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Physical consequences of falls in the elderly: a literature review from 1995 to 2010
European Review of Aging and Physical Activityvolume 11, pages51–59 (2014)
In the last decade, population ageing has been registered as a global phenomenon. A relation exists between falling and ageing, since falling frequency increases significantly with age. In fact, one in three older adult falls annually. Although ageing is generically associated with decrease and degeneration of psychological and physical functions, it is still not common for the correct identification of risk factors to lead to a clinical prognosis of the elder being in risk of falling. Therefore, the goal of this review article is to identify, categorise and analyse typical ageing and fall factors mentioned in the literature as well as to quantify the number of times they were referenced. The research considered hundreds of publications, but analysis was then restricted to the 87 most pertinent articles written in English and published in journals or scientific magazines between 1995 and 2010. We concluded that falls among older adults can be characterised by the following: anatomic characteristics and physiological consequences of ageing; the pathologies that induce falls, which can be neurological, musculoskeletal, cardiovascular and other diseases; causes and risk factors of falls that can be behavioural, biological, environmental or socio-economic; type of physical consequences of falls, including fractures, bruises, injuries or other physical consequences; and strategies to prevent, mitigate or rehabilitate, which can be of a physical, environmental or behavioural nature.
Elderly are currently considered the fastest growing age group worldwide . In the last decades, the number of elderly people in the world has been consistently and proportionally increasing. In 1996, there were a total of 323 million people in the world aged above 65 years . That number increased in 2010 to 440 million  and is forecasted to be 1,555 million by 2050 .
The physical changes inherent to ageing can reduce autonomy and functional independence, which may directly or indirectly lead to falls. Falls are coded as E880–E888 in the International Classification of Disease-9 (ICD-9) and as W00–W19 in ICD-10, being commonly defined as “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects” . About one third of the population over 65 suffers at least one indoor fall every year [33, 47], and about half of the population in this age group who is institutionalised fall each year . Among the elderly, falls are one of the main causes of injuries, physical incapacity and even death. Each year, around 37.3 million falls among elderly will require health care, and about 424,000 lead to death of the faller .
It is thus obvious that the problem of falls among the elderly population has epidemiological levels with a global incidence and dimension. Therefore, the following question was posed: What are the physical consequences of falls in the elderly population?
In order to answer this question, a quantitative review was conducted. This paper aims at identifying, categorising and analysing the typical ageing and fall factors mentioned in the literature as well as quantifying the number of times these factors were referenced. This study considered the incidence of the anatomic characteristics and physiological consequences of ageing, the pathologies that power falls, causes and risk factors for falls, physical consequences of falls and strategies to prevent, mitigate and rehabilitate.
This work is focused on providing an overview of the published literature to researchers, academics and practitioners, who deal with this issue; it does not cover the entire research area of elderly population falls.
Materials and methods
The research was limited to peer-reviewed articles, written in English and published in scientific journals or magazines between the years 1995 and 2010. The research was restricted to the following databases: PubMed, Access Medicine, Science Direct, Oxford Journals and Taylor & Francis Online. Additionally, a manual search was carried out for the other publishers in the areas already mentioned, such as McGraw-Hill and BioMed Central as well as publications edited by organisations that focus the problem of falls in the elderly people, such as the National Center for Injury Prevention and Control and the World Health Organization.
The keywords used, as title and/or abstract and/or keywords of the articles, either for searching scientific publications databases or for manual search in other online publications, were the following: “physical consequences of falls”, “senior population and falls”, “falls pathologies”, “anatomy of ageing”, “causes of falls” and “risk factors”.
After the search, the titles and abstracts were analysed in order to eliminate duplicates and publications with topics that did not meet the purpose of this review work. The remaining publications were thoroughly read and analysed, and all references to the topics addressed in the review article were identified and quantified.
A total of 87 publications were selected and analysed, from which 81 were journal publications from scientific database and 6 were articles published in book chapters or specialty reports obtained from the manual search. The publications came from 25 different countries in the world and represent all continents with the exception of Africa. The strongest geographic incidence, with about 82 % of the total publications was identified in two continents: North America and Europe. South America and Asia represent 18 % of the total publications. Publications from Turkey, Israel and Iran were considered as being from the Asian continent.
Ageing pathologies that potentiate falls
Falls are events that depend on multiple factors and can be related to the presence of pathologies. The pathologies inherent to the process of ageing, which may lead to fall in the elderly population, are numerous and diverse. Therefore, four categories were considered: neurological, musculoskeletal, cardiovascular and other pathologies (see Table 1). The neurologic and musculoskeletal pathologies were the most referenced in the analysed literature. The cardiovascular pathologies also had a considerable incidence of references, although small when compared with the former. Table 1 shows the references in the literature for each pathology type and the number of times they were referenced (in percentage).
In the selected literature, the neurological diseases, such as stroke (13.7 %), dementia (10.3 %), vestibular disorders/balance (10.3 %) and Parkinson (9.1 %), are the most referenced ageing pathologies as propitiating falls in the elderly population.
In terms of musculoskeletal pathologies, osteoporosis was the pathology with a higher incidence of references (16 %), followed by loss of muscle density (9.1 %) and arthritis (6.8 %). Problems in the lower extremities and joint deformities were also diseases common in the falling elderly, but with a lower incidence of references (3.4 and 2.2 %, respectively).
Cardiovascular diseases, such as orthostatic hypotension (6.8 %), arrhythmias (3.4 %) and syncope (3.4 %), are also common pathologies due to the ageing process and may also lead to falls.
In the “other pathologies” category, the following typical pathologies of ageing that can lead to falls were identified: diabetes and depression (4.5 %), pneumonia and lung infections (2.2 %) and sleep disorders (1.1 %).
The causes and risk factors of falls
Table 2 identifies multiple causes and risk factors of falls in the elderly population as well as the respective incidence in the reviewed literature. The causes and risk factors of falls are very diverse, and several of these factors can occur simultaneously. Due to that diversity, the causes and risk factors of falls were grouped in four categories, analogous to those adopted by the World Health Organization, in WHO Global Report on Falls Prevention in Older Age :
Behavioural, characteristics of human actions, emotions or daily choices;
Biological, individual's characteristics pertinent to the human body;
Environmental, interactions between the individual's physical condition and the surrounding environment;
Socio-economic, related to the individual's social and economic situation.
The results of this analysis are shown in Table 2. The behaviour causes and risk factors most referenced in the reviewed literature were overdose of medication (with 32.1 %) and the fear of falling—without having ever fallen before or after the first fall (29.8 and 22.9 %, respectively). The reduction in physical activity (16 %), carrying out activities of daily living (11.4 %) and alcohol consumption (10.3 %) are located in the intermediate incidence group. In the smallest incident group, the following were identified: slip (6.8 %), fainting (4.5 %) as well as smoking and an inappropriate use of footwear (both with 3.4 %).
Concerning the biological causes and risk factors, highest incidence was on a lack of balance during gait (33.3 %), musculoskeletal and sensory degradation (26.4 %), functional dependence in the mobility (25.2 %), cognitive impairment (24.1 %), age (19.5 %) and sex (18.3 %) with higher incidence in females. The decrease in bone density and lack of vision (with 14.9 % each), chronic diseases (13.7 %), depression (12.6 %), occurrence of dizziness and vertigo (11.4 %) and decrease of index bone mass (10.3 %), which weakens the ability to absorb and dissipate impact forces, were intermediate incidence factors. Finally, urinary incontinence, orthostatic hypotension, pain, soft tissue changes, hearing problems and body weight, with between 3.4 and 4.5 % incidence, were identified as causes and behaviour risk factors with least references in the reviewed literature.
With respect to the environmental causes and risk factors, unsafe domestic (17.2 %) and outdoors (16 %) environments were found to have the highest incidence. Falls from hospital beds, mobility aids (for example walkers) and the collision against objects were referenced only one to two times.
Last, the socio-economic causes and risk factors of falls included limited access to health and social services (2.2 %), low income and low educational level (2.2 %) and lack of social interactions (1.1 %). This category had the lowest number of references in the literature, when compared with the other categories of causes and risk factors.
If a profile is established for a senior individual with a high risk of falling based simultaneously on the causes and risk factors more referenced on the four categories, the overall risk of falling and consequent injury gravity for that individual can be expected to be very high.
Physical consequences of falls and physiological effects
Falls among the elderly are associated with a large diversity and heterogeneity of undesired physical consequences, which can be more or less severe. Four main categories were considered for the physical consequences: fractures, bruises, injuries and “other” physical consequences. A fifth category was also defined, focused on the physiological effects associated to the physical consequences of falls.
The results concerning the physical consequences and the physiological effects of falls are shown in Table 3. It was observed that fractures (as consequences of falls) can occur in almost every region in the body. However, the hip fracture and undifferentiated bone fractures are the most referenced in the literature, with 37.9 and 27.5 % incidence, respectively.
The head bruises due to falls, with 10.3 % incidence, were the more referred physical consequence in the bruises category.
For the injuries category, the incidence of references in the literature is more homogeneous than in other categories. The most referenced injuries are soft tissues and the upper extremities, respectively with 6.8 and 5.7 % incidence. Injuries on the elbows are the ones that had the least incidence, namely 2.2 %.
For other consequences, lacerations with 8 % and dislocations with 5.7 % incidence were the most referenced in the literature. This category also included sprains, hematomas and pain, but these were identified in the literature to a smaller extent.
The physiological effects of elderly falls were also identified. The two effects with higher incidence of references were death and morbidity, with 21.8 %, and functional decline, with 20.6 %. Other still significant effects were inactivity, with 14.9 %, functional dependence and loss of autonomy, with 13.7 %, and depression, with 10.3 % incidence.
This analysis reveals a possible cause–effect relation between the different physiological effects. For example, depression can lead to higher functional dependence; in the same way, inactivity can lead to functional decline. On the other hand, the state of physical incapacity and functional dependence as a result of a fall can retract the ability to participate in everyday life activities and increase the chance of depression. These interrelations between causes will be further explored in future work.
Interventions for prevention, rehabilitation and minimization of falls
Many actions, strategies and mechanisms can—and have been—employed for the prevention, minimization and rehabilitation aspects of elderly falls. The different interventions can be categorised into three groups: the first group consists of physical interventions, the second of environmental interventions, and the third with behavioural interventions. For each of those, one can correspond them to the three stages associated with falls: the moment before the fall (interventions to prevent falls), the time during the fall (interventions to minimise the consequences of falls) and the moment after the fall (interventions related with the rehabilitation of the consequences of falls).
The different interventions, related to falls, as well as the respective percentage of references incidence are indicated in Table 4. For each type of intervention (physical, environmental and behavioural), Table 4 also shows at which stage of the fall event they can be applied (prevention, minimization and rehabilitation). Note that these stages are not mutually exclusive.
The physical interventions are those that represented the highest incidence: most notably, adjustment of medication with 18.3 % incidence, hip protection coating systems with 17.2 % incidence and the use of strengthening nutrition programmes with 11.4 % incidence.
The environmental interventions were those that exhibited the lowest incidence and were essentially limited to changes in the home and public environments to reduce the risk of fall, with 11.4 % incidence. Note also that the other intervention “removal of obstacles in the household” is directly related to the former.
Finally, in the behavioural interventions, the highest incidence, of 21.8 %, was found for carrying out activities and exercise. The use of rehabilitation methods based on gait training and management of risk factors of multiple falls, with an incidence of 14.9 and 10.3 %, respectively, were also relevant types of behavioural interventions.
In this review article, we have quantitatively characterised relevant research efforts on this issue of great social relevant over the last decade and a half, by identifying the incidence of articles concerning the anatomic characteristics and physiological consequences of ageing, the pathologies that propitiate falls, the causes and risk factors for falls, the physical consequences of falls and the strategies to prevent, minimise or rehabilitate.
This study will be useful both for those who want to identify key research issues and those who study ageing from the perspective of social sciences. In the future, repeating this study for the period of 2011–2025 will provide a historical time frame for analysis and comparison.
In subsequent work, we aim to study the economic impact of falls, from the individual and societal perspectives.
Abolhassani F, Moayyeri A, Naghavi M, Soltani A, Larijani B, Shalmani H (2006) Incidence and characteristics of falls leading to hip fracture in Iranian population. Bone 39:408–413
Allander E, Gullberg B, Johnell O, Kanis J, Ranstam J, Elffors L (1998) Circumstances around the fall in a multinational hip fracture risk study: a diverse pattern for prevention. Accid Anal Prev 30(5):607–616
Blyth F, Cumming R, Mitchell P, Wang J (2007) Pain and falls in older people. Eur J Pain 11:564–571
Bonjour J, Schurch M, Rizzoli R (1996) Nutritional aspects of hip fractures. Bone 18(3):1395–1445
Boonen S, Dejaeger E, Vanderschueren D, Venken K, Bogaerts A, Verschueren S, Milisen K (2008) Osteoporosis and osteoporotic fracture occurrence and prevention in the elderly: a geriatric perspective. Best Pract Res Clin Endocrinol Metab 22(5):765–785
Canning C, Sherrington C, Lord S, Fung V, Close J, Latt M, Howard K, Allen N, O'Rourke S, Murray S (2009) Exercise therapy for prevention of falls in people with Parkinson's disease: a protocol for a randomised controlled trial and economic evaluation. BioMed Central Neurology. http://www.biomedcentral.com/1471-2377/9/4. Accessed Oct 2010
Chan D, Hillier G, Coore M, Cooke R, Monk R, Mills J, Hung W (2000) Effectiveness and acceptability of a newly designed hip protector: a pilot study. Arch Gerontol Geriatr 30:25–34
Chang C, Chen M, Tsai C, Ho L, Chau Y, Liu C (2010) Medical conditions and medications as risk factors of falls in the inpatient older people: a case-control study. Int J Geriatr Phychiatr 26(6):602–607
Chen Y, Hwang S, Chen L, Chen D, Lan C (2008) Risk factors for falls among elderly men in a veterans home. J Chin Med Assoc 71(4):180–185
Choi W, Hoffer J, Robinovitch S (2010) Effect of hip protectors, falling angle and body mass index on pressure distribution over the hip during simulated falls. Clin Biomech 25:63–69
Choi W, Hoffer J, Robinovitch S (2010) The effect of positioning on the biomechanical of soft shell hip protectors. J Biomech 43:818–825
Church S, Robinson T, Aangles E, Tran Z, Wallace J (2011) Postoperative falls in the acute hospital setting: characteristics, risk factors, and outcomes in males. Am J Surg 201(2):197–202
Coimbra A, Ricci N, Coimbra I, Costallat L (2010) Falls in the elderly of the family health program. Archives of Gerontology and Geriatrics 51(3):317–322
Degoede K, Ashton-Miller J, Schultz A (2003) Fall-related upper body injuries in the older adult: a review of the biomechanical issues. J Biomech 36:1043–1053
Demura S, Sato S, Yamaji S, Kasuga K, Nagasawa Y (2010) Examination of validity of risk assessment items for screening high fall risk elderly among the healthy community-dwelling Japanese population. Archives of Gerontology and Geriatrics 53(1):e41–e45
Derler S, Spierings A, Schmitt K (2005) Anatomical hip model for the mechanical testing of hip protectors. Med Eng Phys 27:475–485
Easterbrook L, Horton K, Arber S, Davidson K (2001) International review of interventions in falls among older people. London: a report for the Health Development Agency, Department of Trade and Industry. http://www.viewcare.co.uk/Publications/fallsint.pdf. Accessed Sep 2010
Faes M, Reelick M, Melis R, Borm G, Esselink R, Olde M (2010) Multifactorial fall prevention for pairs of frail community-dwelling older fallers and their informal caregivers: a dead end for complex interventions in the frailest fallers. Journal of American Medical Directors Association 12(6):451–458
Falls (2010) Geneva: World Health Organization, media centre, fact sheet no. 344, August. http://www.who.int/mediacentre/factsheets/fs344/en. Accessed Mar 2011
Fletcher P, Guthrie D, Berg K, Hirdes J (2010) Risk factors for restriction in activity associated with fear of falling among seniors within the community. J Pacient Saf 6(3):187–191
Formiga F, Navarro M, Duasco E, Chivite D, Ruiz D, Perez-Castejon J, Lopez-Soto A, Pujol R (2008) Factors associated with hip fracture-related falls among patients with a history of recurrent falling. Bone 43:941–944
Gama Z, Conesa A (2008) Morbilidad, factores de riesgo y consecuencias de las caídas en ancianos. Fisioterapia 30(3):142–151
Grabiner M, Donovan S, Bareither M, Marone J, Hamstra-Wright K, Gatts S, Troy K (2008) Trunk kinematics and fall risk of older adults: translating biomechanical results to the clinic. J Electromyogr Kinesiol 18:197–204
Greenspan S, Myers E, Kiel D, Parker R, Hayes W, Resnick N (1998) Fall direction, bone mineral density, and function: risk factors for hip fracture in frail nursing home elderly. Am J Med 104(6):539–545
Hayes W, Myers E, Robinovitch S, Van Den Kroonenberg A, Courtney A, Mcmahon T (1996) Etiology and prevention of age-related hip fractures. Bone 18(1):77S–86S
Hendrich A, Nyhuis A, Kippenbrock T, Soja M (1995) Hospital falls: development of a predictive model for clinical practice. Appl Nurs Res 8(3):129–139
Hilbe J, Schulc E, Linder B, Them C (2010) Development and alarm threshold evaluation of a side rail integrated sensor technology for the prevention of falls. Int J Med Inform 79(3):173–180
Hill A, Hill K, Brauer S, Oliver D, Hoffmann T, Beer C, Mcphail S, Haines T (2009) Evaluation of the effect of patient education on rates of falls in older hospital patients: description of a randomised controlled trial. BioMed Central Geriatrics. http://www.biomedcentral.com/1471-2318/9/14. Accessed Oct 2010
Ho S, Woo J, Chan S, Yuen Y, Sham A (1996) Risk factors for falls in the Chinese elderly population. J Gerontol Ser A 51(5):M195–M198
Holzer L, Skrbensky G, Holzer G (2009) Mechanical testing of different hip protectors according to a European standard. Int J Care Injured 40:1172–1175
Honeycutt P, Ramsey P (2002) Factors contributing to falls in elderly men living in the community. Geriatr Nurs 23(5):250–255
Jung D (2008) Fear of falling in older adults: comprehensive review. Asian Nurs Res 2(4):214–222
Kane RL, Ouslander JG, Abrass IB, Resnick B (2009) Essentials of clinical geriatrics, 6th edn. McGraw-Hill, New York, pp 265–295, Chapter 9
Kanis J, Johnell O, Oden A, Jonsson B, De Laet C, Dawson A (2000) Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 27(5):585–590
Kannus P, Sievanen H, Palvanen M, Jarvinen T, Parkkari J (2005) Prevention of falls and consequent injuries in elderly people. Lancet 366(9500):1885–1893
Kaptoge S, Jakes R, Dalzell N, Wareham N, Khaw K, Loveridge N, Beck T, Reeve J (2007) Effects of physical activity on evolution of proximal femur structure in a younger elderly population. Bone 40:506–515
Keskin D, Borman P, Ersoz M, Kurtaran A, Bodur H, Akyuz M (2008) The risk factors related to falling in elderly females. Geriatr Nurs 29(1):58–63
Kinirons M, Hopper A, Barber M (2006) Falls in older people. Women Health Med 3:173–174
Larson L, Bergmann T (2008) Taking on the fall: the etiology and prevention of falls in the elderly. Clin Chiropr 11(3):148–154
Lauritzen J (1996) Hip fractures: incidence, risk factors, energy absorption, and prevention. Bone 18(1):65S–75S
Laybourne A, Biggs S, Martin F (2008) Falls exercise interventions and reduced falls rate: always in the patient's interest? Age Ageing 37:10–13
Ledsham R, Boote J, Kirkland A, Davies S (2006) What is it like to use hip protectors? A qualitative study of the views and nurses and patients. Clin Eff Nurs 951:97–105
Lehtola S, Koistinen P, Luukinen H (2006) Falls and injurious falls late in home-dwelling life. Arch Gerontol Geriatr 42:217–224
Lin CS, Hsu H, Lay YL, Chiu CC, Chao CS (2007) Wearable device for real-time monitoring of human falls. Measurement 40:831–840
Lockhart T, Kim S, Kapur R, Jarrott S (2009) Evaluation of gait characteristics and ground reaction forces in cognitively declined older adults with an emphasis on slip-induced falls. Assist Technol 21:188–195
Lockhart T, Woldstad J, Smith J (2003) Effects of age-related gait changes on the biomechanics of slips and falls. Ergonomics 46(12):1136–1160
Lord SR, Sherrington C, Menz HB (2007) Falls in older people: risk factors and strategies for prevention, 2nd edn. Cambridge University Press, Cambridge
Mcclure R, Hughes K, Mckenzie K, Dietrich U, Vardon P, Davis E, Newman B (2010) The population approach to falls injury prevention in older people: findings of two community trial. BMC Public Health. http://www.biomedcentral.com/1471-2458/10/79. Accessed Jan 2011
Melton L (1996) Epidemiology of hip fractures: implications of the exponential increase with age. Bone 18(3):121–125
Menz H, Morris M, Lord S (1995) Foot and ankle risk factors for falls in older people: a prospective study. J Gerontol Ser A 61(8):866–870
Michael Y, Lin J, Whitlock E, Gold R, Fu R, O'Connor E, Zuber S, Beil T, Lutz K (2010) Interventions to prevent falls in older adults. Evidence Syntheses, no. 80
Miller W, Speechley M, Deathe B (2001) The prevalence and risk factors of falling and fear of falling among lower extremity amputees. Arch Phys Med Rehabil 82:1031–1037
Moyland K, Binder E (2007) Falls in older adults: risk assessment, management and prevention. Am J Med 120:493–497
Muir S, Berg K, Chesworth B, Klar N, Speechley M (2010) Quantifying the magnitude of risk for balance impairment on falls in community-dwelling older adults: a systematic review and meta-analysis. J Clin Epidemiol 63:389–406
Myers A, Young Y, Langlois (1996) Prevention of falls in the elderly. Bone 18(1):87S–101S
Nieuwenhuizen R, Dijk N, Breda F, Scheffer A, Korevaar J, Cammen T, Lips P, Goslings J, Rooij S (2010) Assessing the prevalence of modifiable risk factors in older patients visiting an ED due to a fall using the CAREFALL triage instrument. Am J Emerg Med 28(9):994–1001
Nyan M, Tay F, Mah M (2008) Application of motion analysis system in pre-impact fall detection. J Biomech 41:2297–2304
Nyan M, Tay F, Murugasu E (2008) A wearable system for pre-impact fall detection. J Biomech 41:3475–3481
O'halloran P, Cran G, Beringer T, Kernohan G, Orr J, Dunlop L, Murray L (2007) Factors affecting adherence to use of hip protectors amongst residents of nursing homes—a correlation study. Int J Nurs Stud 44(5):672–686
Odasso M, Levinson P, Gore B, Tremblay L, Bergman H (2007) A flowchart system to improve fall data documentation in a long-term care institution: a pilot study. J Am Med Dir Assoc 8(5):300–306
Oliver D, Healey F, Haines T (2010) Preventing falls and fall-related injuries in hospitals. Clin Geriatr Med 26(4):645–692
Peterson E, Cho C, Koch L, Finlayson M (2008) Injurious falls among middle aged and older adults with multiple sclerosis. Arch Phys Med Rehab 89:1031–7
Pinheiro M, Ciconelli R, Martini L, Ferraz M (2010) Risk factors for recurrent falls among Brazilian women and men: the Brazilian Osteoporosis Study (BRAZOS). Cad Saúde Pública Rio de Janeiro 26(1):89–96
Prince F, Corriveau H, Hébert R, Winter D (1997) Gait in the elderly. Gait Posture 5:128–135
Pynoos J, Steinman B, Nguyen A (2010) Environmental assessment and modification as fall prevention strategies for older adults. Clin Geriatr Med 26(4):633–644
Rubenstein L, Josephson K (2005) Intervenciones para reducir los riesgos multifactoriales de caídas. Rev Esp Geriatria y Gerontol Suppl 1(40):45–53
Scheffer A, Schuurmans M, Dijk N, Hooft T, Rooij S (2008) Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing 37:19–24
Southard V, Dave M, Davis M, Blanco J, Hofferber A (2005) The multiple tasks test as a predictor of falls in older adults. Gait Posture 22:351–355
Srygley J, Herman T, Giladi N, Hausdorff J (2009) Self-report of missteps in older adults: a valid proxy of fall risk? Arch Phys Med Rehabil 90(5):786–792
Stel S, Smit J, Pluijm SM, Lips P (2004) Consequences of falling in older men and women and risk factors for health service use and functional decline. Age Ageing 33:58–65
Stevens J, Olson S (2000) Reducing falls and resulting hip fractures among older women. Home Care Provider 5(4):134–141
Stevens J, Sogolow E (2008) Preventing falls: what works. National Center for Injury Prevention and Control, Atlanta. http://www.cdc.gov/ncipc/preventingfalls. Accessed Jan 2011
Sturnieks D, Tiedemann A (2008) Falls. International Encyclopedia of Public Health, pp 563-569
Svanstrom L, Ader M, Schelp L, Lindstrom A (1996) Preventing femoral fractures among elderly: the community safety approach. Saf Sci 21(3):239–246
Teasell R, Mcrae M, Foley N, Bhardwaj A (2002) The incidence and consequences of falls in stroke patients during inpatient rehabilitation: factors associated with high risk. Arch Phys Med Rehabil 83:329–333
Tirado P (2010) Fear of falling. Rev Esp Geriatria y Gerontol 45(1):38–44
Tromp A, Pluijm S, Smit J, Deeg D, Bouter L, Lips P (2001) Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol 54:837–844
Varas-Fabra F, Martin E, Torres L, Fernández M, Moral R, Berge I (2006) Falls in the elderly in the community: prevalence, consequences and associated factors. Aten Primaria 38(8):450–455
Vellas B, Wayne S, Romero L, Baumgartner R, Garry P (1997) Fear of falling and restriction of mobility in elderly fallers. Age Ageing 26:189–192
Venegas K, Padial P, Hernández M, Ortega C, Montes J, Molina B, Dader M (2010) Factors of risk in an elderly population: evaluation scales for the prevention of hip fractures. Rev Esp Cir Ortopédica y Traumatologia 54(3):167–173
Weerdestyn V, Niet M, Duijnhoven H, Geurts A (2008) Falls in individuals with stroke. J Rehabil Res Dev 45(8):1195–1214
Weilemann Y, Thali M, Kneubuehl B, Bollinger S (2008) Correlation between skeletal trauma and energy in falls from great height detected by post-mortem multislice computed tomography (MSCT). Forensic Sci Int 180(2–3):81–85
Worfolk J (1997) Keep frail elders warm!: the thermal instabilities of the old have not received sufficient attention in basic educational programs. Geriatr Nurs 18(1):7–11
World Health Organization (2007) WHO global report on falls prevention in older age. World Health Organization, Geneva. http://www.who.int/entity/ageing/publications/Falls_prevention7March.pdf. Accessed Mar 2011
Yelnik A, Bonan I (2008) Clinical tools for assessing balance disorders. Clin Neurophysiol 38:439–445
Yu P, Qin Z, Shi J, Zhang J, Xin M, Wu Z, Sun Z (2009) Prevalence and related factors of falls among the elderly in an urban community of Beijing. Biomed Environ Sci 22:179–187
Zur O, Berner Y, Carmeli E (2006) Correlation between vestibular function and hip fracture following falls in the elderly: a case-controlled study. Physiotherapy 92(4):208–213
We acknowledge the Foundation for Science and Technology (FCT), Lisbon, through the 3º Quadro Comunitario de Apoio, the POCTI and FEDER programmes, project PEst-C/CTM/LA0025/2013, and FCT scholarship SFRH/PROTEC/67465/2010. Partial support has been provided by project PT21, no. 13848, co-financed by the European Community Fund through COMPETE Programa Operacional Factores de Competitividade. The financial sponsors played no role in the design, execution, analysis and interpretation of data or writing of the study.
Conflict of interest
The authors have no conflict of interest to disclose.