Revist a de Saúde Pública
I SSN 0034- 8910 versão im pressaRev Saúde Pública 2004; 38(1)
Falls am ong older adults seen at a São Paulo State public hospital:
causes and consequences
Suzele Cr ist ina Coelho Fabr ício, Rosalina A Par t ezani Rodr igues and Moacyr Lobo da Cost a Junior
Depar t am ent o de Enferm agem Geral e Especializada da Escola de Enferm agem Geral e Especializada de Ribeirão Pret o da Universidade de São Paulo. Ribeirão Pret o, SP, Brasil
ABSTRACT
Objective
To inv est igat e t he hist ory of accident al falls r epor t ed by older adult s, ident ify ing possibly r elat ed fact or s, as w ell as place of occu r r en ce, cau ses, an d con sequ en ces.
M et hods
The sam ple invest igat ed included 50 older adult s, of bot h sexes, ages 60 year s or older , living in t he cit y of Ribeir ão Pr et o, Sout heast er n Br azil, w ho had been seen at t w o inpat ient unit s of a public hospit al. Pat ient r ecor ds w er e ex am ined and household v isit s car r ied out for t he applicat ion of a st r uct ur ed quest ionnair e including open, closed, and m ixed quest ions r elat ed t o t he fall.
Dat a obt ained show a r ealit y not subst ant ially differ ent fr om t hat obser v ed in ot her count r ies. Most event s occurred am ong older w om en ( 66% ) , w it h m ean age 76 years, and at hom e. Causes w ere m ainly r elat ed t o phy sical env ir onm ent ( 54% ) , and br ought ser ious consequences t o t he subj ect s, fr act ur es being t he m ost com m on out com e ( 64% ) . Falls had a gr eat im pact on subj ect s’ lives in t er m s of act iv it ies such as: ly ing dow n/ get t ing up, w alk ing on plain sur faces, cut t ing t oenails, bat hing/ show er ing, w alking out side hom e, t aking car e of financial issues, shopping, using public t r anspor t at ion, and clim bing st air s.
Conclusions
The st udy dem onst r at ed t hat falls occur r ed am ong older adult s hav e ser ious phy sical, psy chological, an d social consequences, r einfor cing t he need for fall pr ev ent ion, in or der t o ensur e gr eat er qualit y of life, aut onom y, and independence for t he elderly.
Keywords
Aged. Accident al falls. Cost of illness. Qualit y of life. Aging healt h.
I N TRODUCTION
Aging m ay be influenced by biological fact or s, disease, and ot her ex t er nal causes. Falls ar e included am ong t he lat t er , accor ding t o t he I nt er nat ional St at ist ical Classificat ion of Diseases and Relat ed Healt h Problem s ( I CD- 10) .1 5 They pose a pr oblem of gr eat im por t ance t o ger ont ologist s, and ar e a sour ce of concer n for r esear cher s in t he field, especially w hen t hey ar e consider ed as nor m al and pr oper of t he ageing pr ocess.
A fall can be defined as “ an unint ent ional event result ing in a change in t he individual’s posit ion from a higher t o a low er lev el” .1 4 According t o Cunha & Guim arães7 ( 1989) , falls ar e t he r esult of a t ot al loss of post ur al balance, and m ay be r elat ed t o a sudden insufficiency of neur al and ost eoar t icular m echanism s involved in post ure m aint enance. A num ber of aut hors6 , 1 3 , 1 8 consider accident al falls as a ger iat r ic sy ndr om e, due t o t heir m ult ifact or ial and het er ogeneous char act er .
I ndividuals of all ages are at risk of falling. For older adult s, how ev er , falls hav e a m uch gr eat er r elev ance, for t hey can lead t o disabilit y , inj ur ies, and deat h. The social cost of falls is enor m ous, and becom es ev en gr eat er w hen t he aged v ict im suffer s r educt ions in aut onom y and independence, or n eeds t o be inst it ut ionalized.
inst it ut ion, t he nosocom ial m ort alit y rat e due t o falls in Febr uar y 2000 w as 2.58% . The gr eat est r at e w as obser v ed in t he Sout heast Region, follow ed by Nor t heast , Sout h, and Cent er- West . I n Finland, Kannus et al9 ( 1999) observed an 80% increase in t he num ber of fall- relat ed bet w een 1971 ( 441 deat hs) and 1995 (793 deat hs) .
Sur v ey s conduct ed in US com m unit ies show t hat 30% of people ov er age 65 y ear s fall at least once a y ear . Of t hese, 40% ar e ov er 80 y ear s old. Fur t her m or e, t hese sur v ey s show t hat 50% of elder ly people who live in resident ial or nursing hom es hav e alr eady suffer ed falls.1 9 Kannus et al9 ( 1999) , in a st udy car r ied out in Finland am ong individuals older t han 50 year s, r epor t ed a significant incr ease ( 284% ) in t he num ber of inj uries am ong older adult s bet ween t he years of 1971 and 1995. The aut hor s ar gue t hat t w o fact or s m ay hav e cont r ibut ed t ow ar ds t his incr ease: dem ogr aphical alt er at ions ( a cont inuous incr ease in older- adult populat ion) and an increase in t he num ber of falls in t his age group.
Despit e t he ev idence suppor t ing an incr ease in t he nu m ber of falls am ong older- adult populat ion, Br azilian ger iat r ic and ger ont ological lit er at ur e cont ains few epidem iological st udies on t he subj ect . Accor ding t o Beck er et al1 ( 1999) , t he sam e problem is observed in Germ any. I n order t o allow pot ent ial pr ev e nt iv e int er v ent ions t o be indicat ed by fur t her st udies, t he pr esent st udy deepens t he invest igat ion of falls am ong older adult s. Thus, our aim is t o invest igat e t he hist or y of falls r epor t ed by elder ly subj ect s, consider ing place of occur r ence, causes, and consequences, and t o descr ibe any changes occur r ed in subj ect s’ daily liv es, aft er t he fall, including t hose r elat ed t o funct ional capabilit ies: alt er at ions in basic daily life act ivit ies ( BDLA) and in inst r um ent al daily life act ivit ies ( I DLA) .
Methods
St udy populat ion w as com posed of indiv iduals ov er age 60 y ear s, of bot h sex es, w it h fix ed r esidence in t he cit y of Ribeir ão Pr et o, Sout heast er n Br azil, w ho w er e seen, due t o ex t er nal causes of accident al t raum a – Falls – I CD- 10 ( W00 – W19) ,1 5 at t w o inpat ient unit s of a univ er sit y hospit al in t he sam e cit y in 2000. Dat a on t he older adult s seen at t he above m ent ioned unit s w ho had Falls diagnosed in t heir r ecor ds w er e pr ov ided by t he hospit al’s Medical Dat a Depar t m ent . Follow ing t he ident ificat ion of st udy populat ion, older adult s w ho did not live in Ribeir ão Pr et o or w ho had also been seen at t he hospit al’s Em ergency Unit and t hen t ransferred wit hin t he sam e hospit al for a longer adm ission period were ex cluded. St udy populat ion t hus com pr ised 251 older adult s seen in 2000, from which a 50- su b j ect sam ple was syst em at ically drawn ( random st art one, skip five) . I nform at ion including nam e, age, fall hist or y , inpat ient adm ission w er e obt ained fr om t he hospit al r ecor ds of t he select ed subj ect s in or der t o v er if y t h e infor m at ion concer ning t he fall obt ained t hr ough t hese files. Nam e and addr ess w er e r ecor ded for subsequent household int er v iew s.
Figure 1 – Medication used by older adults prior to suffering falls, Ribeirão Preto, Brazil, 2000.
m eals) . The pr esent st udy adopt s t he pr ot ocol pr oposed by Yuaso & Sguizzat t o2 1 ( 1996) , elaborat ed based on t he Kat z and Law t on scales, for daily act iv it y ev aluat ion pur poses. Subj ect int er v iew s w er e preform ed in t he presence of a fam ily m em ber ( or caret aker) , who confirm ed and helped clarify t he dat a obt ained. When t he subj ect suff er ed fr om any cognit iv e dy sfunct ion t hat im peded quest ionnair e answ er ing, quest ions w er e asked t o t he fam ily m em ber / car et aker .
A num ber of subj ect s had died or m ov ed t o differ ent addr esses befor e int er v iew scheduling. I n case of deat h, quest ions w er e answered by a fam ily m em ber/ caret aker t hat could provide inform at ion about t he incident . I n case of change of addr ess ( w hen a new addr ess could not be found) t he lost subj ect w as r eplaced by anot her subj ect of sam e sex and age, accor ding t o t he gener al pat ient list ing. A t ot al 26 subj ect s w er e r eplaced.
This r esear ch pr oj ect w as appr ov ed by t he Hospit al das Clínicas of t h e Faculdade de Medicina de
Ribeir ão Pr et o/ Universidade de São Paulo Et hics Com m it t ee.
Results
Of t he select ed subj ect s, 6 6 % w er e fem ale and 34% , m ale. Mean age w as 76 years. 54% of t he subj ect s int er v iew ed had a hist or y of pr ev ious falls, of w hich 48% w er e in t he 80 - 89 years age group and 66% w er e w om en. I nadequat e sur r oundings w er e t he m ain cause of falls ( 54% ) , follow ed by neur ological disease ( 14% ) and heart disease ( 10% ) . The cause for 10% of all falls w as ignored. Most falls w ere from t he subj ect ’s ow n height , and relat ed t o problem s in t he surroundings, including: slipper y sur faces ( 26% ) , obj ect s on t he floor ( 22% ) , bum ping int o ot her people ( 11% ) , clim bing on obj ect s in or der t o r each for t hings ( 7% ) , pr oblem s w it h st eps ( 7% ) , and ot her s, in lesser degr ee.
Aft er t he incident , a num ber of subj ect s r epor t ed t he appear ance of diseases such as: cer ebr ov ascular accident ( 10% ) ost eopor osis, ( 4%) , pneum onia ( 4% ) , art hrit is ( 2% ) , urinary t ract infect ion ( 2% ) and car diopat hy ( 2% ) . Sensor ial diseases w er e also r epor t ed, of w hich 36% w er e r elat ed t o v isual problem s, and 14% t o hearing problem s.
No dir ect r elat ionship w as obser v ed bet w een m edicat ion use and falls. How ev er , dat a collect ion r ev ealed t hat 70% of subj ect s w er e on som e t y pe of m edicat ion pr ior t o t he incident , all of w hich w er e phy sician- pr escr ibed. No significant differ ence w as found in t er m s of m edicat ion use bet w een m en ( 70% ) and wom en ( 72% ) .
Figure 1 – Medication used by older adults prior to suffering falls, Ribeirão Preto, Brazil, 2000.
66% of falls occur r ed in t he subj ect s ow n hom e, and 22% out of door s. The r em ainder occur r ed in th e houses of r elat iv es or fr iend’s.
Figure 2 – Consequences presented by older adults after falls, Ribeirão Preto, 2000.
Accor ding t o subj ect and fam ily m em ber / car et ak er r epor t s, falls also pr om ot ed incr eases in difficult y and dependence for t he per for m ance of daily - life act iv it ies ( DLA) . The Table show s t he num ber of su bj ect s w h o car r ied ou t t hese act iv it ies befor e and aft er t he fall, accor ding t o t he lev els of difficult y pr esent ed by t hem . DLAs m ost affect ed w er e ly ing dow n/ get t ing up, w alk ing on plain sur faces, bat hing/ show er ing, w alk ing out side hom e, t ak ing car e of financial issues, cut t ing t oenails, shopping, using public t ransport at ion, and clim bing st airs.
Table – Per cent age of older adult s, accor ding t o lev el of difficult y in per for m ing daily life act iv it ies, before and aft er fall, Ribeirão Pret o, 2000.
Levels of difficulty Level of
difficulty
Without
difficulty
With difficulty,
without help
With partial
help
With
total help
Someone
else
does it
Cannot perform
consegue
Does
not
do it
AVDDLA B A B A B A B A B A B A B A
Walking on plain surfaces 68 19 19 36 9 23 2 15 - - 2 4 - 2 Lying down/getting up 79 28 13 36 4 13 2 15 - - 2 6 - 2 Bathing/showering 70 30 15 28 4 17 6 17 - - 4 6 - 2 Cutting toenalis 17 8 21 11 2 2 4 9 15 15 36 49 4 6 Walking outside home 53 11 19 25 19 17 2 23 - - 4 17 2 6 Taking care of finances 53 38 15 11 2 2 6 11 6 8 11 21 6 8
Shopping 42 17 9 9 9 4 15 19 13 11 6 32 6 8
Using public transportation 42 11 11 15 6 8 9 11 - - 19 40 13 15 Climbing stairs 55 11 17 23 13 15 8 28 - - 4 17 2 6
Brushing teeth 74 60 2 4 4 6 4 8 - - 11 15 4 6
Difficulty going to the lavatory 77 55 8 13 4 6 4 6 - - 6 17 - 2
Eating 89 79 4 9 2 4 4 2 - - - 4 - 2 Taking medication 57 45 2 - 6 6 11 17 2 2 17 23 4 6 Preparing meals 36 19 8 6 2 - 4 4 19 17 19 38 11 15
Housecleaning 34 4 6 15 - 6 2 2 17 17 21 34 19 21
B – before the fall.
A – after the fall.
DLA – daily life activities.
As m ent ioned befor e, falls m ay cause t he deat h of older adult s. Four t een ( 28% ) subj ect s in t he sam ple had died, of which 78.5% were wom en and 21.5% m en. 42.8% of deat hs occur r ed less t han one m ont h aft er t he fall, i.e., due t o consequences dir ect ly r elat ed t o t he incident , including fem ur fr act ur e - relat ed em bolism ( 50% ) and neurological lesions due t o int ense t raum a aft er t he fall ( 50% ) . Th e ot her 57.2% of deat hs occur r ed less t han one y ear aft er t he fall. Many of t he subj ect s w er e bedridden, and present ed m ent al confusion, pneum onia, and pressure ulcers.
Discussion
The gr eat er fr equency of falls ober v ed am ong w om en is consist ent w it h dat a pr es ent ed by Ber g et al2 ( 1997) . These aut hor s include am ong t he v ar iables w hich m ay account for t his differ ence adv anced age, low er fr equency of ex t er nal act iv it ies, use of lar ge quant it ies of dr ugs, use of psy chot r opic dr ugs, and decr eased pr ehensile st r engt h.
The causes of falls am ong older adult s ar e sev er al and m ay be associat ed am ong t hem selv es. Fact or s r esponsible for t hese falls hav e been classified in t he lit er at ur e as int r insic – i.e., due t o phy siological alt er at ions r elat ed t o t he aging pr ocess, dis ease, an d t o m edicat ion ef f ect s – and ext rinsic – i.e., fact or s t hat depend on social and env ir onm ent al cir cum st ances t hat ar e challenges for t he elder ly . I n general, environm ent - r elat ed pr oblem s ar e caused by occasional ev ent s t hat pose r isk s t o older adu lt s, especially t o t hose w ho alr eady pr esent difficult ies in balance or gait . Sit uat ions t hat fav or slipping, t ripping, false st eps, or bum ping ( int o obj ect s, anim als, or ot her people) m ust be considered. Such problem s will be m ore dangerous t he great er t he individual’s vulnerabilit y and t he great er t he inst abilit y t hat t he pr oblem m ay cause. Gener ally speak ing, older adult s do not fall as a consequence of danger ous act iv it ies ( clim bing ladder s or on chair s) but as a r esult of r out ine act iv it ies. I n t he pre sent st udy , only t w o cases of falls w er e due t o r isk y act iv it ies ( one due t o clim bing on a chair t o r each for som et hing, and anot her doe t o clim bing on scaffolding) . Pr oblem s r elat ed t o t he env ir onm ent w er e also t he m ost fr equent causes in t he st udy by Ber g et al2 ( 1997) . I n t his st udy , t r ipping and slipping account ed for 59% of falls, and pr oblem s w it h st eps for 12% .
Am ong int r insic fact or s, t he appear ance of diseases t hat cause r educt ions of phy sical capabilit ies m ay affect post ur al cont r ol or balance. Ma j or pat hological condit ions leading t o falls, accor ding t o Kay et al1 0 ( 1995) and Lipsit z,1 2 ( 1996) , are: car diov ascular , neur ological, endocr inologic, m usculosk elet al,
genit our inar y , psy chiat r ic, and sensor ial diseases . Sev er al st udies in t he lit er at ur e show t he
I n addit ion t o pr esent ing a r elat ionship t o pr ev iously diagnosed diseases, som e aut hor s suggest t hat falls m ay be a pr edict or for ot her healt h pr oblem s, and m ay indicat e t he im m inence of a disease not y et diagnosed.1 0 Many infect ious diseases ar e clinically at y pical in older adult s, and falls m ay be t he fir st sign of illness.3
Sev er al st udies found in t he lit er at ur e concer ning m edicat ion use – also consider ed as a pot ent ial int r insic cause of falls, and inv est igat ed in t he pr esent st udy – report t hat drug use m ay be a risk fact or , especially if m ult iple dr ugs ar e used. Br it o et al3 ( 2001) r epor t t hat m edicat ions such as diu r et ic, psy ch ot r opic, an t i- hy per t ensiv e, and ant ipar k ins onian dr ugs m ay be consider ed as liable t o cause falls. This is oft en due t o dim inut ions in m ot or funct ion, m uscular w eak ness, fat igue, v er t igo, or post ur al hy pot ension, all of w hich m ay be caused by t hese dr ugs. The findings r elat ed t o t he use of m ultiple dr ugs in t he pr esent st udy ar e in agr eem ent w it h t hose of Robbins et al1 6 ( 1989) . These aut hor s st at e t hat t he use, by older adult s, of four or m or e associat ed dr ugs m ay lead t o a gr eat er r isk of falling, due t o t he st r ong associat ion bet w een differ ent drugs, or t o t he pr ecar ious healt h st at us im plied by t r eat m ent w it h m ult iple dr ugs. Thus, it is essent ial t hat pr ofessionals, upon pr escr ibing m edicat ion, t hor oughly ev aluat e t he r eal need for t he dr ugs pr escr ibed, giv en t he close r elat ionship bet w een t h e u s e of new dr ugs, or even of dosage adj ust m ent , and incr eased r isk of falling.
The sit e of t he fall is also im port ant for environm ent - r elat ed fact or ident ificat ion pur poses. I n a r et r ospect iv e st udy car r ied out in Ribeir ão Pr et o w it h older w om en of t he com m unit y w ho had suffer ed falls, a larger proport ion of falls in t he subj ect ’s own hom e was also verified.1 7 Cam pbell et al5 ( 2000) , in an inv est igat ion of accident s am ong older adult s liv ing in a com m unit y , found t hat falls account ed for 5 1 % of t h e acciden t s r egist er ed, and t hat t hey occur r ed m ost ly inside t he subj ect ’s ow n house ( 44% of falls) . These dat a ar e ex t r em ely elucidat iv e for t he planning of pr ev ent iv e m easur es for falls am ong t he elderly.
Am ong t he subj ect s of t he pr esent st udy , fr act ur es w er e t he m ost com m on consequence of falls. How ev er , t he fact t hat t he indiv iduals par t icipat ing in t he st udy w er e r ecr uit ed at inpat ient hospit al unit s m ay hav e int er fer ed in t hese r esult s, since t hese ar e t he indiv iduals t hat pr esent t he sev er est consequences im mediat ely aft er t he fall. Kannus et al9 in Finland and Becker et al1 in Germ any also ident ified fr act ur es, especially of t he fem ur , as t he m ost fr equent consequence of falls am ong older adult s.
Fear of fur t her falls, also k now n as t he “ post - fall syndrom e” ( t he second consequence m ost r epor t ed by st udy subj ect s) , w as also r epor t ed by sev er al aut hor s1 , 1 6 , 2 0 Post - fall fear m ay im ply fear not only of furt her falls, but also of inj uries, hospit al adm ission, im m obilizat ion, declining healt h, and of dependence on ot her people for self - car e or for daily life act iv it ies, or , in ot her w or ds, of t he consequences inher ent t o falling.1 1 The cum ulat iv e effect of such feelings m ay br ing about im por t ant em ot ional, psy chological and social changes, such as: loss of aut onom y and independence for BDLA and I DLA, r educt ion of social act iv it ies, and feelings of fr agilit y and insecur it y .
For DLAs w alking on plain sur faces, lying dow n/ get t ing up, and bat hing/ show er ing, subj ect s pr esent ed loss of independence aft er t he fall, m ost ly due t o im pair ed funct ional capabilit ies ( Table 1) . Such act iv it ies, pr ev iously car r ied out w it h less difficult y , becam e pr oblem at ic aft er t he fall. For DLAs shopping, using public t r anspor t at ion, and clim bing st air s, subj ect s pr esent ed gr eat er locom ot ion dependence aft er t he fall. Clim bing st air s w as one of t he act iv it ies m ost affect ed. Housecleaning, pr epar ing food, and t aking m edicat ion w er e alr eady per for m ed fair ly r ar ely by subj ect s even befor e t he fall, and w er e usually done by ot her per sons, m ost ly r e lat iv es. Br ushing t eet h, get t ing t o t he lav at or y in t im e, com bing hair , and eat ing w er e t he act iv it ies least affect ed by falling.
Refraining from carrying out such act ivit ies, or even requiring help for such purposes, m ay cause im m obilit y and consequent m uscular dy st r ophy , t hus facilit at ing t he occur r ence of falls. When older adult s fall, t her e is a t r end t ow ar ds dim inut ion of daily act iv it ies, be it due t o fear of ex posur e t o r isk of fur t her falls, be it due t o pr ot ect iv e at t it udes on t he par t of societ y and fam ily m em ber s/ car et ak er s. Ot her people m ay consider t he older adult t hat falls as w eak, oft en w it hdraw ing him or her from such act iv it ies.
All t he difficult ies pr esent ed by t he subj ect s of t he pr esent st udy w er e in som e w ay r elat ed t o consequences of fall, be t hey phy sical, psy chological, or social. The im pact upon DLA per for m ance incr eased subj ect dependence on ot her per sons, especially for I DLAs. Changes w er e obser v ed ev en in act ivit ies previously perform ed w it h ease and w it hout ext ernal help. The inabilit y t o perform DLAs due t o fall- related im m obility m ay, in t he long r un, hav e consequences not only for t he older adult s t hem selves, but also for t heir fam ilies – who m ust m obilize t hem selves in order t o provide t reat m ent and pr om ot e t he r ecov er y of t he older adult – and for healt h ser v ices.
Accident al inj ur ies ar e t he six t h m ost im por t ant cause of deat h am ong indiv iduals aged 75 y ear s or older , and falls account for 70% of t his m or t alit y .1 2 The im por t ance of falls m ust not be under est im at ed, since t hey m ay r esult in deat h. I n t he pr esent st udy , deat h follow ing a fall occur r ed m ore frequent ly am ong w om en, in disagreem ent w it h dat a present ed by Cam pbell et al4 ( 1985) in a pr ospect iv e st udy in w hich a gr eat er r isk of m or t alit y w as ascr ibed t o m ale subj ect s. The gr eat er m ort alit y am ong wom en in t he present st udy m ay be r elat ed t o t he gr eat er absolut e num ber fem ale faller s. Fr act ur es, one of t he consequences of falls t hat m ay lead t o deat h, m ay be r elat ed t o t he gr eat er fr equency of ost eopor osis am ong older w om en, in light of t he st r ong associat ion bet w een t his disease and fr act ur es.
I t is im port ant t o em phasize t hat falls are a real event in older adult life, bringing about a num ber of consequences, som et im es ir r ev er sible. Ther efor e, t he appr oach t o fall v ict im s m ust include a br oad and com plet e ev aluat ion. Healt hcar e pr ofessionals m ust t hus car r y out t hor ough anam neses of t he causes of t he incident . At t his t im e, k now ing about t he ex ist ence of any pr ev ious falls m ay dir ect ev aluat ion. A det ailed inv est igat ion of t he r ole of ex t r insic fact or s ( env ir onm ent , clot hing) is im por t ant . Such ev aluat ion m ay pr ev ent fur t her incident s, as w ell as pr om ot e a bet t er under st anding of t he pr esent fall.
Anot her form of dealing wit h falls is t heir prevent ion by m eans of household visit s. The Brazilian Nat ional Older- Adult Healt hcar e Po licy is alr eady consider ing t his t y pe of assist ance. To t his end, it w ill be necessar y for st at es and m unicipalit ies t o t r ain healt hcar e pr ofessionals and t o or ganize healt hcar e ser v ices so t hat older adult assist ance becom es a gov er nm ent al policy . Healt hc are program s m ust est ablish pr ot ocols for t he ident ificat ion of pot ent ial int r insic and ex t r insic r isk fact or s for falling. A fur t her aspect is t o r einfor ce t he im por t ance of self - care and t o alert fam ily m em bers/ caret akers so t hat t hey m ay act iv ely par t ic ipat e in t he pr ev ent ion of falls am ong older adult s.
REFEREN CES
1 . Becker RC, Gebhard F, Mucher R, Scheible S, Nikolaus T. Epidem iologie von st ürzen ält erer. Z
2 . Berg WP, Alessio HM, Mills EM, Tong C. Cir cunst ances and consequences of falls in independent com m unit y – dwelling older adult s. Age & Ageing 1997; 26: 261- 8 .
3 . Br it t o FC, Cost a SMN. Quedas. I n: Papaleo Net t o M, Brit o FC. Urgências em geriat ria. São Paulo: Ed. At he neu; 2001. p. 323- 35.
4 . Cam pbell AG, Diep C, Reinken J, McCosh L. Fact ors predict ing m ort alit y in a t ot al populat ion sam ple of elderly. J Epidem iol Com m Healt h 1985; 39: 337.
5 . Cam pbell EM, Cart er SE, Sanson- Fisher RW, Gillespie WJ. Accident s in older peop le living at hom e: a com m unit y - basead st udy assessing pr ev alence, t y pe, locat ion and inj ur ies. Aust ralian Zeland
J Public Healt h 2000; 24: 633- 6 .
6 . Carvalhaes N, Rossi E, Paschoal S, Perracini N, Perracini M, Rodrigues RAP. Quedas. I n: Congr esso Paulist a de Geriat ria e Geront ologia 1, São Paulo, 24 a 27 de j unho de 1998. Consensos de geront ologia . São Paulo: Sociedade Brasileira de Geriat ria e Geront ologia; 1998. p. 5- 18.
7 . Cunha UG de V, Guim arães RM. Sinais e sint om as do aparelho locom ot or. I n: Guim arães RM, Cunha UG de V. Sinais e sint om as em geriat ria. Rio de Janeiro: Revint er; 1989. p. 141- 54.
8 . Fuller GF. Falls in t he elderly. Am Fam ily Fhy sician 2000; 61: 2159- 68.
9 . Kannus P, Parkkari J, Koskinen S, Niem i S, Palvanen M, Järvinen M, Vuori I . Fall – indu ced inj uries and deat hs am ong older adult s. JAMA 1999; 281: 1895- 9.
10. Kay PD, Tideiksaar R. Quedas e dist úrbios de m archa. I n: Abram s WB, Berkow R. Manual Mer ck de Ger iat r ia. São Paulo: Ed Roca; 1995.
11. Kong KS, Lee F, Mack enzie AE, Lee DTF. Psy chosocial consequences of falling: t he per spect iv e of older Hong Kong chinese w ho had ex per ienced r ecent falls. J Adv anced Nur sing 2002; 37: 234- 42.
12. Lipsit iz LA. An 85 years - old wom an wit h a hist ory of falls. JAMA 1996; 276: 59 - 66.
13. Mart ins VMC. Quedas em pacient es ger iát r icos. Rio de Janeir o: Escola Nacional de Saúde Pública - Fundação Osw aldo Cr uz; 1999. p. 51.
14. Moura RN, Sant os FC dos, Driem eier M, Sant os LM dos, Ram os LR. Quedas em idosos: fat ores de r isco associados. Ger ont ologia 1999; 7( 2) : 15- 21.
15. Organização Mundial da Saúde. CI D- 10. São Paulo; 2000. p. 1017- 9 .
16. Robbins AS, Rubenst ein LZ, Josephson KR, Schulm an BL, Ost erweil D, Fine G. Predict ors of falls am ong elder ly people. Result s of t w o populat ion based st udies. Ar ch I nt er n Med 1989; 149: 1628 -33.
17. Rocha FL, Cunha UG de V. Aspect os psicológicos e psiquiát r icos das quedas do idoso. Arq Bras
Med 1994; 68: 9- 13.
19. Tin et t i ME, Speechley M. Pr ev ent ion of falls am ong t he elder ly . N Engl J Med 1989; 330: 1055- 9.
20. Vellas BJ, Wayne SJ, Rom ero LJ, Baum gart ner RN, Garry PJ. Fear of falling and r est r ict ion of m obilit y in elderly fallers. Age & Aging 1997; 26: 189- 93.
21. Yuaso DR, Sguizzat t o GT. Fisiot erapia em pacient es idosos. I n: Papaleo Net o M. Geront ologia . São Paulo: At heneu; 1996. p. 331- 3 .
Address to correspondence
Suzele Crist ina Coelho Fabrício
Avenida dos Bandeir ant es, 3900 Cam pus Universidade de São Paulo 14040 - 902 Ribeirão Pret o, SP, Brasil
E- m ail: r osalina@eer p.usp.br
Based on a Mast er ’s disser t at ion pr esent ed at t he Escola de Enferm agem de Ribeirão Pret o, Universidade de São Paulo, in 2002
Received on 14/ 9/ 2002. Reviewed on 18/ 6/ 2003. Approved on 21/ 7/ 2003.
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