Medication Related Falls in Older People

by Allen R. Huang and Louise Mallet

Medication Related Falls in Older People Author Allen R Huang and Louise Mallet Isbn 9783319323022 File size 4MB Year 2016 Pages 261 Language English File format PDF Category Medicine Comprising a single repository of knowledge and scientific evidence in the field this book provides strategies to mitigate fall risk by providing information on the complex interactions between aging processes co morbid conditions and prescribed medications in older patients Geriatric health is becoming a more prominent issue as the population ages

Publisher :

Author : Allen R. Huang and Louise Mallet

ISBN : 9783319323022

Year : 2016

Language: English

File Size : 4MB

Category : Medicine



Medication-Related Falls in Older People

Allen R. Huang • Louise Mallet
Editors

Medication-Related Falls
in Older People
Causative Factors and Management Strategies

Editors
Allen R. Huang
Head, Division of Geriatric Medicine
University of Ottawa and
The Ottawa Hospital
Associate Professor of Medicine
University of Ottawa
Adjunct Professor of Medicine
McGill University
Montréal, Québec
Canada

Louise Mallet
Head, Faculty of Pharmacy
Université de Montréal
Montréal, Québec
Canada
Clinical Pharmacist in Geriatrics
McGill University Health Centre
Montréal, Québec
Canada

ISBN 978-3-319-32302-2
ISBN 978-3-319-32304-6
DOI 10.1007/978-3-319-32304-6

(eBook)

Library of Congress Control Number: 2016944151
© Springer International Publishing Switzerland 2016
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Preface

The aging of the world population is highlighting the problems encountered by
older people as they seek health care. Medication use is a double-edged sword: the
beneficial effects of drug therapy must be balanced against potential and real side
effects that drugs can cause in older patients. The situation is made more complex
for individual patients because of the multiple factors involved, such as the physiologic changes in the body due to aging processes, the accumulation of comorbidities, and the use of drugs to manage various conditions and symptoms. Falls are a
dreaded event in older people. It can affect a person biologically, resulting in soft
tissue and bony trauma including fractures, psychologically resulting in fear of falling and mental health well-being resulting in depression. The identification of and
reduction in fall risks in older people is a worldwide concern. Falls (or the reduction
in their numbers) are a ubiquitous quality measure of health care delivery. Medication
use is an important and potentially modifiable factor. This book serves as a repository of knowledge and scientific evidence concerning medications and their effects
on falls risk. The book will inform readers of the complexity of the issue of medication-related falls in older people and provide strategies for its management. The
target audience for this book includes (1) health professionals with an interest in
researching and caring for older people, (2) managers of institutions or health systems, (3) policy-makers and health system funding decision-makers, and (4) the
general public seeking high-quality information on this topic – especially those
individuals with aging parents who have experienced falls or medication problems.
This book will not be able to provide a single solution to this important clinical
problem because of its complexity. Perhaps in the future, as a convergence of
genomics, proteomics, and therapeutics occurs, health science may be able to optimize medication use in each individual person to minimize the risk of side effects
and adverse events.
Ottawa, ON, Canada
Montréal, QC, Canada

Allen R. Huang
Louise Mallet

v

Contents

Part I: Background
1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Allen R. Huang and Louise Mallet

2

The Aging Population and Falls: Consequences and Costs . . . . . . . . . . 7
Paula M. Horsley and Allen R. Huang

3

Falls Count and Counting Falls: Making Sense
of Data About Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Nancy E. Mayo and Sabrina M. Figueiredo

Part II: Drugs and Falls: Why Are Older People at Risk?
4

Polypharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Susan K. Bowles

5

Pharmacology of Drugs in Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Louise Mallet

6

Age-Related Physical and Physiologic Changes and
Comorbidities in Older People: Association with Falls . . . . . . . . . . . . . 67
Gustavo Duque

7

Adverse Events and Falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Shirley C.C. Huang and Alan J. Forster

8

Risk Factors for Falls in the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
E. Kwan, S. Straus, and J. Holroyd-Leduc

Part III: Medications Associated with Falls in the Elderly
9

Psychotropic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Andrea Iaboni and Benoit H. Mulsant

10

Benzodiazepines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Annemie Somers and Mirko Petrovic
vii

viii

Contents

11

Drugs for Degenerative Neurologic Conditions: Antiparkinson
Medications, Cholinesterase Inhibitors, and Memantine . . . . . . . . . . 135
Geneviève Lemay

12

Antihypertensives and Cardiovascular Medications . . . . . . . . . . . . . . 147
Rebecca L. Salbu, Rosanne M. Leipzig, and Fred C. Ko

13

Glucose Control Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Louise Mallet

Part IV: Management of Medication-Related Falls
14

Inappropriate Medications and Risk of Falls
in Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Jennifer Greene Naples, Joseph T. Hanlon, Christine M. Ruby,
and Susan L. Greenspan

15

Identifying Explicit Criteria for the Prevention of Falls . . . . . . . . . . . 179
Denis Curtin, Stephen Byrne, and Denis O’Mahony

16

Approach to Medication Reviews in Older Adults . . . . . . . . . . . . . . . 191
Derek Dyks

17

Withdrawal of Fall Risk-Increasing Drugs . . . . . . . . . . . . . . . . . . . . . 199
Nathalie van der Velde and Tischa J.M. van der Cammen

18

Benzodiazepine Withdrawal in the Elderly:
A Practical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Louise Mallet

19

Role of Information and Communication Technologies . . . . . . . . . . . 223
Allen R. Huang

20

A Novel Personalized Fall Risk Calculator: A Prototype
for Improving the Safety of Prescribing Through Computerized
Decision Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Robyn Tamblyn

21

Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Allen R. Huang

Part I

Background

Chapter 1

Introduction
Allen R. Huang and Louise Mallet

Abstract Every person will fall throughout their life. More than one-third of
community-dwelling older adults fall every year. One of the important risk factors
for falling is taking medications. The contents of this book will help the reader
understand the various factors involved in increasing the risk for falls in older adults
and the various medications that contribute to that risk. This book represents a
repository of scientific evidence current at the time of its publication and can help
students and researchers understand the problem. People involved in health policymaking may also be engaged to help address this global problem. Additionally anyone with an interest in this topic can learn about medications and falls.
Books, in all their variety, offer the human intellect the means whereby civilisation may be
carried triumphantly forward. (Winston Churchill, November 8, 1937, Statement for the
National Book Fair)

The inspiration for this book came from the editor-in-chief of the journal Drugs
and Aging, Professor David Williamson. The invitational e-mail message arrived in
my inbox one morning, asking whether I would be interested in editing a book on
the topic of medication-related falls in the elderly. This topic was the subject of a
review article published in Drugs and Aging in 2012 that was among the top 10
downloaded articles from that journal and was frequently cited in other works. After
reflecting for a few hundreds of milliseconds, accounting for my aging neurones, I
replied “yes” and immediately consulted with my colleague and geriatric pharmacist Louise Mallet. The idea of producing a book in the era of digital data, 9-second

A.R. Huang, MDCM, FRCPC (*)
Division of Geriatric Medicine, University of Ottawa and The Ottawa Hospital,
Ottawa, ON, Canada
Adjunct Professor of Medicine, McGill University, Montréal, QC, Canada
e-mail: [email protected]
L. Mallet, BScPharm, PharmD, CGP, FESCP
Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada
Department of Pharmacy, McGill University Health Centre, Montréal, QC, Canada
e-mail: [email protected]
© Springer International Publishing Switzerland 2016
A.R. Huang, L. Mallet (eds.), Medication-related falls in older people,
DOI 10.1007/978-3-319-32304-6_1

3

4

A.R. Huang and L. Mallet

sound bites1, and instant information where “google” is now a verb2 initially seemed
counter-intuitive. This book project reminds me of one of the original Star Trek
television episodes, entitled “Court Martial” (season 1, episode 20, 1967) when
Captain Kirk was accused of reckless behaviour during an ion storm, resulting in the
ejection of a research pod in order to save the starship. His legal case was defended
by attorney Samuel T. Cogley, who insisted on trusting his books and not relying on
computer records. His case was won when the logician, Mr. Spock, observed that he
was able to repeatedly win at computer chess, indicating that something had changed
in the ship’s computer and therefore also the logs. The episode came to the conclusion that computers are not infallible and that human intuition, logic, and understanding of out of range results are needed to arrive at the truth. Similarly, I feel that
books lend a permanency to information and knowledge. Maybe it represents a
subconscious comfort, reliving the time spent in the medical library, searching for
information by poring through references in the huge tomes of Index Medicus.
Although a published work may appear static, the words and writing it contains
embody the deep knowledge and personalities of the authors. Therefore, a book
lives and breathes. The words tell the reader about the knowledge and wisdom the
author wishes the reader to understand.
Every person will fall throughout their life: as a toddler learning to walk, as a
child and adolescent partaking in sporting activities, as an adult partaking in thrillseeking activities and finally as an older adult. More than one-third of communitydwelling older adults fall every year. One of the important risk factors for falling is
taking medications. Prescription medications are a double-edged sword: they help
manage various medical conditions and they also have potential side effects that can
affect an older person’s blood pressure and neuromuscular control resulting in an
increased risk for falling. The topic of medication-related falls in older people has
many moving parts: physical and physiologic changes in the aging body, changes in
the way the body handles medications and the effects of those medications, the puzzling presentation of illness in older people, the medication cascade, the need for
health-care workers and professionals to think differently and health-care systems
that need to better manage older patients. After all, we wish to improve the healthcare system to look after ourselves when we grow old and need those services for
ourselves.
We hope that this book will help health-care providers recognize the role of
medications in increasing the risk of falls. With this awareness, more frequent
review of medications and targeting of fall risk-increasing drugs and proactive interventions with the goal of fall prevention can occur. This book is divided into four
parts. The Background section describes the scope of the global problem of falls
and how to critically interpret the myriad published data on falls. Part 2, “Why Are
Older People At Risk?” describes the various factors, both intrinsic to older people
and extrinsic, that are modifiable which conspire to put older people at higher risk
1

Ryfe and Kemmelmeier [1].
The word “google” was added as a transitive verb to the Oxford English Dictionary on June 15,
2006.
2

1

Introduction

5

for falls. Part 3 drills down into the details of various medication classes that have
been identified as being associated with increased fall risk. Finally in Part 4,
“Management of Medication-Related Falls” evidence supporting various strategies
will be presented that clinicians can use to modify fall risk in older patients taking
medications.
This work was designed to serve several purposes. Firstly, it represents a repository
of scientific evidence concerning the topics discussed in each chapter. We had thought:
“Wouldn’t it be handy to have a single volume containing all the significant references
so that future students, and investigators would have this information at their fingertips?” Secondly, a reader who wishes to skim the chapters and scan the abstracts or
very important points (VIPs) boxes can get a good overview of this important clinical
topic. Thirdly, people who are involved in policy-making can use this book and the
knowledge and data embedded in its chapters to develop systems (environmental,
social, health, education) which can help address this global problem. Finally, people
who are sometimes patients can read and learn about medications and falls.
Although this book is destined to be available primarily in electronic format, we
hope that it also finds a place on your bookshelf. For me a book is best embodied in
its paper form. Paper is a universal operating system. It does not crash. Page corner
turndowns become satisfying bookmarks. Touching a line of text with a highlighter
pen or underlining with a pencil or pen somehow reinforces the understanding and
memory of what was just read. Whatever your preference, Louise and I hope that
this book will help you understand and appreciate the topic of medication-related
falls in the elderly.
Acknowledgments Lastly, Louise and I wish to gratefully acknowledge and thank all the
contributors who invested their time to write in order to communicate their knowledge within
this book.

Reference
1. Ryfe DM, Kemmelmeier M (2011) Quoting practices, path dependency and the birth of modern journalism. J Stud 12:10–26

Chapter 2

The Aging Population and Falls:
Consequences and Costs
Paula M. Horsley and Allen R. Huang

Abstract Adults 60 years of age and older are the fastest-growing group in the
world. Falling is defined as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” and is a common clinical and
public health problem that affects many older adults. Approximately 5-10% of falls
result in serious injury to the person. Bipedal locomotion that evolved as humans
evolved places us at higher risk for falling. Perturbations to circulatory, respiratory,
nervous, and musculoskeletal systems, along with impaired cognition and concentration, can increase fall risk. Falls are costly. Falls can also have a significant impact
on the quality of life of older adults. Fall prevention is paramount. Strategies aimed
at preventing falls need to be multifaceted and widespread to address the many
different risk factors.
Adults over the age of 60 years are the fastest-growing group within the global
population [28]. It is projected that this population group will increase in number
from 841 million in 2013 to over 2 billion in 2050 [21]. This means that older adults,
who currently make up 12% of the population, will more than double in size and
make up 21.1 % of the population in the year 2050 [21]. By 2050 (or even a few
years earlier), it is expected that older adults will outnumber children for the first
time in the history of the world [21]. The growth of this population group is not
expected to stop in 2050; in fact, the United Nations predicts that the number of
older adults will continue to grow and will triple in number by the year 2100 [22,
23]. This tremendous increase in the global population of older adults will significantly impact society and our world as we know it.

P.M. Horsley (*)
Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
e-mail: [email protected]
A.R. Huang, MDCM, FRCPC
Division of Geriatric Medicine, University of Ottawa and The Ottawa Hospital,
Ottawa, ON, Canada
Adjunct Professor of Medicine, McGill University, Montréal, QC, Canada
e-mail: [email protected]
© Springer International Publishing Switzerland 2016
A.R. Huang, L. Mallet (eds.), Medication-related falls in older people,
DOI 10.1007/978-3-319-32304-6_2

7

8

P.M. Horsley and A.R. Huang

Although older adults make up a large proportion of our global population, it is
important to note that some regions within the world have a greater impact on these
numbers than others [30]. Based on statistics taken by the World Health Organization
in 2013, the Region of the Americas, the Western Pacific Region, and the European
Region currently have the highest proportion of adults over the age of 60 years (14 %,
15 %, and 21 %, respectively) [30]. Older adults in the African Region, Eastern
Mediterranean Region, and Southeast Asia Region make up a smaller proportion of
their populations, ranging from 5 to 8 % [30]. Therefore, the impact that this growing
global population group has on each country varies geographically. Particular attention has been placed on the cohort of people aged 85 years and older, since this cohort
is expanding at the most rapid rate and life expectancy for males and females combined in Canada is projected to increase from 82.6 years to 92.2 years by the year
2100 [23].
Falling is a common clinical and public health problem that affects many older
adults around the world [15, 17, 20, 28, 29]. The World Health Organization defines
a fall as “an event which results in a person coming to rest inadvertently on the
ground or floor or other lower level” [27, 29]. Falls are a significant concern for
many older adults, as approximately one-third of older adults living in the community fall each year [3, 6, 24]. As one ages, there is an increased risk of falling and
the falls are often of greater significance [14]. This risk continues to increase over
time [24], as evidenced by fatal fall rates peaking in the 85-year-old and older category [28]. Although not every fall leads to a serious injury, approximately 5–10 %
do [3]. A fall can lead to chronic pain, fear of future falls, decreased independence,
and decreased quality of life [28], as well as immobility, morbidity, early long-term
care placement, and even death [15]. In 2012 alone, 28,753 deaths in the United
States were due to unintentional falls [13]. Globally, unintentional falls are the second leading cause of injury resulting in death and most commonly occur in adults
over the age of 60 years [27, 29].
In order to understand why humans fall, it is important to consider many factors
that increase one’s risk of falling, starting with our desire to walk on two feet. The
evolution of the human ability to walk upright occurred in a stepwise manner, as
evidenced by differing physical features seen in our ancestors as we transitioned
from quadrupeds to bipeds [26]. As a biped, the human body relies heavily on the
musculoskeletal system and brain to continuously make adjustments to one’s posture due to the lack of rigid fixation between our vertically stacked body parts [16].
This lack of fixation, combined with a constant force of gravity acting upon it,
increases our risk of falling whenever we move and disturb this vertical alignment
[16]. A high center of mass, as a result of our upright posture, and small surface area
with which to balance on further contribute to our instability as bipeds [16].
The pathophysiology of a fall in older adults is complex and often involves a
combination of many different factors [1, 12]. Adding to this complexity is the significant amount of diversity between older adults, which makes it even more difficult to determine an individual person’s risk for falling [28]. The intricate interplay
of many different systems, such as the coordinated interactions of the circulatory,
respiratory, nervous, and musculoskeletal systems, along with functioning cognition

2

The Aging Population and Falls: Consequences and Costs

9

and concentration, plays an important role in fall prevention [1, 15, 20]. With age,
these systems start to become less efficient and effective, which increases one’s risk
for falling [1]. Older adults often have a more rigid and less coordinated gait than
younger populations, which, in combination with decreased reflexes, muscle
strength, and posture control, impairs their ability to maintain balance [15]. There
are also many external factors that can increase an individual’s risk for falling, such
as environmental hazards [28, 29], individual behaviors (such as risk-taking and
ethanol consumption) [28], pain [19], and a selection of associated medications [1,
4, 7, 9, 20, 24]. The subsequent chapter on “Age-Related Physical and Physiologic
Changes and Co-morbidities in Older People: Association With Falls” will describe
these factors in detail.
Falls are costly. Approximately 0.85–1.5 % of total health-care dollars in North
America, Australia, the United Kingdom, and Europe are spent on costs relating to
falls [8, 14]. Based on the data collected by Stevens and colleagues [18] and correcting for inflation, the Centers for Disease Control and Prevention estimated that the
direct medical costs for falls in the elderly in 2013 in the United States were approximately US$ 34 billion [2]. The actual cost is likely higher, as estimates do not take
into account the costs associated with disability, reliance on others, time lost from
both in-home and out-of-home work, or decreased quality of life [2]. Current projections indicate a continued increase in the costs associated with falls, as the global
population ages and more falls occur [2].
Not only are falls costly, but they can also have a significant impact on the life of
older adults. The fear of falling is a common concern that affects many individuals,
even in those who have no previous history of falling [11]. Sixty-three percent of
seniors in long-term care and 26–55 % of community dwelling older adults are
afraid of falling [10]. Older adults will often limit their activities, resulting in physical deconditioning and a decreased quality of life, due to fear of injuring themselves
when mobilizing [10, 15]. In addition to concerns about injury, older adults often
fear falling because they do not want to be embarrassed socially, lose their independence, or need to move out of their own home [28].
Fall prevention is paramount. Strategies aimed at preventing falls need to be multifaceted and widespread to address many different risk factors that play a role in
falling [29]. As described by the World Health Organization in their recent agefriendly world initiative, proper community planning, such as ensuring that buildings are accessible, public transportation is safe, and social and leisure activities are
abundant and available for older adults, is an essential component in fall prevention
[31]. Assessing and modifying one’s own home environment, particularly in highrisk fallers, to increase safety and minimize hazards have also been found to reduce
the risk of falling in older adults [6]. Promoting healthy societal and individual attitudes, such as encouraging older adults to stay active, participate in social activities,
and ask for help when needed, would help dispel the false belief that falling is a
normal age-related change and would also help engage individuals in fall prevention
precautions [25, 28, 31]. Physical activity has been shown to help prevent falls in the
elderly [5, 6], including falls that would have resulted in severe injury [5]. Muscle
strengthening, flexibility, and improving sense of balance have been shown to be

10

P.M. Horsley and A.R. Huang

cost-effective ways to address this multifaceted issue. Last but certainly not least,
proper management of medications plays a key role in preventing falls [4, 7, 9, 24].
Polypharmacy is a common clinical challenge that must be reviewed and evaluated
at each clinical encounter, as many medications, especially when taken improperly,
increase one’s risk for falling [4, 7, 9, 24]. Spending time to review medications can
help ensure that patients are taking the correct medications, at the correct doses, and
all unnecessary medications are deprescribed appropriately, in order to maximize
benefit and minimize potential harm [4, 9]. Limiting the number and frequency of
medications, educating patients about their medications, and organizing the medications for patients, such as in blister packs or dosette boxes, can help improve adherence and possibly decrease the risk for medication-related falls [7]. Details will
follow in subsequent chapters in this book.
In summary, the global population is aging; projections suggest that the number
of older adults will increase twofold by 2050 and threefold by 2100. Falls are a common health concern among older adults and have a significant impact on both the
individual and the health-care system. A proactive approach to fall prevention needs
to be implemented, as reactionary approaches have been shown to be more costly.
Designing interventions that work at the individual, environmental, social, and governmental levels will ensure many different risk factors are targeted and outcomes
are optimized. We invite the readers to explore the contents of this book in order to
understand the opportunities that exist for improving this significant health-care
problem.

References
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3. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E (2010) Risk factors for
falls in community-dwelling older people: a systematic review and meta-analysis.
Epidemiology 21(5):658–668
4. Dyks D, Sadowski CA (2015) Interventions to reduce medication-related falls. Can Geriatr
Soc J Contin Med Educ 5(1):23–31
5. El-Khoury F, Cassou B, Charles MA, Dargent-Molina P (2013) The effect of fall prevention
exercise programmes on fall induced injuries in community dwelling older adults: systematic
review and meta-analysis of randomised controlled trials. Br Med J 347, F6234. doi: 10.1136/
bmj.f6234 (Published 29 October 2013)
6. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE
(2012) Interventions for preventing falls in older people living in the community. Cochrane
Database Syst Rev (9):CD007146. DOI: 10.1002/14651858.CD007146.pub3.
7. Hart M, Giancroce P (2015) Safer prescribing in elderly patients. Can Geriatr Soc J Contin
Med Educ 5(1):16–22
8. Heinrich S, Rapp K, Rissmann U, Becker C, Konig HH (2010) Cost of falls in old age:a
systemati review. Osteoporosis International 21(6):891–902
9. Huang AR, Mallet L, Rochefort CM, Eguale T, Buckeridge DL, Tamblyn R (2012) Medicationrelated falls in the elderly. Drugs Aging 29(5):360–376

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J Am Med Dir Assoc 14(8):573–577
11. Liu JYW (2015) Fear of falling in robust community-dwelling older people: results of a crosssectional study. J Clin Nurs 24:393–405. doi:10.1111/jocn.12613
12. López-Soto PJ, Manfredini R, Smolensky MH, Rodríguez-Borrego MA (2015) 24-hour
pattern of falls in hospitalized and long-term care institutionalized elderly persons: a systematic review of the published literature. Chronobiol Int 32(4):548–556
13. Murphy SL, Kochanek KD, Xu J, Heron M (2015) Deaths: final data for 2012. Accessed on 18
Jan 2016. From http://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_09.pdf
14. Peel NM (2011) Epidemiology of falls in older age. Can J Aging/La Rev Can Vieillissement
30(01):7–19
15. Rubenstein LZ (2006) Falls in older people: epidemiology, risk factors and strategies for prevention. Age Ageing 35:ii37–ii41
16. Skoyles JR (2006) Human balance, the evolution of bipedalism and disequilibrium syndrome.
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20. Tinetti ME, Speechley M, Ginter SF (1988) Risk factors for falls among elderly persons living
in the community. N Engl J Med 319(26):1701–1707
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WorldPopulationAgeing2013.pdf
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http://agefriendlyworld.org/en/

Chapter 3

Falls Count and Counting Falls: Making Sense
of Data About Falls
Nancy E. Mayo and Sabrina M. Figueiredo

Abstract It is often challenging to make sense of research reports on falls. The
choice of statistical method depends on whether the outcome is binary (faller:
yes/no), a rate (falls per person-time in view), ordinal (number of falls per person) or time to fall (first). The most useful methods for analysing falls are those
that estimate parameters as they provide an estimated value for risk associated
with different levels of a factor or intervention. Less useful are statistics that
simply provide a yes/no answer as to whether the factor or intervention affects
risk (hypothesis testing). As falls are negative events, when parameters such as
odds ratios (OR), incidence rate ratios (IRR), hazard ratios (HR), proportional
odds ratios (POR) or cumulative odds ratios (COR) are greater than 1.0, they
indicate that the factor is associated with a higher risk of falls; when <1.0, the
factor or the intervention is associated with a lower risk of falls. All of these
statistical parameters can be used to identify risk factors for falls or to evaluate
effective interventions.

N.E. Mayo, BSc(PT), MSc, PhD (*)
Center for Outcomes Research and Evaluation, McGill University Health Centre Research Institute, Montreal, QC, Canada
Faculty of Medicine, Division of Clinical Epidemiology, McGill University,
Montreal, QC, Canada
Faculty of Medicine, School of Physical and Occupational Therapy, McGill University,
Montreal, QC, Canada
e-mail: [email protected]
S.M. Figueiredo, BSc(PT), MSc
Division of Clinical Epidemiology, McGill University, Montreal, QC, Canada
Faculty of Medicine, School of Physical and Occupational Therapy, McGill University,
Montreal, QC, Canada
e-mail: [email protected]
© Springer International Publishing Switzerland 2016
A.R. Huang, L. Mallet (eds.), Medication-related falls in older people,
DOI 10.1007/978-3-319-32304-6_3

13

14

N.E. Mayo and S.M. Figueiredo

Abbreviations
AR
CI
COR
df
FRIDs
GEE
HR
IRR
IR
NNH
NNT
OBD
OR
PAR
POR
RCT
RR
SD
VIP

3.1

Attributable risk
Confidence interval
Cumulative odds ratios
Degree of freedom
Fall risk-increasing drugs
Generalised estimating equations
Hazard ratio
Incidence rate ratio
Incidence rate
Number needed to harm
Number needed to treat
Occupied bed days
Odds ratio
Population attributable risk
Proportional odds ratios
Randomised controlled trial
Rate ratio
Standard deviation
Very important point

Falls Are an Important Health Concern

Falls are the leading cause of injury amongst seniors across Canada [1] resulting in
disability, chronic pain, loss of independence, reduced quality of life and even death
[2–5]. In 2012–2013, Canadian seniors experienced almost 85,000 fall-related hospitalizations; of those, 39 % involved a hip fracture and 8 % resulted in an in-hospital
death [6].
In addition to physical disabilities, falls also lead to psychosocial consequences.
Falls may result in fear of falling, which opens a vicious cycle of reduced confidence, reduced mobility and social participation, weakness and deconditioning,
which then culminate with recurrent falls [7, 8].
Going beyond patients’ perspective, falls also represent a financial burden to the
health-care system [6]. According to the Public Health Agency of Canada [1], more
than $2 billion is spent each year with fall-related expenses in the senior population. For instance, on average, patients admitted with a fall-related hospitalisation
stayed 6 days longer than all other hospitalizations and 29 % of nonresidential care
patients were transferred to residential care after a fall-related hospitalisation [9].
These physical, mental and economic implications are even more alarming due
to the fact that the number of falls is expected to increase as seniors are the fastestgrowing segment of the population [9, 10].

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