International Journal of Clinical Medicine, 2010, 1, 16-23
doi:10.4236/ijcm.2010.11004 Published Online August 2010 (http://www.SciRP.org/journal/ijcm)
Falls and Physical Performance among Frail
Sexagenarians and Septuagenarians
Ganesan Kathiresan, Sandra Devie, Sunnelly Velintina, Stellah Lenson, Nur Idawanny, Nur Asyikin,
Nurul Hijah
Department of Physiotherapy, School of Allied Sciences, Masterskill University College, Sabah, Malaysia.
Received August 9th, 2010; revised August 10th, 2010; accepted August 12th, 2010.
ABSTRACT
Background: In Malaysia, there are few population-based studies on the factors associated with falls, and there is a
lack of prevention of falls among older adults in primary and secondary health care, particularly in terms of physical
activity that could improve the physical performance of individuals at risk of falling. Therefore, the objective of the
present study was to determine the relationship between physical performance, the number of falls and the sociodemo-
graphic, physical, clinical and functional characteristics of older adult fallers. Methods: Cross-sectional study carried
out among 72 older adults with a history of falls in the past year, 65.3% of which were women. The participants re-
ceived care at the geriatric outpatient clinic and divided into the following groups: worst physical performance (WPP)
and best physical performance (BPP), one-time fallers (1F) and frequent fallers (2F). Sociodemographic, clinical,
physical and functional characteristics were considered as independent variables. Comparison analysis between the
groups was conducted. Results: The WPP group was older and had a higher number of illnesses and less independence
in most motor dimension tasks compared to the BPP group. The 2F group had a higher number of illnesses, less hand-
grip strength and less independence in the bowel management task in the motor dimension of the Functional Independ-
ence Measure (FIM) compared to the 1F group. Conclusions: Among older adults fallers, poor physical performance is
associated with more advanced age, more illnesses and less functional independence. Moreover, recurrent falls are
associated with more illnesses, less muscle strength and less functional independence in the bowel management task.
Keywords: Aging, Exercise, Fall, Gait
1. Introduction
Falls in older adults lead to consequences related not
only to social aspects, but also to economic, physical and
psychological aspects of the individual’s life [1]. The
incidence of falls in individuals over 60 years of age
stands out due to the fact that the consequences of a fall
can be complex and lead older adults to conditions of
morbidity, mortality and dependence in the activities of
daily living (ADLs) [2-4]. Falls are a significant cause of
morbidity and mortality among the elderly [5].
According to the literature, changes in the mobility of
older adults result from environmental factors, physio-
logical modifications associated with the aging process,
or even from the consequences of the lifestyle adopted by
the individual throughout his life [6-8]. The decline in
physical capacity is related to the reduction in muscle str-
ength, to impairments in gait performance and to changes
in static balance [9,10]. These parameters can vary acco-
rding to the individual’s socio demographic, physical and
functional characteristics, and they are linked to falls be-
cause falling can result from the body instability caused
by this decline.
Older adults often seek outpatient care to treat these
consequences that affect the functionality and quality of
life of this age group. Studies of this nature are important
because they describe the profile of the older adults that
are at greater risk of falling, which can prevent the oc-
currence of this event, maintain a standard of quality of
life for older adults and reduce costs to the country’s
public health systems [11,12].
In Malaysia, there are few population-based studies on
the factors associated with falls, and there is a lack of pr-
evention of falls among older adults in primary and se-
condary health care [13], particularly in terms of physical
activity that could improve the physical performance of
individuals at risk of falling. Therefore, the objective of
the present study is to determine whether there is a rela-
tionship between physical performance, the number of
falls and the socio demographic, physical, clinical and

Falls and Physical Performance among Frail Sexagenarians and Septuagenarians
17
functional characteristics of older adult fallers.
2. Materials and Methods
This is a cross-sectional study, in which the sample was
composed of male and female Sexagenarians (60 to 69
years) and Septuagenarians (70 to 79 years) from the
Kota kinabalu, East Malaysia area, who received care at
the Geriatric Outpatient Clinic.
As many older adults as possible were approached ea-
ch day to inquire about their willingness to take part in
the study, their availability for an interview and their co-
mpatibility with the inclusion criteria. Data were collec-
ted through an individual interview, with or without the
presence of the caregiver. Each interview lasted from one
hour to one and a half hours. Of the 145 older adults in-
terviewed, 72 had a history of falls and were selected to
join the present study which aimed to describe the char-
acteristics of fallers only.
2.1 Exclusion Criteria
If they had not fallen in the past year, refused to particip-
ate, received care on a Stretcher, had cognitive impair-
ment identified by the Mini-Mental State Examination
[14] or had a diagnosis that would impair the comprehe-
nsion of the questionnaires of the study’s protocol or im-
pair the performance of the tasks contained in this proto-
col.
2.2 Outcome Measures
The following instruments were used for data collection.
• First, the socio demographic characteristics were ob-
tained, including sex, age group and literacy.
• Second, the clinical characteristics were recorded,
including the occurrence of falls (number, fractures, hos-
pitalizations), according to the Kellogg International
Work Group (KIWG) on the Prevention of Falls by the
Elderly [15]. The older adults and/or their caregiver were
asked about the incidence of a fall in the past year and
about the number of associated diseases, medications in
use, and visual capacity determined by the measure of
visual acuity using the Snellen chart. Visual acuity
≥20/60 in the best eye, with corrective lenses, if used,
was considered low vision.
• Third, the physical characteristics were obtained for
regular physical activity, levels of physical performance
through the Short Physical Performance Battery (SPPB)
in the domains balance, gait, and lower limb (LL)
strength [16], and handgrip strength (HS) measured with
Hand held dynamometer.
• Finally, functional characteristics were assessed thro-
ugh the Functional Independence Measure (FIM) [17,
18].
For the comparison analysis of the present study, we
considered the criterion variables of physical perform-
ance level (gait, balance and LL muscle strength) and
number of falls as outcome. The groups were divided
into 1F (one-time fallers) and 2F (frequent fallers in the
past year), and they were also divided into worst physical
performance (WPP) for scores 0-6 in the SPPB and best
physical performance (BPP) for scores 7-12 in the SPPB.
The median was 6.0; therefore the WPP group was de-
fined as those who scored from 1 to 6, and the BPP from
7 to 12.
The statistical analyses were descriptive and compara-
tive by means of chi-square tests (categorical data), Stu-
dent’s t test (parametric, ordinal or interval data) and
Mann-Whitney (non-parametric, ordinal and interval),
considering the results of the data normality test (Kol-
mogorov-Smirnov). The significance value was set at p <
0.05.
3. Results
Most of the older adults were female (65.3%), Septuage-
narians (58.3%), with an incidence of two or more falls
(56.2%) in the past year and without low vision (63.9%;
Table 1).
With regard to functional independence, the older ad-
ults had high mean scores in each of the FIM motor tasks,
and more than a half of the participants reported com-
plete independence in these tasks, except in the items of
dressing the lower body, bladder management, walking
Table 1. Description of socio demographic and clinical
variables of older adults (n = 72)
Variables N (%)
Sex
Male 25 (34.7%)
Female 47 (65.3%)
Age
Sexagenarians (60-69 years) 30 (41.7%)
Septuagenarians (70-79 years) 42 (58.3%)
Literacy
Yes 41 (56.9%)
No 31 (43.1%)
Number of falls*
1 32 (43.8%)
≥ 2 40 (55.6%)
Associated illnesses
0-4 28 (38.9%)
≥ 5 44 (61.1%)
Number of medications
0-4 31 (43.1%)
≥ 5 41 (56.9%)
Low vision**
Yes 24 (34.3%)
No 46 (65.7%)
Fracture due to fall*
Yes 7 (9.7%)
No 65 (90.3%)
Hospitalization due to fall*
Yes 17 (23.6%)
No 54 (76.4%)
*Values according to past year; **Missing = 2.

Falls and Physical Performance among Frail Sexagenarians and Septuagenarians
18
and stairs (Table 2).
When the criterion variable was physical performance,
in the socio demographic and clinical variables, there
was a significant difference between the WPP and BPP
groups as to age group and number of associated diseases.
Most of the older adults in the WPP group were Septua-
genarians and had five or more associated diseases. Con-
cerning functional independence, the WPP and BPP gro-
ups showed significant differences in most of the motor
tasks of the FIM, except feeding and bowel management.
Those with a poor performance were less independent in
the tasks (Table 3).
In the analysis of the number of falls, in the socio
demographic, clinical and physical variables, the findings
showed a significant difference between the one-time
fallers and the frequent fallers regarding the number of
associated diseases (p < 0.001) and to HS (p = 0.024).
The frequent-fallers had more associated diseases and
less HS. Considering the functional variables, the fre-
quent-fallers had a significant difference in the motor
dimension of the FIM, specifically bowel management,
in which they reported lower independence (Table 4).
4. Discussion
In the present study, the majority of fallers were Septua-
genarians females with a high number of illnesses and
use of medication and two or more falls. Additionally,
most of them had poor physical performance, higher in-
dependence levels in ADLs and good visual acuity. Th-
ese characteristics may be due to the location of the sur-
vey, as older outpatients differ from community-dwelling
older adults in these factors [3,5].
These findings indicate that the present study partici-
pants had debilitating characteristics and factors often
associated with the occurrence of falls; however they
also showed alternative ways to overcome the functional
difficulties that emerged due to age-related impairments
or the consequences of falls. These data support studies
conducted in outpatient or hospital settings [19].
It is important to note that, in the analysis of the fac-
tors associated to falls, it is difficult to identify which
variables are causes and which are consequences of these
events. Low levels of muscle strength, for example, can
be a cause of falls, and the incidence of one or more falls
can limit movement and, consequently, reduce the level
of muscle strength. In this context, Gazzola et al. [10]
and Estefani [20] reported that the fear of falling prompts
relatives to take protective measures that lead the older
fallers to restrict their movements to avoid the conse-
quences of a another fall. This fact can increase the cycle
of sedentary lifestyle and low physical and functional
performance, causing isolation and insecurity and leading
the older adult to a condition of morbidity or mortality.
Table 2. Description of physical performance of older adults according to physical and functional variables (n = 72)
Variables Items Tasks N (%) Mean (±SD)
Yes 19 (26.4%)
Regular physical activity No 53 (73.6%)
Balance* 2.7 (±1.3)
Gait* 1.1 (±1.0)
Lower limb strength* 1.1 (±0.8)
Short Physical Performance Battery (SPPB)
Total Score** 5.9 (±2.6)
Handgrip strength (0 to 50 kg) 20.6 (±8.1)
1. Eating 56 (77.8%)
2. Grooming 59 (81.9%)
3. Bathing/showering 49 (68.1%)
4. Dressing upper body 52 (72.2%)
5. Dressing lower body 34 (47.2%)
Self-care
6. Toileting 54 (75.0%)
1. Bladder management 33 (45.8%)
Sphincters 2. Bowel management 48 (66.7%)
1.Transfers: bed/chair/wheelchair 44 (61.1%)
2. Transfers: toilet 44 (61.1%)
3. Transfers: bathtub/shower 43 (59.7%)
4. Locomotion: walking/wheelchair34 (47.2%)
Functional Independence Measure† ***
Mobility
5. Locomotion: stairs 10 (13.9%)
*Values = 0 to 4, varying from worst to best performance; **Values = 0 to 12, varying from worst to best performance; ***Values = 1 to 7, varying
from worst to best performance; †N (%) of subjects with total independence (±SD) in the FIM scores.

Falls and Physical Performance among Frail Sexagenarians and Septuagenarians
19
Table 3. Comparison between older adults with best and worst physical performance according to sociodemographic, physi-
cal, clinical and functional variables (n = 72)
Physical Performance
WPP (n = 41) BPP (n = 31)
Variable
N (%) Mean (±SD)N (%)π Mean (±SD)
p Value
Sex α
Male 13 (31.7%) 12 (38.7%)
Female 28 (68.3%) 19 (61.3%) 0.537
Age α
Sexagenarians (60-69 years) 12 (29.3%) 18 (58.1%)
Septuagenarians (70-79 years) 29 (70.7%) 13 (41.9%)
0.014
Number of falls α
1 15 (36.6%) 17 (54.8%)
≥ 2 26 (63.4%) 14 (45.2%)
0.123
Associated illnesses α
0-4 12 (29.3%) 16 (51.6%)
≥ 5 29 (70.7%) 15 (48.4%) 0.042
Number of medications α
0-4 16 (39.0%) 15 (48.4%)
≥ 5 25 (61.0%) 16 (51.6%)
0.054
Low vision α
Yes 13 (31.7%) 11 (37.9%)
No 28 (68.3%) 18 (62.1%)
0.589
physical activity α
Yes 10 (24.4%) 9 (29.0%)
No 31 (75.6%) 22 (71.0%) 0.658
Handgrip strength (kg) ∞ 19.3 (6.9) 20.6 (8.2)0.458
Functional Independence Measure β
1. Eating 29 (70.7%) 27 (87.1%) 0.079
2. Grooming 30 (73.2%) 29 (93.5%) 0.032
3. Bathing/showering 21 (51.2%) 28 (90.3%) P < 0.001
4. Dressing upper body 24 (58.5%) 28 (90.3%) 0.003
5. Dressing lower body 13 (31.7%) 21 (67.7%) 0.001
Self-care
6. Toileting 25 (61.0%) 25 (80.6%) 0.002
1. Bladder management 14 (34.1%) 19 (61.3%) 0.034
Sphincters 2. Bowel management 24 (58.5%) 24 (77.4%) 0.094
1.Transfers: bed/chair/wheelchair19 (46.3%) 25 (80.6%) 0.002
2. Transfers: toilet 19 (46.3%) 25 (80.6%) 0.003
3. Transfers: bathtub/shower 17 (41.5%) 26 (83.9%) P < 0.001
4. Locomotion: walking/wheelchair11 (26.8%) 23 (74.2%) P < 0.001
Mobility
5. Locomotion: stairs 2 (4.9%) 8 (25.8%) P < 0.001
α Chi-square test; p-value < 0.05; β Mann-Whitney test; p-value < 0.05; ∞ Student t test; p-value < 0.05; WPP = worst physical performance; BPP =
best physical performance; π N (%) of subjects with total independence (± SD) in the FIM scores.

Falls and Physical Performance among Frail Sexagenarians and Septuagenarians
20
Table 4. Comparison between one-time fallers and recurrent fallers according to sociodemographic, physical, clinical and
functional variables (n = 72)
Number of Fall
1 (n = 32) ≥ 2 (n = 40)
Variable
N (%) Mean (±SD)N (%)π Mean (±SD)
p Value
Sex α
Male 14 (43.7%) 11 (27.5%)
Female 18 (56.3%) 29 (72.5%)
0.150
Age α
Sexagenarians (60-69 years) 13 (33.3%) 17 (42.5%)
Septuagenarians (70-79 years) 19 (66.6%) 23 (57.5%) 0.856
Associated illnesses α
0-4 20 (62.5%) 8 (20.0%)
≥ 5 12 (37.5%) 32 (80.0%) P < 0.001
Number of medications α
0-4 14 (43.7%) 17 (42.5%)
≥ 5 18 (56.3%) 23 (57.5%)
0.915
Low vision α
Yes 18 (56.5%) 29 (72.5%)
No 14 (43.5%) 11 (27.5%) 0.851
physical activity α
Yes 8 (25.0%) 11 (27.5%)
No 24 (75.0%) 29 (72.5%) 0.811
Physical Performance (SPPB)
Balance 2.9 (±1.2) 2.3 (±1.2) 0.055 β
Gait 1.9 (±1.0) 2.0 (±1.1) 0.621 β
Lower limb strength 1.0 (±0.8) 2.3 (±1.2) 0.845 β
Total Score 6.0 (±2.5) 5.3 (±2.5) 0.938∞
Handgrip strength (kg) ∞ 22.1(±8.3) 18.1(±6.3) 0.024
Functional Independence Measure β
1. Eating 23 (71.9%) 33 (82.5%) 0.373
2. Grooming 27 (84.4%) 32 (80%) 0.559
3. Bathing/showering 25 (78.1%) 24 (60.0%) 0.156
4. Dressing upper body 25 (78.1%) 27 (67.5%) 0.287
5. Dressing lower body 18 (56.3%) 16 (40.0%) 0.172
Self-care
6. Toileting 25 (78.1%) 29 (72.5%) 0.647
1. Bladder management 16 (50.0%) 17 (42.5%) 0.686
Sphincters 2. Bowel management 26 (8.3%) 22 (55.0%) 0.014
1.Transfers: bed/chair/wheelchair 22 (68.8%) 22 (55.0%) 0.308
2. Transfers: toilet 23 (71.9%) 21 (52.5%) 0.100
3. Transfers: bathtub/shower 23 (71.9%) 20 (50.0%) 0.056
4. Locomotion: walking/wheelchair16 (50.0%) 18 (12.5%) 0.264
Mobility
5. Locomotion: stairs 5 (15.6%) 5 (12.5%) 0.932
α Chi-square test; p-value < 0.05; β Mann-Whitney test; p-value < 0.05; ∞ Student t test; p-value < 0.05; π N (%) of subjects with total independence
(±SD) in the FIM scores.

Falls and Physical Performance among Frail Sexagenarians and Septuagenarians
21
Physical activity is recommended as an intervention
that may reduce the structural loss of physical fitness
associated with aging. Most of the study participants
were sedentary and had poor physical performance,
which indicates that older adult fallers should be en-
couraged to adopt an active lifestyle to prevent falls. The
WPP found in the Septuagenarians may be explained by
the progressive degeneration of the physical components
throughout life, together with the high number of chro-
nic-degenerative diseases that advanced age tends to ma-
nifest. These chronic diseases, especially the muscu-
loskeletal ones, lead to a stiffening of the joints and con-
tribute to poor gait and balance performance [5,21-23],
which can explain the relationship between physical per-
formance and the number of diseases found in the present
study.
The older adults with less HS were those who reported
the occurrence of two or more falls. This measure has
been regarded as a good predictor of musculoskeletal
function [23-25]. The literature has also linked it to low
bone mass in menopausal women, which represents a
higher risk of lower limb fracture and conditions associ-
ated with frailty and falls [8,25].
Regarding functional independence, the use of stairs,
which depends on an ideal physical performance in gait,
balance and strength, was one of the tasks associated
with WPP in the present study. According to Fabricio,
Rodrigues and Costa Junior [19], it is one of the most
impaired activities after a fall. Still regarding functional-
ity, the participants who reported less independence in
bowel management had recurrent falls. The conseque-
nces of these events may be related to neurological dis-
eases, such as stroke, which can reduce sphincter control
and/or require the use of more medication. According to
Oliveira et al. [26], the side effects of antacids (with cal-
cium or aluminum), antispasmodics, diuretics, analgesics,
anticonvulsants and antidepressants, used by older adults
with severe consequences from a fall, increase the cha-
nces of impaired bowel function. These findings can also
be understood in light of the bowel urgency experienced
by some older adults, which leads to quick and unbal-
anced movements toward the bathroom and increases the
risk for falls.
Older adults with less functional independence in 12
of the 14 FIM tasks had poor physical performance. Sat-
isfactory levels of functional independence seem to gen-
erate sufficient movement to maintain physical perform-
ance; however that is insufficient to avoid falls. In a lon-
gitudinal study, Parayba and Simoes [27] verified, in the
functional tasks performed by older adults, a “slight dif-
ficulty” in walking 100 meters and a decrease in the pre-
valence of functional disability. However, in the present
research, this prevalence was distinct and related to worst
physical performance, which may be explained by the
debilitating characteristics of the studied group.
Although the literature shows a relationship between
the occurrence of falls and low visual acuity and physical
activity [23,28-30], this was not observed in the two
comparative analyses of the present study. These results
may be explained by the limiting factors of this research,
such as the low rate of active older adults, the predomi-
nance of normal or close to normal vision, the lack of de-
tails in the FIM motor tasks, as well as the indirect
measures of strength, gait and balance. Environmental
factors were not assessed in the present investigation, but
should be considered when analyzing falls because they
represent one of the major causes of these events [10,31].
In addition to the vulnerability of older adults and the
consequences of diseases, environmental factors further
increase the chance of falling.
This study helps increase the number studies on falls
in Malaysia, especially in specific settings such as outpa-
tient clinics, however, it is worth noting that a relevant
limitation was the sample size caused by the characteris-
tics of the group studied, which limits data extrapolation
to other population groups. Given the limitations of this
study, some recommendations could be made to future
studies in a country that lacks studies on falls among
older adults, i.e., the use of a larger sample, a longitudi-
nal study design, a better description of the fall, the addi-
tion of tests using direct measures and the refinement of
some factors frequently associated with falls.
The present research data point to the occurrence of
falls and their associated characteristics as important
factors to be assessed in the clinical health practice of
physical therapists, physical education professionals,
nurses or physicians. Fabricio, Rodrigues and Costa Jun-
ior [19] stated that a fall is indicative of undiagnosed
diseases and can be a starting point for a more detailed
assessment. However, the results of this and other studies
show that the prevention of falls appears to be more rel-
evant, as their consequences can be serious and, in some
cases, deadly. This fact may bring about the need to shift
the attention of basic health toward family support in
older adult care. The reduction in the risk of falls repre-
sents a strategy to decrease the costs of older adult care
and becomes possible as the predisposing factors are
analyzed [8].
5. Conclusions
This study suggests that, among older adult fallers, the
worst levels of physical performance were related to mo-
re advanced age, greater number of diseases and lower
functional independence. Furthermore, recurrent falls
were related to a greater number of diseases, less hand-
grip strength and lower functional independence in bowel
management. Government incentives are also important
to help in the development of educational strategies as-
sociated with prevention and exercises that improve
walking and static and dynamic balance to maintain the

Falls and Physical Performance among Frail Sexagenarians and Septuagenarians
22
movement stability and functionality of older adults.
These interventions are necessary to detect the risk of
falls and to recommend prevention and/or rehabilitation
strategies for older adult fallers.
6. Acknowledgements
I like to thank Mr. S. Ganesh Pandian, coordinator and
Lecturers of Physiotherapy Department, Masterskill Col-
lege of Nursing and Health, Sabah, Malaysia for their
Support and Co operation to initiate this Research work.
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