See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/6871657
The Falls Risk Awareness Questionnaire: Development and Validation for Use With Older Adults
Article in Journal of Gerontological Nursing · September 2006
DOI: 10.3928/00989134-20060801-07 · Source: PubMed
CITATIONS
37
READS
25,867
4 authors, including:
Cheryl Sadowski University of Alberta
124PUBLICATIONS 1,862CITATIONS SEE PROFILE
Allyson Jones University of Alberta
209PUBLICATIONS 6,422CITATIONS SEE PROFILE
David Feeny McMaster University
443PUBLICATIONS 36,983CITATIONS SEE PROFILE
Cheryl A. Wiens, BsC(Pharm), PharmD, TAmAr KoleBA, BsC(Pharm), PharmD, C. Allyson Jones, PT, PhD, AnD DAviD F. Feeny, PhD
The Falls Risk Awareness
Questionnaire
Development and Validation for Use With Older Adults
F
alling is a significant cause of disability and death among older adults. A recent U.S.Centers for Disease Control and Prevention report listed fall-related injuries as the leading cause of inju- ry-related morbidity and mortality in elderly individuals (2006). Ap- proximately 30% of community- dwelling older adults fall each year, of whom 50% fall more than once (Tinetti & Speechley, 1989; Tinetti, Speechley, & Ginter, 1988). Up to 10% of falls result in serious soft tissue injuries, including hemato- mas, sprains, and joint dislocations (Tinetti & Speechley, 1989). An ad-
ditional 5% result in bone fractures of the humerus, wrist, pelvis, and hip (Tinetti & Speechley, 1989).
Length of hospital stay has been found to be twice as high for elderly patients hospitalized after a fall com- pared to elderly persons hospitalized for other reasons (Scott & Gallagher, 1999). Falls not only lead to increased use of health-care resources for acute treatment (Alexander, Rivara, &
Wolf, 1992; Rizzo, Baker, McAvay,
& Tinetti, 1996), but elderly indi- viduals who sustain an injury from a fall are more likely to use health care services such as nursing care in the ensuing year (Wilkins, 1999).
Falls also affect the confidence, independence, and quality of life of older persons (Tinetti, Mendes de Leon, Doucette, & Baker, 1994).
Between 40% and 73% of com- munity-dwelling older adults say they have a fear of falling (Arfken, Lach, Birge, & Miller, 1994; Tinetti, Mendes de Leon, et al., 1994), and many restrict their activities as a re- sult (Arfken et al., 1994; Tinetti &
Williams, 1998).
A significant amount of research has been conducted to describe the risk factors for falls in older popu- lations, and physical, behavioral, environmental, and medication-re-
lated risk factors for falling are well- documented (Grisso et al., 1991;
Leipzig, Cumming, & Tinetti, 1999a, 1999b; Nevitt, Cummings, Kidd,
& Black, 1989; Tinetti et al., 1988).
However, there is a relative paucity of information about older adults’
awareness of or opinions about risks for falling (Braun, 1998).
Braun (1998) made an initial at- tempt at identifying knowledge and perception of risks for falls in older adults. A self-administered ques- tionnaire was completed by 120 community-dwelling older adults.
The study concluded older adults perceived falls as preventable and understood risks for falling but did not consider themselves to be per- sonally in danger of falling. The study was an important step in as- sessing older adults’ knowledge and perception of fall risks. However, it did not include questions about fall- related risks of specific medications, a wide variety of physical condi- tions, environmental factors, and other plausible risks (Braun).
The primary aim of this study was to develop, validate, and pilot a survey instrument to assess aware- ness and perception of a wide range of risk factors for falling among two convenience samples of older adults and to investigate associations be- tween personal attributes and expe- riences, and awareness and percep- tions of risks for falling.
MeThods
Cross-sectional surveys of three separate convenience samples were conducted to examine the validity of the Fall Risk Awareness Ques- tionnaire (FRAQ). The samples in- cluded two groups of older adults and one group of health care pro- fessionals. Test results from the three samples were examined and compared.
Groups were chosen based on convenience of sampling and pre- sumed awareness of fall risk fac- tors. It was assumed that health care professionals working in clinical
geriatrics have a significantly higher awareness of fall risk factors than community-dwelling or hospital- ized older adults. Therefore, sig- nificantly higher scores for health professionals compared to elderly respondents on the FRAQ would demonstrate preliminary construct validity of the instrument.
One sample group consisted of persons older than 60 attending a 2-week public health immunization campaign administered by Capital Health Authority (CHA) from Oc- tober 15 to 25, 2002, in Edmonton, Alberta, Canada. Participants in sev- eral shopping malls were approached randomly by the interviewer to par- ticipate in the study (n = 102).
The second sample (n = 50) com- prised persons older than age 60 who were hospitalized in two CHA hos- pitals from September 2003 to April 2004. One facility was a 239-bed acute care hospital, and the second was a 248-bed rehabilitation hospi- tal. Half of this sample was collected at each hospital location.
The third sample (n = 50) was made up of multidisciplinary health care professionals attending a week- ly regional Geriatric Grand Rounds seminar at three separate hospital sites across the CHA region. Influ- enza-clinic attendees and hospital- ized respondents were included if they attended the CHA public health campaign or were admitted to one of the two participating hospitals, were age 60 years or older, and consented to participate in the survey.
Exclusion criteria were inability to communicate effectively in Eng- lish, illiteracy, age younger than 60, and lack of consent. Patients also were excluded from the analysis if more than one page of the question- naire was not completed. Health professional respondents were in- cluded if they were in attendance at a weekly geriatric educational session and returned their question- naire to the researcher.
Data collection was accomplished by the administration of the FRAQ.
The instrument was designed by identifying published risks for falls through a literature search of Med- line, CINAHL, and Ageline, and by developing multiple-choice ques- tions to assess awareness or per- ception of select characteristics as a possible risk for falling. Questions from the Canadian Heart Health Surveys (Kirkland et al., 1999) and the Health Utilities Health Status Classification System (Furlong, Feeny, & Torrance, 1999) were re- viewed and adapted for the current instrument. Only listing known risk factors might have induced spurious positive responses. To avoid this problem, “distracter” items that were judged by the research group to not be risk factors were included in the questionnaire.
After administration of the ques- tionnaire to older adults attending influenza clinics, minor wording revisions were made based on par- ticipant and expert feedback. The revised version of the question- naire was then tested in a popula- tion of hospitalized older adults and health professionals. Only results of questions with identical wording in all three survey ver- sions were compared.
Established risk factors for falls addressed in the FRAQ include impaired neuromuscular function, muscle weakness, impaired balance, vestibular pathophysiology, impaired proprioception, abnormalities of the feet, dementia and impaired cogni- tion, acute illness, advanced age, fe- male gender, stroke, and fear of falling (Cumming, 1998; Grisso et al., 1991;
O’Loughlin, Robitaille, Boivin, & Su- issa, 1993; Tinetti et al., 1988; Tinetti, Mendes de Leon, et al., 1994; Tinetti
& Williams, 1998). Medication items include use of multiple medications and psychotropic drugs such as anti- depressants, antipsychotics, anxiolyt- ics, and hypnotics (Cumming, 1998;
Cummings & Nevitt, 1994; Leipzig et al., 1999a; Liu et al., 1998; Ray, Griffin, Schaffner, Baugh, & Melton, 1987; Thapa, Gideon, Cost, Milam, &
Ray, 1998; Tinetti, Mendes de Leon, et al., 1994; Tinetti, Inouye, Gill, &
Doucette, 1995). Also included were fear of falling, improper use of am- bulation aids, activities that displace one’s center of gravity, and inappro- priate footwear (Cumming, Salkeld, Thomas, & Szonyi, 2000; Grisso et al., 1991; Murphy, Dubin, & Gill, 2003; Murphy, Williams, & Gill, 2002;
Tinetti, Mendes de Leon, et al., 1994).
Studies investigating some items in- cluded as possible risks in the survey instrument have reported conflicting results. The controversial risk factors for falls include visual problems, hear- ing impairment, dizziness, alcohol use, diuretics, antihypertensives, and narcotics (Arfken et al., 1994; Cum- ming, 1998; Grisso et al., 1991; Law- lor, Patel, & Ebrahim, 2003; Leipzig et al., 1999b).
The questionnaire tested in influenza-clinic and hospitalized re- spondents was divided into four por- tions. The first portion was adminis- tered by the interviewer (TK) and was used to assess initial awareness of risks for falling and sources of information about fall risks. The second portion was completed by the respondent and con- sisted of a series of 27 (influenza-clinic version) or 19 (hospital version) writ- ten multiple-choice questions assessing awareness of risks for falls. The third portion, completed by the respondent, consisted of multiple-choice questions to collect demographic information.
An interviewer-administered debrief- ing portion also was included. The in- terviewer (TK) was available to assist with reading the self-administered por- tions of the questionnaire if requested by the respondent.
The health professional version of the questionnaire was entirely a self- complete, written, multiple-choice format. It consisted of a brief demo- graphic section and 19 multiple-choice questions, identical in wording to those used in the influenza-clinic and hospital versions, assessing awareness of risks for falls.
The University of Alberta Health Research Ethics Board—Panel B in
TABLe 1
ChARACTeRIsTICs oF oLdeR AduLT ResPoNdeNTs
Characteristic
influenza-Clinic respondents
(n = 102)
hospitalized respondents
(n = 50)
Age (mean ± SD) 73 ± 6.3 years 80 ± 7.4 years
Female participants 57 (56%) 31 (62%)
self-reported health status
Good, very good, or excellent 92 (90%) 35 (70%)
Fair or poor 10 (10%) 15 (30%)
self-reported distance able to walk
Unlimited 67 (66%) 17 (34%)
1 to 10 blocks 29 (29%) 18 (36%)
Less than 1 block 6 (6%) 15 (30%)
Assistive walking devices required 9 (9%) 31 (62%) have fallen in the past at any time 67 (66%) 26 (52%)
have fallen in the past year 32 (31%) 22 (44%)
medications used in the last month among options listed
Antiinflammatories 45 (44%) 29 (58%)
Antihypertensives 43 (42%) 23 (46%)
Diuretics 28 (27%) 23 (46%)
Narcotics 25 (25%) 13 (26%)
Other cardiac medications 16 (16%) 20 (40%)
Sedative-hypnotics 13 (13%) 15 (30%)
Antidepressants 7 (7%) 7 (14%)
Anxiolytics 5 (5%) 5 (10%)
Antipsychotics 2 (2%) 0 (0%)
number of medications (mean ± SD) 2.4 ± 2.0 2.7 ± 1.6 self-reported chronic conditions among options listed
Eye problems 37 (36%) 26 (52%)
Deafness 23 (23%) 16 (32%)
Back problems 53 (52%) 20 (40%)
Arthritis 51 (50%) 31 (62%)
Hypertension 42 (41%) 28 (56%)
Heart disease 23 (23%) 21 (42%)
Osteoporosis 24 (24%) 18 (36%)
Bladder or bowel incontinence 21 (21%) 11 (22%)
Cancer 11 (11%) 10 (20%)
Diabetes 10 (10%) 12 (24%)
Effects of stroke 3 (3%) 6 (12%)
Alzheimer’s disease 2 (2%) 1 (2%)
Epilepsy 1 (1%) 0 (0%)
number of chronic conditions (mean ± SD) 2.9 ± 2.0 4.0 ± 2.2
Edmonton, Alberta, approved the study design and protocol. Influenza- clinic and hospitalized respondents were required to sign a consent form to participate in the survey. Health professional consent to participate was assumed if questionnaires were returned completed.
ANALysIs
Results were analyzed using Sta- tistical Package for the Social Scienc- es (SPSS Inc., Chicago, IL) and Ex- cel software (Microsoft, Redmond, WA). Frequency distributions were inspected for each variable in the survey instrument. Questions with identical wording in all three survey versions that were judged by expert opinion to have a correct answer
were each given equal weight to yield a general score for each respondent (total possible points = 24). General scores were examined by respon- dent type (influenza-clinic patient, hospitalized patient, or health care professional) using analysis of vari- ance, with a Bonferroni adjustment for multiple statistical tests. Patient scores also were examined by history of falling using analysis of variance.
Cross tabulation was conducted on selected variables determined a priori. Chi-square analyses were used to determine differences be- tween influenza-clinic and hospital- ized patient scores based on need for an ambulation device, place of resi- dence (community or institutional), education level, number of chronic
conditions, and number of medica- tions. Statistical testing was at a .05 level of significance (two-tailed).
ResuLTs demographics
The demographics of the older adult groups are shown in Table 1. A description of the health care profes- sionals is shown in Table 2.
Questionnaire Completion
The questionnaire took approxi- mately 15 minutes to complete in the influenza clinics and hospitals.
The version of the questionnaire completed by the health professional population required 3 to 5 minutes for completion. There were 37 refus- als to participate by influenza-clinic attendees and 14 refusals by hospi- talized patients. Seventy-six percent of health professional questionnaires were returned.
General Questionnaire scores General scores (Table 3) were examined by respondent type (in- fluenza-clinic patient, hospitalized patient, or health care professional) using analysis of variance. There was a statistically significant differ- ence in general score between both influenza-clinic respondents and hospitalized older adults compared to health professionals (p , .001).
There was no significant difference in score between the two groups of older adults. The mean score was 54% (13.0 6 3.3 of 24 correct) for influenza-clinic respondents, 55%
(13.2 6 3.6 of 24 correct) for hospi- talized respondents, and 81% (19.5 6 3.6 of 24 correct) for health pro- fessionals. There was also a small but statistically significant difference in score between older adults who had fallen compared with those who had not fallen (57% versus 51%, p = .02) differences Between older Adult Groups
A significantly greater proportion of hospitalized older adults than in- fluenza-clinic older adults required TABLe 2
ChARACTeRIsTICs oF heALTh PRoFessIoNAL ResPoNdeNTs (n = 50)
Characteristic n (%)
Profession
Physician 8 (16)
Pharmacist 2 (4)
Registered nurse 16 (32)
Licensed practical nurse 1 (2)
Physiotherapist 1 (2)
Occupational therapist 1 (2)
Social worker 9 (18)
Dietician 2 (4)
Resident or medical student 6 (12)
Other* 4 (8)
Practice setting
Inpatient geriatric acute care 23 (46)
Outpatient geriatric care 18 (36)
Long term geriatric care 7 (14)
Multiple sites (in training) 5 (10)
years of practice
Less than 2 years 9 (18)
2 to 5 years 2 (4)
More than 5 years 39 (78)
*Includes advanced nurse practitioner, community worker, dietician intern, and neuropsychologist.
ambulation devices (62% versus 9%, respectively, p , .001), lived in an in- stitution (16% versus 0%, respective- ly, p , .001), had no post-secondary education (82% versus 44%, respec-
tively, p , .001), were limited in walk- ing distance (66% versus 34%, re- spectively, p , .001) and used four or more medications (38% versus 15%, respectively, p = .006).
Questionnaire Responses
Less than two thirds of influenza-clinic and hospital re- spondents felt personally at risk of falling (n = 62 and 30, respec- TABLe 3
QuesTIoNNAIRe ResPoNses
influenza Clinic respondents
(n = 102)
hospitalized respondents
(n = 50)
health Professional respondents
(n = 50)
item n (%) n (%) n (%)
older age increases a person’s risk of falling 96 (94) 39 (78) 46 (92)
The following may increase an older adult’s chance of falling:
Bunions 4 (4) 14 (28) 27 (34)
Balance problems 93 (91) 45 (90) 50 (100)
Feeling dizzy 86 (84) 40 (80) 50 (100)
Limping or difficulty walking 59 (58) 38 (76) 48 (96)
Weak legs 75 (74) 40 (80) 49 (98)
Standing on a stool 98 (96) 36 (72) 44 (88)
Being sick with a cold 18 (18) 22 (44) 29 (58)
Feeling tired or fatigued 80 (78) 35 (70) 47 (94)
health problems like Alzheimer’s disease affect an older adult’s chance of falling
68 (67) 29 (58) 45 (90)
having had a stroke affects an older adult’s chance of falling 84 (82) 44 (88) 50 (100) Being deaf increases an older adult’s chance of falling 34 (33) 21 (42) 28 (56) ear problems such as vertigo or ear infections affect an
older adult’s chance of falling 89 (87) 38 (76) 50 (100)
The risk of falling is increased by drinking alcohol 97 (95) 44 (88) 49 (98) The following medications may increase an older adult’s
chance of falling:
Medicines that treat anxiety 27 (26) 10 (20) 38 (76)
Medicines to help with sleeping 44 (43) 25 (50) 39 (78)
Water pills 4 (4) 7 (14) 26 (52)
Medicines that help your mood 20 (20) 5 (10) 25 (50)
Tranquilizers or “nerve pills” for symptoms such as
hallucinations 41 (40) 9 (18) 40 (80)
Medicines to lower blood pressure 27 (26) 8 (16) 38 (76)
Taking more than one medication may increase an older adult’s chance of falling
12 (12) 25 (50) 41 (82)
Difficulty controlling bladder or bowels may lead to falls 32 (31) 22 (44) 45 (90) Being concerned about falling may increase the
likelihood of an older adult falling 48 (47) 24 (48) 26 (52)
older adults are more likely to fall than younger adults 93 (91) 42 (84) 48 (96)
tively). The most commonly cited causes of falls were balance prob- lems or unsteadiness (34%), out- door environmental hazards such as snow and ice (22%), visual impairment (14%), and lower-ex- tremity weakness (11%). Influen- za-clinic respondents mentioned media (24%), friends (12%), and family (11%) most often as a source of information on risks for falling, while hospital respondents mentioned health care workers al- most exclusively (52%).
dIsCussIoN
The FRAQ was generally well received by respondents. Wording adjustments were made to 11 ques- tions, and 3 questions were deleted in the revised questionnaire based on participant feedback and dis- cussion among the research group.
Changes were made to clarify or delete questions that appeared to be ambiguous or confusing. In comparison to the instrument de- veloped by Braun (1998), the cur- rent instrument attempts to assess awareness of fall risk due to a wider range of risk factors, including spe- cific medication classes and chronic conditions.
The FRAQ displayed prelimi- nary construct validity, demon- strated by its ability to significantly discriminate health professionals from older adults who attended a influenza clinic or older adults who were hospitalized. There was no statistical difference in general test scores between the two older adult groups. This suggests the FRAQ may be suitable for a broad range of patients and practice settings.
FRAQ test scores were signifi- cantly higher for older adults who had fallen in the past compared to those who had not fallen. This result is encouraging because individuals who have fallen are at increased risk for subsequent falls. Older adults may be more receptive to fall risk information following a fall, and this may be an opportune time for
health care professionals to provide education on risks for falls to pre- vent further injury.
A number of fall risk categories are addressed by the FRAQ, includ- ing physical, behavioral, environ- mental, and medication-related risk factors for falling. Thus, the FRAQ score provides a general indication of patient knowledge of risk fac- tors for falls. Accurate information about awareness of risks for falls in an older population is an important
building block in any fall preven- tion program or campaign (Grisso et al., 1991). A Cochrane Review of randomized trials aimed at reduc- ing falls in older adults indicated interventions targeting multiple risk factors or behavioral modifica- tions significantly prevented falls in elderly participants (Gillespie et al., 2003).
A more recent meta-analysis as- sessing the effectiveness of 40 in- tervention trials to prevent falls in older individuals reported an overall significant reduction in relative risk
of falling and reduction in monthly fall rate (Chang et al., 2004). Ben- efits were derived primarily from multifactorial fall risk assessment and management programs and ex- ercise programs.
Exposing areas of low knowl- edge in a population of older adults allows for specific targeting of fall intervention programs. These pro- grams can be costly (Tinetti, Baker, McAvay, Claus, Garrett, Gott- schalk, Koch, Trainor, & Horwitz, 1994), and monetary and personnel resources often are limited. Target- ing interventions at risk factors of which older adults are unaware or reluctant to modify may make eco- nomic sense in systems where pub- lic health care funding is finite.
In this survey, older adults ap- peared to have a relative lack of knowledge about medication risks for falls. In previous studies, an as- sociation between the use of many individual medications or the use of more than four medications (Ti- netti, Baker, et al., 1994) and an increased risk of falling has been demonstrated. However, in this study, none of the high-risk medi- cation classes listed was selected as a risk for falling by more than 50%
of older adults. Medication usage is one of the most easily modified risk factors for falling, yet few respon- dents appear to have identified this as a problem.
Health care professionals such as physicians, pharmacists, and nurses are well suited to educate older adults on the risks of medi- cation usage. This survey popula- tion was generally well educated and therefore likely able to under- stand information about fall risk.
Also, a large proportion of the survey respondents used medica- tions and had one or more chronic conditions; therefore, they likely have had frequent contact with the health care system. However, only 14 respondents indicated they had received information on fall risks from a health care professional.
Identifying those
groups that are at
high risk of falling
but possess little
knowledge of fall
risk factors is an
important first step.
There is a need for improved edu- cation on falls risk reduction on the part of health care professionals.
This study was only intended to pilot the FRAQ. However, the re- sults of the pilot appear to highlight significant deficits in awareness of fall risk factors in the group of com- munity-dwelling older adults sur- veyed. The majority of respondents felt falling is a preventable health problem, older adults are more likely to fall compared to younger persons, and older age increases an individual’s risk of falling. Howev- er, only 61% of influenza-clinic re- spondents and 60% of hospitalized patients felt they were personally at risk of falling.
The risk that respondents attrib- uted to the cohort does not appear to have been personalized in approxi- mately one third of respondents.
This finding closely resembles the results of Braun’s survey (1998), in which 86% of surveyed individuals appeared to be aware of the signifi- cance and preventable nature of fall risk factors, but most respondents perceived themselves to be substan- tially less likely to fall than other older adults.
The tendency to perceive oneself as being less at risk than one’s group may be common. A telephone sur- vey conducted for the American Heart Association assessing aware- ness of cholesterol as a risk factor for heart disease indicated 71% of respondents estimated their per- sonal risk of developing heart dis- ease as average or below average despite a relatively high rate of self- reported risk factors for cardiovas- cular disease (Nash et al., 2003).
Also noteworthy is the proportion of respondents in this study who selected, “I don’t know,” on certain survey questions. That these indi- viduals admit to poor knowledge of fall risk factors may be an asset when attempting to provide educa- tion in this area.
A study assessing a screening and educational intervention at a
health fair showed individuals old- er than age 65 at high risk for falls were more likely to implement fall risk-reduction behaviors than indi- viduals at low risk for falls (Ness, Gurney, & Ice, 2003). It appears as though an educational interven- tion targeted at older adults at high risk for falls may achieve a higher fall reduction rate than those in- terventions involving older adults with varying degrees of falls risk.
Identifying those groups that are at high risk of falling but possess little knowledge of fall risk factors is an important first step in reduc- ing falls and injuries caused by falls. Subject to further testing, the FRAQ may play an important role in identifying specific differences in the knowledge of risk factors.
This study had several limita- tions. The selection of individu- als for participation in the study was not random, and sample sizes were relatively small. The writ- ten survey instrument may have biased the sample toward literate, English-speaking individuals. This was the first step in validation of the FRAQ and therefore results
are preliminary and require fur- ther testing.
CoNCLusIoN
This preliminary investigation demonstrates the validity of the Fall Risk Awareness Questionnaire.
Further testing of the instrument is needed to establish its validity and reliability, including test–retest re- liability, inter-rater reliability, and longitudinal responsiveness of the instrument. The short length and self-administered format of the FRAQ may provide a quick and inexpensive method of evaluating an individual’s fall risk awareness.
The questionnaire may be useful in a broad range of practice settings.
ReFeReNCes
Alexander, B.H., Rivara, F.P., & Wolf, M.E.
(1992). The cost and frequency of hospi- talization for fall-related injuries in older adults. American Journal of Public Health, 82, 1020-1023.
Arfken, C.L., Lach, H.W., Birge, S.J., & Miller, J.P. (1994). The prevalence and correlates of fear of falling in elderly persons living in the community. American Journal of Pub- lic Health, 84, 565-570.
Braun, B.L. (1998). Knowledge and perception of fall-related risk factors and fall-reduction
KeyPoINTs
F alls R isk a waReness
Wiens, C.A., Koleba, T., Jones, C.A., & Feeny, D.F. The Falls risk Awareness Questionnaire: Development and validation for Use With older Adults. Journal of Gerontological Nursing, 2006, 32(8):
43-50.
1
Falling is a significant cause of disability and death among older adults, and assessing awareness of risk factors is the first step to developing falls intervention programs.2
Older adults who had fallen in the past were more aware of risk factors for falls, and may be receptive to fall risk information following a fall. This may be an opportune time for health care professionals to provide education on risks for falls to prevent further injury.3
The Falls Risk Awareness Questionnaire (FRAQ) was validated in a range of patients and practice settings, and after further test- ing, the FRAQ may play an important role in identifying specific differences in the knowledge of risk factors.techniques among community-dwelling elderly individuals. Physical Therapy, 78, 1262-1276.
Centers for Disease Control and Prevention.
(2006). Falls and hip fractures among older adults. Retrieved June 7, 2006, from www.
cdc.gov/ncipc/factsheets/falls.htm.
Chang, J.T., Morton, S.C., Rubenstein, L.Z., Mojica, W.A., Maglione, M., Suttorp, M.J., Roth, E.A., & Shekelle, P.G. (2004). Inter- ventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. British Medi- cal Journal, 328, 680.
Cumming, R.G. (1998). Epidemiology of medication-related falls and fractures in the elderly. Drugs and Aging, 12, 43-53.
Cumming, R.G., Salkeld, G., Thomas, M., &
Szonyi, G. (2000). Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission. Journal of Gerontology Series A, Biological Sciences and Medical Sciences, 55, M299-M305.
Cummings, S.R., & Nevitt, M.C. (1994). Falls.
New England Journal of Medicine, 331, 872-873.
Furlong, W. J., Feeny, D.H., & Torrance, G.W.
(1999). Health Utilities Index (HUIR) measurement system: Health status ques- tionnaire. Dundas, ON, Canada: Health Utilities.
Gillespie, L.D., Gillespie, W.J., Robertson, M.C., Lamb, S.E., Cumming, R.G., &
Rowe, B.H. (2003). Interventions for pre- venting falls in elderly people. The Co- chrane Database of Systematic Reviews, CD000340.
Grisso, J.A., Kelsey, J.L., Strom, B.L., Chiu, G.Y., Maislin, G., O’Brien, L.A., Hoff- man, S., & Kaplan, F. (1991). Risk factors for falls as a cause of hip fracture in wom- en. The Northeast Hip Fracture Study Group. New England Journal of Medicine, 324, 1326-1331.
Kirkland, S.A., MacLean, D.R., Langille, D.B., Joffres, M.R., MacPherson, K.M.,
& Andreou, P. (1999). Knowledge and awareness of risk factors for cardiovascu- lar disease among Canadians 55 to 74 years of age: Results from the Canadian Heart Health Surveys, 1986-1992. Canadian Medical Association Journal, 161, S10-S16.
Lawlor, D.A., Patel, R., & Ebrahim, S. (2003).
Association between falls in elderly women and chronic diseases and drug use: Cross sectional study. British Medical Journal, 327, 712-717.
Leipzig, R.M., Cumming, R.G., & Tinetti, M.E. (1999a). Drugs and falls in older peo- ple: A systematic review and meta-analy- sis: I. Psychotropic drugs. Journal of the
American Geriatrics Society, 47, 30-39.
Leipzig, R.M., Cumming, R.G., & Tine- tti, M.E. (1999b). Drugs and falls in older people: A systematic review and meta- analysis: II. Cardiac and analgesic drugs.
Journal of the American Geriatrics Society, 47, 40-50.
Liu, B., Anderson, G., Mittmann, N., To, T., Axcell, T., & Shear, N. (1998). Use of se- lective serotonin-reuptake inhibitors of tricyclic antidepressants and risk of hip fractures in elderly people. The Lancet, 351, 1303-1307.
Murphy, S.L., Dubin, J.A., & Gill, T.M.
(2003). The development of fear of falling among community-living older women:
Predisposing factors and subsequent fall events. Journal of Gerontology Series A, Biological Sciences and Medical Sciences, 58, M943-M947.
Murphy, S.L., Williams, C.S., & Gill, T.M.
(2002). Characteristics associated with fear of falling and activity restriction in com- munity-living older persons. Journal of the American Geriatrics Society, 50, 516-520.
Nash, I.S., Mosca, L., Blumenthal, R.S., Da- vidson, M.H., Smith, S.C., Jr., & Paster- nak, R.C. (2003). Contemporary aware- ness and understanding of cholesterol as a risk factor: Results of an American Heart Association national survey. Archives of Internal Medicine, 163, 1597-1600.
Ness, K.K., Gurney, J.G., & Ice, G.H. (2003).
Screening, education, and associated be- havioral responses to reduce risk for falls among people over age 65 years attending a community health fair. Physical Therapy, 83, 631-637.
Nevitt, M.C., Cummings, S.R., Kidd, S., &
Black, D. (1989). Risk factors for recurrent nonsyncopal falls. A prospective study.
Journal of the American Medical Associa- tion, 261, 2663-2668.
O’Loughlin, J.L., Robitaille, Y., Boivin, J.F., &
Suissa, S. (1993). Incidence of and risk fac- tors for falls and injurious falls among the community-dwelling elderly. American Journal of Epidemiology, 137, 342-354.
Ray, W.A., Griffin, M.R., Schaffner, W., Baugh, D.K., & Melton, L.J., III. (1987).
Psychotropic drug use and the risk of hip fracture. New England Journal of Medi- cine, 316, 363-369.
Rizzo, J.A., Baker, D.I., McAvay, G., & Tine- tti, M.E. (1996). The cost-effectiveness of a multifactorial targeted prevention pro- gram for falls among community elderly persons. Medical Care, 34, 954-969.
Scott, V.J., & Gallagher, E.M. (1999). Mortal- ity and morbidity related to injuries from falls in British Columbia. Canadian Jour- nal of Public Health, 90, 343-347.
Thapa, P.B., Gideon, P., Cost, T.W., Milam, A.B., & Ray, W.A. (1998). Antidepressants and the risk of falls among nursing home residents. New England Journal of Medi- cine, 339, 875-882.
Tinetti, M.E., Baker, D.I., McAvay, G., Claus, E.B., Garrett, P., & Gottschalk, M., Koch, M.L., Trainor, K., & Horwitz, R.I. (1994) A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine, 331, 821-827.
Tinetti, M.E., Inouye, S.K., Gill, T.M., &
Doucette, J.T. (1995). Shared risk factors for falls, incontinence, and functional de- pendence. Unifying the approach to geri- atric syndromes. Journal of the American Medical Association, 273, 1348-1353.
Tinetti, M.E., Mendes de Leon, C.F., Dou- cette, J.T., & Baker, D.I. (1994). Fear of falling and fall-related efficacy in relation- ship to functioning among community- living elders. Journal of Gerontology, 49, M140-M147.
Tinetti, M.E., & Speechley, M. (1989). Preven- tion of falls among the elderly. New Eng- land Journal of Medicine, 320, 1055-1059.
Tinetti, M.E., Speechley, M., & Ginter, S.F.
(1988). Risk factors for falls among elderly persons living in the community. New England Journal of Medicine, 319, 1701- 1707.
Tinetti, M.E., & Williams, C.S. (1998). The ef- fect of falls and fall injuries on function- ing in community-dwelling older persons.
Journal of Gerontology Series A, Biological Sciences and Medical Sciences, 53, M112- M119.
Wilkins, K. (1999). Health care consequences of falls for seniors. Health Reports, 10, 47- 55.
About the AuthorS
Dr. Wiens is Associate Professor, and Dr. Koleba is student, Faculty of Phar- macy and Pharmaceutical Sciences, Uni- versity of Alberta, Edmonton, Alberta, Canada. Dr. Jones is Assistant Professor, Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada.
Dr. Feeny is Senior Scientist, Kaiser Per- manente Northwest Center for Health Research, Portland, Oregon.
Address correspondence to Cheryl A.
Wiens, BSc(Pharm), PharmD, Associ- ate Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3118 Dentistry/Pharmacy Centre, Edmonton, Alberta, Canada T6G 2N8.
