INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 9: 17-23 (1993)

FALLS AMONG COMMUNITY-DWELLING PSY CHOGERIATRIC PATIENTS

TAKASHI ASADA AND TETSUHIKO KARIYA Department of Neurology and Psychiatry, Yamanashi Medical University, Tamaho, Yamanashi 409-38, Japan

EIJI KITAJIMA Sophia School of Social Welfare, Kioi, Chiyoda-ku, Tokyo I02, Japan

TATSUYUKI KAKUMA Institute of Chronobiology, New York Hospital-Cornell Medical Center, Westchester Division, White Plains, N Y

10605, USA

MITSURU YOSHIOKA Kamikawa Hospital, Hachioji, Tokyo 192-01, Japan

SUMMARY

Although increasing interest has been focused on falling in the elderly, little is known about the incidence and consequence of falls in psychogeriatric outpatients. We conducted a 1-year prospective study of falling in 102 community-dwelling elderly patients with psychiatric morbidity (mean age: 70 years) and 100 mentally intact elderly patients (controls, mean age: 74 years). The subject group comprised 79 patients with depression, 14 with dementia and nine with combined disease based on DSM-111-R criteria. Overall, 216 falls in the subject group and 54 in the controls were reported. At the end of the study, recurrent fallers aged 75 years and older showed significant physical deterioration. Multiple logistic regression analysis of selected medical and demographic variables indicated that the most influential variable regarding falling of the subjects was severity of depression rated using the Hamilton scale. Unexpectedly, the analysis revealed that the use of antidepressants was associated with a lower likelihood of falling. On the basis of the two variables, 75% of all respondents were correctly classified as fallers or non-fallers.

KEY woms-Fall, elderly, psychogeriatric patients, community study.

There is now increasing interest in falling in the elderly, and consequently a lot of attention has been directed to the psychiatric aspects of falls in elderly subjects (Forstl, 1992). Many researchers have pointed out that depression, cognitive dys- function and psychotropic drug use are associated with an increased risk of falling (Campbell et al., 1981; Prudham and Evans, 1981; Ray et al., 1987; Tinetti et al., 1988). In addition, studies showing a high prevalence of depression and cognitive impairment in patients evaluated after hip fracture (Billing et al., 1986; Mossey et al., 1990) appear to support the hypothesis that cerebral dysfunction

Address for reprint requests: T. Asada, Department of Neruo- logy and Psychiatry, Yamanashi Medical University, Tamaho, Yamanashi 409-38, Japan.

predisposes elderly subjects to falls. However, with the exception of a few previous studies (Rosen et al., 1985; Buchner and Larson, 1987; Morris et al., 1987; Spar et al., 1987), little attention has been paid to falls in elderly individuals with psychiatric morbidity and to the specific problems arising from their falls.

We conducted a 1-year prospective study of falls in community-dwelling psychogeriatric patients with the aim of determining accurately the fre- quency of their falls compared with that of mentally healthy controls, identifying factors associated with falling, paying particular attention to the severity of the patients’ affective status and psycho- tropic drug use, and evaluating the degree of psy- chophysical deterioration in recurrent fallers during the follow-up period.

Received 10 February 1993 Accepted 1 July 1993

08856230/94/01OO17-O7$08.50 0 1994 by John Wiley & Sons, Ltd.

18 T. ASADA, T . KARIYA, E . KITAJIMA ET AL.

METHODS

Subjects and controls

Originally, 167 outpatients from the neuropsy- chiatry clinics of the Yamanashi Medical Univer- sity and Yamashi Kosei hospitals participated in this study. All the subjects were in our charge and met the following eligibility criteria: at least 55 years of age; independently mobile; living in a pri- vate residence; and suffering from depressive dis- order and/or mild dementia, based on DSM-111-R (American Psychiatric Association, 1987) criteria, within 1 yr of the baseline examination. The demented patients lived with caregivers who were able to attend the outpatient clinic with them and report any falls they had sustained.

As control subjects, 103 volunteers were rec- ruited from the urban district of Kofu City. After undergoing the procedure described in detail below, 100 elderly subjects who met the above-men- tioned eligibility criteria but did not suffer from depression and/or dementia participated in the study.

Baseline data

All the study and control subjects underwent a baseline examination consisting of an interview, physical examination, mental examination and laboratory tests.

The interview elicited demographic data and information about their psychiatric and medical history, all the medications currently being used, history of falling in the past 12 months, functional disabilities, including foot and leg problems, and the body mass index (body wt (kg)/height (m)2). The physical examination included the assessment of ADL using the Barthel index (Mahoney and Barthel, 1965), tandem gait, Romberg test and manual neurological and musculoskeletal examin- ations. Ambulatory status was assessed by a dicho- tomous variable, and ‘poorly ambulatory’ was assigned if the subject could neither run nor walk up and down stairs independently. The blood pres- sure was measured, paying attention to postural change, and visual acuity was determined using Snellen’s test type at a distance of 3 m with subjects wearing their best correction spectacles. The Hamilton rating scale (Hamilton, 1960) was used to assess depression, and cognitive function was evaluated using Hasegawa’s dementia screening

scale (Hasegawa, 1984). Laboratory tests, including a complete blood count, total serum protein and serum albumin, were carried out and a standard electrocardiogram was obtained.

The original 103 control subjects underwent the same assessments as the study subjects, except for the mental examinations and identification of medi- cations taken. Their mental status was assessed according to the following procedure. The Beck Depression Inventory (Beck er al., 1961) and Hase- gawa scale score were assigned to each subject. We interviewed six subjects with Beck Depression Inventory scores in excess of 5 and assessed their affective status using Hamilton’s scale. We excluded from the control group two of these six subjects who showed Hamilton scores greater than 10, since they were depressed. We regarded those with Hasegawa scores of over 21.5 as cognitively intact elderly and, according to this definition, one more control subject was excluded. Consequently, 100 control subjects were enrolled in the study. In order to identify their drugs, one of the authors (TA) visited each subject and examined all the drugs taken using a drug code book.

Outcome and follow-up

A fall was defined as a subject’s unintentionally coming to rest on the ground or at some other lower level, not as a result of a major intrinsic event (eg stroke or syncope) or overwhelming hazard (Gib- son er al., 1987).

For the study subjects, information on falls and their circumstances was obtained during a check-up at our outpatient clinic every month, but blood pressure and postural changes (Davie el al., 1981) were assessed bimonthly. In order to obtain reliable data on the falls sustained, a log diary for recording them was given to each subject. Additionally, at the time of monthly check-ups, we repeatedly instructed the patients with depression and care- givers of the demented to record any falls sustained by subjects. If a monthly clinic attendance was missed, the patient was asked at the next attendance about falls since the last contact. At the end of the I-yr follow-up period, we reassessed the affec- tive status, cognitive function, ADL and laboratory data, as described for the baseline examinations. At the same time, we investigated fall phobia (Mur- phy and Isaacs, 1982) in the subjects with depression who had fallen twice or more during the year by asking about the presence or absence

FALLING 19

of fear of falling and whether or not their activities such as walking or bathing had been curtailed.

For the control subjects, we held bimonthly check-up meetings at a community centre, where we obtained information about falls and carried out blood pressure measurements as described for the study subjects. If a check-up was missed, we visited the subject as soon as possible to obtain this information.

Statistical analysis

We determined the differences between the study and control subject variables using Student’s t-test for continuous variables and chi-squared test for categorical variables. The unadjusted relative risk values and 95% confidence intervals for each vari- able were calculated using unconditional logistic regression analysis.

Forward logistic regression analysis was per- formed to determine which variables were most strongly associated with, and to derive a predictive equation for, falling. Adjusted relative risk values were obtained from the final model. For the logistic regression analysis, the dependent variable, namely fall status, was divided into two categories: fallers (those who fell twice or more during the year) and non-fallers (those who did not fall or fell only once during the year). We used all the data except those of blood pressure and postural change obtained from the baseline examination as independent vari- ables. Recently, it was reported that intra-indivi- dual blood pressure varies from time to time (Lipsitz et al., 1985), so we assessed blood pressure and postural change on five different occasions dur- ing the study, besides the baseline examination, and we determined the difference in these data between the study and control subjects using Student’s t- test.

In order to determine the effects of falling on the physical and psychological well-being of the study subjects, we also analysed the differences in the affective status, cognitive function, ADL and laboratory data at the start and end of the study between the fallers and non-fallers using Student’s t-test and chi-squared test. The data were analysed using the SPSS computer package. Differences at p < 0.05 were considered to be significant.

RESULTS

At the end of the follow-up, 94 study and 97 control subjects were still participating in the study. Of the original 167 study subjects, 35 stopped attending the outpatient clinic after remission of depression, 1 1 were hospitalized because of physical problems, including spontaneous fractures, five were trans- ferred to nursing homes, two were bedridden in their own home, one died, and 11 became unavail- able. Two control subjects died and one was trans- ferred to a nursing home. Of these dropout subjects, those who had fallen twice or more by the time of their final check-up were included in the analysis. A final total of 102 study and 100 control subjects were available for analysis. The former group com- prised 79 with depression (major depression and dysthymia), 14 with mild dementia (primary dege- nerative and multi-infarct) and nine with combined disease. The results of the baseline examinations are shown in Table 1.

Fall occurrence During the study period, the subjects sustained

21 6 falls and the controls 54. The numbers of fallers (falling twice or more during the year) were 40 among the subjects and 14 among the controls. Nine of the 216 falls sustained by the study subjects resulted in fractures, including three of the femur neck. The results of the assessment of risk factors associated with falls in both groups are presented in Table 2. In order to examine the hypothesis that depression and/or cognitive dysfunction predispose the elderly to falling, we performed the following analysis. The presence or absence of depression and/or dementia was added as another variable to the risk factors presented in Table 2, and we applied forward logistic regression analysis to the 202 parti- cipants (combined study and control subjects) to determine the variables most strongly associated with falling. Two risk factors significantly and inde- pendently predicted falling in the combined popu- lation: the presence of depression and/or dementia and the Barthel index score (Table 3). To examine the validity of this result, we selected 56 pairs of subjects and controls who were matched for age, sex and ADL (difference within 5 on the Barthel index). The characteristics of the pairs were: age, 72.1 f 4.9 yr; female, 35; score on Barthel index, 96.0 f 6.0 for the subjects, 97.4 f 4.4 for the controls. Twenty-one (37.5%) fallers in the subject group and six (10.7%) in the control group were

20 T. ASADA, T. KARIYA, E. KITAJIMA ET AL.

Table 1 . Baseline characteristics of studv DarticiDants

Age: mean f SD (range) Gender F: M Living alone HDS score? Hamilton scale

Medication No. of total drugs No. of:

Antidepressants Anti psychotics Hypno tics-anxiolytics Cardiovascular drugs

BMI (kg/m*) Barthel index$ Poorly ambulatory Romberg’s sign Poor tandem gait Falls in past year Leg and foot problems$ Visual acuity Abnormal ECG Malnutrition$$ Anaemiaq

Subject Control ( N = 102)

69.9 f 8.7 (56-88)

( N = 100)

73.8 f 7.3 (55-91) ** 70:32 68:32 11.8% 18.0%

24.6 f 8.5 28.0 f 5.3 ** 10.9 f 7.0 -

5.7 f 2.8 2.5 f 2.6 **

0.6 f 0.7 0.3 f 0.5 1.2f 1 . 1 0.5 f 0.9

22.0 f 3.2 95.9 f 7.6

21.6% 10.8% 35.3% 41.2% 34.3%

0.6 f 0.3 23.5% 7.1%

10.2%

0 ** 0 **

0.3 f 0.5 ** 0.6 f 0.8

22.7 f 3.1 97.9 f 3.6 *

18.0% 5.0%

33.0% 19.0% ** 26.0% 0.5 f 0.3 24.0?’0 12.0% 22.00/0 *

t Hasegawa’s dementia screening scale: total score 32.5, I 21.5; dementia suspected. $ Barthel index: score range 0 (most severe impairment)-100 (no impairment) in 5-point increments. $ Including Parkinson’s disease, hemiplegia, osteoarthritis, etc. $8 Malnutrition: at least one of serum total protein 56 .0 g/dl, albumin I 3.5 g/dl. IAnaemia: at least one of RBC< 350 x lo4, Hgb< 1 l.Og/dl, Hct< 35%. l1 Forty-nine study subjects took antidepressants. Forty-seven of 49 took non-tricyclic antidepressants. * * p < 0.01; * p < 0.05.

found among the 56 pairs (chi-squared = 11 .O, p < 0.001). These results appear to confirm the importance of mental status as the risk factor strongly associated with falling.

Logistic regression analysis performed on the subject group revealed two significant and indepen- dent fall-predicting factors (Table 3). The Hamilton score was most strongly associated with falling. Unexpectedly, use of antidepressants was asso- ciated with a lower likelihood of falling. Logistic regression analysis of the subjects’ results yielded a predictive equation using the forward stepwise selection method. (The equation at the final step was: ln[p/l - p ] = 0.20 (Hamilton score) - 1.52 (use of antidepressants) - 2.11 .) Overall, 75% of the subjects were classified correctly. This equation predicted fallers in the subject population with 87.0% specificity and 53.3% sensitivity.

After classifying the fallers into three groups in

order of age, we assessed the changes in the Hamil- ton score, the nutritional condition defined in Table 1 and ADL rated by the Barthel index during the study period in each of the groups. For the eldest group, aged 75 yr and over, the results for nutrition and ADL at the end of the study were worse than those at the baseline. However, no evidence of deterioration in these two factors was found for the fallers aged less than 74 yr. The Hamilton score in each of the groups had decreased by the study end.

The results of blood pressure and postural change measurement revealed significantly lower mean blood pressure for the study subjects (subject group, 134 f 21/64 It 10 mmHg; control group, 143 k 17/72 f 9 mmHg) but a similar frequency of postural hypotension in both groups (number of occasions of an observed postural drop of more than 20 mmHg in systolic blood pressure among

FALLING 21

Table 2. Risk factors associated with two or more falls

Risk factor Subject (40 fallers) Control (14 fallers) Unadjusted relative Unadjusted relative

risk (95% CI) risk (95% CI)

Age* < 65 1 1 6 5 s <75 1.4 (1.0-1.9) 1.1 (1.0-1.2)

75 s 2.2 (1.3-3.9) 1.1 (1.0-1.3)

Living alone 0.5 (0.1-1.9) 0.3 (0.0-2.4) HDS*

Female gender 2.0 (0.8-5.0) 1.1 (0.5-2.4)

> 30 1 1 30> 2 2 0 1.6(1.0-2.5) 1.5 (1 &2.3) 202 >10 2.3 (1.0-5.5) 102 4.8 (1.4-16.3)

< 10 I 10s <20 1.7 (1.1-2.6) 20 s 9.6 (2.3-39.3)

Hamilton *

No of medication* Total

0 5 <5 1 1 5s <10 1.1 (0.8-1.5) 1.8 (0.9-3.8)

1 0 s 2.1 (0.S5.6) 1.0 (1 .o-1 . I ) Antidepressant 0.9 (0.61.4) Antipsychotic 0.7 (0.61.5) H ypno tics-anxiol ytics 1 .O (0.8-1.4) 2.9 (1.46.0) Cardiovascular drugs 1.1 (0.62.0) 1.1 (0.62.2)

B 15 1 1 1 5 s <25 1.0 (0.9-1.0) 1 .o (1 .o-1 . I ) 25 s 0.9 (0.7-1.1) 1.0 (1.0-1.1)

BMI*

Barthel index: < 90 10.0 (2.1-48.6) 6.2 (0.4-105)

Romberg’s sign 2.7 (0.8-8.7) 8.8 (1.6-48.3) Poor tandem gait 2.4 (1.44.2) 3.3 (2.1-5.3)

Poorly ambulatory 3.6(1.4-9.7) 2.9 (0.8-9.8)

Falls in past year 2.8 (1.7-4.6) 10.0 (4.7-21.4) Leg and foot problems 1.5 (0.9-2.5) 1.7 (0.8-3.7) Visual acuity*

2 1.0 1 1

<0.5 1 .O (0.3-3.6) 1.2 (1 .O-1.4) Abnormal ECG 1.3 (0.7-2.6) 1.5 (0.7-3.5)

1.0> 20.5 0.9 (0.61.2) 1.1 (1.0-1.2)

Malnutrition 1.2 (0.3-5.0) 2.0 (0.644)

Risk factors without *are defined as dichotomous variables.

Anaemia 6.3 (1 .628.2) 0.9 (0.3-2.7)

six measurements: subject group, 0.78 f 0.99; con- DISCUSSION trol group, 0.92 f 1.07). Finally, the examination of fall phobia showed that 18 of the 40 fallers from The results of this study confirm the particular the study group were afraid of falling, and that importance of depressive status as a contributory seven of these 18 subjects with phobia reported that factor to falling among the elderly. Some the falls had curtailed their daily living activities. researchers have speculated that recurrent falls,

22 T. ASADA, T. KARIYA, E. KITAJIMA ET AL.

Table 3. Results of logistic regression analysis

Regression coefficient Significance Adjusted odds ratio

Combined (N = 202) Psychiatric morbidity 1.202 0.0012 3.33 ADL (Barthel index) -0.140 0.0002 0.25* Constant 11.776 0.0012

Hamilton score 0.197 0.0001 7.17*

Constant -2.112 0.0002

Subject (N = 102)

Antidepressants use - 1.524 0.0190 0.22

*Calculated in 10-point increments for each scale.

fear of falling, curtailment of activities and psycho- physical deterioration constitute a vicious circle, which may lead to consequent institutionalization (Nickens, 1983; Brummel-Smith, 1989; Cwikel et al., 1990). Although our results do not prove the validity of this hypothesis, the decline in nutritional status and ADL observed in the oldest faller group suggests that depression may reflect this kind of vicious circle, at least in fallers aged 75 yr and over.

Depression and antidepressants have been indi- cated as the major factors contributing to falls among the community-dwelling elderly in previous studies (Granek et al., 1987; Ray et al., 1987; Tinetti et al., 1988). The present study revealed that the severity of depression was the most important fac- tor related to falling, whereas antidepressant use was associated with a lower likelihood of falling. To our knowledge, no previous study has reported such a beneficial association. However, we believe our observations are valid for the following rea- sons. First, although most of the antidepressants taken by patients in the reported studies were tri- cyclics, as shown in Table 1, 96% of those taken in the present study were non-tricyclics, namely, setiptiline, maprotiline and mianserin. The non-tri- cyclics have fewer adverse effects such as psycho- motor retardation and sedation (Schmidt et al., 1986). Psychomotor retardation has been con- sidered as a risk factor for falls (Tinetti et al., 1988). In addition, the observed postural hypotension, which has been indicated as a factor contributing to falls (Glassman et al., 1979), was similar in the subject group to that in the control group. Further- more, even if the severity of depression at the base- line is the most important factor contributing to falling, depression, by its nature, is a reversible ill- ness. When antidepressants improve the patient’s state, the risk of falling might decrease subse- quently. As noted in the Results section, it can be

said that the severity of depression in the subjects had generally improved by the end of the study. Therefore, the use of antidepressants at the baseline might have resulted in a reduction of falling risk as well as ameliorating the depression.

It has been stressed that psychotropics other than antidepressants are also associated with the risk of falling and fracture (Granek et al., 1987; Ray et al., 1987). However, as far as our psychogeriatric subjects were concerned, the results of this study revealed that neither hypnotics--anxiolytics nor antipsychotics were risk factors for falling.

Finally, the percentage of our control subjects who reported falls was similar to the rate of falling estimated in previous community-based studies in generally normal elderly subjects (Campbell et al., 1981; Prudham and Evans, 1981). The reliability of reporting falls is the most important aspect of this type of study (Cummings et al., 1988), especially in a mentally impaired elderly popula- tion. In order to gain the most accurate information possible, we checked falling in the study subjects monthly, and bimonthly in the control subjects, using fall-recording notes. Nevertheless, the fre- quency of falling may have been underestimated and the different intervals between the check-ups in the two groups may also have been a source of bias. Further controlled trials are needed to improve the above-mentioned limitations of our study design.

ACKNOWLEDGEMENTS

We are grateful to Dr M. Hayashi, Division of Neurology, Kofu Municipal Hospital, for his help- ful comments and to the district nurses of Kofu City Office and Mrs K. Fukasawa for their help.

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