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International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

Original Article:

Effect of comorbidities and polypharmacy on fall risk among older adults

Hand F Mahmoud1, Hebatullah EMZ Elmedany1

Abstract 

Introduction: Fall is considered by far one of the leading causes of morbidity and mortality 
in the elderly population. Fall is almost always multifactorial. This study looks into the 
relation between different comorbidities, polypharmacy and falls. Methods: A descriptive 
and prospective study, the study population comprised 150 elderly patients aged > 60 years 
old, males and females, patients with previous history of falls are excluded. Comorbidity 
burden, polypharmacy and risk of falls were assessed. Results and Discussion: There was 
a significant positive correlation between Number of comorbidities, medications and risk 
of falls and there was a significant association between high risk of falls and presence of 
DM, PVD, OLD CVA and UI. Also, there was a significant positive correlation between 
age and risk of falls. Conclusion: Multiple comorbidities, polypharmacy and increasing 
age increase risk of falls.

Keywords: Falls, comorbidities, polypharmacy.

Correspondence to: Hand F Mahmoud, Geriatrics and Gerontology department, Faculty of Medicine, 
Ain Shams University, Cairo, Egypt. E-mail: hend.fawzy@med.asu.edu.eg

1. Geriatrics and Gerontology department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.

International Journal of Human and Health Sciences Vol. 06 No. 01 January’22 Page : 75-79
DOI: http://dx.doi.org/10.31344/ijhhs.v6i1.380   

Introduction

Life expectancy is increasing all over the world. 
Most people nowadays are expected to live into 
their sixties and beyond. By 2050, the world’s 
population aged 60 years and older is expected 
to total 2 billion up from 900 million in 2015.
With increased life expectancy, some elderly will 
age gracefully, others will experience decreased 
mobility and functional decline and increase 
susceptibility to falls.1

Falls defined as an unanticipated incident in which 
a person come to rest on the ground or a lower level 
2. Falls are the most common type of accidents 
among older people 3. One in three people over 65 
years of age experience at least one fall every year, 
and injuries occur in approximately 20% of such 
cases 4 and It has been estimated that nearly 40% 
of falls in older people are preventable 5.

The etiology of falls has always known to be 
multifactorial. Both intrinsic and extrinsic factors 
are involved in falls in older adults. Intrinsic 

factors include comorbidities leading to decreased 
mobility, physiological changes with ageing 
in balance and coordination. Extrinsic factors 
including environmental hazards as slippery floors, 
unsecure stairs and poor lighting 6. This research 
project focuses on the impact of the comorbidity 
burden on the risk of falls. 

Medications are a well-recognized cause of falls in 
elderly. Classes of medications that have long been 
known as culprits are antipsychotics, sedatives, 
and hypnotics 7. This current study investigates 
the effect of polypharmacy and correlation with 
falls.

Polypharmacy  is  defined  as  the  prescription  of 
multiple medications and it has been identified as 
one of the most important factors associated with 
falls among older people 8-9.

Adverse  effects  of  falls  range  from  injuries  to 
decrease mobility and fear of falling. Physical 
injuries include major lacerations, hip fractures, 
non-vertebral fractures. Other complications of 



International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

76

falls and long lie include rhabdomyolysis, acute 
kidney injury, dehydration, aspiration pneumonia. 
Psychological adverse effects of falls are not by 
any means less important. These include fear 
of falling, decreased mobility, social isolation, 
depression, and institutionalization.1

Materials and Methods

This descriptive and prospective study was 
conducted in Geriatrics and Gerontology 
Department Ain Shams University hospitals. The 
study population comprised 150 elderly patients 
aged > 60 years old, males and females, patients 
with previous history of falls are excluded, consent 
was obtained from all participants, all patients 
underwent comprehensive geriatric assessment 
(detailed medical history and examination, mini-
mental state examination, geriatric depression 
scale, activities of daily living (ADLs), 
instrumental activities of daily living (IADLs) 
all patients underwent assessment with Charlson 
Comorbidity index and Hendrich fall risk model. 

Comorbotidy burden was determined using the 
Charlson Comorbidity index, it was first developed 
in 1987 by Mary Charlson and colleagues as a 
weighted index to predict risk of death within 1 
year of hospitalization for patients with specific 
comorbid conditions. Nineteen conditions were 
included in the index, each category is assigned a 
score of 1,2,3, and 6. These scores are summed up 
for an overall CCI score 10.

This study utilizes the Hendrich fall risk model, a 
tool originally invented by nurses to be utilized in 
the acute care setting, it was designed to be quickly 
administered. It utilizes eight independent risk 
factors. confusion, disorientation, and impulsivity; 
symptomatic depression; altered elimination; 
dizziness or vertigo; male gender; administration 
of antiepileptics (or changes in dosage or 
cessation); administration of benzodiazepines; and 
poor performance in rising from a seated position 
in the Get-Up-and-Go test 11.

Data analysis

Analysis of data was performed by the 16th 
version of Statistical Package for Social Science 
(SPSS). Description of quantitative data was done 
in the form of Mean (M), Standard

Deviation (SD) and range. Frequency and 
percentage were done for qualitative variables.

Comparison of qualitative variables was done 

using the Chi-square test. Correlation of two 
quantitative variables was done using the Pearson 
correlation.

Significance level measured according to P value 
(probability), P>0.05 for insignificant, P<0.05 for 
significant and P<0.01 for highly significant.

Results

The study included 150 participants. The patients’ 
mean age was (65.95) ± 4.724 years. (48.7%) 
of them were women and (51.3%) were men. 
(72%) of them were not working and (28%) were 
working. (20.7%) of our patients were living alone 
but the rest (79.3%) living with others.  (53.3%) 
were illiterate, (34%) educated for less than or 
equal 5 years and (12.7%) for more than 5 years 
education, and (64.7%) of them were nonsmokers 
but smokers were (35.3%) of patients (Table 1).

Number of comorbidities, number of medications 
had highly significant positive correlation with 
risk of falls so, patients suffer from multiple 
comorbidities and receiving multiple medications 
had higher risk of falls than others. Age also had 
high significant positive correlation with risk of 
falls so, risk of falls increases as age of the patient 
increases (Table 2).  

The patients were classified as regard risk of falls 
to two groups (patients with high risk of falls and 
patients with low risk of falls) to evaluate the 
effect of different comorbidities on risk of falls 
and found that there was a significant association 
between high risk of falls and presence of DM, 
PVD, OLD CVA and UI (Table 3).

Table 1. Demographic data.

Minimum Maximum Mean SD

Age 60 80 65.95 4.724

N %

Gender
Male 77 51.3%

Female 73 48.7%

Occupation
Working 42 28%

not working 108 72%

Living 

arrangement

with others 119 79.3%

Alone 31 20.7%

Education
>5 yrs education 19 12.7%

<5 yrs education 51 34%

Illiterate 80 53.3%

Smoking
No 97 64.7%

Yes 53 35.3%



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International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

Table 2. Correlation of fall risk with number of 
comorbidities, medications and age. 

 Hendrich II fall risk

 
 Pearson 

correlation
p value

Charlson Comorbidity index 

(no. of comorbidities)
.788** .000

No. of medications .690** .000

Age .387** 0.000

**. Correlation is significant at the 0.01 level 
(2-tailed

Discussion

Falls are one of the most common causes 
of injuries and dependence among the older 
population12-13. The falls frequency increases with 
increasing age.14 Many factors may contribute to 
falls such as biological, social, environmental, 
and behavioral risk factors among older adults 15. 
Medications and polypharmacy are very important 
items to be considered during comprehensive 
geriatric assessment as one of the adverse events 
related to medications and polypharmacy in 
the elderly are falls 16 and comorbidities are 
considered one of the most frequent intrinsic 
factors associated with falls 17 Although the 
relationship between comorbidities and falls 
has not been studied well. This study examined 
factors increase risk of falls among elderly people 
especially polypharmacy and comorbidities 
association with the risk of falls in elderly patients. 
It involved 150 elderly patients both males and 
females underwent comprehensive geriatric 
assessment and evaluation for comorbidities and 
polypharmacy and risk of falls.

The current study provided evidence for the presence 
of association between comorbidities especially 
DM, PVD, OLD CVA or UI, polypharmacy and 
increasing age and high risk of falls.

The  results  of  this  study  showed  a  significant 
positive correlation between number of 
comorbidities and risk of falls, patients with DM, 
PVD, OLD CVA and UI had higher risk of falls 
and also there was a significant positive correlation 
between number medications (polypharmacy), 
age and risk of falls.

 These results are consistent with the results of the 
study done by Bittencourt et al. who concluded 
that there was an association found between the 

risk of falls and comorbidities and found that 
diabetes mellitus was associated with high risk for 
falls (51.6% of diabetic patients presented a high 
risk of falls and it was 62.2% in the current study) 
18. Also, Wenhua et al. observed that the risk of 
falls in the comorbidity group was higher than that 
in the group without comorbidity and in patients 
more than 75 years old higher than in those less 
than 75 years old 19.

Zaninotto et al. and Ziere et al. conducted a study 
on 6220 participants and found that 7.9% of falls 
occurred among people with polypharmacy (5–9 
medications) and 14.8% among those reporting 
heightened polypharmacy (10 + medications) and 
this agreed with the results of the current study, 
however other studies suggest that polypharmacy 
alone is unlikely to be the risk factor for falls 20-
21. The association between increased falls risk 
and polypharmacy appears more when the older 
person is taking a medication that is known to 
cause falls as a side effect which may double the 
risk of falls 20-21. 

Conclusion

Multiple comorbidities, polypharmacy and 
increasing age increase risk of falls and risk 
of falls also can be affected with different 
comorbidities as shown in the previous results 
if the patient had diabetes mellitus, peripheral 
vascular disease, old cerebrovascular accidents 
or urinary incontinence made patient more liable 
and had higher risk of falls. 

Recommendations:

•	 Screening for falls in older adults is 
considered a very important preventive 
method.

•	 Patients with multiple comorbidities 
are more liable for falls, so frequent 
assessment of falls is recommended in 
patients with multiple comorbidities 
and treatment of their comorbidities as 
possible.

•	 Physicians should try to avoid 
polypharmacy as possible in older adults 
to decrease risk of falls.

•	 Patients with DM, PVD, CVA OR UI 
need special care to decrease risk of falls.

•	 More future studies to investigate the 
effect  of  individualized  medications  on 
risk of falls.



International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

78

Table 3. Comparison between patients with high risk and low risk of falls as regards different 
Comorbidities.

Comorbidities
High risk of falls Low risk of falls

total N % N % x2 P value

DM
NO 68 25 36.8% 43 63.2%

9.618 0.002*
YES 82 51 62.2% 31 37.8%

HTN
NO 28 10 35.7% 18 64.3%

3.079 0.079
YES 122 66 54.1% 56 45.9%

ISHD
NO 104 50 48.1% 54 51.9%

0.910 0.340
YES 46 26 56.5% 20 43.5%

PVD
NO 113 47 41.6% 66 58.4%

15.090 0.000*
YES 37 29 78.4% 8 21.6%

CHF
NO 138 67 48.6% 71 51.4%

3.090 0.079
YES 12 9 75% 3 25%

COPD
NO 98 47 48% 51 52%

0.829 0.363
YES 52 29 55.8% 23 44.2

CVA
NO 135 63 46.7% 72 53.3%

8.642 0.003*
YES 15 13 86.7% 2 13.3%

OA
NO 92 41 44.6% 51 55.4%

3.544 0.060
YES 58 35 60.3% 23 39.7%

UI
NO 123 57 46.3% 66 53.7%

5.114 0.024*
YES 27 19 70.4% 8 29.6%

Acknowledgement: The authors thank to all the 
staff  of  Geriatrics  and  Gerontology  department, 
Faculty of Medicine, Ain Shams University, Cairo, 
Egypt for providing the research facilities.

Conflict of Interest: The authors declare that they 
have no conflict of interest.

Funding Statement: None declared.

Ethical consideration:  Verbal consent was taken 
from every participant in this study.

Authors’ contribution: HF Mahmoud, collected 
patient and data, analysed the results, wrote 
the paper and edited the manuscript. HEMZ 
Elmedany, collected some of the patients and 
wrote part of the paper.



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International Journal of Human and Health Sciences Vol. 06 No. 01 January’22

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