- Email: [email protected]
Quality of life among community-dwelling elderly persons with a history of previous falls
Fisioterapia. 2015;37(1):3---8
www.elsevier.es/ft
ORIGINAL
Quality of life among community-dwelling elderly persons with a history of previous falls J.R. Saiz Llamosas a,∗ , V. Casado Vicente b a b
Fisioterapeuta, C.S. Parquesol, Valladolid, Spain Médico Especialista en Medicina Familiar Comunitaria, C.S. Parquesol, Valladolid, Spain
Received 14 October 2013; accepted 6 March 2014 Available online 11 October 2014
KEYWORDS Community; Elderly; Falls; Quality of life
∗
Abstract Objective: The aim of this research was to study perception of health-related quality of life (HRQL) among community-dwelling elderly persons with a history of accidental falls. Materials and methods: A descriptive analysis was made based on 198 community-dwelling elderly persons aged 65---75 (mean age 69.5 years, 48.5% female). A survey was used in order to find relevant information concerning age, gender, illnesses, falls and HRQL using the EuroQol5D (EQ-5D) protocol. Qualitative results were presented as percentages, with a 95% confidence interval. Continuous data were compared with Mann---Whitney U test. Results: There are a greater percentage of subjects with illnesses within the group having a background of falls (FG --- fall-group) than in the no-fall group (NFG). There are a higher percentage of subjects with EQ-5D limitations in the FG group (mobility 59.4%, self-care 29.0%, usual activities 60.6%, pain/discomfort 87.5% and anxiety/depression 62.5%) than in the NFG (mobility 28.8%, self-care 11.3%, usual activities 22.9%, pain/discomfort 65.4%, anxiety/depression 28.9%). A statistically significant difference of 20 points was found between groups in favor of NFG in terms of EQ-5D’ Visual Analog Scale score (P < .000) (FG 51.36 ± 22.79, NFG 71.65 ± 18.93). Conclusions: Elderly persons having a history of falls in the last 12 months have poorer perception of HRQL than those without these events. Further investigations are needed in order to clarify if this is related to the falling itself or some other variables such as chronic illnesses. © 2013 Asociación Espa˜ nola de Fisioterapeutas. Published by Elsevier España, S.L.U. All rights reserved.
Corresponding author. E-mail address: [email protected] (J.R. Saiz Llamosas).
http://dx.doi.org/10.1016/j.ft.2014.03.001 0211-5638/© 2013 Asociación Espa˜ nola de Fisioterapeutas. Published by Elsevier España, S.L.U. All rights reserved.
4
J.R. Saiz Llamosas, V. Casado Vicente
PALABRAS CLAVE Comunidad; Mayores; Caídas; Calidad de vida
Calidad de vida de las personas mayores que viven en la comunidad con caída previa Resumen Objetivos: Estudiar la percepción de la calidad de vida relacionada con la salud (CVRS) entre las personas mayores que viven en la comunidad, con antecedente de caída accidental. Material y métodos: Estudio descriptivo basado en una muestra de 198 personas de entre 65-75 a˜ nos residentes en la comunidad (edad media 69,5 a˜ nos, 48,5% mujeres). Se les administró una encuesta en la que se solicitó información sobre edad, sexo, enfermedades, caídas accidentales y CVRS utilizando la encuesta EuroQol-5D (EQ-5D). Los resultados cualitativos fueron presentados como porcentajes, con un intervalo de confianza del 95%. Los datos continuos fueron comparados usando el estadístico U de Mann-Whitne. Resultados: Existe un mayor porcentaje de sujetos con enfermedades en el grupo con antecedente de caída (AC) en comparación con el grupo sin antecedente de caída (NC). Existe un mayor porcentaje de sujetos con problemas en las 5 dimensiones del EQ-5D en el grupo AC (movilidad 59,4%, cuidado personal 29,0%, actividades cotidianas 60,6%, dolor/malestar 87,5% y ansiedad/depresión 62,5%), que en el grupo NC (movilidad 28,8%, cuidado personal 11,3%, actividades cotidianas 22,9%, dolor/malestar 65,4%, ansiedad/depresión 28,9%). Se encontró una diferencia estadísticamente significativa de 20 puntos a favor del grupo NC en la escala visual analógica del EQ-5D (p < 0,000) (AC 51,36 ± 22,79, NC 71,65 ± 18,93). Conclusiones: Las personas mayores con AC durante los últimos 12 meses tienen peor percepción de su CVRS. Son necesarias más investigaciones para aclarar si se debe a la caída y/o a otras variables, como presentar enfermedades crónicas. © 2013 Asociación Espa˜ nola de Fisioterapeutas. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.
Introduction Falls have a high prevalence among elderly communitydwelling people. In a number of researches carried out in Spain with 65-year-old subjects, prevalence has been measured at 14.4%1 ---31.78%.2 Prevalence of falls increases with age, reaching a 50.3%3 among subjects over 75. In the USA, a group of people of different ages were monitored for a period of 2 years, and it was found that 34.8% of the subjects over 65 years old had suffered a fall; the percentage of falls among subjects with ages between 46 and 65 years was 21%, and between 20 and 45, it was a mere 18%.4 In the UK the incidence ratio of falls is 3.58/100 individuals per year, which gives 475,000 annual falls.5 Falls are relevant because a high percentage of them have consequences for health. Between 41%1 and 73.9%2 of falls have physical/functional consequences (superficial wounds, fractures, mobility limitations) and/or psychosocial consequences (fear of falling, the perception that falling changed one’s life).6 It has been estimated that between 21.7%7 and 30%2 of the elderly who suffer falls require urgent health-care, and between 3.3%2 and 18.9%1 require hospitalization. According to WHO8 estimates, falls among the elderly constitute an important and growing cause of injuries, treatment expenses and death, having more serious consequences than accidental falling injures in young people. According to Vellas et al.9 subjects who have suffered a fall with traumatism often perceive that the incident has changed their lives (odds ratio --- OR = 6.34). According to research carried out in the UK on individuals of 60 or more years who lived in community, mortality for recurrent fallers was about twice that of general population controls.5
It is likely that the consequences of falls on the health of the community-dwelling elderly will affect their perception of their health-related quality of life (HRQL). Nowadays, we rely on quite robust questionnaires, that can be administered in a quick and simple way, and that allow us to obtain valid and reliable results, to evaluate HRQL as EuroQol-5D (EQ-5D).10 A lower score on the analogical visual scale (VAS) of the EQ-5D protocol on health-related quality of life is statistically correlated (logistic regression) with falls among elderly community-dwelling people.2 Two in every three trauma-related hospital admittances in the Spanish National Health System were fractures, 31.5% being hip fractures. A fall is the cause of these fractures in 90% of the cases, 9 in every ten require surgery and 4.71% of them result in death. Hip fracture global hospitalization costs have increased more than twice in the last 10 years.11 Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults: Medical management of psychotropics (psychotropic medication withdrawal) and tai chi groups are the least-costly, most-effective options, but they were also the least studied. Excluding these interventions, the least-expensive, mosteffective options are vitamin D supplementation and home modifications.12 The goal of this investigation is to study the perception of health related quality of life (HRQL) in community dwelling elderly people that have a history of accidental falls in the last 12 months. The outcome of this research could be relevant for the design of interventions aimed to improve quality of life, by preventing falls among the community-dwelling elderly.
Quality of life among elderly persons with a history of previous falling
Method
Table 1
5 Demographic data of the population sample.
Study design We carried out a descriptive study (cross-sectional study) of a basic health area (BHA) in Northwest Spain, through posted questionnaires.
Total, n (%) Age (years), average ± SD
Women
Men
Total
96 (48.5) 69.5 ± 3.29
102 (51.5) 69.39 ± 3.31
198 (100.0) 69.4 ± 3.3
SD: standard deviation.
Subjects We selected for our study all subjects between 65 and 75 years of age within the BHA, a total of 1214 elderly people. The population sample was estimated considering a prevalence of falls among community-dwelling people beyond 65 between 14.4%1 and 31.78%2 according to previous studies. For a population of 1214 people, with a confidence interval of 95%, the sample size should theoretically range between 161 and 255 people, with a 5% alpha error and ±0.05 precision. We randomly selected 330 people --- that is, 255 people plus 30% for prospective loss --- aging between 65 and 75, from the BHA and ascribed to a Primary Care Health Center in Northwest Spain, by using the MedoraCyl randomizer. The questionnaire was sent to their homes through the mail. Since we received less filled questionnaires than expected, we readjusted the sample to a 55% of loss, and issued a second sending of questionnaires to 97 new people. A total of 427 questionnaires were sent. Inclusion criteria were ages between 65 and 75 years (in order to acquire quality of life information of this group, toward which interventions for falls prevalence increase prevention over the age of 75 should be addressed), reside in this community, participation acceptance and have signed a consent. Exclusion criteria were: to reside in a nursing home or a tutored home and do not accept to participate.
anxiety/depression). These dimensions were presented to all participants in the same order, and each of them included three levels of seriousness (no problem, some/moderate problems, many problems). The ‘‘some/moderate’’ and ‘‘many problems’’ variables are compiled in the ‘‘with problems’’ variable in the Results section, this last one being the addition of subjects from both variables as seen in Azpiazu et al. (2003).14 Each participant had to tick the level of seriousness, within each dimension, that most accurately described their state of health ‘‘today’’. We also used the VAS of the EQ-5D as a quantitative analysis of the general state of health of an individual or a group of individuals, therefore allowing for both intra- and inter-individual comparisons. Since VAS renders a quantitative measure, it allows a statistical analysis we can use for comparing arithmetic means and median values across groups as well as changes over time.
Data analysis
The questionnaire included questions about personal data (age, gender), a section devoted to their quality of life (EuroQol-5D protocol), a record of falls during the previous year, and questions about illnesses.
All data resulting from the survey were stored in an ACCESS database and were processed with the statistical package SPSS 15.0® for Windows. The quantitative results will be presented as arithmetic means and standard deviation [×(DS)], with a confidence interval of 95% (95% CI). Qualitative results have been presented as percentages, with a confidence interval of 95% (95% CI). Continuous data (VAS) were compared with Mann---Whitney U test, since Kolmogorov---Smirnov test showed this variable did not follow a normal distribution.
Measures
Ethics
Procedure
- Demographic data: age, gender. - Survey on falls: ‘‘Have you suffered any fall in the last twelve months’’. - Survey on illnesses: have you had any of these illnesses during the last twelve months: serious heart disease, ictus or cerebral thrombosis after effects, recent myocardial infarction, malignant tumoral processes, serious illnesses of the nervous system such as Parkinson, dementia, Alzheimer, multiple sclerosis, severe mobility limitation due to amputation, severe rheumatological disease or hip/knee prosthesis, serious respiratory diseases, severe osteoporosis, intense infections or inflammations. - EuroQol-5D questionnaire on health-related quality of life (Spanish version)13 : We have used EQ-5D which consists of a description --- self-completed by the polled subjects --- of their own health in terms of five dimensions (mobility, self-care, usual activities, pain/discomfort,
Ethics approval was obtained from the Ethics Committee of a public health service area of Northwest Spain. Informed and voluntary participation of subjects was guaranteed by the signing of a Consent Document.
Results 198 people agreed to participate in the study and answered the interview. 229 people did not answer the mailed questionnaire. None of the ones who replied denied their participation. Table 1 shows the demographic data concerning the participants. Up to 33 subjects (26 women and 7 men) had suffered one fall in the last 12 months. Table 2 shows the percentages of participants who had illnesses in the FG (fall group) (at least 1 fall during last 12 months) and in the NFG (no-fall group) (0 falls during last
6
J.R. Saiz Llamosas, V. Casado Vicente Table 2
Percentage of subjects with illnesses. NFG (CI 95%)
Serious heart illness After effects of ictus or cerebral thrombosis Recent myocardial infarction Malignant tumoral processes Serious illnesses of the nervous system: Parkinson, dementia, Alzheimer, multiple sclerosis Severe limitation of mobility due to amputations, severe rheumatologic diseases, or hip/knee prosthesis. Serious respiratory illnesses Severe osteoporosis Severe infections or inflammation
7.4% 1.2% 1.2% 4.3% 0.0%
(4.1---10.7%) (0---2.4%) (0---2.4%) (1.8---6.8%)
FG (CI 95%) 12.1% 3.0% 3.0% 12.1% 15.2%
(8.0---16.2%) (0.83---5.17%) (0.83---5.17%) (8.0---16.2%) (10.7---19.7%)
8.6% (5.1---12.1%)
21.2% (16.0---26.4%)
2.5% (0.64.4%) 8.0% (4.6---11.4%) 6.8% (3.6---10.0%)
9.1% (5.5---12.7%) 18.2% (13.3---23.1%) 21.2% (16.0---26.4%)
CI: confidence interval; FG: fall-group; NFG: no-fall group.
12 months). There are a higher percentage of subjects with illnesses in the FG than in the NFG. In the assessment of the quality of life through the EuroQol-5D descriptive system, we have found the following percentages of subjects with problems related to each of the 5 dimensions of the EQ-5D questionnaire in the FG and NFG (Table 3). The FG registers a higher percentage of individuals with problems in all five dimensions of the EQ-5D than the NFG. In response to the question of ‘‘how is your health today in comparison with your health during the last 12 months’’, 71.6% (CI 95%, 65.8---77.3%) of the NFG subjects state that their health today is the same as during the last 12 months, compared to 48.5% (CI 95%, 42.1---54.8%) of FG subject who provide the same answer. 16.8% (CI 95%, 12.1---21.5%) of NFG subjects report that their health is worse today, against 33.3% (CI 95%, 27.3---39.3%) of FG subjects declaring the same. Within the NFG, 11.6% (CI 95%, 7.6---15.6%) of the polled subjects inform that their health is better, in comparison with the 18.2% (CI 95%, 13.3---23.1%) of subjects in the FG who state the same. As expected, the percentage of individuals who consider that their health is worse today is higher in the NFG than in the FG. When measuring their state of health today (from 0 to 100) by means of VAS tool provided by EQ-5D, the NFG presents an average score (arithmetic means) and standard deviation of 71.65 ± 18.93, whereas that of the FG
Table 3
is 51.36 ± 22.79. There was a significant difference of 20 points between groups in favor of NFG in terms of VAS score (the U-value was 1103. P < .000).
Discussion The FG registers a statistically significant higher percentage of individuals with problems in all five dimensions of the EQ-5D than the NFG.15 The percentage of individuals with problems in all 5 dimensions of the EQ-5D protocol is much higher in the FG than in any of the other studies compared,14,16,17 highlighting the remarkable impact of falls in the quality of life of the elderly. In all these studies, the dimension with a lower percentage of problems among individuals is that of self-care, while pain/discomfort was the dimension in which a higher percentage of individuals claim to have problems. Such high percentage of people over 65 with problems in pain/discomfort items of EQ-5D found in the present study (in the FG but also NFG) must be taken into account for its clinical relevance, supporting that people who suffer pain, are at higher risk of accidental falling.18---20 Our study shows that a high percentage of people claimed to have problems in the anxiety/depression section of EQ5D. Interventions like the one designed by Katsura et al.21 successfully used aquatic exercises with water-resistance
Percentage of people beyond 65 with problems in the EQ-5D dimensions.
Mobility Self-care Usual activities Pain/discomfort Anxiety/depression EQ-5D: Euroqol 5-D; FG: fall-group; NFG: no-fall group.
NFG (CI 95%)
FG (CI 95%)
28.8% 11.3% 22.9% 65.4% 28.9%
59.9% 29.0% 60.6% 87.5% 62.5%
(23.1---34.5%) (7.3---15.3%) (17.6---28.2%) (59.4---71.4%) (23.2%-34.6%)
(53.7---66.1%) (23.3---34.7%) (54.4---66.8%) (83.3---91.7%) (56.4---68.6%)
Quality of life among elderly persons with a history of previous falling equipment in order to significantly reduce nervous tension and anxiety (measured with profile of mood states POMS), which could have influence in the improvement of perception in this section of EQ-5D. The VAS (EQ-5D) average score (arithmetic means) of the FG was much lower than that of the other studies, 66.6,14 70.0,16 60.6.17 This confirms the assumption that having a lower score in the EQ-5D questionnaire correlates with a higher risk of fall.2 This research showed a higher percentage of subjects with illnesses in the FG than in the NFG. It is important to develop a prospective study that would allow discerning if poor quality of life perception in FG is related with falling or the diseases they suffer. Our research has shown that elderly people who have had falls have a poorer perception of their quality of life. Further prospective studies are needed in order to determine if poor perception of HRQL in people that have suffered falls previously are related to this fact or other causes, such as chronic illnesses or to have had physical or psychological consequences from falling. Besides, for improving the quality of life we should design interventions that promote the prevention of falls; these interventions might consist in physical exercise of the kind used by Saiz-Llamosas et al.,22 who managed, with 16 sessions of physical exercise, a statistically significant improvement in mobility, balance, strength and quality of life, as well as a decrease of falls, among elderly between 65 and 75, with previous falls. One limitation in this study is the sample size. However, the trial has the methodological strength of been randomized.6 Another limitation found was the mailed questionnaire. It is a relatively cheap and effective way to reach the subjects, but may undercut participation of physically or socially depending people.
Conclusion Elderly people with history of falling in the last 12 months have poorer perception of HRQL than those without these events. Further investigations are needed in order to clarify if this is related to falling itself or some other variables such as chronic illnesses. These findings should be considered in the studying of falls and their consequences in elderly people and in the design of interventions aimed to improve HRQL, by preventing falls.
Funding This project has been financed by the General Management for Health Development --- Regional Health Management --Health Ministry of Castilla y León (Spain) through a grant for the development of research in the fields of biomedicine, biotechnology and sciences of health, to be carried out in Primary Health Care premises, during the year 2008 and 2009. (Signed by the Managing Director of the Regional Health Management of Castilla y León on August 1st 2008, and March 12th 2009).
7
Ethical responsibilities Protecting people and pets. The authors declare that procedures conformed to the ethical standards of the responsible committee on human experimentation and in accordance with the World Medical Association and the Declaration of Helsinki. Data privacy. The authors have obtained informed patients and/or subjects referred to in Article consent. This document is in the possession of the author of correspondence. Right to privacy and informed consent. The authors have obtained informed patients and/or subjects referred to in Article consent. This document is in the possession of the author of correspondence.
Conflict of interests The authors declare to have no conflict of interests.
Acknowledgements The authors thank Dr. Xavier Badia for authorizing the use of the Spanish version of the Euro-Qol-5D survey on health related quality of life; Dr. Enrique Cámara-Arenas, Dr. Ma Teresa Pérez-García, and Dr. Andrés Enrique Álvarez-Hodel for helping us with the English translation; and Dr. Gemma Almonacid-Canseco and Dr. Sandra M. Navarro-Contreras, for their contribution to this research.
References 1. Rubio JI, Zunzunegui MV, Béland F. The prevalence of and factors associated with falls in older persons living in the community. Med Clin (Barc). 1997;108:128---32. 2. Varas-Fabra F, Martín E, Pérula de Torres LA, Fernández MJ, Moral R, Berge I. Falls in the elderly in the community: prevalence, consequences, and associated factors. Aten Primaria. 2006;38:450---5. 3. Gómez MI, Plata MT, Bustamante MA, Ramos R, Del pino B, Gil de Pareja MJ. Prevalencia de caídas en ancianos del EAP Los Ángeles (Área 11 Madrid). Centro de Salud. 2002:478---86. 4. Talbot LA, Musiol RJ, Witham EK, Metter EJ. Falls in young, middle-aged and older community dwelling adults: perceived cause, environmental factors and injury. BMC Publ Health. 2005;5:86. 5. Gribbin J, Hubbard R, Smith C, Gladman J, Lewis S. Incidence and mortality of falls amongst older people in primary care in the United Kingdom. QJM. 2009;102:477---83. 6. Gama ZA, Conesa A, Ferreira M. Epidemiology of falls in the elderly in Spain: a systematic review, 2007. Rev Esp Salud Publica. 2008;82:43---55. 7. Salvà A, Bolíbar I, Pera G, Arias C. Incidence and consequences of falls among elderly people living in the community. Med Clin (Barc). 2004;122:172---6. 8. WHO. Envejecimiento activo: un marco político. Rev Esp Geriatr Gerontol. 2002;37(S2):74---105 http://ccp.ucr.ac.cr/bvp/ pdf/vejez/oms envejecimiento activo.pdf 9. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. Once-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45:735---8.
8 10. Herdman M, Badia X, Berra S. EuroQol-5D: a simple alternative for measuring health-related quality of life in primary care. Aten Primaria. 2001;28:425---9. 11. Instituto de Información Sanitaria. Estadísticas comentadas: La Atención a la Fractura de Cadera en los hospitales del SNS [Publicación en Internet]. Madrid: Ministerio de Sanidad y Política Social; 2010. Available from: http://www.msssi.gob.es/ estadEstudios/estadisticas/docs/Estadisticas comentadas 01. pdf 12. Frick KD, Kung JY, Parrish JM, Narrett MJ. Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. J Am Geriatr Soc. 2010;58:136---41. 13. Badia X, Roset M, Montserrat S, Herdman M, Segura A. The Spanish version of EuroQol: a description and its applications. Eur Qual Life Scale Med Clin (Barc). 1999;112 Suppl. 1:79---85. 14. Azpiazu M, Cruz A, Villagrasa JR, Abadanes JC, García N, Álvarez C. Quality of life in noninstitutionalized persons older than 65 years in two health care districts in Madrid. Aten Primaria. 2003;31:285---94. 15. Saiz-Llamosas JR, Casado-Vicente V, Santamaría-Solla N, González-Rebollar T. Prevalencia de caídas, consumo de fármacos, presencia de enfermedades y calidad de vida de las
J.R. Saiz Llamosas, V. Casado Vicente
16.
17.
18.
19. 20.
21.
22.
personas mayores que viven en la comunidad. Fisioterapia. 2014 [in press]. Health Survey in Navarra; 2000. http://www.cfnavarra.es/ salud/docencia.investigacion/encuesta salud/marco encuesta. htm Badia X, Schiaffino A, Alonso J, Herdman M. Using the EuroQol 5-D in the Catalan general population: feasibility and construct validity. Qual Life Res. 1998;7:311---22. Leveille SG, Jones RN, Kiely DK, Hausdorff JM, Shmerling RH, Guralnik JM, et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA. 2009;302:2214---21. Tinetti ME, Kumar C. The patient who falls: it’s always a tradeoff. JAMA. 2010;303:258---66. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Foot pain, plantar pressures, and falls in older people: a prospective study. J Am Geriatr Soc. 2010;58:1936---40. Katsura Y, Yoshikawa T, Ueda SY, Usui T, Sotobayashi D, Nakao H, et al. Effects of aquatic exercise training using water-resistance equipment in elderly. Eur J Appl Physiol. 2010;108:957---64. Saiz-Llamosas JR. Impacto de un programa de fisioterapia sobre la movilidad, el equilibrio y la calidad de vida en las personas mayores [tesis doctoral]. Valladolid: Universidad de Valladolid; 2012.
www.elsevier.es/ft
ORIGINAL
Quality of life among community-dwelling elderly persons with a history of previous falls J.R. Saiz Llamosas a,∗ , V. Casado Vicente b a b
Fisioterapeuta, C.S. Parquesol, Valladolid, Spain Médico Especialista en Medicina Familiar Comunitaria, C.S. Parquesol, Valladolid, Spain
Received 14 October 2013; accepted 6 March 2014 Available online 11 October 2014
KEYWORDS Community; Elderly; Falls; Quality of life
∗
Abstract Objective: The aim of this research was to study perception of health-related quality of life (HRQL) among community-dwelling elderly persons with a history of accidental falls. Materials and methods: A descriptive analysis was made based on 198 community-dwelling elderly persons aged 65---75 (mean age 69.5 years, 48.5% female). A survey was used in order to find relevant information concerning age, gender, illnesses, falls and HRQL using the EuroQol5D (EQ-5D) protocol. Qualitative results were presented as percentages, with a 95% confidence interval. Continuous data were compared with Mann---Whitney U test. Results: There are a greater percentage of subjects with illnesses within the group having a background of falls (FG --- fall-group) than in the no-fall group (NFG). There are a higher percentage of subjects with EQ-5D limitations in the FG group (mobility 59.4%, self-care 29.0%, usual activities 60.6%, pain/discomfort 87.5% and anxiety/depression 62.5%) than in the NFG (mobility 28.8%, self-care 11.3%, usual activities 22.9%, pain/discomfort 65.4%, anxiety/depression 28.9%). A statistically significant difference of 20 points was found between groups in favor of NFG in terms of EQ-5D’ Visual Analog Scale score (P < .000) (FG 51.36 ± 22.79, NFG 71.65 ± 18.93). Conclusions: Elderly persons having a history of falls in the last 12 months have poorer perception of HRQL than those without these events. Further investigations are needed in order to clarify if this is related to the falling itself or some other variables such as chronic illnesses. © 2013 Asociación Espa˜ nola de Fisioterapeutas. Published by Elsevier España, S.L.U. All rights reserved.
Corresponding author. E-mail address: [email protected] (J.R. Saiz Llamosas).
http://dx.doi.org/10.1016/j.ft.2014.03.001 0211-5638/© 2013 Asociación Espa˜ nola de Fisioterapeutas. Published by Elsevier España, S.L.U. All rights reserved.
4
J.R. Saiz Llamosas, V. Casado Vicente
PALABRAS CLAVE Comunidad; Mayores; Caídas; Calidad de vida
Calidad de vida de las personas mayores que viven en la comunidad con caída previa Resumen Objetivos: Estudiar la percepción de la calidad de vida relacionada con la salud (CVRS) entre las personas mayores que viven en la comunidad, con antecedente de caída accidental. Material y métodos: Estudio descriptivo basado en una muestra de 198 personas de entre 65-75 a˜ nos residentes en la comunidad (edad media 69,5 a˜ nos, 48,5% mujeres). Se les administró una encuesta en la que se solicitó información sobre edad, sexo, enfermedades, caídas accidentales y CVRS utilizando la encuesta EuroQol-5D (EQ-5D). Los resultados cualitativos fueron presentados como porcentajes, con un intervalo de confianza del 95%. Los datos continuos fueron comparados usando el estadístico U de Mann-Whitne. Resultados: Existe un mayor porcentaje de sujetos con enfermedades en el grupo con antecedente de caída (AC) en comparación con el grupo sin antecedente de caída (NC). Existe un mayor porcentaje de sujetos con problemas en las 5 dimensiones del EQ-5D en el grupo AC (movilidad 59,4%, cuidado personal 29,0%, actividades cotidianas 60,6%, dolor/malestar 87,5% y ansiedad/depresión 62,5%), que en el grupo NC (movilidad 28,8%, cuidado personal 11,3%, actividades cotidianas 22,9%, dolor/malestar 65,4%, ansiedad/depresión 28,9%). Se encontró una diferencia estadísticamente significativa de 20 puntos a favor del grupo NC en la escala visual analógica del EQ-5D (p < 0,000) (AC 51,36 ± 22,79, NC 71,65 ± 18,93). Conclusiones: Las personas mayores con AC durante los últimos 12 meses tienen peor percepción de su CVRS. Son necesarias más investigaciones para aclarar si se debe a la caída y/o a otras variables, como presentar enfermedades crónicas. © 2013 Asociación Espa˜ nola de Fisioterapeutas. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.
Introduction Falls have a high prevalence among elderly communitydwelling people. In a number of researches carried out in Spain with 65-year-old subjects, prevalence has been measured at 14.4%1 ---31.78%.2 Prevalence of falls increases with age, reaching a 50.3%3 among subjects over 75. In the USA, a group of people of different ages were monitored for a period of 2 years, and it was found that 34.8% of the subjects over 65 years old had suffered a fall; the percentage of falls among subjects with ages between 46 and 65 years was 21%, and between 20 and 45, it was a mere 18%.4 In the UK the incidence ratio of falls is 3.58/100 individuals per year, which gives 475,000 annual falls.5 Falls are relevant because a high percentage of them have consequences for health. Between 41%1 and 73.9%2 of falls have physical/functional consequences (superficial wounds, fractures, mobility limitations) and/or psychosocial consequences (fear of falling, the perception that falling changed one’s life).6 It has been estimated that between 21.7%7 and 30%2 of the elderly who suffer falls require urgent health-care, and between 3.3%2 and 18.9%1 require hospitalization. According to WHO8 estimates, falls among the elderly constitute an important and growing cause of injuries, treatment expenses and death, having more serious consequences than accidental falling injures in young people. According to Vellas et al.9 subjects who have suffered a fall with traumatism often perceive that the incident has changed their lives (odds ratio --- OR = 6.34). According to research carried out in the UK on individuals of 60 or more years who lived in community, mortality for recurrent fallers was about twice that of general population controls.5
It is likely that the consequences of falls on the health of the community-dwelling elderly will affect their perception of their health-related quality of life (HRQL). Nowadays, we rely on quite robust questionnaires, that can be administered in a quick and simple way, and that allow us to obtain valid and reliable results, to evaluate HRQL as EuroQol-5D (EQ-5D).10 A lower score on the analogical visual scale (VAS) of the EQ-5D protocol on health-related quality of life is statistically correlated (logistic regression) with falls among elderly community-dwelling people.2 Two in every three trauma-related hospital admittances in the Spanish National Health System were fractures, 31.5% being hip fractures. A fall is the cause of these fractures in 90% of the cases, 9 in every ten require surgery and 4.71% of them result in death. Hip fracture global hospitalization costs have increased more than twice in the last 10 years.11 Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults: Medical management of psychotropics (psychotropic medication withdrawal) and tai chi groups are the least-costly, most-effective options, but they were also the least studied. Excluding these interventions, the least-expensive, mosteffective options are vitamin D supplementation and home modifications.12 The goal of this investigation is to study the perception of health related quality of life (HRQL) in community dwelling elderly people that have a history of accidental falls in the last 12 months. The outcome of this research could be relevant for the design of interventions aimed to improve quality of life, by preventing falls among the community-dwelling elderly.
Quality of life among elderly persons with a history of previous falling
Method
Table 1
5 Demographic data of the population sample.
Study design We carried out a descriptive study (cross-sectional study) of a basic health area (BHA) in Northwest Spain, through posted questionnaires.
Total, n (%) Age (years), average ± SD
Women
Men
Total
96 (48.5) 69.5 ± 3.29
102 (51.5) 69.39 ± 3.31
198 (100.0) 69.4 ± 3.3
SD: standard deviation.
Subjects We selected for our study all subjects between 65 and 75 years of age within the BHA, a total of 1214 elderly people. The population sample was estimated considering a prevalence of falls among community-dwelling people beyond 65 between 14.4%1 and 31.78%2 according to previous studies. For a population of 1214 people, with a confidence interval of 95%, the sample size should theoretically range between 161 and 255 people, with a 5% alpha error and ±0.05 precision. We randomly selected 330 people --- that is, 255 people plus 30% for prospective loss --- aging between 65 and 75, from the BHA and ascribed to a Primary Care Health Center in Northwest Spain, by using the MedoraCyl randomizer. The questionnaire was sent to their homes through the mail. Since we received less filled questionnaires than expected, we readjusted the sample to a 55% of loss, and issued a second sending of questionnaires to 97 new people. A total of 427 questionnaires were sent. Inclusion criteria were ages between 65 and 75 years (in order to acquire quality of life information of this group, toward which interventions for falls prevalence increase prevention over the age of 75 should be addressed), reside in this community, participation acceptance and have signed a consent. Exclusion criteria were: to reside in a nursing home or a tutored home and do not accept to participate.
anxiety/depression). These dimensions were presented to all participants in the same order, and each of them included three levels of seriousness (no problem, some/moderate problems, many problems). The ‘‘some/moderate’’ and ‘‘many problems’’ variables are compiled in the ‘‘with problems’’ variable in the Results section, this last one being the addition of subjects from both variables as seen in Azpiazu et al. (2003).14 Each participant had to tick the level of seriousness, within each dimension, that most accurately described their state of health ‘‘today’’. We also used the VAS of the EQ-5D as a quantitative analysis of the general state of health of an individual or a group of individuals, therefore allowing for both intra- and inter-individual comparisons. Since VAS renders a quantitative measure, it allows a statistical analysis we can use for comparing arithmetic means and median values across groups as well as changes over time.
Data analysis
The questionnaire included questions about personal data (age, gender), a section devoted to their quality of life (EuroQol-5D protocol), a record of falls during the previous year, and questions about illnesses.
All data resulting from the survey were stored in an ACCESS database and were processed with the statistical package SPSS 15.0® for Windows. The quantitative results will be presented as arithmetic means and standard deviation [×(DS)], with a confidence interval of 95% (95% CI). Qualitative results have been presented as percentages, with a confidence interval of 95% (95% CI). Continuous data (VAS) were compared with Mann---Whitney U test, since Kolmogorov---Smirnov test showed this variable did not follow a normal distribution.
Measures
Ethics
Procedure
- Demographic data: age, gender. - Survey on falls: ‘‘Have you suffered any fall in the last twelve months’’. - Survey on illnesses: have you had any of these illnesses during the last twelve months: serious heart disease, ictus or cerebral thrombosis after effects, recent myocardial infarction, malignant tumoral processes, serious illnesses of the nervous system such as Parkinson, dementia, Alzheimer, multiple sclerosis, severe mobility limitation due to amputation, severe rheumatological disease or hip/knee prosthesis, serious respiratory diseases, severe osteoporosis, intense infections or inflammations. - EuroQol-5D questionnaire on health-related quality of life (Spanish version)13 : We have used EQ-5D which consists of a description --- self-completed by the polled subjects --- of their own health in terms of five dimensions (mobility, self-care, usual activities, pain/discomfort,
Ethics approval was obtained from the Ethics Committee of a public health service area of Northwest Spain. Informed and voluntary participation of subjects was guaranteed by the signing of a Consent Document.
Results 198 people agreed to participate in the study and answered the interview. 229 people did not answer the mailed questionnaire. None of the ones who replied denied their participation. Table 1 shows the demographic data concerning the participants. Up to 33 subjects (26 women and 7 men) had suffered one fall in the last 12 months. Table 2 shows the percentages of participants who had illnesses in the FG (fall group) (at least 1 fall during last 12 months) and in the NFG (no-fall group) (0 falls during last
6
J.R. Saiz Llamosas, V. Casado Vicente Table 2
Percentage of subjects with illnesses. NFG (CI 95%)
Serious heart illness After effects of ictus or cerebral thrombosis Recent myocardial infarction Malignant tumoral processes Serious illnesses of the nervous system: Parkinson, dementia, Alzheimer, multiple sclerosis Severe limitation of mobility due to amputations, severe rheumatologic diseases, or hip/knee prosthesis. Serious respiratory illnesses Severe osteoporosis Severe infections or inflammation
7.4% 1.2% 1.2% 4.3% 0.0%
(4.1---10.7%) (0---2.4%) (0---2.4%) (1.8---6.8%)
FG (CI 95%) 12.1% 3.0% 3.0% 12.1% 15.2%
(8.0---16.2%) (0.83---5.17%) (0.83---5.17%) (8.0---16.2%) (10.7---19.7%)
8.6% (5.1---12.1%)
21.2% (16.0---26.4%)
2.5% (0.64.4%) 8.0% (4.6---11.4%) 6.8% (3.6---10.0%)
9.1% (5.5---12.7%) 18.2% (13.3---23.1%) 21.2% (16.0---26.4%)
CI: confidence interval; FG: fall-group; NFG: no-fall group.
12 months). There are a higher percentage of subjects with illnesses in the FG than in the NFG. In the assessment of the quality of life through the EuroQol-5D descriptive system, we have found the following percentages of subjects with problems related to each of the 5 dimensions of the EQ-5D questionnaire in the FG and NFG (Table 3). The FG registers a higher percentage of individuals with problems in all five dimensions of the EQ-5D than the NFG. In response to the question of ‘‘how is your health today in comparison with your health during the last 12 months’’, 71.6% (CI 95%, 65.8---77.3%) of the NFG subjects state that their health today is the same as during the last 12 months, compared to 48.5% (CI 95%, 42.1---54.8%) of FG subject who provide the same answer. 16.8% (CI 95%, 12.1---21.5%) of NFG subjects report that their health is worse today, against 33.3% (CI 95%, 27.3---39.3%) of FG subjects declaring the same. Within the NFG, 11.6% (CI 95%, 7.6---15.6%) of the polled subjects inform that their health is better, in comparison with the 18.2% (CI 95%, 13.3---23.1%) of subjects in the FG who state the same. As expected, the percentage of individuals who consider that their health is worse today is higher in the NFG than in the FG. When measuring their state of health today (from 0 to 100) by means of VAS tool provided by EQ-5D, the NFG presents an average score (arithmetic means) and standard deviation of 71.65 ± 18.93, whereas that of the FG
Table 3
is 51.36 ± 22.79. There was a significant difference of 20 points between groups in favor of NFG in terms of VAS score (the U-value was 1103. P < .000).
Discussion The FG registers a statistically significant higher percentage of individuals with problems in all five dimensions of the EQ-5D than the NFG.15 The percentage of individuals with problems in all 5 dimensions of the EQ-5D protocol is much higher in the FG than in any of the other studies compared,14,16,17 highlighting the remarkable impact of falls in the quality of life of the elderly. In all these studies, the dimension with a lower percentage of problems among individuals is that of self-care, while pain/discomfort was the dimension in which a higher percentage of individuals claim to have problems. Such high percentage of people over 65 with problems in pain/discomfort items of EQ-5D found in the present study (in the FG but also NFG) must be taken into account for its clinical relevance, supporting that people who suffer pain, are at higher risk of accidental falling.18---20 Our study shows that a high percentage of people claimed to have problems in the anxiety/depression section of EQ5D. Interventions like the one designed by Katsura et al.21 successfully used aquatic exercises with water-resistance
Percentage of people beyond 65 with problems in the EQ-5D dimensions.
Mobility Self-care Usual activities Pain/discomfort Anxiety/depression EQ-5D: Euroqol 5-D; FG: fall-group; NFG: no-fall group.
NFG (CI 95%)
FG (CI 95%)
28.8% 11.3% 22.9% 65.4% 28.9%
59.9% 29.0% 60.6% 87.5% 62.5%
(23.1---34.5%) (7.3---15.3%) (17.6---28.2%) (59.4---71.4%) (23.2%-34.6%)
(53.7---66.1%) (23.3---34.7%) (54.4---66.8%) (83.3---91.7%) (56.4---68.6%)
Quality of life among elderly persons with a history of previous falling equipment in order to significantly reduce nervous tension and anxiety (measured with profile of mood states POMS), which could have influence in the improvement of perception in this section of EQ-5D. The VAS (EQ-5D) average score (arithmetic means) of the FG was much lower than that of the other studies, 66.6,14 70.0,16 60.6.17 This confirms the assumption that having a lower score in the EQ-5D questionnaire correlates with a higher risk of fall.2 This research showed a higher percentage of subjects with illnesses in the FG than in the NFG. It is important to develop a prospective study that would allow discerning if poor quality of life perception in FG is related with falling or the diseases they suffer. Our research has shown that elderly people who have had falls have a poorer perception of their quality of life. Further prospective studies are needed in order to determine if poor perception of HRQL in people that have suffered falls previously are related to this fact or other causes, such as chronic illnesses or to have had physical or psychological consequences from falling. Besides, for improving the quality of life we should design interventions that promote the prevention of falls; these interventions might consist in physical exercise of the kind used by Saiz-Llamosas et al.,22 who managed, with 16 sessions of physical exercise, a statistically significant improvement in mobility, balance, strength and quality of life, as well as a decrease of falls, among elderly between 65 and 75, with previous falls. One limitation in this study is the sample size. However, the trial has the methodological strength of been randomized.6 Another limitation found was the mailed questionnaire. It is a relatively cheap and effective way to reach the subjects, but may undercut participation of physically or socially depending people.
Conclusion Elderly people with history of falling in the last 12 months have poorer perception of HRQL than those without these events. Further investigations are needed in order to clarify if this is related to falling itself or some other variables such as chronic illnesses. These findings should be considered in the studying of falls and their consequences in elderly people and in the design of interventions aimed to improve HRQL, by preventing falls.
Funding This project has been financed by the General Management for Health Development --- Regional Health Management --Health Ministry of Castilla y León (Spain) through a grant for the development of research in the fields of biomedicine, biotechnology and sciences of health, to be carried out in Primary Health Care premises, during the year 2008 and 2009. (Signed by the Managing Director of the Regional Health Management of Castilla y León on August 1st 2008, and March 12th 2009).
7
Ethical responsibilities Protecting people and pets. The authors declare that procedures conformed to the ethical standards of the responsible committee on human experimentation and in accordance with the World Medical Association and the Declaration of Helsinki. Data privacy. The authors have obtained informed patients and/or subjects referred to in Article consent. This document is in the possession of the author of correspondence. Right to privacy and informed consent. The authors have obtained informed patients and/or subjects referred to in Article consent. This document is in the possession of the author of correspondence.
Conflict of interests The authors declare to have no conflict of interests.
Acknowledgements The authors thank Dr. Xavier Badia for authorizing the use of the Spanish version of the Euro-Qol-5D survey on health related quality of life; Dr. Enrique Cámara-Arenas, Dr. Ma Teresa Pérez-García, and Dr. Andrés Enrique Álvarez-Hodel for helping us with the English translation; and Dr. Gemma Almonacid-Canseco and Dr. Sandra M. Navarro-Contreras, for their contribution to this research.
References 1. Rubio JI, Zunzunegui MV, Béland F. The prevalence of and factors associated with falls in older persons living in the community. Med Clin (Barc). 1997;108:128---32. 2. Varas-Fabra F, Martín E, Pérula de Torres LA, Fernández MJ, Moral R, Berge I. Falls in the elderly in the community: prevalence, consequences, and associated factors. Aten Primaria. 2006;38:450---5. 3. Gómez MI, Plata MT, Bustamante MA, Ramos R, Del pino B, Gil de Pareja MJ. Prevalencia de caídas en ancianos del EAP Los Ángeles (Área 11 Madrid). Centro de Salud. 2002:478---86. 4. Talbot LA, Musiol RJ, Witham EK, Metter EJ. Falls in young, middle-aged and older community dwelling adults: perceived cause, environmental factors and injury. BMC Publ Health. 2005;5:86. 5. Gribbin J, Hubbard R, Smith C, Gladman J, Lewis S. Incidence and mortality of falls amongst older people in primary care in the United Kingdom. QJM. 2009;102:477---83. 6. Gama ZA, Conesa A, Ferreira M. Epidemiology of falls in the elderly in Spain: a systematic review, 2007. Rev Esp Salud Publica. 2008;82:43---55. 7. Salvà A, Bolíbar I, Pera G, Arias C. Incidence and consequences of falls among elderly people living in the community. Med Clin (Barc). 2004;122:172---6. 8. WHO. Envejecimiento activo: un marco político. Rev Esp Geriatr Gerontol. 2002;37(S2):74---105 http://ccp.ucr.ac.cr/bvp/ pdf/vejez/oms envejecimiento activo.pdf 9. Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. Once-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45:735---8.
8 10. Herdman M, Badia X, Berra S. EuroQol-5D: a simple alternative for measuring health-related quality of life in primary care. Aten Primaria. 2001;28:425---9. 11. Instituto de Información Sanitaria. Estadísticas comentadas: La Atención a la Fractura de Cadera en los hospitales del SNS [Publicación en Internet]. Madrid: Ministerio de Sanidad y Política Social; 2010. Available from: http://www.msssi.gob.es/ estadEstudios/estadisticas/docs/Estadisticas comentadas 01. pdf 12. Frick KD, Kung JY, Parrish JM, Narrett MJ. Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. J Am Geriatr Soc. 2010;58:136---41. 13. Badia X, Roset M, Montserrat S, Herdman M, Segura A. The Spanish version of EuroQol: a description and its applications. Eur Qual Life Scale Med Clin (Barc). 1999;112 Suppl. 1:79---85. 14. Azpiazu M, Cruz A, Villagrasa JR, Abadanes JC, García N, Álvarez C. Quality of life in noninstitutionalized persons older than 65 years in two health care districts in Madrid. Aten Primaria. 2003;31:285---94. 15. Saiz-Llamosas JR, Casado-Vicente V, Santamaría-Solla N, González-Rebollar T. Prevalencia de caídas, consumo de fármacos, presencia de enfermedades y calidad de vida de las
J.R. Saiz Llamosas, V. Casado Vicente
16.
17.
18.
19. 20.
21.
22.
personas mayores que viven en la comunidad. Fisioterapia. 2014 [in press]. Health Survey in Navarra; 2000. http://www.cfnavarra.es/ salud/docencia.investigacion/encuesta salud/marco encuesta. htm Badia X, Schiaffino A, Alonso J, Herdman M. Using the EuroQol 5-D in the Catalan general population: feasibility and construct validity. Qual Life Res. 1998;7:311---22. Leveille SG, Jones RN, Kiely DK, Hausdorff JM, Shmerling RH, Guralnik JM, et al. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA. 2009;302:2214---21. Tinetti ME, Kumar C. The patient who falls: it’s always a tradeoff. JAMA. 2010;303:258---66. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR. Foot pain, plantar pressures, and falls in older people: a prospective study. J Am Geriatr Soc. 2010;58:1936---40. Katsura Y, Yoshikawa T, Ueda SY, Usui T, Sotobayashi D, Nakao H, et al. Effects of aquatic exercise training using water-resistance equipment in elderly. Eur J Appl Physiol. 2010;108:957---64. Saiz-Llamosas JR. Impacto de un programa de fisioterapia sobre la movilidad, el equilibrio y la calidad de vida en las personas mayores [tesis doctoral]. Valladolid: Universidad de Valladolid; 2012.