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Fear of falling, recurrence of falls and quality of life in elderly patients with a low energy fracture – an observational study

P. C. R. van der Vet

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

J. Q. Kusen

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

M. Rohner-Spengler

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

B. C. Link

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

R. M. Houwert

Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands

R. Babst

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

C. Henzen

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

M. Knobe

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

L. Schmid

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

F. J. P. Beeres

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

DOI: 10.15761/PMRR.1000217

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Abstract

Question 1: What is the prevalence of Fear of Falling (FoF) and subsequent falls and -fractures in elderly patients with a Low Energy Fracture (LEF)?

Question 2: How affects FoF patients’ lives in terms of Quality of Life (QoL), mobility and activity levels?

Question 3: What is the participation rate of a voluntary preventive intervention?

Design: Retrospective cohort study

Participants: Elderly (>50 years of age) patients with a LEF, defined as a fracture resulting from a fall from standing height or less, who were treated between May 2012 and December 2015 were analyzed one year after injury.

Intervention: A voluntary intervention assessing the risk of falling and providing patients with fall prevention strategies was implemented in the largest hospital of Central-Switzerland to reduce the recurrence of falls and fractures in elderly patients with a LEF.

Outcome measures: Primary outcomes were FoF (assessed through both the Falls-Efficacy Score-International (FES-I) and a binary patient-reported outcome), and number of subsequent falls and fractures. Secondary outcomes were QoL (measured by the EuroQol-5-Dimensions-3-Levels (EQ5D-3L)), mobility, hours of outside activity and participation rate in the fall prevention program.

Results: A total of 411 patients were included for analysis. Mean age was 72±9.3 and mean FoF in all patients was 21.1±7.7. In the sixty patients with a subsequent fall (15.1%), mean FoF was 23.7±9.8 and in the 15 patients with a subsequent fracture (4.2%) it was 25.3±9.22. FoF scores were moderate to high in 39.6% of all patients. The mean QoL score in all patients was 0.86±0.20. In patients without a subsequent fall it was 0.90±0.20 whereas it was 0.77±0.24 in patients with a fall (P=0.003). In patients with high FoF (FES > 27) QoL was significantly lower than in patients with low to moderate FoF scores (0.53±0.25 vs. 0.9±0.13; P<0.001). Overall, there was a significant negative correlation between FoF and QoL at a moderate level (R=0.64; P<0.001). Further, high FoF correlated with higher age (R=0.252, P<0.001) number of postoperative falls (R=0.127, P=0.006) and a lower activity level (R=-0.288, P<0.001). Twenty-one patients (6%) visited the fall-prevention consult.

Conclusion: One year after LEF, 40% of the patients suffered from FoF which seems to negatively affect patients’ QoL. Nevertheless, participation in a voluntary fall prevention program was very low. Simply informing patients about their susceptibility to falls and recommending participation in a fall prevention program therefore does not seem sufficient to motivate and recruit patients into such a program. Based on our findings we strongly suggest implementing repeated fall risk and FoF screenings as standard procedures in the follow up period of patients with LEF.

Key words

Fear of falling, low energy fractures, fall prevention

Introduction

The prevalence of falls in elderly is high and the incidence increases exponentially with age [1]. Annually, one in three patients aged 65 years or older experience one or more falls [2,3]. The consequences in frail elderly are often severe, many resulting in a fracture. The physical, social and psychological outcomes after a fracture in elderly patients are known to be poor and a fall itself is an independent risk factor for a subsequent fall [4]. The fall-related mortality rates are high and increase with age [5-7]. Therefore, it is no surprise that fear of falling (FoF) amongst elderly is a common health problem, its prevalence is estimated to be between 20 and 55% [5]. Previous literature report that FoF negatively affects recovery after a fracture [5,8]. Furthermore, high FoF has been associated with the occurrence of (secondary) fractures, poorer Quality of Life (QoL) outcomes and lower activity levels, all of which have economic consequences [6,9-11]. FoF potentially causes total avoidance of activities, loss of functional independence and reduction in social activities [11-13]. FoF exists not only in patients who already experienced falls but is also present in up to 35% of patients who have never experienced a fall [9,14]. With the aging population, the number of falls will continue to increase, and efficient fall prevention strategies are needed.

We studied a strategy that was implemented to reduce the recurrence of falls and fractures in elderly patients referred to the emergency unit for a low energy fracture (LEF). LEF is defined as a fracture resulting from a fall from standing height or less. The prevention strategy was based on the implementation of dedicated health professionals (HPs) who were trained to inform patients on fall risks and osteoporosis and who aimed to motivate patients to participate in a fall prevention program (FPP).

We hypothesized that FoF would still be present one year after LEF and that it would be higher in patients with subsequent falling or with a secondary fracture. Furthermore, we believed that there would be a relation between FoF and QoL.

The research questions were:

1. What is the prevalence of FoF and subsequent falls and – fractures in elderly LEF patients after one year?

2. How does FoF affect patients ’lives in terms of QoL, mobility and activity levels?

3. Is the minimal information procedure of dedicated HPs sufficient to motivate and recruit patients into visiting the FPP?

Method

Design: Single-center cohort study. This study is written in accordance with the STROBE-criteria [15].

Participants, center: Patients who were treated for LEF between May 2012 and December 2015 and who met all inclusion criteria according to Table 1 were eligible for inclusion. One year after LEF, all eligible patients were sent a study invitation. Along with the study information, patients received an informed consent form and a structured questionnaire, both to be completed and returned to the study coordinator. All patients who returned the completed study documents and therefore were willing to participate in the study, were included. This study was conducted in the largest hospital of central Switzerland.

Table 1. Eligibility criteria.

Inclusion Criteria

Exclusion Criteria

50-85 years of age

Severe Dementia or Alzheimer

Severe Neurological diseases (e.g. Multiple Sclerosis, cerebrovascular accident, M. Parkinson, paraplegia)

Severe alcohol abuse

Low energy fracture

Non-judicious patients living in a health care institute (elderly-, nursing home)

Inability to speak German

Patient receiving ambulatory or stationary treatment

Inability to attend the hospital

Secondary fall prevention intervention: To improve secondary prevention of falls and fractures after primary LEF, dedicated HPs were implemented. The first duty of the dedicated HPs was 1) to screen the patient list of the emergency unit for fracture patients equal or older than 50 years, 2) to screen the electronic medical records (EMR) of these preselected patients and 3) to include all patients with a report of LEF into the secondary FPP. Thereafter, the HPs were assigned to 1) inform the patients about their susceptibility to subsequent falls and fractures and 2) to motivate them to visit the dedicated physiotherapist with specific skills in fall prevention. Patients were informed about the FPP in two ways. First, inpatients were personally informed during their hospital stay by the dedicated HPs. Secondly, outpatients or patients who could not be reached during their hospital stay were contacted and informed by an informative letter and by telephone. The patients who visited the dedicated physiotherapist received a comprehensive fall risk assessment and individual recommendations for fall prevention.

Data Collection

Data collection started in 2013. Baseline data at time of injury and follow-up data after a one-year follow-period were collected. Age, gender, body mass index (BMI) and American Society of Anesthesiologists (ASA) scores were obtained through the patients' EMR. The fractures were grouped based on anatomic localization (humerus, clavicle, rib, radius/ulna, femur, tibia, fibula, patella, malleolar segment, spine, pelvic ring, acetabulum, hand, foot or craniomaxillofacial bones). For the collection of one-year follow-up data, patients received both a standardized, multiple-choice questionnaire by mail and a telephone interview, consisting of structured questions with multiple-choice answers. To improve data quality some questions in the interview and questionnaire were redundant Table 2.

Table 2. Baseline characteristics.

Age (years) mean ± SD

71.9 ± 9.3

Gender

Male n (%)

Female n (%)

83(20.2)

328(79.8)

ASA classification

ASA classification 1 n (%)

47(14.0)

ASA classification 2 n (%)

204(60.7)

ASA classification 3 n (%)

84(25.0)

ASA classification 4 n (%)

1(0.3)

Body Mass Index  

<18 kg/m2 (underweight) n (%)

11(2.9)

18-24.9 kg/m2 (normal weight) n (%)

199(51.7)

25-29.9 kg/m2 (overweight) n (%)

123(31.9)

≥30 kg/m2 (obese)

52(13.5)

Fracture distribution

Humerus n (%)

80(19.5)

Clavicle n (%)

7(1.7)

Rib fracture n (%)

7(1.7)

Radius/Ulna n (%)

139(33.8)

Femur n (%)

62(15.1)

Tibia/Fibula/Patella n (%)

22(5.4)

Tibia/Fibula, malleolar segment n (%)

46(11.2)

Spine, cervical segment n (%)

1(0.2)

Spine, thoracic segment n (%)

5(1.2)

Spine, lumbar segment n (%)

13(3.2)

Pelvic ring n (%)

12(2.9)

Acetabulum n (%)

2(0.5)

Hand n (%)

6(1.5)

Foot n (%)

8(1.9)

Craniomaxillofacial bones n (%)

1(0.2)

n: number of patients. Numbers are noted in percentages of the total number of study patients (missing values were excluded from analysis). SD: Standard Deviation. ASA classification: American Society of Anesthesiologists Physical Status Classification System. ASA classification 1: a normal healthy patient. ASA classification 2: a patient with mild systemic disease. ASA classification 3: a patient with severe systemic disease. ASA classification 4: a patient with severe systemic disease that is a constant threat to life.

Primary outcomes: FoF (assessed through both the Falls-Efficacy Score-International (FES-I) and a binary patient-reported outcome) and the number of subsequent falls and fractures. The FES-I has scores rating from 16 (lowest) to 64 (highest). In addition, the FES-I score was subcategorized into three categories, based on previous literature: ‘Low' (FES-I score of 16-19), 'medium' (FES-I score of 20-27) and 'high' (FES-I score of 28-64) [8,16].

Secondary outcomes: QoL (measured by the EuroQol-5-Dimensions-3-Levels (EQ5D-3L)), mobility, hours of outside activity and participation rate in the fall prevention program.

The EQ-5D-3L exists of a questionnaire and a visual analogue scale (VAS), with scores varying from 0 to 1.0 (0 being the lowest possible QoL score and 1 being the highest QoL score) [17]. Postoperative mobility was scored into 'ambulant' if the patient could walk independently or 'mobility accessories' if the patient used one or two walking aids (e.g. walkers, crutches, canes). Hours of activity was categorized into: 'less than 20 minutes per day', 'more than 20-30 minutes per day', 'more than 1 hour per day' and 'more than 2 hours per day' Table 3.

Table 3. Postoperative outcome measures.

Fear of Falling in

 

All patients mean ± SD

21.1 ± 7.7

Patients with ≥ 1 postoperative fall   mean ± SD

23.7 ± -9.8

Patients without postoperative fall   mean ± SD

20.7 ± 7.1

Patients aged 50-69 years mean ± SD

19.9 ± 6.9

Patients aged 70-79 years mean ± SD

20.6 ± 6.4

Patients aged 80 plus year mean ± SD

23.3 ± 9.5

Fear of Falling categorized

Low (FES-I score: 16-19) n (%)

245(60.3)

Moderate (FES-I score: 20-27) n (%)

109(26.8)

High (FES-I score: 28-64) n (%)

52(12.8)

Secondary Falls

0 falls n (%)

326(84.5)

1 fall n (%)

44(11.4)

2 falls n (%)

9(2.3)

3 falls n (%)

3(0.8)

4 falls n (%)

4(1.0)

Hours of Daily Outdoor Activity

< 30 minutes n (%)

62(16.8)

≥ 30 minutes n (%)

127(34.4)

> 1 hour n (%)

131(35.5)

> 2 hours n (%)

49(13.3)

Postoperative Mobility

Ambulant n (%)

353(99.4)

Mobility accessories n (%)

2 (0.6)

Quality of Life

EQ-5D-3L   mean ± SD

0.9 ± 0.2

Visits to the Osteofit Consult

Yes n (%)

21(6)

No n (%)

330(94)

n: number of patients. Numbers are noted in percentages of the total number of analyzed study patients. SD: Standard Deviation. FES: Falls Efficacy Score. EQ-5D-3L: EuroQol-5-Dimension-3-Level score.

Data Analysis

Results were evaluated descriptively, using total numbers and percentages for categorical variables. Mean values (M) along with the standard deviations (SD) were used for numeric data. The Shapiro-Wilks test was used to assess normal distribution. Missing values were assessed through available case analyses and we used the Spearman test to assess potential correlations. We used the X2-test to assess differences in categorical values. P-values with a significance level of 0.05 were considered statistically significant. The Mann-Whitney U-test or the Kruskal-Wallis test were used for continuous non-parametric data. Data were analysed using SPSS Statistics version 24.0.0.1 (IBM Corporation Armonk, NY). Baseline data of non-participants was compared to baseline data of participants.

Results

Flow of participants

Figure 1 shows the participant flowchart. A total of 2230 patients were treated for a fracture between 2012 and 2015, 823 of which had LEF and met the eligibility criteria of this study and therefore received a study invitation. Of those, 411 were willing to participate and returned their informed consent form and the completed study questionnaire to the study coordinator. For the telephone interviews, 390 patients were reached.

Figure 1. Patient flowchart.

Prevalence of FoF and subsequent falls and -fractures

The mean FES-I score of all patients was 21.1±7.7. Sixty patients (15.5%) experienced one or more falls after one year and fifteen patients experienced a subsequent fracture (4.2%, n=358), ten of which expressed FoF. Mean FES-I score of the patients with a subsequent fracture was 25.3±9.22 as compared to patients without a subsequent fracture who had a mean FES-I score of 21±7.5 (P=0.05). In patients who did not fall in the one-year follow-up period mean FES-I score was 20.7±7.1, whereas it was 23.7± 9.8 in patients who did have a subsequent fall (P= 0.006). Moderate to high FoF scores, as measured with the FES I, was found in 161 patients (39.6%) and FoF as measured as a binary outcome with the simple question ‘are you afraid of falling’ was answered with 'yes' in 152 of all patients (40.2%, n=378 patients). In patients who experienced a subsequent fall 67% reported to be afraid of falling.

Effect of FoF on QoL, mobility and activity levels

Mean QoL score in all patients was 0.86±0.20. In patients with high FoF (FES > 27), QoL was significantly lower than in patients with low to moderate FoF scores (0.53±0.25 versus 0.9±0.13, P<0.001). Overall, there was a significant negative correlation between FoF and QoL at a moderate level (R=0.64; P<0.001). FoF also correlated with a higher number of postoperative falls (R=0.127, P<0.006) and a lower activity level (R=-0.288, P<0.001). 36.5% of the patients with high FES I scores (FES I > 27) were active for less than 30 minutes a day outside compared to patients with FES I scores lower than 19, 9.4% reported to be active less than 30 minutes (P<0.001). At follow-up, 99.4% of patients were still ambulatory (353 out of 355 patients) and the number of patients using one or more walking aid devices was 2 (0.6%, n=355).

Participation rate at the FPP

In total 21 patients (6%) chose to visit the dedicated physiotherapist for fall risk assessment and fall prevention.

Discussion

In this study we observed that one year after LEF in a population of mostly ambulatory, community-dwelling elderly adults, the prevalence of FoF was 40%. In recurrent fallers and in patients who experienced a subsequent fracture in the follow-up period FoF was even more accentuated and FES-I scores were significantly higher. In patients with high expressions of FoF, QoL and activity level were significantly lower and a significant negative correlation at a moderate level was found between FoF and QoL. Furthermore, FoF correlated with higher age, number of postoperative falls and a lower activity level. The fall prevention intervention that was recommended and offered to all patients was poorly visited (6%).

Previous literature on FoF in elderly trauma patients report that the prevalence of FoF in community dwelling elderly ranges between 22 and 55% and that FoF is present in patients who did experience a fall and in patients who did not [5,18,19]. Cumming et al. investigated FoF in 418 community-dwelling patients of 65 years of age or older and found a prevalence of 30% (as measured by an answer to a binary question). Comparable to our results, they also reported that FoF negatively affects recovery in terms of mobility, QoL and activity level after a fracture [20]. The higher prevalence of FoF in our study may be attributed to the fact that we investigated patients who already experienced a fracture and its consequences. Another study from England, which included 2212 community-dwelling adults between 65 and 84 years old, found that the prevalence of FoF after a 20 months follow-up period was 23.2%. The authors reported FoF to be an independent risk factor for experiencing a subsequent fall. In contrast to our study, 72.2% of their study participants did not have a history of falls at baseline (e.g. in the previous 12 months) and FoF in their study was assessed both at baseline and at follow up, enabling the investigation of the causality of FoF and subsequent falls. Their findings support our hypothesis that higher FES-I scores in patients who had a subsequent fall, as compared to the ones who did not fall, may be both a result and a cause of the subsequent fall in the one year of follow up. Even though we found a high prevalence of FoF and its negative consequences, adherence to the recommendation to visit the fall prevention specialist for a comprehensive falls risk assessment was very low.

Amacher et al. and Child et al. came to the same conclusions and found that the main reasons for not adhering to the recommendations were: costs of the FPP, transportation, shortage of time, unwillingness to participate and unable to visit the hospital [21,22]. Mihaljcic et al. concluded that elderly undergoing inpatient rehabilitation underestimate their personal falls risk. Based on their findings in 2017 they suggested self-awareness of falls risk to be associated with rehabilitation engagement and motivation and concluded that improving patient self-awareness of falls risk may increase engagement in therapy. Hill et al. added that improved communication and education strategies and engaging family may also increase adherence. Mikolaizak et al. found that both high baseline intention to adhere and a higher number (>3) of recommendations prescribed were the most important factors that determine adherence to the multifactorial fall-prevention intervention [23-27]. Elley et al. investigated the effectiveness of a community-based, nurse-led multifactorial falls and fracture prevention intervention. They concluded that implementation and adherence was dependent on referral to other health professionals and that this may have limited the effectiveness of the interventions.

Various mono- and multifactorial interventions have been proven effective in reducing fall risk and FoF in different populations and lots of efforts have been undertaken by health care providers to build-up comprehensive FPPs and facilitate access [28-30]. Nevertheless, as discussed above and observed in this study, recruiting patients into such programs and adherence to recommendations remains a major challenge.

This study has a number of limitations. First, we sent out study invitations one year after trauma, which caused patients to answer some questions from memory. This may have led to recall bias and an underestimation in the number of subsequent falls [31]. Nevertheless, considering the binary question whether they had had at least one subsequent fall, we believe the results to be rather robust. To minimize interviewer bias, we used validated instruments and structured multiple-choice questionnaires. Secondly, we did not have FES-I scores of the patients at baseline. Consequently, we cannot make any conclusions about the causality of FoF on subsequent falls and fractures. Based on previous literature, we consider our 50% response rate to be acceptable [7,18,19,22]. To control for a potential selection bias, comparison of relevant baseline data was performed and revealed that non-participants were comparable to participants considering age, gender distribution, fracture type and treatment setting (P>0.05). Therefore, the risk of selection bias is minor. Third, considering generalization, it should be noted that the patients included in this study were younger than in others and mostly community-dwelling. This was a deliberate decision, because we aimed to study specifically those patients in which a secondary FPP, consisting of fall prevention and the prevention of osteoporosis, would be most beneficial.

Conclusion

To our knowledge, this study is the first evaluating FoF in relation to subsequent falls, subsequent fractures and to QoL measures in a cohort of LEF patients one year after trauma. Even in this relatively young and mobile population, the prevalence of FoF is high and negatively affects the patients' QoL and activity level. Despite this finding, participation in a voluntary FPP was very low and unsatisfactory. Simply informing patients about their potential risk of falling and advising them to have their fall risk assessed does not seem to be sufficient to encourage and recruit LEF patients into an FPP. Hence, more efforts need to be undertaken. The implementation of simple fall risk assessments taken directly in the emergency or trauma unit may could help to improve patients’ self-awareness of falls risk and may be an option to recruit more patients into a comprehensive FPP.

Furthermore, we recommend to not only to incorporate physical but also psychological measures such as FoF into the follow up of LEF patients. Patients screened at risk for falling or with high expressions of FoF need to be prescribed and referred to adequate fall preventive interventions.

Lastly, to further improve self-awareness of falls risk, repeated screenings should be performed on a regular basis throughout the rehabilitation process.

Disclosure Statement

Conflict of interest: P.C.R. van der Vet, J. Q. Kusen, M. Rohner-Spengler, B.C. Link, M. Houwert, R. Babst, C. Henzen, L. Schmid and F.J.P. Beeres declare no conflict of interest

Human rights statements and informed consent: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and its later amendments. Informed consent was obtained from all patients for being included in the study.

Ethics approval: The Regional Ethics Committee of the Canton of Lucerne approved this study. All participants gave written informed consent before data collection began.

Competing interests: None

Source(s) of support: None

References

  1. Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, de Rooij SE (2008) Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 37: 19-24. [Crossref]
  2. Tinetti ME, Richman D, Powell L (1990) Falls Efficacy as a Measure of Fear of Falling. J Gerontol 45: 239-243. [Crossref]
  3. Legters K (2002) Fear of falling. Phys Ther 82: 264-272. [Crossref]
  4. Visschedijk J, Achterberg W, Van Balen R, Hertogh C (2010) Fear of falling after hip fracture: a systematic review of measurement instruments, prevalence, interventions, and related factors. J Am Geriatr Soc 58: 1739-1748. [Crossref]
  5. Friedman SM, Munoz B, West SK, Rubin GS, Fried LP (2002) Falls and fear of falling: which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. J Am Geriatr Soc 50: 1329-1335. [Crossref]
  6. Yardley L, Smith H (2002) A Prospective Study of the Relationship Between Feared Consequences of Falling and Avoidance of Activity in Community-Living Older People. The Gerontologist 42: 17-23. [Crossref]
  7. Oude Voshaar RC, Banerjee S, Horan M, Baldwin R, Pendleton N, et al. (2006) Fear of falling more important than pain and depression for functional recovery after surgery for hip fracture in older people. Psychol Med 36: 1635-1645. [Crossref]
  8. Kempen GI, Yardley L, van Haastregt JC, Zijlstra GA, Beyer N, et al. (2008) The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling. Age Ageing 37: 45-50. [Crossref]
  9. Howland J, Peterson EW, Levin WC, Fried L, Pordon D, et al. (1993) Fear of falling among the community-dwelling elderly. J Aging Health 5: 229-243. [Crossref]
  10. Tinetti ME, Mendes de Leon CF, Doucette JT, Baker DI (1994) Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. J Gerontol 49: 140-147. [Crossref]
  11. Lachman ME, Howland J, Tennstedt S, Jette A, Assmann S, et al. (1998) Fear of falling and activity restriction: the survey of activities and fear of falling in the elderly (SAFE). J Gerontol B Psychol Sci Soc Sci 53: 43-50. [Crossref]
  12. Suzuki M, Ohyama N, Yamada K, Kanamori M (2002) The relationship between fear of falling, activities of daily living and quality of life among elderly individuals. Nurs Health Sci 4: 155-161. [Crossref]
  13. Murphy S, Tickle-Degnen L (2001) Participation in daily living tasks among older adults with fear of falling. Am J Occup Ther 55: 538-544. [Crossref]
  14. Aoyagi K, Ross PD, Davis JW, Wasnich RD, Hayashi T, et al. (1998) Falls among community-dwelling elderly in Japan. J Bone Miner Res 13: 1468-1474. [Crossref]
  15. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, et al. (2008) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 61: 344-349. [Crossref]
  16. Jonasson SB, Nilsson MH, Lexell J (2017) Psychometric properties of the original and short versions of the Falls Efficacy Scale-International (FES-I) in people with Parkinson's disease. Health Qual Life Outcomes 15: 116. [Crossref]
  17. Williams A (1990) EuroQol--a new facility for the measurement of health-related quality of life. Health policy 16: 199-208. [Crossref]
  18. Arfken CL, Lach HW, Birge SJ, Miller JP (1994) The prevalence and correlates of fear of falling in elderly persons living in the community. Am J Public Health 84: 565-570. [Crossref]
  19. Lach HW (2005) Incidence and risk factors for developing fear of falling in older adults. Public Health Nurs 22: 45-52. [Crossref]
  20. Cumming RG, Salkeld G, Thomas M, Szonyi G (2000) Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. J Gerontol A Biol Sci Med Sci 55: 299-305. [Crossref]
  21. Child S, Goodwin V, Garside R, Jones-Hughes T, Boddy K, et al. (2012) Factors influencing the implementation of fall-prevention programmes: a systematic review and synthesis of qualitative studies. Implement Sci 7: 91. [Crossref]
  22. Amacher AE, Nast I, Zindel B, Schmid L, Krafft V, et al. (2016) Experiences of general practitioners, home care nurses, physiotherapists and seniors involved in a multidisciplinary home-based fall prevention programme: a mixed method study. BMC Health Services Research 16: 469. [Crossref]
  23. Mihaljcic T, Haines TP, Ponsford JL, Stolwyk RJ (2015) Self-Awareness of Falls Risk Among Elderly Patients: Characterizing Awareness Deficits and Exploring Associated Factors. Arch Phys Med Rehabil 96: 2145-2152. [Crossref]
  24. Mihaljcic T, Haines TP, Ponsford JL, Stolwyk RJ (2017) Investigating the relationship between reduced self-awareness of falls risk, rehabilitation engagement and falls in older adults. Arch Gerontol Geriatr 69: 38-44. [Crossref]
  25. Mikolaizak AS, Lord SR, Tiedemann A, Simpson P, Caplan GA, et al. (2017) A multidisciplinary intervention to prevent subsequent falls and health service use following fall-related paramedic care: a randomised controlled trial. Age Ageing 46: 200-207. [Crossref]
  26. Elley CR, Robertson MC, Garrett S, Kerse NM, McKinlay E, et al. (2008) Effectiveness of a falls-and-fracture nurse coordinator to reduce falls: a randomized, controlled trial of at-risk older adults. J Am Geriatr Soc 56: 1383-1389. [Crossref]
  27. Hill KD, Day L, Haines TP (2014) What factors influence community-dwelling older people's intent to undertake multifactorial fall prevention programs? Clin Interv Aging 9: 2045-2053. [Crossref]
  28. Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, et al. (2004) Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ 328: 680. [Crossref]
  29. Hopewell S, Adedire O, Copsey BJ, Boniface GJ, Sherrington C, et al. (2018) Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 7: CD012221. [Crossref]
  30. Palvanen M, Kannus P, Piirtola M, Niemi S, Parkkari J, et al. (2014) Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: a randomised controlled trial. Injury 45: 265-271. [Crossref]
  31. Cummings SR, Nevitt MC, Kidd S (1988) Forgetting falls. The limited accuracy of recall of falls in the elderly. J Am Geriatr Soc 36: 613-616. [Crossref]

Editorial Information

Editor-in-Chief

Martin Grabois
Baylor College of Medicine

Article Type

Research Article

Publication history

Received: September 16, 2020
Accepted: September 23, 2020
Published: October 07, 2020

Copyright

©2020 Van der Vet P. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Van der Vet PCR, Kusen JQ, Rohner-Spengler M, Link BC, Houwert RM, et al. (2020) Fear of falling, recurrence of falls and quality of life in elderly patients with a low energy fracture – an observational study. Phys Med Rehabil Res. 5. DOI: 10.15761/PMRR.1000217

Corresponding author

Puck van der Vet

Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000 Lucerne 16, Switzerland

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Figure 1. Patient flowchart.

Table 1. Eligibility criteria.

Inclusion Criteria

Exclusion Criteria

50-85 years of age

Severe Dementia or Alzheimer

Severe Neurological diseases (e.g. Multiple Sclerosis, cerebrovascular accident, M. Parkinson, paraplegia)

Severe alcohol abuse

Low energy fracture

Non-judicious patients living in a health care institute (elderly-, nursing home)

Inability to speak German

Patient receiving ambulatory or stationary treatment

Inability to attend the hospital

Table 2. Baseline characteristics.

Age (years) mean ± SD

71.9 ± 9.3

Gender

Male n (%)

Female n (%)

83(20.2)

328(79.8)

ASA classification

ASA classification 1 n (%)

47(14.0)

ASA classification 2 n (%)

204(60.7)

ASA classification 3 n (%)

84(25.0)

ASA classification 4 n (%)

1(0.3)

Body Mass Index  

<18 kg/m2 (underweight) n (%)

11(2.9)

18-24.9 kg/m2 (normal weight) n (%)

199(51.7)

25-29.9 kg/m2 (overweight) n (%)

123(31.9)

≥30 kg/m2 (obese)

52(13.5)

Fracture distribution

Humerus n (%)

80(19.5)

Clavicle n (%)

7(1.7)

Rib fracture n (%)

7(1.7)

Radius/Ulna n (%)

139(33.8)

Femur n (%)

62(15.1)

Tibia/Fibula/Patella n (%)

22(5.4)

Tibia/Fibula, malleolar segment n (%)

46(11.2)

Spine, cervical segment n (%)

1(0.2)

Spine, thoracic segment n (%)

5(1.2)

Spine, lumbar segment n (%)

13(3.2)

Pelvic ring n (%)

12(2.9)

Acetabulum n (%)

2(0.5)

Hand n (%)

6(1.5)

Foot n (%)

8(1.9)

Craniomaxillofacial bones n (%)

1(0.2)

n: number of patients. Numbers are noted in percentages of the total number of study patients (missing values were excluded from analysis). SD: Standard Deviation. ASA classification: American Society of Anesthesiologists Physical Status Classification System. ASA classification 1: a normal healthy patient. ASA classification 2: a patient with mild systemic disease. ASA classification 3: a patient with severe systemic disease. ASA classification 4: a patient with severe systemic disease that is a constant threat to life.

Table 3. Postoperative outcome measures.

Fear of Falling in

 

All patients mean ± SD

21.1 ± 7.7

Patients with ≥ 1 postoperative fall   mean ± SD

23.7 ± -9.8

Patients without postoperative fall   mean ± SD

20.7 ± 7.1

Patients aged 50-69 years mean ± SD

19.9 ± 6.9

Patients aged 70-79 years mean ± SD

20.6 ± 6.4

Patients aged 80 plus year mean ± SD

23.3 ± 9.5

Fear of Falling categorized

Low (FES-I score: 16-19) n (%)

245(60.3)

Moderate (FES-I score: 20-27) n (%)

109(26.8)

High (FES-I score: 28-64) n (%)

52(12.8)

Secondary Falls

0 falls n (%)

326(84.5)

1 fall n (%)

44(11.4)

2 falls n (%)

9(2.3)

3 falls n (%)

3(0.8)

4 falls n (%)

4(1.0)

Hours of Daily Outdoor Activity

< 30 minutes n (%)

62(16.8)

≥ 30 minutes n (%)

127(34.4)

> 1 hour n (%)

131(35.5)

> 2 hours n (%)

49(13.3)

Postoperative Mobility

Ambulant n (%)

353(99.4)

Mobility accessories n (%)

2 (0.6)

Quality of Life

EQ-5D-3L   mean ± SD

0.9 ± 0.2

Visits to the Osteofit Consult

Yes n (%)

21(6)

No n (%)

330(94)

n: number of patients. Numbers are noted in percentages of the total number of analyzed study patients. SD: Standard Deviation. FES: Falls Efficacy Score. EQ-5D-3L: EuroQol-5-Dimension-3-Level score.