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Characteristics and risk factors of fall injury in Taiwan in 1999 vs 2007

Yih-Jian Tsai* MD, MSc, PhD candidate LSHTM

140 th APHA

4275.0 International Health and Aging and Healthcare Policy

2:54-3:06 pm, Moscone Convention Center West, San Francisco, CA

* Section Chief, Adult and Elderly Health Division, Bureau of Health Promotion, Department of Health, Taiwan, ROC

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Outline

Introduction Subjects and Methods Results Discussion Conclusions

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Introduction

Falls are one of the leading causes of global

burden of disease (Barss et al., 1998)

Fallers are more likely to be admitted into hospitals, nursing homes, and to consume more medical care resources, and to have more functional limitations in ADLs and IADLs (Kiel et al., 1991)

Among fallers of injury fall events, 42.3 ％ need hospitalization, and 37.0 ％ of those hospitalised have to move into nursing homes after discharge (Sattin et al., 1990)

Emergency Department Visits

In 2006, 10.5 % of all ED visits among the elderly in the US were claimed by injurious falls, of whichabout seven tenth was released from the ED; the remaining three tenths resulted in hospital

admission. The overall rate of ED visits for injurious falls was

57.4 visits per 1000 person 65 years and older.

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Ref: Owens PL, Russo CA, Spector W, Mutter R. Emergency Department Visits for Injurious Falls among the Elderly, 2006: Statistical Brief #80. <http://www.ncbi.nlm.nih.gov/pubmed/21452495> Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Health Care Policy and Research (US); 2006 Feb-.

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Figure 1.1 Prevalences of falls leading to medical care and those leading to hospitalisationin Taiwan, 2001 (Chang, Tsai & Wu, 2003)

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

0-6 7-14 yr 15-24 25-44 45-64 65+

Age (year)

Prev

alen

ce

Falls leading to medical care

Falls leading to hospitalisation

The elderly top the other age groups in the prevalence of injurious falls

Chang FC, Tsai YJ, Wu SL. Nonfatal unintentional injuries in Taiwan. Taiwan J Public Health 2003;22:492-500. [in Chinese]

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Questions

What is the difference of injurious falls in terms of induced fall injury, consequent medical care utilization, and risk factors in the elderly in Taiwan between 1999 and 2007?

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Subjects and Methods

Elderly participants of 1999 and 2007 Taiwan Longitudinal Study on

Ageing (TLSA) :Survey of Health and Living Status of the Middle Aged and Elderly

Tool of measurement: structured questionnaires Data collection: face-to-face interview Population base: registered 65y ≧ living in non-

mountainous regions Sampling :Three-stage stratified sampling

It was not until 1999 that fall-related items were incorporated into the TLSA series.

Year No. of Respondents

Age No. of Non-respondents

Response rate

1989 4049 (B) 60+ 363 91.8%

1993 3155 (B) 64+ 312 91.0%

1996 2669 (B) 67+ 333 88.9%

2462 (A) 50-66 570 81.2%

1999 2310 (B) 70+ 253 90.1%

2130 (A) 53-69 222 90.6%

2003 1743 (B) 74+ 173 91.0%

2035 (A) 57-73 174 92.1%

1599 (C) 50-56 423 79.1%

2007 1268 (B) 78+ 120 91.4%

1864 (A) 61-77 188 90.8%

1402 (C) 54-60 159 89.8%

Chronological sample size of respondents by age

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Fall

C8. During the past one year, have you fallen down (including falling while walking, due to a slippery surface, while sitting down or standing up, due to fainting, or while trying to lie down, no matter if there was injury or not)?

___ 1 Yes ___0 No [Skip to C13]

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Injurious falls, Fall Injury

Injurious falls: Did that fall cause a bone fracture or hairline fracture, sprain or dislocation?

___0 No [Skip to C11] ___1 Yes

Fall Injury: Where (i.e., what part of the body) was the fracture, hairline fracture, sprain or dislocation? [Can choose more than one.] Head, Neck, Spine, Lower limb, Upper limb, Hip, Trunk, Other

Medical care utilization

C10b. Where did you go for treatment? [Can choose more than one.]___1 Didn’t go for treatment; respondent treated

it himself/herself (self care)___2 Bone-setting clinic or healing martial arts

center__ 3 Chinese medicine hospital or clinic___4 Western medicine hospital or clinic___5 Other (please explain):_______

Socio-demographic factors:AgeSexADLIADLMedical factors, Physical

and Mental function : Sleeping pills or sedative useVisionWalk aid useExerciseNo. of chronic diseasesIncontinenceBody painDepressive symptomsCognitive function

1999 、 2007 TLSAInjurious falls

Medical care utilization

Body site injured

Study framework

Socio-demographic factors

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Age (yr) 65-69; 70-74; 75-79; 80-84; 85+

Sex Male; Female

ADL dependency with any dependency in terms of eating, getting in/out of bed (or sitting down in/get up from a chair), walking around the house, getting dressed, bathing, and using the toilet 

IADL dependency  

with any dependency in terms of light housework- e.g. straightening up the living room, washing dishes, etc.; buying everyday use items; managing finances- e.g. performing calculations, and paying bills; making telephone calls  

Medical factors, Physical function

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Sleeping pills or sedative use

Yes; no

Vision very clear/clear; average; and unclear/very unclear).

Walk aid use Yes; no

Exercise frequency of exercise per week: no, irregular exercise ( 2 times per week), regular exercise (3 or more times ≦per week

Medical factors, Physical function

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No. of chronic diseases

History of fourteen chronic diseases was taken and total number of chronic diseases were classified into three categories 0; 1; 2≧

Hypertension , diabetes, heart diseases, stroke, cataract, respiratory diseases (bronchitis/respiratory tract infection/other respiratory disorder/asthma), arthritis/rheumatism, gastric ulcer/stomach ailment, liver or gall bladder diseases, hip fracture, cataract, kidney disease, gout, spinal spur.

Incontinence If with trouble of incontinence: either with urination or with defecation, or both.

Body pain categorized into three groups: None/a little; Medium; More or very serious

Mental functionDepressive symptoms

Depressive symptom: measured with ten CES-D scale questions, eight are negative, while two are positive. Each question was scored 0-3 according to the frequency of the feeling. Question scores were summed to provide the depression score, which was dichotomised, with modification to Andresen & Malmgren (1994) as: 0-7, without depressive symptoms; 8, with depressive symptom.

Cognitive impairment

Cognitive function was measured with the SPMSQ. Each question was given 1 score if answered correctly, and 0 if erroneous. Question scores of right answers were summed to provide the cognitive function score, which was divided and modulated according to educational level (Wu & Chang, 1997). For people of primary school level, their cognition were categorised by the cognitive function score as normal if scored 7-10, mildly impaired if 5-6, moderately impaired if 2-4, and severely impaired if 0-1. The corresponding categories are respectively 6-10, 4-5, 1-3, and 0 for those illiterate, and 8-10, 6-7, 3-5 and 0-2 for those of secondary school level or higher.

Data analysis To compare the 1999 with 2007 surveys in terms of:

Prevalence of falls/of injurious falls Type of injury, injury rate Body site injured Consequent medical care utilization Risk factors:

Uni- & bi-variate analyses: chi square test for categorical variables

Multi-variate logistic regression model adjusted for age, sex, IADL dependency, walk aid use, exercise, sleeping pills or sedative use,

vision, No. of chronic conditions, cognitive impairment

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Prevalence of falls/of injurious falls, and injury rate of fallers in the elderly in Taiwan, 1999 vs 2007

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Type of injury among injurious fallers in Taiwan, 1999 vs 2007

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Distribution of injury among injurious fallers by body site in Taiwan, 1999 vs 2007

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Medical care utilized

1999(N=205)

2007(N=189)

n % n %

Western medicine 142 67.56 157 79.99

Chinese medicine 31 16.75 24 13.72

Bone setting clinic/healing martial arts center

42 21.79 30 17.52

Self care 19 10.31 (22*) (12.19)

Other care 5 2.56 1 0.32

*Note: Out of 211 injurious fallers, 22 took self care.

Medical care utilization among injurious fallers in Taiwan, 1999 vs 2007

Prevalence of falls and of injurious falls in the elderly in Taiwan by selected variables, 1999 vs 2007

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Variable

1999 2007

  FallersInjurious Fallers

 Fallers

Injurious Fallers

N n % n % N n % n %

Total 2825 538 18.1 206 6.7 2700 655 22.7 211 7.2

Mean age(y, ±sd)74.6

±6.1 

 76.2

±7.2   

Age                    

65-69 585 80 13.8 27 4.7 648 125 20.2 43 6.9

70-74 964 163 17.3 59 5.9 507 97 19.5 25 5.0

75-79 730 157 21.5 59 8.1 592 143 23.7 52 8.7

80-84 347 87 25.1 43 12.4 586 180 29.0 59 8.9

85+ 199 51 25.6 18 9.1 367 110 29.5 32 8.7

Sex                    

Male 1541 222 13.8 80 4.9 1362 286 18.9 82 5.5

Female 1284 316 23.2 126 8.9 1338 369 26.3 129 8.9

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Variable (base)1999 2007

AOR (95%CI) AOR (95%CI)

Age (65-69)70-74 1.21 (0.74-1.97) 0.64 (0.37-1.08)

75-79 1.31 (0.80-2.16) 0.76 (0.47-1.23)80-84 1.79 (1.04-3.08) 0.73 (0.45-1.18)85+ 0.97 (0.49-1.92) 0.46 (0.26-0.81)

Sex (Male)Female 1.65 (1.20-2.26) 1.24 (0.90-1.72)IADL dependency (None)1 1.12 (0.71-1.77) 1.58 (0.93-2.69)

≧ 2 1.67 (1.07-2.62) 2.58 (1.57-4.25)Sedatives or sleeping pills use (No) Yes 1.48 (0.98-2.23) 1.06 (0.71-1.56)

Vision (Clear)Fare 1.02 (0.69-1.50) 0.89 (0.59-1.35)

Unclear 0.93 (0.64-1.36) 1.18 (0.82-1.72)

Walk aid use (No)Yes 2.41 (1.66-3.49) 1.87 (1.31-2.67)Exercise (No)Irregular 0.86 (0.43-1.71) 0.66 (0.31-1.42)

Regular 0.84 (0.60-1.17) 0.75 (0.53-1.05)

No. of chronic diseases (0)1 1.00 (0.56-1.78) 0.77 (0.41-1.46)≧ 2 1.23 (0.73-2.07) 0.84 (0.48-1.46)

Cognitive impairment (No)Yes 0.85 (0.58-1.24) 1.35 (0.94-1.95)

Multi-variate logistic regression model for injurious falls in Taiwan, 1999 vs 2007

Main findings

During 1999 and 2007, prevalence of falls↑ prevalence of injurious falls ↑ injury rate of fallers↓ multiple injuries ↑ a rising utilization rate for Western medicine care↑ a decreasing utilization rate for Chinese medicine care, and

for bone setting clinic/healing martial arts center ↓ The top three body sites injured were lower limb , upper

limb and hip.

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Discussion Demographic transition: with a rapidly ageing

population, female elderly will have 1.24 times the population size of male counterpart by 2025, when the share of elderly population will be more than 20% as a whole.

Epidemiologic transition: Prevalence of chronic diseases Morbidity expansion: a selectively beneficial effect on old-age survival

of those who had severe functional limitations (climbing stairs, walking) between 1993-1996-1999* under full coverage of the National Health Insurance program launched in 1995?.

*Zimmer, Martin & Chang. Population Studies 2002;56:265-276

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Filial piety decayed? Health Inequality? Age-friendly environments?

Toward an Age-friendly society?

From 1999 to 2007, a rising utilization rate for Western medical care was found among injured fallers, Probably due to competitive use of a variety of

medical care, especially since the launch of NHI program.

The risk factors of injurious identified in multiple regression model were compatible with preceding study?

Advanced age: Sattin, Lamber Huber, DeVito et al. 1990, O’Loughlin et al. 1993; Yasumura et al., 1994

Female: weakness quadriceps, indoor stay (Yasumura et al., 1996; Schultz, Ashton-Miller & Alexander, 1997; Lord, Sambrook, Gilbert et al., 1994)

IADL dependency: Nourhashémi, Andrien, Gillette-Guyonnet et al. (2001), Lin et al.(2002)

Walk aid use: Tinetti, Williams, Mayewski et al., 1986b; Stalenhoef et al., 1997

but not for other risk factors: such as taking sleeping pills or sedative, vision, chronic conditions, cognitive impairment, exercise

Probably due to relatively fewer number of injurious fallers

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Strength

The 1999 & 2007 TLSA dataNational representativeLarge sample sizeQuality assurance of data collection

Interviewers’ training Questionnaire validity

Stable estimates for prevalence of injurious falls

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Limitations

Cross-sectional survey on falls Recall bias Just association, instead of causal relationship

No further verification with medical record

Thanks for your attention

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