Falls in Indian older adults: A barrier to active ageing

Abstract

Objectives. Rapid population ageing is predicted in India. Falls are one of the causes of injuries and non-communicable diseases associated with old age. Studies on falls in Indian older adults were reviewed to determine the prevalence, consequences, risk factors, and interventional strategies for falls. Data sources. MEDLINE, PubMed, Google, and IndMED. Study selection. Studies related to falls in Indian older adults published after 2000 were found using the key words: falls, Indian older adults or older adults, prevalence, circumstances and consequence, injuries, risk factors, health, balance, and mobility. Data extraction. The search resulted in 16 publications and 3 unpublished research studies. Data synthesis. The prevalence of falls in Indian older adults ranges from 14% to 53%. Falls result in considerable morbidity and mortality. Indian elderly people are facing challenges secondary to the changing socio-economic scenario, economic dependency, and decreasing family support. Fall-related injuries impose a substantial financial burden on older adults and their families, in addition to dependency for daily activities and activity restriction. Conclusion. Falls are an emerging public health problem and a barrier to active ageing in India. There is an urgent need for coordinated and collaborative efforts of health professionals, researchers, policy makers, and health care delivery systems to prevent falls and promote active ageing.

Full text

REVIEW ARTICLE
Asian J Gerontol Geriatr 2014; 9: 33–40
33
Asian Journal of Gerontology & Geriatrics Vol 9 No 1 June 2014
Falls in Indian older adults: a barrier
to active ageing
SA Dsouza1, PhD, B Rajashekar2, PhD, HS Dsouza3, PhD, KB Kumar4, PhD
ABSTRACT
Objectives. Rapid population ageing is predicted in India. Falls are one
of the causes of injuries and non-communicable diseases associated
with old age. Studies on falls in Indian older adults were reviewed to
determine the prevalence, consequences, risk factors, and interventional
strategies for falls.
Data sources. MEDLINE, PubMed, Google, and IndMED.
Study selection. Studies related to falls in Indian older adults published
after 2000 were found using the key words: falls, Indian older adults or
older adults, prevalence, circumstances and consequence, injuries, risk
factors, health, balance, and mobility.
Data extraction. The search resulted in 16 publications and 3
unpublished research studies.
Data synthesis. The prevalence of falls in Indian older adults ranges
from 14% to 53%. Falls result in considerable morbidity and mortality.
Indian elderly people are facing challenges secondary to the changing
socio-economic scenario, economic dependency, and decreasing family
support. Fall-related injuries impose a substantial financial burden
on older adults and their families, in addition to dependency for daily
activities and activity restriction.
Conclusion. Falls are an emerging public health problem and a barrier
to active ageing in India. There is an urgent need for coordinated and
collaborative efforts of health professionals, researchers, policy makers,
and health care delivery systems to prevent falls and promote active
ageing.
Key words: Accidental falls; Aged; Prevalence; Primary prevention; Risk
factors
1 Department of Occupational Therapy,
Manipal College of Allied Health
Sciences, Manipal University, Manipal,
India
2 Manipal College of Allied Health
Sciences, Manipal University, Manipal,
India
3 Manipal Life Sciences Centre, Manipal
University, India
4 Sweekar Academy of Rehabilitation
Sciences, Secunderabad, India
Correspondence to: Dr Sebestina Anita
Dsouza, Department of Occupational
Therapy, Manipal College of Allied Health
Sciences, Manipal University, Manipal,
576104, India. Email:
sebestina.dsouza@manipal.edu
years and older) is expected to increase 4-fold; these
increases are faster than for any other age-groups.4
The average remaining length of life is around 18
years (16.7 years for men, 18.9 years for women)
at age 60 years and <12 years (10.9 years for men
and 12.4 years for women) at age 70 years.5 The
old-age dependency ratio has increased over the
past 2 decades, which increases the burden on the
working population.6 In most developed countries,
population ageing is a gradual process associated
with steady socio-economic growth. In India, the
process is compressed into 2 to 3 decades.1
INTRODUCTION
By 2050, the worldwide population of older adults
may grow to almost 2 billion, with 80% living in
developing countries.1 This is alarming as over half
of the world’s older adults live in Asia.2 In India, a
‘senior citizen’ or ‘older adult’ is defined as a person
aged 60 years and older.3 This is the fastest growing
population in India, increasing from 6.7% in 1991 to
10% in 2021. Between 2001 and 2051, the number
of old-old (age 70 years and older) is projected to
increase 5-fold, and that of the oldest-old (age 80

34 Asian Journal of Gerontology & Geriatrics Vol 9 No 1 June 2014
Dsouza et al
Traditionally, older adults are taken care of by
their families. A caregiving crisis is predicted owing
to changing gender roles, employment of women,
erosion of traditional family values, and an increasing
trend for nuclear families. The number of older adults
living alone is increasing.6 With decreased family
support and informal caregivers, more older adults
in India care for themselves.1,7
The World Health Organization proposes ‘active
ageing’, which aims to extend healthy life expectancy
and quality of life for all people as they age, including
those who are frail, disabled, and in need of care.2 It
emphasises on promoting an active lifestyle, which
saves substantial health care–related expenditure.8
Considering the magnitude of the ageing population
and socio-economic changes in India, measures to
keep older people healthy and active are of utmost
importance.2 Preventing non-communicable chronic
diseases (such as fall) is one such measure.2,6 Fall is a
major cause of injuries associated with old age.9
The present paper reviewed the literature on
falls in Indian older adults using Medline, PubMed,
Google, and IndMED. Studies related to falls in
Indian older adults published after 2000 were
found using the key words: falls, Indian older adults
or older adults, prevalence, circumstances and
consequence, injuries, risk factors, health, balance,
and mobility. The search resulted in 16 publications
and 3 unpublished research data.
EPIDEMIOLOGY OF FALLS
Falls are defined as inadvertently coming to rest on
the ground, floor, or other lower level, excluding
intentional change in position to rest.9 In the US,
30% of individuals aged 65 years and older fall at
least once a year.10 In Japan, the prevalence of falls
was 13.7%,11 and in China it was 26.4%.12 In India,
the prevalence of falls among older adults aged 60
years and older was 14% to 53% (Table 1).13-16 These
studies vary in terms of sample size, geographical
region, fall history criteria, and methods. Falls are
highly under-reported, and the actual prevalence
is likely to be higher. In India, fall prevalence
increases with age and is the highest in women and
institutionalised older adults.13,14,17
CONSEQUENCES OF FALLS
Falls are a leading cause of death in older adults.18
Falls lead to 20% to 30% of mild-to-severe injuries,
and are the underlying cause of 10% to 15% of all
emergency department visits.19 The major clinical
conditions for fall-related hospital admissions are
hip fractures, traumatic brain injuries, and upper
limb injuries. The duration of hospital stay after fall
injuries ranges from 4 to 15 days9 and may be longer
when associated with hip fractures,20 advancing age,
and frailty. 30% to 50% of older adults fear a fall, and
one-third report restricting their activities.21
Study Location Design Fall history criteria No. of participants No. of
men/
women
Prevalence of
falls (%)
All/>3
falls
Men/
women
Dsouza et al,13 2008 Manipal and Udupi,
Karnataka
Cross-sectional
survey
Falls in the previous
2 years
190 (169 community
dwelling, 21 old-age
home residents)
109/81 38/5 31/47
Johnson,14 2006 Trivandrum, Kerala Cross-sectional
survey
Falls in the previous
year
145 women (82
community dwelling, 63
long-term care home
residents)
0/145 53/- 0/53
Joshi et al,15 2003 Chandigarh city and
rural population of
Haryana state
Cross-sectional
survey using
cluster sampling
techniques
All falls 200 (100 urban, 100
rural)
98/102 51.5/2 -
Krishnaswamy and
Gnanasambandam16
10 Indian states Multi-centric
community study
Single fall in the
previous 6 months
10 200 equally
distributed in urban and
rural areas
- 14/- -
Table 1
Studies of fall prevalence in Indian older adults

35
Asian Journal of Gerontology & Geriatrics Vol 9 No 1 June 2014
Falls in Indian older adults
In India, falls are associated with considerable
mortality and morbidity (Table 2).13-15,22-25 Soft-
tissue injuries were most common, followed by
fractures, especially hip fractures. In an unpublished
study of 312 older adults admitted for fall-related
injuries, 12% died and 68% required surgical
management. Hip, femoral, and pelvic injuries were
most common. The mean duration of hospital stay
was 12 to 15 days. Documentation of the fall event,
cause, and consequences was inadequate. There are
psychosocial consequences of fall such as fear of fall,
decreased balance confidence, and activity restriction
that may affect quality of life. Mortality after falls
was high (53-86%). Based on mortality surveillance
methods, including verbal autopsy and accessing
medical records of people reported to have died
from unintentional falls (based on the International
Classification of Diseases, 10th Revision), the actual
prevalence of fall-related consequences may be
higher due to under-reporting of fall events and
inadequate documentation of fall-related injuries.22,23
ECONOMIC COSTS OF FALLS
Direct costs of falls include health care costs,
and indirect costs include societal productivity of
individuals or caregivers (such as income loss).9 The
mean costs of falls are US$3476 per faller, US$10 749
per injurious fall, and US$26 483 per fall requiring
hospital admission.26 The total economic burden
of falls may be significantly higher if direct non-
medical, intangible, and indirect costs of falls are also
included.27
The costs related to medical management,
hospital stay, and rehabilitation of fall-related
injuries are considerable. The consequent morbidity
and dependency for daily activities may require
assistance of family members (informal caregivers)
or nursing aides (formal caregivers). Both types
of assistance are associated with considerable
direct and indirect costs. In an unpublished study,
the mean cost per hospitalisation for fall-related
injuries to a tertiary hospital was 44 266 Indian
rupees (US$835).
In India, one-third of older adults aged 60 years
and older live below poverty line.3 Up to 65% of
older adults are economically dependent, especially
widowed women.5 In India, private sector employees
may not necessarily receive pension and retirement
benefits. Inadequate income is a major problem for
Study Location Fall history
criteria
Consequences of falls in older adults
Mortality Injuries Psychosocial impact
Jagnoor et al,22 2011 28 states and 7 union
territories covered by
the Sample Registration
System
- Deaths in 2001-2003
(65%), high death rates
above 70 years of age
- -
Dsouza et al,13 2008 Manipal and Udupi,
Karnataka
Fall in the
previous 2 years
- Injuries (59%), fractures
(16%), physician
consultation (47%),
hospital admission (19%)
Fear of fall (53%),
activity restriction (31%)
Cardona et al,23 2008 Andhra Pradesh - Fatal injuries (86%) Non-fatal injuries (34%) -
Kaushik and
Dsouza,24 2008
Not specified - - - 40% of elderly with
fall history reported
decreased balance
confidence
Johnson,14 2006 Trivandrum, Kerala Fall in the
previous year
- Cuts, bruises, and
fractures requiring
medical attention (74%)
-
World Health
Organization,25 2004
India - Deaths in 2004 (53%) - -
Joshi et al,15 2003 Chandigarh All falls - Fractures (21%) Fall history and fall
frequency associated
with disability and
psychological distress
Table 2
Fall-related mortality and morbidity in older adults

36 Asian Journal of Gerontology & Geriatrics Vol 9 No 1 June 2014
Dsouza et al
older adults.28 Non-affordability is a cause of not
seeking medical treatment among older adults.29
In India, only 25% of people have health insurance
coverage, and medical expenses are predominantly
borne out-of-pocket.30 Fall-related injuries may affect
a person’s savings, increase the economic burden of
caregivers, and contribute to neglect of older adults.
RISK FACTORS OF FALLS
According to the World Health Organization global
report on fall prevention in older age, risk factors for
falls involve biological, environmental, behavioural,
and socio-economic factors. Biological (intrinsic)
risk factors include sex, race, age-related declines
in strength, balance, vision, cognition, and chronic
diseases.9 The most common predictors of falls are
abnormalities of gait or balance and a history of fall in
the past year.31 Behavioural risk factors include risky
behaviours such as hurrying, sedentary lifestyle, and
multiple medications. Socio-economic risk factors
include low income, low education, inadequate
housing, and limited access to health care services.
Environmental (extrinsic) risk factors include physical
environmental features in the home or community
that may pose hazards, such as slippery or uneven
surfaces, steps, and poor building design.9 Extrinsic
factors are more likely to be the cause of falls for the
age-group of 60 to 74 years, whereas intrinsic factors
are more likely to be the cause for those aged 75
years and older.32
In Indian adults older than 70 years, intrinsic
causes for falls and recurrent falls are the most
likely factors.33 Gait disorders34 and poor physical
mobility are associated with difficulty in activities of
daily living.6 Age-related decline in lower extremity
strength and balance has been reported in Indian
community-dwelling older adults.35 Difficulty in
getting up from a chair (indicative of lower limb
weakness) and decreased physical activity increase
the risk for hip fractures.36 Compared with older
adults without a history of falls, older adults with a
history of fall have decreased lower limb strength,
impaired balance and functional mobility, decreased
balance confidence,24 and more comorbidities.13
Medical conditions that are risk factors for
falls include musculoskeletal problems, visual
impairment, and neurological disorders. Sedatives
are risk factors; long-term medications are a risk
factor for hip fractures.33,36
Compared with western countries, more younger
patients had hip fractures, which is attributed to
low bone mineral density caused by vitamin D
deficiency, especially in post-menopausal women.37
Poor sunlight exposure, skin pigmentation, and a diet
deficient in vitamin D are the common causes. Among
Indians aged 50 years and older, the prevalence of
vitamin D deficiency was 91.2%, that of osteoporosis
was 31.2%, and that of osteopenia was 50.2%.38
The other intrinsic risk factors for fall include
depression (21.9%),39 dementia (0.6-4.8%),40 urinary
incontinence (20%),15 and chronic diseases such as
diabetes (5.5-11.75%)13,15 and hypertension (39.8-
51.2%).13,15,41 Of great concern is the early onset
and high prevalence of cardiovascular disease and
diabetes in young and middle-aged adults in India.42
Falls are associated with the geriatric syndromes
of depression,43 cognitive impairment,17 urinary
incontinence,44 and chronic diseases, especially
cardiovascular disease.45 Older adults commonly
have more than one chronic disease, and the risk of
fall increases with the number of chronic diseases.45
Indian older adults have high prevalences of
anaemia (41.8-66.5%) and respiratory disorders,
especially asthma (6.0-16.5%)15,34 and chronic
obstructive pulmonary disease (42%)15 and hence
are susceptible to falls.46,47 It is hypothesised that the
symptoms of weakness, fatigue, dyspnoea, syncope,
and postural hypotension contribute to decrease in
activity levels and subsequent physical deterioration
that increase risk for fall.47
Indian older adults are predominantly of the
young-old age-group and thus more active.13,33
Falls occurred most commonly at home and in
the bathroom.13 Outdoors, most falls occurred
on the roads. The circumstance (location, activity
being performed, time) of falls has implications
for developing fall prevention programmes. Falls
commonly occur during walking or bathing and are
caused by slips and trips and often in the morning.
Indians prefer completing self-care and household
chores in the morning, resulting in hurrying or
rushing. The use of mobility aids was also associated
with falls.13
Inadequate income, poor housing, limited access
to health care, and low literacy are some of the salient
socio-economic issues in India that affect the health

37
Asian Journal of Gerontology & Geriatrics Vol 9 No 1 June 2014
Falls in Indian older adults
of elderly people.48 These issues could contribute to
injurious falls and poor treatment outcomes. These
socio-economic factors in India may also contribute
to environmental or extrinsic risk factors in the
home and community such as inadequate power
supply resulting in poor lighting, poor building
structures, transport facilities, and roads.49 The risk
of falls and injuries increases with the number of
risk factors.9
FALL PREVENTION
Fall prevention programmes commonly involve
education, exercises, medication review and
Study Type of
Intervention
Participants Study design Outcome measures Conclusion
Parnami et al,53
2005
Nutritional Elderly women
aged ≥60 years
No iron folic acid
(IFA) [n=30] vs. IFA
supplementation for 6
weeks (n=30)
Pre- and post-test assessment
of haemoglobin levels, physical
performance (standing balance,
walking speed and lower limb
strength), cognitive functions
(attention, concentration, and
memory)
Haemoglobin levels, standing
balance, and cognitive
functions improved significantly
with IFA supplementation
Rege and
Joshi,54 2005
Visual
perception,
depth
perception and
balance training
Elderly aged
≥60 years
Activities for visual
perception and depth
perception, functional
balance training for 6
weeks (n=20)
Pre- and post-test assessment
of Test of Visual Perception Skills,
Depth Perception Instrument,
Timed Up and Go Test,
subjective report
Intervention improved visual
perception, sense of well
being, and confidence for
outdoor activities
Bhat and
Walia,55 2010
Balance and
mobility training
Elderly aged
≥65 years
Task-oriented training
with (n=24) vs. without
(n=24) altered sensory
input
Pre- and post-test assessment
of Berg Balance Scale (BBS),
Modified Clinical Test of Sensory
interaction for Balance, 10 meter
walk test
Interventions improved balance
and mobility
Jahagirdgar and
Kenkre,56 2010
Balance and
mobility training
Elderly aged
≥60 years
Electromyography
biofeedback, Swissball/
peanut ball and
conventional functional
balance exercises
(n=16)
Pre- and post-test assessment
of Performance Oriented Mobility
Assessment (POMA), Manual
Muscle strength, Dartmouth-
Northern New England Primary
Care Cooperative Information
Project functional assessment
charts
Interventions improved balance
and mobility
Choudhary and
Mohammad,57
2011
Ankle exercises Elderly in
old-age home
aged 60-80
years
No intervention (n=27)
vs. ankle mobilisation,
stretching, and
strengthening for 6
weeks (n=24)
Pre- and post-test assessment
of Functional Reach Test, POMA,
and ankle range of motion
Interventions improved balance
Dsouza et al58 Balance
training under
dual task
conditions with
graded sensory
context
Elderly at risk
for fall aged
≥60 years
Postural control training
under single task
conditions (n=23) vs.
postural control training
with manual dual tasks
(n=24) vs. postural
control training with
manual-cognitive dual
tasks (n=23) vs. postural
control training with
manual-cognitive dual
tasks under graded
sensory context (n=23)
Pre- and post-test, and 12-
week follow-up assessment of
Functional Reach Test, Lateral
Reach Test, BBS, Dynamic
Gait Index, Timed Up and Go
Test under single and dual task
conditions (manual, cognitive,
and manual-cognitive tasks), falls
and near-falls, fear of fall, Geriatric
Depression Scale-15, Survey of
Activities, and Fear of Fall
Training under single and dual
task conditions equally effective
in decreasing falls. Dual-
task training had additional
benefits on automaticity of
functional mobility, balance
and fear of fall. Intervention
effects of dual-task training
are influenced by type of
task. Manual-cognitive tasks
are suitable for functionally
independent elderly. Training in
graded sensory context does
not enhance the effectiveness
of dual-task training
Anuradha et
al,59 2012
Balance and
mobility training
Frail
institutionalised
elderly aged
≥65 years
General balance
exercises (n=25)
vs. specific balance
strategy training with
functional strength,
flexibility, balance
strategy training,
sensory integration, and
additional attentional
demands (n=25)
Pre- and post-test assessment of
BBS and Timed Up and Go Test
Both interventions improved
balance and mobility. Specific
balance training improved BBS
Krishnamurthy
and Telles,60
2007
Yoga and
Ayurveda
Elderly aged
60-95 years
No intervention (n=23)
vs. yoga (n=23) vs.
Ayurveda (n=23) for 6
months, 6 days a week
Pre- and post-test assessment
with Tinetti balance and gait
evaluation and Timed Up and
Go Test
Yoga improved balance, gait,
and mobility
Table 3
Interventions for older adults towards fall prevention

38 Asian Journal of Gerontology & Geriatrics Vol 9 No 1 June 2014
Dsouza et al
modifications, home safety interventions by
occupational therapists, correction of refractive
errors, and prescription of appropriate assistive
devices.9,50 A comprehensive programme of
strengthening, balance, and/or endurance training
effectively reduces falls and fall risks in older
adults.50,51 Exercises alone are effective in reducing
fall rates in older adults in community and sub-acute
settings, whereas multifactorial interventions are
more effective in long-term care settings.52
Fall prevention studies in Indian older adults
are summarised in Table 3.53-60 Limitations of
these studies include the lack of blinding and/
or controls, and inadequate description of sample
size estimation, randomisation, and/or sampling
methods. Nevertheless, these studies suggest that
balance and mobility improves with training. Only
one study reported a decrease in falls and fall risks
(physical and psychological) after intervention.
In Indian older adults, falls are emerging as a
prevalent public health problem. Falls are potentially
predictable and preventable. The World Health
Organization designed a comprehensive fall
prevention model based on 3 highly interrelated and
mutually dependent pillars: awareness, assessment,
and intervention.9
Awareness is critical for the success of fall
prevention programmes. Culturally relevant
educational programmes are required to improve
awareness of older adults, their families, the
community at large, health agencies, and the
government. Initial fall events without serious injuries
are considered ‘coincidental’ or ‘accidental’ and are
often ignored. Educational programmes should
emphasise the importance of reporting fall events,
even if they are not associated with serious injury.
Older adults commonly do not acknowledge falls,
owing to negative stereotyping and embarrassment
at loss of control. Educational programmes should
emphasise the positive outcomes (health and
functional independence) of interventions, positive
self-image, and social participation.9 Considering
India’s collective culture and traditional roots of
family, active ageing and fall prevention should be
encouraged as means to continue to contribute to
the family, rather than living alone independently.
Media are powerful tools to increase awareness, as
many older adults watch television for leisure.
Assessment of fall risk factors is important to
develop effective fall prevention programmes. It
is cost-effective and easier to prevent rather than
treat falls. Fall-specific comprehensive assessments
should be available at primary health centres for
older adults. Screening for intrinsic risk factors can
help identify at-risk older adults. Assessment of
the home and bathroom for hazards is important,
especially for older adults with a history of fall.
Assessment of intrinsic factors is important for the
old-old and oldest-old, whereas assessment of
extrinsic risk factors is important for the young-old.
Accessibility and safety of roads, public places, and
transport services also need to be assessed.
Detailed documentation of the fall event,
consequent injuries, and management is important,
as is culture-specific assessment. In India, bathrooms
are different to those in the West, and bathing
involves an ‘oil bath’, which may predispose older
adults to falls. Similarly, most balance assessments
do not assess the ability to sit and rise from the
floor, which is a common activity in various religious
rituals, traditional practices, and daily routine tasks.
This activity may pose a risk of fall that can be
identified with suitable assessments.
It is also important to design and implement
culturally appropriate interventions to decrease
falls. More research is needed on multifactorial and
multidisciplinary fall prevention programmes in the
Indian context, especially in rural areas. Problems
specific to Indian older adults such as osteoporosis,
anaemia, poor nutrition, and non-communicable
chronic diseases need to be addressed. Effective fall
prevention programmes should include assessment
with targeted interventions, for example, surgery for
cataracts, vitamin D supplementation for vitamin D
deficiency, and iron supplements for anaemia.
Yoga can improve balance and gait. Yoga involves
‘asanas’ which require stretching, maintaining
positions, and various stances that improve
flexibility, strength (trunk and lower limbs), and
balance.60 Older adults can practise independently
at home after supervised training. Older adults are
encouraged to participate in daily activities such as
household chores and gardening to improve physical
activity. An active and healthy lifestyle should be
emphasised to young and middle-aged adults, the
future older adults.2

39
Asian Journal of Gerontology & Geriatrics Vol 9 No 1 June 2014
Falls in Indian older adults
Home and bathroom modifications (installation
of grab bars, use of non-skid mats or flooring with
matt-finished tiles, bidirectional doors, permanent
bathing seats, improved ventilation, and hand
showers) are important, especially for the oldest-
old, as they spend most of their time at home and
most falls occur at home and in the bathroom.61
Outdoors, safe road-crossing, accessible public
transport services, barrier-free pavements, low
curbs, and universal architectural designs are some
recommendations, as is management of fall-related
injuries and strategies to promote quality of life after
a fall. In view of the increasing ageing population
in India (particularly in rural areas) and diverse
sociocultural and geographical influences, novel
solutions may be required to design and implement
comprehensive fall prevention programmes that are
easily available and accessible to elderly people.
Public health policies and strong legislation
effectively decrease falls in older adults.9 Nonetheless,
the actual translation of these policies is a problem,
especially in health promotion.62 Fall prevention
must be emphasised in public health policies and
health programmes for elderly people. Falls are
an emerging public health problem and a barrier
to active ageing in India. There is an urgent need
for coordinated and collaborative efforts of health
professionals, researchers, policy makers, and health
care delivery systems to prevent falls and promote
active ageing.
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