Risk of Falls in Older Adults in the Rural Region
Case Study Paccha Cuenca, Ecuador
Johanna Campoverde
, Jessica González
and Ana Pérez
Medical Sciences Faculty, Universidad de Cuenca, Av. 12 de Abril s/n, Cuenca, Ecuador
Keywords: Aging, Old Age, Accidental Falls, Risk Assessment.
Abstract: The growing aging of the population constitutes a challenge in the social and health system which considers
the risk of falls as one of its main health problems. The objective of the study is to determine the risk of falls
in the elderly population of the La Fortaleza group - Paccha, Cuenca. This research corresponds to a
descriptive and cross-sectional case study, where the unit of analysis was the elderly from the La Fortaleza
group. The Tinetti scale determine the risk of falls in older adults, with a reliability 0.95 - 0.8 and Cronbach's
Alpha 0.91. The frequency and distribution statistics were analyzed in the SPSS version 25 program and to
determine the statistical significance the Chi- Square statistic was used 86 older adults with a mean age of
76.65 years (SD = 7.35) were evaluated, determining a high risk of falls (61.6%) in this population. An
association was obtained between the risk of falls and the age variable (p = 0.000); furthermore, the
equilibrium dimension of the Tinetti scale had a greater implication than the march in the risk of falls of the
older adults. Conclusion: The high risk of falls in this population is associated with older age and alterations
in balance. Finally, the need for more studies of different characters and scales is analyzed.
Aging corresponds a series of structural and
functional changes that are accentuated after the age
of 65. The theory of aging tells us that we begin to
age from the moment we are born (Morejón et al.,
2018) this process decreases motor, cognitive and
social capacities; making older adults susceptible to
falls or accidents in the environment in which they
operate (Alvarado & Salazar, 2014). According to the
World Health Organization (OMS, 2017) within 50
years, it is estimated that there will be a growing
population of older adults worldwide, this is because
the population pyramid tends to flatten at the top, as
a result of a decrease in fertility and a significant
increase in life expectancy (González, R., 2018). In
Ecuador, a person over 65 years of age is considered
an older adult (Ochoa et al., 2018).
According to data from the Institute of Statistics
and Censuses of Ecuador (INEC, 2015) in 2010 the
adult population was 940,000, which represented
6.5% of the population at the national level. The
Ministry of Economic and Social Inclusion of
Ecuador (MIES), considering data from the
Economic Commission of Latin America and the
Caribbean (ECLAC), established that Ecuador has an
aging index of 28 older adults for every 100 children
under 15 years of age and According to the INEC
population projections in 2020 there were 1,264,423,
in 2050 it will represent 17% and in 2075 it will be
26% of the total population (INEC, 2015). With these
data, it is evident that population aging is on the rise
both nationally and globally, therefore, as society
ages, social and health problems increase (Terra et al.,
Older adults due to the conditions indicated above
present a series of risks such as suffering from
cardiovascular, respiratory, muscular, joint, and
metabolic diseases and the risk of suffering falls. On
the other hand, falls are defined as any involuntary
event that results in loss of balance and causes the
Campoverde, J., González, J. and Pérez, A.
Risk of Falls in Older Adults in the Rural Region Case Study Paccha Cuenca, Ecuador.
DOI: 10.5220/0011000600003188
In Proceedings of the 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2022), pages 204-212
ISBN: 978-989-758-566-1; ISSN: 2184-4984
2022 by SCITEPRESS Science and Technology Publications, Lda. All rights reserved
body to hit the ground or another firm surface that
stops it (Gómez et al., 2016).
Falls are one of the great Geriatric syndromes and
a frailty factor in this population due to its
considerable prevalence percentage that varies
between 30 to 50% and the annual incidence between
25 to 35%, in addition to the fact that as age increases,
the risk of falls increases being 30% in people over
65 to 50% in people over 80 (Villar et al., 2015).
Falls affect the biopsychosocial sphere of the
elderly, since they are the cause of physical and
psychological injuries that require prolonged periods
of treatment and rehabilitation, in addition to
limitations in activity and social participation (Gómez
et al., 2016).
The WHO and the Ministry of Public Health of
Ecuador recognize the negative impact of falls and
the importance of working on it to provide the elderly
with a quality of life that meets their needs, in
Ecuador it is done through a model of Prioritization
of Health Research 2013-2017 where falls are part of
the line of investigation of unintentional or transport
injuries, this document seeks to optimize resources to
carry out research on this problem and from the
results achieve a positive impact in the lives of adults
(Ministry of Public Health, 2013) despite this
information the evaluation of the risk of falls goes
unnoticed by health professionals, this because older
adults do not usually mention these events, they are
not asked about the recurrence of falls because in
some cases there are no serious injuries and mainly
because it is attributed to the normal aging process
(Villar et al., 2015).
Therefore, a comprehensive geriatric assessment
where intrinsic factors are clearly identified (personal
pathologies, sense organs), extrinsic factors
(environmental risks) and circumstantial factors
(related to the activity being carried out) (Villar et al.
, 2015) will allow taking the measures of health
promotion and prevention according to the needs of
the elderly and work in a timely manner through the
implementation of effective measures, such as:
eliminating architectural barriers, work on muscle
strengthening, proprioception, balance exercises -
coordination , in addition to making adaptations at
home and thus preserving/improving the
independence and autonomy of the elderly (Terra
Jonas et al., 2014).
Several scales allow the assessment of falls in the
elderly, among these we have: the Downton scale that
assesses risk factors such as previous falls, use of
medications, sensory deficit, mental state, and gait;
Tromp's multiple falls scale that assesses visual
problems, urinary incontinence; and the Get up and
Go Test that assesses mobility about the risk of falls.
Although there is a wide variety of measurement
instruments that allow assessing the risk of falls, the
Tinetti scale is appropriate for assessing gait and
balance; this scale is observational, standardized, and
used to measure and determine the risk of falls in
older adults individually with a total score of 28
points (Beorlegui et al., 2017).
The present case study is done in the context of
the Physical Therapy career of the University of
Cuenca. It was carried out in a rural parish of the city
of Cuenca-Ecuador, where the risk of falls in older
adults was evaluated in this community. Whose
objective was: to determine the risk of falls in the
elderly population of the La Fortaleza group of the
rural parish Paccha. Cuenca - Ecuador (González &
Pérez, 2021).
The document is structured as follows, section 1
presents a brief introduction to the article, in section
2 related works on the proposed research topic are
shown, in section 3 the case study and its planning
design are written, sections 5 - 6 cover the
discussion and conclusion reached by the authors
respectively. Finally, section 7 is contemplated for
future work.
Finally, we emphasize the role played by the
older adult within society and each of their families
with their active participation within the social
context; without a doubt they constitute a true
example for future generations.
In recent years there have been several studies related
to the risk of falls in older adults. The article
presented below indicates that falls occur at any age
being children and older adults the groups with the
highest incidence, but mortality and disability are
high in the latter. In addition, people who are
dependent on their activities of daily living (ADL)
have a 78% higher risk of falling than an older adult
who does not have ADL limitations, also in this same
article it is considered that 50% of falls are due to
extrinsic factors, such as environmental factors,
architectural environment or elements of personal use
(Álvarez, 2015).
On the other hand, in the study by Topka et al.
(2020) it is mentioned that one in three older adults
falls at least once a year; these events are caused by
the interaction of various internal and external
factors. For (Morales, 2016) other factors related to
falls in older adults are the collateral effects of
medications, physical inactivity, cognitive and visual
Risk of Falls in Older Adults in the Rural Region Case Study Paccha Cuenca, Ecuador
alterations, and the lack of adaptations at home.
Another study reports that from the age of 60, 15% of
older adults present gait alterations and at 85 years
these gait alterations increase by up to 50%
predisposing them to falls in the older adult (Pérez et
al., 2020).
Approximately 30% of 65-year-old older adults
living in the community suffer at least one fall per
year, this number increases when the elderly lives in
institutions, 50% of these falls require medical
attention, and 10% end in fracture (Suárez et al.,
2018). Finally, falls and their consequences are a
persistent long-term problem in the older adult, it is
evidenced that there are fewer falls between midnight
and six am, concluding that falls occur more during
daily movement than at night; and that these occur
mostly in the bedroom - bathroom (Anderson & Lane,
It is essential to know as part of a comprehensive
geriatric assessment the risk of falls in the elderly
population so that health professionals such as
physiotherapists, kinesiologists, and personnel
dedicated to the care of the elderly carry out timely
activities of promotion and prevention of them.
In Ecuador there have been few studies on falls or
similar in the elderly population, among the most
recent is a research work entitled ¨Evaluation of the
physiotherapeutic intervention in the prevention of
falls in the elderly at the Hogar Sagrado Corazón de
Jesús¨ (Cunalata & Garcés, 2017), even when it is
considered that a fall entails expenses at the health
level that imply treatment, rehabilitation, loss of
productivity, early retirements, whether due to
disability, widowhood (Calero et al., 2016); and, at
the province of Azuay little updated bibliography is
reported that provides information on this problem
(Alvarado, L et al., 2014), therefore, this article
provides updated information on the risk of falls in
older adults in a rural parish of Cuenca- Ecuador.
This study is quantitative, descriptive in scope, and
cross-sectional. The participants were older adults
from the “La Fortaleza” group belonging to the
Decentralized Autonomous Government project of
the Paccha - Cuenca parish, which was evaluated in
July 2021, to determine the risk of falls in this
This section presents the design and execution of
the case study according to the guidelines of Runeson
& Höst (2008) that propose the following
organization: i) the design and planning of the case
study, ii) the preparation and collection of data, iii)
analysis and interpretation of the findings and iv)
threats to the validity of the study.
3.1 Design and Planning
Carrying out a design and planning of the collection
and the subsequent analysis of data allows
guaranteeing the directionality of the study to comply
with the objectives set. In this sense, the objectives,
the delimitation of the case and the unit of analysis, a
brief frame of reference, and the research questions
are presented.
3.1.1 Objectives of the Case Study
This case study has the following objectives:
Characterize the participants according to
age and sex.
Identify the level of risk of falls by
applying the Tinetti scale.
Compare the factors with the highest and
lowest scores derived from the Tinetti scale.
3.1.2 The Case and the Unit of Analysis
This case study corresponds to a holistic-unique
study. In other words, the phenomenon (risk of falls)
will be analyzed in a single context and the
characteristics of the cases (participants) are
homogeneous, as shown in figure 1.
Figure 1: Case study design.
Context: in Ecuador, the Decentralized Autonomous
Governments are institutions that make up the
territorial organization of the state with political,
administrative, and financial autonomy regulated by
the Constitution of the Republic of Ecuador and the
Organic Code of Territorial Organization, Autonomy
and Decentralization (COOTAD) (Mafla, 2019). The
rural parishes constitute remote sectors of the city,
where its inhabitants live from agricultural and
livestock activities. Paccha is a rural parish that is
2,600 meters above sea level, located northeast of the
city of Cuenca, inhabits 6,467 inhabitants and covers
a territorial area of 26.4 km, which represents 0.8%
of the total cantonal territory (GAD Paccha, 2019).
The population over 65 years of age represents 9.5%
ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health
of the total population of the Paccha parish
Case: the group "La Fortaleza" is directed -
coordinated by a Graduate in Physiotherapy; among
its objectives is to provide comprehensive care to the
elderly in the Paccha parish. This group is attached to
the Municipal GAD previously described in an
agreement with the Ministry of Economic and Social
Inclusion (MIES) since 2015 (Ministry of Economic
and Social, 2015).
Theory: Falls are the fourth geriatric syndrome
with the highest prevalence, they produce a decrease
in the functionality of the older adult and an increase
in admission to emergencies. The Tinetti scale is an
instrument that makes it possible to assess older adult
mobility by assessing the gait and balance domains to
detect the risk of falls in the geriatric population
(Guevara & Lugo, 2012). The first domain assesses
balance in various actions (for example: sitting,
attempts to get up, immediate standing) with a
maximum score of 16 pts; For its part, the gait domain
includes items related to the start of the gait, length,
step height, among others; scoring a maximum value
of 12 pts, which adds up to a total of 28 (Rodriguez
& Lugo, 2012).
3.1.3 Research Questions: Constructing the
Questions from the Dimensions
With all the aforementioned, this case study seeks to
answer the following research questions:
Are there differences between men and
women with respect to standing balance?
Who is at slight risk of falls, men or women?
What age range is at high risk of falls or
suspected of a claudication pathology?
3.2 Data Preparation and Collection
Lehtbridge (2005) points out that before data
collection it is essential to identify the degree of
involvement of the researcher at the time of data
collection. In a case study, the collection is director of
the first degree; that is, the researcher uses data
collection methods that allow him to be in direct
contact with the subjects and the data is collected in
real-time. Therefore, the observation is based on the
protocol designed and validated by Tinetti. Runeson
& Höst (2008) propose different types of observation
depending on the degree of interaction by the
researcher and the degree of knowledge of the
observed subjects. The types of research can be of 4
categories as presented in Table 1.
Table 1: Types of case study observed research.
Knowledge of the observed
High Low
Degree of
interaction by the
High Category 1 Category 2
Low Category 3 Category 4
This study belongs to category 1 and the analysis
approach will be quasi-statistical or descriptive
3.3 Analysis and Interpretation of the
The results are presented below based on the
objectives set out in section 3.1.1. The characteristics
of the participants are shown in Table 2. It is evident
that the majority of the participants are women (n =
56) and range between 75 and 79 years; being the
mean age of all participants 76.65 years (SD = 7.35).
Table 2: Sociodemographic characteristics.
Sociodemographic characteristic N %
Men 30 34,9
Women 56 65,1
65 – 69 10 11,6
70 – 74 12 14,0
75 – 79 21 24,4
80 – 84 19 22,1
85 – 89 16 18,6
90 – 94 6 7,0
95 – 99 2 2,3
The level of risk of falls of the participants is
shown in Figure 2. It is evidenced that the majority of
older adults have a high risk of falls (n = 53; 61.6%)
and only 7.0% (n = 6) reports a slight risk of falling.
Figure 2: Frequency of risk of falls.
Risk of Falls in Older Adults in the Rural Region Case Study Paccha Cuenca, Ecuador
Table 3: Sociodemographic characteristics and level of risk
of falls.
Mild Moderate High
n % n % n %
Female 2 3,6 16 28,6 38 67,9
Male 4 13,3 11 36,7 15 50,0
65to69years 4 36,4 7 63,6 ‐ ‐
70to74years 1 8,3 8 66,7 3 25
75to79years 1 4,8 10 47,6 10 47,6
80to84years ‐ 2 11,1 16 88,9
85to89years ‐ ‐ 16
≥to90years ‐ ‐ 8
The characteristics related to the level of risk of falls
are shown in Table 3. It is evidenced that the risk of
falls has a statistically significant difference in the
different age groups (X2 = 53.691; df = 10; p =
0.000), being participants over 80 years of age those
with a higher level of risk. Regarding sex, there are
no statistically significant differences between men
and women (X2 = 4.087; df = 2; p = 0.130); however,
women (n = 38; 67.9%) score a higher risk of falls
according to the Tinetti scale. The frequency of
scoring the balance and gait factors is shown in Table
4. Regarding the gait parameter, it is evident that none
of the participants obtained the maximum score (12
points); on the contrary, 18.60% (n = 16) of the older
adults obtained a score of 8. On the other hand,
concerning balance, it is shown that almost half of the
participating older adults (n = 41; 47, 68%) oscillate
a score between 8 and 11 points out of a total of 16 in
this dimension.
Table 4: Frequency of Balance and Gait Score.
Balance Gait
% N
3 0 0,00 2 2,33
4 1 1,16 6 6,98
5 6 6,98 13 15,12
6 7 8,14 12 13,95
7 6 6,98 13 15,12
8 10 11,63 16 18,60
9 11 12,79 11 12,79
10 9 10,47 9 10,47
11 11 12,79 4 4,65
12 7 8,14 0 0,00
13 5 5,81
14 6 6,98
15 7 8,14
16 0 0,00
3.4 Threats of Validity
A case study, due to the nature of the research, entails
threats to validity that need to be mitigated. Next, the
threats that this study has had and the different
solutions to face them are presented.
3.4.1 Construct Validity
The theoretical proposal about the assessment of the
risk of falls has been consolidated by Dr. Mary Tinetti
(1986). This construct has been widely addressed by
the scientific community (Köpke & Meyer, 2006;
Stucka et al., 1999). To evaluate it, scales have been
validated that allow quantifying the dimensions that
compose it (gait and balance). The Tinetti scale is a
tool whose main objective is to determine the risk of
falls in the elderly, it is made up of two dimensions:
balance, which is subdivided into 9 items and gait into
7 items. The responses of the items are scored as: 0
when it is not possible to maintain stability in the face
of postural changes or has an abnormal gait pattern, 1
when there is stability in the face of postural changes
or gait patterns through postural compensation and 2
when there is no difficulty. to carry out the activities
of the scale.
The maximum score of the balance dimension is
16 points and the gait dimension is 12 points. The sum
of both dimensions gives us a total score of 28 points,
categorizing the risk of falls as mild with a score of
less than 19 points, moderate between 19 to 24 points
and high risk with a score lower than 19 points.
3.4.2 Internal Validity
The factors that can influence the results during the
application of the Tinetti Scale are: the use of
medications in the wrong doses, confusion in the
administration of very frequent situations in the
elderly population, or the use of medications such as
antidepressants and diuretics that mainly affect
mobility, gait, and balance (Cabrera, Roy, & Toriz,
2019). Therefore, in the present study older adults
who meet these conditions were considered
exclusion criteria.
3.4.3 External Validity
The data provided by the Tinetti Scale on falls in the
elderly are of vital importance for the Ministry of
Public Health, Geriatric Centre’s and Decentralized
Autonomous Governments due to the costs in
treatment and rehabilitation, as it requires the hiring
of gerontologists and the specialization of nurses,
ICT4AWE 2022 - 8th International Conference on Information and Communication Technologies for Ageing Well and e-Health
doctors, physiotherapists in the specific management
the older adult (Villar. T., 2015).
3.4.4 Reliability
The Tinetti scale in Latin America has been validated
in Spanish since 2012 with inter-and intra-observer
reliability of 0.95 - 0.8 and a Cronbach's Alpha of 0.91
(Rodriguez & Lugo, 2012); the gait dimension has a
sensitivity of 88% - specificity of 63%, while the
balance dimension has a sensitivity of 81% and
specificity of 75% (Park, et al., 2018).
The objective of this case study is to determine the
risk of falls in the elderly population of the La
Fortaleza group - Paccha, Cuenca. The importance of
it lies in the fact that older adults are especially
sensitive to physiological changes derived from the
aging process that can reduce their locomotion and
hence their functionality. In the geriatric age, falls
represent the most common cause of accidents
generating physical, psychological, and economic
consequences that negatively influence the quality of
life of the elderly (de Alejo et al., 2020).
After applying the Tinetti scale, it was determined
that the study population presents a risk of falls, being
distributed as follows: high risk of falls 61.6%,
moderate risk of falls 31.4% and low risk of falls 7 %,
results similar to those obtained in the study by Silva
et al. (2014) in which it was recorded that 54.7% had a
high risk of falls, in the same way in the study by
Samper et al. (2016) 73.1% presented a high risk of
falls, as can be seen in these studies there are
significant values of high risk of falls which
demonstrates the importance of evaluating balance
and gait through a standardized scale such as the
Tinetti scale since through this assessment the
geriatric patient could be recommended and guided
about any technical help they would need to prevent
and/or reduce this problem.
In the descriptive analysis of the present study,
when relating the risk of falls with sex, there was no
statistical relevance (p = 0.13), coinciding with the
study by Carballo et al., (2018). However, several
studies indicate that the female sex has a higher risk
of falls arguing that the physiological and structural
characteristics at the musculoskeletal level, hormonal
changes related to menopause and the performance of
multiple housework predispose the possibility of
suffering a fall (Petronila et al., 2017; Samper et al.,
2016; Silva et al., 2014; Smith et al., 2017). It is
important to mention that most of the studies are
carried out in a sample made up of more women than
men, as in our study where 65.1% belong to the female
sex, this difference between the female and male sex
could be justified because the life expectancy is
greater in women (Samper et al., 2016).
The average age in our study was 76.65 (SD =
7.35) years and statistically the risk of falls was
higher in advanced ages, observing a high risk of falls
in ages over 80 years. About this, the study by Samper
et al., (2016) mentions that there is controversy
regarding the age range and the risk of falls because
on the one hand it is stated that the risk of falls is
higher in the 80 years and that people have more
pathologies; and on the other hand, people under 75
years of age fall more because they have more
movement, which increases exposure to risk factors,
in addition to not recognizing that their physical
condition is decreasing and they may suffer falls due
to carelessness.
According to a study where the Tinetti scale was
applied to a group of older adults it concluded that
when the balance is slightly compromised there was
a slight deterioration in gait, especially in activities of
daily living (Álvarez, M & Espinosa, A., 2018).
As can be seen older adults are at risk of falling,
therefore, it is suggested that physical activity plans
and programs that involve balance exercises,
coordination, dissociation of upper and lower limbs,
muscle strengthening, and gait be promoted.
According to Martínez et al., (2018) aging is
considered an achievement in public health and
socioeconomic policies, which is why the
Ecuadorian state seeks to implement public policies
with an emphasis on human rights and social
participation with the family, community and state,
by promoting active ageing multifactorial and
multicomponent preventive interventions are
considered the most effective because they have as
pillars physical exercise, medical evaluation,
environmental modification and medication
adjustment in preventive interventions. (MIES,
At the end of the study, it was determined that of the
86 older adults evaluated with the Tinetti scale,
61.6% had a high risk of falls. The factor that was
associated with a high risk of falls was age (p = 0.000)
being statistically significant; about sex, there are no
statistically significant differences between men and
women. And regarding the gait and balance
Risk of Falls in Older Adults in the Rural Region Case Study Paccha Cuenca, Ecuador
parameter of the Tinetti scale, it is evidenced that
none of the participants obtained the maximum score
in the gait parameter (12 points) and 18.60% (n = 16)
of the older adults obtained a score of 8; on the
contrary, in the equilibrium parameter, it is shown
that almost half of the participating older adults (n =
41; 47.68%) obtained a score between 8 and 11 points
out of a total of 16 in this dimension which this means
that the balance dimension had a greater implication
than the walking dimension in determining the risk of
falling according to the Tinetti scale in the older adults
of the La Fortaleza group, this may be because
balance demands the integral performance of multiple
systems such as the vestibular, visual and
proprioceptive; and if there is an alteration at the level
of balance the risk of suffering a fall is imminent. The
application of the Tinetti scale has proven to be
feasible in our study population allowing us to
evaluate the risk of falls and collect information of
interest to the Autonomous Decentralized
Government (GAD) of the urban parish ¨Paccha¨ to
interventions and strategies are developed to reduce
the risk of falls.
This research is a case study that has the limitation of
not being able to extrapolate the results to other
contexts; therefore, it is suggested to carry out
multicentre studies, which allow characterizing the
risk factor. For this reason, it is also suggested that
analytical and longitudinal studies be carried out to
identify factors associated with the loss of
functionality of the Elderly.
In addition, it is recommended to generate kinetic
intervention programs which combine balance and
coordination exercises aimed at the elderly
population, empower older adults on the prevention
of falls, their causes, and consequences through
communication strategies, develop studies that
analyse the risk of falls about the influence of
extrinsic factors, finally we suggest that the
governments of the day develop projects aimed at the
development of comprehensive geriatric care framed
in the improvement of the physical and mental health
of the elderly.
This research was developed thanks to the support
provided by the University of Cuenca through support
strategies for teachers and students interested in
generating research. We thank the Vice-Rector for
Research and Postgraduate Studies of the University
of Cuenca for the technical, academic and financial
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