Prevalence and predictors of falls and dizziness in people younger and older than 80 years of age—A longitudinal cohort study

Prevalence and predictors of falls and dizziness in people younger and older than 80 years of age—A longitudinal cohort study

U. Olsson Mo¨ller

*, P. Midlo¨v

, J. Kristensson

, C. Ekdahl

, J. Berglund

, U. Jakobsson

aCenterforPrimaryHealthCareResearch,FacultyofMedicine,LundUniversity,SE-20502Malmo¨,Sweden

bVa˚rdalinstitutet,TheSwedishInstituteforHealthSciences,LundUniversity,P.O.Box187,SE-22100Lund,Sweden

cDepartmentofClinicalSciencesinMalmo¨,FacultyofMedicine,LundUniversity,SE-20502Malmo¨,Sweden

dDepartmentofHealthSciences,FacultyofMedicine,LundUniversity,P.O.Box157,SE-22100Lund,Sweden

eSchoolofHealthScience,BlekingeInstituteofTechnology,SE-37179Karlskrona,Sweden

1. Introduction

Onethirdofolderpeoplefalleachyearandthenumberoffalls increasewithageandfrailtylevel(WHO,2007).Ofallfallsinolder adults 10–20% results in injury, hospitalisation and/or death (Rubenstein,2006).Manystudieshaveinvestigatedriskfactorsfor fallsinolderpeopleandasmanyas400havebeenrevealed(NICE, 2004).Longitudinalstudiesinvestigatingpredictorsforfallsalso showedtheimportanceofavarietyoffactorsincludingahistoryof falling,gaitproblems,vertigoanddruguse(Deandreaetal.,2010).

Thelargenumberofriskfactorsindicates thecomplexityofthe problemandthattheriskfactorsidentifieddifferdependingon studydesignandstudypopulation.Commonriskfactorsforfalls aremorefrequentathigheragesandtheriskoffallingriseswith

thenumberofriskfactorsforfallspresent.Thismayimplythatthe predictorsforfallsdifferindifferentagecohorts.

Inarecentmeta-analysisofriskfactorsforfallsincommunity- dwellingolderpeople,thestrongestpredictorsforfallswerefound tobeahistoryoffalls,gaitproblems,useofawalkingaid,vertigo, Parkinson disease and antiepileptic drug use (Deandrea et al., 2010).Moststudiesthatinvestigateriskfactorsforfallsinclude people65+yearsbutafewstudieshaveinvestigatedassociated factorsand predictorsforfallsinpeople 80+years(Iinattiniemi, Jokelainen,&Luukinen,2009;Grundstrom,Guse,&Layde,2012).A studyin555people85+yearsshowedhistoryofrecurrentfalls, poorvision,antipsychoticdrugsandfeelingsofanxiety,nervous- nessorfeartobeindependentriskfactorsforfalls(Iinattiniemi et al., 2009). Another study comparing risk factors for falls in people younger and older than 85+ years revealed that even thoughmanyriskfactorsforfallsweresimilarbetweenthegroups, higherageaswellasmalegenderandgeneralhealthstatuswere morestronglyassociatedwithanincreasedfallriskinthose85 yearsandolder(Grundstrometal.,2012).Thosedifferencesmight indicatethatpredictorsoffallsdifferaccordingtoagebut,toour knowledge, no study has investigated predictors for falls in ARTICLE INFO

Articlehistory:

Received30May2012

Receivedinrevisedform21August2012 Accepted23August2012

Availableonline19September2012

Keywords:

Aged Accidentalfalls Dizziness Longitudinalstudy SNAC

ABSTRACT

Theobjectivesweretoinvestigatetheprevalenceandpredictorsforfallsanddizzinessamongpeople youngerandolderthan80yearsofage.ThesamplewasdrawnfromtheSwedishNationalstudyonAging andCare(SNAC)andcomprised973and1273subjectswithdataontheoccurrenceoffallsanddizziness respectivelyatbaseline.Follow-upsweremadeafter3-and6-years.Dataincludedsocio-demographics, physicalfunction,healthcomplaints,cognition,qualityoflifeandmedications.Theprevalenceoffalls was16.5%inthoseunderaged80and31.7%inthose80+yearswhiledizzinesswasreportedby17.8%

and31.0%respectively.Predictorsforfallsinthoseunderaged80wereneuroleptics,dependencyin personalactivitiesofdailyliving(PADL),ahistoryoffalling,visionimpairmentandhigherage,andin those80+yearsahistoryoffalling,dependencyininstrumentalactivitiesofdailyliving(IADL),fatigue andhigherage.Factorspredictingdizzinessinthoseunderaged80wereahistoryofdizziness,feeling nervousandreducedgripstrengthandinthose80+yearsahistoryofdizzinessandoffalling.Predictors forfallsanddizzinessdifferedaccordingtoage.Specificfactorswereidentifiedinthoseunderaged80.In those 80+ years more general factors were identified implying the need for a comprehensive investigationtopreventfalls.Thislongitudinalstudyalsoshowedthatfallinganddizzinessinmany olderpeoplearepersistentandthereforeshouldbetreatedaschronicconditions.

ß2012ElsevierIrelandLtd.Allrightsreserved.

*Correspondingauthorat:CenterforPrimaryHealthCareResearch,Facultyof Medicine,LundUniversity,SE-20502Malmo¨,Sweden.Tel.:+46462221833;

fax:+46462221934.

E-mailaddress:[email protected](U.OlssonMo¨ller).

ContentslistsavailableatSciVerseScienceDirect

Archives of Gerontology and Geriatrics

j ou rna l h om e pa ge : w w w. e l s e v i e r. co m/ l oc a t e / a rch ge r

0167-4943/$–seefrontmatterß2012ElsevierIrelandLtd.Allrightsreserved.

http://dx.doi.org/10.1016/j.archger.2012.08.013

differentagecohorts.Thisknowledgemightrevealspecificage- related predictors, which could be useful when screening for people at risk for subsequent falls and when designing fall preventiveinterventionsforpeopleofvariousages.

Thestrategyforpreventingfallsiseliminationoftheriskfactors forfalls.Dizzinessisaknownriskfactorforfalls(Deandreaetal., 2010)andpredictorsfordizzinessareindirectpredictorsforfalls.

Variousstudiesreporttheprevalenceofdizzinessinolderpeople asbeingbetween11and31%withanincreasewithage(Gassman

& Rupprecht, 2009; Stevens, Lang, Guralnik, & Melzer, 2008;

Tinetti, Speechley, & Ginter, 2000a). The most common major contributory causesofdizziness inelderly (65+years) patients were cardiovascular disease, peripheral vestibular disease and psychiatricillness(Maarsinghetal.,2010)andalthoughfallsmay be the most disabling consequence of dizziness (Mendel, Bergenius,&Langius-Eklo¨f,2010)itisalsoassociatedwithpoor self-related health (Gassman & Rupprecht, 2009) and reduced qualityoflife(Ekwall,Lindberg,&Magnusson,2009),indicating theimportanceofprevention.Aprospectivecohortstudyin620 people65+yearsshowedhigherage,femalegender,comorbidity, polypharmacy, poor subjectivehealth status, falls and mobility problems tobe predictors of dizziness (Gassman & Rupprecht, 2009).Toourknowledgenostudyhasinvestigatedpredictorsfor dizzinessstratifiedbyageandthisknowledgemayidentifyage- specificfactorsthatoughttobeeliminatedtopreventdizziness andtherebyfalls.Theobjectivesofthisstudyweretoinvestigate theprevalenceandpredictorsforfallsanddizzinessamongpeople youngerandolderthan80yearsofageinalongitudinalcohort studywith3-and6-yearfollow-ups.

2. Methods

2.1. Sample

ThesamplewasdrawnfromtheSNAC,anational,longitudinal, multidisciplinarystudyinvolvingfourresearchcenters(Lagergren etal.,2004).Thepresentstudyuseddatafromthesub-studyofthe CountyofBlekinge(SNAC-B)withbaselinedatacollectionin2001–

2003on1402people60–96yearsofage.SNAC-Bfocusedonone municipalitywithapproximately60000inhabitants,locatedinthe south-easternpartofSwedenincludingbothurbanandruralareas.

Thefouryoungestagecohorts(60,66,72and78 yearsold),i.e.

those under aged 80 were selected, using computer-based randomization, monthlyfrom theSwedish Populationdatabase (StatisticsSweden).Theolderagecohorts(81,84,87,90,93and96 years old), i.e. those 80+ years, included the entire population (Halling & Berglund, 2006). At baseline 973 subjects were interviewedbymeansofself-reportedfallsinthepastyearand 1273subjectsbymeansofself-reporteddizzinessinthepastthree monthsandwhereincludedinthepresentstudy.Thesesamples werethendividedinsubjectsunderage80and80+years(Fig.1).

There were two follow-ups, the first after three years on subjectsaged80+yearsatbaseline.Thissampleincluded237and 224 subjectswith valid dataat baseline on fallsand dizziness respectively(Fig.1).Thesubjectswhodroppedoutbeforethefirst follow-up interview were significantly older in both groups (p<0.001) and significantly more of female gender in the dizzinessgroup(p=0.009).Thesecondfollow-upaftersixyears included subjects included all at baseline and comprised 616 subjectswithvalidbaselinedataonfalls;441subjectsunderaged 80and175subjects80+years,and677subjectswithvalidbaseline dataondizziness;531subjectsunderaged80and146subjects80+

years (Fig.1). Thesubjectswhodroppedout beforethesecond follow-up interview were significantly older in both groups (p<0.001)butwithnogenderdifferences.

2.2. Datacollection

Atbaselinetheselectedsubjectswereinvitedbymailtotake partinthestudy.Iftherewasnoresponse,theyweregivenone moreinvitationbytelephoneandifparticipationwasrefusedthe reasonwasregistered.Theenrolledsubjectswhowereunableto cometotheresearchcenterwereofferedanexaminationintheir homes. The subjects included were examined medically and cognitively, andwere asked survey questions by theresearch team(physiciansandnurses)intwosessionseachlastingabout 3h.Afterthefirstsession,anewvisittotheresearchcenterwas bookedandaquestionnairewasfilledinbythesubjectsduringthe timeperiodbetweenthetwosessions.Thesubjectswereoffered helpfillinginthequestionnairesifneeded,andtheresearchteam wasaccessibleduringofficehours.Thesameprocedurewasused atbothfollow-ups,wheretheenrolledsubjectswerecontacted3

Baseline N=1402

Have you experienced a fall in the past year?

Baseline n=973*

226 subjects (23.2 %) reported falls

Have you experienced dizziness in the past three months?

Baseline n = 1273*

301 subjects (23.6 %) reported dizziness

Under aged 80

Baseline

80+ years Under aged 80 80+years

3-year follow-up

6- year follow-up

n=544*

90 subjects (16.5 %) reported falls

N/A

n=561*

174 subjects (31.0 %) reported dizziness n=712*

127 subjects (17.8 %) reported dizziness n=429*

136 subjects (31.7 %) reported falls

n=441* n=175* n=531* n=146*

n=224*

n=237* N/A

Fig.1.Flowchartwithfallsanddizzinessprevalenceratesatbaseline.*Itemresponserate.

and 6 years (three months) after inclusion in the study. The RegionalEthicsReviewBoardinLundapprovedthestudy(LU605- 00,LU744-00)andwrittenconsentwasobtainedfromallenrolled subjects.

2.3. Questionnairesandmeasures

Known risk factors and potential predictors for falls and dizziness (Deandreaet al., 2010; Gassman & Rupprecht, 2009;

Gassmann,Rupprecht,&Freiberger,2009;NICE,2004;Rubenstein, 2006;Tinetti,Speechley,etal.,2000)that wereavailablein the originalSNAC-Bstudyatbaselinewereusedinthepresentstudy.

Thisstudyincludeddataonsocio-demographicvariables,physical function,self-reportedhealthcomplaints,cognition,health-relat- edqualityoflife(HRQoL)andmedication.

2.3.1. Socio-demographicvariables

Demographicdataincludedage,sexandlivingconditions,with subjects divided into those who lived in ordinary housing (community-dwelling)andthosewholivedinspecialaccommo- dation(nursing homes, modified facilities withstaff on call or aroundtheclock).

2.3.2. Physicalfunction

Activities ofdailyliving(ADL)wereassessedusingquestions thatdirectlycorrespondedtotheADLstaircase(Sonn &A˚sberg, 1991).Theitemoncontinencewasexcludedinthisstudy(Sonn&

A˚sberg,1991). TheADL staircaseassesses dependence/indepen- denceindailylivingandcomprisesfivePADL:bathing;dressing;

going to the toilet; transfer; feeding and four IADL: cleaning;

shopping;transportationandcooking.Theresponsealternatives weredichotomized(can orcannot)accordingtoSonn&A˚sberg (1991).Subjectswithascoreof0weredefinedasindependent.The maximumtotalscorewas0–9,with0–5inthePADLsubscaleand 0–4intheIADLsubscaleusedintheanalyses.

TheRombergtestwasperformedbystandingwithfeettogether andarmsalongthesideofthebodywitheyesopen(EO)andeyes closed (EC) (can or cannot). Grip strength wasmeasured using Grippit ¹ (Nordenskio¨ld & Grimby, 1993), where the force in newton(N)from0to999Nisregistered.Inthepresentstudythe maximumstrengthintherighthandwasused.

2.3.3. Self-reportedhealthcomplaints

Inthisstudythenumberoffallswasmeasuredbymeansofself- reportedfallsinthepastyear(0,1,2,3,4,>4falls)andthesubjects weredividedintwogroups;nofalls(0)orfalls(1).Dizzinesswas reportedthroughasingle-itemquestion;‘‘Haveyouexperienced dizzinessinthelastthreemonths?’’(yesorno).Dizzinessinthis study isused asan umbrellaterm andmay alsoinclude other sensations such as vertigo, disequilibrium, or presyncope. The sample was dividedinto two groups based on whether ornot dizziness occurred. Health status included the self-reported presenceofbalanceimpairment,fatigue,sleepingproblems,poor appetiteorfeelingnervousinthelastthreemonths(yesorno).Fear Table1

Baselinecharacteristicsofsubjectsolderthan80yearsofagewithfalls(F)ornofalls(NF)atthe3-yearfollow-up.

80+years(n=237) F

n=88

NF n=149

p-Value

Socio-demographicvariables

Age,mean(SD) 85.7(3.9) 83.8(3.1) <0.001^a

Gender,female,n(%) 52(59.1) 87(58.4) 0.916^b

Community-dwelling,n(%) 83(96.5)^c 140(94.6)^c 0.750^b

Functionalcapacity

PADLdependency,n(%) 9(10.2) 11(7.4) 0.447^b

IADLdependency,n(%) 46(52.3) 41(27.7)^c <0.001^b

Rombergtest(EO),pos,n(%) 11(15.1)^e 11(7.8)^c 0.097^b

Rombergtest(EC),pos,n(%) 32(44.4)^e 40(28.8)^c 0.023^b

Gripstrength,right,mean(SD) 191(97)^e 210(100)^d 0.183^a

Self-reportedhealthproblems

Historyoffall,n(%) 32(36.4) 32(21.5) 0.013^b

Dizziness,n(%) 25(29.4)^c 32(21.6)^c 0.183^b

Fearoffalling,n(%) 36(42.9)^c 37(25.2)^c 0.005^b

Self-reportedbalanceimpairment,n(%) 39(47.0)^c 46(31.7)^c 0.022^b

Fatigue,n(%) 58(67.4)^c 70(47.6)^c 0.003^b

Sleepingproblems,n(%) 39(45.9)^c 51(34.5)^c 0.085^b

Poorappetite,n(%) 15(18.1)^c 18(12.2)^c 0.226^b

Feelingnervous,n(%) 20(24.4)^c 29(19.7)^c 0.409^b

Hearingimpairment,n(%) 51(58.0) 63(42.3) 0.020^b

Visionimpairment,n(%) 50(56.8) 55(36.9) 0.003^b

CognitionandHRQoL

MMSE24,n(%)1.1 27(31.0)^c 31(20.8) 0.078^b

SF12(PCS),mean(SD) 34.9(10.6)^d 42.9(11.4)^d <0.001^a

SF12(MCS),mean(SD) 51.1(9.5)^d 54.9(7.5)^d 0.004^a

Medications

Neuroleptics,n(%) 4(4.5) 1(0.7) 0.065^b

Sedatives,n(%) 9(10.2) 16(10.7) 0.902^b

Hypnotics,n(%) 26(29.5) 22(14.8) 0.006^b

Benzodiazepines,n(%) 21(23.9) 19(12.8) 0.027^b

Medium-andlong-actingbenzodiazepines,n(%) 19(21.6) 11(7.4) 0.001^b

SSRI,n(%) 4(4.5) 6(4.0) 1.000^b

Boldvaluesindicatesstaticallysignificantp-value0.05.

SD=standarddeviation.

aStudent’st-test.

bChi²-test.

cMissingvalue:0.7–6.8%.

dMissingvalue:9.4–12.5%.

eMissingvalue:17.0–21.6%.

offallingwasmeasuredusingasingle-itemquestions;‘‘Areyou afraidoffallingwhenoutdoors?’’(yesorno).Hearingandvision wasself-ratedwitha singleitem;‘‘Doyou haveproblemswith yourhearing/vision?’’(yesorno).

2.3.4. CognitionandHRQoL

Cognitive impairment wasmeasured using theMini-Mental StateExamination(MMSE)(Folstein,Folstein,&McHugh,1975).

Themaximumtotalscoreis30points.Thesampleinthepresent studywasdividedintotwogroupswith24asthelimit.HRQoL wasassessedusingthe12-itemShort-formHealthSurvey(SF12) (Ware,Kosinski,&Keller,1996).Thequestionnaireconsistsoftwo sub-scores; a Physical ComponentSummary Scale (PCS) and a MentalComponentSummary Scale(MCS)and werescored and transformedaccordingtotheSwedishmanual(Sullivan,Karlsson,

&Taft, 1997), where a higher score indicates a higherlevel of HRQoL.

2.3.5. Medication

Thesubjects wereasked tobring their medication and/or a prescriptionlisttothemedicalexamination.Medicationusewas classifiedaccordingtotheAnatomicalTherapeuticChemical(ATC) classification system (WHO, 2000). The medication groups includedinthisstudyaremedicationsknowntoincreasetherisk factorforfallsanddizziness(Leipzig,Cumming,&Tinetti,1999;

Tinetti,Speechley,etal.,2000),i.e.neuroleptics(N05A),sedatives (N05B), hypnotics (N05C), and selective serotonin reuptake

inhibitor (SSRI)(N06AB). Benzodiazepine includedboth N05BA and N05CD with a subgroup of medium- and long-acting benzodiazepines.Themedium-actingbenzodiazepinesprescribed in Sweden are nitrazepam (N05CD02) and flunitrazepam (N05CD03)whereasdiazepam(N05BA01)istheonlylong-acting benzodiazepine. The datawere dichotomizedas yes, taking the medicationorno,nottakingthemedication.

2.4. Statisticalanalysis

Prevalenceratesofthetotalsampleatbaseline aswellasin different age groups were calculated. Bivariate analyses with independentvariablesatbaselineanddataontheoccurrenceof fallsanddizzinessatthetwofollow-upsasdependentvariables weremadetoexploredifferencesbetweenfallersandnon-fallers anddizzyandnon-dizzysubjects.ThePearsonchi-squaretestfor nominaldataandStudent’st-testforintervaldatawereusedfor groupcomparisons.Ap-value0.05wasconsideredstatistically significant. To identify predictors for falls and dizziness the significantvariablesfromthebivariateanalysesatbaselinewere includedasindependentvariablesinmultiplelogisticregression analyses(manualbackward),withdataontheoccurrenceoffalls anddizzinessatthetwofollow-upsasdependentvariables.Crude odds ratios (ORs) were calculated for the identified predictors.

AnalysesformulticollinearityweretestedwithVarianceinflation factorandtolerance.TheHosmerandLemeshowgoodness-of-fit testandNagelkerkeR²testwereusedasmeasuresofthequalityof

Table2

Baselinecharacteristicsofsubjectsyoungerandolderthan80yearsofagewithForNFatthe6-yearsfollow-up.

Underaged80(n=441) 80+years(n=175)

F n=81

NF n=360

p-Value F

n=75

NF n=100

p-Value

Socio-demographicvariables

Age,mean(SD) 69.8(6.1) 67.3(6.4) <0.001^a 84.4(3.3) 84.0(3.4) 0.395^a

Gender,female,n(%) 47(58.0) 187(51.9) 0.310^b 51(68.0) 57(57.0) 0.160^b

Community-dwelling,n(%) 81(100.0) 358(100.0)^c N/A^b 73(98.6)^c 98(98.)0 1.000^b

Functionalcapacity

PADLdependency,n(%) 4(5.0)^c 2(0.6)^c 0.012^b 6(8.1)^d 3(3.0) 0.174^b

IADLdependency,n(%) 10(12.5)^c 14(3.9) 0.005^b 35(46.7) 20(20.0) <0.001^b

Rombergtest(EO),pos,n(%) 1(1.3)^c 2(0.6)^c 0.458^b 5(7.1)^d 9(9.7)^d 0.554^b

Rombergtest(EC),pos,n(%) 5(6.3)^c 18(5.1)^c 0.591^b 24(36.4)^e 24(26.4)^d 0.195^b

Gripstrength,right,mean(SD) 255(112)^c 299(120)^c 0.003^a 194(89)^e 215(102)^d 0.166^a

Self-reportedhealthproblems

Historyoffall,n(%) 23(28.4) 41(11.4) <0.001^b 30(40.0) 14(14.0) <0.001^b

Dizziness,n(%) 21(25.9) 47(13.2)^c 0.004^b 19(26.0)^c 18(18.2)^c 0.229^b

Fearoffalling,n(%) 17(21.0) 36(10.1)^c 0.006^b 23(31.5)^c 27(27.0) 0.546^b

Self-reportedbalanceimpairment,n(%) 17(21.0) 33(9.2)^c 0.003^b 35(47.9)^c 23(24.2)^c 0.002^b

Fatigue,n(%) 38(46.9) 153(43.2)^c 0.532^b 49(66.2)^c 43(43.4)^c 0.004^b

Sleepingproblems,n(%) 29(35.8) 100(28.1)^c 0.165^b 35(47.3)^c 35(35.0) 0.113^b

Poorappetite,n(%) 5(6.2) 15(4.2)^c 0.392^b 7(9.7)^c 14(14.1)^c 0.372^b

Feelingnervous,n(%) 15(18.5) 54(15.3)^c 0.468^b 21(29.2)^c 18(18.4)^c 0.105^b

Hearingimpairment,n(%) 32(40.0)^c 97(27.1) 0.023^b 39(52.0) 45(45.0) 0.323^b

Visionimpairment,n(%) 28(35.0)^c 57(15.8) <0.001^b 36(48.0) 39(39.0) 0.256^b

CognitionandHRQoL

MMSE24,n(%) 5(6.2) 21(5.8) 0.799^b 17(22.7) 27(27.0) 0.489^b

SF12(PCS),mean(SD) 43.8(11.4)^d 47.0(9.4)^c 0.022^a 37.7(12.0)^e 42.4(11.4)^e 0.015^a

SF12(MCS),mean(SD) 54.1(9.8)^d 55.9(7.2)^c 0.141^a 52.5(9.0)^e 54.4(8.3)^e 0.166^a

Medications

Neuroleptics,n(%) 3(3.7) 2(0.6) 0.045^b 2(2.7) 1(1.0) 0.578^b

Sedatives,n(%) 8(9.9) 9(2.5) 0.005^b 8(10.7) 6(6.0) 0.269^b

Hypnotics,n(%) 9(11.1) 24(6.7) 0.167^b 14(18.7) 15(15.0) 0.538^b

Benzodiazepines,n(%) 9(11.1) 18(5.0) 0.067^b 13(17.3) 13(13.0) 0.441^b

Medium-andlong-actingbenzodiazepines,n(%) 6(7.4) 15(4.2) 0.244^b 7(9.3) 10(10.0) 0.866^b

SSRI,n(%) 4(4.9) 11(3.1) 0.493^b 4(5.3) 2(2.0) 0.405^b

Boldvaluesindicatesstaticallysignificantp-value0.05.

aStudent’st-test.

b Chi²-test.

cMissingvalue:0.5–1.9(0.5-5%).

d Missingvalue:6.7–9.3%.

eMissingvalue:12.0–14.0%.

theregression models.The statistical analyseswere performed usingSPSS17.0(Chicago,IL,USA).

3. Results

3.1. Prevalenceoffallsandassociatedfactors

At baselineatotal of23.2%of subjectsreportedfalls,those underaged 80reported a prevalence of 16.5% and those 80+

years 31.7% (Fig. 1). Many of the baseline variables were significantly associated in the expected direction and with higherprevalenceratesinthose80+yearsexceptdizzinessthat showedthesameprevalencerateinyoungerandolderfallers, i.e.26% (Table2).

Inthoseunderaged80afallwassignificantlyassociatedwith higherage,ADLdependency,reducedgripstrength,a historyof fallinganddizziness,fear offalling,balance,hearingand vision impairmentandreducedphysicalHRQoLintheexpecteddirection (Table 2). Significant differencesbetween thegroups regarding medicationwereseeninneurolepticsandsedatives(Table2).

In those 80+ years a fall was at the 3-year follow-up significantly associated with higher age, IADL dependency, Romberg test EC, a history of falling, fear of falling, balance impairment,fatigue,hearingandvisionimpairmentandreduced HRQoL(Table1).Astatisticallysignificantdifferencewasalsoseen

inhypnotics, allbenzodiazepinesand medium-andlong acting benzodiazepines(Table1).Atthe6-yearfollow-up(Table2)IADL dependency,ahistoryoffalling,balanceimpairment,fatigueand reduced physical HRQoL was associated with a higher risk for falling.

3.2. Prevalenceofdizzinessandassociatedfactors

Atbaseline23.6%ofsubjectsreporteddizziness,17.8%inthose under aged 80 and 31.0% in those 80+ years (Fig. 1). The independentfactorsshowedahigherprevalencerateintheolder agegroupexceptsleepingproblemswith47%intheyoungerage group compared with 41% in the older (Table 4). Variables significantlyassociatedwithdizzinessinthoseunderaged80were higher age, female gender, reduced grip strength, a history of falling ordizziness, fearof falling,balance impairment,fatigue, sleeping problems, poor appetite, feeling nervous, vision im- pairment, reduced HRQoL, hypnotics, all benzodiazepines and medium-andlongactingbenzodiazepines(Table4).Inthose80+

yearssignificantassociationsintheexpecteddirectionatthe3- yearfollow-upwereseenin gender, IADLdependency,reduced gripstrength,ahistoryoffallingordizziness,fearoffalling,balance impairment,fatigueandreducedphysicalHRQoL(Table3).Atthe 6-yearfollow-upIADLdependency,ahistoryoffallingordizziness, balanceimpairment,fatigue,feelingnervousandreducedHRQoL

Table3

Baselinecharacteristicsofsubjectsolderthan80yearsofagewithandwithoutdizzinessatthe3-yearfollow-up.

80+years(n=224) Yes

n=80

No n=144

p-Value

Socio-demographicvariables

Age,mean(SD) 84.3(2.5) 83.7(3.2) 0.126^a

Gender,female,n(%) 52(65.0) 74(51.4) 0.049^b

Community-dwelling,n(%) 78(100.0)^c 144(100.0) N/A^b

Functionalcapacity

PADLdependency,n(%) 5(6.3) 3(2.1)^c 0.139^b

IADLdependency,n(%) 31(38.8) 30(20.8) 0.004^b

Rombergtest(EO),pos,n(%) 5(7.2)^e 9(7.0)^d 1.000^b

Rombergtest(EC),pos,n(%) 22(32.4)^e 40(31.5)^d 0.903^b

Gripstrength,right,mean(SD) 191(78)^e 222(101)^d 0.018^a

Self-reportedhealthproblems

Historyoffall,n(%) 22(41.5)^g 18(16.2)^f <0.001^b

Dizziness,n(%) 45(56.3) 12(8.3) <0.001^b

Fearoffalling,n(%) 34(43.0)^c 32(22.9)^c 0.002^b

Self-reportedbalanceimpairment,n(%) 48(61.5)^c 34(24.6)^c <0.001^b

Fatigue,n(%) 54(67.5) 72(50.0) 0.011^b

Sleepingproblems,n(%) 37(47.4)^c 52(36.1) 0.100^b

Poorappetite,n(%) 10(12.8)^c 15(10.4) 0.589^b

Feelingnervous,n(%) 22(27.8)^c 24(16.8)^c 0.051^b

Hearingimpairment,n(%) 43(53.8) 65(45.1) 0.217^b

Visionimpairment,n(%) 41(51.3) 55(38.2) 0.059^b

CognitionandHRQoL

MMSE24,n(%) 13(16.3) 20(13.9) 0.633^b

SF12(PCS),mean(SD) 38.3(10.9)^e 42.0(10.8)^d 0.023^a

SF12(MCS),mean(SD) 53.0(10.1)^e 54.5(8.1)^d 0.264^a

Medications

Neuroleptics,n(%) 2(2.5) 1(0.7) 0.291^b

Sedatives,n(%) 5(6.3) 11(7.6) 0.699^b

Hypnotics,n(%) 16(20.0) 22(15.3) 0.367^b

Benzodiazepines,n(%) 10(12.5) 20(13.9) 0.770^b

Medium-andlong-acting 9(11.3) 14(9.7) 0.718^b

Benzodiazepines,n(%)

SSRI,n(%) 2(2.5) 4(2.8) 1.000^b

Boldvaluesindicatesstaticallysignificantp-value0.05.

aStudent’st-test.

bChi²-test.

cMissingvalue:0.7–4.2%.

dMissingvalue:6.9–11.8%.

eMissingvalue:13.8–17.5%.

f Missingvalue:22.9%.

gMissingvalue:33.8%.

wereassociatedwithahigherriskoffalling(Table4).Therewasno significantdifferenceintheolderagegroupbetweenthosewith and without dizziness regarding any of the medications used (Tables3and4).

3.3. Predictorsoffalls

ThepredictorsoffallsareshowninTable5.Themultivariate logistic regression showed significant ORs with regard to the Table4

Baselinecharacteristicsofsubjectsyoungerandolderthan80yearsofagewithorwithoutdizzinessatthe6-yearfollow-up.

Underaged80(n=531) 80+years(n=146)

Yes n=114

No n=417

p-Value Yes

n=58

No n=88

p-Value

Socio-demographicvariables

Age,mean(SD) 69.4(6.3) 67.0(6.2) <0.001^a 83.2(2.5) 83.2(2.6) 0.985^a

Gender,female,n(%) 84(73.7) 213(51.1) <0.001^b 40(69.0) 48(54.5) 0.081^b

Community-dwelling,n(%) 112(100.0)^c 415(100.0)^c N/A^b 57(98.3) 87(100.0)^c 0.400^b

Functionalcapacity

PADLdependency,n(%) 3(2.7)^c 4(1.0)^c 0.172^b 2(3.4) 1(1.1) 0.563^b

IADLdependency,n(%) 4(3.5) 18(4.3) 1.000^b 15(25.9) 10(11.4) 0.023^b

Rombergtest(EO),pos,n(%) 0(0.0) 4(1.0)^c 0.587^b 4(7.8)^d 4(5.1)^d 0.711^b

Rombergtest(EC),pos,n(%) 8(8.0)^d 29(7.4)^c 0.839^b 13(26.5)^d 19(24.1)^d 0.753^b

Gripstrength,right,mean(SD) 224(97)^c 303(116)^c <0.001^a 201(89)^c 223(103)^c 0.200^a

Self-reportedhealthproblems

Historyoffall,n(%) 19(23.5)^f 38(11.5)^e 0.005^b 13(32.5)^f 7(10.4)^e 0.005^b

Dizziness,n(%) 46(40.4) 40(9.6) <0.001^b 25(43.1) 10(11.4) <0.001^b

Fearoffalling,n(%) 29(25.4) 37(8.9)^c <0.001^b 20(35.1)^c 20(22.7) 0.104^b

Self-reportedbalanceimpairment,n(%) 32(29.1)^c 34(8.3)^c <0.001^b 24(42.9)^c 21(24.7)^c 0.024^b

Fatigue,n(%) 69(61.1)^c 158(38.1)^c <0.001^b 37(63.8) 37(42.0) 0.010^b

Sleepingproblems,n(%) 53(46.9)^c 100(24.0) <0.001^b 24(41.4) 31(35.2) 0.453^b

Poorappetite,n(%) 14(12.4)^c 15(3.6) <0.001^b 10(17.5)^c 9(10.2) 0.202^b

Feelingnervous,n(%) 31(27.9)^c 48(11.6)^c <0.001^b 19(32.8) 11(12.5) 0.003^b

Hearingimpairment,n(%) 41(36.0) 123(29.6)^c 0.190^b 30(51.7) 36(40.9) 0.199^b

Visionimpairment,n(%) 35(30.7) 87(20.9)^c 0.028^b 28(48.3) 37(42.0) 0.459^b

CognitionandHRQoL

MMSE24,n(%) 5(4.4) 20(4.8) 0.855^b 7(12.1) 10(11.4) 0.897^b

SF12(PCS),mean(SD) 42.0(10.4)^c 47.9(9.1)^c <0.001^a 38.1(12.2)^d 43.7(10.3)^d 0.005^a

SF12(MCS),mean(SD) 53.8(9.5)^c 56.5(6.8)^c 0.005^a 52.4(10.2)^d 55.7(7.9)^d 0.035^a

Medications

Neuroleptics,n(%) 2(1.8) 3(0.7) 0.293^b 1(1.7) 1(1.1) 1.000^b

Sedatives,n(%) 8(7.0) 14(3.4) 0.108^b 3(5.2) 4(4.5) 1.000^b

Hypnotics,n(%) 15(13.2) 19(4.6) 0.001^b 9(15.5) 14(15.9) 0.949^b

Benzodiazepines,n(%) 13(11.4) 17(4.1) 0.003^b 6(10.3) 11(12.5) 0.691^b

Medium-andlong-actingbenzodiazepines,n(%) 11(9.6) 12(2.9) 0.004^b 4(6.9) 8(9.1) 0.764^b

SSRI,n(%) 7(6.1) 10(2.4) 0.066^b 3(5.2) 3(3.4) 0.682^b

Boldvaluesindicatesstaticallysignificantp-value0.05.

aStudent’st-test.

b Chi²-test.

cMissingvalue:0.2–6.0%.

d Missingvalue:7.9–15.5%.

eMissingvalue:20.6–23.9%.

f Missingvalue:28.9–31.0%.

Table5

Predictorsoffallsinsubjectsyoungerandolderthan80yearsofageinthe3and6-yearfollow-ups.

Finalmodel OR^a,b,c 95%CIforOR p-Value CrudeOR 95%CIforcrudeOR p-ValueforcrudeOR

Underaged80

6-yearfollow-up(n=438)

Neuroleptics 10.82 1.62–72.15 0.014 6.88 1.13–41.90 0.036

PADLdependency 6.58 1.00–43.18 0.050 9.37 1.68–52.08 0.011

Historyoffalling 2.63 1.42–4.89 0.002 3.08 1.72–5.52 <0.001

Visionimpairment 2.29 1.28–4.09 0.005 2.86 1.67–4.91 <0.001

Higherage 1.05 1.01–1.09 0.022 1.07 1.03–1.11 <0.001

80+years

3-yearfollow-up(n=233)

Historyoffalling 2.05 1.10–3.82 0.024 2.09 1.16–3.75 0.013

Fatigue 2.00 1.12–3.58 0.019 0.44 0.25–0.26 0.004

Higherage 1.16 1.07–1.26 <0.001 0.00 1.07–1.26 <0.001

6-yearfollow-up(n=174)

Historyoffalling 3.18 1.49–6.80 0.003 4.10 1.97–8.50 <0.001

IADLdependency 2.72 1.35–5.47 0.005 3.50 1.80–6.82 <0.001

Boldvaluesindicatesstaticallysignificantp-value0.05.

Dependentvariable(falls)codedas:0=nofalls,1=falls.

aHosmerandLemeshowgoodness-of-fittest:underaged80p=0.886,80+years3-yearsp=0.4206-yearsp=0.406.

b NagelkerkeR²:underaged800.138,80+years3-years0.1536-years0.167.

cVariablesatbaselineenteredintotheregressionanalysis(manualbackward):3-year:age,IADL,RombergEC,historyoffall,fearoffalling,self-reportedbalance impairment,fatigue,hearing,vision,hypnotics.6-year:underaged80:age,IADL,gripstrength,historyoffall,dizziness,fearoffalling,self-reportedbalanceimpairment, hearing,vision,neuroleptics,sedatives.80+years:IADL,historyoffall,self-reportedbalanceimpairment,fatigue.