Muscle_strength_and_the_risk_of_falls_in_community

Malahayati International Journal of Nursing and Health Science, Volume 06, No.
7, January 2024: 509-516
ARTICLE INFORMATION
Received: November, 29, 2023
Revised: January, 16, 2024
Available online: January, 20, 2024
at : http://ejurnalmalahayati.ac.id/index.php/nursing/index
Muscle strength and the risk of falls in community-dwelling elderly in Central Java
in urban and rural areas
Nur Annisa*, Dwi Rosella Komalasari
Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

Corresponding author: *E-mail: drks133@ums.ac.id
Abstract
Background: The elderly are individuals aged 60 and above, marking the final stage of the life cycle. The World
Health Organization classifies the elderly into four groups: middle-aged elderly (45-59 years), elderly (60-74
years), older elderly (75-90 years), and very old elderly (above 90 years). Currently, there are 142 million people
aged 60 and above in the 11 Southeast Asian WHO member countries. By 2050, this number is expected to
triple, prompting the WHO to urge nations to prioritize aging on World Health Day. Decreased muscle strength for
postural control is a risk factor for falls in the elderly, and a significant portion of falls may be attributed to this
component. In Indonesia, the rate of fall-related injuries due to balance disorders is found to be 49.4% in
individuals above 55 years, 67.1% in those above 65 years, and up to 35% in individuals between 70-75 years.
Purpose: To determine the influence of muscle strength on the risk of falls in the elderly in urban and rural areas.
Method: This study employed a cross-sectional study design, investigating the correlation between risk factors
(independent) and outcomes (dependent) based on data collection through observations conducted at a single
point in time. The research was conducted in Gonilan village as a representative urban area and Boyolali
Regency, Central Java, as a representative rural area in August 2023. The study population included the elderly
in Gonilan and Boyolali. Non-probability sampling with quota sampling was used, resulting in 204 participants
meeting the survey criteria.
Results: Muscle strength in urban areas with low categories had an odds ratio (OR) of -0.282, Exp B of 1.048, ρ-
value of 0.824 with a 95% confidence interval (CI) of 0.962. In contrast, urban areas with high categories had an
OR of 0.037, Exp B of 0.754, ρ-value of 0.310 with a 95% CI of 1.130. This indicates that the ρ-value for all areas
is greater than 0.05, meaning there is no influence of muscle strength on the risk of falls in urban and rural areas.
Conclusion: Based on the research findings, there is no influence of muscle strength on the risk of falls in the
elderly in urban and rural areas. The risk of falls is influenced by various factors, including environmental
conditions.
Keywords: Elderly; Fall; Muscle Strength; Risk Factor.
INTRODUCTION
Elderly individuals are those who have reached years (World Health Organization, 2022). Currently,
the age of 60 and above, referred to as the final there are 142 million people aged 60 and above in
stage of the life cycle (Lachman, Teshale, & the 11 Southeast Asian WHO member countries. By
Agrigoroaei, 2015). The World Health Organization 2050, this number is estimated to triple, prompting
classifies the elderly into four groups: middle-aged the WHO to urge countries to prioritize aging on
elderly in the age range of 45-59 years, elderly in the World Health Day (World Health Organization, 2012).
age range of 60-74 years, older elderly in the age The elderly are defined as individuals aged 60
range of 75-90 years, and very old elderly above 90 years or older, regardless of gender, who are still
DOI: https://doi.org/10.33024/minh.v6i7.13166
509
Malahayati International Journal of Nursing and Health Science, Volume 06, No.7, January 2024: 509-516
Muscle strength and the risk of falls in community-dwelling elderly in Central Java in urban and rural areas
engaged in activities and work or unable to support the likelihood of falling. One of the main factors that
themselves and must rely on assistance from others increases the risk of death in the elderly is falling
(Shanas, Townsend, Wedderburn, Friis, Milhoj, & (Murtiyani, & Suidah, 2019).
Stehouwer, 2017). The elderly are divided into four As much as 7.63% of the Indonesian population
categories: middle-aged (virility) represents the stage resides in rural areas, characterized by life in West
of preparation for those aged 45–54 years, showing Java's Pasir Langu Primary Health Center located in
mental and physical maturity. Early elderly Cisarua, West Bandung Regency, where the majority
(prasenium) refers to those approaching the age of the population works as farmers. A total of 3,194
range of 55–64 years. The elderly group (senium) elderly individuals actively participate in the
includes residents aged 65 years and above, and the integrated health posts at Pasir Langu Primary
high-risk elderly are those aged above 70 years Health Center. Additionally, 7.49% of the elderly
(Ministry of Health of the Republic of Indonesia, population in Indonesia resides in metropolitan
2016). areas. Previous research has analyzed the
Based on a survey, Indonesia is expected to relationship between the strength and balance of
experience the largest increase in the elderly lower limb muscles and the risk of falling. It found
population. Furthermore, the proportion of the elderly that improved balance can reduce the likelihood of
population in Indonesia is 9.92% or 26.82 million falling, correlating with the strength of the front thigh
people in 2020. Central Java Province is among the muscles (Asti, Yanti, & Astuti, 2020).
top three provinces with the highest proportion of the The elderly are highly susceptible to the risk of
elderly (12.59%) (Central Statistics Agency, 2020). falling, an unexpected event that causes a person to
On the other hand, the bodies of elderly individuals lie or sit on the floor or a lower surface without losing
undergo structural and functional changes in organ consciousness or sustaining injuries. One of the
tissues with age, which may affect body balance major geriatric tragedies is falling, especially among
(Tieland, Trouwborst, & Clark, 2018). the elderly. The most common causes are issues
In the elderly, a decline in the strength of the with the sensory, cognitive, and central nervous
lower extremity muscles can impact body balance. systems that disturb balance, muscle strength, and
The front thigh and hamstring muscles are the ones muscle flexibility (Reimann, Ramadan, Fettrow,
that lose their strength most rapidly. According to Hafer, Geyer, & Jeka, 2020).
previous research, Body Mass Index (BMI) can lead The decline in muscle strength for postural
to a decrease in the strength of lower extremity control is one of the risk factors for falls in the
muscles, which is crucial for maintaining balance elderly, and most falls may be caused by this
while standing (Valentina, Kurniawati, & Maramis, component (Ranti, 2021). In Indonesia, the rate of
2019). Cognitive function in the elderly undergoes fall-related injuries due to balance disorders is found
changes in the central nervous system (CNS) that to be 49.4% in individuals above 55 years, 67.1% in
affect balance, including the loss of neurons and those above 65 years, and up to 35% in individuals
dendrites, low metabolism, and cerebral perfusion between 70-75 years. Previous research indicates
neurotransmitter synthesis. Another study states that that 46% of elderly patients at the Medan Johor
the number of cholinergic neurons decreases with Primary Health Center's primary care unit are at high
age, leading to a decrease in acetylcholine risk of falling, 36% at low risk, and 18% not in danger
neurotransmitter and a decline in brain function (Rohima, Rusdi, & Karota, 2020).
(Janeczek, Gefen, Samimi, Kim, Weintraub, Bigio, & The Time Up and Go Test (TUG) is one of the
Geula, 2018). measurement tools applied to assess the degree of
A history of falls can affect balance in the elderly the risk of falling. TUG is a direct clinical test used to
due to failures in detecting shifts and the improper evaluate mobility, balance, lower extremity function,
repositioning of body gravity (Ramadhani, and the risk of falling in various populations (Lusardi,
Munawwarah, Maratis, & Ivanali, 2021). Falling is Fritz, Middleton, Allison, Wingood, Phillips, & Chui,
another term for the disturbed balance of an 2017; Sari, Motik, & Sudaryanto, 2023). Body
individual, especially in the elderly, due to weakened balance is greatly influenced by muscle strength.
muscles disrupting the balance system, increasing Static balance and dynamic balance are two

510
categories included in body balance. Dynamic experiencing pain in one or both limbs affecting walking
balance refers to the body's ability to maintain proper patterns, having a history of injury, facing
posture during mobilization, while static balance neuromuscular disorders such as stroke, Parkinson's,
refers to the body's ability to maintain the center of ataxia, coordination disorders, and having diabetes
gravity while supporting the body in an upright mellitus and heart disease.
position while standing or sitting. The quality of life in The independent variable in this study is muscle
the elderly is influenced by their ability to maintain strength, while the dependent variable is the risk of
postural control during daily activities, supported by falling. Research instruments used included a
maintaining balance to reduce the risk of falling questionnaire sheet, stopwatch, chair with a height of
±43 cm, a chair with armrests (backrest), and
(Annisyah, Idramsyah, Bakara, & Ratnadhiyani,
measuring tools. The researcher collected participants
2020).
according to inclusion criteria who had provided
The Sit-to-Stand test is often applied to evaluate informed consent. Explanation of the research purpose
the strength and balance of the lower extremities. and objectives was given to participants before
The Five Times Sit-to-Stand Test (FTSTS) is a quick intervention. The first intervention involved the five-time
and inexpensive way to assess functional strength sit-to-stand exercise using a standard chair with a
and balance in the lower extremities, applicable for straight backrest. Participants were instructed to sit on
conducting sit-to-stand tests. It is recommended for the chair, rest their back, fold their hands in front of the
primary care doctors to implement FTSTS as a chest, and then perform sit-to-stand five times. The
screening tool to assess the risk of falling in elderly second intervention was the Time Up and Go test
patients. The test is conducted using a chair without (TUG), which is a walking exercise with or without
armrests with a height of ± 43 cm. Patients perform assistive devices. Participants walked 3 meters from
five quick iterations with increasing complexity. The the chair, turned around, walked back to the chair, and
body functions better the faster the process. This test sat down, repeated five times. The researcher recorded
has very strong inter-level reliability (ICC ≥ 1.0) in the results of each participant's exercise and analyzed
healthy elderly individuals and inter-rater reliability them after 7 sessions over a week of intervention.
(ICC ≥ 0.64) in the elderly community. In this study, there are assessment indicators for
the variables used, including BMI categories:
RESEARCH METHOD underweight if BMI <18.5, normal if in the range of
This research applied a cross-sectional study 18.5-24.9, overweight if in the range of 25-29.9, and
design, a research design that sought to find obesity if >30. Low muscle strength is indicated if the
correlations between risk factors (independent) and scale is <3, and high if the scale is >3. Successfully
outcomes (dependent) based on data collection completing the TUG test in more than 12.6 seconds
through observations conducted at a single point in indicates a high risk of falling, and low risk if <12.6
time. The study was carried out in the village of Gonilan seconds. Five times sit-to-stand is considered low if the
as a representative urban area and Boyolali Regency, score is ≥12 seconds and high if the score is >15
Central Java, as a representative rural area in August seconds.
2023. The population in this study consisted of elderly The analysis used includes descriptive data
individuals in Gonilan and Boyolali Village. analysis, presenting participant characteristics, and
The sampling technique employed was non- inferential analysis, including normality tests and impact
probability sampling using quota sampling, resulting in tests (linear regression). Tests applied include the
a sample of 204 participants that met the survey Spearman Rho correlation test for correlation, the
criteria. Inclusion criteria included being above 60 years Kolmogorov-Smirnov test for normality, and linear
old, in good physical and mental health, capable of regression analysis as a statistical technique.
communication, both male and female, and willing to This research has obtained ethical clearance from
participate as a respondent. Exclusion criteria involved the Health Research Ethics Committee (HREC) of Dr.
elderly individuals with physical and mental disorders, Moewardi Regional General Hospital with number:
using mobility aids, suffering from knee osteoarthritis, 1.398/VII/HREC/2023.

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RESEARCH RESULTS
Table 1. Characteristic of Participants (N=204)
Variables Urban (n=102) Rural (n=102)

Age (Mean±SD)(Range)(Year) (65.9± 3.826)(60-89) (65.6± 4.632) (60-89)
Gender (n/%)
Male 19/18.6 15/14.7
Female 83/81.4 87/85.3
Occupation (n/%)
Housewife 65/63.7 51/50
Employee 20/19.6 15/14.7
Farmer 5/5 32/31.4
Civil Servant 12/11.7 4/3.9
BMI (n/%)
Underweight 10/9.8 15/14.7
Normal 78/76.5 75/73.5
Overweight 12/11.8 11/10.9
Obesity 2/1.9 `1/0.9
Time Up and Go Test (n/%)

Falling risk - low 34/33.3 28/27.4
Falling risk - high 68/66.4 74/72.6
Five Times Sit to Stand (n/%)

Low 4/3.9 22/21.6
High 98/96.1 80/78.4
Based on Table 1, the total population in urban and rural areas consists of 204 samples, divided into two
groups: 102 elderly individuals in urban areas and 102 elderly individuals in rural areas. The number of elderly
females dominates in both urban and rural areas, with 83 (81.4%) and 87 (85.3%) participants, respectively. In
urban areas, the dominant employment status among the elderly is housewives with 65 (63.7%), and employee
with 20 (19.6%). In rural areas, the dominant employment status is housewives with 51 (50%) and farmers with
32 (31.4%). BMI in both urban and rural areas falls within the normal range, with 68 (66.4%) and 75 (73.5%)
participants, respectively. Both urban and rural areas show a high risk of falling in the time-up-and-go test, with 68
(66.4%) and 74 (72.6%) participants, respectively. The muscle strength in the five times sit-to-stand test is high in
both urban and rural areas, with 98 (96.1%) and 80 (78.4%) participants, respectively.
Table 2. Mann-Whitney Test for Data Normality
Muscle’s Strength
Risks of Falling
Average (second) p-value
Urban 93.71 0.033
Rural 111.29 0.194

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Based on Table 2, it can be observed that there is a difference in muscle strength between urban and rural
areas. The muscle strength in urban areas has an average of 93.71 seconds with a ρ-value of 0.033, while in
rural areas, the average is 111.29 seconds with a ρ-value of 0.194. This indicates that better muscle strength is
present in urban areas.
Table 3. Test of the Influence of Muscle Strength on the Risk of Falling
Risks of Falling
Muscle’s Strength
OR Exp B ρ-value 95%CI
Urban
Low -0.282 1.048 0.824 0.962
High 0.037 0.754 0.310 1.130
Rural
Low -0.124 0.884 0.915 0.926
High 0.037 1.038 0.523 1.164
Based on Table 3, muscle strength in the urban area with the low category has an odds ratio (OR) of -0.282,
an Exp B of 1.048, a ρ-value of 0.824, and a 95% confidence interval (CI) of 0.962. Meanwhile, in the urban area
with the high category, the OR is 0.037, Exp B is 0.754, ρ-value is 0.310, and 95% CI is 1.130. This indicates that
the ρ-value for all areas is greater than 0.05, meaning there is no influence of muscle strength on the risk of
falling in urban and rural areas.
DISCUSSION
Based on the characteristic of participants’ data, ρ-value of 0.033. Based on the influence test, the ρ-
it is evident that the elderly age range is between 60- values for both urban and rural areas are above
89 years. The majority of the population is female, in 0.05, indicating that muscle strength does not have
line with previous research indicating that elderly an effect on the risk of falling in the elderly.
women are perceived to have a better quality of life Urban areas, also known as urban, are regions
than men because women often receive support with primary activities other than agriculture.
from family and relatives (Seangpraw, Typically, urban areas serve as places for urban
Ratanasiripong, & Ratanasiripong, 2019). On the settlements, concentration and distribution of
other hand, elderly women are more susceptible to government services, social services, and economic
the risk of falling due to hormonal changes, activities. Generally, urban areas are densely
experiencing menopause around the age of 45, populated. On the other hand, rural areas or rural
compared to men who go through andropause until regions are areas with primary agricultural activities,
the age of 70 (Astria, & Ariani, 2016). The majority of including the management of natural resources.
elderly people are still married, this shows that their Rural areas function as rural settlements, service
quality of life is higher when they live with their centers, government services, social services, and
partner than when they are widowed or widowed economic activities, characterized by a more
(Rachmatika, Komalasari, Widodo, & Rahman, expansive residential area (Nugraha, 2020).
2022). The World Health Organization classifies the
The participants' occupational status is elderly into four groups: middle-aged elderly (45-59
predominantly housewives, and previous research years), elderly in the range of 60-74 years, elderly in
also states that the elderly with low income have a the range of 75-90 years, and very old elderly over
higher quality of life compared to those without 90 years (World Health Organization, 2022). The
income (Zin, Saw, Saw, Cho, Hlaing, Noe, & average age of the research subjects is 65 years,
Hamajima, 2020). The results also indicate that categorized as elderly. In the elderly phase,
muscle strength in the urban elderly is better than in individuals undergo physical, cognitive, and
rural areas, with an average of 93.71 seconds and a psychosocial changes.

513
Based on overall physical health conditions, there 70, experience falls, with around 32-42% each year,
is a decline since entering the elderly phase of life. and 40% of these individuals reported repeated
Functioning physical health enables the elderly to falling incidents (Boehm, Franklin, & King, 2014).
achieve quality aging. However, psychologically, The risk of falls in the elderly is influenced by
those not prepared to face these changes may various factors. Risk factors for falling incidents are
experience a lower quality of life (Utomo, 2010; divided into intrinsic, extrinsic, or a combination of
McPhee, French, Jackson, Nazroo, Pendleton, & both. Intrinsic factors are internal factors, including
Degens, 2016). age and the decline in sensory organ functions such
The elderly phase involves a degenerative as visual acuity and hearing. Extrinsic factors involve
process that progresses with manifestations such as the environment and living conditions that can
a decrease in muscle mass and strength. The potentially affect falls in the elderly (Yoo, Kim, Yim, &
process of declining muscle mass and strength Jeon, 2016).
involves the interaction of the peripheral and central Falls are the leading cause of non-fatal injuries
nervous systems, hormonal factors, nutritional but can result in death in older adults. Prevention or
status, immunological factors, and insufficient reduction of the risk of falling has become the main
physical activity. At the biomolecular level, this is focus of various health issues. Over the past two
caused by a decrease in the speed of muscle protein decades, clinical-related research has provided
synthesis and/or an increase in the breakdown of doctors with various screening tools to measure the
muscle protein that is not proportional. risk factors for falling incidents. Most processes have
Generally, the neuropathy process has the most focused on a single intra-individual domain, such as
significant influence because this part is responsible body balance, muscle strength, and vision function.
for the degeneration of alpha motor nerves that Additionally, there are extra-individual factors, such
supply muscle fiber innervation, leading to the loss of as home safety to prevent the risk of falling (Renfro,
motor units. Other research indicates the impact of & Fehrer, 2011).
age on muscle strength, showing a loss of motor Approximately one-third of the elderly will
units with increasing age, as evidenced by surface experience a falling incident at least once a year.
electromyography results in elderly patients showing Secondary conditions arising from falling incidents
a decrease in the complexity of their graphs (Hida, can increase the risk of injuries, such as hip fractures
Shimokata, Sakai, Ito, Matsui, Takemura, & Harada, and head injuries. Currently, fall risk reduction
2016). programs have significantly increased in public
Based on previous research, the risk of injury due health. This is done to easily identify elderly
to falls depends on the vulnerability of each patient individuals who need interventions to reduce or
and the environmental hazards surrounding them. A manage the risk of falling itself (Lusardi, Fritz,
good environment is less likely to pose a risk of Middleton, Allison, Wingood, Phillips, & Chui, 2017).
falling, while a less favorable environment is more One fairly effective way to reduce the incidence
likely to lead to a risk of falling. This is particularly of falls is to practice a healthy lifestyle, whether in
related to the geographical location, where urban urban or rural areas. Avoiding stress and engaging in
areas, despite being densely populated, generally physical activities such as walking, strength training,
have well-organized surroundings with fewer slippery or customized physical activities for each individual
surfaces. On the other hand, rural areas are often can contribute to a healthier lifestyle. Additionally,
associated with dirt roads that can be slippery. physical exercise has benefits in improving the
The frequency of falls in an individual is related to functional capacity of the body's organs in weakened
the cumulative effects of various disturbances that elderly individuals. Certainly, exercise programs
occur due to aging (Ravindran, & Kutty, 2016). Falls tailored to this population have proven effective in fall
are a common health issue in individuals aged 65 prevention (Cadore, Rodriguez-Maias, Sinclair, &
and above (Delle Fave, Bassi, Boccaletti, Izquierdo, 2013).
Roncaglione, Bernardelli, & Mari, 2018). In some
countries, it has been found that 28-35% of
individuals aged 65 and above, or individuals aged

514
CONCLUSION
Based on results of the research, there is no Hida, T., Shimokata, H., Sakai, Y., Ito, S., Matsui, Y.,
influence of muscle strength on the risk of falling in Takemura, M.,& Harada, A. (2016). Sarcopenia
the elderly in urban and rural areas. The risk of and sarcopenic leg as potential risk factors for
falling is influenced by various factors, and one of acute osteoporotic vertebral fracture among older
them is the environmental conditions. women. European Spine Journal, 25, 3424-3431.
Janeczek, M., Gefen, T., Samimi, M., Kim, G.,
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Malahayati International Journal of Nursing and Health Science, Volume 06, No.

7, January 2024: 509-516

Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

Keywords: Elderly; Fall; Muscle Strength; Risk Factor.

Nur Annisa*, Dwi Rosella Komalasari

Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

Nur Annisa*, Dwi Rosella Komalasari

Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

Table 1. Characteristic of Participants (N=204)

Variables Urban (n=102) Rural (n=102)

Time Up and Go Test (n/%)

Five Times Sit to Stand (n/%)

Table 2. Mann-Whitney Test for Data Normality

Nur Annisa*, Dwi Rosella Komalasari

Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

Table 3. Test of the Influence of Muscle Strength on the Risk of Falling

Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

Nur Annisa*, Dwi Rosella Komalasari

Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

Nur Annisa*, Dwi Rosella Komalasari

Fakultas Ilmu Kesehatan, Universitas Muhammadiyah Surakarta

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