Japan, in order to improve nursing care plans to help prevent falls implemented by public health and clinical nurses.

METHODOLOGY

Setting

Koga is a city located in the middle of the Kanto region in eastern Japan with a population of about 58,000 (the percentage of people aged 65 or over is 10.5%). The study sample is known as "The Aging Research Project on Daily Living and Health Status in Koga (ADK)."

Method

A random sample of 1,000 out of about 6,000 of subjects aged 65 or over were selected through the public welfare office in Koga in November 1991. A self-administered questionnaire was used to gather: 1) demographic data and information concerning health status, 2) information on disease, physical symptoms, cognitive impairment and functioning affecting activities of daily living (ADL), 3) the number of falls during the past year, and 4) the 13-item index of competence (TMIG index) which was developed for measuring activities of the elderly living in communities in Japan, including three domains. Instrumental SelfMaintenance, Intellectual Activity and Social Role. The validity of the TMIG index was established previously, and the reliability coefficient was reported to be at 0.913 (Koyano, Shibata, Haga, Suyama, & Nakazato, 1989). The questionnaire was mailed to the 1,000 subjects, to be completed and returned as soon as possible. In the event that the elderly persons could not answer the questions by themselves, their families were asked to answer for them.

Definition

We defined a "fall" as an unintentional fall, where the body touches a floor or the ground.

Data Analysis

Categorical variables were analyzed using the chi-square test. The relative risk of falling was compared to not falling as calculated for each variable. Next potential risk factors from the results of univariate analyses were selected, and multiple logistic regression analysis in order to identify the risk factors for falls was conducted; analyses were performed using the Statistical Analysis System (SAS) version 6.08.

RESULTS

Of the 1,000 subjects randomly selected, 746 completed the questionnaire, 324 men and 422 women. These subjects ranged in age from 65-99 years, with the average age (standard deviation) being 72.9 (6.5) years for the men and 73.4 (6.4) years for the women. Five hundred eightyone subjects (77.9%) completed the questionnaire by themselves, for 51 subjects (6.8%) their spouses completed the questionnaire, for 3 subjects (0.4%) their brothers or sisters completed the questionnaire, for 107 subjects (14.4%) their children or grandchildren completed the questionnaire, for 4 subjects, others (0.5%) completed the questionnaire.

Table

TABLE 1Incidence of Faffs by Age and Gender

TABLE 1

Incidence of Faffs by Age and Gender

A total of 177 subjects had experienced falls in the previous year: 63 men and 114 women. A total number of 231 time falls (men, 100 falb; women, 131 falls) were reported and 141 subjects (men, 51; women, 90) had fallen at least once in the previous year and 36 subjects (men, 12; women, 24) had fallen more than twice. A greater proportion of women than men reported having fallen, 27.0% versus 19.4% (p<0.05). With few exceptions, the number of subjects who had fallen increased progressively with age among both the men and the women (Table 1).

Among the men, the factors most strongly associated with falls were being bedridden, limb impairment, cognitive impairment, urinary incontinence, and dependency according to the TMIG Index, particularly Instrumental SelfMaintenance (p<0.05) (Table 2).

Most risk factors were more weakly associated with falls among the women than among the men (Table 3). Odds ratios for each risk factor ranged from 1.66 to 4.61 among the women, and the highest odds ratios among the women were for urinary incontinence. The following factors were related to falls among the men: heart disease, cerebrovascular disease, rheumatoid arthritis, back pain, being bedridden, vision impairment, limb impairment, urinary incontinence and Instrumental Self-Maintenance (p<0.05).

To examine independent contributions of risk factors for falls, a multivariate logistic regression analysis was conducted. Table 4 shows the results of the multiple logistic regression analysis for the men. Variables with the highest odds ratios in Table 2 were selected for the logistic regression model. In the case of the logistic regression model for the men, limb impairment, urinary incontinence, back pain, cognitive impairment and Instrumental Self-Maintenance in the TMIG Index were included as independent variables in the model. Since old age has been reported as a risk factor for falls, age (years) was also included as one of the independent variables. Limb impairment, cognitive impairment and Instrumental SelfMaintenance were identified for men as shown in Table 4 (p<0.05).

Table

TABLE 2Characteristics of Elderly Men Who Did/Did Not fall

TABLE 2

Characteristics of Elderly Men Who Did/Did Not fall

Age (years), cerebrovascular disease, limb impairment, urinary incontinence, back pain, being bedridden. Instrumental SelfMaintenance and cognitive impairment were selected for multiple logistic regression analysis for the women (Table 5). Urinary incontinence and back pain were the only independent risk factors for falls among the women in the final analysis (p<0.05).

DISCUSSION

The number of people aged 65 and over in Japan is still increasing. Research on falls among the elderly has not been as extensive in Japan as in western countries. Therefore, we investigated risk factors among Japanese elderly, in particular based on gender differences. The sample frame used here is representative of subjects aged 65 and over in Koga. Regarding the incidence of falls, women in Koga showed a significantly higher rate than men, 27.0% versus 19.4%. These findings are similar to ones obtained in other studies. Campbell, Borrie, and Spears (1989, 1990) also reported that falls are more common among the women and that risk factors for falls differ between women and men. It may be important to identity gender differences in risk factors for falls for improving community falls prevention programs. Therefore, we explored potential differences in risk factors for falls between men and women in this study.

Table

TABLE 3Characteristics of Elderly Women Who Did/Did Not Fall

TABLE 3

Characteristics of Elderly Women Who Did/Did Not Fall

In age-adjusted models, limb impairment and cognitive impairment are independent risk factors for falls among men, whereas men who achieved a high score Instrumental Self-Maintenance score had a lower risk of falls than other men. Campbell, Borrie, and Spears (1989) and Tinetti, Speechley, and Ginter (1988) pointed out that lack of physical activity and loss of stability were associated with an increasing risk of falls among both genders. Body sway was not measured in the current study, but the elderly with limb impairment tend to lose their stability. Elderly men have greater muscle strength than elderly women (Reed, Pealmutter, Yochun, Meredith, & Modradian, 1992) and are better at maintaining postural stability (Overstall, ExtonSmith, & Imms, 1977). Therefore, we speculate that limb impairment may have a greater effect on postural imbalance in men than in women, which might explain why it was identified as a risk factor for falls in the men in this community study.

Cognitive impairment was significant only for men in the final model, but previous studies have found a correlation between falls and serious cognitive impairments such as Alzheimer's disease regardless of gender (Buchner & Larson, 1987; Morris, Rubin, Morris, & Mandel, 1987). A low Instrumental SelfMaintenance was also identified as a risk factor for falling in the men in the multiple logistic-regression analysis. The TMIG index was developed to measure the higher-level competence of the elderly, which cannot be adequately assessed by existing scales of ADL (Koyano, Shibata, Haga, Suyama, & Nakazato, 1989). Instrumental Self-Maintenance score is a measure of the ability of elderly subjects to ride a bus or train and to carry out other similar daily activities. Daily activities were reported to be associated with falling (O'Loughlin, Robitaille, Boivin, & Suissa, 1993; Tmetti, Speechley, & Ginter, 1988). Our results indicate that it is important for the elderly to maintain a high level activity such as physical exercise to maintain physical strength and fitness, and prevent falls.

Table

TABLE 4Risk Factors for Falls* Ansang Elderly Men

TABLE 4

Risk Factors for Falls* Ansang Elderly Men

Table

TABLE 5Risk Factors for Falls* Among Elderly Women

TABLE 5

Risk Factors for Falls* Among Elderly Women

Back pain is a symptom of osteoporosis, and was a risk factor for falls among the women in this study. Osteoporotic vertebral fractures, a cause of back pain, are common among elderly Japanese women (Ross et al., 1995) and may lead to impaired mobility, increasing the risk of falls.

Urinary incontinence was more common among elderly women than elderly men in most studies (Diokno, Block, & Brown, 1986; Koyano, Shibata, Haga, & Suyama, 1986), and was an important risk factor for falls among women in the current study (Tinetti, Inouye, Gill, & Doucette, 1995). Urinary incontinence and falls are common gerontological problems. These problems often co-exist, and it is not easy for the elderly to recover from them. According to the Japanese Urban Community study (Yasumura et al., 1994), urinary incontinence was also associated with falls among women. Thus, it appears that there are several differences in risk factors for falls between men and women.

Limitations of Study

It is possible that some falls may not have been reported, since a selfadministered questionnaire was used to gather information regarding the number of falls during a period of one year. Cummings, Nevitt, & Kidd (1988) reported that the elderly recalled 87% of the falls in the previous year, and tended to forget minor fall-related injuries. The incidence of falls in this study is considered almost the same as in other Japanese community studies interviews (Niino et al, 1995; Yasumura, Haga, Nagai, & Shibata, 1991, 1994), giving this study high validity.

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TABLE 1

Incidence of Faffs by Age and Gender

TABLE 2

Characteristics of Elderly Men Who Did/Did Not fall

TABLE 3

Characteristics of Elderly Women Who Did/Did Not Fall

TABLE 4

Risk Factors for Falls* Ansang Elderly Men

TABLE 5

Risk Factors for Falls* Among Elderly Women

10.3928/0098-9134-19970101-12

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