Falls are a major public health problem, contributing to significant morbidity and mortality among older adults in the United States. This article summarizes and compares (1) fall prevalence rates, (2) fall risk factors, (3) consequences of falls, and (4) current knowledge about fall prevention interventions between community-dwelling older adults and people aging with physical disability. In this latter group, the article focuses on individuals with multiple sclerosis, late-effects of polio, muscular dystrophies, and spinal cord injuries.
Falls are a major public health problem. In the United States, falls are the leading cause of injury deaths for adults over age 65 and the most common cause of nonfatal injuries and hospital admissions for traumatic injuries. Nonfatal fall injuries are associated loss of independence as well as significant use of health care services. By 2020, the combined direct and indirect costs of injurious falls among people over the age of 65 are expected to exceed $54.2 billion dollars in the United States.
A fall is an unexpected event during which the individual comes to rest on the ground, floor, or lower level, typically during the performance of basic daily activities (eg, walking, getting up from a chair, bending down). To date, most falls-related research has focused on older community-dwelling adults. Only recently have researchers started to study falls among adults and older adults with chronic illness or existing physical disability.
The purposes of this article are to summarize and then compare (1) fall prevalence rates, (2) fall risk factors, (3) consequences of falls, and (4) current knowledge about fall prevention interventions between community-dwelling older adults and people aging with physical disability. In this latter group, the article focuses on individuals with multiple sclerosis (MS), late effects of polio, muscular dystrophies, and spinal cord injuries. These groups have been selected because they are the target populations for the work currently being conducted through the Rehabilitation Research and Training Center on Aging with Physical Disability, based at the University of Washington at Seattle. To locate falls-related information on these populations, a MEDLINE search was conducted using the index term “accidental falls” in combination with one of the following index terms: “multiple sclerosis,” “postpoliomyelitis syndrome,” “muscular dystrophies,” or “spinal cord injuries.”
Prevalence of falls
Prevalence of Falls Among Community-Dwelling Older Adults
Approximately 30% of community-dwelling adults aged 65 years or older fall each year. Among individuals aged over 75 years, the proportion increases to 50%. Based on data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey, which was drawn from interviews involving 92,808 persons aged 65 years or older, Stevens and colleagues found that approximately 5.8 million (almost 16%) of people aged 65 years or older reported falling at least once during the preceding 3 months. Recurrent falls are common. For example, in one study conducted over a 48-week period, researchers followed 409 community-dwelling persons aged 65 years or more and found that 11.5% fell two or more times.
Prevalence of Falls Among People Aging with Physical Disability
MS
Rates of falls have been reported in three cross-sectional studies and one longitudinal study of people with MS. In one of the cross-sectional studies, an Italian research team found 54% of 50 participants (20 from the community, 30 from an extended care ward) reported at least one fall in the previous 2 months, and 32% of these fallers experienced recurrent falls. The average age of the fallers was 40 years (SD = 11). The other two cross-sectional studies were conducted by a US research team. In one of their studies, the researchers found 52% of 1089 participants aged 45 to 90 years from the Midwest had experienced a fall over the previous six-month period. Using a national US sample, this same research team reported that 64% of 354 study participants, aged 55 to 94 years, reported at least two falls per year. Of these individuals, 30% reported falling once a month or more.
The longitudinal study was conducted in Sweden with 76 participants, ranging in age from 25 to 75 years. Falls data were collected prospectively over 9 months. In this period, 63% (48 of 76) of participants reported at least one fall. Among the fallers, 32 participants fell two times or more, and 11 fell 10 times or more. A total of 2352 near-fall incidents were reported across the study period.
Late effects of polio
Two cross-sectional studies were identified that reported on fall prevalence rates among people with late effects of polio. In the first study, an Australian team reported prevalence of falling among 40 people with prior polio, who had an average age of 50.7 years. Of these individuals, 47.5% reported falling three or more times in the previous year, and an additional 20% reported falling twice. The remaining participants either experienced a single fall or no falls at all (not reported separately). In the second study, a US team reported that 84% of 172 survey respondents experienced a fall over the previous year. Average participant age was not reported, although the median age of post-polio syndrome onset was 48 years.
Muscular dystrophies
Only one study was located that reported fall prevalence rates among adults with a form of muscular dystrophy. In this study, 13 adults with myotonic dystrophy, with a mean age of 46.5 years (SD = 1.68), reported retrospectively on falls and also monitored falls prospectively for 13 weeks. Retrospectively, 5 of 13 (38%) participants reported that they fell and injured themselves more than once in the past 6 months. Over the prospective monitoring period, 10 of 13 (77%) participants experienced a total of 127 stumbles, and 6 of 13 (46%) participants experienced a total of 34 falls. On average, participants experienced a total of 12.2 events over the 13 weeks (falls and stumbles combined).
Spinal cord injuries
Only one study was located that reported the prevalence of falling among people with spinal cord injury. In this retrospective survey study, 75% of 119 individuals with incomplete spinal cord injury (average age 52.2 years), reported falling in the past year.
Summary and Comparison
Although the time periods considered across the studies reported in this section vary from 2 months to 1 year, findings suggest that the fall rates are considerably higher among people aging with physical disability compared with community-dwelling older adults aged 65 years and over. From the findings reported here, it appears that in some cases, the fall rates of people aging with physical disability may be double that of their community-dwelling older adult peers. Even if one considers only the fall rates among community-dwelling older adults 75 years and older, the rates for people aging with physical disability are still often greater.
Fall risk factors
Research to identify risk factors for falls has been fairly consistent in showing that most falls result from multiple, interacting factors. Fall risk factors typically are classified as intrinsic (within-subject) or extrinsic. Overall, balanced attention to both intrinsic and extrinsic risk factors is warranted, because the interaction between a person’s physical abilities and his or her exposure to environmental stressors appears to influence fall risk.
Fall Risks Among Community-Dwelling Older Adults
To date, epidemiologic research to inform fall prevention efforts among community-dwelling older adults has focused heavily on intrinsic fall risk factors. This research has led to understanding of both modifiable and nonmodifiable fall risk factors, and the realization that the risk of falling increases dramatically as the number of risk factors increases. For community-dwelling older adults, nonmodifiable risk factors include being female, having a history of falls, and higher age. Several cohort studies have identified gait and balance disorders, functional impairment, visual deficits, and cognitive impairment as the most important intrinsic risk factors for falling. Often, these risk factors are modifiable.
Data from a prospective cohort study of community-dwelling older adults (n = 1285) that was undertaken to construct a fall-risk model suggest that key risk factors for men and women may differ. Findings indicated that previous falls and visual impairment were the strongest predictors for women (area under curve = .66), whereas previous falls, visual impairment, urinary incontinence, functional limitations, and low level of physical activity were the strongest predictors for men (area under curve = .74). Other research has suggested that psychosocial risk factors, including depressive symptoms, fear of falling (ie, a lasting concern about falling that leads an individual to avoid activities that he/she remains capable of performing) and low falls self-efficacy (ie, perceived self-efficacy or confidence to avoid falls during essential, nonhazardous activities of daily living) also may place community dwelling older adults at increased risk for falls. Growing evidence suggests that fear of falling and low falls-self efficacy are experienced by both fallers and nonfallers.
With respect to extrinsic fall risk factors for community-dwelling older adults, polypharmacy (ie, four or more medications) and certain classes of drugs, especially psychotropic medications, increase the risk of fall. Although home hazards have received wide attention as an extrinsic fall risk factor, no consistent association has been found between common household hazards and falls in several prospective studies. Current thinking suggests that most falls in the home result from an interaction between environmental stressors and physical abilities or risk-taking behaviors. Furthermore, hazards in the home may not present equal risk to all older adults. Findings from secondary analyses of data from two prospective studies suggest that environmental hazards contribute to falls to a greater extent in older vigorous people than in older frail people.
Fall Risk Factors Among People Aging with Physical Disability
Multiple sclerosis
Three studies were identified that examined risk factors for falls among people with MS, two cross-sectional ones and one longitudinal. With the exception of the large study by Finlayson and colleagues, which used self-report through telephone interviews, the other studies used a combination of self-report instruments and performance-based evaluations. The variability in sample size, age range, study designs, data collection methods, and time periods examined may explain the variability in fall risk factors identified across these studies ( Table 1 ). Despite the variability in findings, several consistencies are noteworthy.
| Factors Increasing the Likelihood of Reporting the Dependent Variable | Fall in the Past 2 Months a | Fall in the Past 6 Months b | Fall Over 9 Months c |
|---|---|---|---|
| Age | No | No | No |
| Gender | No | Being male | Being male |
| MS status/disability | Not examined | Yes | Yes |
| Balance | Yes | Yes | No |
| Cognition | No | Yes | No |
| Incontinence of bladder | Not examined | Yes | No |
| Mobility device | Yes | Yes | Yes |
| Fear of falling | Not examined | Yes | No |
| Fatigue | Not examined | No | No |
| Spasticity | No | No | Yes |
| Disturbed proprioception | Not examined | Not examined | Yes |
| Ambulation | Yes | Not examined | Yes |
| ADL abilities | No | Not examined | Not examined |
a Retrospective recall, cross-sectional design, n = 50.
b Retrospective recall, cross-sectional design, n = 1089.
All studies found that mobility devices were in some way associated with falling. Cattaneo and colleagues found that more fallers used a cane than nonfallers, and Nilsågard and colleagues found that individuals who used walking aids either indoors or out had double the risk of a fall compared with those who used no walking aid. Compared with people who always used a wheelchair for mobility, Finlayson and colleagues found that never users and sometimes users had approximately two times greater risk of a fall. Together with other findings regarding balance and ambulation across these studies, it is clear that further investigation of role of mobility device use in fall risk is warranted. Although the findings simply may reflect that mobility device users are more disabled, and therefore at greater risk, Finlayson and colleagues also suggest that mobility device decision-making (eg, to use any device, to use a more supportive device under specific circumstances) also may be playing a role.
Other factors that were found to increase risk of a fall in at least two of the studies include being male and MS status/disability. Findings about the role of specific symptoms are variable, and will require further investigation in the future.
Late effects of polio
Only one study was identified that examined risk factors for falls among people previously affected by polio, and it focused primarily on the role of lower extremity strength. The study included 40 people with prior polio and 38 age- and sex-matched controls. To examine predictors of falls within the polio group, researchers divided the group into people experiencing zero falls or one fall in the past year (n = 13), those who fell twice (n = 8), and those who fell multiple times (n = 19). Compared with people who fell twice, the multiple fallers had reduced strength in ankle dorsiflexors, greater lower extremity weakness, slower hand and foot reaction times, slower foot-tapping speed, and increased body sway on a compliant surface under both eyes-open and eyes-closed conditions. Of these differences, the ones with the greatest discriminating power were body sway and composite strength. The authors concluded that weakness has a direct association with falls among people with prior polio, as well as an indirect effect mediated through increased body sway.
Muscular dystrophies
Only one study was identified that examined fall risk factors among people with myotonic dystrophy type 1. The study included 13 people with myotonic dystrophy and 12 healthy volunteers matched for sex, weight, and body mass index. In bivariate analyses, fallers (n = 6) and nonfallers (n = 7) within the myotonic dystrophy group were compared. Findings showed that fallers were more likely to have a lower Rivermead Mobility Index score, more likely to use mobility devices or a person to aid mobility indoors or outdoors, have a slower self-selected gait speed, and higher depression. Although the authors also report regression analysis, the small sample size and large number of variables raise questions about the validity of the findings.
Spinal cord injuries
Only one study was identified that examined fall risk factors among people with spinal cord injury, specifically those with incomplete injury. Using a mail-out survey, researchers gathered information on falls and fall risk factors among 119 people. Three multivariable logistic regression models evaluated differences between fallers and nonfallers.
The first model examined differences in demographic and injury characteristics, and no statistically significant differences were found. The second model examined differences in health-related data, and found that fallers were more likely to
Have had more days of poor physical health in the past year
Have greater numbers of medical conditions
Have arthritis
Experience dizziness
Report lower self-rated health
Report worse health compared with the previous year.
The third model examined differences in physical activity and found that fallers exercised less frequently, were fearful of falling, limited activities because of fear of falling, used a cane (vs not), and used a walker (vs not). When the significant variables from all three models were combined into a final model, the most significant factors associated with a fall among people with incomplete spinal cord injuries were exercising less than 8 times per month and not using a walker.
Summary and Comparison
A surge in fall-related research over the past 10 to 15 years has dramatically enhanced understanding of fall risk factors, particularly among community-dwelling older adults. It is clear that knowledge related to fall risks among people aging with physical disability is lagging far behind. To date, the literature on fall risk factors among people aging with multiple sclerosis, late effects of polio, muscular dystrophies, or spinal cord injuries has not addressed extrinsic risk factors, including the potential role of multiple medication use and home hazards in increasing fall risk. Among intrinsic factors across these four groups, vision has not been investigated, and the evaluation of the role of cognition, fear of falling, falls self-efficacy, depression, and functional status has been inconsistent at best. Future work needs to address these gaps in knowledge, and consider the application of consistent frameworks for organizing thinking about risk factors (eg, intrinsic vs extrinsic, modifiable vs not) and how they interact and build on each other to influence an individual’s fall-related risk.
Fall risk factors
Research to identify risk factors for falls has been fairly consistent in showing that most falls result from multiple, interacting factors. Fall risk factors typically are classified as intrinsic (within-subject) or extrinsic. Overall, balanced attention to both intrinsic and extrinsic risk factors is warranted, because the interaction between a person’s physical abilities and his or her exposure to environmental stressors appears to influence fall risk.
Fall Risks Among Community-Dwelling Older Adults
To date, epidemiologic research to inform fall prevention efforts among community-dwelling older adults has focused heavily on intrinsic fall risk factors. This research has led to understanding of both modifiable and nonmodifiable fall risk factors, and the realization that the risk of falling increases dramatically as the number of risk factors increases. For community-dwelling older adults, nonmodifiable risk factors include being female, having a history of falls, and higher age. Several cohort studies have identified gait and balance disorders, functional impairment, visual deficits, and cognitive impairment as the most important intrinsic risk factors for falling. Often, these risk factors are modifiable.
Data from a prospective cohort study of community-dwelling older adults (n = 1285) that was undertaken to construct a fall-risk model suggest that key risk factors for men and women may differ. Findings indicated that previous falls and visual impairment were the strongest predictors for women (area under curve = .66), whereas previous falls, visual impairment, urinary incontinence, functional limitations, and low level of physical activity were the strongest predictors for men (area under curve = .74). Other research has suggested that psychosocial risk factors, including depressive symptoms, fear of falling (ie, a lasting concern about falling that leads an individual to avoid activities that he/she remains capable of performing) and low falls self-efficacy (ie, perceived self-efficacy or confidence to avoid falls during essential, nonhazardous activities of daily living) also may place community dwelling older adults at increased risk for falls. Growing evidence suggests that fear of falling and low falls-self efficacy are experienced by both fallers and nonfallers.
With respect to extrinsic fall risk factors for community-dwelling older adults, polypharmacy (ie, four or more medications) and certain classes of drugs, especially psychotropic medications, increase the risk of fall. Although home hazards have received wide attention as an extrinsic fall risk factor, no consistent association has been found between common household hazards and falls in several prospective studies. Current thinking suggests that most falls in the home result from an interaction between environmental stressors and physical abilities or risk-taking behaviors. Furthermore, hazards in the home may not present equal risk to all older adults. Findings from secondary analyses of data from two prospective studies suggest that environmental hazards contribute to falls to a greater extent in older vigorous people than in older frail people.
Fall Risk Factors Among People Aging with Physical Disability
Multiple sclerosis
Three studies were identified that examined risk factors for falls among people with MS, two cross-sectional ones and one longitudinal. With the exception of the large study by Finlayson and colleagues, which used self-report through telephone interviews, the other studies used a combination of self-report instruments and performance-based evaluations. The variability in sample size, age range, study designs, data collection methods, and time periods examined may explain the variability in fall risk factors identified across these studies ( Table 1 ). Despite the variability in findings, several consistencies are noteworthy.
| Factors Increasing the Likelihood of Reporting the Dependent Variable | Fall in the Past 2 Months a | Fall in the Past 6 Months b | Fall Over 9 Months c |
|---|---|---|---|
| Age | No | No | No |
| Gender | No | Being male | Being male |
| MS status/disability | Not examined | Yes | Yes |
| Balance | Yes | Yes | No |
| Cognition | No | Yes | No |
| Incontinence of bladder | Not examined | Yes | No |
| Mobility device | Yes | Yes | Yes |
| Fear of falling | Not examined | Yes | No |
| Fatigue | Not examined | No | No |
| Spasticity | No | No | Yes |
| Disturbed proprioception | Not examined | Not examined | Yes |
| Ambulation | Yes | Not examined | Yes |
| ADL abilities | No | Not examined | Not examined |
a Retrospective recall, cross-sectional design, n = 50.
b Retrospective recall, cross-sectional design, n = 1089.
All studies found that mobility devices were in some way associated with falling. Cattaneo and colleagues found that more fallers used a cane than nonfallers, and Nilsågard and colleagues found that individuals who used walking aids either indoors or out had double the risk of a fall compared with those who used no walking aid. Compared with people who always used a wheelchair for mobility, Finlayson and colleagues found that never users and sometimes users had approximately two times greater risk of a fall. Together with other findings regarding balance and ambulation across these studies, it is clear that further investigation of role of mobility device use in fall risk is warranted. Although the findings simply may reflect that mobility device users are more disabled, and therefore at greater risk, Finlayson and colleagues also suggest that mobility device decision-making (eg, to use any device, to use a more supportive device under specific circumstances) also may be playing a role.
Other factors that were found to increase risk of a fall in at least two of the studies include being male and MS status/disability. Findings about the role of specific symptoms are variable, and will require further investigation in the future.
Late effects of polio
Only one study was identified that examined risk factors for falls among people previously affected by polio, and it focused primarily on the role of lower extremity strength. The study included 40 people with prior polio and 38 age- and sex-matched controls. To examine predictors of falls within the polio group, researchers divided the group into people experiencing zero falls or one fall in the past year (n = 13), those who fell twice (n = 8), and those who fell multiple times (n = 19). Compared with people who fell twice, the multiple fallers had reduced strength in ankle dorsiflexors, greater lower extremity weakness, slower hand and foot reaction times, slower foot-tapping speed, and increased body sway on a compliant surface under both eyes-open and eyes-closed conditions. Of these differences, the ones with the greatest discriminating power were body sway and composite strength. The authors concluded that weakness has a direct association with falls among people with prior polio, as well as an indirect effect mediated through increased body sway.
Muscular dystrophies
Only one study was identified that examined fall risk factors among people with myotonic dystrophy type 1. The study included 13 people with myotonic dystrophy and 12 healthy volunteers matched for sex, weight, and body mass index. In bivariate analyses, fallers (n = 6) and nonfallers (n = 7) within the myotonic dystrophy group were compared. Findings showed that fallers were more likely to have a lower Rivermead Mobility Index score, more likely to use mobility devices or a person to aid mobility indoors or outdoors, have a slower self-selected gait speed, and higher depression. Although the authors also report regression analysis, the small sample size and large number of variables raise questions about the validity of the findings.
Spinal cord injuries
Only one study was identified that examined fall risk factors among people with spinal cord injury, specifically those with incomplete injury. Using a mail-out survey, researchers gathered information on falls and fall risk factors among 119 people. Three multivariable logistic regression models evaluated differences between fallers and nonfallers.
The first model examined differences in demographic and injury characteristics, and no statistically significant differences were found. The second model examined differences in health-related data, and found that fallers were more likely to
Have had more days of poor physical health in the past year
Have greater numbers of medical conditions
Have arthritis
Experience dizziness
Report lower self-rated health
Report worse health compared with the previous year.
The third model examined differences in physical activity and found that fallers exercised less frequently, were fearful of falling, limited activities because of fear of falling, used a cane (vs not), and used a walker (vs not). When the significant variables from all three models were combined into a final model, the most significant factors associated with a fall among people with incomplete spinal cord injuries were exercising less than 8 times per month and not using a walker.
Summary and Comparison
A surge in fall-related research over the past 10 to 15 years has dramatically enhanced understanding of fall risk factors, particularly among community-dwelling older adults. It is clear that knowledge related to fall risks among people aging with physical disability is lagging far behind. To date, the literature on fall risk factors among people aging with multiple sclerosis, late effects of polio, muscular dystrophies, or spinal cord injuries has not addressed extrinsic risk factors, including the potential role of multiple medication use and home hazards in increasing fall risk. Among intrinsic factors across these four groups, vision has not been investigated, and the evaluation of the role of cognition, fear of falling, falls self-efficacy, depression, and functional status has been inconsistent at best. Future work needs to address these gaps in knowledge, and consider the application of consistent frameworks for organizing thinking about risk factors (eg, intrinsic vs extrinsic, modifiable vs not) and how they interact and build on each other to influence an individual’s fall-related risk.
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