Falls among older adults in the South of Brazil: prevalence and determinants

Luna S Vieira Ana Paula Gomes Isabel O Bierhals Simone Farías-Antúnez Camila G Ribeiro Vanessa I A Miranda Bárbara H Lutz Thiago G Barbosa-Silva Natália P Lima Andréa D Bertoldi ... About the authors

ABSTRACT

OBJECTIVE

Evaluate the prevalence and the factors associated with the occurrence of falls among older adults.

METHODS

A cross-sectional study with a representative sample of 1,451 elderly residents in the urban area of Pelotas, RS, in 2014. A descriptive analysis of the data was performed and the prevalence of falls in the last year was presented. The analysis of demographic, socioeconomic, behavioral and health factors associated with the outcome was performed using Poisson regression with adjustment for robust variance according to the hierarchical model. The variables were adjusted to each other within each level and for the higher level. Those with p ≤ 0.20 were maintained in the model for confounding control and those with p < 0.05 were considered to be associated with the outcome.

RESULTS

The prevalence of falls among older adults in the last year was 28.1% (95%CI 25.9–30.5), and most occurred in the person’s own residence. Among the older adults who fell, 51.5% (95%CI 46.6–56.4) had a single fall and 12.1% (95%CI 8.9–15.3) had a fracture as a consequence, usually in the lower limbs. The prevalence of falls was higher in women, adults of advanced age, with lower income and schooling level, with functional incapacity for instrumental activities, and patients with diseases such as diabetes, heart disease, and arthritis.

CONCLUSIONS

The occurrence of falls reached almost a third of the older adults, and the prevalence was higher in specific segments of the population in question. About 12% of the older adults who fell fractured some bone. The factors associated with the occurrence of falls identified in this study may guide measures aimed at prevention in the older adult population.

Aged; Accidental Falls; Prevalence; Risk Factors; Cross-Sectional Studies

INTRODUCTION

The rapid aging of the population in low- and middle-income countries results in a significant change in morbidity and mortality due to the increase in the prevalence of chronic non-communicable diseases11. Lee SY, Gallagher D. Assessment methods in human body composition. Curr Opin Clin Nutr Metab Care. 2008;11(5):566-72. https://doi.org/10.1097/MCO.0b013e32830b5f23
https://doi.org/10.1097/MCO.0b013e32830b...
,22. Monteiro CA. Novos e velhos males da saúde no Brasil: a evolução do país e de suas doenças. São Paulo: Hucitec; 1995. (Coleção Saúde em Debate, 91).. In addition to increased comorbidities, the use of different medications, slow gait, and decreased visual acuity and hearing tend to generate a disabling process of the elderly over time11. Lee SY, Gallagher D. Assessment methods in human body composition. Curr Opin Clin Nutr Metab Care. 2008;11(5):566-72. https://doi.org/10.1097/MCO.0b013e32830b5f23
https://doi.org/10.1097/MCO.0b013e32830b...
,33. Hirano ES, Fraga GP, Mantovani M. Trauma no idoso. Medicina (Ribeirao Preto). 2007 [cited 2016 May];40(3):352-7. Available from: http://revista.fmrp.usp.br/2007/vol40n3/6_trauma_no_idoso.pdf
http://revista.fmrp.usp.br/2007/vol40n3/...
. As a consequence of these functional changes, there is an exponential increase in the occurrence of trauma due to external causes, especially falls.

According to the World Health Organization (WHO), a fall is the unintentional movement of the body to a level lower than the initial position, with the inability to correct it in a timely manner44. Bergman RN, Stefanovski D, Buchanan TA, Sumner AE, Reynolds JC, Sebring NG, et al. A better index of body adiposity. Obesity (Silver Spring). 2011;19(5):1083-9. https://doi.org/10.1038/oby.2011.38
https://doi.org/10.1038/oby.2011.38...
. The fall is determined by multifactorial circumstances, in which intrinsic (physiological changes characteristic of aging, presence of morbidities, deficits in balance, vision, hearing or walking) and extrinsic (environmental risks due to poor lighting or slipperiness, risky behaviors, such as climbing chairs or stairs, and those related to daily activities) factors are involved. Most of the time, it results from the interaction between these factors55. Machado AF. Dobras cutâneas: localização e procedimentos. Motricidade. 2008 [cited 2016 May];4:41-5. Available from: http://www.scielo.mec.pt/pdf/mot/v4n2/v4n2a05.pdf
http://www.scielo.mec.pt/pdf/mot/v4n2/v4...
.

About 30% of older adults suffer falls in a one-year period in Brazil, according to the Ministry of Health11. Lee SY, Gallagher D. Assessment methods in human body composition. Curr Opin Clin Nutr Metab Care. 2008;11(5):566-72. https://doi.org/10.1097/MCO.0b013e32830b5f23
https://doi.org/10.1097/MCO.0b013e32830b...
. Although falls are responsible for the increased risk of injury, emotional problems, and death in this population group, and therefore represents a serious public health problem, it does not receive due attention from Brazilian society3,6–8. Thus, evaluating the factors that most often put older adults at risk of falling can provide important information for the planning of public policies that aim to prevent the occurrence of this incident in this population.

The objective of this study was to estimate the prevalence of self-reported falls in older adults (60 years or older) in a medium-sized city in the southern region of Brazil, and to identify their main associated factors.

METHODS

A cross-sectional population-based study in the urban area of Pelotas in 2014, with the objective of understanding the health characteristics of the population aged 60 years and over. The research was conducted by the graduate program in Epidemiology of the Universidade Federal de Pelotas through the research consortium of master’s students99. Barros AJD, Menezes AMB, Santos IS, Assunção MCF, Gigante D, Fassa AG, et al. O Mestrado do Programa de Pós-graduação em Epidemiologia da UFPel baseado em consórcio de pesquisa: uma experiência inovadora. Rev Bras Epidemiol. 2008;11 Supl 1:133-44. http://dx.doi.org/10.1590/S1415-790X2008000500014
http://dx.doi.org/10.1590/S1415-790X2008...
.

The calculation of the sample size for the prevalence study considered a prevalence of falls in older adults of 34.8%1010. Siqueira F, Facchini LA, PiccinX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saude Pubica. 2007;41(5):749-56. https://doi.org/10.1590/S0034-89102007000500009
https://doi.org/10.1590/S0034-8910200700...
, a 95% confidence level, a margin of error of four percentage points, and a design effect of two. With an increase of 10% for losses, the minimum sample size required would be 1,198 older adults. The minimum sample required for the association study was estimated at 1,113 older adults, a result of the association between falls and gender, based on the following parameters: 95% confidence level, 80% power, 40/60 ratio between unexposed and exposed, fall prevalence of 26.5% among unexposed (male gender)1010. Siqueira F, Facchini LA, PiccinX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saude Pubica. 2007;41(5):749-56. https://doi.org/10.1590/S0034-89102007000500009
https://doi.org/10.1590/S0034-8910200700...
, prevalence ratio of 1.5, design effect of two, additional 10% for losses and refusals, and 15% for control of possible confounding factors.

The sampling process was carried out in two stages. Initially, the census tracts were ordered according to the average income of each inhabitant based on the census of the Brazilian Institute of Geography and Statistics (IBGE) of 20101111. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro: IBGE; 2010 [cited 2016 May]. Available from: https://censo2010.ibge.gov.br/resultados.html
https://censo2010.ibge.gov.br/resultados...
. The first stage of the sampling process comprised the random draw of the tracts, which resulted in 133 selected tracts. In the second stage, the selection of approximately 30 households in each tract was made through a systematic draw. At the end of the process, 4,123 households were selected for the survey. Based on a previous estimate of the same census, which found 0.43 older adult/domicile, we expected to find at least 12 older adults people per tract, which would result in a sample of approximately 1,700 older adults (all the older adults of the household were included in the study). This number was considered adequate for the outcome, since, according to the sample calculation, a minimum sample of 1,198 older adults would be necessary.

The data collection was performed from January to August 2014 in the household of the older adult, by trained interviewers, through a questionnaire previously tested and built in a digital format, which was applied with the help of netbooks.

The outcome was the prevalence of falls in the older adult in the last year, investigated by the following question: “Have you fallen down from <month in the previous year> to today?”. Older adults who reported an affirmative answer had their past-year history of falls investigated by two additional questions about the number of falls that occurred and whether a limb fractured because of the fall.

Demographic characteristics examined as independent variables: gender (female or male), age (categorized as 60–69, 70–79 and 80 years old or more) and marital status (with partner or without partner). The socioeconomic characteristics were classified according to an instrument of the Brazilian Association of Research Companies (ABEP)1111. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro: IBGE; 2010 [cited 2016 May]. Available from: https://censo2010.ibge.gov.br/resultados.html
https://censo2010.ibge.gov.br/resultados...
and categorized into classes A/B, C, D/E), schooling level in complete years of study (none, 1 to 3, 4 to 7, 8 to 10, 12 or more), currently employed (no or yes). Regarding health variables, the following morbidities were studied: systemic arterial hypertension, diabetes, heart disease, arthritis, osteoporosis, Parkinson’s disease, nephropathy, glaucoma, and emphysema. We also investigated the occurrence of stroke at some point in life. Considering the presence of these diseases, a morbidity score was created, categorized as “none”, “1”, “2” or “≥ 3” morbidities.

The presence of sarcopenia was assessed according to the criteria proposed by the European Working Group on Sarcopenia in Older People1212. Cruz-Jentoft A, Baeyens J, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39(4):412-23. https://doi.org/10.1093/ageing/afq034
https://doi.org/10.1093/ageing/afq034...
. The loss of muscle mass was determined by measuring with an inextensible tape (Cescorf, Brazil) the circumference of the calves of the older adult, based on cut-off points established in the population studied (≤ 34 cm for men and ≤ 33 cm for women were indicative loss of muscle mass)1313. Barbosa-Silva TG, Bielemann RM, Gonzalez MC, Menezes AMB. Prevalence of sarcopenia among community-dwelling elderly of a medium-sized South American city: results of the COMO VAI? study. J Cachexia Sarcopenia Muscle. 2016;7(2):136-43. https://doi.org/10.1002/jcsm.12049
https://doi.org/10.1002/jcsm.12049...
. Muscle strength was estimated based on hand grip strength, evaluated by digital manual dynamometry (Jamar Digital Plus + Hand Dynamometer and Simmons Preston, Canada). Cut-off points for loss of strength were < 30 kg for men and < 20 kg for women1414. Lauretani F, Russo CR, Bandinelli S, Bartali B, Cavazzini C, Di Iorio A, et al. Age-associated changes in skeletal muscles and their effect on mobility: an operational diagnosis of sarcopenia. J Appl Physiol (1985). 2003;95(5):1851-60. https://doi.org/10.1152/japplphysiol.00246.2003
https://doi.org/10.1152/japplphysiol.002...
. Finally, the muscular performance was evaluated by the 4 meter gait speed test, considering as “loss” a path velocity < 0.8 m/s1414. Lauretani F, Russo CR, Bandinelli S, Bartali B, Cavazzini C, Di Iorio A, et al. Age-associated changes in skeletal muscles and their effect on mobility: an operational diagnosis of sarcopenia. J Appl Physiol (1985). 2003;95(5):1851-60. https://doi.org/10.1152/japplphysiol.00246.2003
https://doi.org/10.1152/japplphysiol.002...
. The combination of these tests allowed the categorization of individuals into sarcopenic (presence of loss of muscle mass associated with loss of muscle strength or performance) or non-sarcopenic. The detailed methodology of collecting the above data can be verified in a previous article originating from the same study1313. Barbosa-Silva TG, Bielemann RM, Gonzalez MC, Menezes AMB. Prevalence of sarcopenia among community-dwelling elderly of a medium-sized South American city: results of the COMO VAI? study. J Cachexia Sarcopenia Muscle. 2016;7(2):136-43. https://doi.org/10.1002/jcsm.12049
https://doi.org/10.1002/jcsm.12049...
.

The use of medication was evaluated in the 15 days prior to the interview. To better qualify the information, respondents were asked to show the packaging or prescription of the medicines used. We carried out a classification by pharmacological groups according to the ATC classification (Anatomical Therapeutic Chemical Classification System) recommended by WHO1515. Hughes VA, Frontera WR, Roubenoff R, Evans WJ, Singh MA. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am J Clin Nutr. 2002 [cited 2016 May];76(2):473-81. Available from: http://ajcn.nutrition.org/content/76/2/473.full.pdf+html
http://ajcn.nutrition.org/content/76/2/4...
. Among the drugs, we classified those potentially related to the occurrence of falls among the elderly: psychoanalytics, psycholeptics, antiepileptics, calcium channel blockers, diuretics, muscle relaxants and, among the medications used for cardiac therapy, digoxin.

Functional ability was assessed from basic activities (eating, bathing, dressing, using the toilet, lying down and getting up from the bed or chair, and controlling the functions of urinating or evacuating) using the Katz index1616. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. the Index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914-9. https://doi.org/10.1001/jama.1963.03060120024016
https://doi.org/10.1001/jama.1963.030601...
and instrumental activities (using the telephone, going to distant places using transportation, shopping, tidying up, washing clothes, preparing meals, taking medication, and taking care of money) measured by the Lawton scale1717. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-86.. For both instruments, the participants were classified as independent (did not need help to perform any activity) or dependent (they needed partial or total help to perform at least one activity).

Regarding the behavioral characteristics, self-reported alcohol dependence (measured by the CAGE method)1818. Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of new alcoholism screening instrument. Am J Psychiatry. 1974;131(10):1121-3. was evaluated positive for the person’s perception of their dependence on alcoholic beverages (up to one positive answer = negative; two or more positive answers = positive) and the level of physical activity, measured by the International Physical Activity Questionnaire (IPAQ)1919. Matsudo S, Araújo T, Marsudo V, Andrade D, Andrade E, Oliveira LC, et al. Questinário Internacional de Atividade Física (IPAQ): estudo de validade e reprodutibilidade no Brasil. Rev Bras Ativ Fis Saude. 2001 [cited 2016 May];6(2):5-18. Available from: https://periodicos.ufpel.edu.br/ojs2/index.php/RBAFS/article/view/931/1222
https://periodicos.ufpel.edu.br/ojs2/ind...
, classified as active those who reported practicing ≥ 150 weekly minutes of physical activities in leisure and travel.

The gross and adjusted prevalence ratios were obtained by means of Poisson regression, with robust adjustment for the variance, with the calculation of the p-value for heterogeneity or linear trend for ordinal variables. The adjusted analysis was performed respecting the hierarchical levels: in the first, the demographic, socioeconomic and occupational variables (sex, age, marital status, education, economy class, work situation) were added; in the second, the behavioral and health-related variables (physical activity level, self-reported alcohol dependence, sarcopenia and morbidity score) were added; in the third level, we added the drugs that could potentially cause falls and in the fourth and last level we added the variables of disabilities. The variables were adjusted to each other within each level and for the higher level. Those with p ≤ 0.20 were maintained in the model for confounding control and those with p < 0.05 were considered to be associated with the outcome. Due to the complex design, the analyses were weighted considering the census tract (cluster). For the Poisson regression analysis, the svy command was used to correct for complex sampling.

The analyses were conducted in the Stata 12.1® program.

The research was approved by the Research Ethics Committee of the Faculdade de Medicina of the Universidade Federal de Pelotas (Protocol 472.357/2013). The study participants signed the free and informed consent form.

RESULTS

We identified 1,844 eligible older adults and, after successive contact attempts, 393 losses and refusals were recorded (21.3%). Of the set of 1,451 elderly interviewed, 1,448 presented complete information on the evaluated outcome, constituting the final sample of this study.

The majority of the older adults were female (63.0%) and about 50.0% were between 60 and 69 years old. Approximately 53.0% of the interviewees reported having a partner and 56.8% were of economy class C. Regarding education, 31.0% had four to seven years of schooling and 80.4% were not employed in the interview period. The prevalence of three or more morbidities was 38.0% and sarcopenia approximately 14.0%. Only 1.0% of the elderly had alcohol dependence, about 60.0% were insufficiently active in leisure and travel. Almost 70.0% of the elderly were using some medication that could cause falls, and about 35.0% were dependent for basic and instrumental activities of daily living (Table 1).

Table 1
Description of the sample according to demographic, socioeconomic, behavioral and health variables. Pelotas, state of Rio Grande do Sul, 2014. (n = 1.448)

The prevalence of falls in the last year was 28.1% (95%CI 25.9–30.5). Regarding the number of falls, 51.5% (95%CI 46.6–56.4) of the older adults suffered a single fall, 25.2% (95%CI 21.0–29.5) fell twice and 23.3% (95%CI 19.1–27.4) fell three or more times in the last year (data not shown in the table). Most of the participants who fell had fallen at home (56.4%) or in the street (46.6%) (Table 2). As a consequence of the fall, 12.1% (CI95% 8.9–15.3) reported having fractured some bone (data not shown), and the most affected sites were the lower limbs (4.9%) and the upper limbs (3.9%).

Table 2
Description of the location of the falls and occurrence of fractures among older adults living in Pelotas, state of Rio Grande do Sul, 2014.

Self-reported alcohol dependence and drug use were not significantly associated with the outcome in the gross analysis. In the adjusted analysis, the occurrence of falls among older adults was associated with gender, age, economic class, schooling, current work, morbidity and functional capacity by the Lawton scale. The women presented a prevalence of falls almost 1.5 times greater when compared to the men. Regarding age, a linear trend was observed, and the highest prevalence of falls was among those aged 80 years or older (PR = 1.27, 95%CI 0.97–1.66), when compared with those aged 60 to 69 years old. Older adults in the C and D/E classes had a higher prevalence of falls when compared to those in the A/B economic class, with a linear trend. For schooling, a linear trend was also observed, and older adults with no schooling presented a 47.0% greater prevalence of falls when compared to those with a high schooling level. The prevalence of falls was 50.0% lower among older adults with a chronic disease when compared to those without chronic disease. However, protection decreased with increasing numbers of chronic diseases. Older adults who were not employed had 30.0% greater prevalence of falls compared to those who were working. Older adults who were dependent for instrumental activities of daily living (Lawton) also had a higher prevalence of falls compared to independent participants (PR = 1.38, 95%CI 1.10–1.73) (Table 3).

Table 3
Factors associated with the occurrence of falls by the elderly. Pelotas, state of Rio Grande do Sul, 2014. (n = 1,448)

Diabetes, heart disease, stroke, arthritis, osteoporosis and Parkinson’s disease were associated with the occurrence of the outcome in the gross analysis. Associations with osteoporosis, sarcopenia and Parkinson’s disease lost statistical significance in the adjusted analysis. The prevalence of falls was higher among older adults with diabetes (PR = 1.24, 95%CI 1.03–1.50), heart problem (PR = 1.24, 95%CI 1.02–1.51), who had a stroke (PR = 1.44, 95%CI 1.14–1.81) and had arthritis (PR = 1.25, 95%CI 1.06–1.48), when compared to those without these diseases (Table 4).

Table 4
Main health problems related to the occurrence of falls by the elderly. Pelotas, state of Rio Grande do Sul, 2014. (n = 1,448)

DISCUSSION

One in three older adults suffered at least one fall in the last year and 12.0% of them fractured some bone as a result of that fall. The injury occurred mainly in their own residence. The prevalence of falls was higher in women, individuals of more advanced age, lower educational level and economic class, who were not employed and who presented functional incapacity for instrumental activities. The prevalence of falls was also higher in patients with diabetes, heart disease, arthritis and those who reported having had a stroke.

The prevalence of falls in the last year found in this study (28.1%) is similar to that found in other Brazilian studies, whose prevalence ranges from 28% to 37.5%10,20–22, as well as those found in studies conducted in countries in Latin America and the Caribbean, where prevalence ranged from 21.0% to 34.0%2323. McCarthy HD, Cole TJ, Fry T, Jebb SA, Prentice AM. Body fat reference curves for children. Int J Obes (Lond). 2006;30(4):598-602. https://doi.org/10.1038/sj.ijo.0803232
https://doi.org/10.1038/sj.ijo.0803232...
,2424. Laurson KR, Eisenmann JC, Welk GJ. Body fat percentile curves for U.S. children and adolescents. Am J Prev Med. 2011;41(4 Suppl 2):S87-92. https://doi.org/10.1016/j.amepre.2011.06.044
https://doi.org/10.1016/j.amepre.2011.06...
. Differences in prevalence among studies should be interpreted with caution, since they may be due to the delineation of studies and the methodologies adopted or because they are point estimates that have error margins2525. Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTBT, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saude Publica. 2012;46(1):138-46. https://doi.org/10.1590/S0034-89102011005000087
https://doi.org/10.1590/S0034-8910201100...
.

As in other studies, the majority of the sample was female10,25–29, which can be explained by the fact that women live longer than men3030. Instituto Brasileiro de Geografia e Estatística. Tábuas completas de mortalidade para o Brasil – 2015: breve análise de evolução da mortalidade no Brasil. Rio de Janeiro: IBGE; 2015 [cited 2016 May]. Available from: http://ftp.ibge.gov.br/Tabuas_Completas_de_Mortalidade/Tabuas_Completas_de_Mortalidade_2015/tabua_de_mortalidade_analise.pdf2015
http://ftp.ibge.gov.br/Tabuas_Completas_...
. In addition, the prevalence of falls in this and other studies was higher among women10,25–29, but the mechanisms underlying this association are still unclear. Some factors pointed out by other authors concern the difference in the body composition of the women when compared to the men. Women have lean mass and muscle strength in smaller amounts and greater loss of bone mass due to the reduction of estrogen levels. This increases the likelihood of osteoporosis in this group2525. Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTBT, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saude Publica. 2012;46(1):138-46. https://doi.org/10.1590/S0034-89102011005000087
https://doi.org/10.1590/S0034-8910201100...
,2929. Rezende CP, Gaede-Carrillo MRG, Sebastião ECO. Queda entre idosos no Brasil e sua relação com o uso de medicamentos: revisão sistemática. Cad Saude Publica. 2012;28(12):2223-35. https://doi.org/10.1590/S0102-311X2012001400002
https://doi.org/10.1590/S0102-311X201200...
,3131. Foldvari M, Clark M, Laviolette L, 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. https://doi.org/10.1093/gerona/55.4.M192
https://doi.org/10.1093/gerona/55.4.M192...
and, consequently, the risk of falls.

Age was positively associated with the outcome, which confirms findings in the national and international literature10,25,32–34. This relationship occurs because the biological aging process involves structural and functional changes, such as decreased muscle strength and elasticity, impairment of joint stability and dynamics, and changes in the sensory and nervous system. Such changes compromise postural control and are capable of altering gait and balance, culminating, consequently, in an elevated risk of this outcome2828. Toledo DR, Barela JA. Diferenças sensoriais e motoras entre jovens e idosos: contribuição somatossensorial no controle postural. Rev Bras Fisioter. 2010;14(3):267-75. https://doi.org/10.1590/S1413-35552010000300004
https://doi.org/10.1590/S1413-3555201000...
,3535. Abreu SSE, Caldas CP. Velocidade de marcha, equilíbrio e idade: um estudo correlacional entre idosas praticantes e idosas não praticantes de um programa de exercícios terapêuticos. Rev Bras Fisioter. 2008;12(4):324-30. https://doi.org/10.1590/S1413-35552008000400012
https://doi.org/10.1590/S1413-3555200800...
.

Economic class and schooling were inversely associated with the risk of falls, an association also found in other studies1010. Siqueira F, Facchini LA, PiccinX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saude Pubica. 2007;41(5):749-56. https://doi.org/10.1590/S0034-89102007000500009
https://doi.org/10.1590/S0034-8910200700...
,3636. Gill T, Taylor A, Pengelly A. A population-based survey of factors relating to the prevalence of falls in older people. Gerontology. 2005;51(5):340-5. https://doi.org/10.1159/000086372
https://doi.org/10.1159/000086372...
. A possible explanation for this association would be the greater difficulty of individuals with low socioeconomic status to access health services and consequently prevent factors that could lead to falls3636. Gill T, Taylor A, Pengelly A. A population-based survey of factors relating to the prevalence of falls in older people. Gerontology. 2005;51(5):340-5. https://doi.org/10.1159/000086372
https://doi.org/10.1159/000086372...
.

The prevalence of falls was higher in unemployed older adults. The literature shows an inverse association between income and risk of falls6,36–38. It is likely that employed older adults will have a better financial situation, as well as being healthier, as they are fit for work and therefore less likely to fall66. World Health Organization. WHO global report on falls prevention in older age. Geneva; 2007 [cited 2016 May]. Available from: http://www.who.int/ageing/publications/Falls_prevention7March.pdf
http://www.who.int/ageing/publications/F...
.

Physical activity is indicated for the prevention of falls among older adults, since certain activities, such as those involving strength and balance, promote increased muscle and bone strength, coordination, walking speed, functional ability and quality of life3939. Stevens JA, Burns E. A CDC compendium of effective fall Interventions: what works for community-dwelling older adults. 3.ed. Atlanta: National Center for Injury Prevention and Control; 2015 [cited 2016 May]. Available from: http://www.cdc.gov/homeandrecreationalsafety/falls/compendium.html
http://www.cdc.gov/homeandrecreationalsa...
. However, the present study did not observe an independent association, perhaps because it did not distinguish the types of activity performed by the participants, presenting only whether they were active or not.

Likewise, there was no statistically significant association between falls and sarcopenia after adjustment for several factors, including gender. Baumgartner, in 1998, when stratifying the occurrence of falls by gender, found an increased risk for falls among sarcopenic older adults, but this association was also not statistically significant for females4040. Baumgartner RN, Koehler KM, Gallagher D, Romero L, Heymsfield SB, Ross RR, et al. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol. 1998;147(8):755-63. https://doi.org/10.1093/oxfordjournals.aje.a009520
https://doi.org/10.1093/oxfordjournals.a...
. Nevertheless, even when the analysis was stratified by gender, no association was found between sarcopenia and occurrence of falls (data not shown in the table). Muscular weakness is cited as one of the risk factors for falls in a guideline drawn up by different medical societies4141. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49(5):664-72. https://doi.org/10.1046/j.1532-5415.2001.49115.x
https://doi.org/10.1046/j.1532-5415.2001...
and corroborated by Sayer in an analysis of the Hertfordshire cohort4242. Sayer AA, Syddall HE, Martin HJ, Dennison EM, Anderson FH, Cooper C. Falls, sarcopenia, and growth in early life: findings from the Hertfordshire cohort study. Am J Epidemiol. 2006;164(7):665-71. https://doi.org/10.1093/aje/kwj255
https://doi.org/10.1093/aje/kwj255...
. However, muscle weakness is not a necessary or sufficient criterion for sarcopenia – only a collaborator. Perhaps the combination with the other diagnostic factors for the syndrome (loss of muscle mass and muscular performance) influences this association to the point of taking away the statistical significance. Therefore, although theoretically the association between falls and sarcopenia was plausible, it was not verified in this study.

The occurrence of falls was associated with functional capacity, assessed through instrumental activities (Lawton scale), while the association was not observed for basic activities (Katz scale). This result may be due to the fact that basic activities are more closely related to personal care and instrumental activities assess the ability of the older adults to perform activities to manage their life and home independently. Some of these activities involve getting around (using transportation, shopping, tidying up, washing clothes), and failure to perform them efficiently can increase the risk of falls. Perracini et al. report that older adults with difficulty to perform between one and three activities of daily living have 2.37 times more chance of suffering falls2727. Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saude Publica. 2002;36(6):709-16. https://doi.org/10.1590/S0034-89102002000700008
https://doi.org/10.1590/S0034-8910200200...
. However, the relationship between falls and functional disability is subject to reverse causality bias. Falls among older adults can result in functional disability, either due to the occurrence of fractures that make it impossible to perform the activities or the fear of suffering a new fall4343. Legters K. Fear of falling. Phys Ther. 2002;82(3):264-72. https://doi.org/10.1093/ptj/82.3.264
https://doi.org/10.1093/ptj/82.3.264...
. Older adults, with functional limitations that hamper daily activities, which may occur due to lack of balance or motor coordination, are at increased risk of falls.

Elderly people with arthritis, depressive symptoms, orthostatic hypotension, and cognitive, visual, balance, gait, or muscular strength deficits are at increased risk for falls4444. Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med. 2003;348(1):42-9. https://doi.org/10.1056/NEJMcp020719
https://doi.org/10.1056/NEJMcp020719...
,4545. Durso S, Bowker L, Price J, Smith S. Oxford American Handbook of Geriatric Medicine. New York: Oxford University Press; 2010.. As for diabetes, this relationship is well established in several studies4646. Schwartz AV, Vittinghoff E, Sellmeyer DE, Feingold KR, Rekeneire N, Strotmeyer ES, et al. Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care. 2008;31(3):391-6. https://doi.org/10.2337/dc07-1152
https://doi.org/10.2337/dc07-1152...
,4747. Menezes RL, Bachion MM. Estudo da presença de fatores de riscos intrínsecos para quedas, em idosos institucionalizados. Cienc Saude Coletiva. 2008;13(4):1209-18. https://doi.org/10.1590/S1413-81232008000400017
https://doi.org/10.1590/S1413-8123200800...
, with complications due to peripheral neuropathy, reduced vision and decreased renal function as the main causes. Balance, strength, and gait issues are likely intermediate factors in any association between diabetes complications and increased risk of falls4646. Schwartz AV, Vittinghoff E, Sellmeyer DE, Feingold KR, Rekeneire N, Strotmeyer ES, et al. Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care. 2008;31(3):391-6. https://doi.org/10.2337/dc07-1152
https://doi.org/10.2337/dc07-1152...
. Strokes may lead to hemiplegia or paresis of the lower limbs, affecting the gait of the individual, who assumes an unstable erect position with an impaired support base. As a consequence, visual dysfunction and spatial-visual injury may also occur, thus influencing the older adult’s balance and mobility4747. Menezes RL, Bachion MM. Estudo da presença de fatores de riscos intrínsecos para quedas, em idosos institucionalizados. Cienc Saude Coletiva. 2008;13(4):1209-18. https://doi.org/10.1590/S1413-81232008000400017
https://doi.org/10.1590/S1413-8123200800...
. In relation to heart problems, certain arrhythmias, such as atrioventricular blocks, sinus node changes and bradycardia may also cause falls4848. Chaimowicz F. Rede de atenção: saúde do idoso. 2.ed. Belo Horizonte: Nescon UFMG; 2013. https://www.nescon.medicina.ufmg.br/biblioteca/imagem/3836.pdf
https://www.nescon.medicina.ufmg.br/bibl...
. In addition, the fall may be the first sign of an acute asymptomatic myocardial infarction4949. Ferreira DCO, Yoshitome AY. Prevalência e caraterísticas das quedas de idosos institucionalizados. Rev Bras Enferm. 2010;63(6):991-7. https://doi.org/10.1590/S0034-71672010000600019
https://doi.org/10.1590/S0034-7167201000...
.

Regarding the use of medication considered to potentially cause falls, this study found no association, although several studies have demonstrated the plausibility of this relationship50–53. However, in this study, only drugs that could potentially cause falls were evaluated, whereas in studies that show an association, any type of medication is considered, which could explain in part the divergence in the results.

This study has limitations. The prevalence of falls found may be underestimated, because, due to survival bias, older adults who suffered falls and who had more serious health complications caused by the fall may already have died. The memory bias is also not discarded, considering the study population. However, hopefully this was not such a big problem since factors such as the occurrence of falls tend to be strongly recalled because of the impact they usually have on health. As strengths of the study, it is worth mentioning the quality of the sample method, which allowed the analysis of a representative sample of older adults from the urban area of Pelotas. In addition, quality control was performed in the various stages of the study, such as interviewer training, instrument testing, data quality control, and ensuring greater credibility of the analyzed data. The study was also able to evaluate a series of factors that, according to previous literature, could be related to the occurrence of falls, allowing us to draw a profile of characteristics predisposing to the occurrence of this injury.

The high prevalence of falls among older adults makes it clear that steps should be taken to prevent them. Prevention strategies should be focused on vulnerable groups, i.e. at higher risk for falls, such as older people with low socioeconomic status who are not working and are dependent for functional capacity.

REFERENCES

  • 1
    Lee SY, Gallagher D. Assessment methods in human body composition. Curr Opin Clin Nutr Metab Care 2008;11(5):566-72. https://doi.org/10.1097/MCO.0b013e32830b5f23
    » https://doi.org/10.1097/MCO.0b013e32830b5f23
  • 2
    Monteiro CA. Novos e velhos males da saúde no Brasil: a evolução do país e de suas doenças. São Paulo: Hucitec; 1995. (Coleção Saúde em Debate, 91).
  • 3
    Hirano ES, Fraga GP, Mantovani M. Trauma no idoso. Medicina (Ribeirao Preto). 2007 [cited 2016 May];40(3):352-7. Available from: http://revista.fmrp.usp.br/2007/vol40n3/6_trauma_no_idoso.pdf
    » http://revista.fmrp.usp.br/2007/vol40n3/6_trauma_no_idoso.pdf
  • 4
    Bergman RN, Stefanovski D, Buchanan TA, Sumner AE, Reynolds JC, Sebring NG, et al. A better index of body adiposity. Obesity (Silver Spring) 2011;19(5):1083-9. https://doi.org/10.1038/oby.2011.38
    » https://doi.org/10.1038/oby.2011.38
  • 5
    Machado AF. Dobras cutâneas: localização e procedimentos. Motricidade 2008 [cited 2016 May];4:41-5. Available from: http://www.scielo.mec.pt/pdf/mot/v4n2/v4n2a05.pdf
    » http://www.scielo.mec.pt/pdf/mot/v4n2/v4n2a05.pdf
  • 6
    World Health Organization. WHO global report on falls prevention in older age. Geneva; 2007 [cited 2016 May]. Available from: http://www.who.int/ageing/publications/Falls_prevention7March.pdf
    » http://www.who.int/ageing/publications/Falls_prevention7March.pdf
  • 7
    Edelberg H. Falls and function. How to prevent falls and injuries in patients with impaired mobility. Geriatrics 2001;56(3):41-5; quiz 9.
  • 8
    Maciel A. Quedas em idosos: um problema de saúde pública desconhecido pela comunidade e negligenciado por muitos profissionais da saúde e por autoridades sanitárias brasileiras. Rev Med Minas Gerais 2010 [cited 2016 May];20(4):554-7. Available from: http://rmmg.org/artigo/detalhes/336
    » http://rmmg.org/artigo/detalhes/336
  • 9
    Barros AJD, Menezes AMB, Santos IS, Assunção MCF, Gigante D, Fassa AG, et al. O Mestrado do Programa de Pós-graduação em Epidemiologia da UFPel baseado em consórcio de pesquisa: uma experiência inovadora. Rev Bras Epidemiol 2008;11 Supl 1:133-44. http://dx.doi.org/10.1590/S1415-790X2008000500014
    » http://dx.doi.org/10.1590/S1415-790X2008000500014
  • 10
    Siqueira F, Facchini LA, PiccinX, Tomasi E, Thumé E, Silveira DS, et al. Prevalência de quedas em idosos e fatores associados. Rev Saude Pubica 2007;41(5):749-56. https://doi.org/10.1590/S0034-89102007000500009
    » https://doi.org/10.1590/S0034-89102007000500009
  • 11
    Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Rio de Janeiro: IBGE; 2010 [cited 2016 May]. Available from: https://censo2010.ibge.gov.br/resultados.html
    » https://censo2010.ibge.gov.br/resultados.html
  • 12
    Cruz-Jentoft A, Baeyens J, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010;39(4):412-23. https://doi.org/10.1093/ageing/afq034
    » https://doi.org/10.1093/ageing/afq034
  • 13
    Barbosa-Silva TG, Bielemann RM, Gonzalez MC, Menezes AMB. Prevalence of sarcopenia among community-dwelling elderly of a medium-sized South American city: results of the COMO VAI? study. J Cachexia Sarcopenia Muscle 2016;7(2):136-43. https://doi.org/10.1002/jcsm.12049
    » https://doi.org/10.1002/jcsm.12049
  • 14
    Lauretani F, Russo CR, Bandinelli S, Bartali B, Cavazzini C, Di Iorio A, et al. Age-associated changes in skeletal muscles and their effect on mobility: an operational diagnosis of sarcopenia. J Appl Physiol (1985) 2003;95(5):1851-60. https://doi.org/10.1152/japplphysiol.00246.2003
    » https://doi.org/10.1152/japplphysiol.00246.2003
  • 15
    Hughes VA, Frontera WR, Roubenoff R, Evans WJ, Singh MA. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am J Clin Nutr 2002 [cited 2016 May];76(2):473-81. Available from: http://ajcn.nutrition.org/content/76/2/473.full.pdf+html
    » http://ajcn.nutrition.org/content/76/2/473.full.pdf+html
  • 16
    Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. the Index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963;185:914-9. https://doi.org/10.1001/jama.1963.03060120024016
    » https://doi.org/10.1001/jama.1963.03060120024016
  • 17
    Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 1969;9(3):179-86.
  • 18
    Mayfield D, McLeod G, Hall P. The CAGE questionnaire: validation of new alcoholism screening instrument. Am J Psychiatry 1974;131(10):1121-3.
  • 19
    Matsudo S, Araújo T, Marsudo V, Andrade D, Andrade E, Oliveira LC, et al. Questinário Internacional de Atividade Física (IPAQ): estudo de validade e reprodutibilidade no Brasil. Rev Bras Ativ Fis Saude 2001 [cited 2016 May];6(2):5-18. Available from: https://periodicos.ufpel.edu.br/ojs2/index.php/RBAFS/article/view/931/1222
    » https://periodicos.ufpel.edu.br/ojs2/index.php/RBAFS/article/view/931/1222
  • 20
    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. https://doi.org/10.1590/S1809-98232010000100009
    » https://doi.org/10.1590/S1809-98232010000100009
  • 21
    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 Saude Publica 2011;27(9):1819-26. https://doi.org/10.1590/S0102-311X2011000900015
    » https://doi.org/10.1590/S0102-311X2011000900015
  • 22
    Soares WJS, Moraes SA, Ferriolli E, Perracini MR. Fatores associados a quedas e quedas recorrentes em idosos: estudo de base populacional. Rev Bras Geriatr Gerontol 2014;17(1):49-60. https://doi.org/10.1590/S1809-98232014000100006
    » https://doi.org/10.1590/S1809-98232014000100006
  • 23
    McCarthy HD, Cole TJ, Fry T, Jebb SA, Prentice AM. Body fat reference curves for children. Int J Obes (Lond) 2006;30(4):598-602. https://doi.org/10.1038/sj.ijo.0803232
    » https://doi.org/10.1038/sj.ijo.0803232
  • 24
    Laurson KR, Eisenmann JC, Welk GJ. Body fat percentile curves for U.S. children and adolescents. Am J Prev Med 2011;41(4 Suppl 2):S87-92. https://doi.org/10.1016/j.amepre.2011.06.044
    » https://doi.org/10.1016/j.amepre.2011.06.044
  • 25
    Cruz DT, Ribeiro LC, Vieira MT, Teixeira MTBT, Bastos RR, Leite ICG. Prevalência de quedas e fatores associados em idosos. Rev Saude Publica 2012;46(1):138-46. https://doi.org/10.1590/S0034-89102011005000087
    » https://doi.org/10.1590/S0034-89102011005000087
  • 26
    Fabrício SCC, Rodrigues RAP Costa Junior ML. Causas e conseqüências de quedas de idosos atendidos em hospital público. Rev Saude Publica 2004;38(1):93-9. https://doi.org/10.1590/S0034-89102004000100013
    » https://doi.org/10.1590/S0034-89102004000100013
  • 27
    Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de idosos residentes na comunidade. Rev Saude Publica 2002;36(6):709-16. https://doi.org/10.1590/S0034-89102002000700008
    » https://doi.org/10.1590/S0034-89102002000700008
  • 28
    Toledo DR, Barela JA. Diferenças sensoriais e motoras entre jovens e idosos: contribuição somatossensorial no controle postural. Rev Bras Fisioter. 2010;14(3):267-75. https://doi.org/10.1590/S1413-35552010000300004
    » https://doi.org/10.1590/S1413-35552010000300004
  • 29
    Rezende CP, Gaede-Carrillo MRG, Sebastião ECO. Queda entre idosos no Brasil e sua relação com o uso de medicamentos: revisão sistemática. Cad Saude Publica 2012;28(12):2223-35. https://doi.org/10.1590/S0102-311X2012001400002
    » https://doi.org/10.1590/S0102-311X2012001400002
  • 30
    Instituto Brasileiro de Geografia e Estatística. Tábuas completas de mortalidade para o Brasil – 2015: breve análise de evolução da mortalidade no Brasil. Rio de Janeiro: IBGE; 2015 [cited 2016 May]. Available from: http://ftp.ibge.gov.br/Tabuas_Completas_de_Mortalidade/Tabuas_Completas_de_Mortalidade_2015/tabua_de_mortalidade_analise.pdf2015
    » http://ftp.ibge.gov.br/Tabuas_Completas_de_Mortalidade/Tabuas_Completas_de_Mortalidade_2015/tabua_de_mortalidade_analise.pdf2015
  • 31
    Foldvari M, Clark M, Laviolette L, 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. https://doi.org/10.1093/gerona/55.4.M192
    » https://doi.org/10.1093/gerona/55.4.M192
  • 32
    Bueno-Cavanillas A, Padilla-Ruiz F, Jiménez-Moleón JJ, Peinado-Alonso CA, Gálvez-Vargas R. Risk factors in falls among the elderly according to extrinsic and intrinsic precipitating causes. Eur J Epidemiol 2000;16(9):849-59. https://doi.org/10.1023/A:1007636531965
    » https://doi.org/10.1023/A:1007636531965
  • 33
    Lord SR, Menz HB, Sherrington C. Home environment risk factors for falls in older people and the efficacy of home modifications. Age Ageing 2006;35 Suppl 2:ii55-ii59. https://doi.org/10.1093/ageing/afl088
    » https://doi.org/10.1093/ageing/afl088
  • 34
    Gama ZAS, Gómez-Conesa A. Factores de riesgo de caídas en ancianos: revisión sistemática. Rev Saude Publica 2008;42(5):946-56. https://doi.org/10.1590/S0034-89102008000500022
    » https://doi.org/10.1590/S0034-89102008000500022
  • 35
    Abreu SSE, Caldas CP. Velocidade de marcha, equilíbrio e idade: um estudo correlacional entre idosas praticantes e idosas não praticantes de um programa de exercícios terapêuticos. Rev Bras Fisioter 2008;12(4):324-30. https://doi.org/10.1590/S1413-35552008000400012
    » https://doi.org/10.1590/S1413-35552008000400012
  • 36
    Gill T, Taylor A, Pengelly A. A population-based survey of factors relating to the prevalence of falls in older people. Gerontology 2005;51(5):340-5. https://doi.org/10.1159/000086372
    » https://doi.org/10.1159/000086372
  • 37
    Trujillo A, Puvanachandra P, Hyder AA. Individual income and falls among the elderly in Latin America. Geriatr Gerontol Int 2011;11(2):180-90. https://doi.org/10.1111/j.1447-0594.2010.00662.x
    » https://doi.org/10.1111/j.1447-0594.2010.00662.x
  • 38
    World Health Organization. Falls. Geneva: WHO; 2012 [cited 2016 May]. (Fact sheet, 344). Available from: http://www.who.int/mediacentre/factsheets/fs344/en
    » http://www.who.int/mediacentre/factsheets/fs344/en
  • 39
    Stevens JA, Burns E. A CDC compendium of effective fall Interventions: what works for community-dwelling older adults. 3.ed. Atlanta: National Center for Injury Prevention and Control; 2015 [cited 2016 May]. Available from: http://www.cdc.gov/homeandrecreationalsafety/falls/compendium.html
    » http://www.cdc.gov/homeandrecreationalsafety/falls/compendium.html
  • 40
    Baumgartner RN, Koehler KM, Gallagher D, Romero L, Heymsfield SB, Ross RR, et al. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epidemiol 1998;147(8):755-63. https://doi.org/10.1093/oxfordjournals.aje.a009520
    » https://doi.org/10.1093/oxfordjournals.aje.a009520
  • 41
    American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49(5):664-72. https://doi.org/10.1046/j.1532-5415.2001.49115.x
    » https://doi.org/10.1046/j.1532-5415.2001.49115.x
  • 42
    Sayer AA, Syddall HE, Martin HJ, Dennison EM, Anderson FH, Cooper C. Falls, sarcopenia, and growth in early life: findings from the Hertfordshire cohort study. Am J Epidemiol 2006;164(7):665-71. https://doi.org/10.1093/aje/kwj255
    » https://doi.org/10.1093/aje/kwj255
  • 43
    Legters K. Fear of falling. Phys Ther 2002;82(3):264-72. https://doi.org/10.1093/ptj/82.3.264
    » https://doi.org/10.1093/ptj/82.3.264
  • 44
    Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med 2003;348(1):42-9. https://doi.org/10.1056/NEJMcp020719
    » https://doi.org/10.1056/NEJMcp020719
  • 45
    Durso S, Bowker L, Price J, Smith S. Oxford American Handbook of Geriatric Medicine. New York: Oxford University Press; 2010.
  • 46
    Schwartz AV, Vittinghoff E, Sellmeyer DE, Feingold KR, Rekeneire N, Strotmeyer ES, et al. Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care 2008;31(3):391-6. https://doi.org/10.2337/dc07-1152
    » https://doi.org/10.2337/dc07-1152
  • 47
    Menezes RL, Bachion MM. Estudo da presença de fatores de riscos intrínsecos para quedas, em idosos institucionalizados. Cienc Saude Coletiva 2008;13(4):1209-18. https://doi.org/10.1590/S1413-81232008000400017
    » https://doi.org/10.1590/S1413-81232008000400017
  • 48
    Chaimowicz F. Rede de atenção: saúde do idoso. 2.ed. Belo Horizonte: Nescon UFMG; 2013. https://www.nescon.medicina.ufmg.br/biblioteca/imagem/3836.pdf
    » https://www.nescon.medicina.ufmg.br/biblioteca/imagem/3836.pdf
  • 49
    Ferreira DCO, Yoshitome AY. Prevalência e caraterísticas das quedas de idosos institucionalizados. Rev Bras Enferm 2010;63(6):991-7. https://doi.org/10.1590/S0034-71672010000600019
    » https://doi.org/10.1590/S0034-71672010000600019
  • 50
    Vega GL, Adams-Huet B, Peshock R, Willett DW, Shah B, Grundy SM. Influence of body fat content and distribution on variation in metabolic risk. J Clin Endocrinol Metab 2006;91(11):4459-66. https://doi.org/10.1210/jc.2006-0814
    » https://doi.org/10.1210/jc.2006-0814
  • 51
    Reis JP, Macera CA, Araneta MR, Lindsay SP, Marshall SJ, Wingard DL. Comparison of overall obesity and body fat distribution in predicting risk of mortality. Obesity (Silver Spring) 2009;17(6):1232-9. https://doi.org/10.1038/oby.2008.664
    » https://doi.org/10.1038/oby.2008.664
  • 52
    Gibson R. Principles of nutritional assessment. 2.ed. Oxford: Oxford University Press; 2005.
  • 53
    Gomes FS, Anjos LA, Vasconcellos MTL. Antropometria como ferramenta de avaliação do estado nutricional coletivo de adolescentes. Rev Nutr 2010;23(4):591-605. https://doi.org/10.1590/S1415-52732010000400010
    » https://doi.org/10.1590/S1415-52732010000400010

  • Funding: Resources from the Epidemiology Master’s Research Consortium from the Universidade Federal de Pelotas 2013/2014 (Processes CAPES/PROEX 23038.003968/2013;99. AUXPE-PROEX 1107/2013).

History

  • Received
    2 Mar 2017
  • Accepted
    20 Apr 2017
  • Online publication
    26 Feb 2018
Faculdade de Saúde Pública da Universidade de São Paulo São Paulo - SP - Brazil
E-mail: revsp@org.usp.br