RESUMO

Objetivo

Identificar fatores de risco de queda em idosos residentes na comunidade para atualização da taxonomia II da NANDA Internacional.

Método

Revisão sistemática da literatura, com pesquisa na plataforma EBSCOHost^®, na CINAHL e MEDLINE, no período de dezembro de 2010 a dezembro de 2014. Utilizaram-se os descritores (Fall* OR Accidental Fall) AND (Community Dwelling OR Community Health Services OR Primary health care) AND (Risk OR Risk Assessment OR Fall Risk Factors) AND (Fall* OR Accidental Fall) AND (Community Dwelling OR older) AND Nurs* AND Fall Risk Factors.

Resultados

Obteve-se uma amostra de 62 estudos e um total de 50 fatores de risco, dos quais, apenas 38 estão presentes na classificação.

Conclusões

São propostas duas novas categorias de fatores: os psicológicos e socioeconômicos. Foram identificados novos fatores de risco de queda dos idosos residentes na comunidade, o que contribui para a atualização deste diagnóstico na taxonomia II da NANDA Internacional.

Acidentes por quedas; Fatores de risco; Diagnóstico de enfermagem; Idoso

RESUMEN

Objetivo

Identificar los factores de riesgo de caídas en los ancianos residentes en la comunidad.

Método

Revisión sistemática de la literatura. La búsqueda fue realizada en plataforma EBSCOHost®, en CINAHL y MEDLINE, entre diciembre de 2010 y diciembre de 2014. Los descriptores utilizados fueron (Fall* OR Accidental Fall) AND (Community Dwelling OR Community Health Services OR Primary health care) AND (Risk OR Risk Assessment OR Fall Risk Factors) AND (Fall* OR Accidental Fall) AND (Community Dwelling OR older) AND (Nurs*) AND (Fall Risk Factors).

Resultados

Fueron seleccionados 62 artículos en los cuales se identificaron 50 factores de riesgo, de los que apenas 38 están presentes en la NANDA Internacional.

Conclusiones

Se proponen dos nuevas categorías de factores: los psicológicos y los socioeconómicos. Se identificaron nuevos factores de riesgo de caídas en los ancianos residentes en la comunidad, lo que contribuyó para la actualización de la taxonomía II NANDA Internacional.

Accidentes por caídas; Factores de riesgo; Diagnóstico de enfermería; Anciano

ABSTRACT

Objective

To identify the risk factors for falls of the community-dwelling elderly in order to update the Taxonomy II of NANDA International.

Method

A systematic literature review based on research using the following platforms: EBSCOHost®, CINAHL and MEDLINE, from December 2010 to December 2014. The descriptors used were (Fall* OR Accidental Fall) AND (Community Dwelling OR Community Health Services OR Primary health care) AND (Risk OR Risk Assessment OR Fall Risk Factors) AND (Fall* OR Accidental Fall) AND (Community Dwelling OR older) AND Nurs* AND Fall Risk Factors.

Results

The sample comprised 62 studies and 50 risk factors have been identified. Of these risk factors, only 38 are already listed in the classification.

Conclusions

Two new categories of risk factors are proposed: psychological and socio-economical. New fall risk factors for the community-dwelling elderly have been identified, which can contribute to the updating of this nursing diagnosis of the Taxonomy II of NANDA International.

Accidental falls; Risk factors; Nursing diagnosis; Aged

INTRODUÇÃO

A queda é um evento inesperado, no qual as pessoas passam de um nível superior, para o chão ou nível mais baixo(¹1. Caldevilla M, Costa M, Teles P, Ferreira PM. Evaluation and cross-cultural adaptation of the Hendrich II Fall Risk Model to Portuguese. Scand J Caring Sci. 2013 Jun 1;27(2):468-74.). A prevenção de lesões associadas a este evento é fundamental, especialmente em pessoas idosas(²2. Miake-Lye EM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158 (5 Pt 2):390-6.) quer pela morbilidade e mortalidade que este evento acarreta, mas também por ser uma das principais causas de internamento hospitalar(³3. Ministério da Saúde (PT). Despacho nº 1400-A/2015. Plano Nacional para a Segurança dos Doentes (PNSD) 2015-2020. Diário da República, 2ª série. 2015 fev 10 (28):3882(2-10).). Mundialmente em pessoas com mais de 65 anos, a taxa de queda anual situa-se entre os 28 a 35%, elevando-se para 32 a 42% em pessoas com mais de 70 anos(³3. Ministério da Saúde (PT). Despacho nº 1400-A/2015. Plano Nacional para a Segurança dos Doentes (PNSD) 2015-2020. Diário da República, 2ª série. 2015 fev 10 (28):3882(2-10).). Pelo exposto entende-se que o risco de quedas deve ser um dos focos de atenção dos enfermeiros para a população idosa a nível comunitário.

Para se conseguir nomear o diagnóstico de enfermagem risco de queda, implica conhecimento sobre a sua natureza multifatorial, ou seja, que fatores de risco de queda concorrem para este evento. A história de queda anterior, a toma de medicação, os défices na mobilidade, na força muscular, na deambulação e no equilíbrio, estão descritos na literatura como fatores de risco frequentes para a queda(⁴4. Sturnieks DL, George R, Lord SR. Balance disorders in the elderly. Neurophysiol Clin. 2008;38:467-78.-⁵5. Baixinho C, Dixe MA. Monitoramento de episódios de quedas em instituição para idosos. Rev Eletr Enf. 2014;16(1):28-34.), estando integrados na NANDA Internacional (NANDA-I) como fatores de risco para o diagnóstico risco de queda (00155).

O enunciado de diagnóstico de enfermagem “Risco de quedas” (00155) define-se como: “vulnerabilidade para maior suscetibilidade às quedas, que podem causar dano físico e comprometer a saúde”^{(6, p.384)}.

Desta forma, os idosos estarão tão suscetíveis à queda consoante os fatores de risco que apresentam. No que respeita a adultos, os fatores listados na NANDA-I são: Idade superior ou igual a 65 anos, história de quedas, viver sozinho, prótese no membro inferior e uso de auxiliar de marcha. Os fatores ambientais são: ambiente desorganizado, exposição a condições de insegurança relacionadas com as condições climatéricas (ex. piso molhado, gelo), iluminação insuficiente, material antiderrapante insuficiente no WC, ambiente não familiar, uso de contenções e uso de tapetes soltos. Os agentes farmacológicos nomeados como fatores de risco são o consumo de álcool e fármacos. Nos fatores fisiológicos encontram-se a doença aguda, alteração da glicémia, anemia, artrite, condições que afetam os pés, diminuição na força das extremidades inferiores, diarreia, dificuldade na deambulação, desmaio ao estender o pescoço, desmaio ao virar o pescoço, compromisso da audição, compromisso do equilíbrio, compromisso do equilíbrio, compromisso da mobilidade, incontinência, neoplasia, neuropatia, hipotensão ortostática, período de recuperação pós-cirúrgico, défice propriocetivo, insónia, urgência urinária, doença vascular e compromisso visual. Por último os fatores cognitivos relacionam-se com alterações na função cognitiva(⁶6. Herdman TH, Kamitsuru S, editors. NANDA International Nursing Diagnoses: definitions and classification 2015-2017. Oxford: Wiley-Blackwell; 2014.).

Para a prática clínica da enfermagem comunitária, é fundamental uma avaliação do risco de queda, assente na natureza multifatorial deste evento. Sendo desejável a utilização das classificações e linguagens padronizadas, que representam o conhecimento atual. O enfermeiro com informação relevante para um diagnóstico acurado pode intervir de forma adequada, visando resultados positivos na saúde dos idosos. Pelo relatado, revisões aprofundadas sobre os conceitos do diagnóstico e dos seus elementos, bem como pesquisa clínica que introduza evidência de natureza clínica, são importantes para a melhoria da fundamentação da prática clínica.

Para a revisão sistemática da literatura (RSL) partimos da seguinte questão norteadora: Quais os fatores de risco de queda do idoso residente na comunidade?

A RSL permite uma avaliação rigorosa, associada à síntese das evidências científicas, com o mínimo de enviesamentos, aliada à possibilidade de serem reproduzidas(⁷7. Bettany-Saltikov, J. How to do a systematic literature review in Nursing: a step-by-step guide. Berkshire: McGraw-Hill International; 2012.). O uso de métodos sistemáticos são específicos para identificar, selecionar, avaliar criticamente e sintetizar as evidências de pesquisa para resolver um problema particular da prática clínica(⁸8. Grove SK, Burns N, Gray JR. The practice of nursing research: appraisal, synthesis and generation of evidence. 7th ed. St. Louis: Elsevier Saunders; 2013.).

METODOLOGIA

Através da resenha histórica do diagnóstico de enfermagem da NANDA-I risco de queda, obteve-se informação sobre a data da sua inclusão (2000)(⁹9. North American Diagnosis Association, organizador. Diagnósticos de enfermagem da NANDA: definições e classificação 2001-2002. Porto Alegre: Artmed; 2002. 288 p.) e a data da sua revisão (2013). A partir desses dados, bem como da evidência atualmente disponível em relação a este fenómeno, optou-se por realizar uma RSL, incluindo apenas estudos originais de investigação.

Considerou-se as guidelines do Joanna Briggs Institute (JBI)(¹⁰10. The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011.) e formulou-se a questão de investigação a partir da estratégia PICo, onde considerou-se Population (P), os idosos; Interest Area /Intervention (I), fatores de risco de quedas; Context (Co), comunidade.

Neste estudo, considerou-se as sete fases recomendadas para RSL(¹¹11. Galvão CM, Sawada NO, Trevizan MA. Revisão sistemática: recurso que proporciona a incorporação das evidências na prática da enfermagem. Rev Latino-Am Enfermagem. 2004; 12(3):549-56.): a construção do protocolo; a adaptação da pergunta; a busca dos estudos; a seleção; a avaliação crítica dos mesmos; a coleta de dados; e a síntese dos dados. Assim, procedeu-se à coleta da evidência científica relativa ao risco de queda no idoso residente na comunidade, fatores de risco relacionados, identificação dos tipos de pesquisa, procedimentos metodológicos, descrição e análise crítica dos resultados e, por último, a sua síntese.

A pesquisa eletrónica foi efetuada durante o mês de janeiro de 2015 através da plataforma EBSCOHost® e nas bases de dados CINAHL Complete e MEDLINE Complete. Utilizaram-se os descritores: (Fall* OR Accidental Fall) AND (Community Dwelling OR Community Health Services OR Primary health care) AND (Risk OR Risk Assessment OR Fall Risk Factors) AND (Fall* OR Accidental Fall) AND (Community Dwelling OR older) AND Nurs* AND Fall Risk Factors. Considerou-se a presença dos termos no resumo.

Além dos critérios definidos pela questão e estratégia PICo, considerou-se ainda incluir estudos no idioma português, inglês ou espanhol, estudos com texto integral disponível, publicados entre dezembro de 2010 e dezembro de 2014 e com desenho experimental, quase-experimental, de coorte e ou quantitativos descritivos. Foram excluídos estudos referentes a idosos institucionalizados.

A pesquisa foi realizada por dois revisores de forma independente, de modo a garantir o rigor do método e a fidedignidade dos resultados. Os artigos a incluir na amostra foram selecionados através da sequência: leitura de título, leitura de resumo e leitura do texto integral. Na discordância entre os dois revisores, os artigos eram incluídos na etapa seguinte de análise.

As orientações do JBI(¹⁰10. The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011.) e da Registered Nurses’ Association of Ontario(¹²12. Registered Nurses’ Association of Ontario (CA). Falls prevention: building the foundations for patient safety: a self learning package. Toronto: RNAO; 2007.) foram aplicadas para a classificação dos níveis de evidência (NE).

Por último, foram aplicadas as tabelas do JBI referentes a ensaios clínicos controlados e randomizados; estudo de coorte/estudo caso controle; estudos descritivos/estudos de séries de casos, estudos de avaliação económica(¹⁰10. The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011.) e revisões sistemáticas(¹³13. Bugalho A, Carneiro AV. Intervenções para aumentar a adesão terapêutica em patologias crónicas. Lisboa: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina; 2004.) que permitiram avaliar os critérios de viabilidade, adequação, significância e eficácia de modo a incluir os artigos na RSL. Nesta fase, foram excluídos 4 estudos por não apresentarem pelo menos 75% dos critérios(¹⁰10. The Joanna Briggs Institute (AT). Joanna Briggs Institute’s user manual: version 5.0 System for the Unified Management, Assessment and Review of Information. Adelaide: The Joanna Briggs Institute; 2011.,¹³13. Bugalho A, Carneiro AV. Intervenções para aumentar a adesão terapêutica em patologias crónicas. Lisboa: Centro de Estudos de Medicina Baseada na Evidência, Faculdade de Medicina; 2004.) (Figura 1).

A tradução dos novos termos em inglês referentes aos fatores de risco de queda que emergiram nesta revisão bem como os fatores de risco classificados na NANDA-I, foram traduzidos por dois tradutores independentes para português europeu.

Recorreu-se a uma tabela na leitura integral dos estudos para sistematizar a informação, auxiliar o tratamento dos dados e a sua interpretação.

Visto o objeto de estudo serem os artigos, considerou-se o princípio do respeito pela propriedade intelectual dos autores dos artigos que constituem a amostra, através da citação completa e rigorosa dos mesmos(¹⁴14. Nunes L. Considerações éticas a atender nos trabalhos de investigação académica de enfermagem. Setubal: Instituto Politécnico de Setubal, Escola Superior de Saúde, Departamento de Enfermagem; 2013.-¹⁵15. Polit DF, Beck CT. Fundamentos de pesquisa em enfermagem: avaliação de evidências para a prática da enfermagem. Porto Alegre: Artmed; 2011.).

RESULTADOS

Dos 62 artigos incluídos nesta revisão, 60% foram publicados em 2012(¹⁶16. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.

17. Currin ML, Comans TA, Heathcote K, Haines TP. Staying safe at home: home environmental audit recommendations and uptake in an older population at high risk of falling. Australas J Ageing. 2012;31(2):90-5.

18. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.

19. Elliott SJ, Ivanescu A, Leland NE, Fogo J, Painter JA, Trujillo LG. Feasibility of interdisciplinary community-based fall risk screening. Am J Occup Ther. 2012;66(2):161-8.

20. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.

21. Freiberger E, Häberle L, Spirduso WW, Zijlstra GA. Long-term effects of three multicomponent exercise interventions on physical performance and fall-related psychological outcomes in community-dwelling older adults: a randomized controlled trial. J Am Geriatr Soc. 2012;60(3):437-46.

22. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.

23. Jenkyn KB, Hoch JS, Speechley M. How much are we willing to pay to prevent a fall? Cost-effectiveness of a multifactorial falls prevention program for community-dwelling older adults. Can J Aging. 2012;31(2):121-37.

24. Kelsey JL, Procter-Gray E, Berry SD, Hannan M, Kiel DP, Lipsitz LA, et al. Reevaluating the implications of recurrent falls in older adults: location changes the inference. J Am Geriatr Soc. 2012;60(3):517-24.

25. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.

26. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.

27. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.

28. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.

29. Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age Ageing. 2012;41(3):299-308.

30. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.

31. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.

32. Taylor ME, Ketels MM, Delbaere K, Lord SR, Mikolaizak AS, Close JC. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators. Age Ageing. 2012;41(5):665-9.

33. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.-³⁴34. Zheng JJ, Lord SR, Close JC, Sachdev PS, Wen W, Delbaere K, et al. Brain white matter hyperintensities, executive dysfunction, instability, and falls in older people: a prospective cohort study. J Gerontol. 2012;67(10):1085-91.) e 2013(³⁵35. de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.

36. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.

37. Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8.

38. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.

39. Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.

40. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.

41. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62.

42. Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.

43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.

44. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.

45. Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7.

46. Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.

47. Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.

48. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.

49. Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5.

50. Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053.

51. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.-⁵²52. Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.). Relativamente ao país encontrou-se 15 origens, dos quais se destacam os Estado Unidos da América(¹⁸18. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.-¹⁹19. Elliott SJ, Ivanescu A, Leland NE, Fogo J, Painter JA, Trujillo LG. Feasibility of interdisciplinary community-based fall risk screening. Am J Occup Ther. 2012;66(2):161-8.,²⁴24. Kelsey JL, Procter-Gray E, Berry SD, Hannan M, Kiel DP, Lipsitz LA, et al. Reevaluating the implications of recurrent falls in older adults: location changes the inference. J Am Geriatr Soc. 2012;60(3):517-24.-²⁵25. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.,³⁰30. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.,³³33. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.,³⁹39. Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.,⁵³53. Buracchio TJ, Mattek NC, Dodge HH, Hayes TL, Pavel M, Howieson DB, et al. Executive function predicts risk of falls in older adults without balance impairment. BMC Geriatr. 2011;11:74.

54. Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85

55. Fischer BL, Gleason CE, Gangnon RE, Janczewski J, Shea T, Mahoney JE. Declining cognition and falls: role of risky performance of everyday mobility activities. Phys Ther. 2014;94(3):355-62.

56. Gangavati A, Hajjar I, Quach L, Jones RL, Kiely DK, Gagnon P, et al. Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011;59(3):383-9.

57. Honaker JA, Shepard NT. Use of the Dynamic Visual Acuity Test as a screener for community-dwelling older adults who fall. J Vestib Res. 2011;21(5):267-6.

58. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R, et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(12):815-25.

59. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31

60. Quach L, Galica AM, Jones RN, Procter-Gray E, Manor B, Hannan MT, et al. The nonlinear relationship between gait speed and falls: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc. 2011;59(6):1069-73.-⁶¹61. Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.) e Austrália(¹⁷17. Currin ML, Comans TA, Heathcote K, Haines TP. Staying safe at home: home environmental audit recommendations and uptake in an older population at high risk of falling. Australas J Ageing. 2012;31(2):90-5.,²⁸28. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.,³²32. Taylor ME, Ketels MM, Delbaere K, Lord SR, Mikolaizak AS, Close JC. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators. Age Ageing. 2012;41(5):665-9.,³⁴34. Zheng JJ, Lord SR, Close JC, Sachdev PS, Wen W, Delbaere K, et al. Brain white matter hyperintensities, executive dysfunction, instability, and falls in older people: a prospective cohort study. J Gerontol. 2012;67(10):1085-91.,³⁶36. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.,⁴²42. Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.,⁴⁴44. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.,⁴⁶46. Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.-⁴⁷47. Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.,⁵²52. Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.,⁶²62. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci. 2011;66(6):674-80.

63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.-⁶⁴64. Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.), com 16 e 13 estudos respetivamente. Segue-se o Canadá(²³23. Jenkyn KB, Hoch JS, Speechley M. How much are we willing to pay to prevent a fall? Cost-effectiveness of a multifactorial falls prevention program for community-dwelling older adults. Can J Aging. 2012;31(2):121-37.,²⁹29. Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age Ageing. 2012;41(3):299-308.,⁴⁰40. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.,⁶⁵65. Arnold CM, Faulkner RA, Gyurcsik NC. The relationship between falls efficacy and improvement in fall risk factors following an exercise plus educational intervention for older adults with hip osteoarthritis. Physiother Can. 2011;63(4):410-20.

66. Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.

67. Hsu CL, Voss MW, Handy TC, Davis JC, Nagamatsu LS, Chan A, et al. Disruptions in brain networks of older fallers are associated with subsequent cognitive decline: a 12-month prospective exploratory study. PloS One. 2014;9(4): e93673.-⁶⁸68. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.)com sete, Holanda(²⁰20. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.,³¹31. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.,³⁵35. de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.,⁵¹51. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.,⁶⁹69. Peeters GM, Heymans MW, de Vries OJ, Bouter LM, Lips P, van Tulder MW. Multifactorial evaluation and treatment of persons with a high risk of recurrent falling was not cost-effective. Osteoporos Int. 2011;22(7):2187-96.) com cinco e Reino Unido(⁴⁸48. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.,⁷⁰70. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.

71. Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. J Am Geriatr Soc. 2011;59(1):26-33.-⁷²72. Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.)com quatro. Com três a China(²⁶26. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.,⁵⁰50. Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053.,⁷³73. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.), França(⁴⁵45. Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7.,⁴⁹49. Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5.,⁷⁴74. Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.) e Suécia(³⁷37. Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8.-³⁸38. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.,⁴¹41. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62.), com dois a Irlanda(⁷⁵75. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14.-⁷⁶76. O’Halloran AM, Pénard N, Galli A, Fan CW, Robertson IH, Kenny RA. Falls and falls efficacy: the role of sustained attention in older adults. BMC Geriatr. 2011;11:85.) e com um a Alemanha(²¹21. Freiberger E, Häberle L, Spirduso WW, Zijlstra GA. Long-term effects of three multicomponent exercise interventions on physical performance and fall-related psychological outcomes in community-dwelling older adults: a randomized controlled trial. J Am Geriatr Soc. 2012;60(3):437-46.), o Brasil(¹⁶16. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.), a Coreia(²⁶26. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.), a Espanha(⁷⁷77. Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.), o Japão(²²22. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.) e a Tailândia(⁴³43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.).

Foram selecionados seis estudos secundários (revisões sistemáticas da literatura) e os restantes 56 são estudos primários que utilizaram metodologia quantitativa, isto é, sete ensaios clínicos aleatórios controlados, dois estudos quase-experimentais, 20 estudos de coorte e 27 estudos descritivos. Dos estudos analisados, seis eram RSL com um nível de evidência Ia(²⁹29. Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis. Age Ageing. 2012;41(3):299-308.,⁴¹41. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62.,⁴⁵45. Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7.,⁵⁸58. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R, et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(12):815-25.,⁶³63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.,⁷⁵75. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14.) e sete eram ensaios clínicos aleatórios com um nível Ib(²¹21. Freiberger E, Häberle L, Spirduso WW, Zijlstra GA. Long-term effects of three multicomponent exercise interventions on physical performance and fall-related psychological outcomes in community-dwelling older adults: a randomized controlled trial. J Am Geriatr Soc. 2012;60(3):437-46.,²³23. Jenkyn KB, Hoch JS, Speechley M. How much are we willing to pay to prevent a fall? Cost-effectiveness of a multifactorial falls prevention program for community-dwelling older adults. Can J Aging. 2012;31(2):121-37.,³⁷37. Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8.,⁵⁵55. Fischer BL, Gleason CE, Gangnon RE, Janczewski J, Shea T, Mahoney JE. Declining cognition and falls: role of risky performance of everyday mobility activities. Phys Ther. 2014;94(3):355-62.,⁶⁵65. Arnold CM, Faulkner RA, Gyurcsik NC. The relationship between falls efficacy and improvement in fall risk factors following an exercise plus educational intervention for older adults with hip osteoarthritis. Physiother Can. 2011;63(4):410-20.,⁶⁹69. Peeters GM, Heymans MW, de Vries OJ, Bouter LM, Lips P, van Tulder MW. Multifactorial evaluation and treatment of persons with a high risk of recurrent falling was not cost-effective. Osteoporos Int. 2011;22(7):2187-96.,⁷¹71. Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. J Am Geriatr Soc. 2011;59(1):26-33.). Quanto aos estudos quase-experimentais representam um total de dois, com um de nível IIa(¹⁷17. Currin ML, Comans TA, Heathcote K, Haines TP. Staying safe at home: home environmental audit recommendations and uptake in an older population at high risk of falling. Australas J Ageing. 2012;31(2):90-5.) e um de nível IIb. Por fim quarenta e sete estudos apresentam nível de evidência III(¹⁶16. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.,¹⁸18. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.,²⁰20. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.,²²22. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.,²⁴24. Kelsey JL, Procter-Gray E, Berry SD, Hannan M, Kiel DP, Lipsitz LA, et al. Reevaluating the implications of recurrent falls in older adults: location changes the inference. J Am Geriatr Soc. 2012;60(3):517-24.

25. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.

26. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.

27. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.-²⁸28. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.,³⁰30. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.

31. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.

32. Taylor ME, Ketels MM, Delbaere K, Lord SR, Mikolaizak AS, Close JC. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators. Age Ageing. 2012;41(5):665-9.

33. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.

34. Zheng JJ, Lord SR, Close JC, Sachdev PS, Wen W, Delbaere K, et al. Brain white matter hyperintensities, executive dysfunction, instability, and falls in older people: a prospective cohort study. J Gerontol. 2012;67(10):1085-91.

35. de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.-³⁶36. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.,³⁸38. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.

39. Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.-⁴⁰40. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.,⁴²42. Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.

43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.-⁴⁴44. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.,⁴⁶46. Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.

47. Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.

48. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.

49. Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5.-⁵⁰50. Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053.,⁵²52. Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.,⁵⁴54. Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85,⁵⁷57. Honaker JA, Shepard NT. Use of the Dynamic Visual Acuity Test as a screener for community-dwelling older adults who fall. J Vestib Res. 2011;21(5):267-6.,⁵⁹59. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31

60. Quach L, Galica AM, Jones RN, Procter-Gray E, Manor B, Hannan MT, et al. The nonlinear relationship between gait speed and falls: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc. 2011;59(6):1069-73.-⁶¹61. Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.,⁶³63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.-⁶⁴64. Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.,⁶⁶66. Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.

67. Hsu CL, Voss MW, Handy TC, Davis JC, Nagamatsu LS, Chan A, et al. Disruptions in brain networks of older fallers are associated with subsequent cognitive decline: a 12-month prospective exploratory study. PloS One. 2014;9(4): e93673.-⁶⁸68. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.,⁷⁰70. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.,⁷²72. Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.

73. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.-⁷⁴74. Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.,⁷⁶76. O’Halloran AM, Pénard N, Galli A, Fan CW, Robertson IH, Kenny RA. Falls and falls efficacy: the role of sustained attention in older adults. BMC Geriatr. 2011;11:85.-⁷⁷77. Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.), com vinte estudos de coorte(²²22. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.,²⁴24. Kelsey JL, Procter-Gray E, Berry SD, Hannan M, Kiel DP, Lipsitz LA, et al. Reevaluating the implications of recurrent falls in older adults: location changes the inference. J Am Geriatr Soc. 2012;60(3):517-24.-²⁵25. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.,²⁸28. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.,³¹31. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.-³²32. Taylor ME, Ketels MM, Delbaere K, Lord SR, Mikolaizak AS, Close JC. Gait impairment and falls in cognitively impaired older adults: an explanatory model of sensorimotor and neuropsychological mediators. Age Ageing. 2012;41(5):665-9.,³⁴34. Zheng JJ, Lord SR, Close JC, Sachdev PS, Wen W, Delbaere K, et al. Brain white matter hyperintensities, executive dysfunction, instability, and falls in older people: a prospective cohort study. J Gerontol. 2012;67(10):1085-91.,⁴⁰40. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.,⁴²42. Klein D, Nagel G, Kleiner A, Ulmer H, Rehberger B, Concin H, et al. Blood pressure and falls in community-dwelling people aged 60 years and older in the VHM&PP cohort. BMC Geriatr. 2013;13:50.

43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.-⁴⁴44. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.,⁴⁶46. Martin KL, Blizzard L, Srikanth VK, Wood A, Thomson R, Sanders LM, et al. Cognitive function modifies the effect of physiological function on the risk of multiple falls: a population-based study. J Gerontol A Biol Sci Med Sci. 2013;68(9):1091-7.-⁴⁷47. Menant JC, Wong A, Sturnieks DL, Close JC, Delbaere K, Delbaere K, et al. Pain and anxiety mediate the relationship between dizziness and falls in older people. J Am Geriatr Soc. 2013;61(3):423-8.,⁵¹51. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.

52. Wong A, Lord S, Sturnieks D, Delbaere K, Trollor J, Close J. Angiotensin system-blocking medications are associated with fewer falls over 12 months in community-dwelling older people. J Am Geriatr Soc. 2013;61(5):776-81.-⁵³53. Buracchio TJ, Mattek NC, Dodge HH, Hayes TL, Pavel M, Howieson DB, et al. Executive function predicts risk of falls in older adults without balance impairment. BMC Geriatr. 2011;11:74.,⁵⁹59. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31-⁶⁰60. Quach L, Galica AM, Jones RN, Procter-Gray E, Manor B, Hannan MT, et al. The nonlinear relationship between gait speed and falls: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc. 2011;59(6):1069-73.,⁷⁰70. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.,⁷⁷77. Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.) e vinte sete estudos descritivos e correlacionais(¹⁶16. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.,¹⁸18. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.,²⁰20. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.,²⁶26. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.-²⁷27. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.,³⁰30. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.,³³33. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.,³⁵35. de Vries OJ, Peeters GM, Lips P, Deeg DJ. Does frailty predict increased risk of falls and fractures? A prospective population-based study. Osteoporos Int. 2013;24(9):2397-403.-³⁶36. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.,³⁸38. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.-³⁹39. Hardigan PC, Schwartz DC, Hardigan WD. Using latent class analysis to model prescription medications in the measurement of falling among a community elderly population. BMC Med Inform Decis Mak. 2013;13:60.,⁴⁸48. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.

49. Muir SW, Beauchet O, Montero-Odasso M, Annweiler C, Fantino B, Speechley M. Association of executive function impairment, history of falls and physical performance in older adults: a cross-sectional population-based study in Eastern France. J Nutr Health Aging. 2013;17(8):661-5.-⁵⁰50. Ou LC, Sun ZJ, Chang YF, Chang CS, Chao TH, Kuo PH, et al. Epidemiological survey of quantitative ultrasound in risk assessment of falls in middle-aged and elderly people. PloS One. 2013;8(8):e71053.,⁵⁴54. Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85,⁵⁷57. Honaker JA, Shepard NT. Use of the Dynamic Visual Acuity Test as a screener for community-dwelling older adults who fall. J Vestib Res. 2011;21(5):267-6.,⁶¹61. Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.-⁶²62. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci. 2011;66(6):674-80.,⁶⁴64. Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.,⁶⁶66. Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.

67. Hsu CL, Voss MW, Handy TC, Davis JC, Nagamatsu LS, Chan A, et al. Disruptions in brain networks of older fallers are associated with subsequent cognitive decline: a 12-month prospective exploratory study. PloS One. 2014;9(4): e93673.-⁶⁸68. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.,⁷²72. Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.

73. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.-⁷⁴74. Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.,⁷⁶76. O’Halloran AM, Pénard N, Galli A, Fan CW, Robertson IH, Kenny RA. Falls and falls efficacy: the role of sustained attention in older adults. BMC Geriatr. 2011;11:85.).

As amostras nos estudos primários variaram de 27(⁴⁸48. Muhaidat J, Kerr A, Evans JJ, Skelton DA. Exploring gait-related dual task tests in community-dwelling fallers and non-faller: a pilot study. Physiother Theory Pract. 2013;29(5):351-70.) a 21.020(²⁰20. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.) participantes idosos residentes na comunidade.

Nesta RSL apenas um estudo foi realizado no âmbito da enfermagem e teve como objetivo determinar fatores ambientais habitacionais e de saúde nas mulheres coreanas que caiem em casa, bem como as quedas recorrentes na comunidade(²⁷27. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.).

Identificou-se um total de 50 fatores de risco de queda nesta revisão, os quais foram organizados de acordo com as categorias da NANDA-I (Quadro 1).

No que respeita aos adultos, e como atrás exposto, a NANDA-I organiza os indicadores de risco de queda em seis categorias. No entanto, esta RSL permitiu acrescentar duas categorias, que foram denominadas, por consenso, fatores psicológicos e fatores socioeconómicos. Nos fatores pessoais (adulto), os fatores de risco mais prevalentes em relação aos que integram a NANDA-I foi a história de queda (n=7), a idade avançada (n=6) e o género feminino (n=8).

Na categoria de fatores ambientais, os indicadores de risco de queda encontrados foram: ambiente desorganizado (n=4), material antiderrapante insuficiente no WC (n=4) e iluminação insuficiente (n=3). Contudo, foram referenciados dois fatores de risco adicionais, nomeadamente, o acesso a áreas externas sem barras de apoio e corrimão/obstáculo da soleira da porta (n=3) e sanitas sem barras de apoio (n=1).

No grupo dos agentes farmacológicos houve referência a fármacos em geral (n=14), polimedicação (n=11), anti hipertensores (n=2) e benzodiazepinas (n=2). Os anti hipertensores estudados foram diuréticos, inibidores da enzima de conversão angiotensina, bloqueadores dos canais de cálcio, bloqueadores beta-adrenérgicos(⁵³53. Buracchio TJ, Mattek NC, Dodge HH, Hayes TL, Pavel M, Howieson DB, et al. Executive function predicts risk of falls in older adults without balance impairment. BMC Geriatr. 2011;11:74.,⁶³63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.).

A categoria referente a fatores cognitivos é composta por um fator na NANDA-I que foi identificado: alteração na função cognitiva (n=8). Contudo, outro foi identificado nesta revisão: a diminuição das funções executivas (n=3).

A categoria dos fatores fisiológicos apresenta 23 fatores de risco na NANDA-I. Destes fatores os mais referidos foram: dificuldade na deambulação (n=13), compromisso do equilíbrio (n=13), compromisso visual (n=10), hipotensão ortostática (n=5), diminuição na força das extremidades inferiores (n=4), alteração da glicémia (n=3), compromisso da mobilidade (n=3), doença vascular (n=3), insónia (n=2), artrite (n=2), incontinência (n=1) e urgência urinária (n=1). Foram ainda confirmados outros fatores de risco de queda no idoso residente na comunidade, particularmente, o declínio das atividades básicas de vida diária (n=10), comorbilidade/doença crónica (n=6), dor crónica (n=5), declínio das atividades instrumentais de vida diária (n=4) e hipertensão arterial (n=4). Para além destes, outros fatores foram encontrados e estão patentes no quadro. As comorbilidades nomeadas foram, as doenças cardiopulmonares, metabólicas, neurológicas, sensoriais, acidente vascular cerebral e cancro(¹⁷17. Currin ML, Comans TA, Heathcote K, Haines TP. Staying safe at home: home environmental audit recommendations and uptake in an older population at high risk of falling. Australas J Ageing. 2012;31(2):90-5.,⁴³43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.,⁶⁴64. Vu T, Finch CF, Day L. Patterns of comorbidity in community-dwelling older people hospitalised for fall-related injury: a cluster analysis. BMC Geriatr. 2011;11:45.). No que diz respeito, às doenças crónicas os estudos fizeram referencia à hipertensão arterial, artrite, deficiência visual, DPOC, diabetes e doença cardíaca(²⁷27. Lim YM, Sung MH. Home environmental and health-related factors among home fallers and recurrent fallers in community dwelling older Korean women. Int J Nurs Pract. 2012;18(5):481-8.-²⁸28. Menant JC, Close JC, Delbaere K, Sturnieks DL, Trollor J, Sachdev PS, et al. Relationships between serum vitamin D levels, neuromuscular and neuropsychological function and falls in older men and women. Osteoporos Int. 2012;23(3):981-9.,⁶⁸68. Sibley KM, Voth J, Munce SE, Straus SE, Jaglal SB. Chronic disease and falls in community-dwelling Canadians over 65 years old: a population-based study exploring associations with number and pattern of chronic conditions. BMC Geriatr. 2014;14:22.). O síndrome metabólico corresponde à presença de obesidade abdominal, hipertrigliceridémia, hipertensão, tolerância à glicose diminuída(²⁶26. Liao KC, Pu SJ, Lin CH, Chang HJ, Chen YJ, Liu MS. Association between the metabolic syndrome and its components with falls in community-dwelling older adults. Metab Syndr Relat Disord. 2012;10(6):447-51.).

Na categoria dos fatores psicológicos, os estudos confirmaram o medo de cair (n=14) como um dos fatores mais importantes de risco de queda no idoso residente na comunidade. Este medo de cair está associado à execução das atividades de vida diária (básicas e instrumentais), como por exemplo, higiene, vestuário, uso de sanitário, subir e descer escadas, usar transporte público, fazer compras. Os sintomas depressivos/depressão (n=8) foram confirmados como fatores de risco de queda no idoso residente na comunidade. Os sintomas depressivos foram mais prevalentes em pessoas idosas com queda recorrente (44,7% versus 25%)(⁶¹61. Stone KL, Blackwell TS, Ancoli-Israel S, Cauley JA, Redline S, Marshall LM, et al. Sleep disturbances and risk of falls in older community-dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. J Am Geriatr Soc. 2014;62(2):299-305.). A ansiedade (n=2) também foi confirmada como fator de risco. Por último, os fatores socioeconómicos são constituídos por escolaridade baixa (n=1), baixo rendimento familiar (n=1) e Negro/grupo de minoria étnica (n=1), todos mencionados num único estudo.

DISCUSSÃO

A discussão dos resultados deve incidir nas implicações da evidência apresentada em relação às decisões para a prática clinica, assim, e procurando responder à questão norteadora, verificamos que os fatores de risco de queda que não estão classificados na NANDA-I são o género feminino (a mulher têm risco acrescido de queda na comunidade)(²⁰20. Etman A, Wijlhuizen GJ, van Heuvelen MJ, Chorus A, Hopman-Rock M. Falls incidence underestimates the risk of fall-related injuries in older age groups: a comparison with the FARE (Falls risk by Exposure). Age Ageing. 2012;41(2):190-5.,³⁸38. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.,⁴⁰40. Hunter KF, Voaklander D, Hsu ZY, Moore KN. Lower urinary tract symptoms and falls risk among older women receiving home support: a prospective cohort study. BMC Geriatr. 2013;13:46.,⁵⁹59. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31,⁶³63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.,⁷³73. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.-⁷⁴74. Rossat A, Fantino B, Bongue B, Colvez A, Nitenberg C, Annweiler C, et al. Association between benzodiazepines and recurrent falls: a cross-sectional elderly population-based study. J Nutr Health Aging. 2011;15(1):72-7.,⁷⁷77. Mesas AE, López-García E, Rodríguez-Artalejo F. Self-reported sleep duration and falls in older adults. J Sleep Res. 2011;20(1 Pt 1):21-7.), o compromisso na execução das atividades de vida diária (básicas e instrumentais)(¹⁶16. Alexandre TS, Meira DM, Rico NC, Mizuta SK. Accuracy of Timed Up and Go Test for screening risk of falls among community-dwelling elderly. Braz J Phys Ther. 2012;16(5):381-8.,²²22. Ishimoto Y, Wada T, Kasahara Y, Kimura Y, Fukutomi E, Chen W, et al. Fall Risk Index predicts functional decline regardless of fall experiences among community-dwelling elderly. Geriatr Gerontol Int 2012;12(4):659-66.,²⁵25. Kelsey JL, Procter-Gray E, Hannan MT, Li W. Heterogeneity of falls among older adults: implications for public health prevention. Am J Public Health. 2012;102(11):2149-56.,³¹31. Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358-65.,³³33. Yamashita T, Noe DA, Bailer AJ. Risk factors of falls in community-dwelling older adults: logistic regression tree analysis. Gerontologist. 2012;52(6):822-32.,⁵⁴54. Chen TY, Janke MC. Predictors of falls among community-dwelling older adults with cancer: results from the health and retirement study. Support Care Cancer. 2014;22(2):479-85-⁵⁵55. Fischer BL, Gleason CE, Gangnon RE, Janczewski J, Shea T, Mahoney JE. Declining cognition and falls: role of risky performance of everyday mobility activities. Phys Ther. 2014;94(3):355-62.,⁶³63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.,⁷⁰70. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.,⁷³73. Lin CH, Liao KC, Pu SJ, Chen YC, Liu MS. Associated factors for falls among the community-dwelling older people assessed by annual geriatric health examinations. Plos One. 2011;6(4):e18976.), o medo de cair(³⁰30. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.,³⁶36. Delbaere K, Close JC, Taylor M, Wesson J, Lord SR. Validation of the Iconographical Falls Efficacy Scale in cognitively impaired older people. J Gerontol. 2013;68(9):1098-102.

37. Halvarsson A, Franzén E, Farén E, Olsson E, Oddsson L, Ståhle A. Long-term effects of new progressive group balance training for elderly people with increased risk of falling: a randomized controlled trial. Clin Rehabil. 2013;27(5):450-8.-³⁸38. Halvarsson A, Franzén E, Ståhle A. Assessing the relative and absolute reliability of the Falls Efficacy Scale-International questionnaire in elderly individuals with increased fall risk and the questionnaire’s convergent validity in elderly women with osteoporosis. Osteoporos Int. 2013;24(6):1853-8.,⁴⁴44. Kwan MM, Close JC, Wong AK, Lord SR. Falls incidence, risk factors, and consequences in Chinese older people: a systematic review. J Am Geriatr Soc. 2011;59(3):536-43.,⁵¹51. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.,⁵⁹59. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31,⁶²62. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci. 2011;66(6):674-80.-⁶³63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.,⁶⁶66. Filiatrault J, Desrosiers J. Coping strategies used by seniors going through the normal aging process: does fear of falling matter? Gerontology. 2011;57(3):228-36.,⁷⁰70. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.

71. Pighills AC, Torgerson DJ, Sheldon TA, Drummond AE, Bland JM. Environmental assessment and modification to prevent falls in older people. J Am Geriatr Soc. 2011;59(1):26-33.-⁷²72. Stubbs B, Eggermont LH, Patchay S, Schofield PA. Pain interference is associated with psychological concerns related to falls in community-dwelling older adults: multisite observational study. Phys Ther. 2014;94(10):1410-20.), os sintomas depressivos/depressão(¹⁸18. Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-7.,³⁰30. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG. Fear of falling and its relationship with Anxiety, depression, and activity engagement among community-dwelling older adults. Am J Occup Ther. 2012;66(2):169-76.,⁴³43. Kuhirunyaratn P, Prasomrak P, Jindawong B. Factors related to falls among community dwelling elderly. Southeast Asian J Trop Med Public Health. 2013;44(5):906-15.,⁴⁵45. Launay C, Decker L, Annweiler C, Kabeshova A, Fantino B, Beauchet O. Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review. J Nutr Health Aging. 2013;17(2):152-7.,⁵¹51. Scheffer AC, van Hensbroek PB, van Dijk N, Luitse JS, Goslings JC, Luigies RH, et al. Risk factors associated with visiting or not visiting the accident & emergency department after a fall. BMC Health Serv Res. 2013;13:286.,⁵⁹59. Oh-Park M, Xue X, Holtzer R, Verghese J. Transient versus persistent fear of falling in community-dwelling older adults: incidence and risk factors. J Am Geriatr Soc. 2011;59(7):1225-31,⁶³63. Kwan MM, Tsang WW, Lin SI, Greenaway M, Close JC, Lord SR. Increased concern is protective for falls in chinese older people: the chopstix fall risk study. J Gerontol A Biol Sci Med Sci. 2013;68(8):946-53.) e por último, a baixa escolaridade(⁷⁰70. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.), baixo rendimento familiar(⁷⁰70. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.) e minorias étnicas(⁷⁰70. Kumar A, Carpenter H, Morris R, Iliffe S, Kendrick D. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76-84.). Quanto ao nível de evidência destes fatores de risco verificamos que os sintomas depressivos/depressão e o género feminino são mencionados em pelo menos dois artigos de RSL (evidencia Ia), o compromisso na execução das atividades de vida diária e o medo de cair são fatores de risco referidos em pelo menos três ensaios clínicos aleatórios (evidencia Ib), no entanto os outros fatores de risco são descritos em estudos de nível III. Pelo que, quanto à recomendação para a prática clinica e para integração na NANDA-I, existe evidência para a recomendação na atividade diagnóstica de enfermagem dos fatores de risco de queda, sintomas depressivos/depressão, género feminino, compromisso na execução das atividades de vida diária e o medo de cair.

Com base nos resultados da RSL e da proposta da NANDA-I sobre os fatores de risco de queda no idoso residente na comunidade, confirma-se a natureza multifatorial dos fatores de risco, que requer intervenções abrangentes, transdisciplinares, multifatorial /multicomponente(⁴¹41. Karlsson MK, Magnusson H, von Schewelov T, Rosengren BE. Prevention of falls in the elderly: a review. Osteoporos Int. 2013; 24(3):747-62.,⁶⁹69. Peeters GM, Heymans MW, de Vries OJ, Bouter LM, Lips P, van Tulder MW. Multifactorial evaluation and treatment of persons with a high risk of recurrent falling was not cost-effective. Osteoporos Int. 2011;22(7):2187-96.).

Desta forma, a nossa RSL, contribui para o conhecimento dos enfermeiros pela transferibilidade para a prática clinica dos achados, concretizando o que se pretende que sejam os cuidados de enfermagem baseados em evidência.

Estudos recentes com a população idosa, indicam que o risco de queda aumenta com o número de fatores de risco e por cada ano o risco de queda dos idosos dobra por cada fator de risco adicional(⁷⁸78. Al-Aama, T. Falls in the elderly: spectrum and prevention. Can Fam Physician. 2011;57(7):771-6.).

Portanto, para a compreensão deste evento importa conhecer a multiplicidade dos fatores de risco, implicando avaliações adequadas e dirigidas para os idosos da comunidade. Pois, os fatores de risco de queda do idoso residente na comunidade são multifatoriais, como fatores de risco ambientais, agentes farmacológicos, fatores de risco cognitivo, fatores de risco fisiológicos, fatores de risco psicológicos e também fatores de risco socioeconómicos.

CONCLUSÕES

Esta RSL identificou fatores de risco associados ao diagnóstico de enfermagem risco de quedas em idosos residentes na comunidade, alguns já classificados na NANDA-I e outros fatores não, pelo que os resultados serão apresentados à comissão de desenvolvimento de diagnósticos da NANDA-I, concretizando uma das finalidades desta revisão.

As implicações desta RSL para a prática clinica de enfermagem comunitária é a incorporação na atividade diagnóstica, nomeadamente na avaliação do risco de queda, dos fatores de risco de queda sintomas depressivos/depressão, género feminino, compromisso na execução das atividades de vida diária e o medo de cair.

Para o ensino da enfermagem, esta RSL, alerta para a necessidade de oferta formativa nesta área e consequentemente produção científica na área de enfermagem. Na verdade, apenas um estudo que integrou a RSL foi desenvolvido por enfermeiros, por essa razão, sugere-se que mais estudos possam ser realizados, como os estudos de validação clínica de diagnósticos.

Como limitação do estudo referimos o critério de inclusão texto integral disponível.

Por fim, consideramos que mais importante do que reportar os nossos achados é a incorporação dessa informação na prática clínica diária, melhorando a qualidade dos cuidados de enfermagem comunitária.

As classificações e as linguagens padronizadas devem representar a prática clínica, devem ser funcionais e completas, porquanto representam o conhecimento de enfermagem. Por isso, estes estudos de investigação acabam por ter repercussão não só na prática, mas na educação de novos enfermeiros.

REFERÊNCIAS

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