Falls and dizziness in frail older people. Predictors, experiences and the effects of a case management intervention

Falling in old age may have a large impact on daily life. Falls can lead to injuries, reduced mobility and reduced quality of life. The risk of falls increases with age and frailty level. Dizziness is a strong risk factor for falls, and preventing falls and dizziness in older people is essential. The overall aim of this thesis was to investigate risk factors for falls or dizziness and to explore older people’s experiences of living with chronic dizziness. Furthermore, the aim was to evaluate the effects of a home-based case management intervention on falls in frail older people. The thesis comprised three studies. Study I was a longitudinal cohort study, the Swedish National Study on Aging and Care (SNAC), with 1,402 participants in 10 age cohorts from 60 to 96 years. The study started in 2001 and follow-up was done after 3 and 6 years. The sample was divided into subjects aged 60-78 years and 80-96 years and the prevalence and predictors of falls or dizziness were investigated (Paper I). Study II was a qualitative study exploring the experiences of living with chronic dizziness in old age and included 13 people (7 women and 6 men, aged 73 to 87 years). Interviews were conducted and were analysed by content analysis (Paper II). Study III was a randomized controlled trial (RCT) including 153 participants randomly assigned to a case management intervention (n=80) or a control group (n=73). The study included people aged 65+ years who lived in their ordinary homes with functional dependency and repeated health care contacts. The intervention included home visits by a nurse and a physiotherapist at least once a month during 12 months. Data from this study were used in two papers. Paper III investigated predictive validity for falls and optimal cut-off scores for the Downton Fall Risk Index (DFRI), Timed Up and Go (TUG) and the Romberg Test (RT). Paper IV investigated the effects of the case management intervention on falls, injurious falls and falls resulting in medical care. The results in Paper I show almost doubled prevalences in the older age cohort. In the younger age cohort 16% reported falls and 18% reported dizziness. In the older age cohort 32% reported falls and 31% reported dizziness. The strongest predictors differed between the age cohorts. The strongest predictors for falls were use of neuroleptics and personal activities of daily living (PADL) in the younger age cohort, and history of falling and instrumental activities of daily living (IADL) in the older age cohort. The strongest predictors for dizziness were history of dizziness and feeling nervous (younger age cohort) and history of dizziness and history of falling (older age cohort). In Paper II the experiences of the interviewees were interpreted as fighting for control in an unpredictable life. This included fumbling for a cure and improvements, struggling to maintain an ordinary life and a restricted everyday life with constant threats. Health care had not been able to meet the needs of older people with chronic dizziness. The results in Paper III show that no test had high predictive validity for falls. DFRI (cut-off ≥ 3 points) and TUG (cut-off ≥12 seconds) showed about 80% sensitivity and 30% specificity. RT show low sensitivity and is not recommended to be used in frail older people at home. The home-based case management intervention in Paper IV did not show any effect on falls, injurious falls and falls resulting in medical care. Falls and dizziness are common, serious health complaints in frail older people and deserve attention. The complex interaction between falls, dizziness and related factors suggests that fall prevention interventions should be individualized. Older people with chronic dizziness have, in spite of frequent health care contacts, needs that are unmet. Besides identifying and treating the underlying cause of dizziness, managing older people with dizziness may also focus on appropriate coping strategies in daily life and should not end until the individual has regained control of their daily life. DFRI and TUG were not able to correctly identify people with and without a high fall risk. They may be used as screening tools, but a comprehensive assessment of a person’s risk factors for falls is needed before a fall prevention intervention is introduced. Preventing falls in frail older people is challenging. The home-based case management intervention did not show any effect on falls, injurious falls and falls resulting in medical care, and further research is needed on how to prevent falls in frail older people living at home