Psychological risk factors associated with falls among elderly people in Baghdad city, Iraq

doi:10.4236/ojpm.2013.37059

Paper Menu >>

Journal Menu >>

Vol.3, No.7, 441-445 (2013) Open Journal of Preventiv e Me dic ine

http://dx.doi.org/10.4236/ojpm.2013.37059

Psychological risk factors associated with falls

among elderly people in Baghdad city, Iraq

Mohammed A. Abdal Qader1*, Rahmah Mohd. Amin2, Shamsul Azhar Shah1, Zaleha Md. Isa1,

Khalib Abdul Latif1, Hasanain Faisal Ghazi1

1Department of Community Health, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia;

*Corresponding A u thor: [email protected]

2Medical and Health Science Faculty, Universiti Sultan Zainal Abidin (City Campus), Jalan Sultan Mahmud, Kuala Terengganu, Malaysia

Received 15 August 2013; revised 21 September 2013; accepted 6 October 2013

tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

cited.

ABSTRACT

Background: Ageing of the population is one of

the most im portant demographic fac t s th at c ome

to the foreground in the 21st century. Objective:

To assess the relationship between psycho-

logical factors (depression, loneliness, using

anti anxiety medication, fear from falls and in-

ternal displacement of the population) and falls

among elderly people in Baghdad city, Iraq.

Methods: A match ed 1:1 comm unity based ca se-

control study involving 716 elderly respondents,

recruited randomly from six Non Governmental

Organization (NGO) in different areas of Bagh-

dad. Interviews to each respondent were done

accordingly. Geriatric depression scale (GDS)

was used to assess the depression among the

elderly people. Results: The minimum age for

cases and controls was 60 years old while the

maximum age for cases was 87 and for controls

was 85 years old. The female was predominant

than male, 53.6% to 46.4% respectively. The re-

lation between depression, fear from fall, using

anti anxiety medication, internal displacement

and falls was statistically significant (p < 0.001).

Conclusions: Psychological factor especially

depression among elderly people is one of the

important risk factors contributing to falls acci-

dent. Fear from falls, displacement and taking

anti anxiety medication were also in significant

relation.

Keywords: Falls; Elderly; Depression; Fear from

Fall; Baghdad

1. INTRODUCTION

Ageing of the population is one of the most important

demographic facts that come to the foreground in the

21st century. Psychological problems of depression,

loneliness and dependency feelings are very common

among elderly people. Another common issue is falls

accident which has a great impact on or leads to many

consequences such as bedridden, total dependence on

others and can even cause death [1].

According to United Nations report in 2009, the per-

centage of 60+ age population in Iraq was 3.9% for men

and 5.6% for women, while the sex ratio in 60+ age

group was 70 men to each 100 women. Some elderly

Iraqis have lost all their relatives over the past few years

and now have to depend totally on themselves. Being

unable to work because of age or poor health conditions,

some of them have urged for begging in the streets and

become homeless people while others are supported by

their neighbours and relatives[2].

Falls accident could be preventable and is a promising

issue to be dealt with in preventive medicine. Hence the

public health experts should take into consideration, this

preventive issue involving falls among the elderly people

seriously. More research is needed to be done to reduce

the burden of falls to the community. It is obvious that

lack of knowledge about risk factors and how to prevent

them will contribute to a high prev alence of falls. There-

fore, lack of knowledge in this issue will lead to a lack of

preventive actions that should be taken, thus resulting in

more falls [3].

Psychological relationships to falls accident were less

clear. However, depression and falls, which can be corre-

lated to the decrease of functional independence, loss of

physical fitness, reduc ed gait velocity and loss of muscle

strength are due to immobility and lethargy, which are

*The authors declare t hat they have no conflict of interest.

M. A. A. Qader et al. / Open Journal of Preventive Medicine 3 (2013) 441-445

442

common in depression [4].

Fear of falling (FOF) is a major health problem among

the elderly living in communities. This feeling can be

expressed in older people both who have fallen and also

in older people who have never experienced a fall. The

main consequences were identified as a decline in

physical and mental performance, an increased risk of

falling and progressive loss of health-related quality of

life [5]. A study by Elliott et al. [6] in eastern North

Carolina, United States showed a significant relation be-

tween living alone and falls accident to themselves.

In Iraq, there are no available studies or literature re-

view that assays the epidemiolog y and aetiology of falls,

that could be considered as evidence that warrants some

attention. The objective of this study is to assess the rela-

tionship between psychological factors and falls accident

among elderly people in Baghdad city, Iraq.

2. Methods

A case control study matched by sex and age was

conducted between January and March 2012 in Baghdad

city, Iraq. 716 elderly respondents, recruited randomly

from six Non Governmental Organization (NGO) in dif-

ferent areas of Baghdad; These NGOs provide social &

medical services to the community in Iraq. Severely ill

respondents, using wheelchair, an elderly fall outside the

home and elderly with severe psychosomatic disease

were excluded from this study. Face to face interview to

each respondent were done accordingly. Back-to-back

trans-lation to the questionnaire was done (English-Ara-

bic-English). GDS (geriatric depression scale) standard-

ized questionnaire (Arabic version) was used to measure

the level of depression among the elderly people [7].

A pre test of the questionnaire was carried out to im-

prove the questionnaires and make it more understand-

able. This study was approved by the Research and Eth-

ics Committee of Universiti Kebangsaan Malaysia Me-

dical Centre. Code Number FF-017-2012, consent form

was taken from the respondents.SPSS version 19 was

used for statistical analysis of the data and Pearson

chi-square test was performed with a level of signifi-

cance p < 0.05.

3. Results

The minimum age for cases and controls was 60 years

old while the maximum age for cases was 87 and for

controls was 85 years old, the mean age for cases was

67.01 while mean age for controls was 66.28 years old.

The female was predominant than male, 53.6% to 46.4%

respectively. Other socio-demographic characteristics as

shown in Table 1 showdifferences between cases and

controls. Educational level was a significant contributor

for the falls. The employment status was not significant

risk factor, while, the monthly family income and marital

status were significant risk factors for falls among eld-

erly people.

Table 1 also shows the distribution of the respon-

dents’ depression, fear from fall and living alone. The

fear from fall was significantly associated with fall acci-

dent and of p < 0.001, the odds ratio is 2.90, with a 95%

confidence interval ranging from 2.17 to 4, showed that

those who suffer from fear were about 3 times more sus-

ceptible to fall than those elderly who does suffer from

fear of falling. For depression factor, the p value is sig-

nificant (p < 0.001), the odds ratio 2.8, indicating that

those elderly with depression is about 3 times more sus-

ceptible to fall than those elderly without depression.

Living alone was not statistically associated with falls (p

= 0.91) with odds ratio of 1.03, and 95% confidence in-

terval extending from 1.49 to 1.58.

Internal displacement was a significant risk factor of a

p value <0.001, those who internally displaced were

about 2 times more to falls as compared to non displaced

elderly.

Elderly people using anti anxiety medications suffer a

higher significant risk of falls with odds ratio of 2.3.

4. Discussion

Fall is still found to be one of the public health prob-

lems among elderly people; falls are a common and often

devastating problem among older people, causing a tre-

mendous amount of morbidity, mortality and use of

health care services. The most important finding in our

study was depression and fears from fall as they were

significantly associated with an increased risk of being a

faller.

Some of the limitations in this study are recall bias of

the respondents, not an interventional type and logistic

problems because of the security situation in Baghdad.

While the strength of this study is mainly being a com-

munity based study, with large sample size and first kind

of study in Iraq.

In this study, there is a significant difference between

low education and high education among cases and con-

trols, those with low education level were at odds of risk

by about 1.8 times as compared to those with high edu-

cation as shown in other studies [8,9].

There was a significant relationship between monthly

income and falls as supported by other studies. The pos-

sible reason for that could be those with higher monthly

income can get better welfare life, nutrition and more

medical services. There were no significant association

between current employment status (working or not

working) and fall and that was against what some other

studies findings [8,9].

Fear from falls was associated with falls accident as

M. A. A. Qader et al. / Open Journal of Preventive Medicine 3 (2013) 441-445

443

Table 1. The Frequency distribution and relationship of socio-economic and psychological factors with falls accident among the

elderly people in Iraq.

Variables Case (358) N (%) Control (358) N (%) p-valuea POR 95%CI

Educational level

Low 189 (52.8) 130 (36.3) <0.001* 1.96 1.45 - 2.64

High 169 (47.2) 228 (63.7)

Employment status (current)

Unemployed 270 (75.4) 254 (70.9) 0.17 1.25 0.90 - 1.75

Employed 88 (24.6) 104 (29.1)

Marital Status

Married 159 (44.4) 224 (62.6) <0.001* 2.12 1.56 - 2.85

Not Married 199 (55.6) 134 (37.4)

Monthly Income

Low Income 192 (53.6) 164 (45.8) 0.036* 1.36 1.02 - 1.83

High Income 166 (46.4) 194 (54.2)

Fear of Fall

Yes 262 (73.2) 173 (48.3) <0.001* 2.90 2.17 - 4.00

No 96 (26.8) 185 (51.7)

Depression

Yes 284 (79.3) 207 (57.8) <0.001* 2.80 2.01 - 3.89

No 74 (20.7) 151 (42.2)

Living (Household)

Alone 49 (13.7) 50 (14) 0.91 1.03 1.49 - 1.58

Not Alone 309 (86.3) 308 (86)

Internal displacement

Yes 133 (37.2) 77 (21.5) <0.001* 2.15 1.54 - 3.00

No 225 (62.8) 281 (78.5)

Anti anxiety medications

Yes 142 (39.7) 80 (22.3) <0.001* 2.32 1.66 - 3.22

No 216 (60.3) 278 (77.7)

aPearson chi-square test was perfor med; *Level of significance p < 0.05; POR = Prevalence odds ratio.

supported by Yu et al. study, they found that the total

rate of falls-induced fear of repeated episodes of falls

(58.8%) and at the same time the occurrence of falls were

significantly associated with fear of future falls [9].

Kwan et al. in their systematic review found that the

median fall rates was 18%, they found that being com-

plaining of fear of falling was commonly reported factor

[10]. On the other hand, study by Leung et al. did not

match our findings as fear from fall was not significantly

associated with falls [11], this contradictory could be due

to the differences in the culture, habits and welfare be-

tween these two different societies.

While for depression factor, our study was supported

by other studies which found that falls were most strongly

associated wit h sad feeli ng or depression [12,1 3] .

Living alone was one of the risk factors has been

studied, in our study it was not significantly associated

with falls and other studies supported our findings, as the

study done in the city of Mataró, Spain, they stated that

no significant difference was found between the propor-

tion of falls in people living alone (34.3%) or accompa-

nied (31.7%) [14], in another study in Brazil found no

significant association between living with a partner and

fall [13].

According to United Nations High Commissioner for

Refugees (UNHCR), internal displacement remains a

M. A. A. Qader et al. / Open Journal of Preventive Medicine 3 (2013) 441-445

444

major problem, and internally displaced persons (IDPs)

require continued assistance and protection from UNHCR

until a dignified solu tion is found to their troub les. Fami-

lies live in poor settlements without adequate shelter and

with limited access to water, electricity, schools and

health centers [15].

Using anti anxiety drugs were associated with falls as

supported by a study done in Great Britain, they found

that hypnotics and anti anxiety drugs was independently

associated with an increased odds of falling, it was asso-

ciated with an increase of about 50% in the odds of fal-

ling [16]. Another study found that sleeping pills won’t

increase elderly fall risk, they found that it’s insomnia

itself, not sleeping pills, that increases the risk for falls

and injuries among elderly people [17].

5. Conclusion

Psychological factor especially depression among eld-

erly is one of the important risk factors contributing to

falls. Also, fear from falls, displacement and taking anti-

anxiety medications are significant risk factors of falls.

6. Recommendations

Findings from this research enhance knowledge about

the contributing fall-related factors in elderly. Insights

gained from this research will assist community an d pub-

lic health leaders and health care professionals in devel-

oping more effective intervention strategies to prevent or

decrease falls, and associated psychological and physical

consequences

To prevent falls, it is necessary to intervene on factors

associated with falls. Methods include encouraging re-

gular physical activity to improve equilibrium and mus-

cle strength and the continuous monitoring of health

status to prevent further deterioration.

Fall prevention is need ed for elderly individuals living

in the community and should target the elderly adults

with less education level and low monthly income while

helping to en sure that individuals who are living without

family have the appropriate support.

7. ACKNOWLEDGEMENTS

This study was funded by the Universiti Kebangsaan Malaysia

Medical Centre Fundamental Research Grant, Code Number FF-017-

2012 without which the study would not have been poss i b le.

REFERENCES

[1] Graafmans, W.C., Ooms, M.E., Hofstee, H.M.A, Bezemer,

P.D., Bouter, L.M. and Lips, P. (1996) Falls in the elderly:

A prospective study of risk factors and risk profiles.

American Journal of Epidemiology, 143, 11.

http://dx.doi.org/10.1093/oxfordjournals.aje.a008690

[2] UN Office for the Coordination of Humanitarian Affairs

(2007) IRAQ: Elderly most vulnerable to insecurity IRIN,

the humanitarian news and analysis service of the inte-

grated regional information networks, UN-OCHA, Bagh-

dad city.

[3] Tremblay Jr. K.R. and Barber, C.E. (2010) Preventing

falls in the elderly.

http://www.ext.colostate.edu/pubs/consumer/10242.html

[4] Rao, S.S. (2005) Prevention of falls in older patients.

American Family Physici an, 72, 81-88.

[5] Scheffer, A.C., Schuurmans, M.J., van Dijk, N., van der

Hooft, T. and de Rooij SE. (2008) Fear of falling: Meas-

urement strategy, prevalence, risk factors and conse-

quences among ol d er persons. Age and Ageing, 37, 19-24.

http://dx.doi.org/10.1093/ageing/afm169

[6] Elliott, S., Painter, J. and Hudson, S. (2009) Living alone

and fall risk factors in community-dwelling middle age

and older adults. Journal of Community Health, 34, 301-

310. http://dx.doi.org/10.1007/s10900-009-9152-x

[7] Samira, N. (2011)

http://www.stanford.edu/~yesavage/GDS.html

[8] Morgan Robert, O., Virnig Beth. A., Maurice, D., Elsayed

A.-M. and Carolee A. De V. (2003) Low-intensity exer-

cise and reduction of the risk for falls among at-risk eld-

ers. The Journals of Gerontology, 59, M1062-M1067.

http://biomedgerontology.oxfordjournals.org/content/59/1

0/M1062.short-aff-1

[9] Yu, P.L., Qin, Z.H., Shi, J., Zhang, J., Xin, M.Z., Wu, Z.L.

and Sun, Z.Q. (2009) Prevalence and related factors of

falls among the elderly in an urban community of Beijing.

Biomedical Environmental Sciences, 22, 179-187.

http://dx.doi.org/10.1016/S0895-3988(09)60043-X

[10] Kwan, M.M., Close, J.C., Wong, A.K. and Lord, S.R.

(2011) Falls incidence, risk factors, and consequences in

Chinese older people: A systematic review. Journal of the

American Geriatric Society, 59, 536-543.

http://dx.doi.org/10.1111/j.1532-5415.2010.03286.x

[11] Leung, A., Chi, I., Lou, V. W. and Chan, K.S. (2010) Psy-

chosocial risk factors associated with falls among Chi-

nese community-dwelling older adults in Hong Kong.

Health & Social Care in the Community, 18, 272-281.

[12] Stevens, J.A., Ballesteros, M. F., Mack, K.A., Rudd, R.A.,

DeCaro, E. and Adler, G. (2012) Gender differences in

seeking care for falls in the aged Medicare population.

American Journal of Preventive Medicine, 43, 59-62.

http://dx.doi.org/10.1016/j.amepre.2012.03.008

[13] Juliana, G., Lucy, G., Otávio de T.N. and Marcelo, P.R.

(2010) factors related to falls among elderly women resi-

dent in a community. Revista da Associação Médica Bra-

sileira, 56, 327-332.

[14] Salvà, A., Bolíbar, I., Pera, G. and Arias, C. (2004) Inci-

dence and consequences of falls among elderly people

living in the community. Medicina Clinica (Barc), 122,

172-176.

http://dx.doi.org/10.1016/S0025-7753(04)74184-6

[15] United Nations High Commissioner for Refugees (2012)

2012 UNHCR country operations profile, Iraq, UNHCR,

Baghdad city.

M. A. A. Qader et al. / Open Journal of Preventive Medicine 3 (2013) 441-445

445

[16] Lawlor, D.A., Patel, R. and Shah, E. (2013). Association

between falls in elderly women and chronic diseases and

drug use: Cross sectional study. BMJ, 327, 712.

[17] Alon, A. (2005) Sleeping pills won’t increase elderly fall

risk. Health Day News, University of Michigan Health

System.