Commentary for falls in community-dwelling older adults with heart failure: A retrospective cohort study

The age-adjusted incidence of heart failure in the US is declining. Overall incidence and prevalence, however, are increasing. This is likely due to the growing proportion of the US population that is 70+ years of age.^1,2 Heart failure treatments have also improved, which has led to longer survival with the condition.² As survival improves, we need to pay more attention to quality of life among those living with heart failure. Falls and other frailty-related conditions are important drivers of health-related quality of life and are thus important foci for the care and management of individuals living with heart failure. The article by Lee and colleagues³ makes an important contribution to our knowledge about both heart failure and falls by highlighting their association in older adults and the need to develop fall prevention programs specific to the needs of this population. Strengths of this study include the large sample size and the ability to adjust for a number of important fall risk factors including prior falls, demographics, comorbidities, and psychiatric medications. In addition, the authors included a number of factors not often assessed when considering falls, including the impact of the physical and social environment. They also explored the association between functional risk factors (physical, cognitive, sensory, and urinary) and falls and found that while function accounts for some of this association, it does not account for all of it.

Lee and colleagues focused on heart failure as an important marker of falls among adults 65+ years of age. Recent research suggests, however, that a growing number of middle-aged and younger adults (aged 35–64 years) are dying from heart failure, likely due to high rates of hypertension, obesity, and coronary artery disease in this population.⁴ In parallel, there is a growing body of research that suggests that subgroups of middle-aged adults are at risk for falls.^5–7 White and colleagues conducted a study of falls in middle-aged women and found that those with vision impairment, incontinence, poor physical functioning, depression, pain, and fatigue were at increased risk for falls relative to women without these conditions.⁶ Other researchers have identified important subgroups of middle-aged individuals at risk for falls including persons living with HIV,^8,9 those with multimorbidity, polypharmacy, and substance use,⁹ and women.⁵ An important question, then, is whether or not heart failure is another important marker of fall risk in populations younger than 65 years of age.

Much like the work done by Lee and colleagues, large cohort studies are ideal for exploring falls and their outcomes in a variety of populations, including middle-aged and older adults. Sample sizes are large with substantial longitudinal follow-up. Lee and colleagues used data from the National Institute on Aging (NIA)-funded Health and Retirement Study, a longitudinal panel study that includes survey data from approximately 40,000 individuals.³ Participants were interviewed every two years beginning in 1992 and were sampled so as to represent the US population aged 51+ years. This is a publicly available dataset that has provided data for more than 4000 journal articles, dissertations, books, and reports. There is ample documentation on this cohort including information on sampling and methods.¹⁰ This research highlights the advantages of using existing large datasets for research. Falls are a relatively infrequent outcome among middle-aged adults and the younger old. It would be very difficult in the current funding climate to recruit enough subjects to be sufficiently powered to study falls in adults with heart failure. While there are limitations to using secondary data, they provide an excellent opportunity to conduct high-quality, longitudinal research on important outcomes. Using this work as a solid foundation, Lee and colleagues will be able to explore effective fall prevention interventions with a solid understanding of the risk factors that drive falls in this population and of how to adapt current fall prevention interventions to the needs of a population living with heart failure.