Vol.3, No.7, 441-445 (2013) Open Journal of Preventiv e Me dic ine
http://dx.doi.org/10.4236/ojpm.2013.37059
Psychological risk factors associated with falls
among elderly people in Baghdad city, Iraq
Mohammed A. Abdal Qader1*, Rahmah Mohd. Amin2, Shamsul Azhar Shah1, Zaleha Md. Isa1,
Khalib Abdul Latif1, Hasanain Faisal Ghazi1
1Department of Community Health, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia;
*Corresponding A u thor:
2Medical and Health Science Faculty, Universiti Sultan Zainal Abidin (City Campus), Jalan Sultan Mahmud, Kuala Terengganu, Malaysia
Received 15 August 2013; revised 21 September 2013; accepted 6 October 2013
Copyright © 2013 Mohammed A. Abdal Qader et al. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
ABSTRACT
Background: Ageing of the population is one of
the most im portant demographic fac t s th at c ome
to the foreground in the 21st century. Objective:
To assess the relationship between psycho-
logical factors (depression, loneliness, using
anti anxiety medication, fear from falls and in-
ternal displacement of the population) and falls
among elderly people in Baghdad city, Iraq.
Methods: A match ed 1:1 comm unity based ca se-
control study involving 716 elderly respondents,
recruited randomly from six Non Governmental
Organization (NGO) in different areas of Bagh-
dad. Interviews to each respondent were done
accordingly. Geriatric depression scale (GDS)
was used to assess the depression among the
elderly people. Results: The minimum age for
cases and controls was 60 years old while the
maximum age for cases was 87 and for controls
was 85 years old. The female was predominant
than male, 53.6% to 46.4% respectively. The re-
lation between depression, fear from fall, using
anti anxiety medication, internal displacement
and falls was statistically significant (p < 0.001).
Conclusions: Psychological factor especially
depression among elderly people is one of the
important risk factors contributing to falls acci-
dent. Fear from falls, displacement and taking
anti anxiety medication were also in significant
relation.
Keywords: Falls; Elderly; Depression; Fear from
Fall; Baghdad
1. INTRODUCTION
Ageing of the population is one of the most important
demographic facts that come to the foreground in the
21st century. Psychological problems of depression,
loneliness and dependency feelings are very common
among elderly people. Another common issue is falls
accident which has a great impact on or leads to many
consequences such as bedridden, total dependence on
others and can even cause death [1].
According to United Nations report in 2009, the per-
centage of 60+ age population in Iraq was 3.9% for men
and 5.6% for women, while the sex ratio in 60+ age
group was 70 men to each 100 women. Some elderly
Iraqis have lost all their relatives over the past few years
and now have to depend totally on themselves. Being
unable to work because of age or poor health conditions,
some of them have urged for begging in the streets and
become homeless people while others are supported by
their neighbours and relatives[2].
Falls accident could be preventable and is a promising
issue to be dealt with in preventive medicine. Hence the
public health experts should take into consideration, this
preventive issue involving falls among the elderly people
seriously. More research is needed to be done to reduce
the burden of falls to the community. It is obvious that
lack of knowledge about risk factors and how to prevent
them will contribute to a high prev alence of falls. There-
fore, lack of knowledge in this issue will lead to a lack of
preventive actions that should be taken, thus resulting in
more falls [3].
Psychological relationships to falls accident were less
clear. However, depression and falls, which can be corre-
lated to the decrease of functional independence, loss of
physical fitness, reduc ed gait velocity and loss of muscle
strength are due to immobility and lethargy, which are
*The authors declare t hat they have no conflict of interest.

M. A. A. Qader et al. / Open Journal of Preventive Medicine 3 (2013) 441-445
442
common in depression [4].
Fear of falling (FOF) is a major health problem among
the elderly living in communities. This feeling can be
expressed in older people both who have fallen and also
in older people who have never experienced a fall. The
main consequences were identified as a decline in
physical and mental performance, an increased risk of
falling and progressive loss of health-related quality of
life [5]. A study by Elliott et al. [6] in eastern North
Carolina, United States showed a significant relation be-
tween living alone and falls accident to themselves.
In Iraq, there are no available studies or literature re-
view that assays the epidemiolog y and aetiology of falls,
that could be considered as evidence that warrants some
attention. The objective of this study is to assess the rela-
tionship between psychological factors and falls accident
among elderly people in Baghdad city, Iraq.
2. Methods
A case control study matched by sex and age was
conducted between January and March 2012 in Baghdad
city, Iraq. 716 elderly respondents, recruited randomly
from six Non Governmental Organization (NGO) in dif-
ferent areas of Baghdad; These NGOs provide social &
medical services to the community in Iraq. Severely ill
respondents, using wheelchair, an elderly fall outside the
home and elderly with severe psychosomatic disease
were excluded from this study. Face to face interview to
each respondent were done accordingly. Back-to-back
trans-lation to the questionnaire was done (English-Ara-
bic-English). GDS (geriatric depression scale) standard-
ized questionnaire (Arabic version) was used to measure
the level of depression among the elderly people [7].
A pre test of the questionnaire was carried out to im-
prove the questionnaires and make it more understand-
able. This study was approved by the Research and Eth-
ics Committee of Universiti Kebangsaan Malaysia Me-
dical Centre. Code Number FF-017-2012, consent form
was taken from the respondents.SPSS version 19 was
used for statistical analysis of the data and Pearson
chi-square test was performed with a level of signifi-
cance p < 0.05.
3. Results
The minimum age for cases and controls was 60 years
old while the maximum age for cases was 87 and for
controls was 85 years old, the mean age for cases was
67.01 while mean age for controls was 66.28 years old.
The female was predominant than male, 53.6% to 46.4%
respectively. Other socio-demographic characteristics as
shown in Table 1 showdifferences between cases and
controls. Educational level was a significant contributor
for the falls. The employment status was not significant
risk factor, while, the monthly family income and marital
status were significant risk factors for falls among eld-
erly people.
Table 1 also shows the distribution of the respon-
dents’ depression, fear from fall and living alone. The
fear from fall was significantly associated with fall acci-
dent and of p < 0.001, the odds ratio is 2.90, with a 95%
confidence interval ranging from 2.17 to 4, showed that
those who suffer from fear were about 3 times more sus-
ceptible to fall than those elderly who does suffer from
fear of falling. For depression factor, the p value is sig-
nificant (p < 0.001), the odds ratio 2.8, indicating that
those elderly with depression is about 3 times more sus-
ceptible to fall than those elderly without depression.
Living alone was not statistically associated with falls (p
= 0.91) with odds ratio of 1.03, and 95% confidence in-
terval extending from 1.49 to 1.58.
Internal displacement was a significant risk factor of a
p value <0.001, those who internally displaced were
about 2 times more to falls as compared to non displaced
elderly.
Elderly people using anti anxiety medications suffer a
higher significant risk of falls with odds ratio of 2.3.
4. Discussion
Fall is still found to be one of the public health prob-
lems among elderly people; falls are a common and often
devastating problem among older people, causing a tre-
mendous amount of morbidity, mortality and use of
health care services. The most important finding in our
study was depression and fears from fall as they were
significantly associated with an increased risk of being a
faller.
Some of the limitations in this study are recall bias of
the respondents, not an interventional type and logistic
problems because of the security situation in Baghdad.
While the strength of this study is mainly being a com-
munity based study, with large sample size and first kind
of study in Iraq.
In this study, there is a significant difference between
low education and high education among cases and con-
trols, those with low education level were at odds of risk
by about 1.8 times as compared to those with high edu-
cation as shown in other studies [8,9].
There was a significant relationship between monthly
income and falls as supported by other studies. The pos-
sible reason for that could be those with higher monthly
income can get better welfare life, nutrition and more
medical services. There were no significant association
between current employment status (working or not
working) and fall and that was against what some other
studies findings [8,9].
Fear from falls was associated with falls accident as

M. A. A. Qader et al. / Open Journal of Preventive Medicine 3 (2013) 441-445 443
Table 1. The Frequency distribution and relationship of socio-economic and psychological factors with falls accident among the
elderly people in Iraq.
Variables Case (358) N (%) Control (358) N (%) p-valuea POR 95%CI
Educational level
Low 189 (52.8) 130 (36.3) <0.001* 1.96 1.45 - 2.64
High 169 (47.2) 228 (63.7)
Employment status (current)
Unemployed 270 (75.4) 254 (70.9) 0.17 1.25 0.90 - 1.75
Employed 88 (24.6) 104 (29.1)
Marital Status
Married 159 (44.4) 224 (62.6) <0.001* 2.12 1.56 - 2.85
Not Married 199 (55.6) 134 (37.4)
Monthly Income
Low Income 192 (53.6) 164 (45.8) 0.036* 1.36 1.02 - 1.83
High Income 166 (46.4) 194 (54.2)
Fear of Fall
Yes 262 (73.2) 173 (48.3) <0.001* 2.90 2.17 - 4.00
No 96 (26.8) 185 (51.7)
Depression
Yes 284 (79.3) 207 (57.8) <0.001* 2.80 2.01 - 3.89
No 74 (20.7) 151 (42.2)
Living (Household)
Alone 49 (13.7) 50 (14) 0.91 1.03 1.49 - 1.58
Not Alone 309 (86.3) 308 (86)
Internal displacement
Yes 133 (37.2) 77 (21.5) <0.001* 2.15 1.54 - 3.00
No 225 (62.8) 281 (78.5)
Anti anxiety medications
Yes 142 (39.7) 80 (22.3) <0.001* 2.32 1.66 - 3.22
No 216 (60.3) 278 (77.7)
aPearson chi-square test was perfor med; *Level of significance p < 0.05; POR = Prevalence odds ratio.
supported by Yu et al. study, they found that the total
rate of falls-induced fear of repeated episodes of falls
(58.8%) and at the same time the occurrence of falls were
significantly associated with fear of future falls [9].
Kwan et al. in their systematic review found that the
median fall rates was 18%, they found that being com-
plaining of fear of falling was commonly reported factor
[10]. On the other hand, study by Leung et al. did not
match our findings as fear from fall was not significantly
associated with falls [11], this contradictory could be due
to the differences in the culture, habits and welfare be-
tween these two different societies.
While for depression factor, our study was supported
by other studies which found that falls were most strongly
associated wit h sad feeli ng or depression [12,1 3] .
Living alone was one of the risk factors has been
studied, in our study it was not significantly associated
with falls and other studies supported our findings, as the
study done in the city of Mataró, Spain, they stated that
no significant difference was found between the propor-
tion of falls in people living alone (34.3%) or accompa-
nied (31.7%) [14], in another study in Brazil found no
significant association between living with a partner and
fall [13].
According to United Nations High Commissioner for
Refugees (UNHCR), internal displacement remains a

M. A. A. Qader et al. / Open Journal of Preventive Medicine 3 (2013) 441-445
444
major problem, and internally displaced persons (IDPs)
require continued assistance and protection from UNHCR
until a dignified solu tion is found to their troub les. Fami-
lies live in poor settlements without adequate shelter and
with limited access to water, electricity, schools and
health centers [15].
Using anti anxiety drugs were associated with falls as
supported by a study done in Great Britain, they found
that hypnotics and anti anxiety drugs was independently
associated with an increased odds of falling, it was asso-
ciated with an increase of about 50% in the odds of fal-
ling [16]. Another study found that sleeping pills won’t
increase elderly fall risk, they found that it’s insomnia
itself, not sleeping pills, that increases the risk for falls
and injuries among elderly people [17].
5. Conclusion
Psychological factor especially depression among eld-
erly is one of the important risk factors contributing to
falls. Also, fear from falls, displacement and taking anti-
anxiety medications are significant risk factors of falls.
6. Recommendations
Findings from this research enhance knowledge about
the contributing fall-related factors in elderly. Insights
gained from this research will assist community an d pub-
lic health leaders and health care professionals in devel-
oping more effective intervention strategies to prevent or
decrease falls, and associated psychological and physical
consequences
To prevent falls, it is necessary to intervene on factors
associated with falls. Methods include encouraging re-
gular physical activity to improve equilibrium and mus-
cle strength and the continuous monitoring of health
status to prevent further deterioration.
Fall prevention is need ed for elderly individuals living
in the community and should target the elderly adults
with less education level and low monthly income while
helping to en sure that individuals who are living without
family have the appropriate support.
7. ACKNOWLEDGEMENTS
This study was funded by the Universiti Kebangsaan Malaysia
Medical Centre Fundamental Research Grant, Code Number FF-017-
2012 without which the study would not have been poss i b le.
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