Association between arteriosclerosis and the risk of falls in the elderly

doi:10.21203/rs.3.rs-2245022/v1

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Association between arteriosclerosis and the risk of falls in the elderly

https://doi.org/10.21203/rs.3.rs-2245022/v1

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Objective: To study the risk factors of falls in the elderly and explore the correlation between arteriosclerosis and the risk of falls in the elderly.

Method: This is a cross-sectional study. The subjects were inpatients ≥ 60 years old in the cadre ward of the first hospital of Jilin University from May 1, 2019 to December 31, 2020. The following information was obtained from the past comprehensive geriatric assessment database of the cadre ward. Ankle brachial index (ABI) and ankle brachial pulse wave velocity (baPWV) were measured by OMRON arteriosclerosis detection device. We assessed according to the internationally used fall risk assessment tool (FRA), ≤ 2 points are divided into low-risk group, 3 - 9 points are divided into medium-risk group, and ≥ 10 points are divided into high-risk group.

Results: There were significant differences among the three groups in age, weight, educational background, low gait speed, cognitive impairment, malnutrition, ability of daily living, depression (P < 0.05). The baPWV and ABI were higher in high-risk group than in low-risk group; The baPWV in high-risk group was higher than that in medium risk group and low-risk group. For each additional unit of baPWV, the probability of the fall risk increasing by one level is 1.701 times higher than the original (OR= 1.701, 95%CI: 0.533-11.822, P= 0.001). For each additional unit of ABI, the probability of the fall risk increasing by one level is 1.976 times higher than the original (OR= 1.976, 95%CI: 1.213-3.219, P= 0.006).

Conclusion:The increase of baPWV and the decrease of ABI are closely related to the increased risk of falls in the elderly.

elderly

arteriosclerosis

the risk of falls

comprehensive geriatric assessment.

Falls refer to the sudden and unconscious change of body position, loss of balance and falling on the ground or some lower plane due to some risk factors ^[1]. At least 1 / 3 of the elderly aged 65 and above fall every year, of which about 30% will lead to physical injury, such as soft tissue injury, bleeding, fracture and even death ^{[2, 3]}. Falls are the first cause of injury death for the elderly ≥ 65 years old in China. According to the monitoring results of the national disease surveillance system in 2018, the death rate of falls for the elderly ≥ 65 years old in China is 63.83/100000, accounting for 39.72% of all injury deaths of this age group. Recent studies have shown that the incidence of falls increases with the increase of age ^{[3, 4]}, which is an adverse event seriously threatening the safety of the elderly ^[5].

The elderly have increased the incidence of falls due to their own factors, such as skeletal muscle system degradation, unstable center of gravity, balance and coordination function degradation, decreased ability to control body posture balance, decreased vision and brain response, as well as their own diseases, such as arteriosclerosis, hypertension, cardiac insufficiency, arrhythmia and valve disease, vision, gait balance and blood pressure. There are also many drugs that can affect the mind and spirit. Elderly hospitalized patients with cardiovascular diseases are prone to fall due to the degradation of their physiological function, the influence of diseases and drugs, which seriously affects the physical and mental health of elderly patients. It has even become one of the main factors inducing the death of elderly patients with cardiovascular disease. Arteriosclerosis (AS) is a systemic cardiovascular disease; Among them, fat, inflammation, cells and tissue scars accumulate in the arterial wall to form plaques and emboli, which is the root cause of most clinical cardiovascular diseases (CVD) ^[6]. This paper aims to study the risk factors of falls in the elderly and explore the correlation between arteriosclerosis and the risk of falls in the elderly.

2.1 Participants and eligibility criteria:

The subjects were inpatients ≥ 60 years old in the cadre ward of the first hospital of Jilin University from May 1, 2019 to December 31, 2020. Inclusion criteria: (1) age ≥ 60 years; (2) completed the comprehensive assessment questionnaire and test for the elderly; (3) basic data and indicators are complete. Exclusion criteria: Suffering from malignant tumors, immune system diseases, liver diseases and kidney diseases.

2.2 Measurement:

From the electronic case system of the first hospital of Jilin University, the medical record information of all inpatients in line with this study from May 1, 2019 to December 31, 2020, including the measurement of patient height and weight and basic information, such as gender, age, education, smoking history, drinking history, etc. The following information was obtained from the past comprehensive geriatric assessment database of the cadre ward: the 4 meter pace measured by the stopwatch.

2.3 Arteriosclerosis test:

Japan Omron arteriosclerosis detection device was used, which was operated and measured by professional medical personnel. Ask the patient to take off his shoes and socks, turn his feet outward, and rest quietly in the supine position for 5 minutes. Following the standard measurement procedure, place the cuff at the elbow fossa and ankle joint of the upper arm, so that the sensor can clearly detect the pulsation of brachial artery and posterior tibial artery and measure systolic blood pressure. Place the ECG clip on the corresponding wrist and the phonocardiogram sensor on the left edge of the fourth rib to detect the ECG, phonocardiogram and pulse wave waveform. Measure each part twice and take the average value. The average value of ABI on the left and right sides is the patient's ABI. The average value of baPWV on the left and right sides was the baPWV of the patient.

According to baPWV standard: baPWV < 1400 cm / S is normal peripheral arterial hardness, and baPWV ≥ 1400 cm / S is peripheral arteriosclerosis. The international standard ABI reference value > 0.9, and ABI ≤ 0.9 indicates that the subject may have lower extremity arteriosclerosis and obstruction.^{[7, 8]}

2.4 Fall risk assessment:

We assessed according to the internationally used FRA, with a total of 35 items, each item has 1–3 points, the total score of the scale is 53 points, ≤ 2 points are divided into low-risk group, 3–9 points are divided into medium-risk group, and ≥ 10 points are divided into high-risk group.^[9]

2.5 Other Assessment:

Assessment of nutritional status

The MNA was used in most studies to assess the nutritional status of older adults and as a tool for evidence-based screening of older adults. An MNA score < 17 indicates the presence of malnutrition.

Depression assessment

GDS screening questionnaire was designed specifically for older adults. FRA has a total of 30 items, each item has 1 point, the total score of the scale is 30 points, ≤ 10 points are normal, 11–20 points are mild depression, and 21–30 points are moderate to severe depression. In this study, > 10 points were defined as abnormal.

Cognitive Function

The Min-Mental State Examination (MMSE) is the psychometric screening tool most frequently administered to assess cognitive function. In this study, we classified the boundary of cognitive normality according to the level of education into primary school education > 20 points, junior high school or above > 24 points, below which was defined as cognitive dysfunction.

Gait speed

Gait speed was calculated as 4.57 m walk time divided by 4.57 m. Participants walked at daily speed. Time was recorded with a stopwatch (accurate to 0.01 second). The average value was calculated after the second measurement.Gait speed < 0.8m/s indicates low gait speed.

Activity of daily living scale: It is composed of physical self-maintenance scale (PSMS) and instrumental activities of daily living scale (IADL). It is mainly applicable to evaluate the subjects' ability of daily living. Among them, PSMS includes 6 items: eating, dressing, grooming, going to the toilet, bathing and walking indoors; IADL includes 8 items such as taking a bus, shopping, doing housework, washing, cooking, making phone calls, managing money and taking medicine. If the total score is less than 16, it is completely normal, and if it is more than 16, there is varying degrees of functional decline, up to 56 points. The single item is divided into 1 for normal and 2–4 for function decline. If there are 2 or more items ≥ 3 points, or the total score ≥ 22 points, it is regarded as obvious functional impairment.

2.6 Statistical Methods:

SPSS 26.0 statistical software was used for statistical analysis (IBM Corp., Armonk, NY, USA). Continuous variables were presented as mean ± standard deviation (SD) or median (interquartile range, IQR) based on the distribution characteristics of the data. Classified variables were analyzed using percentage. T-test was used for the comparison between two groups of quantitative data, and one way ANOVA test was used for the comparison between multiple groups; chi-square(χ2) test was used to compare the two kinds of indicators such as gender. Ordinal logistic regression analysis was used to determine the correlation between ABI, baPWV and the risk of falls, adjusting for confounding factors ( p < 0.05 ): age, education background, cognitive impairment. All statistical tests were conducted by two-sided test, and the difference was considered to be statistically significant if P < 0.05.

A total of 248 patients were included, including 154 males (62.1%) and 94 females (37.9%), with an average age of 76.3 ± 10.4 years. According to FRA, there were 65 cases in the low-risk group (26.2%), 123 cases in the medium-risk group (49.6%) and 60 cases in the high-risk group (24.2%). (Table 1)

Table 1

Comparison of demographic information of the patients
	All	Low Risk Group(N = 65)	Medium Risk Group(N = 123)	High risk Risk Group(N = 60)	P
Age(years)	76.3 ± 10.4	67.1 ± 6.4	76.6 ± 9.8^a	85.4 ± 5.8^ab	< 0.001^*
Gender					0.695
Male	154(62.1%)	39(60.0%)	75(61.0%)	40(66.7%)
Female	94(37.9%)	26(40.0%)	48(39.0%)	20(33.7%)
Height(cm)	165.7 ± 8.0	167.1 ± 7.3	165.4 ± 8.1	165.0 ± 8.4	0.266
Weight(kg)	67.4 ± 11.6	71.3 ± 10.7	66.2 ± 11.8^a	65.6 ± 11.4^a	0.006^*
Education					0.005^*
Illiteracy	2(0.8%)	0(0.0%)	2(1.6%)	0(0.0%)
Primary School	15(6.0%)	1(1.5%)	9(7.3%)	5(8.3%)
Middle School	60(24.2%)	11(16.9%)	25(20.3%)	24(40.0%)
College Degree and Above	171(69.0%)	53(81.5%)	87(70.7%)	31(18.1%)
Smoking					0.243
Yes	191(77.0%)	46(70.8%)	100(81.3%)	45(75.0%)
No	57(23.0%)	19(29.2%)	23(18.7%)	15(25.0%)
Alcohol					0.354
Yes	174(70.2%)	41(63.1%)	89(72.4%)	44(73.3%)
No	74(29.8%)	24(36.9%)	34(27.6%)	16(26.7%)
Low Gait Speed					< 0.001^*
Yes	90(36.3%)	0(0.0%)	30(24.4%)	60(100.0%)
No	158(63.7%)	65(100.0%)	93(75.6%)	0(0.0%)
Cognitive Impairment					< 0.001^*
Yes	19(7.7%)	0(0.0%)	7(5.7%)	12(20.0%)
No	229(92.3%)	65(100.0%)	116(94.3%)	48(80.0%)
Malnutrition					< 0.001^*
Yes	56(22.6%)	4(6.2%)	28(22.8%)	24(40.0%)
No	192(77.4%)	61(93.8%)	95(77.2%)	36(60.0%)
Ability of Daily Living(score)	16.7 ± 5.4	14.3 ± 1.0	15.4 ± 3.0^a	22.2 ± 8.0^ab	0.003^*
Depressive State(score)	27.4 ± 2.9	24.4 ± 6.7	26.5 ± 7.0	32.4 ± 9.5^ab	< 0.001^*
Skin Assessment(score)	18.4 ± 1.4	19.5 ± 0.6	18.5 ± 1.0^a	17.1 ± 1.7^ab	< 0.001^*
Systolic Pressure(mmHg)	137.3 ± 31.3	127.1 ± 39.1	140.2 ± 30.6^a	142.4 ± 18.5^a	0.008^*
Diastolic Pressure(mmHg)	78.3 ± 11.4	80.7 ± 10.1	78.6 ± 12.0	75.3 ± 11.0^a	0.027^*
Heart Rate(cpm)	71.7 ± 12.3	73.6 ± 11.2	71.1 ± 12.7	70.8 ± 12.5	0.352
^a indicates that the difference is statistically significant compared with the low-risk group;
^b indicates that the difference is statistically significant compared with the medium-risk group;
^* P < 0.05.

3.1 Baseline Characteristics:

As shown in Table 1, it is the comparison of general indicators among low-risk group, medium-risk group and high-risk group. There were significant differences among the three groups in age, weight, educational background, low gait speed, cognitive impairment, malnutrition, ability of daily living, depression, skin evaluation, systolic blood pressure and diastolic blood pressure (P < 0.05).

Compared with the low-risk group, the high-risk group had higher age, ADL score, depression score, systolic blood pressure, and lower weight, skin evaluation score and diastolic blood pressure; Compared with the middle risk group, the high-risk group had higher age, ADL score, depression score and lower skin evaluation score; Compared with the low-risk group, the middle-risk group had higher age, systolic blood pressure, and lower weight and skin evaluation score. The above differences were statistically significant (P < 0.05).

3.2 Comparison of baPWV and ABI in low-risk group, medium-risk group and high-risk group:

Table 2 shows the comparison of baPWV and ABI in the three groups. The baPWV and ABI were higher in high-risk group than in medium risk group and low-risk group ( baPWV: median 2117.7 vs 1650.4, p < 0.001, ABI: median 1.15 vs 1.10, p = 0.005); The baPWV in high-risk group was higher than that in medium risk group(median 2117.7 vs 1865.9, p < 0.001), medium risk group and low-risk group(median 1865.9 vs 1650.4, p < 0.001), and the difference was statistically significant (P < 0.05).

Table 2

Comparison of arteriosclerosis detection index among low-risk group, medium-risk group and high-risk group
	All	Low Risk Group	Medium Risk Group	High risk Risk Group	P
baPWV(right)(cm/s)	1865.9 ± 412.4	1650.4 ± 286.5	1856.9 ± 395.4^a	2117.7 ± 428.7^ab	< 0.001^*
baPWV(left)(cm/s)	1858.9 ± 423.7	1656 ± 270.1	1828.9 ± 379.4^a	2140.1 ± 497.0^ab	< 0.001^*
baPWV(cm/s)	1862.4 ± 400.4	1653.2 ± 273.4	1842.9 ± 360.5^a	2128.9 ± 447.5^ab	< 0.001*
ABI(right)	1.11 ± 0.13	1.15 ± 0.09	1.10 ± 0.14	1.09 ± 0.13^a	0.027^*
ABI(left)	1.11 ± 0.13	1.15 ± 0.12	1.10 ± 0.14	1.09 ± 0.13^a	0.028^*
ABI	1.11 ± 0.12	1.15 ± 0.10	1.10 ± 0.13	1.09 ± 0.12^a	0.015^*
baPWV: brachial-ankle pulse wave velocity. ABI:ankle-brachial index.
^a indicates that the difference is statistically significant compared with the low-risk group;
^b indicates that the difference is statistically significant compared with the medium-risk group;
^* P < 0.05.

3.3 Correlation between the risk of falls and baPWV and ABI:

As shown in Table 3, baPWV was divided into two groups of < 1400cm / s and ≥ 1400cm / s, ABI was divided into two groups of > 0.9 and ≤ 0.9. Compared with the low risk group, baPWV was higher and ABI was lower in the high risk group and medium risk group( baPWV: median 59 vs 54, 116 vs 54, p = 0.003, ABI: median 32 vs 19, 48 vs 19, p = 0.022), the difference was statistically significant.

Table 3

Association between grading of arteriosclerosis detection index and risk of falls
	Low Risk Group(N = 65)	Medium Risk Group(N = 123)	High risk Risk Group(N = 60)	χ²	P
baPWV				11.604	0.003^*
< 1400cm/s	11(16.9%)	7(5.7%)	1(1.7%)
≥ 1400cm/s	54(83.1%)	116(94.3%)	59(98.3%)
ABI				7.639	0.022^*
> 0.9	46(70.8%)	75(61.0%)	28(46.7%)
≤ 0.9	19(29.2%)	48(39.0%)	32(53.3%)
baPWV: brachial-ankle pulse wave velocity. ABI:ankle-brachial index.
^* P < 0.05.

As shown in Table 4, according to the above univariate analysis results, the statistically significant baPWV and ABI indexes were substituted into the ordinal regression model. Taking fall risk as dependent variable and baPWV and ABI as independent variables respectively, adjusting for confounding factors: age, education background, cognitive impairment, ordinal logistic regression analysis was used. The results showed that, for each additional unit of baPWV, the probability of the fall risk increasing by one level is 1.701 times higher than the original (OR = 1.701, 95%CI: 0.533–11.822, P = 0.001). For each additional unit of ABI, the probability of the fall risk increasing by one level is 1.976 times higher than the original (OR = 1.976, 95%CI: 1.213–3.219, P = 0.006).

Table 4

Ordinal logistic regression analysis of ABI and baPWV in low-risk group, medium-risk group and high-risk group
Indicators	B	SE	Wald	OR	95%CI	P
baPWV	0.531	0.479	10.221	1.701	0.553–11.822	0.001^*
ABI	0.681	0.249	7.481	1.976	1.213–3.219	0.006^*

Dependent Variable:the risk of falls. Independent Variable：baPWV,ABI.

Adjusting for confounding factors: age, education background, cognitive impairment.

baPWV：brachial-ankle pulse wave velocity. ABI:ankle-brachial index.

^* P<0.05.

In our study, we found that, increased baPWV and decreased ABI are risk factors for falls in the elderly, and age is one of the risk factors for falls. It is suggested that there is a correlation between falls and arteriosclerosis in the elderly, and the way to connect aging with the greater risk of falls is still unclear. Preclinical CVD is also common in the elderly, and the latest treatment recommendations for CVD risk factors such as hypertension, high cholesterol or procoagulant state (such as atrial fibrillation) have been extended to include more elderly people. ^[10–12]

As a common and dangerous phenomenon in geriatric syndrome, falls are affected by many factors alone or in combination. Patients with cardiac insufficiency fall due to the decrease of cerebral perfusion and cardiac output, unstable standing and other symptoms during acute attack. ^{[13, 14]} cardiovascular disease is common in the elderly, ^{[15, 16]} and is associated with higher fall risk ^{[17, 18]} and fall risk factors. ^[19] Cardiovascular disease itself may directly lead to falls. If not treated, it may theoretically worsen the risk. The cardiovascular system plays several important roles related to body functions, such as maintaining an adequate blood supply to peripheral muscles during activities and stabilizing the blood pressure required for brain perfusion to maintain balance. ^[20] However, treatments designed to prevent cardiovascular events in the elderly, such as the initiation of antihypertensive drugs, are associated with a high risk of falls in the short term. As the main cause of cardiovascular disease in the elderly, arteriosclerosis is also closely related to the risk of falls in the elderly.^{[21, 22]}

This study found that compared with the low-risk group, the age of the medium and high-risk group was significantly higher, and the prevalence of cognitive impairment, malnutrition and decreased ability of daily living were also significantly higher. Considering that age, cognitive function, malnutrition and ability of daily living were the risk factors leading to falls. With the growth of age, the physiological function and mental state of the elderly continue to decline, the ability of memory, attention, reasoning and judgment, comprehensive analysis and so on, and are prone to physical and mental fatigue and decreased physical flexibility.

This study found that, compared with the three groups, baPWV was higher and ABI was lower in the high-risk group, medium-risk group and low-risk group. Logistic regression analysis results showed that the elderly with increased baPWV had increased fall risk; In contrast, elderly people with elevated ABI have a lower risk of falls. It is considered that the increase of baPWV and the decrease of ABI leading to atherosclerosis are risk factors for falls in the elderly. Studies have shown that subclinical cardiovascular disease increases the risk of falls. There are many reasons for falls, including muscle weakness, impaired physical function during the transition (from sitting to standing, walking) and imbalance when standing. ^{[23, 24]} the cardiovascular system plays a key role in all these basic functions, responsible for increasing heart rate with changes in position and peripheral blood supply, and stabilizing blood pressure to resist gravity changes when standing, which is very important for the balance mechanism mediated by the central nervous system. ^{[20, 25]} therefore, functional pathway defects leading to falls may originate from cardiovascular conditions, even before they manifest as clinical cardiovascular disease. This study is consistent with the above conclusions.

Considering the limitations of the sample capacity, it is necessary to further expand the sample capacity for comprehensive analysis. According to our research, it is suggested that the elderly should pay attention to the measurement of arteriosclerosis indicators, monitor ABI and baPWV, evaluate the degree of atherosclerosis, screen cardiovascular related diseases, detect and prevent falls as soon as possible, and improve the health status of the elderly.

The increase of baPWV and the decrease of ABI are closely related to the increased risk of falls in the elderly.

We may have lacked statistical power for the interaction analyses, because the sample size was limited. According to the calculation of statistical sample size, the sample size of this study is sufficient. However, further expanding the sample size should help us conduct more comprehensive analysis and reduce class II errors.Besides, our results may not be generalizable to all populations; While we cannot exclude that we may have missed some events that occurred outside, in our experience this is quite uncommon. We acknowledge that there are other fall risk assessment tools, however FRA is routinely measured on all inpatients at our institution, and we wanted to explore the utility of an existing geriatric measure used in clinical practice.

Ethics approval and consent to participate: In this study, the population is hospitalized patients aged ≥ 60 years in the cadre ward of the first hospital of Jilin University. All data subjects' relevant examination results are collected from the electronic case system of the first hospital of Jilin University, and there is no need to collect additional samples for this clinical work; In the whole process of clinical evaluation and trial, all clinical data will hide personal privacy information and will not be disclosed to any third party. The clinical test results are only used for experimental research and do not involve the subject's personal privacy and genetic information. The arrangement of subjects during the experiment complies with the relevant requirements of the declaration of Helsinki. Written informed consent was obtained from all subjects, and the study protocol was approved by the ethics committee of the first hospital of Jilin University. When the subject is illiterate, the subject gives oral consent in the presence of his/her legally authorized representative, and the legally authorized representative signs the informed consent form and indicates the date.

Consent for publication: Not applicable.

Availability of data and materials: The data and materials that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgements: The contributions of the clinical coordinators are duly acknowledged. The authors thank the staff and participants of this study for their important contributions. We thank all nursing home patients and healthcare workers who participated in this research study.

Competing interests: The authors declare that there are no financial conflicts of interest in regard to this manuscript.

Authors' contributions: All authors were involved in the study concept and design, analysis and interpretation of the data, and preparation of manuscript. Authors KZ, YJ, DY, MC, HL were involved in the acquisition of subjects and/or data.

Funding: The science and technology development plan project "Intelligent evaluation and management platform for elderly health status" (Project No.: 20200404207yy) of the Department of science and technology of Jilin Province. "Epidemiological investigation of senile syndrome and predictive value of machine learning" (Project No.: 2022C043-7) of Jilin Provincial Development and Reform Commission. "Study on related factors of sarcopenia in elderly patients with heart failure" (Project No.: JLSWSRCZX2021-046) of Jilin Provincial Department of Finance.

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No competing interests reported.

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Association between arteriosclerosis and the risk of falls in the elderly

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Abstract

1. Introduction:

2. Materials And Methods:

2.1 Participants and eligibility criteria:

2.2 Measurement:

2.3 Arteriosclerosis test:

2.4 Fall risk assessment:

2.5 Other Assessment:

2.6 Statistical Methods:

3. Results:

3.1 Baseline Characteristics:

3.2 Comparison of baPWV and ABI in low-risk group, medium-risk group and high-risk group:

3.3 Correlation between the risk of falls and baPWV and ABI:

4. Discussion:

5. Conclusion:

6. Limitation:

Declarations

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