This study found that, adjusted for potential confounders, having epilepsy, cancer, depression, low back pain, and osteoarthritis is associated with an increased risk of spontaneous falls in older adults. Moreover, the ability to maintain a tandem gait for ≥ 10 s, being male, engaging in physical activity during the study, and having high serum triglyceride levels are associated with a decreased risk of falls.
Our results show that epilepsy can be associated with an increased risk of falling. Epilepsy, with or without seizures, can cause different fall-related injuries, including fractures (two-fold increase), concussion, and cranial hemorrhage [26,27,28]. One reason is directly related to the seizure episodes and loss of consciousness, while another reason is complications such as reduced bone density, dizziness/sedation, ataxia/gait disturbance (caused by hyperammonemia), and cognitive impairment caused by antiepileptic drugs [29,30,31,32]. On the other hand, low compliance with antiepileptic drugs can also lead to injuries. Antiepileptic drugs in old age have other uses as well, such as for mood disturbance and neuropathic pain [33]. Management of epilepsy in the elderly has controversial details, such as the cost-benefits of prescribing antiepileptic drugs. It seems that the best solution to decrease the risk of falling is tight medical control and consultation on avoiding risky behaviors in elders with epilepsy [28].
Based on the results of this study, it appears that one of the events that occurs in individuals with cancer is falling. More than half of diagnosed cancers occur in people over 65 years old [34, 35]. The toxic effects of chemotherapeutic treatments on different body systems may be an important cause of falls. For example, chemotherapy can cause limb neuropathy, resulting in poor balance [36]. Additionally, other complications such as muscle weakness, frailty, brain and central nervous system metastases, cognitive impairment, depression, and polypharmacy are more common in older adults with cancer [35]. Furthermore, some patients with cancer may face an increased risk of injury and fractures after falls due to factors such as osteoporosis related to parathyroid-related peptides (PTHrp), bone invasion, and metastasis [35]. Because of the nature of cancers, fall-related hospitalization can increase the mortality rate in patients. Therefore, balancing the therapeutic and toxic effects of chemotherapy, especially in high-risk patients, is recommended. Recent studies show that performing a geriatric assessment before cancer treatment could decrease its negative impacts [37].
Neurological diseases (such as Alzheimer’s disease, Parkinson’s disease, and stroke) can increase the risk of falling, and as high as 60–80% of the elderly with dementia experience falling annually. For many years, gait and postural instability were considered the major risk factors for falling; however, some studies have shown that elders’ cognitive state also plays an important role [38,39,40]. The exact link between depression and falls is unclear, but a recent study showed that isolation and depressive symptoms could increase the risk of falls by 30% [41]. Maintaining balance requires a fast and accurate response to perturbation. This response includes physiological and cognitive factors that all come together as reaction time [42,43,44]. Due to the increasing prevalence of depression, cognitive assessment must be a part of any preventive program. However, the main challenge is whether to treat depression in fall-prone elders or not. Antidepressants often have side effects such as orthostatic hypotension, impaired attention, and movement disorders. Additionally, studies have suggested polypharmacy and withdrawal syndrome as risk factors for falling [45, 46]. In this regard, other approaches like Cognitive Behavioral Therapy could be helpful [46, 47].
Musculoskeletal pains increase with aging. Back pain is more common in developing countries [48, 49]. It causes limited physical activity, reduces muscle strength, and has psychological effects such as isolation [38, 50]. Recent studies have focused on low back pain as an independent risk factor for falling [51, 52]. In a recent study, Wong et al. found that chronic lower back pain is significantly associated with osteoarthritis [53]. Patients with low back pain or osteoarthritis have extended degrees of disability, increasing the risk of falling. It also has a synergetic negative effect on the quality of life and abilities of elders [54, 55]. These two factors can also cause higher morbidity after falls, such as fractures [56]. Some studies have shown that low back pain is associated with abdominotrunkal muscle weakness, and patients with pain are predisposed to falling due to its psycho-cognitive effects [57, 58].
We suggest physical activity as a protective factor against falls among the elderly. Exercise and physical activity reduce physical and mental risk factors for falling, prevent sarcopenia, and improve balance and Body Mass Index (BMI) among underweight subjects, as past studies have shown that lower BMI increases fall risk [4]. Additionally, the elderly who exercise more often have less fear of falling as a psychological factor [59]. However, while usual physical activity is beneficial, daily activities like walking need to be a part of a comprehensive strength and balance training program to be effective, as routine life activity cannot be considered an effective tool for preventing falls [60].
We suggest a tandem gait test for assessing the risk of falling in older adults. Our results show that older adults who are able to stand for at least 10 s in the tandem gait exam are less likely to fall. Some recent studies focus on gait features as an accurate classifier for the risk of falling in older adults [61].
Our findings show that high levels of serum triglycerides could be a preventive factor for falling in older adults. The adverse effects of metabolic syndrome in middle age are not applicable to everyone. However, some findings show that in elderly people, metabolic syndrome and its related components can have a positive impact on daily and cognitive function [62]. One possible explanation is that elderly individuals with higher levels of serum triglycerides may lack other more significant risk factors such as muscle mass loss, grip strength, poor nutritional state, etc., which play a greater role in the risk of falling. Another possible explanation at the molecular level involves peroxisome proliferator-activated receptor (PPAR-gamma). PPAR-gamma plays a role in fat tissue differentiation and fatty acid metabolism. More importantly, it has an anti-inflammatory and protective role against cell apoptosis in the central nervous system and skeletal muscles [63, 64]. Further studies are needed to determine the threshold for treating high levels of serum triglycerides in individuals at high risk of falling.
Our results show that older women are more prone to falling. Despite the lower mortality rate of falls in women, conditions such as hip fractures are more common in women. One possible explanation is that the aging process in women is associated with greater muscle mass loss.
Due to the multifactorial nature of falls, we need to approach them differently and design programs that take into account the unique characteristics of each population. Studies have shown that these interventions can reduce falls by 20-40% [65]. Programs such as Stopping Elderly Accidents, Deaths & Injuries (STEADI) (designed by the CDC), the Otago Exercise Program, or the Lifestyle-integrated Functional Exercise Program focus on modifiable risk factors and include screening conducted by physicians to implement preventive measures such as medication adjustment, balance improvement, and physical therapy [60, 66, 67]. Such programs are necessary due to the increasing population of individuals over 65 years old, and especially those over 85.
Since the BEH program did not include people living in nursing homes, our findings may underestimate the rate of falls [20, 68]. Additionally, when interpreting the results, attention should be given to the cross-sectional nature of the study design and the possibility of a reverse causation phenomenon, as well as the potential presence of unknown confounding factors. Furthermore, some studies suggest that low back pain is associated with osteoarthritis, which could lead to misinterpretation if each of these factors is considered an independent risk factor for falling [51].
This study was conducted using data from a large cohort study that focused on the health of the elderly. The aim of the study was to determine the factors contributing to spontaneous falls in this population. The large number of participants and the specific target population of this cohort made it appropriate for the purpose of this study.
However, this study does have some limitations. The scope of the study did not permit a comprehensive analysis of rare diseases or risk factors like alcohol abuse. Specific subtypes of the underlying conditions mentioned, such as various types of epilepsy or specific cancer subtypes, were not examined in detail. Moreover, the absence of data on potential risk factors for falls (e.g., number of medications) limited the ability to study the impact of these factors or address their potential confounding effects. Lastly, as the study was based on cross-sectional data from the baseline measurements of the BEHP, we can only report associations and not establish causal relationships. Further research utilizing follow-up data from cohort studies is necessary to establish causal relationships.
