Abstracts

INTRODUCTION

The increasing proportion of elderly people in the Brazilian population brings up the need to analyze and discuss the main impairing events that affect this age group¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16.. Among these events, the occurrence of falls is relevant, since it has the potential of causing serious risks to health and to the life of the elderly; therefore, it is a very frightening situation¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16..

In Brazil, in 2010, 10,425 deaths were caused by falls, out of which 65.2% involved elderly people²2. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise de Situação em Saúde. Saúde Brasil 2011: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2012.. It is estimated that the Unified Health System (SUS), in Brazil, spent approximately R$ 57.61 million with hospitalizations caused by falls in 2009, and in 2006 this amount was of R$ 49 million²2. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise de Situação em Saúde. Saúde Brasil 2011: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. Brasília: Ministério da Saúde; 2012..

The fall results from the loss of postural balance, and it can be related to the sudden failure of neural and osteoarticular mechanisms involved in postural maintenance³3. Cunha UG, Guimarães RM. Sinais e sintomas do aparelho locomotor. In: Guimarães RM, Cunha UG. Sinais e sintomas em geriatria. Rio de Janeiro: Revinter; 1989. p. 141-54.. The frequency of falls increases significantly with the biological changes associated with age. With aging, the structure and function of skeletal muscles change. In terms of structure, muscle mass decreases because the number and the size of muscle fibers decline after the end of adulthood³3. Cunha UG, Guimarães RM. Sinais e sintomas do aparelho locomotor. In: Guimarães RM, Cunha UG. Sinais e sintomas em geriatria. Rio de Janeiro: Revinter; 1989. p. 141-54.. The loss of muscle mass and, consequently, muscle strength, is directly related with the reduction of mobility and impairment in physical performance, which contributes with the increasing risk of falls⁴4. Leite PF. Exercício, envelhecimento e promoção de saúde. Belo Horizonte: Editora Health; 1996. 125 p..

conducted in different countries point out to the relevance of falls among elderly people, and detect annual frequencies ranging from 6.5% to 42%, depending on the country and on the adopted methods for collecting information⁵5. Gang L, Sufang J, Ying S. The incidence status on injury of the community-dwelling elderly in Beijing. Chi J Prev Med 2006; 40(1): 37. ^{, 6}6. Wannian L, Ying L, Xueqing W. An epidemiological study on injury of the community-dwelling elderly in Beijing. Chin J Dis Control Prev 2004; 8(6): 489-92..

Factors related to falls have been classified as intrinsic, which result from physiological changes related to aging, diseases and effects of medicines, and as extrinsic, which are related to circumstances and environmental conditions⁷7. Fabrício SCC, Rodrigues RAP, Costa Junior ML. Causas e consequências de quedas de idosos atendidos em hospital público. Rev Saúde Pública 2004; 38(1): 93-9..

Several sociodemographic factors¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16. ^{, 8}8. Siqueira FV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, Thumé E, et al . Prevalence of falls in elderly in Brazil: a countrywide analysis. Cad Saúde Pública 2011; 27(9): 1819-26. ^{, 9}9. Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTB, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saúde Pública 2012; 46(1): 138-46. and those related to housing conditions, family arrangements¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16. ^{, 10}10. Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saúde Pública 2007; 41(5): 749-56. ^{, 11}11. Motta LB, Aguiar AC, Coutinho ESF, Huf G. Prevalência e fatores associados a quedas em idosos em um município do Rio de Janeiro. Rev Bras Geriatr Gerontol 2010; 13(1): 83-91., diseases¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16. ^{, 9}9. Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTB, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saúde Pública 2012; 46(1): 138-46. and visual and physical impairment¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16. ^{, 11}11. Motta LB, Aguiar AC, Coutinho ESF, Huf G. Prevalência e fatores associados a quedas em idosos em um município do Rio de Janeiro. Rev Bras Geriatr Gerontol 2010; 13(1): 83-91. have been associated with falls. Indicating factors that are associated with the occurrence of falls among the elderly is a relevant task, since it can contribute with subsidies for public policies and health programs addressed to preventing accidents and reducing their consequences¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16. ^{, 12}12. Bekibele CO, Gureje O. Fall incidence in a population of elderly persons in Nigeria. Gerontology 2010; 56(3): 278-83..

Considering the serious damage that falls can cause for the health of the elderly, besides their social and economic implications, the objective of this study was to identify factors associated with the occurrence of falls among elderly people living in the city of Campinas, São Paulo.

METHODS

This is a cross-sectional, population-based study conducted with a sample of non-institutionalized elderly people (60 years old or more), living in an urban area in the city of Campinas, São Paulo. In 2008, the city had a little more than 1 million inhabitants, and 11% of them were elderly people (60 years old or more). The data in this study are part of the health household survey (ISACamp 2008), conducted from February, 2008, to April, 2009. The survey aimed at obtaining information from several health dimensions regarding three age-related domains: adolescents (10 - 19 years old), adults (20 - 59 years old) and elderly people (60 years old or older).

The minimum number of people to compose the sample of each domain was established by considering the estimation of a 50% proportion, with 95% confidence interval (95%CI), sampling error ranging between 4 and 5 percentage points, and design effect estimated at 2. Therefore, a minimum number of 1,000 interviews was established for each age domain.

The survey sample was obtained by probability sampling procedures, in two-stage clusters: census and household sectors. In the first stage, 50 census sectors were raffled with probability proportional to size (number of households). For these 50 raffled sectors, households were updated in order to enable a posterior raffle. In the second stage, in order to reach the necessary sample size, 2,150, 700 and 3,900 households were independently raffled to obtain the minimum number of adolescents, adults and elderly participants, respectively.

Information was obtained by a structured questionnaire, which was applied by trained and supervised interviewers. Inclusion criteria were: being at least 60 years old and accepting to answer the questionnaire, by signing the informed consent form.

In cases of elderly people with mental disorder, stroke sequels or any another reason that prevented participants from answering the questionnaire, a family member was requested to help with data collection. The analyzed variables were:

The survey data were typed into a data base developed with the software EpiData 3.1 (Epidata Association, Odense, Denmark), and were submitted to an evaluation of consistency. For the analyses in this study, estimates were produced with 95%CI. The associations between variables and the falls that occurred in the past 12 months were analyzed by the χ² test. Besides, simple regression and Poisson multiple regression were used to estimate crude and adjusted prevalence ratios (PR) for sex and/or age.

The analyses were conducted with the software Stata 11.0 (Stata Corp, College Station, United States) and used svy commands which incorporate the necessary weights according to sampling design.

The project of this study was approved by the Ethics Committee of the School of Sciences at Universidade Estadual de Campinas, report n. 079/2007.

RESULTS

Among the selected households to obtain the sample of elderly people, there was a 6.5% loss, due to the impossibility of finding a resident or because the resident refused to describe the individuals living in that household. Out of the elderly people who were selected from the households, and were supposed to be interviewed, 2.3% refused to participate. Therefore, 1,520 elderly people were analyzed in this study.

From the studied population, 59.5% were female, with mean age of 69.9 years old; 6.5% reported falls as being the main accident in the past 12 months. After adjustment for age and/or sex, the main occurrences of falls were observed among female participants (PR = 2.39; 95%CI 1.47 - 3.87), older elderly people (80 years old or more) (PR = 2.50; 95%CI 1.61 - 3.88) and widow(ers) (PR = 1.74; 95%CI 1.04 - 2.89) (Table 1).

Among chronic diseases, the associations deriving from multiple analyses were: rheumatism/arthritis/arthrosis (PR = 1.58; 95%CI 1.00 - 2.48), osteoporosis (PR = 1.71; 95%CI 1.18 - 2.49) and asthma/bronchitis/emphysema (PR = 1.73; 95%CI 1.09 - 2.74). With regard to other health issues, significant associations with falls were observed with: headache (PR = 1.59; 95%CI 1.07 - 2.38), dizziness (PR = 2.82; 95%CI 1.98 - 4.02), insomnia (PR = 1.75; 95%CI 1.16 - 2.65) and CMD (PR = 1.72; 95%CI 1.12 - 2.64). The occurrence of falls was increasing according to the number of morbidities and number of reported health problems, even after adjustments (Table 2). Besides, a significant association was observed between falls and the higher number of used medications (five or more) (PR = 2.50; 95%CI 1.12 - 5.56) and use of cane or walker (PR = 2.16; 95%CI 1.19 - 3.93) (Table 3).

It was possible to observe that elderly people fell mostly in their houses (64%), followed by occurrences in the street (26%). Among the elderly who reported falls as the main accident they were involved in in the past 12 months, 56.7% limited their daily activities, being 57.4% for three days or longer; 58.6% were bedridden, being 58.8% for three days or longer; and 71.2% required medical care because of the fall (Table 4).

DISCUSSION

The occurrence of falls reported as the main accident in the past 12 months was of 6.5%. This frequency is similar to that observed in the study by Gang et al.⁵5. Gang L, Sufang J, Ying S. The incidence status on injury of the community-dwelling elderly in Beijing. Chi J Prev Med 2006; 40(1): 37., conducted in Beijing, and inferior to the mean found in studies assessing the occurrence of falls, regardless of their severity¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16. ^{, 9}9. Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTB, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saúde Pública 2012; 46(1): 138-46.. This study considered only those falls that were considered to be the main accident the person was involved in in the past 12 months, so the most severe falls had more chances of being reported, which may have underestimated the result.

The higher occurrence of falls was observed among females, which is consistent with the findings in national and international literature¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16. ^{, 8}8. Siqueira FV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, Thumé E, et al . Prevalence of falls in elderly in Brazil: a countrywide analysis. Cad Saúde Pública 2011; 27(9): 1819-26. ^{, 9}9. Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTB, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saúde Pública 2012; 46(1): 138-46. ^{, 14}14. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. PLoS One 2011; 6(4): e18976.. Campbell et al.¹⁵15. Campbell AJ, Spears GF, Borrie MJ. Examination by logistic regression modelling of the variables which increase the relative risk of elderly women falling compared to elderly men. J Clin Epidemiol 1990; 42(13): 1415-20., in a prospective study, examined the variables that increased the relative risk of women falling when compared to men, and, even by controlling the effect of numberless variables, it was still observed that the risk among females was twice as high (95%CI 1.40 - 2.92). Fried et al.¹⁶16. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56(3): M146-56. considered that maybe women fall more often because of the lower amount of lean mass and muscle strength they present in relation to men at the same age group. According to Foldvari et al.¹⁷17. Foldvari M, Clark M, Laviolette LC, Bernstein MA, Kaliton D, Castaneda C, et al. Association of muscle power with functional status in community-dwelling elderly women. J Gerontol A Biol Sci Med Sci 2000; 55(4): M192-9., women lose muscle strength earlier than men, getting closer to the limit in which power could compromise the functional status. Women would also be more exposed to extrinsic factors that cause sarcopenia (degenerative loss of mass and muscle strength)¹⁸18. Guimarães LHCT, Galdino DCA, Martins FLM, Vitorino DFM, Pereira KL, Carvalho EM. Comparação da propensão de quedas entre idosos que praticam atividade física e idosos sedentários. Rev Neurociênc 2004; 12(2)., and they are also more exposed to household activities¹⁹19. Fleck AC, Wagner A. A mulher como a principal provedora do sustento econômico familiar. Psicol Estud 2003; 8(número especial): 31-8. ^{, 20}20. Rocha-Coutinho ML. Quando o executivo é uma "dama": a mulher, a carreira, e as relações familiares. In: Féres-Carneiro T (Org.). Família e casal: arranjos e demandas contemporâneas. Rio de Janeiro: Editora PUC-Rio; 2003. p. 15-30..

The occurrence of falls was increasing with age, being 2.5 times more common among elderly people aged 80 years old or more in comparison to those aged 60 to 69 years old. This result is attributed to progressive balance loss and changes in muscle and bone mass, which take place during the aging process⁸8. Siqueira FV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, Thumé E, et al . Prevalence of falls in elderly in Brazil: a countrywide analysis. Cad Saúde Pública 2011; 27(9): 1819-26. ^{, 10}10. Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saúde Pública 2007; 41(5): 749-56. ^{, 21}21. Coutinho ESF, Bloch KV, Rodrigues LC. Características e circunstâncias das quedas seguidas de fratura grave entre idosos no Rio de Janeiro, Brasil. Cad Saúde Pública 2009; 25(2): 455-9.. Studies have shown that one of the ways to minimize balance and muscle mass deficits that occur in this process is the regular practice of physical exercises²²22. Yardley L, Beyer N, Hauer K, McKee K, Ballinger C, Tood C. Recommendations for promoting the engagement of older people in activities to prevent falls. Qual Saf Health Care 2007; 16(3): 230-4., which contributes with the improvement of functional capacity, balance, strength, coordination and movement velocity, thus promoting safer gait and preventing falls¹⁸18. Guimarães LHCT, Galdino DCA, Martins FLM, Vitorino DFM, Pereira KL, Carvalho EM. Comparação da propensão de quedas entre idosos que praticam atividade física e idosos sedentários. Rev Neurociênc 2004; 12(2). ^{, 23}23. Alves Junior ED, Paula FL. A prevenção de quedas sob o aspecto da promoção da saúde. Fit Perf J 2008; 7(2): 123-9..

As to marital status, falls affected widows and widowers almost twice as much, even after adjustment for age and sex. Siqueira et al.¹⁰10. Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saúde Pública 2007; 41(5): 749-56. consider that mutual care between partners could explain the lower occurrence of falls among those who live with a partner⁸8. Siqueira FV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, Thumé E, et al . Prevalence of falls in elderly in Brazil: a countrywide analysis. Cad Saúde Pública 2011; 27(9): 1819-26.. Studies by Perracini and Ramos1 and Siqueira et al.⁸8. Siqueira FV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, Thumé E, et al . Prevalence of falls in elderly in Brazil: a countrywide analysis. Cad Saúde Pública 2011; 27(9): 1819-26. also found increasing occurrence of falls for elderly widows and widowers, and authors analyze that the fact of living alone, which is more common in this condition, could lead the elderly person to have more tasks that, when associated with functional instability, would produce more situations connected to risks of falls.

The frequency of falls reported as the main accident in the past 12 months significantly increased with the number of reported diseases and health problems. It is known that pains and health problems contribute with functional decline and increasing muscle weakness, associated with mobility limitations, and this may lead these people to be more prone to falls²⁴24. Guralnik JM, Fried LP, Salive ME. Disability as a public health outcome in the aging population. Annu Rev Public Health 1996; 17: 25-46. ^{, 25}25. Pérès K, Verret C, Alioum A, Barberger-Gateau P. The disablement process: factors associated with progression of disability and recovery in French elderly people. Disabil Rehabil 2005; 27(5): 263-76..

Among the analyzed diseases, there was an association with rheumatism/arthritis/arthroses and osteoporosis. A study conducted in Juiz de Fora, Minas Gerais⁹9. Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTB, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saúde Pública 2012; 46(1): 138-46., also showed the association between osteoporosis and falls. Arthritis/arthrosis was also associated with falls in other studies⁵5. Gang L, Sufang J, Ying S. The incidence status on injury of the community-dwelling elderly in Beijing. Chi J Prev Med 2006; 40(1): 37. ^{, 12}12. Bekibele CO, Gureje O. Fall incidence in a population of elderly persons in Nigeria. Gerontology 2010; 56(3): 278-83. ^{, 16}16. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56(3): M146-56.. Joint disorders and osteoporosis contribute with the reduced physical capacity of the elderly, causing pain, influencing balance and postural control, and increasing the risk of falls²⁶26. Barlett G, Abrahamowicz M, Grad R, Sylvestre MP, Tamblyn R. Association between risk factors for injurious falls and new benzodiazepine prescribing in elderly persons. BMC Fam Pract 2009; 10:1..

Hypertension and diabetes are not associated with the occurrence of falls in this study, as observed in the study by Lin et al.¹⁴14. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. PLoS One 2011; 6(4): e18976.. Concerning diabetes, studies conducted in other countries²⁷27. Masud T, Morris RO. Epidemiology of falls. Age Aging 2001; 30(Suppl 4): 3-7. ^{, 28}28. Gregg EW, Beckles GL, Williamson DF, Leveille SG, Langlois JA, Engelgau MM, et al. Diabetes and physical disability among older U.S. adults. Diabetes Care 2000; 23(9): 1272-7. found an association between this disease and falls, and report that the latter can be associated to complications related to diabetes, such as peripheral neuropathy, reduced vision, diabetic foot ulcers and damaged kidney function²⁷27. Masud T, Morris RO. Epidemiology of falls. Age Aging 2001; 30(Suppl 4): 3-7..

Among the health problems, dizziness was mostly associated with the occurrence of falls. Bretan et al.²⁹29. Bretan O, Silva Junior JE, Ribeiro OR, Corrente JE. Risco de queda em idosos da comunidade: avaliação com o teste Timed up and go. Braz J Othorhinolaryngol 2013; 79(1): 18-21. also found an association between dizziness and the occurrence of falls among elderly attending an outpatient clinic in the city of Botucatu, São Paulo, as well as the cohort study by Moraes et al.³⁰30. Moraes SA, Soares WJS, Rodrigues RAS, Fett WCR, Ferriolli E, Perracini MR. Tontura em idosos da comunidade: estudo de base populacional. Braz J Otorhinolaryngol 2011; 77(6): 691-9., conducted with the population of elderly people in Cuiabá, Mato Grosso, in which dizziness was present among 51% of the individuals who reported falls in the past year.

It is important to emphasize that changes related to aging and systems related to body balance, as well as the higher prevalence of chronic degenerative diseases, and the chronic or multiple use of medications, among other factors, may favor the onset of dizziness or increase the intensity of this symptom, thus leading to more physical and functional limitations, and also emotional ones, in this age group, which contributes with the increasing risk of falls³¹31. Gazzola JM, Ganança FF, Aratani MC, Perracini MR, Ganança MM. Caracterização clínica de idosos com disfunção vestibular crônica. Rev Bras Otorrinolaringol 2006; 72(4): 515-22..

Insomnia was also identified as a factor associated with the occurrence of falls, as observed in other studies¹²12. Bekibele CO, Gureje O. Fall incidence in a population of elderly persons in Nigeria. Gerontology 2010; 56(3): 278-83. ^{, 32}32. Pereira AA, Ceolim MF, Neri AL. Associação entre sintomas de insônia, cochilo diurno e quedas em idosos da comunidade. Cad Saúde Pública 2013; 29(3): 535-46.. Insomnia represents the most common complaint related to changes in sleep among the elderly³³33. Stone KL, Ensrud KE, Ancoli-Israel S. Sleep, insomnia and falls in elderly patients. Sleep Med 2008; 9(Suppl 1): S18-22.. From the clinical point of view, these complaints are accompanied by damage in the performance of daytime activities, indicated by at least one of the following symptoms: fatigue or lack of energy, daytime sleepiness, attention, concentration and memory deficit, irritability, hyperactivity and aggression, reduced motivation, declining professional performance and social contacts³⁴34. Vaz Fragoso CA, Gill TM. Sleep complaints in community-living older persons: a multifactorial geriatric syndrome. J Am Geriatr Soc 2007; 55(11): 1853-66. ^{, 35}35. Edinger JD, Bonnet MH, Bootzin RR, Doghramji K, Dorsey CM, Espie CA, et al. Derivation of research diagnostic criteria for insomnia: report of an American Academy of Sleep Medicine Work Group. Sleep 2004; 27(8): 1567-96.. Therefore, the clinical consequences of sleep-related problems among elderly people often result in increasing risk of accidents and traumas³⁶36. Ancoli-Israel S. Sleep and its disorders in aging populations. Sleep Med 2009; 10(Suppl 1): S7-11..

CMD was also associated with the occurrence of falls. It is known that CMD is constituted by a set of psychiatric non-psychotic symptoms, characterized by somatic and depressive symptoms, state of anxiety, irritability, insomnia, fatigue, difficulties related to memory and concentration³⁷37. Goldberg D, Huxley P. Common mental disorders: a biosocial model. London: Tavistock; 1992.. Depression, which is included in the set of CMD symptoms, was studied by Rubenstein and Josephson³⁸38. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002; 18(2): 141-58., who detected 2.2 more chances of falls among elderly with depression in comparison to elderly without depression. An analysis conducted in Sweden proves that stressful events, which awaken negative feelings, can be triggering factors for falls among older people³⁹39. Möller J, Hallqvist J, Laflamme L, Mattsson F, Ponzer S, Sadigh S, et al. Emotional stress as a trigger of falls leading to hip or pelvic fracture. Results from the ToFa study - a case-crossover study among elderly in Stockholm, Sweden. BMC Geriatr 2009; 9: 7..

The association between asthma/bronchitis/emphysema and falls was observed in this study, however, it was not demonstrated in other studies¹1. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saúde Pública 2002; 36(6): 709-16. ^{, 27}27. Masud T, Morris RO. Epidemiology of falls. Age Aging 2001; 30(Suppl 4): 3-7., since this association was not analyzed much⁴⁰40. National Center for Health Statistics. National Health Interview Survey (NHIS). Public use core file layouts. Guidelines. 1989.. Headache was also associated with falls among the elderly, however, no studies were found in literature demonstrating such an association. Studies⁴¹41. Rosa TEC, Benício MHD, Latorre MRDO, Ramos LR. Fatores determinantes da capacidade funcional entre idosos. Rev Saúde Pública 2003; 37(1): 40-8. ^{, 42}42. Dellaroza MSG, Pimenta CAM, Matsuo T. Prevalência e caracterização da dor crônica em idosos não institucionalizados. Cad Saúde Pública 2007; 23(5): 1151-60. report that asthma and headache contribute with more vulnerability and decreasing functional capacity. The use of medications, fewer social experiences and the feeling of discomfort associated with these conditions leads to changes in physical and mental mood for the performance of daily activities, so these aspects contribute with the establishment of a more vulnerable situation.

With regard to medications, it was observed that the higher the number of used medications, the higher the prevalence of falls. Hartikainen et al.⁴³43. Hartikainen S, Lönnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci 2007; 62(10): 1172-81. mention that it is extremely important to investigate each of the drugs used individually or together, since many medications present adverse reactions that may induce to the occurrence of falls.

Rezende et al.⁴⁴44. Rezende CP, Gaede-Carrillo MRG, Sebastião ECO. Queda entre idosos no Brasil e sua relação com o uso de medicamentos: revisão sistemática. Cad Saúde Pública 2012; 28(12): 2223-35., in a systematic review about falls and the use of medications among the elderly, observed that the drugs that are mostly associated with the occurrence of falls are psychoactive ones, due to their sedative effects, postural hypotension, shivers, muscle relaxation and weakness, and also the diuretics, due to fatigue and hydroelectrolytic disorder⁴⁵45. Rozenfeld S. Reações adversas aos medicamentos na terceira idade: as quedas em mulheres como iatrogenia farmacoterapêutica [tese de doutorado]. Rio deJaneiro: Instituto de Medicina Social, Universidade do Estado do Rio de Janeiro;1997..

With regard to the use of gait assistive devices, there was a significant association between the use of a cane/walker and the occurrence of falls, as reported in the study by Rubenstein and Josephson³⁸38. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002; 18(2): 141-58.. However, since this is a cross-sectional study, which ignores the date in which the gait assistive device began to be used, it is not possible to make causal inferences. It is a known fact that with age, individuals tend to walk slower, to reduce the pace and to increase the support base and time of permanence in the double support phase, as a strategy to gain stability⁴⁶46. Menz HB, Lord SR, Fitzpatrick RC. Age-related differences in walking stability. Age Ageing 2003; 32(2): 137-42.. Compromised gait among the elderly can increase the risk of falls⁴⁷47. Cesari M, Onder G, Russo A, Zamboni V, Barrillaro C, Ferrucci L, et al. Comorbidity and physical function: results from the aging and longevity study in the Sirente geographic area (ilSIRENTE study). Gerontology 2006; 52(1): 24-32.. Therefore, the technology assisted by assistive devices enables to promote more functional independence, thus facilitating the performance of daily activities by the elderly. This technology is employed to provide support while a person walks and balances, but it can also contribute to an unsafe mobility, thus increasing the risk of falls in case of project flaws and/or inadequate use⁴⁸48. Menezes RL, Bachion MM. Estudo da presença de fatores de riscos intrínsecos para quedas, em idosos institucionalizados. Ciênc Saúde Colet 2008; 13(4): 1209-18..

The most common place where falls occur was the household of the elderly person (64%), followed by the streets (26%). Studies show that falls happen mostly in the bedroom and in the bathroom⁴⁹49. Costa Neto MM. Atenção à saúde do idoso, instabilidade postural e queda. In: Ministério da Saúde. Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Cadernos de Atenção Básica. Brasília: Ministério da Saúde; 2000. ^{, 30}30. Moraes SA, Soares WJS, Rodrigues RAS, Fett WCR, Ferriolli E, Perracini MR. Tontura em idosos da comunidade: estudo de base populacional. Braz J Otorhinolaryngol 2011; 77(6): 691-9., and that facilitating factors that stand out in the house are rugs, wet floor, changes in the position of furniture, little light and staircases⁷7. Fabrício SCC, Rodrigues RAP, Costa Junior ML. Causas e consequências de quedas de idosos atendidos em hospital público. Rev Saúde Pública 2004; 38(1): 93-9.. Therefore, it is important to assess the household environment and the extrinsic factors that contribute with the occurrence of falls, as well as ways to prevent them, such as the use of non-slippery flooring material, adequate lighting, absence of rugs, support bars, and others⁷7. Fabrício SCC, Rodrigues RAP, Costa Junior ML. Causas e consequências de quedas de idosos atendidos em hospital público. Rev Saúde Pública 2004; 38(1): 93-9. ^{, 10}10. Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saúde Pública 2007; 41(5): 749-56..

Understanding and discussing the results obtained in this study should consider some limitations. One of them is the fact that the used question was not specific for falls, but instead, it was addressed to the occurrence of accidents in general, which included falls. So, we obtained data regarding the main accident, or the main fall that occurred in the past 12 months, which may have underestimated the results.

The collection of data about the fall being reported in the past 12 months may also be considered as a limitation, especially for the elderly, which could result in the sub-report of events.

Another limitation lies on the cross-sectional design, which does not allow to infer on the causality of the association, as observed in relation to the association with a cane or walker and the use of medications. In this study, the past three days were used as reference, including continuous medication or not. It is also possible to consider that this study was based on data from a health survey that included more themes, so it was not specifically addressed to falls; therefore, there are not many details about the event.

By identifying the associated factors, this study indicates the segments of elderly people who are more prone to falls. Widow(ers), older and female elderly people, with joint disorders, asthma, headaches, dizziness and insomnia stand out. The presence of these characteristics and diseases should warn health professionals, caretakers and relatives of the elderly to pay special attention in terms of preventing falls. Using many medications, presenting with CMD and using equipment to gait assistive devices distinguish segments of elderly people into situations that require more care. By identifying these factors that are associated with falls, this study can contribute with the planning of public policies and health programs addressed to preventing falls and reducing their consequences.

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