Do muscle strength, functioning, and behavioral factors have the same association with the history of falls?ABSTRACT
This study investigated the association of biological (muscle strength and functioning) and behavioral factors (level of physical activity and fear of falling) with the history of falls in community-dwelling older adults. A cross-sectional study was carried out with 173 older adults. Handgrip strength and functioning were assessed using the timed up and go (TUG) and gait speed tests. Behavioral factors were assessed by physical activity (Minnesota Leisure Time Activities Questionnaire) and fear of falling (Falls Efficacy Scale-International) instruments. The history of falls was assessed by self-reporting of falls that occurred in the last six months. Data were analyzed by the biserial point correlation test (r b ) and by a binomial regression analysis. The biological, handgrip strength (r b =−0.282, p<0.001), gait speed test (r b =−0.082, p=0.151) and TUG (r b =0.167, p=0.018) and behavioral factors, fear of falling (r b =0.098, p=0.162), physical activity (r b =−0.149, p=0.039), were included in the regression model. Only biological factors, handgrip strength (p<0.001; OR: 0.891; 95% CI: 0.885 – 0.898) and functioning by TUG (p<0.001; OR: 1.031; 95% CI: 1.018 – 1.043) explained the history of falls. Lower values of muscle strength and worse performance in the TUG were associated with a history of falls.
Keywords
Accidental Falls; Aged; Physical Functional Performance
RESUMO
O objetivo deste estudo foi investigar a associação de fatores biológicos (força muscular e mobilidade funcional) e comportamentais (nível de atividade física e medo de cair) com o histórico de quedas de idosos de uma comunidade. Foi realizado um estudo transversal com 173 idosos. Foram avaliadas a força de preensão manual e a mobilidade funcional por meio do timed up and go (TUG) e teste de velocidade de marcha. Os fatores comportamentais foram avaliados pelo escore de atividade física ( Minnesota Leisure Time Activities Questionnaire ) e medo de cair ( Falls Efficacy Scale-International ). O histórico de quedas foi avaliado pelo autorrelato de queda(s) ocorrida(s) nos últimos seis meses. Os dados foram analisados pelo teste de correlação por ponto bisserial (r b ) e por uma análise de regressão binomial. Os fatores biológicos, força de preensão manual (r b =−0,282, p<0,001), teste velocidade de marcha (r b =−0,082, p=0,151) e TUG (r b =0,167, p=0,018), além dos fatores comportamentais, medo de cair (r b =0,098, p=0,162) e atividade física (r b =−0,149, p=0,039), foram incluídos no modelo de regressão. Apenas os fatores biológicos de força de preensão palmar (p<0,001; OR: 0,891; IC 95%: 0,885-0,898) e mobilidade funcional pelo TUG (p<0,001; OR: 1,031; IC 95%: 1,018-1,043) explicaram a história de quedas. Menores valores de força muscular e pior desempenho no TUG foram associados ao histórico de quedas.
Descritores
Acidentes por Quedas; Idoso; Desempenho Físico-Funcional
RESUMEN
Este estudio tuvo el objetivo de investigar la asociación de factores biológicos (fuerza muscular y movilidad funcional) y de comportamiento (nivel de actividad física y miedo a caer) con el historial de caídas de personas mayores de una comunidad. Se realizó un estudio transversal con 173 personas mayores. Se evaluaron la fuerza de agarre manual y la movilidad funcional mediante el timed up and go (TUG) y la prueba de velocidad de marcha. Se evaluaron los factores de comportamiento mediante la puntuación de actividad física ( Minnesota Leisure Time Activities Questionnaire ) y el miedo a caer ( Falls Efficacy Scale-International ). Se evaluó el historial de caídas a través del autorrelato de caídas que ocurrieron en los últimos seis meses. Se analizaron los datos mediante la prueba de correlación punto-biserial (r b ) y mediante un análisis de regresión binomial. Los factores biológicos, la fuerza de agarre manual (r b =−0.282, p<0.001), la prueba de velocidad de marcha (r b =−0.082, p=0.151) y el TUG (r b =0.167, p=0.018), además de los factores de comportamiento, el miedo a caer (r b =0.098, p=0.162) y la actividad física (r b =−0.149, p=0.039), se incluyeron en el modelo de regresión. Solamente los factores biológicos de fuerza de agarre palmar (p<0.001; OR: 0.891; IC 95%: 0.885-0.898) y movilidad funcional a través del TUG (p<0.001; OR: 1.031; IC 95%: 1.018-1.043) explicaron el historial de caídas. Valores más bajos de fuerza muscular y un peor rendimiento en el TUG se asociaron al historial de caídas.
Palabras clave
Accidentes por Caídas; Persona Mayor; Rendimiento Físico Funcional
INTRODUCTION
Falls are a major health problem, affecting about 30% of the older population 1 - 3 . A history of falls is a strong indicator of future falls 1 , with physical, social, and psychological consequences 1 - 2 . This results in higher burden to public health due to hospitalizations and deaths 1 - 2 . Identifying the risk of falls is a public health priority, including the assessment of individual, environmental, and behavioral factors 1 - 3 . The World Health Organization (WHO) categorizes risk factors for falls into four domains: biological, socioeconomic, behavioral, and environmental 3 . Muscle strength, functioning, and balance are variables of the biological domain 3 . The behavioral domain includes physical activity level and fear of falling 3 . Recognizing biological and behavioral risk factors is essential for fall prevention, which requires greater attention and investigation 3 .
Biological factors encompass physical and functional characteristics of the individual 3 - 4 . Handgrip strength is used to identify older adults at risk 5 . According to the International Classification of Functioning (ICF), functioning involves tasks related to locomotion. Mobility, examined by timed up and go (TUG), includes several executive functions, which also involve elements of balance in habitual transfers and changes in direction during gait 6 . Habitual gait speed represents a functional marker for several negative health outcomes, such as falls, disability, hospitalization, and mortality 7 - 8 . Therefore, evaluating these factors enables a better understanding of falls in older adults.
The behavioral aspects reflect the importance of maintaining an adequate practice of physical activity and self-efficacy for falls 9 - 10 . However, the relation between physical activity and falls needs to be better explored to understand how this variable behaves in relation to the history of falls, being a risk or protective factor 9 . Fear of falling or self-efficacy for falls is characterized as a psychological concern with the possibility of falling, which may be present regardless of the history of falls 10 - 11 . However, once the individual falls, concerns about falling again increase, and this eventually leads to a vicious cycle of fear, reduced physical activity, deconditioning, and disuse 10 - 11 .
The literature presents many approaches to assess muscle strength, functioning, and behavioral aspects 3 - 4 . However, some instruments that assess these aspects are inconsistent regarding fall prediction 4 , and one must determine the most appropriate tool to assess older individuals regarding the risk of falling, considering the profile of the target audience 4 . Knowing that the older population is heterogeneous, it is necessary to understand how these biological and behavioral aspects are related to the history of falls.
The identification of biological and behavioral factors related to the history of falls can contribute to the adoption of preventive and rehabilitation measures 3 , since these factors are potentially modifiable by physical exercise and lifestyle changes 1 , 3 . In this sense, identifying risk or protective factors can help in the planning of intervention strategies aimed at improving older adults’ physical capacities. Thus, this study aimed to investigate the association of biological factors (muscle strength and functioning) and behavioral factors (level of physical activity and fear of falling) with the history of falls in community-dwelling older adults.
METHODOLOGY
This is a cross-sectional study with non-probabilistic sampling. Participants were selected via active search in health services. The following inclusion criteria were employed: being aged 60 years or older; residing in the community, and having an independent gait. The exclusion criteria were having acute disabling pain in the lower limbs that prevented the performance of the tests, decompensated neurological or cardiac condition and cognitive decline detected by the mini mental state examination (MMSE), according to educational level 12 . Clinical and sociodemographic information was obtained through a semi-structured questionnaire prepared for this study. The sample size was estimated at 101 participants, considering the analysis to be used and the number of independent variables evaluated.
Procedures
The dependent variable was the history of falls collected with the following question: “In the last six months, did you fall?”. The meaning of “fall” was defined as “an unexpected event, in which the individual goes against the ground, or any level lower than the initial position” 2 . Biological factors were assessed by handgrip strength (HGS) and functioning assessed by gait speed and TUG tests. Behavioral factors were assessed by physical activity level and fear of falling.
A JAMAR ®13 dynamometer was used to assess HGS. The recommendations of the American Society of Hand Therapists were followed: the older adult was seated with their feet flat on the floor, arm adducted parallel to the trunk, elbow flexed at 90°, forearm and wrist in a neutral position. The participants were instructed to perform three measurements with the dominant hand exerting maximum isometric force for six seconds, under verbal stimulation provided by the examiner 13 . There was an interval of one minute between each repetition. The arithmetic average of the three repetitions in kilogram-force (kgf) was used for analysis.
In the gait speed test, the participants were instructed to walk a 4.6 meter route, considering two meters for acceleration and two meters for deceleration 14 . Each individual walked at their preferred speed and with their usual shoes; this analysis used meters/seconds as unit of measurement. To perform the TUG 15 - 16 , participants were asked to get up from a chair, walk three meters, return and sit again, supporting the trunk on the chair 15 - 16 , and were timed in seconds to perform the task. The examiners were previously trained to collect data. A single familiarization run was performed for the HGS, gait test, and TUG tests. The authors ensured that all individuals only performed the tests after certifying they had understood the execution. After familiarization, three recording measures were performed, with a rest interval of one minute and the average considered for analysis. For analysis, raw values without normalization were considered.
Physical activity was assessed using the Minnesota Leisure Time Activities Questionnaire (MLTAQ) 17 . This instrument evaluates physical activity, sports and leisure according to weekly energy expenditure (kilocalories/week). Energy expenditure was calculated based on an equation, considering the measurement of metabolic equivalent (MET) in kilocalories (Kcal), time spent in activity in minutes, and weight in kilograms 17 . Fear of falling or self-efficacy to avoid falling was measured with the Falls Efficacy Scale-International (FES-I Brasil) 18 . This scale presents questions about the concern about the possibility of falling when performing 16 activities, from basic to more complex, with respective scores from one to four. The total score can range from 16 (absence of concern) to 64 (extreme concern) 18 .
Statistical analysis
Data were analyzed using the Statistical Package for the Social Sciences – SPSS (version 23.0). Biserial point correlation (r b ) tests were used to identify the bivariate correlation between potential predictors and history of falls. Variables in which bivariate correlations had a p<0.20 significance level were included in a binomial regression model. At the final fit, only the independent variables that were statistically significant (p<0.05) remained in the regression model. The logit link function was used, with adjustment for age and the probability of binomial distribution. The predictive factors obtained were expressed as odds ratio (OR) with 95% confidence intervals (95% CI).
RESULTS
A total of 173 older adults took part in the study, with mean age of 71.8 (±6.2) years. Most were female, non-fallers, with a low number of comorbidities (2.6±1.7), high percentage of visual impairment (93.1%), good perception of overall well-being (52%), good satisfaction with life (67.1%) and low prevalence of depressive symptoms (18.5%) ( Table 1 ).
According to the results of the bivariate correlation, the variables fear of falling (FES-I), physical activity (MLTAQ ) , handgrip strength (HGS), gait speed (GS), and mobility (TUG) (p<0.20) were initially included in the regression model ( Table 2 ).
The regression model showed that a one-unit increase (kgf) in HGS reduced the chance of falling by 10.9% (95% CI: 10.2 – 11.5%); and a one-unit increase in TUG time (seconds) increased the chance of falling by 3.1% (95% CI: 1.8 – 4.3%) ( Table 3 ).
DISCUSSION
This study aimed to investigate the association of biological and behavioral factors with the history of falls in a sample of community-dwelling older adults. The regression results showed that the HGS and TUG biological factors explained the history of falls in the older adults. A negative association between HGS and history of falls and a positive association between time spent in TUG and history of falls was observed. Worse results in the handgrip strength and TUG tests was associated with a history of falls in the older adults. Variables related to the behavioral factor were not selected in the regression model.
Notably, HGS was found to be the biological factor with the greatest association with the history of falls. Higher values of HGS were associated with no history of falls in the last six months. Specifically, a one-unit increase in HGS reduced the chance of the older person falling by 10.9%. Some studies that demonstrated that HGS is a strong predictor of falls in the older population corroborate our finding 19 - 20 . Yang et al. 19 , for example, demonstrated that low HGS was the most significant risk factor for falls in the last year in older Taiwanese adults, especially in the female population. Similarly, the study sample was predominantly composed of women, so that HGS was also the predictor with the greatest strength of association. The predominant sample of women corroborates the process of feminization of old age. Moreover, the mean HGS of the evaluated sample was 23.7kgf. Considering the values attributed to the highest rate of severe falls (HGS <30 kgf in men and HGS <20 kgf in women 21 ), as well as the indicators of severe sarcopenia of HGS <27 kgf for men and <16 kgf for women 22 , the sample of this study does not seem to present significant levels of sarcopenia. These results indicate that HGS needs to be evaluated in older adults due to its potential predictive role for falls.
The time to perform the TUG was another biological factor identified as a predictor for history of falls. Longer time spent performing the test (i.e., worse performance) was associated with a 3.1% greater chance of having a history of falls in the last six months. Similarly, our results are in agreement with data from the literature associating TUG with adverse outcomes including falls, hospitalization, institutionalization, and death 23 . Ansai et al. 24 , for example, demonstrated an association between TUG and risk of falls with a 1.13 OR (95% CI: 1.02 – 1.24). However, a systematic review with meta-analysis indicates that the TUG has limited capacity to assess community-dwelling older adults at risk of falling, demonstrating low sensitivity and specificity values 25 . The OR observed in this study indicates that, although the strength of association was not high, TUG must be included in older adults’ evaluation, since it is one of the most reported instruments in the literature, with low cost and easy applicability 4 .
There was no association of gait speed with the history of falls. The literature shows that this measure is considered a predictor of falls and suggests a cutoff point of 1m/s 8 . One factor that may have influenced the result of this study is related to participants’ profile. The sample of this study had a mean age of 71.8 years and presented low self-report of falls (19.1%). This percentage is considered low when compared to the literature 26 . Moreover, it was observed that the average walking speed was 1.2m/s, which is above the cutoff point suggested by the literature 8 . Thus, gait speed may not be the most appropriate measure to predict falls in more robust and independent older adults, with a few comorbidities and high weekly energy expenditure. The results of this study suggest that, for samples with this profile, the TUG test may be more indicated to identify older adults with a greater chance of falling.
Regarding behavioral factors, no association was identified between the level of physical activity and fear of falling with the history of falls. Based on literature data on the association of high levels of physical activity with lower occurrence of falls 27 , the benefits of physical activity for the health of older adults are evident, and great public efforts aim at keeping the older population active 27 . Fear of falling was not associated with the history of falls in the sample studied, which differs from other studies 10 - 11 . It has been shown that older adults who reported falling were twice as likely to be afraid of falling 28 . Moreover, the fear of falling influences the balance and gait of the individual and may predict limitations in mobility and self-care 299 . Possibly, the low fear of falling found in this study may be due to less concern about the consequences of a fall, since most participants are independent, with low fall reports, and those who fell did not have serious injuries. This perception of non-seriousness of the fall can impact the psychological and behavioral aspect, consequently, the fear of falling. The results may indicate that the relationship between fear and falls is not linear and that, in a sample of older adults with little or moderate concern about the history of falls, the factors may not be associated.
A first limitation of the study is the predominance of females in the sample. However, we identified that gender was not significantly associated with the history of falls (p=0.680) and, therefore, was not included in the regression model for adjustment. The model was age-adjusted as described. In addition, the use of self-report for a history of falls may involve memory bias. However, this is the most common way to explore this phenomenon. It is believed that when considering the information of the last six months and being careful to exclude those with possible cognitive deficits, this bias has been minimized. Another limitation is the absence of anthropometric data related to height, body weight, and body mass index.
This study findings have implications for clinical practice. Biological and behavioral risk factors are determinant for the evaluation and rehabilitation process of older adults with a history of falls 1 - 3 and represent modifiable factors through intervention with exercise and health education 1 . Although behavioral factors have not been associated with a history of falls in this study, they are often established in the management of falls 1 - 3 . We consider that the sample profile may have influenced these outcomes. The sample evaluated presented low self-report of falls, few comorbidities, moderate fear of falling, and a good physical activity level. Thus, the understanding of the predictors (HGS and TUG) associated with the history of falls and absence of association of behavioral factors should be considered in the light of an independent, active sample of older adults with few comorbidities. In this sense, it is possible that in more debilitated and frail older adults, other variables may also be associated with the history of falls. The results reinforce the importance of HGS assessment and the application of the TUG test in community-dwelling older adults. Considering that general muscle strength and mobility are risk factors that can be modified, fall prevention strategies should consider interventions aimed at improving these aspects. It is expected that the improvement in overall muscle strength associated with mobility exercises may reduce the chance of falling.
CONCLUSION
Biological factors, handgrip strength, and functioning assessed via TUG were predictors of the history of falls. Worse results in handgrip strength and TUG were associated with a history of falls in older adults. There was no association between behavioral factors (physical activity level and fear of falling) and a history of falls.
ACKNOWLEDGEMENTS
We thank the Dean’s Office of Research of UFMG, CNPq, FAPEMIG, and CAPES for supporting the research. Thank you to Professor PhD. Lygia Paccini Lustosa ( in memoriam ) for her contributions to the design and conduct of this study.
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Study carried out at the Universidade Federal de Minas Gerais (UFMG) – Belo Horizonte, (MG), Brazil.
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Financing source:
National Council of Scientific and Technological Development (CNPq), Minas Gerais Research Foundation (FAPEMIG) and the Coordination for the Improvement of Higher Education Personnel (CAPES) Approved by the local Research Ethics Committee under CAAE No. 14129513.7.1001.5149.
