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Falls and Depression in Older People

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DOI: 10.1159/000079128 · Source: PubMed

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 Clinical Section
Gerontology 2004;50:303–308
DOI: 10.1159/000079128
Falls and Depression in Older People
Alin Turcu Sandrine Toubin France Mourey Philippe D’Athis
Patrick Manckoundia Pierre Pfitzenmeyer
Service de Gériatrie, Hôpital de Champmaillot, Centre Hospitalier Universitaire, Dijon, France
Key Words
Falls W Depression W Posture and gait abnormalities W
Older patients
Abstract
Background: Depression is one of the most common risk
factors for falls, but links between falls and depression
are still unclear. Few studies have examined the relation-
ship between depression and gait alteration, which may
increase the risk of fall. Objective: This study aims to
assess a possible relationship between depression, pos-
tural and gait abnormalities, and falls. Methods: We con-
ducted a 1-year prospective study on patients 670 years
who were admitted to a geriatric unit for ‘spontaneous’
unexplained falls. Patients were tested for depression
using the 30-item Geriatric Depression Scale (GDS).
Their motor performances were assessed using the Mini
Motor Test (MMT), which is an easy direct-observation
test, validated in France, for assessment of frail old peo-
ple who present with severe postural and gait impair-
ment. This scale is composed of 4 categories of items:
(1) abilities in bed; (2) quality of the sitting position;
(3) abilities in the standing position, and (4) quality of
gait. Results: Sixty-nine patients were included. Depres-
sion was found in 46 patients (66.7%). The MMT score
© 2004 S. Karger AG, Basel
ABC 0304–324X/04/0505–0303$21.00/0
Fax + 41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/ger
Received: February 19, 2003
Accepted: September 9, 2003
was higher in the non-depressed fallers (NDF) group
(GDS ^10) compared to the depressed fallers (DF) group
(GDS1 10; p ! 0.05). The 2 groups were compared for
each of the 4 items of the MMT: the difference between
the DF and NDF groups was mainly explained by the
impairment of postural abilities in the standing position.
Conclusions: Our results support the idea that depres-
sion is associated with postural abnormalities in the
standing position, which may predispose to falls. In clini-
cal practice, more attention should be given to old fallers
concerning diagnosis and treatment of associated de-
pression.
Copyright © 2004 S. Karger AG, Basel
Introduction
Falls are among the most common and serious prob-
lems facing older persons [1]. They usually result from an
interaction between environmental challenges and nu-
merous deficits concerning particularly cognitive, neuro-
muscular or cardiovascular functions. Diverse risk factors
and situations act on a background of age-related func-
tional impairment with consequent vulnerability when
walking.
Prof. Pierre Pfitzenmeyer
Service de Gériatrie, Hôpital de Champmaillot, CHU
2, Rue Jules Violle
FR–21034 Dijon (France)
Tel. +33 3 80 29 39 70, Fax +33 3 80 29 36 21, E-Mail ppfitzenmeyer@chu-dijon.fr
 Numerous studies have shown that falls and depres- Table 1. Items of the Mini-Motor Test (MMT)
sion were linked in the old: (1) depression is considered as
1 0
one of the most common risk factors for falls [2]; (2) anti-
depressants may be associated with an increasing inci- In bed
dence rate of falls [3], and (3) subjects who fall are more 1 Able to roll to one side – –
prone to anxiety and depression [4]. 2 Able to rise from lying to sitting position – –
Studies concerning gait and postural abnormalities in Sitting position
depressed older people are scarce. Abnormal gait patterns 3 No retropulsion of the trunk – –
have been observed in depressed patients [5]. Changes in 4 Able to bend trunk forward – –
gait may be an important component of psychomotor 5 Able to rise from a chair – –
retardation which is characterized by impairment of gait Standing position
and stride. In older adults, depressive symptoms were cor- 6 Possible – –
related with gait speed [6, 7]. Moreover, compared to 7 Without assistance (material or human) – –
8 Able to stand on two legs with closed eyes – –
adult controls, depressed subjects showed reduced stride 9 Able to stand on one leg – –
length and double limb support [8]. 10 No retropulsion – –
We conducted a prospective study in older fallers 11 Reactive postural responses – –
admitted to a geriatric acute care unit in order to deter- 12 Protective reactions of upper limbs – –
mine the prevalence of depression in this population, and 13 Stepping reactions forwards – –
14 Stepping reactions backwards – –
to clinically search for a relationship between depression,
posture, and gait abnormalities in these patients. Gait
15 Possible – –
16 Without assistance (material or human) – –
17 Normal heel strike – –
Methods 18 No knee flexion – –
19 No retropulsion – –
All patients aged 70 years and over who were admitted to our 20 Harmonious turn round – –
geriatric hospital unit for ‘spontaneous’ unexplained falls during a Total: –/20
1-year period were included. For these patients, we assessed the pres-
ence of depression, cognitive function, motor performance, blood
pressure, and the number of falls prior to admission. Subjects who
presented with malaise and other direct causes of falls in which envi-
ronmental factors could be held responsible were excluded. Patients
who could not perform the required depression test were also
excluded. and validated in a French study that included 4 geriatric centers
The diagnosis of depression was made using the Geriatric De- (Strasbourg, Saint-Etienne, Marseille, and Dijon) [14]. MMT was
pression Scale (GDS). This scale has 30 items and scores range from created as a 20-item measure (table 1). These 20 items can be catego-
0 to 30. A score of 11 or more characterizes depression with a sensi- rized into 4 parts: (i) abilities in bed; (ii) quality of the sitting posi-
tivity of 65–100% and a specificity of 89–93% [9, 10]. Clinical signs tion; (iii) abilities in the standing position, and (iv) quality of gait.
of major anxiety were systematically noted by the clinician. Three of these 20 items assess the trend to backward disequilibrium
Cognitive performance was investigated using the Mini-Mental because this postural impairment, in our experience, was the main
Status Examination [11]. characteristic of several frail older people [12]. We have called back-
The capacities in daily activities were measured using the Katz ward disequilibrium ‘retropulsion’. Based on clinical observation,
index [12] in grades A, B, C, D, E, F and G, where A is the least and G this test has only 2 levels. When the response to the item is ‘yes’, the
the most dependent grade. Dependence was retained if subjects were score is 1, and when the response is ‘no’, the score is 0. Thus, the
not able to wash themselves or eat without aid. maximum total score of MMT (20/20) is reached by the patients who
Blood pressures were measured using standard sphygmomanom- show the best physical abilities. MMT is accepted by numerous
eter measurements in the supine position and after 3 min of standing. French geriatric centers. This scale is an easy direct observation test
Orthostatic hypotension (OH) was defined as a drop in systolic blood which may be particularly useful in frail old people who present with
pressure of at least 20 mm Hg from the supine to the standing posi- severe postural and gait impairment in order to develop rehabilita-
tion at 3 min, or a drop in diastolic blood pressure of at least 10 mm tion goals.
Hg while standing, or both [13]. Walking speed was also calculated over a distance of 10 m and is
The number of falls in the past 6 months was noted using expressed in meters per second. All these gait and postural tests were
patient’s history notes and the information provided by the patient’s performed by our department’s physiotherapists.
family. These data were then correlated in order to determine an
Motor disturbances were assessed using a scale named the Mini eventual relationship with the presence of depression. Data were
Motor Test (MMT). MMT was elaborated 10 years ago in our center compared using the ¯2, and Fisher statistical tests.

304 Gerontology 2004;50:303–308 Turcu/Toubin/Mourey/D’Athis/

Manckoundia/Pfitzenmeyer
Table 2. General characteristics of the patients Results

Sex (female/male) 48/21

We included 69 older fallers (48 women and 21 men).
Mean age, years 84.1B6.6 (70–100)
Mini-Mental Status examination 21.8B6 (8–29) The mean age was 84.1 B 6.6 (range 70–100) years. Gen-
Geriatric Depression Scale 13.3B6.4 (3–24) eral characteristics of the patients are given in table 2.
Mini-Motor Test 13.6B4.9 (6–20) Depression was found in 46 fallers, corresponding to a
Walking speed, m/s 0.45B0.36 (0.08–0.96) prevalence of 66.7% (table 3). A comparison was made
Falls in the last 6 months 3.2B2.7
between depressed fallers (DF; GDS 110) and fallers
Orthostatic hypotension 16 (23%)
High level of dependency1 29 (42%) without depression (NDF; GDS ^10). The results are
shown in table 3. Depression was significantly more fre-
Unless otherwise indicated the values are the means B SD with quent among female fallers (p ! 0.05). Concerning the
ranges in parentheses. past history of depression, there was no statistically signif-
1 Patients in grades D, E, F and G, of the Katz index.
icant difference between the DF and the NDF groups (p =
0.087). Major anxiety was significantly more frequent in
the DF group compared to the NDF group (p = 0.015).
Although the number of past falls was higher in the DF
group compared to the NDF group (3.6 vs. 2.3), no signifi-
Table 3. Comparison of depressed fallers (DF group) and fallers cant difference was observed.
without depression (NDF group) There was no significant difference for OH in the DF
group compared to the NDF group (p = 0.157). This lack
NDF group DF group ¯2/Fisher
(n = 23) (n = 26)
of significant difference persisted after eliminating pa-
tients who had been taking antidepressive treatment.
Sex (male/female) 13/10 8/38 p! Although high levels of dependency were more fre-
0.001 quent in the DF group than in the NDF group (52.2 vs.
Past history of depression 7 (30%) 24 (52%) NS 21.8% of patients in grades D, E, F and G of the Katz
Major anxiety 2 (9%) 18 (39%) p ! 0.05
index), the difference did not reach the significant level
Orthostatic hypotension 3 (13%) 13 (28%) NS
High level of dependency1 5 (22%) 24 (52%) p= (p = 0.053).
0.053 We were able to perform the MMT for 54 patients. The
7 remaining patients either refused or presented osteoar-
The NDF group was composed of patients who presented a GDS ticular or neurological diseases which made evaluation
of ^10, and the DF group was composed of patients with a GDS of
impossible. Comparison of motor performances between
1 10.
1 Patients in grades D, E, F and G of the Katz index. the DF and the NDF groups are given in table 4. The
MMT score was significantly lower in the DF group com-

Table 4. Relationship between depression and MMT, walking speed, falls, associated diseases and MMSE

NDF group DF group ANOVA

Fisher test
patients mean B SD patients mean B SD

MMT 16 15.6B3.74 38 12.8B5.2 p ! 0.05

Walking speed, m/s 14 0.56B0.56 31 0.40B0.21 NS
Falls1 23 2.3B1.4 46 3.6B3.1 NS
Associated diseases 23 3.1B1.3 46 3.4B1.4 NS
MMSE 23 20.7B6.7 46 22.3B5.6 NS

1 Number of falls in the past 6 months.

Falls and Depression Gerontology 2004;50:303–308 305

Table 5. Comparison of depressed fallers
(DF) and fallers without depression (NDF) NDF group (n = 16) DF group (n = 38) ¯2/Fisher
for each part of the MMT (abilities in n % n %
bed, quality of the sitting position, abilities
in the standing position, and quality of gait) In bed score
0–1 4 25 9 23.7 NS
2 12 75 29 76.3
Sitting position score
0–2 3 18.7 10 26.3 NS
3 13 81.3 28 73.7
Standing position score
0–6 3 18.7 19 50 p ! 0.01
7–9 13 81.3 19 50
Gait score
0–3 7 43.7 26 68.4 NS
4–6 9 26.3 12 31.6

The NDF group was composed of patients who presented a GDS of ^10, and the DF
group was composed of patients with a GDS of 1 10.

pared to the NDF group (12.8 B 5.2 vs. 15.6 B 3.7). The
2 groups were then compared for each part of the MMT
(abilities in bed, quality of the sitting position, abilities in
the standing position, and quality of gait). A significant
difference between groups was noted only for abilities in
the standing position; impairment was more pronounced
in the DF that in the NDF group (table 5).
Walking speed was measured in 41 patients. The
remaining 28 patients did not show enough standing and
walking abilities to allow walking velocity to be measured.
Although walking speed was higher in the NDF than in
the DF group (0.56 B 0.56 vs. 0.40 B 0.21 m/s), the dif-
ference was not statistically significant (table 4).
Discussion
Our results show a high prevalence of depression
among hospitalized fallers (66.7%). In elderly hospital-
ized patients, numerous studies have shown that the prev-
alence of depression was high with a range between 12
and 45% [15]. To assess depression, a variety of self-rated
instruments have been used, and therefore may produce
marker difference in prevalence rates. The GDS has been
widely used and seems to be particularly suitable for the
diagnosis of depression in hospitalized elderly people
because: (1) GDS focuses on the cognitive aspects of
depressive illness rather than physical symptomatology
[15], and (2) GDS has been validated in just as well medi-
cal outpatients as in medical inpatients [16].
Previous studies have suggested that depression is
associated with falls, and particularly with falls which
resulted in serious injury [17, 18]. To our knowledge,
there are no published data showing the prevalence of
depression in old hospitalized fallers. Such a high preva-
lence makes it essential to systematically search for de-
pression in old hospitalized fallers in order to initiate psy-
chological support and possibly antidepressive drug treat-
ment.
A significant difference in the MMT score between the
DF and NDF groups was observed, showing that our
depressed patients had lower motor performances than
non-depressed ones. We choose to use the MMT score
over other validated geriatric assessments of posture and
gait in order to identify subjects at high risk of falling [19–
22]. This choice was imposed by the fact that, contrary to
other tests, the MMT can assess motor abilities in bed and
in the sitting position in frail older patients who usually
show great disabilities in the standing position and walk-
ing. Then, this test makes it possible to assess the minimal
motor and postural abilities which may be dramatically
altered in depressed patients with motor retardation.
When comparisons were made according to the 4 parts of
the MMT test (abilities in bed, quality of the sitting posi-
tion, abilities in the standing position, and quality of gait),
only postural abilities in the standing position were signif-

306 Gerontology 2004;50:303–308 Turcu/Toubin/Mourey/D’Athis/

Manckoundia/Pfitzenmeyer
icantly altered in the DF compared to the NDF group. To
assess our population, the choice of MMT may be dis-
cussed, because validation of this scale has been insuffi-
ciently published in international literature. Nevertheless,
MMT assessment has largely been used in France for sev-
eral years. Moreover, numerous items of the MMT which
assess disabilities in the standing position are used in the
majority of other postural assessment scales such as the
Tinetti test: quality of immediate standing with or with-
out support; quality of balance with eyes closed; quality of
one leg standing balance, and quality of reactive postural
responses. That is why, we would like to think that our
results, which showed that postural abilities in the stand-
ing position were significantly altered in DF compared to
NDF, can be accepted.
Nevertheless, the correlation between postural distur-
bance and depression observed in present study cannot
make causal attributions: we do not know if depression
was a consequence of a fall, or if depression had triggered
the fall. Nevertheless, several suggestions may be given to
explain the link between depression and falls observed in
present study. (1) The use of the GDS to screen our frail
very elderly patients is not without problems. In previous
works [15, 23], we noted that alterations in postural abili-
ties were highly correlated with frontal-subcortical dys-
function (called ‘psychomotor disadaptation syndrome’
in the French literature) which is characterized by major
psychomotor retardation. Within the relationship be-
tween psychological state and movement patterns, psy-
chomotor retardation appears as a common point be-
tween depression and falling [23]. Several items of the
GDS are interested in slowness of activity which is associ-
ated with psychomotor retardation, this neurological
manifestation being common to depression and frontal-
subcortical dysfunction. In this way, we can hypothesize
that high rates of false-positive score may be observed
when the GDS is used in patients with frontal-subcortical
dysfunction. (2) Brain damage in subcortical areas may be
common in depression and postural abnormalities. Re-
cent work has shown that white matter lesions (WML)
were associated with major depression in the older people
[24]. WML in depressed older patients were also corre-
lated with a poor prognosis, and associated with altera-
tions in cognitive performance [25, 26]. On the other
hand, several reports have suggested that WML might be
associated with gait disorders, postural abnormalities and
mobility problems in very old patients, independent of
specific medical illness [23, 27–29]. Our results show that
depressed patients showed no more frequent history of
depression than non-depressed subjects, and these find-
ings support the idea that depression in our fallers may be
linked to organic neurological lesions.
Consequently, we think that depression and falls in
very elderly subjects might be closely linked by a common
pathophysiology. Nevertheless, more work is needed to
establish the relationship between falls, depression and
WML.
In conclusion, this study observed a high prevalence of
depression among hospitalized fallers. Depression was
associated with postural abnormalities probably consecu-
tive to psychomotor retardation. Organic subcortical le-
sions may perhaps contribute to both the occurrence of
depression and postural impairment. Nevertheless,
pathophysiological links between postural abnormalities
and depression still need to be elucidated.

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