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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 61:399-404 (2006)
© 2006 The Gerontological Society of America

Impact of Falls on the Balance, Gait, and Activities of Daily Living Functioning in Community-Dwelling Chinese Older Adults

Leung-Wing Chu, Alice Y. Y. Chiu and Iris Chi

1 Division of Geriatric Medicine, University Department of Medicine, Queen Mary Hospital, The University of Hong Kong.
2 Department of Physiotherapy, Queen Mary Hospital, Hong Kong.
3 Sau Po Centre on Ageing, the University of Hong Kong.

Address correspondence to Leung-Wing Chu, FRCP, University Department of Medicine, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong, Hong Kong SAR. E-mail: lwchu{at}hkucc.hku.hk


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Objective. The objective of the present study was to investigate the impact of incident falls on the balance, gait, and Activities of Daily Living functioning in community-dwelling older adults.

Methods. This was a population-based, 1-year prospective cohort study in older adults. We performed baseline assessment of potential predictors, the 1-year occurrence of falls, and then 1-year reassessment of the following outcome measures: the Barthel Index (BI), Lawton's Instrumental Activities of Daily Living (IADL) scale, gait speed, and Tinetti Balance and Gait Evaluation's total mobility score (TMS). At 1 year of follow-up, participants who had declined by ≥1 standard deviation (SD) below the baseline mean value of each outcome measure were classified as "decliners."

Results. Of the 1517 participants, 93.5% (n = 1419) completed the 1-year follow-up reassessment of BI and IADL. For gait speed and TMS, respectively, 88.2% (n = 1338) and 88.3% (n = 1339) completed the 1-year outcome assessment. Fallers, particularly recurrent fallers, experienced significantly greater 1-year declines in the four functional measures. Multivariate logistic regression analyses showed that an incident fall was a significant independent predictor for decliners in the BI, Lawton's IADL score, gait speed, and TMS after adjustment of all significant confounding factors. The relative risks of an incident fall as an independent predictor for decliners in the BI, IADL score, gait speed, and TMS were 2.4 (95% confidence interval [CI], 1.4–4.0; p =.01), 2.9 (95% CI, 1.7–5.2; p <.001), 2.4 (95% CI, 1.5–3.8; p <.001), and 4.6 (95% CI, 2.7–7.8; p <.001), respectively.

Conclusions. Incident falls have a significant negative impact on the balance, gait, and Activities of Daily Living functioning in community-dwelling older adults.

FALLS occur commonly in approximately one-third of community-dwelling older adults each year (1–11). Physical injuries and psychological "fear of falling" consequences have been reported previously (1–13). However, the impact of falls on the balance, gait, and Activities of Daily Living (ADL) is less well investigated. In a retrospective study on self-reported change in physical functioning after falls, 35.3% of the fallers have reported a decline. Female sex, the number of medications, and depressive symptoms are independent risk factors for functional decline after falls (12). Kiel and colleagues (14) have reported that fallers have greater difficulties in basic ADL and Instrumental Activities of Daily Living (IADL) than do nonfallers. Tinetti and Williams (15) have reported that falls and fall injuries are associated with decline in basic ADL and IADL at both 1-year and 3-year follow-up. However, the effect of falls on balance and gait functioning has not been reported previously. Both chronic diseases and functional disability are common in older adults (16,17). There is a need to investigate further the independent functional impact of falls on balance and gait performance as well as ADL and IADL in older adults. The objective of the present prospective cohort study was to investigate the impact of incident falls on the balance, gait, and ADL functioning in community-dwelling older adults.


   METHODS
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 Abstract
 Methods
Results
 Discussion
 References
 
This was a prospective population-based cohort study performed in the community of Hong Kong. For the purpose of this study, a fall was defined as an event which resulted in a person coming to rest unintentionally on the ground or other lower level, not due to any intentional movement, a major intrinsic event, or extrinsic force (7,11,13).

A random population-based sample of community-dwelling Chinese older adults aged 65 years or older was taken in Hong Kong. A multistage sampling method was adopted with reference to the 1996 Hong Kong population census (18). A detailed description of this sample has been reported previously (11). The inclusion criteria were being Chinese, being at least 65 years old, living at home, having the ability to walk independently or with a walking aid, and providing informed consent. The exclusion criteria were being non-Chinese, younger than 65 years old, nonambulatory, and unable to cooperate in the assessment.

Baseline Assessment of Participants
Direct interviews of the participants were conducted at the participants' homes. For participants with cognitive impairment, additional information was obtained from family members. Demographic data, socioeconomic conditions, known diseases, medications history, and ADL were assessed by using a structured questionnaire at baseline. A clinical and functional assessment was carried out following the interview. The assessment tools included the Barthel Index (BI) for basic ADL (19–21), Lawton's IADL scale (22), the Abbreviated Mental Test (AMT) for brief cognitive assessment (23), and the short form of the Chinese Geriatric Depression Scale (GDS-15) for depressive mood assessment (24–27). We assessed vision in both eyes by using a handheld Rosenbaum visual acuity chart. Functional assessments of muscle strength, gait, and balance were assessed by direct assessment during home visits. Hand grip and knee extension strength were measured using the Jamar hand dynamometer (Sammons Preston, Mississauga, Ontario, Canada) and Nicholas Manual Muscle Tester (MMT; Lafayette Instrument Co., Lafayette, IN), respectively (7,11,13).

Follow-Up Assessment and Outcome Measures
Every participant was followed-up for 1 year for incident falls after entry into the study. Ascertainment of the occurrence of falls was performed every 2 months by phone follow-up. The participants and caregivers were asked about the occurrence of falls and any injury after falls. A reassessment of the outcome measures of BI, IADL score, gait speed, and Tinetti Balance and Gait Evaluation were performed at 1-year follow-up by home visits. ADL was assessed by the modified BI, which was reported to be a reliable and widely used clinical measure of basic ADL (19–21). IADL was evaluated by Lawton's IADL scale (22). Gait speed was calculated from the 5-meter walking time. In our previous study, the inter-rater reliability was good with a Spearman correlation rho of 0.93 (p <.001) (13).

The Tinetti Balance and Gait Evaluation were used for balance and gait assessment. The original version of the Tinetti Balance and Gait Evaluation was used in this study. The balance subscale consists of 9 items with a maximum score of 16. The gait subscale consists of 8 items with a maximum score of 12. The total mobility score (TMS) was the sum of the balance and gait scores with a maximum of 28. In our previous study, the inter-rater reliability was good with a Spearman correlation rho of 0.97 (p <.001) (13).

Data Analyses
Descriptive analyses were performed for baseline variables as well as for changes in the BI, IADL score, gait speed, and TMS in the Tinetti Balance and Gait Evaluation over 1 year. The impact of falls and recurrent falls on the 1-year change in BI, IADL score, gait speed, or TMS score among nonfallers, single fallers, and recurrent fallers was analyzed by one-way analysis of variance (ANOVA) with post hoc comparison (Bonferroni). Participants were classified as "decliners" if the 1-year values of their respective BI, IADL score, gait speed, or TMS had declined by more than 1 standard deviation (SD) of the baseline values of that parameter (i.e., BI, IADL score, gait speed, or TMS). The prevalence of decliners in BI, IADL score, gait speed, and TMS was then analyzed by descriptive statistics. Bivariate analyses of the impact of falls (i.e., fallers vs nonfallers) and potential confounding variables on functional change (i.e., decliners vs nondecliners) in BI, IADL score, gait speed, and TMS were tested by the chi-square statistic for categorical data and by Student t test for continuous data. Multivariate logistic regression analyses of incident falls as a predictor for functional decline (i.e., decliners vs nondecliners) in BI, IADL score, gait speed, and TMS were then performed for variables with p <.2 in the bivariate analyses. Statistical significance was taken to be p <.05 (two-tailed). The statistical package SPSS (version 11.5; SPSS, Inc., Chicago, IL) for Windows was used for data analyses.


   RESULTS
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 Methods
 Results
Discussion
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Baseline Characteristics of Participants With 1-Year Follow-Up
The baseline sample consisted of 1517 participants aged 65 years and older. A total of 1419 participants (93.5%) completed the 1-year follow-up assessment. The mean age of these participants (n = 1419) was 73.1 ± 6.2 years, and 49.5% were women. Comorbid diseases were common, with 7.9% of participants having five or more chronic diseases (Table 1).


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  		Table 1. Baseline Characteristics of Chinese Older Adults With 1-Year Follow-Up (N = 1419).

 
Among the 1419 participants who had the 1-year reassessment, the numbers were lower for gait speed (n = 1338) and TMS (n = 1339), as these participants refused the tests. Thus, the two tests could not be rated in these participants, but they were not defaulters. With the exception of gait speed, comparison of the baseline performance of BI, IADL, gait speed, and TMS also did not show any significant difference (p >.05, independent t test) between older adults who could complete the 1-year reassessment and those who could not. The baseline gait speed was approximately 10% slower in those who could not complete the gait speed and/or TMS tests versus those who had the 1-year reassessment (mean ± SD: 0.715 ± 0.208 vs 0.781 ± 0.214 m/s, respectively, p =.008, independent t test).

Incident Falls and Functional Declines in BI, IADL Score, Gait Speed, and TMS
Overall, 401 new falls occurred in 294 persons over 12 months of follow-up of the 1517 community-living elderly participants. The mean BI, IADL score, gait speed, and TMS decreased by 0.5%, 1.6%, 3.0%, and 1.3%, respectively, over 1 year of follow-up. Moreover, 5.1%, 4.7%, 7.2%, and 5.3% of the participants' BI, IADL score, gait speed, and TMS had declined by more than 1 SD of the baseline values of the respective parameters. These participants were classified as "decliners" in the BI, IADL score, gait speed, and TMS, respectively. Older adults who had fallen (i.e., had incident falls) during the 1-year follow-up period had significantly higher proportions of decliners in BI, IADL score, gait speed, and TMS than did nonfallers (Table 2). The magnitudes of the mean declines in BI, IADL score, gait speed, and TMS were all greatest in recurrent fallers, followed by single fallers and then nonfallers (Table 3).


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  		Table 2. Impact of Falls on Functional Declines in BI, Lawton IADL Score, Gait Speed, and TMS in Fallers and Nonfallers (N = 1419).

 

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  		Table 3. Functional Decline in Single and Recurrent Fallers at 1 Year.

 
Incident Falls as Independent Predictor of Functional Decline
Bivariate analyses showed that incident falls were a significant predictor of the participants who would have functional decline on 1-year follow-up (i.e., decliners) in BI, IADL score, and TMS. Many baseline variables were significantly associated with decliner status in the four outcome measures (Table 4). Multivariate logistic regression analyses showed that an incident fall was a significant independent predictor for participants who would have functional decline (i.e., decliners) on 1-year follow-up in the BI, IADL score, gait speed, and TMS, after adjustment for all confounding variables which remained statistically significant in the final logistic regression models. For incident fallers, the relative risks of being decliners in BI, IADL score, gait speed, and TMS were 2.37, 2.93, 2.42, and 4.57, respectively (Table 5).


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  		Table 4. Bivariate Analyses for Predictors of 1-Year Functional Decline in BI, IADL Score, Gait Speed, and TMS in Chinese Older Adults (N = 1419).

 

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  		Table 5. Logistic Regression Analyses of the Impact of Incident Falls on Functional Declines in BI, IADL Score, Gait Speed, and TMS (N = 1419).

 

   DISCUSSION
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 Methods
 Results
 Discussion
References
 
Functional Decline After Falls
Very few studies have investigated the impact of falls on declines in ADL, balance, and gait functioning in fallers as well as the predictors of functional decline after falls. Kiel and colleagues (14) have reported that greater declines in basic ADL and IADL occurred in fallers than in nonfallers. In another retrospective study, 35.3% of fallers have self-reported a decline in physical functioning after falls. Female gender, a higher number of medications used, and depressive symptoms were independent risk factors for functional decline after falls (12). Tinetti and Williams (15) have reported that falls and fall injuries are associated with decline in basic ADL and IADL at both 1-year and 3-year follow-up. No objective functional assessment was performed in these studies.

To our knowledge, no previously published prospective study has reported the magnitude of declines in balance and gait performance among fallers versus nonfallers. We believe that the present study is the first study which has investigated the magnitude of decline in balance and gait functioning after falls. In our study, we used the TMS and gait speed as two objective balance and gait functional outcome measures (11,13,28). For assessments of basic ADL and IADL performance, we adopted the BI (19–21) and Lawton's IADL scale (22). We found that the presence of incident falls had a detrimental effect on the balance, gait, and ADL functioning in fallers versus nonfallers. Fallers experienced significant declines in BI, IADL, gait speed, and TMS of the Tinetti Balance and Gait Evaluation. Over 1 year, 5.1%, 4.7%, 7.2%, and 5.3% of the participants (i.e., decliners) declined by more than 1SD of the BI, IADL score, gait speed, and TMS baseline values, respectively.

We believe that the present study is also the first study which has examined the role of incident falls as predictors of functional decline in balance and gait performance 1 year after falls. The effect of falls on basic ADL and IADL performance has been reported previously in the Caucasian but not Chinese populations. Our results showed that the proportions of decliners in BI, IADL score, gait speed, and TMS for fallers were two to six times higher than were those of nonfallers (Table 2). Older adults who had incident falls were 2.4, 2.9, 2.4, and 4.6 times more likely to become decliners in BI, IADL score, gait speed, and TMS than were nonfallers (Table 5). The declines in these four physical functioning measures occurred in both single fallers and recurrent fallers. Furthermore, recurrent fallers experienced the largest degree of declines in all four functional measures (Table 3).

Apart from incident falls, many sociodemographic, clinical, psychological, and functional factors were associated with decliners in the 1-year BI, IADL scores, gait speed, and TMS in bivariate analyses. However, the female gender was not a predictor of future decline in ADL, balance, and gait functioning in older adults.

In the present study, many of the significant predictors in bivariate analyses had become insignificant in the multivariate analyses (Tables 4 and 5). Eventually, incident falls, old age, fear of falling (29), Parkinson's disease (30), and slow gait speed were the common independent predictors for decliners in BI (for ADL), IADL score, and TMS (balance and gait performance). We found that depressive mood affected IADL score but not BI and TMS (12,24–27). Moreover, a baseline history of previous hip fracture (31) was not an independent predictor for decliners in BI but was an independent predictor for decliners in TMS. Coronary heart disease (32) was an independent predictor for decliners in BI (ADL) but not in IADL or TMS.

To our knowledge, the present study is the first prospective, population-based cohort study which reports clinically significant declines in balance and gait functioning in older adults 1 year after falls. In agreement with studies reported from Caucasian older populations (12,14,15), we observed significant declines in both ADL and IADL in Chinese older adults after falls. Compared to incident falls, a previous history of falls was not an independent predictor for decliners in BI, IADL score, gait speed, and TMS. This was in agreement with the lack of effect of previous history of falls on ADL disability in the study by Dunn and colleagues (33). Our present findings have important and practical implications from the perspective of secondary falls prevention. It is well proven that falls prevention programs can prevent new falls (34–39). We believe that identifying older adults who have a previous history of falls and then giving them a secondary falls prevention program would very likely prevent future functional declines in basic ADL, IADL, balance, and gait functioning. However, a randomized controlled trial of falls prevention with these functional outcome measures is recommended in the future to confirm these benefits.

Limitations of the Study
Our study participants represented a random population-based sample of community-dwelling older adults in Hong Kong. Our findings might not be totally applicable to older adults living in the nursing home. Also, a limitation was the use of bimonthly telephone follow-up instead of using monthly falls calendars with telephone follow-up for incomplete and unreturned calendars. There was a possibility of incomplete ascertainment of falls with telephone follow-up alone. Of the Hong Kong Chinese older adults, 51% received no formal education (11) and were unable to write on the monthly calendars. Telephone follow-up of the participants plus information from their caregivers was therefore adopted.

Another potential limitation was the loss to follow-up. There might be a concern that the defaulters might be very different (e.g., functionally) than those who completed the follow-up. Participants who completed the BI, IADL, gait speed, and TMS assessments were largely comparable to those who did not complete them, except for the baseline gait speed. Thus, there might be an underestimation of the magnitude of decline.

Conclusion
In community-dwelling older adults, an incident fall is an independent predictor for decline in balance, gait, and ADL functioning. Prevention of new falls by fall prevention programs can prevent falls, fall-related injuries, and probably future declines in balance, gait, and ADL functioning in the future.


   Acknowledgments
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 Methods
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 Discussion
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We thank The Health Services Research Committee of Hong Kong for funding the present project (HSRC # 631004).


   Footnotes
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Decision Editor: Luigi Ferrucci, MD, PhD

Received August 4, 2005

Accepted December 5, 2005


   References
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