Fractures & falling

Falls


LASA*187,
LASA*605, LASAD705,
LASA*o00/o01/02, LASADo72/73,
LASAC805, LASAC815

Contact: Natasja van Schoor

Background
Falls are an important public health problem among older persons because they occur frequently and may have severe consequences.(1-4) Thirty percent of people over the age of 65 who live in the community fall at least once a year.(5-7) Falls can result in serious injuries, such as fracture and head trauma,(2-8) and may cause fear of falling, functional decline and limitation of activity.(4,6,9,10) Moreover, fall-related injuries are the third leading cause of years lived with disability according to the WHO report “Global burden of disease”.(11) These serious consequences emphasise the need to implement strategies to decrease the burden of falls in older people.

Measurement instruments in LASA

Main data
The presence of self-reported falls in the previous year was ascertained retrospectively during the medical (LASA*187) and telephone interviews (LASA*605, LASAD705).

Side studies

  1. A three-year prospective fall calendar
    A three-year fall follow-up was performed in respondents who participated in the second data collection cycle of LASA (1995/96) and were born in or before 1930 (aged 65 years and older as of January 1, 1996) (n=1509). At the end of the second medical interview (1995/1996) respondents received a ‘fall calendar’ and were asked to record fall events weekly until the third medical interview (1998/1999). Participants were instructed to record weekly whether or not they had fallen and if they had fallen inside or outside. Subsequently, they were asked to mail the calendar to the institute at the end of every three-month period. They were contacted by telephone if they were not able to complete the ‘fall calendar’, if no calendar was returned even after a reminder, or if the calendar was completed incorrectly. Proxies were contacted if participants were not able to respond. For the respondents, a fall was defined as ‘an unintentional change in position resulting in coming to rest at a lower level or on the ground’(12) (LASACo00/01/02).
  2. Falls: Prevention of fall incidents
    A one-year fall follow-up using a fall calendar was performed in a subsample from the first cohort (n=439) from 1999/2000 to 2000/2001 (LASADo072/73). See: Falls: Prevention of fall incidents
  3. Frailty study
    The presence of self-reported falls in the previous year was ascertained retrospectively during the frailty study of 1998/1999 (LASAC705, LASAC715).
  4. A one-year prospective fall calendar (LASAGo01/02)
    a one-year fall follow-up using a fall calendar was performed in a subsample from the second cohort (LASAGo01/02). See: A one-year prospective fall calendar: (LASAGo01/02)


Circumstances and consequences of falls

During the third data-collection of LASA (1998/1999) the circumstances and consequences of falls were investigated (LASAD187). The circumstances and consequences of a maximum of two falls in the year before the interview were assessed (asked retrospectively). The location (e.g. living room, street, kitchen) and the occasion (e.g. trips, slips, dizziness) of falls, the activity performed just before falling (e.g. walking, gardening, bicycling), physical injuries (fracture, brain injury, open wound) and the use of medical help because of a fall (e.g. general practitioner, hospital, nursing home) were assessed. Furthermore, we asked whether the respondent changed anything in the house because of falling (e.g. antislip in bathroom, higher toilet, more light in the room). The circumstances and consequences of falls were also determined (in more detail) within a smaller subsample (n=439) of the LASA population (see: Prevention of fall accidents). In this substudy, we asked about the circumstances and consequences of the last fall in the year before the interview.

Questionnaires
LASAC187 / LASAD187 / LAS3B187 / LASMB187 (medical interview, in Dutch);
LASAC605 / LASAD605 (telephone interview with PROXY, in Dutch));
LASAD705 (telephone interview with RESP, in Dutch);
LASAo00/o01/02 (under construction);
LASADo72/73 (under construction);
LASAC805 (under construction);
LASAC815 (under construction)

Variable information
LASAC187 / LASAD187 / LAS3B187 / LASMB187
(pdf) ;
LASAC605 / LASAD605
(pdf);
LASAD705
(pdf);
LASAo00/o01/02 (under construction);
LASADo72/73 (under construction);
LASAC805 (under construction);
LASAC815 (under construction)

Table 1. Availability of information per wave 1 

 

B

C

D

E

 
2B*2

F

G

H



3B*2

MB*2

I*

LASA187

 

Me2

Me2

 

 

 

 

 

Me2

Me2

 

LASA605

 

Te2,4

Te2,5

 

 

 

 

 

 

 

 

LASAD705

 

 

Te2,6

 

 

 

 

 

 

 

 

LASAo00/o01/02

 

Me3

 

 

 

 

Me3

 

 

 

 

LASADo72/73

 

 

Int3,7

 

 

 

 

 

 

 

 

LASAC805

 

Qu3,8

 

 

 

 

 

 

 

 

 

LASAC815

 

Te3,9

 

 

 

 

 

 

 

 

 

1 More information about the LASA data collection waves is available here.

 * 2B=baseline second cohort;
    3B=baseline third cohort;
    MB=migrants: baseline first cohort

Me=data collected in medical interview
Te=data collected in telephone interview with respondent or proxy

2 Retrospective follow-up
3 Prospective follow-up
4 Telephone interview with respondent or proxy
5 Telephone interview with proxy
6 Telephone interview with respondent
7  Side study “Falls: Prevention of fall incidents”: face-to-face interview
8  Side study “Frail study” performed in respondents by questionnaire
9  Side study “Frail study” performed in proxies by telephone interview

Previous use in LASA
Tromp et al. (1998) identified urinary incontinence, impaired mobility, use of analgesics and use of antiepileptic drugs as the predictors most strongly associated with recurrent falls. In 2001, Tromp et al. developed a fall-risk screening test, which is based on four easily measurable predictors: physical, cognitive, emotional and social functioning. This fall-risk screening test can be used for fall-risk stratification in community-dwelling elderly. Van Schoor et al. (2002) conclude that ‘immediate memory’ is an independent risk factor for recurrent falls in persons aged 75 and older. Stel et al. (2003) developed a classification tree which included 11 end groups differing in the risk of recurrent falling, based on a specific combination of a maximum of six easily measurable predictors. In 2004, Stel et al. described the consequences of falls. Pluijm et al. (2006) develop a risk profile for for identifying community-dwelling elderly with a high risk of recurrent falling during three years of follow-up. Research of Peeters et al. (2010) shows that at higher levels of physical activity, the risk of recurrent falling decreased, while there was no association with fall risk. Pijpers et al. (2012) show that individuals with diabetes had an increased risk on recurrent falls. Factors that partly explained this increased risk were: greater number of medication, higher levels of pain, poorer self-perceived health, lower physical activity and grip strength, more limitations in ADL, lower-extremity physical performance and cognitive impairment.

  • Tromp AM, Smit JH, Deeg DJH, Bouter LM, Lips P. Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. J Bone Miner Res 1998; 13: 1932-9.
  • Tromp AM, Pluijm SMF, Smit JH, Deeg DJH, Bouter LM, Lips P. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001; 54: 837-44.
  • van Schoor NM, Smit JH, Pluijm SM, Jonker C, Lips P. Different cognitive functions in relation to falls among older persons. Immediate memory as an independent risk factor for falls. J Clin Epidemiol. 2002 Sep: 55(9):855-862.
  • Stel VS, Pluijm SM, Deeg DJ, Smit JH, Bouter LM, Lips P. A classification tree for predicting recurrent falling in community-dwelling older persons. J Am Geriatr Soc 2003; 51(10):1356-1364.
  • Stel VS, Smit JH, Pluijm SM et al. Consequences of falling in older men and women and risk factors for health service use and functional decline. Age Ageing 2004; 33(1): 58-65.
  • Pluijm, S.M.F., Smit, J.H., Tromp, E.A.M., Stel, V.S., Deeg, D.J.H., Bouter, L.M., Lips, P.T.A. A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study.Osteoporos Int 2006, 17, 417-425.
  • Peeters, G.M.E.E., Van Schoor , N.M., Pluijm, S.M.F., Deeg, D.J.H., Lips, P.T.A. Is there a U-shaped association between physical activity and falling in older persons? Osteoporos Int 2010; 21, 1189-1195.
  • Pijpers, E., Ferreira, I., De Jongh, R.T., Deeg, D.J.H., Lips, P.T.A., Stehouwer, C.D.A., Nieuwenhuijzen Kruseman, A.C. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing 2012; 41, 358-365.

References

  1. Kiel DP, O’Sullivan P, Teno JM, Mor V. Health care utilization and functional status following a fall. Med Care 1991; 29: 221-8.
  2. Nevitt MC, Cummings SR, Kidd S, Black D. Risk factors for recurrent nonsyncopal falls: a prospective study. JAMA 1989; 261: 2663-8.
  3. Tinetti ME, Liu WL, Claus EB. Predictors and prognosis of inability to get up after falls among elderly persons. JAMA 1993; 269: 65-70.
  4. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing 1997; 26: 189-93.
  5. O'Loughlin JL, Robitaille Y, Boivin JF, Suissa S. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol 1993; 137: 342-54.
  6. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319: 1701-7.
  7. Tromp AM, Smit JH, Deeg DJH, Bouter LM, Lips P. Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. J Bone Miner Res 1998; 13: 1932-9.
  8. Sattin RW, Lambert Huber DA, DeVito CA et al. The incidence of fall injury events among the elderly in a defined population. Am J Epidemiol 1990; 131: 1028-37.
  9. Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald YL. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing 1990; 19: 136-41.
  10. Kosorok MR, Omenn GS, Diehr P, Koepsell TD, Patrick DL. Restricted activity days among older adults. Am J Public Health 1992; 82: 1263-7.
  11. Murray CJL, Lopez AD. Global and regional descriptive epidemiology of disability: incidence, prevalence, health expectancies and years lived with disability. In: Murray CJL, Lopez AD, eds. The global burden of disease. Boston: Harvard University Press, 1996: 201-46.
  12. Kellogg International Work Group on the prevention of falls by the elderly. The prevention of falls in later life. Dan Med Bull 1987; 34: 1-24.
  13. Tromp AM, Pluijm SMF, Smit JH, Deeg DJH, Bouter LM, Lips P. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 2001; 54: 837-44.
  14. Pluijm SM, Smit JH, Tromp EA et al. A risk profile for identifying community-dwelling elderly with a high risk of recurrent falling: results of a 3-year prospective study. Osteoporos Int 2006; 17(3): 417-25.
  15. van Schoor NM, Smit JH, Pluijm SM, Jonker C, Lips P. Different cognitive functions in relation to falls among older persons. Immediate memory as an independent risk factor for falls. J Clin Epidemiol. 2002 Sep: 55(9):855-862.
  16. Stel VS, Pluijm SM, Deeg DJ, Smit JH, Bouter LM, Lips P. A classification tree for predicting recurrent falling in community-dwelling older persons. J Am Geriatr Soc. 2003 Oct: 51(10):1356-1364.

 

Appendix: Fall definitions in LASA

  1. Retrospective recording of falls(7)
    a. A ‘faller’ was defined as a subject who fell at least once in the year preceding the interview. b. A ‘recurrent faller’ was defined as a subject who fell at least twice in the year preceding the interview.
  2. Prospective one-year follow-up(13)
    a. A ‘faller’ was defined as a subject who fell at least once in the one-year follow-up.
    b. A ‘recurrent faller’ was defined as a subject who fell at least twice in the one-year follow-up.
  3. Prospective three-year follow-up(14,15,16) (see syntax: syntax LASACo01)
    With three years of fall follow-up (instead of one year) we were able to use a more stringent definition (number of falls within six months instead of one year) for a recurrent faller.
    a. A ‘faller’ was defined as a subject who fell at least once during the three-year fall follow-up. Fall1 and TTF1 corresponds to being a faller (yes/no) and the time to first fall respectively and can be used for survival analyses. The criteria for censoring (time to censor) were soft refusal, not contacted, ineligible, refusal or dead. Participants were included until the first missing calendar sheet.
    (see syntax: syntax (time to) first fall)
    b. A ‘recurrent faller’ was defined as a subject who fell at least two times within six months during the three-year fall follow-up.(14,15)
    c. For reasons of comparability with definition of 3a, the ‘survival time’ was defined as the time to the second fall, on the condition that the first fall had occurred within six months before the second fall. If the first fall had not occurred within six months before the second fall, the survival time was defined as the time to the third fall, but only if the second fall had occurred within six months before the third fall, and so on.(16)

 

In LASA, two recurrent faller-variables exist: veelval and status. Both variables use the definition of recurrent falling as explained above. All participants had to be at least 6 months at risk to be classified as recurrent faller in either veelval and status. The variable status should be used in survival analyses in combination with the variable timeall (which contains the number of weeks until the second fall within a six-month period). In status, the participants who were censored are still included in the analyses. The ones who were not recurrent fallers until censoring were classified as not-recurrent faller, with corresponding time to censor. Otherwise, they were classified as recurrent faller, with corresponding time to fall. Time to censor was defined as time to the first calendar sheet that was missing due to not contacted, ineligible, refusal or dead. Missings in status were respondents who had died, were ineligible or who refused participation in the first six months. The variable veelval can be used in logistic regression analyses. Missing in veelval are those respondents who deceased, refused participation or were ineligible in the first or second period or who started at the end of the first period and deceased, refused participation or were ineligible in the third period. As a result, the variable veelval contains more missings than variable status.

In the articles of Saskia Pluijm(14) and Vianda Stel(16), participants who gave soft refusal or who were not contacted in the first two periods were not excluded in veelval (n=78 and n=18, respectively) or status (n=81 and n=31, respectively). Later, it was decided that those participants who did not provide any information could not be classified as a (recurrent) faller or not-(recurrent) faller. Therefore, in the articles written by Geeske Peeters, those who had soft-refusals in the first two periods and no additional information in later periods were also excluded from the analyses (n=16). In addition, participants who gave soft refusals in later periods were included in the study until the time point of the first missing calendar sheet and thus 22 participants were censored. In other words, time to censor was defined as time to the first calendar sheet that was missing due to any reason (i.e. soft refusal, not contacted, ineligible, refusal or dead).
(see syntax: syntax (time to) recurrent falling)