Falls among elderly individuals represent a significant yet underrecognized public health concern in Lebanon. This pioneering study examines gender differences in falls and mobility patterns among nursing home residents aged 65 and older, providing insights to guide future research and interventions in Lebanon and neighboring countries.
The results align with previous research [39][40–43], demonstrating a higher incidence of falls among women, particularly those admitted to the geriatric medicine department for chronic conditions such as dementia and strokes. Hip fractures emerged as the most frequent injury following a fall, consistent with prior research [44].
Marital status and the nursing care environment were protective factors against falls, highlighting the importance of social support and structured care in fall prevention [45].
4.1. Health and Physical Risk Factors
Consistent with previous findings [46, 47], poor balance and postural hypotension significantly increased fall risk. In addition, the use of sleeping pills and mood stabilizers was also linked to a higher fall likelihood [48]. Effective assessment tools included the Tinetti Balance and Gait Assessment and the Morse Fall Scale. Better performance on the Timed Up and Go (TUG) test and the Katz ADL was inversely related to fall risk, highlighting the importance of maintaining functional mobility and incorporating these tools into routine evaluations in elderly care settings [49].
4.2. Types of Falls and Regional Factors
Contrary to other studies [50], most falls were accidental rather than anticipated physiological falls. Intrinsic risk factors, including osteoporosis, vitamin D deficiency, diabetes, hypertension, strokes, and visual impairment, were prevalent. The lifestyle and habits in the Chouf region, such as limited sun exposure due to traditional clothing, contribute to these risks [39, 51, 52].
4.3. Extrinsic Risk Factors and Environmental Factors
Extrinsic risk factors, such as a lack of nursing staff, unlocked beds, and unsuitable equipment, contribute to falls [53]. Unlike hospitals, nursing homes often lack the supervision provided by family members. Nurses’ assessments of psychological status and fall risk often lack accuracy and validation, leading to misclassification. Depression linked to falls was frequent due to relocation, non-family care, economic issues, and unexpected diagnoses [54, 55].
4.4. Gender-Specific Findings
In the present study, no significant association was found between gender and a history of falls. This lack of association could be partly explained by the sample size distribution and the subjectivity of the answers related to the presence of previous falls. However, some differences were found in the risk factors associated with falls among women and men.
Stratification analysis by gender revealed distinct differences in fall risk factors. Among elderly men, the Morse Fall Scale and unsteady walking were significant predictors of falls, highlighting the need for targeted interventions addressing balance and gait stability in this population [56].
As for elderly women, the factors associated with falls were similar to those for the overall population, with additional factors such as the use of a walking device shown to be protective. Women were more exposed to depression and consumed more sleeping pills and mood stabilizers compared to men, which was significantly associated with more falls among them [57, 58].
4.5. Medication and Hospitalization
Medications such as benzodiazepines, antihypertensives, diuretics, and combinations of polypharmacy may increase the risk of falls [13, 48, 59–61]. This association was not found in the present study, likely due to the small number of participants using these medications. Consistent with our findings, research has shown that extended hospital stays were a primary risk factor for falls attributed to muscle weakness, decreased appetite, depression, and fatigue [62].
Studies have shown that multiple factors interact to increase fall rates [63, 64], consistent with our findings, particularly regarding the concurrent presence of gait and balance disturbances and dizziness among older adults. Many of these patients experienced post-stroke hemiplegia, visual and hearing impairments, and orthostatic hypotension, all of which led to many recorded fall episodes.
Moreover, many inpatients fell while attempting to get out of bed, as previously reported in the literature [35]. This risk is exacerbated in patients with higher frailty levels, potentially leading to severe injuries [65]. Another possible explanation is that walking aids are not often within easy reach, as noticed by the physical therapist during data collection at the elderly center. Consequently, patients have to get out of bed unassisted to reach their walking devices, increasing the risk of falls.
Previous studies have reported a strong association between alcohol intake and multiple falls for both female and male elderly patients [66, 67]. However, in the present study, no such association was found, as only a few participants consumed alcohol. This low percentage is due to the religious beliefs and cultural norms of the majority of the patients residing in the Chouf region of Lebanon.
A positive association was found between fear of falling and actual falls among both genders, consistent with previous studies [68, 69]. Also aligning with prior findings, muscle weakness and blurred vision were identified as risk factors for falls [70], highlighting medical conditions as the primary cause of falls [68]. The Tinetti Balance and Gait Assessment was also found to be the most effective tool for detecting the risk of falls among our sample [71].
Contrary to previous findings showing a positive association between physical activity and reduced fall incidence, physical activity was not significant in the present study [72, 73]. This discrepancy could be attributed to a lack of education on the importance of regular physical activity among our study population.
4.6. Limitations and strengths of the study
This study had some limitations that may have influenced the results, necessitating cautious interpretation. The cross-sectional design of this study is a primary limitation, as it shares the potential for recall bias inherent in observational studies. Patients may have over- or underestimated fall episodes and related injuries over the past twelve months when recalling from memory. To mitigate this bias and get more detailed and accurate information, more questions were added to the study questionnaire regarding fall history and risk factors, and objective, well-known tools were used to assess fall risk and mobility among the older population. However, future studies are needed to validate these tools, specifically among the elderly Lebanese population.
A language bias should be considered as the questionnaire underwent real-time translation from English into Arabic and French based on participants’ preferences. Translations may introduce errors, inaccuracies, or nuances lost when conveying complex concepts, potentially affecting the validity and reliability of the data collected. To minimize this bias, all medical and scientific terms were verified by two investigators (D.S. and R.R.) to ensure the adequacy of the scientific terms used in Arabic or French with the patient.
Another limitation is the lack of estimations for the extrinsic risk factors and causes of falls within the environment, which have a great impact on fall episodes. Some variables were not assessed and completed due to the patient’s medical and psychological condition, resulting in missing variables. Therefore, the multivariable analysis accounted for confounding factors such as unsteady walking, dependency level, cause of admission, and others, thus reducing the probability of differential bias. Moreover, the results cannot be generalized to the entire Lebanese elderly population until confirmed by further studies covering a broader spectrum of nursing homes across all Lebanese governorates.
Despite these limitations, the strengths of this study include the use of a questionnaire that helped capture many risk factors and the most prevalent causes of falls in relation to the history of falls among the elderly population, as well as objective assessment tools that measure mobility patterns and fall risks.
4.7. Implications for Fall Prevention
These findings highlight critical areas for intervention. Regular assessments using tools like the Morse Fall Scale and the Tinetti Balance and Gait Assessment can help identify high-risk individuals. Tailored exercise programs focusing on strength, balance, and coordination are essential, particularly for those with poor balance and postural hypotension. Additionally, careful management of medications, especially sedatives and mood stabilizers, is crucial to reducing fall risk. Healthcare providers should regularly review and adjust medication regimens to minimize adverse effects related to balance and stability.
4.8. Practical implications
The assessment of falls and potential risk factors among the elderly population should be an ongoing and rigorous process, not just a one-time assessment done upon admission. Preventing falls for elderly inpatients requires coordinated and sustained efforts, resulting in an increase in the number of health professionals and staff dedicated to providing enhanced assistance and supervision, especially for high-fall-risk residents. Allocating adequate resources toward achieving this goal should be a priority for elderly care facilities.