ASSESSMENT OF MOBILITY AND RISK FACTORS FOR FALLS AMONG ELDERLY INDIVIDUALS

Objective: To assess functional mobility and risk factors for falls among elderly individuals cared for in a Primary Health Care center. Method: this descriptive, field study with a quantitative approach was conducted in a Primary Health Care center with a sample of 197 elderly individuals. A form was used to address the participants’ social and health characteristics, and intrinsic, extrinsic, and behavioral factors that trigger falls, along with a functional mobility test. Descriptive and inferential statistical methods were used: D’Agostino-Pearson test, Chisquare(10),Student’s t-test, and Analysis of Variance (ANOVA). Results: Most participants presented incomplete middle school (65.5%), were married (45.7%), resided with one child (54.8%), watched TV for leisure (47.2%), presented moderate self-perceived health (46.7%), and were women (70.1%). The factors related to a greater likelihood of falls are having a fracture, dislocation, or difficulty walking, inadequate lighting at home, and taking five or more medications. Conclusion: The results show that the elderly participants are at the risk of falling; however, the youngest still present appropriate functional mobility.


INTRODUCTION
Trauma is considered a public health problem and is the fifth leading cause of death in the elderly, with almost 14,000 deaths/day. Physical trauma such as falls, burns, and traffic accidents (run over or collisions) are the most frequent. Among the factors predisposing to falls, the following stand out: immobility or functional disability to perform activities of daily living, decreased muscle strength, dizziness, and chronic diseases (1) .
The consequences of falls with trauma include a potential decline in a function or the onset of a new disease, with disastrous and striking outcomes (2) . Falls are considered the primary cause of accidents among elderly individuals, impairing their health, being one of the main reasons these individuals are admitted in emergency services, and a factor that triggers institutionalization (3) . The prevalence of falls among the elderly in Brazil is 32.1%. Post-fall injuries are the 6 th leading cause of death among 65-year-old or older individuals (4) . A total of 70% of the deaths are related to falls among individuals 75+ years old (5) .
Elderly individuals are more susceptible to problems such as morphological, functional, and biochemical changes. With aging, the organism goes through changes and becomes exposed to intrinsic, extrinsic, and behavioral factors, to factors present in the individuals' environment, the individuals' perception regarding their physical environment, and reckless behavior (5,6) .
The functional balance of elderly individuals is an essential factor in keeping their autonomy, considering the aging process and functional changes. Therefore, assessing balance and functional mobility is essential to implement interventions intended to prevent falls (7) . Identifying risk factors within the Primary Health Care (PHC) sphere is essential to establish strategies to promote elderly individuals' health and support their families by enabling greater independence, autonomy, and safety to performactivities of daily living (8). Given the previous discussion, this study's objective is to assess functional mobility and risk factors for falls among elderly individuals cared for by a PHC center.

METHOD
This descriptive, field study, with a quantitative approach, was performed in a PHC center located in the administrative district of Benguí, Belém, PA, Brazil. The total population was composed of 396 elderly individuals, and the sample was determined by a probabilistic method with a significance levelat 5% and confidence levelat 95% for the sampling error, resulting in a sample of 197 elderly individuals. Inclusion criteria were being 60 years old or older, both sexes, and being registered in the PHC unit. Exclusion criteria were being unable to walk, having vestibular disorders, blindness, or other disorders that impeded the individual from taking the test. The authors developed a semi-structured interview to collect data. The interview script consisted of two stages. The first stage, intended to characterize the participants' social profile, addressed the participants' level of education, marital status, with whom they resided with, leisure, and self-perception of health. The second stage, intended to identify intrinsic, extrinsic, and behavior factors that trigger falls, was performed using the functional mobility test Timed Up & Go (TUG). Data were collected from August to October 2018.
Descriptive and inferential statistic methods were used. The qualitative variables were presented using absolute and relative frequencies.
The quantitative variables were presented using central tendency and variation measures. The normality of the quantitative variables was assessed using the D'Agostino-Pearson Test. The distribution of the qualitative variables was assessed using the Chi-square test. The quantitative variables were compared using the Student's t-test and ANOVA (Analysis of Variance). The significancelevel was established at alpha=0.05 (alpha error margin of 5%) to reject the null hypothesis. Data analysis was planned using dEASYgner version 3.0, and BioEstat version 5.3 was used in the statistical processing. In accordance to the ethical principles established by Resolution 466/2012 CNS/MS8, the participants received clarification regarding the study's objectives and signed free and informed consent forms. The Institutional Review Board at the Faculdade Metropolitana da Amazônia approved the project (Opinion report No. 3,067,316).

Participants' characterization and TUG results according to sex and age
This study presents data from n=197 elderly individuals: 70.1% (138 individuals) were women, and 29.9% (59 individuals) were men. Age ranged from 60 to 87 years old, with an average of 68 years old and a standard deviation of 7.5 years. The most frequent age range was 60 to 69 years old, with 61.4% (121 individuals). The TUG test presented a mean of 15.5 seconds and a standard deviation of 5.6 seconds. Graph 1 shows that most participants performed the test in less than 20 seconds; that is, low risk of falling. The test shows that those aged between 80 and 87 years old are more likely to fall (TUG=21.9 s), p-value<0.0001* (highly significant). On the other hand, no differences were found between individuals aged between60 and 69 years old (TUG=14 s) and between 70 and 79 years old (TUG=16s).   Regarding the intrinsic factors, the individuals with fractures, dislocation, or difficulty walking were more likely to fall (p-value<0.0001*, highly significant). Elderly individuals with a previous fall, two or more falls, hematoma, Diabetes Mellitus, problems to perform activities of daily living (ADL)/bathing, or other ADL (e.g., dressing, going to toilet, transfer, continence, feeding), or presented some hearing impairment, presented a moderate risk of falling. Only one participant presented a high risk of falling: hospitalization (TUG=31 s).

Intrinsic, Extrinsic and Behavioral Factors and Correlation with the TUG Results
Regarding extrinsic factors, the elderly individuals whose homes were inadequately lighted were more likely to fall (p-value=0.0221*, highly significant), presenting a moderate risk of falling. As for behavioral factors, the individuals taking five or more medications were more likely to fall (p-value=0.0308*, highly significant), however, the mean these individuals obtained in the TUG test was below 20 s, which corresponds to low risk of falling.

DISCUSSION
Over time elderly individuals become increasingly vulnerable to falls. This vulnerability may be linked to poor education and low economic level, considering that low income, poor education, lack of social support, and lifestyle may intensify vulnerabilities, making elderly individuals more susceptible to falls (9) . The low educational level found in this study is considered an important predisposing factor. These individuals may experience greater impairment that prevents them from performing activities of daily living, considering they have difficulties understanding measures intended to prevent falls; the higher the educational level, the greater one's ability to understand orientations concerning self-care. These individuals seek health care services, which in turn, support the prevention of falls (10) .
Family co-residency has been a source of discussion regarding the importance of supporting elderly individuals. Family support is vital in the lives of elderly individuals to meet their needs, often reflecting social and economic needs. Adult children are often caregivers, helping elderly individuals to perform daily tasks, and solving social and financial problems. Usually, the closest child assumes this role and provides concrete support, promoting a sense of security (11) .
This study shows that most of the participants usually spend their leisure time watching TV. Options of leisure tend to decrease with advanced age due to the various factors interfering in these practices such as social and economic conditions, lack of energy, low educational level, or visual/hearing impairments. Leisure activities among elderly individuals with limited mobility usually take place at home, such as watching TV or receiving visits. Individuals with higher mobility levels perform leisure activities outside the home (12) . According to the literature, self-assessment is an instrument intended to improve the health condition and access of elderly individuals to health services. The participants addressed in this study presented a negative self-perception of health. Health encompasses physical, cognitive, and emotional aspects. Poor health is considered a predictor of functional disability. It reflects feelings of frailty and insecurity, thus, becoming an important indicator of mortality, contrasting with individuals who report excellent health, relating self-perception with the actual or objective health condition (13) .
The feminization of old age was found in this study in which most participants were women. This is worth noting because it is a factor that influences the risk of falling (14) . Physiologically, women's bone mass decreases more rapidly than among men, due to decreased estrogen levels, making women more vulnerable to unwanted events. These risks are increased when there is a combination of factors such as eating disorders, morbidities, and sadness (15) .
Most participants were aged between 60 and 69 years old, an age range that is considered to be young, however, already presents risk factors. Advanced aging is the leading factor for the risk of falling,; thus, it is essential to devise strategies to prevent adverse events (8) .
The mean obtained in the TUG test was 15.5 s, which corresponds to a low risk of falling. However, when these results were correlated with age, theparticipants between 80 and 87 years old presented a higher likelihood of falling. Falls may increase ten times the risk of death among octogenarian women (16) .
As for intrinsic factors, elderly individuals with fractures, dislocations, or difficulty walking are more likely to fall. The main intrinsic factors among individuals with a previous fall include difficulty walking, change of balance, and dizziness (17) . Having a fracture caused by a fall may lead to hospitalization and bronchoaspiration due to vomiting caused by intense pain immediately after the fall, resulting in being immobilized for an indefinite time, which in turn, increases vulnerability (18) .
Intrinsic factors aggravate the health of elderly individuals because they directly influence their functional performance due to the use of medications, poor visual or auditory acuity, abnormal gait and balance, functional decline, awkward movements, or syncope (14) .
As for the extrinsic factors, elderly individuals with inadequate lighting at home are more likely to fall. It seems that most accidents due to falls occur at home, caused by lowlighting, the height of bedrooms, lack of security bars in bathrooms, or slippery or uneven floors (19) .
Regarding behavioral factors, the elderly individuals taking five or more medications are also more likely to fall, though, these individuals obtained a mean below 20 s in the TUG test, which indicates a low risk of falling. This information shows that the behavioral factor and the use of medications may increase the 6

Silva IRG, Dias CMD, Silva TP, Carvalho DN, Lima FC, Aguiar VFF
Cienc Cuid Saude 2020;19:e48469 likelihood of falling compared to other factors; however, the participants addressed in this study presented a TUG result within normal parameters. This may be related to the participants' age range, which is considered young.
People tend to present more noncommunicable chronic diseases in old age, and consequently, take multiple medications. These medications may decrease alertness and psychomotor functions due to inappropriate dosage, adverse effects, or medication interaction, resulting in muscle weakness, dizziness, arrhythmias, or postural hypotension, leading to falls (20) .
Assessing mobility and the factors that influence falls among elderly individuals is important to support clinical practice and recognize the weaknesses leading to these incidents, as well as to devise strategies to identify and intervene on these factors timely to impede or minimize falls and favor healthy aging, preserving the autonomy and independence of these individuals with quality of life.

FINAL CONSIDERATIONS
This study's findings show that the risk of falls among elderly individuals is associated with being a woman, low educational level, being married, residing with son/daughter, spending leisure time watching TV, and presenting a moderate health self-perception. The intrinsic, extrinsic, and behavioral risk factors mainly include having a fracture, dislocation, or difficulty walking; inadequate lighting; and polypharmacy, respectively. Even though the functional mobility test results were negative for the risk of falling, older elderly individuals are more likely to fall.
The results show that the elderly participants are at the risk of falling; however, the youngest still present appropriate functional mobility. This study's limitations include the number of participants and the impossibility to make comparisons between functional mobility and risk factors because the study was not conducted in other facilities, though, the findings can support other studies in the future.
It is essential to reflect upon the importance of this subject because even though it is a widely known problem, actions have not favored improved strategies intended to provide integral care to elderly individuals and their families to minimize the negative impact and complications of falls.