Abstract

This study aimed to validate of Fall Risk Tracking Tool (FRRISque) in elderly community dwellers. A cross-sectional evaluative screening study was carried out on a sample of 854 elderly. In addition to the pilot version of FRRISque, the QuickScreen® tool was applied as a standard reference in order to validate a concurrent criterion, determining sensitivity and specificity values. Most of the elderly people were female (57.6%) with an average age of 71.87 years. The multivariate logistic regression analyses showed that only 10 FRRISque items contribute to increased elderly fall risk and they refer to the risk factors of previous falls, use of a walking aid device, polypharmacy, use of psychotropic substances, difficulty to ascend and descend a slope, difficulty to walk for a distance of 100 meters, visual and hearing impairment, low physical activity and poorly lit environment. This risk stratification model assumes sensitivity values of 91.3% and specificity values of 73.4%. The FRRISque is defined as a valid, simple, low-cost and of easy and rapid application tool that can be used by all primary health care professionals, including community health workers.

Key words
Elderly; Fall-related accidents; Risk factors; Validation studies

Introduction

Falls are a geriatric syndrome and can have serious consequences, compromising the health and quality of life of the elderly. In addition, it is a problem in practice in general, due to its high prevalence¹1 Gomez F, Wu YY, Auais M, Vafaei A, Zunzunegui M-V. A simple algorithm to predict falls in primary care patients aged 65 to 74 years: the international mobility in aging study. J Am Med Dir Assoc 2017; 18(9):774-779.. In Brazil, the prevalence of falls is 27.6% in elderly living in the community²2 Siqueira FV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, Thumé E, Silva SM, Dilélio A. Prevalence of falls in elderly in Brazil: a countrywide analysis. Cad Saude Publica 2011; 27(9):1819-1826.. Fall is defined as “an unexpected event in which individuals drop to the ground or to a lower level”³3 Lamb SE, Jorstad-Stein EC, Hauer K, Becker C. Development of a common outcome data set for fall injury prevention trials: the prevention of falls network Europe consensus. J Am Geriatr Soc 2005; 53(9):1618-1622..

Falling involves intrinsic and extrinsic risk factors⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.. In a more detailed way, intrinsic and extrinsic factors can be classified into four realms: biological, socioeconomic, behavioral and environmental⁵5 World Health Organization (WHO). WHO Global report on falls prevention in older age. Geneva: WHO publications; 2007..

Biological factors include individual characteristics that are relevant to the human body and some of them are not modifiable, such as gender, age and ethnicity. They are also associated with the physiological changes and typical conditions of the elderly, such as muscle weakness, gait change, postural instability, cognitive impairment, functional limitation, visual impairment, chronic diseases and depression⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.

5 World Health Organization (WHO). WHO Global report on falls prevention in older age. Geneva: WHO publications; 2007.

6 Cleary K, Skornyakov E. Predicting falls in community dwelling older adults using the Activities-specific Balance Confidence Scale. Arch Gerontol Geriatr 2017; 72(June):142-145.^-77 Nascimento CF, Duarte YAO, Lebrão ML, Chiavegatto Filho ADP. Individual and contextual characteristics of indoor and outdoor falls in older residents of São Paulo, Brazil. Arch Gerontol Geriatr 2017; 68:119-125.. Behavioral risk factors include the use of several medications, alcohol use, sedentarism, fear of falling, use of inappropriate footwear and use of gaiters⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.^,55 World Health Organization (WHO). WHO Global report on falls prevention in older age. Geneva: WHO publications; 2007.. Socioeconomic risk factors include factors such as low income, low level of schooling, inadequate housing conditions, impaired social interaction and limited access to health⁵5 World Health Organization (WHO). WHO Global report on falls prevention in older age. Geneva: WHO publications; 2007.. Environmental factors include domestic and public environment hazards such as slippery surfaces, carpets, poor lighting, lack of support bars in bathrooms and corridors, public road with irregularities and poorly maintained⁵5 World Health Organization (WHO). WHO Global report on falls prevention in older age. Geneva: WHO publications; 2007.^,88 Kim SH. Risk factors for severe injury following indoor and outdoor falls in geriatric patients. Arch Gerontol Geriatr 2016; 62(January-February):75-82..

Most elderly falls result from a complex interaction between risk factors, with impairment of the systems involved in maintaining balance⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.. Falls can have several consequences such as injuries, fractures, functional disabilities, loss of independence, institutionalization and even death⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.. While they are a serious public health problem, elderly falls are preventable, representing great possibilities for health professionals and researchers to design and implement interventions to prevent them.

However, employing such prevention strategies implies being equipped with a tool to screen or assess the risk of elderly falls. In the primary care setting, health professionals require tools that enable them to identify the risk of falls. In other words, they need a simple but consistent device that identifies older people with lower and higher risk of falls and, thus, can develop strategies for the prevention of such events in this population, in order to prioritize those at greater risk.

Although there is some consensus in specific scientific literature regarding risk factors for falls in the community, an assertive assessment of these factors in the elderly becomes relevant. The availability of a valid tool may favor their identification and the most appropriate decision-making regarding proposed interventions to prevent falls of elderly living in the community, with a view to preserving their quality of life, maintaining their security, non-institutionalization and, consequently, reducing secondary and tertiary care costs.

In view of the above, this study evaluates the validity of concurrent criteria of the Fall Risk Tracking Tool (FRRISque) in elderly people living in the community.

Methods

This is an evaluative screening study⁹9 Gordis L. Epidemiology. 4ª ed. Rio de Janeiro: Revinter; 2010.. FRRISque was developed in a previous study¹⁰10 Jonas LT, Silva JV, Mendes MA. Construção da Escala avaliativa do risco de quedas para pessoas idosas não institucionalizadas. Rev Enferm UFPE online 2015; 9(Supl. 4):7977-7985.^,1111 Chini LT. Validação da escala avaliativa do risco de quedas (EARQUE) em pessoas idosas que vivem na comunidade [tese]. Ribeirão Preto: Universidade de São Paulo; 2017. and assessed face, content and semantic validity¹¹11 Chini LT. Validação da escala avaliativa do risco de quedas (EARQUE) em pessoas idosas que vivem na comunidade [tese]. Ribeirão Preto: Universidade de São Paulo; 2017.. Once referred to as EARQUE (Fall Risks Evaluation Scale), this tool was renamed FRRISque considering that the term tracking is the identification of people at greater risk of falls, while assessment corresponds to the identification of factors that increase the risk of a fall¹²12 Close JCT, Lord SR. Fall assessment in older people. BMJ 2011; 343:d5153.. That is, the scale identifies people from the community with lower and higher risk of falls and can trigger a more comprehensive, detailed assessment. FRRISque involves fall-related risk factors, which are biological, behavioral, social and economic.

This study was developed in Alfenas-MG, which has a population of 79,222 inhabitants, of which 9,113 are elderly, representing 12.5% of the total population¹³13 Instituto Brasileiro de Geografia e Estatística (IBGE). [Internet]. IBGE. Cidades. Rio de Janeiro: IBGE; 2017. [acessado 2017 Jul 10]. Disponível em: http://cidades.ibge.gov.br/xtras/home.php
http://cidades.ibge.gov.br/xtras/home.ph... . Considering that the tool was developed to be applied by health professionals, we decided to apply it at the household of the elderly enrolled in the Family Health Strategy (ESF) facilities.

The defined study population was based on the universe of elderly enrolled in the 14 ESF establishments of the urban area of Alfenas-MG. A list of the elderly enrolled in the ESF facilities enabled access to the total number of subjects per facility. Four ESF establishments were defined as the field of study because they had the largest number of elderly people – 1,826 subjects – and because it is a field of practice and teaching that is closer to the main researcher.

At first, we defined that the sample of this study would be comprised of 1,000 elderly people selected through a stratified random sampling process with proportional sharing. An additional 10% was used for losses and refusals. Nunnaly¹⁴14 Nunnaly JC. Psychometric theory. New York: Mc Graw-Hiel Book Company; 1967. states that it is not possible to say, beforehand, how many subjects are required to obtain data for validation of the items of a measuring tool. However, the author prescribes a minimum of 300 cases, preferably 1,000 or more, and warns that the result may be misleading in the statistical analysis process if there are not at least five cases per item.

The number of elderly individuals from each stratum was 334 in ESF 1 (total of 555 elderly), 293 in ESF 2 (total of 486 elderly), 255 in ESF 3 (total of 423 elderly) and 218 in ESF 4 (total of 362 elderly). Of the 1,100 elderly people randomly selected, 28 did not agree to participate in the study, 33 died, 46 changed their address and 139 presented one of the exclusion criteria, such as cognitive alterations, lower limbs fracture, total loss of vision and hip and knee arthroplasty in the last three months. Considering the achievement of a representative sample, the difficulty of recruiting field researchers and at the end of the estimated period for data collection, no new drawings were made. Thus, the final sample consisted of 854 participants.

The elderly selected for this sample had the following eligibility criteria: age 60 years or older; be aware, oriented and able to interact during the interview and to move around even if using some walking aid (walker, cane). The elderly with cognitive alterations detectable by the Mini Mental State Examination (MMSE)¹⁵15 Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral. Impacto da escolaridade. Arq Neuropsiquiatr 1994; 52(1):1-7., infectious disease in the acute phase, fractures in the lower limbs or elderly patients with other medical condition that prevented tests from being performed, interaction and communication during the interview, such as severe hypoacusia, total loss of vision and hip and knee arthroplasty in the last three months were excluded from the sample.

Subjects were interviewed by field researchers through home visits from December 2015 to June 2016. These professionals were properly trained in the approach with the elderly, in the way of application of the tools and in the performance of tests. In total, 10 field researchers trained in the health area and experienced in the approach to the elderly and practice in field research, nine nurses and one pharmacist participated in the study. Throughout data collection, these researchers were submitted to calibration, that is, an adjustment in relation to the data collection technique and clarifying issues in order to avoid possible errors that could interfere in the validation of the tool.

In addition to a sociodemographic evaluation tool and the pilot version of the FRRISque, the QuickScreen® Clinical Falls Risk Assessment tool¹⁶16 Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci 2010; 65A(8):896-903. was used as a standard reference in order to evaluate the validity of concurrent criteria, determining the sensitivity and specificity values. QuickScreen® includes performance testing, is reliable, has adequate external validity and can accurately predict multiple falls in the elderly, i.e. the probability of future falls increases 7% with the identification of none or one risk and 49% with the identification of six or more risks. It consists of eight items: fall history, use of medications, use of psychotropic drugs, visual acuity test, feet protective skin sensitivity test, semitandem position test, step test and sitting-standing test¹⁶16 Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci 2010; 65A(8):896-903..

Descriptive analyses were performed to characterize the sample, using measures of central tendency, variability and frequency distribution. Data normality was verified by the Kolmogorov-Smirnov test.

The chi-square test (X²) was used to verify gaps in proportions between FRRISque items and the groups obtained from the QuickScreen® application. The prevalence ratio (PR) and its respective 95% Confidence Interval (95% CI) were used as a measure of effect. Significant associations were deemed at a value of p ≤ 0.05.

The third step consisted of multivariate logistic regression analysis to identify the association between the various items of FRRISque and the greater risk of falls in the elderly. Thus, all FRRISque variables were initially included in the multivariate analysis and, as variables were associated with QuickScreen® items (p ≤ 0.05), they were selected for further multivariate analyses, consequently, those with a value of p<0.05 remained in the final model of the scale.

Finally, the precision measurements, namely, sensitivity, specificity, positive predictive value and negative predictive value were analyzed. The ROC (Receiver Operating Characteristic) curve was used to represent sensitivity and specificity values and to identify the best cutoff point. Data were analyzed in the statistical software Med Calc version 16.4.1. A significance level of 5% was considered for all analyses.

This study was submitted to the Research Ethics Committee (CEP) of the Hospital das Clínicas, Medical School of Ribeirão Preto, Brazil, and approved. After acceptance in participating in the study, participants signed or stamped their right thumb the Informed Consent Form.

Results

In total, 854 elderly individuals who met the inclusion criteria were divided into two groups according to the results of the gold standard test, the QuickScreen®, distributed as follows: elderly people who scored from 0 to 3 risk factors were allocated to Group I (control group or lower risk group) and those who scored 4 or more were allocated to Group II (case group or higher risk group). This distribution was made considering that a score of four or more in the application of QuickScreen® indicates an increased risk of falls¹⁶16 Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci 2010; 65A(8):896-903..

Regarding the sociodemographic characteristics, it was observed that most of the elderly were female (492, 57.6%), with a mean age of 71.87 years (SD = 7.62), white (642, 75.1%) and married (523, 61.2%). In addition, 751 (87.9%) of the elderly lived with their relatives, 496 (58%) reported having attended up to fourth grade elementary school, 734 (85.9%) were retired and 341 (39.9%) had a household income of one minimum wage (Table 1). The prevalence of falls found in this study was 30.8%.

According to comparative analyses between groups (Table 2), there is evidence that items 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 31, 36 and 43 are related to an increased risk of falls in the elderly. On the other hand, there is evidence that items 27, 28, 32 and 40 are associated with fall protection.

Next, a multivariate analysis was performed by logistic regression, including the 27 items that achieved statistical association with the highest risk of falls in the elderly. The four items considered as fall protection factors were excluded from the model, since the tool to be validated is a fall risk assessment and not an evaluation of fall protective factors in the elderly.

Two multivariate analyzes were carried out. In the first one, the first 24 items were inserted (Table 3), considering that the Med Calc statistical software allows the introduction of a maximum of 24 variables per model analysis.

In the second model, the items that had a value of p ≤ 0.05 in the first model and the other items 31, 36 and 43 (Table 4) were inserted. Finally, only 10 FRRISque items were found that contribute to increased risk of falls in the elderly.

FRRISque was analyzed for sensitivity and specificity by means of the Receiver Operator Characteristic (ROC) curve, constructed with the 10 items that remained in the final model after the multivariate analysis. This curve showed that the best cutoff point for differentiating elderly with lower and higher risk of falls is score three, which assumes sensitivity values of 91.3% and specificity of 73.4% (Figure 1).

Discussion

The highest percentage of female elderly in this study, representing 57.6% of the total respondents highlights the process of feminization of old age. On average, women in the Western Pacific region live longer than men¹⁷17 World Health Organization (WHO). Ageing and health in the westerm pacific region. Geneva: WHO publications; 2014.. This means that the female population grows faster than the male population, possibly due to a higher male mortality rate and a higher life expectancy in females¹⁸18 Pinho TAM, Silva AO, Tura LFR, Moreira MASP, Gurgel SN, Smith AAF, Bezerra VP. Avaliação do risco de quedas em idosos atendidos em Unidade Básica de Saúde. Rev da Esc Enferm 2012; 46(2):320-327.. According to the latest census, in Brazil, the female contingent over 60 years old rose from 2.2% in 1940 to 4.7% in 2000, and 6% in 2010¹⁹19 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo 2010 - Disponibiliza informações sobre os resultados do censo 2010. [Internet]. Rio de Janeiro: IBGE; 2010. [acessado 2017 Jul 10]. Disponível em: %3Chttp://www.ibge.gov.br/censo2010/resultados_do_censo2010.php%3E
%3Chttp://www.ibge.gov.br/censo2010/resu... .

Item 2 “Have you fallen in the last 12 months?” refers to the previous fall variable and is widely cited in the literature as a predictor for future fall⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.

5 World Health Organization (WHO). WHO Global report on falls prevention in older age. Geneva: WHO publications; 2007.

6 Cleary K, Skornyakov E. Predicting falls in community dwelling older adults using the Activities-specific Balance Confidence Scale. Arch Gerontol Geriatr 2017; 72(June):142-145.

7 Nascimento CF, Duarte YAO, Lebrão ML, Chiavegatto Filho ADP. Individual and contextual characteristics of indoor and outdoor falls in older residents of São Paulo, Brazil. Arch Gerontol Geriatr 2017; 68:119-125.

8 Kim SH. Risk factors for severe injury following indoor and outdoor falls in geriatric patients. Arch Gerontol Geriatr 2016; 62(January-February):75-82.

9 Gordis L. Epidemiology. 4ª ed. Rio de Janeiro: Revinter; 2010.

10 Jonas LT, Silva JV, Mendes MA. Construção da Escala avaliativa do risco de quedas para pessoas idosas não institucionalizadas. Rev Enferm UFPE online 2015; 9(Supl. 4):7977-7985.

11 Chini LT. Validação da escala avaliativa do risco de quedas (EARQUE) em pessoas idosas que vivem na comunidade [tese]. Ribeirão Preto: Universidade de São Paulo; 2017.

12 Close JCT, Lord SR. Fall assessment in older people. BMJ 2011; 343:d5153.

13 Instituto Brasileiro de Geografia e Estatística (IBGE). [Internet]. IBGE. Cidades. Rio de Janeiro: IBGE; 2017. [acessado 2017 Jul 10]. Disponível em: http://cidades.ibge.gov.br/xtras/home.php
http://cidades.ibge.gov.br/xtras/home.ph...

14 Nunnaly JC. Psychometric theory. New York: Mc Graw-Hiel Book Company; 1967.

15 Bertolucci PH, Brucki SM, Campacci SR, Juliano Y. O Mini-Exame do Estado Mental em uma população geral. Impacto da escolaridade. Arq Neuropsiquiatr 1994; 52(1):1-7.

16 Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci 2010; 65A(8):896-903.

17 World Health Organization (WHO). Ageing and health in the westerm pacific region. Geneva: WHO publications; 2014.

18 Pinho TAM, Silva AO, Tura LFR, Moreira MASP, Gurgel SN, Smith AAF, Bezerra VP. Avaliação do risco de quedas em idosos atendidos em Unidade Básica de Saúde. Rev da Esc Enferm 2012; 46(2):320-327.

19 Instituto Brasileiro de Geografia e Estatística (IBGE). Censo 2010 - Disponibiliza informações sobre os resultados do censo 2010. [Internet]. Rio de Janeiro: IBGE; 2010. [acessado 2017 Jul 10]. Disponível em: %3Chttp://www.ibge.gov.br/censo2010/resultados_do_censo2010.php%3E
%3Chttp://www.ibge.gov.br/censo2010/resu... ^-2020 Jansen S, Schoe J, van Rijn M, Abu-Hanna A, Moll van Charante EP, van der Velde N, de Rooij SE. Factors associated with recognition and prioritization for falling, and the effect on fall incidence in community dwelling older adults. BMC Geriatrics 2015; 15(1):169-179.. People who have fallen are three times more likely to be at risk of falling again. Recurrent falls may be related to underlying causes, such as gait disorder, orthostatic hypotension or may be indicative of disease progression, for example Parkinson’s disease or dementia. Alternatively, it may be a new acute problem, such as dehydration or infection⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824..

Item 5 “Do you use a walking aid (walking stick, crutch or walker)?” Refers to the variable use of a walking aid device (WAD) and is an important risk factor for falls in the elderly²¹21 West BA, Bhat G, Stevens J, Bergen G. Assistive device use and mobility-related factors among adults aged ≥ 65 years. J Safety Res 2015; 55:147-150.^,2222 Andersen DA, Roos BA, Stanziano DC, Gonzalez NM, Signorile JF. Walker use, but not falls, is associated with lower physical functioning and health of residents in an assisted-living environment. Clin Interv Aging 2007; 2(1):123-137.. Elderly in general are reluctant to use WAD, such as walking sticks and walkers because of the denial of need, fear of dependence and embarrassment²²22 Andersen DA, Roos BA, Stanziano DC, Gonzalez NM, Signorile JF. Walker use, but not falls, is associated with lower physical functioning and health of residents in an assisted-living environment. Clin Interv Aging 2007; 2(1):123-137.. Probably, elderly who use WAD have more mobility problems than those who do not use them²¹21 West BA, Bhat G, Stevens J, Bergen G. Assistive device use and mobility-related factors among adults aged ≥ 65 years. J Safety Res 2015; 55:147-150.^,2222 Andersen DA, Roos BA, Stanziano DC, Gonzalez NM, Signorile JF. Walker use, but not falls, is associated with lower physical functioning and health of residents in an assisted-living environment. Clin Interv Aging 2007; 2(1):123-137.. Moreover, studies indicate that elderly people who use WAD are frailer and, therefore, at greater risk of falling and suffering an injury²²22 Andersen DA, Roos BA, Stanziano DC, Gonzalez NM, Signorile JF. Walker use, but not falls, is associated with lower physical functioning and health of residents in an assisted-living environment. Clin Interv Aging 2007; 2(1):123-137.^,2323 Rico NC, Lemos ND, Ferreira CV, Ferreira CG. Uso de dispositivo de auxílio à marcha: a percepção dos idosos. Rev Equilíbrio Corpor e Saúde 2012; 44(22):42-50..

Another hypothesis that may explain this relation is the fact that elderly people acquire this equipment without adequate orientation, or are advised on the acquisition and use, but are not trained nor receive the proper use guidelines²³23 Rico NC, Lemos ND, Ferreira CV, Ferreira CG. Uso de dispositivo de auxílio à marcha: a percepção dos idosos. Rev Equilíbrio Corpor e Saúde 2012; 44(22):42-50.. Such devices, when improperly adjusted or used cause an increase in energy expenditure and even changes in gait and balance, leading to the occurrence of falls²³23 Rico NC, Lemos ND, Ferreira CV, Ferreira CG. Uso de dispositivo de auxílio à marcha: a percepção dos idosos. Rev Equilíbrio Corpor e Saúde 2012; 44(22):42-50.. It is worth mentioning that a WAD should be recommended by health professionals, preferably physiotherapists. In addition to the need for gait training, the indication of suitable equipment is required because it is adapted and adjusted to the height and distance of the elderly person’s body²³23 Rico NC, Lemos ND, Ferreira CV, Ferreira CG. Uso de dispositivo de auxílio à marcha: a percepção dos idosos. Rev Equilíbrio Corpor e Saúde 2012; 44(22):42-50..

Item 7 “Do you take four or more medications a day?” refers to polypharmacy. While there is no consensus on the definition, polypharmacy can be conceptualized as the use of more drugs than is clinically necessary²⁴24 Tjia J, Velten SJ, Parsons C, Valluri S, Briesacher BA. Studies to reduce unnecessary medication use in frail older adults: a systematic review. Drugs Aging 2013; 30(5):285-307.. In addition, the literature provides definitions that include the use of four or more drugs²⁵25 Rollason V, Vogt N. Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist. Drugs Aging 2003; 20(11):817-832., as well as five or more drugs²⁶26 Linjakumpu T, Hartikainen S, Klaukka T, Veijola J, Kivelä SL, Isoaho R. Use of medications and polypharmacy are increasing among the elderly. J Clin Epidemiol 2002; 55(8):809-817.. In this study, we chose to use the definition regarding the use of four or more drugs, considering that the item referring to polypharmacy in the gold standard test used in this study was based on the definition of four or more drugs.

Polypharmacy is a concern, especially when it comes to elderly, as they are more prone to age-related and disease-related pharmacokinetic / pharmacodynamic changes and therefore are more drug therapy-sensitive²⁷27 Mangoni AA, Jackson SHD. Age-related changes in pharmacokinetics and pharmacodynamics: Basic principles and practical applications. Br J Clin Pharmacol 2004; 57(1):6-14.. Elderly polypharmacy is associated with several negative health indicators, which include functional impairment, harmful drug interactions, adverse drug reactions, falls and health-related costs²⁸28 Lim LM, McStea M, Chung WW, Azmi NN, Aziz SAA, Alwi S, Kamarulzaman A, Kamaruzzaman SB, Chua SS, Rajasuriar R. Prevalence, risk factors and health outcomes associated with polypharmacy among urban community-dwelling older adults in multiethnic Malaysia. PLoS One 2017; 12(3):1-18..

In this investigation, polypharmacy was the item with the highest association with the risk of falls. A study conducted in Canada comparing elderly people who did not fall with those who had two or more falls evidenced that the amount of medication was associated with an increased risk of falls²⁹29 Fletcher PC, Berg K, Dalby DM, Hirdes JP. Risk factors for falling among community-based seniors. J Patient Saf 2009; 5(2):61-66.. A household survey conducted with 729 elderly people from Uberaba-MG, Brazil also identified that polypharmacy was associated with falls (PR: 1.17; 95% CI: 0.81-1.68)³⁰30 Nascimento JS, Mara D, Tavares S. Prevalence and factors associated with falls in the elderly. Texto Context Enferm 2016; 25(2):1-9..

Item 8 “Do you take psychotropic medications?” refers to the use of drugs that act on the central nervous system, such as antidepressants, hallucinogens and tranquilizers (anxiolytics and antipsychotics). A meta-analysis conducted in 2009 showed that the use of sedatives and hypnotics, antidepressants and benzodiazepines is associated with falls in the elderly³¹31 Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009; 169(21):1952-1960.. The adjusted OR estimates were 1.39 (95% CI:0.94-2.00) for neuroleptics and antipsychotics, 1.36 (95% CI:1.13-1.76) for antidepressants and 1.41 (95% CI:1.20-1.71) for benzodiazepines³¹31 Woolcott JC, Richardson KJ, Wiens MO, Patel B, Marin J, Khan KM, Marra CA. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009; 169(21):1952-1960.. In this study, the prevalence ratio was 6.17 for psychotropics in general.

It should be emphasized that long half-life hypnotics and sedatives may cause significant residual sedation, especially in elderly people, due to changes in their tissue body composition, considering that there is a lower proportion of body water and greater adipose tissue, which may result in occurrence of dizziness and confusion, among other factors that predispose the occurrence of falls³²32 Rezende CDP, Gaede-Carrillo MRG, Sebastião ECDO. Queda entre idosos no Brasil e sua relação com o uso de medicamentos : revisão sistemática. Cad Saude Publica 2012; 28(12):2223-2235..

Item 12 “Do you have difficulty ascending or descending a slope?” relates to functional capacity and muscular strength. It is an important activity to perform the instrumental and advanced activities of daily life and reveals the person’s ability to live independently or not outside his/her home⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.. Decreased muscular strength is associated with falls and increases fourfold the risk of falling (OR: 4.4, 95% CI: 1.5-10.3)⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.. Muscle weakness may arise due to sedentary lifestyle along with other debilitating chronic health conditions, such as heart failure and lung disease⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824..

Like item 12, item 13 “Do you need help walking 100 meters?” relates to the ability of the elderly person mobility. This item is related to dependence in the activities of daily living and may depict the onset of elderly functional capacity decline and frailty³³33 Ramos LR, Andreoni S, Coelho-Filho JM, Lima-Costa MF, Matos DL, Rebouças M, Veras R. Screening for dependence in activities of daily living in the elderly: minimum set of questions. Rev Saude Publica 2013; 47(3):506-513..

Items 19 “Do you have visual impairment?” and 20 “Do you have difficulty hearing what other people tell you?’ are related to the sensory system, one of the first systems to suffer the consequences of physiological ageing.

About 18% of elderly people living in the community over 70 years of age have some considerable visual impairment, with cataracts being the most prevalent disease, followed by glaucoma and macular degeneration⁴4 Rubenstein LZ, Josephson KR. Falls and Their Prevention in Elderly People: What Does the Evidence Show? Med Clin North Am 2006; 90(5):807-824.^,3434 Menezes RL, Bachion MM. Condições visuais autorrelatadas e quedas em idosos institucionalizados. Rev Bras Oftalmol 2012; 71(1):23-27.. A large part of the chain of visual processes related to body movement and spatial relationships involves the frontal magnocellular and parietal cerebral pathways, which are essential to postural control.

As a result, elderly people with visual impairments may show alterations in postural control and, thus, are more prone to falls³⁵35 Macedo BG de, Pereira LSM, Gomes PF, Silva JP da, Castro ANV de. Impacto das alterações visuais nas quedas, desempenho funcional, controle postural e no equilíbrio dos idosos: uma revisão de literatura. Rev Bras Geriatr e Gerontol 2008; 11(3):419-432.. Moreover, visual impairments, when associated with poorly lit environments, favor slips and slides on irregular surfaces³⁴34 Menezes RL, Bachion MM. Condições visuais autorrelatadas e quedas em idosos institucionalizados. Rev Bras Oftalmol 2012; 71(1):23-27..

In this study, elderly people who reported visual impairment are 1.96 times more likely to suffer a fall. Similar to that found, the study by Perracini and Ramos³⁶36 Perracini MR, Ramos LR. Fall-related factors in a cohort of elderly community residents. Rev Saude Publica 2002; 36(6):709-716. shows that the predictive model of recurrent falls was composed of six variables, one of which was visual impairment (OR = 1.53, 95% CI: 1.00-2.34).

On the other hand, hearing loss is also related to falls and is one of the most prevalent chronic conditions in the elderly. When associated with the physiological ageing process, it is called presbycusis and is among the sensory deprivations with the greatest impact on the elderly’s communication, since it can lead to social isolation, which compromises their quality of life³⁷37 Lacerda CF, Silva LO, Canto RS de T, Cheik NC. Efeitos da adaptação às próteses auditivas na qualidade de vida, no equilíbrio e no medo de queda em idosos com perda neurossensorial. Int Arch Otorhinolaryngol 2012; 16(2):156-162.. Several mechanisms may explain the association between hearing loss and falls. Concomitant to the dysfunction of the cochlear system, there may be a change of the vestibular system in view of the shared location within the bony labyrinth of the ear, eventually affecting postural control. In addition, decreased auditory sensitivity may restrict perception to auditory cues necessary for environmental risk awareness³⁸38 Lin FR, Ferrucci L. Hearing loss and falls among older adults in the united states. Arch Intern Med 2012; 172(4):369-371.. A survey conducted in Finland showed that people with hearing loss were three to four times more likely to be at risk of falling compared to people with good hearing³⁹39 Viljanen A, Kaprio J, Pyykkö I, Sorri M, Pajala S, Kauppinen M, Koskenvuo M, Rantanen T. Hearing as a predictor of falls and postural balance in older female twins. J Gerontol A Biol Sci Med Sci 2009; 64(2):312-317..

Item 31 “Do you exercise during the week?” refers to the physical exercise variable. Significant changes in muscle structure and function occur throughout the ageing process, leading to decreased muscle mass and, thus, decreased muscle strength. The causes of these muscular changes are countless and include neurological, endocrine and inflammatory aspects, as well as behavioral factors such as low performance of physical exercise⁴⁰40 Schoene D, Kiesswetter E, Sieber CC, Freiberger E. Skelettmuskulare faktoren, sarkopenie und sturze im alter. Z Gerontol Geriat 2017; 52(1):37-44.. Thus, physical exercise performed in a structured way and guided by a health professional plays a fundamental role in the prevention of falls and in the management of functional decline⁴¹41 Olij BF, Erasmus V, Kuiper JI, van Zoest F, van Beeck EF, Polinder S. Falls prevention activities among community-dwelling elderly in the Netherlands: A Delphi study. Injury 2017; 48(9):2017-2021..

Thus, physical exercise is a fall prevention intervention widely discussed in the scientific literature. A meta-analysis by Gillespie et al.⁴²42 Gillespie L, Robertson M, Gillespie W, Sherrington C, Gates S, Clemson L, Close JC, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012; 12(9):CD007146. showed that group physical exercise programs reduce the rate and the risk of falling (rate of 0.71; 95% CI 0.63 to 0.82 and risk rate 0.85, 95% CI: 0.76 to 0.96 versus fall rate of 0.68, 95% CI: 0.58 to 0.80 and risk rate of 0.78, 95% CI: 0.64 to 0.94).

Finally, the only environmental risk factor that remained in the final risk model for falls refers to the poorly lit environmental risk factor – item 43 “Is environment poorly lit?” Domestic environmental risk factors are considered significant for falls of elderly people living in the community, although they may contribute to an increased risk in people with recurrent falls⁴³43 Letts L, Moreland J, Richardson J, Coman L, Edwards M, Ginis KM, Wilkins S, Wishart L. The physical environment as a fall risk factor in older adults: Systematic review and meta-analysis of cross-sectional and cohort studies. Aust Occup Ther J 2010; 57(1):51-64.. The “wet floor” environmental risk factor did not remain in the final model and this can be explained by the fact that older people adapt better to this risk, compensating for the risk of slipping and a probable fall. The poorly lit environment is a greater risk, especially in elderly people with visual impairment.

In short, the results of this study showed that it is possible to carry out the risk stratification of elderly people living in the community through the application of FRRISque, which contains ten items in its final version. Most of these items are risk factors for falls that are subject to interventions to eliminate or mitigate them. Thus, the identification of risk factors is an important step in the development of effective fall prevention programs for elderly community dwellers.

In order to assist health professionals in the use of FRRISque, a cutoff point was suggested for the result of its application. When analyzing the ROC curve performed with the 10 items of the last version of FRRISque, score 3 was shown as a cutoff point to differentiate the elderly people it classified. Thus, the elderly with a score of up to two points can be classified as with a lower risk for falls; those with 3 points, with moderate risk for falls; and finally, those with 4 or more points, with high risk for falls.

In the international setting and in Brazil, community elderly dwellers’ fall risk evaluation, both in the context of clinical practice and in research is carried out using single-factor functional tests, mainly the Berg Balance Scale (BBS) and Timed Up and Go Test (TUGT)⁴⁴44 Ansai JH, Glisoi SFN, Oliveira T, Soares AT, Cabral KN, Sera CTN, Paschoal SMP. Revisão de dois instrumentos clínicos de avaliação para predizer risco de quedas em idosos. Rev Bras Geriatr Gerontol 2014; 17(1):177-189. and multifactor tests, such as Fall Risk Score⁴⁵45 Schiaveto FV. Avaliação do risco de quedas em idosos na comunidade [dissertação]. Ribeirão Preto: Universidade de São Paulo; 2008. and most recently QuickScreen®¹⁶16 Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci 2010; 65A(8):896-903..

The BBS evaluates the performance of the functional balance in 14 common items of daily life and its application requires instruments such as ladder step (or step), chair with or without arms, measuring tape, stopwatch, pen and table⁴⁴44 Ansai JH, Glisoi SFN, Oliveira T, Soares AT, Cabral KN, Sera CTN, Paschoal SMP. Revisão de dois instrumentos clínicos de avaliação para predizer risco de quedas em idosos. Rev Bras Geriatr Gerontol 2014; 17(1):177-189.. The TUGT evaluates mobility and balance and consists in the act of getting up from a chair, walking for three meters, turning around, going back to the chair and sitting down, measuring the time taken to perform such a task. While they are characterized as simple and low-cost tools, they require adequate materials and physical space.

The Fall Risk Score⁴⁵45 Schiaveto FV. Avaliação do risco de quedas em idosos na comunidade [dissertação]. Ribeirão Preto: Universidade de São Paulo; 2008. tool validated for the Brazilian population showed sensitivity of 74.2% and specificity of 58.8%. It uses five items to measure the risk of falls, namely, previous falls, medications taken by the elderly, sensory impairment, mental status assessed through the MMSE and gait evaluation. The score on this scale ranges from zero to eleven points, and scores greater than or equal to three suggest that the elderly are at high risk for falls. With the use of the MMSE, about ten minutes extra time is given in its application. As mentioned earlier, QuickScreen®¹⁶16 Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci 2010; 65A(8):896-903. involves performance testing, which requires extra time in its application and proper materials.

In view of the above, FRRISque appears as a promising tool in view of its psychometric properties and its easy and quick applicability in the clinic. Health professionals’ choice of FRRISque as a tool to track the risk of falls in the elderly community dwellers to the detriment of existing ones is justified by its high sensitivity (91.3%) and good specificity (73.4%), because it is a simple, low cost, easy and quick application tool (two minutes), that is, it does not require longer application tests and can be used by all primary health care professionals, including community health workers (CHW), which characterizes an unprecedented contribution. In this primary care setting, CHWs stand out as important allies in fulfilling their role of identifying the most common risk situations to which the elderly are exposed⁴⁶46 Santos RKM, Maciel ACC, Britto HMJS, Lima JCC, Souza TO. Prevalência e fatores associados ao risco de quedas em idosos adscritos a uma Unidade Básica de Saúde do município de Natal, RN, Brasil. Cien Saude Colet 2015; 20(12):3753-3762.^,4747 Veras R. Em busca de uma assistência adequada à saúde do idoso: revisão da literatura e aplicação de um instrumento de detecção precoce e de previsibilidade de agravos. Cad Saude Publica 2003; 19(3):705-715. , as well as transmitting such information to the health staff to optimize resources and elucidate interventions in the prevention of diseases.

We recommend that FRRISque be applied by health professionals in health facilities or at the elderly’s own residence upon a home visit. It is a simple and quick application scale that lasts about two minutes.

In the application of FRRISque, each item answered as positive (yes) scores a point, that is, it is a risk factor, except item “Do you exercise during the week?”, whose score is inverted, that is, the positive answer is not a risk factor and is worth zero (0). In this item, the negative answer (no) scores as a risk factor.

Final considerations

This study aimed to validate a scale to evaluate the risk of falls in elderly people living in the community with a view to filling the gap in the literature of a simple, but dense, quick application and low cost tool.

FRRISque is a valid tool. However, a limitation of this study bumps into the exclusion criteria itself established, that is, the sample did not involve high-risk populations, such as elderly people with impaired cognitive function and dementia or Alzheimer’s, for example. Thus, the results of this study cannot be generalized for elderly people with these characteristics.

Another limitation of the study refers to the fact that it did not evaluate the reliability of FRRISque. On the other hand, we propose that later studies analyze the need to evaluate the reliability of FRRISque (also called precision, reproducibility), whether comparing measurements made by the same person (intraobserver reproducibility) or by different people (interobserver reproducibility).

In addition, in order to confirm FRRISque’s ability to predict future falls, it is necessary to evaluate the validity of the predictive criterion. That is, the elderly evaluated in this study must be reevaluated as to the results of applying the final version of FRRISque through a 1-2 years cohort study.

Finally, its implementation and use in clinical practice may avoid unnecessary expenses, in terms of use of the Unified Health System (SUS), in view of the serious consequences of falls, such as fractures and hospitalizations. The evaluation of the risk of falls with the implementation of FRRISque in the primary care network may be the key part of care as suggested by guidelines of geriatrics and gerontology.

Acknowledgments

We wish thank the Foundation for Research Support of the State of São Paulo (FAPESP) for their financial support.

References

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