Association of depressive symptoms with recurrent falls: A cross-sectional elderly population based study and a systematic review

Abstract

Background

Screening of depressive symptoms is recommended in recurrent fallers. Compared to the 30-item and 15-item Geriatric Depression Scales (GDS), the 4-item GDS is easier to administer and quicker to perform. The association between abnormal 4-item GDS score and recurrent falls has not yet been examined, hi addition, while depressive symptoms-related gait instability is well known, the association with recurrent falls has been few studied.

Objective

1) To examine the association between abnormal 4-item GDS score and recurrent falls in community-dwelling older adults using original data from health examination centers (HEC) of French health insurance of Lyon, and 2) to perform a systematic review of studies that examined the association of depressive symptoms with recurrent falls among older adults.

Methods

Firstly, based on a cross-sectional design, 2,594 community-dwellers (mean age 72.1±54years; 49.8% women) were recruited in HEC of Lyon, France. The 4-item GDS score (abnormal if score>l) and recurrent falls (i.e., 2 or more falls in the past year) were used as main outcomes. Secondly, a systematic English and French Medline literature search was conducted on May 28, 2012 with no limit of date using the following Medical Subject Heading (MeSH) terms “Aged OR aged, 80 and over”, “Accidental falls”, “Depressive disorder” and “Reccurence”. The search also included the reference lists of the retrieved articles.

Results

A total of 19.0% (n=494) participants were recurrent fallers in the cross-sectional study. Abnormal 4-item GDS score was more prevalent among recurrent fallers compared to non-recurrent fallers (44.7% versus 25.0%, with P<0.001), and was significantly associated with recurrent falls (Odd ratio (OR)=1.82 with P<0.001 for full model; OR=1.86 with P<0.001 for stepwise backward model). In addition to the current study, the systematic review found only four other studies on this topic, three of them examining the association of depressive symptoms with recurrent falls using 30-item or 15-item GDS. All studies showed a significant association of depressive symptoms with recurrent falls.

Conclusions

The current cross-sectional study shows an association between abnormal 4-item GDS score and recurrent falls. This association of depressive symptoms with recurrent falls was confirmed by the systematic review. Based on these results, we suggest that recurrent falls risk assessment should involve a systematic screening of depressive symptoms using the 4-item GDS.

Introduction

The prevalence of depression is high in older adults and has been estimated around 30% (1). Depression imposes high costs on public health and social services due to adverse consequences including gait and balance disorders (2). For instance, depression-related inability to maintain a stable walking pattern has been reported, which may lead to gait unsteadiness and thus to a high risk of falls (2, 3). Although the adverse impact of depressive symptoms on gait stability is well-described, the association with recurrent falls -defined as two or more falls in a 12-month period- has been few studied. Interestingly, it has been reported that depressive symptoms evaluated with the 30-item and 15-item Geriatric Depression Scales (GDS) could explain the recurrence of falls (4, 5).

Fall risk assessment is the first step towards efficient fall prevention strategies (1, 2, 6, 7) and, thus, should include an evaluation of depressive symptoms, as underlined in the last guidelines for the management of recurrent falls published by the French Society of Geriatrics and Gerontology (7). Unfortunately, physicians miss depressive symptoms in a substantial proportion of their patients, especially because the evaluation of depression is time-consuming and thus not easy to administer in daily practice (6., 7., 8., 9.). Compared to the 30-item and 15-item GDS, the 4-item GDS is easier to administer and quicker to perform (4, 5, 10). Therefore, it may advantageously replace longer scales for the screening of depressive symptoms in clinical routine while assessing the risk of falls.

The association between abnormal 4-item GDS score and recurrence of falls has not yet been shown. We hypothesized that an abnormal 4-item GDS score (i.e., ≥1) could be associated with the recurrence of falls (i.e., ≥ 2 falls in a 12-month period) in older adults. In addition, because depressive symptoms have not received yet a structured critical evaluation as a risk factor for recurrent falls, we also hypothesized that a critical analysis of the literature could help to better understand the association of depressive symptoms and recurrent falls. The aim of this study was 1) to examine the association between abnormal 4-item GDS score and recurrent falls among community-dwelling older adults using original data from health examination centers (HEC) of French health insurance of Lyon, and 2) to perform a systematic review of studies that examined the association of depressive symptoms and recurrent falls among older adults.

Methods

Original study

Participants

Between August 2008 and October 2010, 2,594 community-dwelling volunteers aged 65 and older were recruited in HEC of French health insurance of Lyon, localized in Eastern France, during a free medical examination. The exclusion criterion was an acute medical illness in the past 3 months.

Clinical assessment

Participants underwent a full medical examination. The use of psychoactive drugs including benzodiazepines, antidepressants or neuroleptics, and the number of drugs daily taken were recorded. Body mass index (BMI, in kg/m²) was calculated based on anthropometry measurements (i.e., weight in kg and height in m). Lower limb proprioception was evaluated with a graduated diapason placed on the tibial tuberosity. The mean value obtained for the left and right sides was used in the present data analysis. Distance binocular vision was measured at 5 m with a standard Monoyer letter chart (11). Vision was assessed with corrective lenses on if used by the subject. The maximal isometric voluntary contraction (MVC) strength of handgrip was measured with computerized hydraulic dynamometers (Martin Vigorimeter, Medizin Tecnik, Tutlingen, Germany). The test was performed one time on each side. The highest MVC value recorded was used in the present data analysis. Cognitive function was assessed using the clock drawing test (12). Cognitive decline was considered while the test was abnormal. Depression was evaluated with the use of the 4-item GDS score (10). A score ≥1 indicated the presence of depressive symptoms. The participants were interviewed using a standardized questionnaire, gathering information on the history of falls over the past year. This face-to-face interview was based on 22 standardized questions exploring the number, delay and place of falls (i.e., inside or outside the participant’s house), the evoked causes and circumstances of falls (i.e., syncope or other acute medical event, body transfer from sit position or walking or other physical activities such as cycling), and all physical traumatisms and inability to get up from ground after a fall. A fall was defined as an event resulting in a person coming to rest unintentionally on the ground or at other lower level, not as the result of a major intrinsic event or an overwhelming hazard. Thus, falls resulting from acute medical events and/or external force were excluded from the analysis. The study was conducted in accordance with the ethical standards set forth in the Helsinki Declaration (1983). All participants provided written informed consent and the entire study protocol was approved by the Lyon Ethical Committee.

Statistics

The participants’ baseline characteristics were summarized using means and standard deviations or frequencies and percentages, as appropriate. Normality of data distribution was checked using skewness-kurtosis test. As the number of observations was > 40 for each group, no transform was applied. Participants were classified into two groups: those who reported ≥2 falls over the past year and those who had one or no (<2) fall. Comparisons between both groups were performed using Wilcoxon matched-pairs signed-ranks test, Student’s t-test or Chi-square test, as appropriate. Multiple (i.e., full adjusted model and stepwise backward method) logistic regressions were used to examine the association between abnormal 4-item GDS score (i.e., ≥1; independent variable) and history of recurrent falls (i.e., ≥2 in the past year; dependant variable) while considering the effects of potential confounders. P-values less than 0. 05 were considered as statistically significant. All statistics were performed using the SPSS statistics program (version 17.0; SPSS, Inc., Chicago, IL).

Systematic Literature search

A detailed literature search was conducted to identify articles published in the English and French language evaluating the association of depressive symptoms with recurrent falls among older adults. MEDLINE electronic database was used for the search, which was conducted on May 28, 2012 with no restriction of date. The following Medical Subject Heading (MeSH) terms “Aged OR aged, 80 and over”[MeSH], “Accidental falls”[MeSH], “Depressive disorder”[MeSH] and “Reccurence”[MeSH]. An iterative process was used to ensure all relevant articles had been obtained. A further hand search of bibliographic references of extracted papers and existing reviews was also conducted to identify potential studies not captured in the electronic database searches.

One member of the team (CL) screened abstracts from the initial search and obtained articles deemed potentially relevant. The abstracts were independently evaluated by two reviewers (CL and OB) to determine if they met the inclusion criteria for full review. Initial screening criteria for the abstracts were: 1) observational studies (cohort, case-control and cross-sectional studies were included), 2) depression or depressive symptoms and fall used as outcomes, 3) participants without neurological diseases such as Parkinson disease explaining gait instability and related falls and 4) aged 60 years and older. The full articles were lastly screened, using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist method criteria for observational studies, for the inclusion of recurrent falls (i.e., ≥2 in a 12-month period) as an outcome. The definition of fall was an event resulting in a person coming to rest unintentionally on the ground or at other lower level, not as the result of a major intrinsic event or an overwhelming hazard. The study selection is shown on a flow diagram (Figure 1). Articles selected for the full review had the following information extracted: authors, date of publication, study design, setting and study population, depressive symptoms and recurrent falls information.

Figure 1.

Flowchart of the literature search for the selection of studies to be included in the systematic review

Results

Among the studied sample of participants of Lyon HEC, 19.0% (n=494) participants were recurrent fallers. Recurrent fallers were older (P=0.006), more frequently women (P<0.001), took more drugs per day (P<0.001), use more frequently psychoactive drugs (P<0.001), had a lower distance vision score (P<0.001) and handgrip strength (P<0.001) than non-recurrent fallers (Table 1). In addition, an abnormal 4-item GDS score was more prevalent in the group of recurrent fallers than in the other group (44.7% versus 25.0%, with P<0.001). There were no between-group significant differences with regards to the other clinical characteristics. Table 2 displays the results of the multivariate logistic regression analysis. The female gender (Odd ratio (OR)=1.65 with P<0.001 for full adjusted model, and OR=1.67 with P<0.001 for stepwise backward model), the number of drugs daily taken (OR)=1.08 with P<0.001 for full and stepwise backward model) and an abnormal 4-item GDS score (OR=1.82 with P<0.001 for full adjusted model, and OR=1.86 with P<0.001 for stepwise backward model) were positively associated with recurrent falls, whereas a high distance vision score (OR=0.95 with P=0.020 for full adjusted model, and OR=0.95 with P=0.025 for stepwise backward model) was negatively associated with recurrent falls.

Table 1.

Participants’ baseline characteristics (n=2594) and comparison of participants classified into two groups according to the history of recurrent falls^* over the last 12 months

	< 2 fall (n=2100)	≥ 2 falls (n=494)	P-Value†
Age, mean ± SD (years)	71.9 ± 5.3	72.7 ± 5.8	0.006
Female, n (%) Number of drugs per day, mean ± SD	956 (45.5) 2.8 ± 2.4	335 (67.8) 3.8 ± 2.9	<0.001 <0.001
Use of psychoactive drugs ‡ n (%)	1722 (82.0)	350 (70.9)	<0.001
Body mass index, mean ± SD (kg/m2)	26.3 ± 4.0	26.4 ± 4.3	0.400
Lower limb proprioception score || (/8)	5.3 ± 2.1	5.4 ± 1.8	0.174
mean ± SD
Distance vision acuity § (/10), mean ± SD	7.7 ± 2.3	7.3 ± 2.5	<0.001
Handgrip strength ¶ (N.m-2), mean ± SD	30.5 ± 11.7	25.5 ± 9.9	<0.001
Cognitive decline #, n (%)	556 (26.5)	149 (30.2)	0.103
Abnormal 4-item GDS score **, n (%)	526 (25.0)	221 (44.7)	<0.001

GDS: Geriatric Depression Scale;

^*: At least 2 falls over the last 12 months; †: Based on Wilcoxon matched-pairs signed-ranks test, Student’s t-test or Chi-square test, as appropriate ‡: Use of benzodiazepines or antidepressants or neuroleptics; ||: Mean value of left and right side and based on graduated diapason placed on the tibial tuberosity; §: Binocular vision acuity at distance of 5 m with a standard Monoyer letter chart; ¶: Mean value of the highest value of maximal isometric voluntary contraction strength measured with computerized dynamometers expressed in Newton per square meter; #: Abnormal Clock drawing test;

^**: 4-item GDS score ≥ 1

Table 2.

Multiple logistic regression analysis showing the association between abnormal 4-item GDS score (independent variable) and recurrent falls^* (dependent variable) adjusted for participants’ baseline characteristics (n=2594)

	Full adjusted model OR [95%CI] (P-Value)	Stepwise backward model OR [95%CI] (P-Value)
Age	1.00 [0.98-1.03]	−
	(0.712)
Female	1.65 [1.21-2.25]	1.67 [1.23-2.26]
	(0.001)	(0.001)
Number of drugs per day	1.08 [1.05-1.15]	1.08 [1.06-1.14]
	(<0.001)	(<0.001)
Use of psychoactive drugs†	0.93 [0.72-1.21]	−
	(0.590)
Body mass index	1.01 [0.99-1.04]	−
	(0.409)
Lower limb proprioception score ‡	1.05 [0.99-1.09]	−
	(0.083)
Distance vision acuity ||	0.95 [0.91-0.99]	0.95 [0.91-0.99]
	(0.020)	(0.025)
Handgrip strength §	0.98 [0.78-1.23]	0.99 [0.97-1.00]
	(0.867)	(0.050)
Cognitive decline ¶	0.98 [0.78-1.23]	−
	(0.867)
Abnormal 4-item GDS score #	1.82 [1.46-2.27]	1.86 [1.50-2.30]
	(<0.001)	(<0.001)

OR: Odds Ratio; GDS: Geriatric Depression Scale;

^*: At least 2 falls over the past 12 months; †: Use of benzodiazepines or antidepressants or neuroleptics; ‡: Mean value of left and right side and based on graduated diapason placed on the tibial tuberosity; ||: Binocular vision acuity at distance of 5 m with standard Monoyer letter chart; §: Mean value of the highest value of maximal isometric voluntary contraction strength measured with computerized dynamometers expressed in Newton per square meter; ¶: Abnormal Clock drawing test; #: 4-item GDS score ≥ 1

For the systematic review, a total of 63 abstracts were identified as potentially relevant based on the key search terms and the hand search of bibliographic references. Eight of the 63 identified abstracts were first identified after screening using the initial inclusion criteria. Review of the full text papers resulted in the further exclusion of 4 manuscripts because recurrent falls were not an outcome. The remaining 4 observational studies were included in this systematic review (4, 5, 13, 14) and were summarized in Table 3. Among selected studies, the number of participants ranged from 134 to 1261 (7, 16). The majority of studies (n=3) examined the association of depressive symptoms with recurrent falls using 30 or 15-item GDS. On study used the Center for Epidemiological Studies-Depression scale (CES-D) (13). Three studies focused on community-dwellers (5, 13, 14), one on older inpatients (4). Women represented from 57.4% to 78.7% of the studied populations (5, 14). Two studies were cross-sectional (4, 5) and the two others used a cohort design (13, 14). All studies showed a significant association between depressive symptoms and recurrent falls (4, 5, 13, 14).

Table 1.

Summary of main characteristics of the studies included in the systematic review

References	Design / settings / population	Outcomes Depressive symptoms	Recurrent falls	Association of depressive symptoms and recurrent falls
Retrospective studies Somader et al.; 2007 (4)	− Cross-sectional - Inpatients - N= 134 (67 recurrent fallers; 67 non-recurrent fallers) - Mean age: recurrent fallers 82.5±5.5; non recurrent fallers 81.7±6.9 - Women, (%): recurrent fallers (61.2); non recurrent fallers (64.2)	− 30 items GDS - Depressive symptoms if score ≥ 10/30	− Non-standardized definition - Self-reported - ≥ 2 falls	− Yes - Prevalence of depressive symptoms higher in recurrent fallers than non recurrent fallers (44.8% versus 26.9%, P=0.03) - OR=1.4 (1.2-1.7) with P<0.001)
Wada et al.; 2008 (5)	− Cross-sectional - Community-dwelling - N= 1261 (399 fallers; 862 non fallers) - Mean age: fallers 76.9±7.5; non fallers 74.7±6.9 - Women (%): fallers (59.8); non fallers (57.4)	− 15 items GDS - Depressive symptoms if score ≥ 10/15	− Non-standardized definition - Self-reported - Number of falls	− Yes - Correlation between number of falls and GDS-15 score (P=0.002)
Prospective studies Biderman et al.; 2002 (14)	− Cohort study - Follow-up period: 1 year - Community-dwelling - N= 283 (34 recurrent fallers; 249 non-recurrent fallers) - Aged ≥60 years and over - Women (%): (58.0)	− 15 items GDS - Depressive symptoms if score ≥ 7/15	− Standardized definition - Self-reported - ≥ 2 falls	− Yes - RR=2.83 (1.50-5.34) with P<0.01
Anstey et al.; 2008 (13)	− Cohort study - Follow-up period: 8 years - Community-dwelling - N= 787 - Aged ≥70 years and over - Women (%): recurrent fallers (78.7); non fallers (53.8)	− 60 items CES-D - No cut-off value defined	− Standardized definition - Self-reported - ≥ 2 falls	− Yes - Higher CES-D score in recurrent fallers than non fallers (8.9±7.6) versus 6.3±6.2, P=0.001 - IRR=1.03 (1.02-1.04) with P<0.001

GDS: Geriatric depression scale; OR: odds ratio, RR: Relative risk; CES-D: Center for Epidemiological Studies-Depression scale IRR: incident rate ratio

Discussion

We found in the current cross-sectional study that female gender, high number of drugs daily taken, low distance vision and abnormal 4-item GDS score (i.e., score ≥1) were associated with recurrent falls. The latter finding is confirmed by the systematic review that underlines a significant association of depressive symptoms with recurrent falls. These findings highlight that the screening of depressive symptoms should be performed while evaluating the risk of recurrent falls, and that the shortest version of GDS (i.e., 4-item GDS) may be helpful while assessing the risk of the recurrent falls in community-dwelling older adults.

The main finding of our cross-sectional study was that depressive symptoms evaluated with 4-item GDS score were associated with recurrent falls. This is in concordance with studies selected in the systematic review, which highlighted that depressive symptoms were risk factors of recurrent falls (4, 5, 13, 14). The reported association between depressive symptoms and recurrent falls was independent of other risk factors for falls. Indeed, in the current original study as well in prior studies, analyses were adjusted on potential confounders such as age, gender, comorbidities, psychoactive drugs or cognitive decline (4-6, 13, 14).

The threshold of GDS score used to identify depressive symptoms changed across studies. While Somader et al. (4) and Biderman et al. (14) chose a threshold including mild depressive symptoms, Wada et al. (5) selected only individuals with severe depressive symptoms. The result of our cross-sectional study is in concordance with the fact that mild depressive symptoms were associated with recurrent falls. Indeed, 4-item GDS is a scale with a binary results (i.e., depressive symptoms or not) without distinction between levels of severity of symptoms while positive. In addition, it appears that using a simple scale like 4-item GDS did not reduce the magnitude of the association between depressive symptoms and recurrent falls. The OR calculated at approximately 1.8 in the current study is in the range of previous published data.

The association of depressive symptoms and recurrence of falls may be explained by depression-related gait disorders. Indeed, falling usually results from gait disorders (2, 15., 16., 17., 18.). A strong association between gait and mood has been reported (18., 19., 20.). The negative mood may induce gait disturbances; depressed patients walked slower than healthy controls with a lower stride length, a higher double limb support, and a longer gait cycle duration (3, 9). Also, persons with high positive mood are less likely to develop slow gait speed than those in low positive mood (19). Although depression-related changes in gait patterns are well characterized, little is known about pathophysiological mechanisms. Some authors suggested that deficiencies in the motor control system might occur during depression (3, 9, 20). A cerebral network connecting amygdala - the center for integrating pleasant and unpleasant emotions - to basal ganglia and frontal cortex may be involved (18., 19., 20., 21.).

The presence of such an organic cerebral network is in favor of a causal relationship between depression and recurrent falls.

The efficiency and cost-effectiveness of falls prevention strategies require two consecutive steps (7, 8, 18). First step is the identification of older adults with high risk of recurrent falls and/or adverse consequences; second step is the determination of an adapted intervention (8, 16, 18). However, application of fall prevention strategies proves challenging, especially in primary care and among non-geriatricians because multi-factorial fall risk assessment is often complex and time-consuming, and thus not easy to implement in clinical routine. 4-item GDS is easier to administer and quicker to perform compared to 30-item and 15-item GDS (10). What is more, as reported in the present study, 4-item GDS was successfully performed in the largest sample of community-dwellers so far (n=2594) which is the biggest reported to the best of our knowledge. Therefore, we suggest that it could be successfully used for the assessment of the risk of recurrent falls in community-dwelling older adults. This point is particularly important because older fallers with depressive symptoms are at high risk of fall-related adverse events including fractures, as reported in a recent meta-analysis on 14 cohort studies (22). One explanation for this association between depression and fractures could be based on a higher bone loss in patients with depressive symptoms compared to their healthy counterparts (23). However, based on results of the current cross-sectional study and of the systematic review, we suggest that another explanation may rely on the higher occurrence of recurrent falls among depressed older adults, for example because of the use of psychoactive medication. Of note, we have previously showed that the use of benzodiazepines and antidepressants was associated in older adults with a loss of gait stability, illustrated by increased gait variability (24), resulting in a higher risk of falls (25).

In line with previous studies, we showed in our cross-sectional study that female gender was associated with recurrent falls (15, 16, 26). A greater loss of fat-free in women compared to men mass with aging and the gender-related differences in circumstances of falls could explain a higher recurrence of falls in women compared to men (15, 17, 26., 27., 28.).

Our results also showed that polypharmacy was associated with the recurrence of falls. Polypharmacy may be considered as a surrogate measure of comorbidities, which may affect postural stability and increases the risk of falling (2, 15, 16, 22). A large proportion of falls in the elderly occurs while walking or standing up and sitting down (16, 17). An efficient dynamic stability, defined as the ability to control the whole body position during motor activities in which the body’s center of mass is displaced outside the base of support (29, 30), is required during these daily motor activities. Human postural stability depends on the interaction of multiple sensory, motor and integrative systems (29, 30). It has been shown that the sensory system, and in particular vision, is important to keep control of body position (2, 8, 16, 26). Consistently with our findings, previous studies showed that impaired vision was related to falls and their recurrence (12, 16, 17, 26).

There were methodological limitations. Firstly, the cross-sectional design used in the current original study is not the more adapted design to examine the risk factors for recurrent falls compared to a prospective cohort study design. Secondly, although we were able to control for many characteristics likely to modify this relationship, residual potential confounders might still be present in our study. Thirdly, 30% of studied participants had a cognitive decline. Thus they may forget the occurrence of falls that could lead a recall bias (31). Fourthly, a diagnosis of depressive symptoms should not be based on GDS score alone. Although GDS scales, regardless of the number of items, have well-established reliability and validity for the diagnosis of depressive symptoms (4, 5), they should be confirmed by a psychiatrist to affirm the diagnosis of depression. Fifthly, the failure to find any inconclusive studies in the systematic review could be related to a possible publication bias of positive results and not negative.

In conclusion, the current cross-sectional study shows an association between abnormal 4-item GDS score and recurrent falls. This association of depressive symptoms with recurrent falls was confirmed by the systematic review. Based on these results, we suggest that recurrent falls risk assessment should involve a systematic screening of depressive symptoms using the 4-item GDS. Further research is needed to corroborate this finding.

Conflict of interest

There is no conflict of interest among any of the authors with this work.

Financial Disclosure(s)

The authors have no relevant financial interest in this manuscript.

Sponsor’s Role

None

Author Contributions: –

Launay has full access to the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analyses. – Study concept and design: Beauchet. – Acquisition of data: Launay and Fantino – Analysis and interpretation of data: Launay, de Decker, Annweiler, Fantino and Beauchet. – Drafting of the manuscript: Launay, Annweiler, and Beauchet. – Critical revision of the manuscript for important intellectual content: de Decker, Kabeshova and Fantino. – Statistical expertise: Beauchet and Kabeshova. – Administrative, technical, or material support: Launay and Fantino. – Study supervision: Beauchet.