G Model
JINJ-6185; No. of Pages 5 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Epidemiology of falls among older adults: A cross sectional study from Chandigarh, India Nalini K. Tripathy a, Jagnoor Jagnoor b, Binod K. Patro a, Mandeep S. Dhillon c, Rajesh Kumar a,* a b c
Department of Community Medicine, Post Graduate Institute of Medical Education & Research, Chandigarh, India George Institute for Global Health, University of Sydney, Australia Department of Orthopaedics, Post Graduate Institute of Medical Education & Research, Chandigarh, India
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 29 April 2015
Background: Fall is an important cause of injury morbidity in older adults. However, epidemiological information on fall is limited in low- and middle-income countries. We investigated the extent, pattern, characteristics, and context of falls in Chandigarh. Methods: A cross sectional survey was carried out among 300 persons (60 years), sampled from urban, rural and slums areas of Chandigarh, India from March 2011 to October 2012 using multistage cluster sampling. A pre-tested interview schedule was used and relevant medical examinations were conducted. Multivariable logistic regression was carried out to estimate Odds Ratio (OR) and 95% confidence interval (CI). Results: In the past one year, 31% (92/300) respondents reported one or more falls. On an average 0.67 fall episodes occurred/person/year (202/300). Most (68%; 63/92) falls occurred at home; 75% (47/ 63) occurred while carrying out activities such as toileting, bathing, sleeping and eating etc. Injuries due to falls were reported by 67% (62/92). In these cases, lower extremities, 37% (23/62) were the most common site of injury. Eight percent (5/62) reported fractures. A general physician was consulted by 44% (27/62), and 11% (7/62) utilized emergency services whilst another 11% (7/62) of fall injuries required hospital admission. Risk of fall was higher among females (OR 1.6, 95%CI 1.0–2.8, p 0.068), those taking four or more medicines (OR 2.1, 95%CI 1.2–3.5, p 0.009) and having poor body balance (OR 1.9, 95%CI 1.0– 3.4, p 0.037). Conclusion: Fall injuries were common in older adults of Chandigarh. Large cohort studies are needed to identify risk factors particularly those related to home environment. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Fall Injury Risk factor Prevalence Incidence Geriatric Elderly
Introduction Falls are the second leading cause of injury mortality worldwide. The 2010 Global Burden of Disease and Injury Study estimated that 12% of all unintentional injury deaths are due to falls [1]. Injury related to falls also leads to significant disability in the population with an estimated loss of 375 Disability Adjusted Life Years per 100,000 population in India [1]. Community-based studies have reported prevalence of fall among 60 years and older adults to be 14–50% in India [2–5]. Fall injury was the cause of 25% of all unintentional injuries in India with 160,000 deaths in 2005, only marginally less than the road
* Corresponding author. Tel.: +91 9876017948; fax: +91 1722744401. E-mail address: [email protected] (R. Kumar).
traffic injury deaths (185,000) [6,7]. High mortality due to fall injury amongst older ages is indicative of the need for a public health response to the issue. Few studies have reported context and characteristics of falls in older adults in India [5], however, better epidemiological understanding is required for planning appropriate prevention and control programmes. Therefore, a community-based study was conducted to determine the extent, pattern, characteristics, and context of falls in Chandigarh among older adults aged 60 years and beyond. Methods This study was carried out from March 2011 to October 2012 in Chandigarh, India after obtaining approval from the Institute Ethics Committee. As per the Census of India conducted in 2011,
http://dx.doi.org/10.1016/j.injury.2015.04.037 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Tripathy NK, et al. Epidemiology of falls among older adults: A cross sectional study from Chandigarh, India. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.037
G Model
JINJ-6185; No. of Pages 5 2
N.K. Tripathy et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
the population of Chandigarh Union Territory was about one million. It had marginally lower proportion of older adults (6.4%) compared to rest of the country (8.6%). A cross-sectional cluster survey design was used to conduct the study among older adults (60 years or more) who were living in Chandigarh for at least a year. Sample size requirement was estimated to be 300, considering expected true population prevalence of falls to be 10%, desired absolute precision to be 5%, confidence level of 95%, and design effect of 2. Multistage stratified cluster sampling method was employed. Clusters were sampled based on the population of older adults in the voter lists prepared in 2011 by Chandigarh Election Commission. Urban area, villages and slums had 76.2%, 8.6%, and 15.2% of the population respectively. Stage one stratification was based on area of residence that is urban, rural and slums. These areas were geographically well demarcated. In the second stage clusters were sampled from each stratum (urban, slums and rural) on the basis of probability proportional to size (PPS). Based on the population proportion, 23 clusters were chosen from 57 urban clusters, 3 from 9 rural, and 4 from 15 slum clusters by systematic random sampling. In stage three, within each cluster, a prominent land mark was chosen such as temple or school, thereafter one house was selected randomly from a list of first 10 households which existed on the street on the right side of the landmark, and then, from the first randomly selected household next nearest households were chosen until the required sample was achieved. Household was defined as a group of people living in a house who were sharing food from a common kitchen. In the last stratification stage, if there were more than one eligible person in the sampled households, one of them was sampled using Kish grid method [8]. Thus, from each sampled cluster 10 eligible participants who agreed to participate were chosen for the study. A semi-structured interview schedule and general physical examination proforma, based on WHO injury surveillance for India [9], was pre-tested, and required modifications were made. Written informed consent was obtained from the respondents. Using the interview schedule information was collected by a community physician (NKT) on socio-demographic status, morbidity, medication use, and history of fall in previous 12 month in any setting. In the most recent fall detailed information on fall and fall related injury was collected such as time, place, activity, body part injured, nature of injury and any form of residual disability. Physical examination was also conducted. Based on participant history, change in the characteristics, morbidity, and behaviours which were made after the fall were not included in the analysis. The average time for interview schedule and examination was 45 min per participant. Standard instruments and methods were used for conducting general physical examination by a qualified community physician (NKT) in home setting. Blood pressure was measured by mercury sphygmomanometer, height by a measuring tape, weight by digital weighing machine. Participants who had been taking antihypertensive medications or those who had systolic blood pressure more than or equal to 140 mm of Hg and/or had diastolic blood pressure of more than 90 mm Hg at the time of clinical examination were classified as hypertensive. Visual acuity was assessed by Snellen chart. Pallor was accessed clinically by observing lower palpebral conjunctiva in both eyes, nail beds and tongue in daylight. Moderate and severe pallor was classified as ‘pallor’ in the analysis. Cognition level of the participant was measured by using Hindi Mini Mental Status Examination (HMSE), which was modified version of Mini Mental Status Examination validated for Indian population. Gait was measured by 6 m walk test. Balance was assessed using 180 degree turn test. For minimising the biases, laboratory-based reports or previous prescriptions were recorded for the diagnosis of morbidity.
Statistical Package for the Social Sciences (SPSS), version 20, and Epi Info, version 7, was used for data entry and data analysis. Variables were summarized using summary statistics like mean and percentage. The extent of fall was computed by dividing the number of respondents who reported history of any fall (one or more) during one year period by the number of respondents interviewed. The average number of falls per person during one year was computed by dividing total number of falls that were reported in one year by the number of respondents interviewed. For assessment of the associations of the characteristics of respondents with falls, Odds Ratio (OR) and 95% of confidence interval (CI) were estimated. Chi-squared test with Yate’s continuity correction was used to determine statistical significance. Multivariable logistic regression was performed to find the predictors of falls. Results Of the 357 adults aged 60 years and beyond who were invited to take part in the study, 300 (84%) agreed to participate, 50 refused, and 7 were ineligible being bedridden due to health conditions other than fall injuries. The mean age of the participants was 68 years (range 60–97 years). More than half (53%) of the respondents were male. The socio-demographic characteristics of the respondents are presented in Table 1. Out of the 300 respondents, a significant proportion reported multiple health conditions like hypertension (47%), diabetes (29%), arthritis (27%), stroke (5%) and epilepsy (6%). Frequent micturition (more than three times during night or more than 10 times during day) was reported by 21%. A general physical examination revealed low visual acuity (60 years) in Chandigarh, India.
Characteristics of the most recent fall (n = 92), which had occurred in the 12 month period, are presented in Table 2. Most falls (41%) occurred during the morning hours (6 am–11 am). Majority (68%) of the falls were at home followed by the falls on the road/street (26%). Most (75%, 47/63) of the falls at home occurred while carrying out daily activities like toileting, bathing, sleeping and eating etc. Most falls were same level falls on the road/street. Only 1% (1/92) of the falls were intentional. Out of the 92 falls, 62 (67%) resulted in injury. The characteristics and context of fall such as time, location and activity did not differ significantly among those who had suffered injury (n = 62) compared to those who did not have a fall related injury (n = 30) (data not shown). However, location of fall was significantly associated with injury (p 0.01). Injuries were more common in falls on road/street compared to home (Table 2). The nature of the injuries is reported in Table 3. Out of the 62 fall injuries, 29 (47%) were severe injuries (fracture/dislocation/sprain/ loss of consciousness). Lower extremity (37%) was the most common site of injury followed by upper extremity (29%). The type of injury did not have specific association with body part injured or the type of treatment received. Nearly 76% (47/62) of the falls needed medical attention. Disability was reported in 21% (13/62) which had resulted in restriction of mobility or self-care activities: unable to move one arm (n = 1), unable to walk (n = 2), severe back pain (n = 2), pain and swelling in leg (n = 3), and unable to perform activities of daily living (n = 5). The leading contributing factors
3
identified by 62 respondents who sustained injury due to fall were wet/slippery surfaces (n = 24), loss of balance (n = 10), dizziness (n = 9), weakness (n = 9), uneven surfaces (n = 5), and inadequate lighting (n = 5). Older adults with multiple falls (>1 fall in 12 month period) had non-significantly higher injury rate (71%, 34/48) as compared to those with history of one fall (64%, 28/44) (p 0.6). Those with multiple falls were admitted to hospital non-significantly less often (4%, 2/48) compared to those with one fall (11%, 5/44) (p 0.4). However, disabilities were significantly less common (4%, 2/48) among those who had multiple fall than those who had single fall (25%, 11/44) (p 0.01). The association of socio-demographic and health conditions with falls is presented in Table 4. Female sex, poor body balance, and intake of four or more medicines were significantly associated with falls. Age and body mass index did not have significant association with falls. The multivariable logistic regression analysis presented in Table 5 shows that the multiple medication use and poor body balance are the predictors of falls in this community. Discussion To the best our knowledge, this is the first community-based study on falls among older adults in India which is conducted in a representative population. We achieved high participation rate. On an average fall occurrence rate was 0.67 episodes/person/year. Other population-based studies have reported falls rate varying from 0.3 to 1.6 per person annually among older people (age >65 years) living in different community settings [10]. Similar to earlier reports, most of falls did not result into serious injury. Though most of the falls do not lead to an injury but falls do impact the quality of life of the older adults. Fall has been reported to lead to ‘‘post falls syndrome’’ which is associated with loss of confidence and immobility [11]. Several participants in our study (14%, 13/92) experienced restricted mobility and self-care issues after the fall. We observed falls to be significantly higher among women as has also been reported in previous studies. Worldwide, among older ages, women are more likely than men to be injured due to fall [3,12]. Some of the other factors which have been reported in previous studies globally and also in India are – increased rate of fall with age [6,10,13], homes as the most common setting for fall [3,5,6,12], and same level falls while doing an activity of daily living [2,4,6]. Our findings are in coherence with previous research.
Table 2 Characteristics of last fall during 12 month period among older adults (>60 years) in Chandigarh, India. Variable
Time of fall Morning (6 am–11 am) Afternoon (12 pm–4 pm) Evening (5 pm–8 pm) Night (9 pm–5 am) Activity preceding fall Walking Working Sports Activities of daily livingb Others Injury Yes No a b
Location of fall
All (N = 92) N (%)
Homea (N = 63)
Work place (N = 2)
Road/street (N = 24)
Public building (N = 3)
29 15 7 12
0 1 1 0
7 4 12 1
2 1 0 0
38 21 20 13
(41) (23) (22) (14)
9 4 2 44 4
0 2 0 0 0
21 1 0 1 1
2 0 0 0 1
32 7 2 45 6
(35) (8) (2) (49) (6)
37 26
2 0
22 2
1 2
62 (67) 30 (33)
Home includes garden and courtyard outside of the house also. While involved in performing activities such as toileting, bathing, sleeping, and eating.
Please cite this article in press as: Tripathy NK, et al. Epidemiology of falls among older adults: A cross sectional study from Chandigarh, India. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.037
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JINJ-6185; No. of Pages 5 N.K. Tripathy et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
4
Table 3 Nature of injuries sustained due to the most recent fall among older adults (>60 years) in Chandigarh, India. Fracture N=5
Variable
Location Home Work place Road/street Public building Body part injured Head/neck Trunk Spine Upper extremities Lower extremities Treatment type Emergency room Hospital admission Allopathic doctor Ayurveda/homoeopathy Home/self-treatment No treatment Disability Yes No
Dislocation/sprain N = 16
Falls/total
a
Reference.
All N = 62 N (%)
8 0 8 0
4 0 4 0
20 2 10 1
37 2 22 1
(60) (3) (35) (2)
0 0 1 2 2
0 0 3 8 5
2 2 1 1 2
7 2 3 7 14
9 4 8 18 23
(15) (6) (13) (29) (37)
1 2 1 0 0 1
2 3 7 0 2 2
0 2 3 2 0 1
4 0 16 4 3 6
7 7 27 6 5 10
(11) (11) (44) (10) (8) (16)
4 1
6 10
3 5
0 33
13 (21) 49 (79)
Table 4 Association of socio-demographic and biological factors with falls among older adults (60 years) in Chandigarh, India. Variable
Cut/bruise/abrasion N = 33
5 0 0 0
People living in slum areas had higher incidence rate of fall. Socio-demographic gradient has also been reported in other studies [14,15]. The increased risk in slums and rural area may be mediated through poor home environment, poor nutrition and lower health status. A Thai study found that lack of electricity in the house and ‘bad’ or ‘fairly bad’ health was associated with falls [16]. Poor social status could lead to poor household environment and it may also be associated with other health issues like untreated vision problems or nutritional related conditions like anaemia and other disorders which are associated with falls [17,18]. We also observed association of falls with poor body balance. Co-morbidities may impair the body structure and function. Further the medications used for management of comorbidities could affect the body balance, a predisposing factor for fall. Cross-sectional research, such as this study, rely on history of fall and related injuries. This study design has the limitation to generally under-estimate fall incidence as falls which do not result
Residence place Rural 11/40 Urban 81/260 Age (years) 60–79 80/270 80–99 12/30 Sex Male 40/160 Female 52/140 Body mass index (kg/m2)
JINJ-6185; No. of Pages 5 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Epidemiology of falls among older adults: A cross sectional study from Chandigarh, India Nalini K. Tripathy a, Jagnoor Jagnoor b, Binod K. Patro a, Mandeep S. Dhillon c, Rajesh Kumar a,* a b c
Department of Community Medicine, Post Graduate Institute of Medical Education & Research, Chandigarh, India George Institute for Global Health, University of Sydney, Australia Department of Orthopaedics, Post Graduate Institute of Medical Education & Research, Chandigarh, India
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 29 April 2015
Background: Fall is an important cause of injury morbidity in older adults. However, epidemiological information on fall is limited in low- and middle-income countries. We investigated the extent, pattern, characteristics, and context of falls in Chandigarh. Methods: A cross sectional survey was carried out among 300 persons (60 years), sampled from urban, rural and slums areas of Chandigarh, India from March 2011 to October 2012 using multistage cluster sampling. A pre-tested interview schedule was used and relevant medical examinations were conducted. Multivariable logistic regression was carried out to estimate Odds Ratio (OR) and 95% confidence interval (CI). Results: In the past one year, 31% (92/300) respondents reported one or more falls. On an average 0.67 fall episodes occurred/person/year (202/300). Most (68%; 63/92) falls occurred at home; 75% (47/ 63) occurred while carrying out activities such as toileting, bathing, sleeping and eating etc. Injuries due to falls were reported by 67% (62/92). In these cases, lower extremities, 37% (23/62) were the most common site of injury. Eight percent (5/62) reported fractures. A general physician was consulted by 44% (27/62), and 11% (7/62) utilized emergency services whilst another 11% (7/62) of fall injuries required hospital admission. Risk of fall was higher among females (OR 1.6, 95%CI 1.0–2.8, p 0.068), those taking four or more medicines (OR 2.1, 95%CI 1.2–3.5, p 0.009) and having poor body balance (OR 1.9, 95%CI 1.0– 3.4, p 0.037). Conclusion: Fall injuries were common in older adults of Chandigarh. Large cohort studies are needed to identify risk factors particularly those related to home environment. ß 2015 Elsevier Ltd. All rights reserved.
Keywords: Fall Injury Risk factor Prevalence Incidence Geriatric Elderly
Introduction Falls are the second leading cause of injury mortality worldwide. The 2010 Global Burden of Disease and Injury Study estimated that 12% of all unintentional injury deaths are due to falls [1]. Injury related to falls also leads to significant disability in the population with an estimated loss of 375 Disability Adjusted Life Years per 100,000 population in India [1]. Community-based studies have reported prevalence of fall among 60 years and older adults to be 14–50% in India [2–5]. Fall injury was the cause of 25% of all unintentional injuries in India with 160,000 deaths in 2005, only marginally less than the road
* Corresponding author. Tel.: +91 9876017948; fax: +91 1722744401. E-mail address: [email protected] (R. Kumar).
traffic injury deaths (185,000) [6,7]. High mortality due to fall injury amongst older ages is indicative of the need for a public health response to the issue. Few studies have reported context and characteristics of falls in older adults in India [5], however, better epidemiological understanding is required for planning appropriate prevention and control programmes. Therefore, a community-based study was conducted to determine the extent, pattern, characteristics, and context of falls in Chandigarh among older adults aged 60 years and beyond. Methods This study was carried out from March 2011 to October 2012 in Chandigarh, India after obtaining approval from the Institute Ethics Committee. As per the Census of India conducted in 2011,
http://dx.doi.org/10.1016/j.injury.2015.04.037 0020–1383/ß 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Tripathy NK, et al. Epidemiology of falls among older adults: A cross sectional study from Chandigarh, India. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.037
G Model
JINJ-6185; No. of Pages 5 2
N.K. Tripathy et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
the population of Chandigarh Union Territory was about one million. It had marginally lower proportion of older adults (6.4%) compared to rest of the country (8.6%). A cross-sectional cluster survey design was used to conduct the study among older adults (60 years or more) who were living in Chandigarh for at least a year. Sample size requirement was estimated to be 300, considering expected true population prevalence of falls to be 10%, desired absolute precision to be 5%, confidence level of 95%, and design effect of 2. Multistage stratified cluster sampling method was employed. Clusters were sampled based on the population of older adults in the voter lists prepared in 2011 by Chandigarh Election Commission. Urban area, villages and slums had 76.2%, 8.6%, and 15.2% of the population respectively. Stage one stratification was based on area of residence that is urban, rural and slums. These areas were geographically well demarcated. In the second stage clusters were sampled from each stratum (urban, slums and rural) on the basis of probability proportional to size (PPS). Based on the population proportion, 23 clusters were chosen from 57 urban clusters, 3 from 9 rural, and 4 from 15 slum clusters by systematic random sampling. In stage three, within each cluster, a prominent land mark was chosen such as temple or school, thereafter one house was selected randomly from a list of first 10 households which existed on the street on the right side of the landmark, and then, from the first randomly selected household next nearest households were chosen until the required sample was achieved. Household was defined as a group of people living in a house who were sharing food from a common kitchen. In the last stratification stage, if there were more than one eligible person in the sampled households, one of them was sampled using Kish grid method [8]. Thus, from each sampled cluster 10 eligible participants who agreed to participate were chosen for the study. A semi-structured interview schedule and general physical examination proforma, based on WHO injury surveillance for India [9], was pre-tested, and required modifications were made. Written informed consent was obtained from the respondents. Using the interview schedule information was collected by a community physician (NKT) on socio-demographic status, morbidity, medication use, and history of fall in previous 12 month in any setting. In the most recent fall detailed information on fall and fall related injury was collected such as time, place, activity, body part injured, nature of injury and any form of residual disability. Physical examination was also conducted. Based on participant history, change in the characteristics, morbidity, and behaviours which were made after the fall were not included in the analysis. The average time for interview schedule and examination was 45 min per participant. Standard instruments and methods were used for conducting general physical examination by a qualified community physician (NKT) in home setting. Blood pressure was measured by mercury sphygmomanometer, height by a measuring tape, weight by digital weighing machine. Participants who had been taking antihypertensive medications or those who had systolic blood pressure more than or equal to 140 mm of Hg and/or had diastolic blood pressure of more than 90 mm Hg at the time of clinical examination were classified as hypertensive. Visual acuity was assessed by Snellen chart. Pallor was accessed clinically by observing lower palpebral conjunctiva in both eyes, nail beds and tongue in daylight. Moderate and severe pallor was classified as ‘pallor’ in the analysis. Cognition level of the participant was measured by using Hindi Mini Mental Status Examination (HMSE), which was modified version of Mini Mental Status Examination validated for Indian population. Gait was measured by 6 m walk test. Balance was assessed using 180 degree turn test. For minimising the biases, laboratory-based reports or previous prescriptions were recorded for the diagnosis of morbidity.
Statistical Package for the Social Sciences (SPSS), version 20, and Epi Info, version 7, was used for data entry and data analysis. Variables were summarized using summary statistics like mean and percentage. The extent of fall was computed by dividing the number of respondents who reported history of any fall (one or more) during one year period by the number of respondents interviewed. The average number of falls per person during one year was computed by dividing total number of falls that were reported in one year by the number of respondents interviewed. For assessment of the associations of the characteristics of respondents with falls, Odds Ratio (OR) and 95% of confidence interval (CI) were estimated. Chi-squared test with Yate’s continuity correction was used to determine statistical significance. Multivariable logistic regression was performed to find the predictors of falls. Results Of the 357 adults aged 60 years and beyond who were invited to take part in the study, 300 (84%) agreed to participate, 50 refused, and 7 were ineligible being bedridden due to health conditions other than fall injuries. The mean age of the participants was 68 years (range 60–97 years). More than half (53%) of the respondents were male. The socio-demographic characteristics of the respondents are presented in Table 1. Out of the 300 respondents, a significant proportion reported multiple health conditions like hypertension (47%), diabetes (29%), arthritis (27%), stroke (5%) and epilepsy (6%). Frequent micturition (more than three times during night or more than 10 times during day) was reported by 21%. A general physical examination revealed low visual acuity (60 years) in Chandigarh, India.
Characteristics of the most recent fall (n = 92), which had occurred in the 12 month period, are presented in Table 2. Most falls (41%) occurred during the morning hours (6 am–11 am). Majority (68%) of the falls were at home followed by the falls on the road/street (26%). Most (75%, 47/63) of the falls at home occurred while carrying out daily activities like toileting, bathing, sleeping and eating etc. Most falls were same level falls on the road/street. Only 1% (1/92) of the falls were intentional. Out of the 92 falls, 62 (67%) resulted in injury. The characteristics and context of fall such as time, location and activity did not differ significantly among those who had suffered injury (n = 62) compared to those who did not have a fall related injury (n = 30) (data not shown). However, location of fall was significantly associated with injury (p 0.01). Injuries were more common in falls on road/street compared to home (Table 2). The nature of the injuries is reported in Table 3. Out of the 62 fall injuries, 29 (47%) were severe injuries (fracture/dislocation/sprain/ loss of consciousness). Lower extremity (37%) was the most common site of injury followed by upper extremity (29%). The type of injury did not have specific association with body part injured or the type of treatment received. Nearly 76% (47/62) of the falls needed medical attention. Disability was reported in 21% (13/62) which had resulted in restriction of mobility or self-care activities: unable to move one arm (n = 1), unable to walk (n = 2), severe back pain (n = 2), pain and swelling in leg (n = 3), and unable to perform activities of daily living (n = 5). The leading contributing factors
3
identified by 62 respondents who sustained injury due to fall were wet/slippery surfaces (n = 24), loss of balance (n = 10), dizziness (n = 9), weakness (n = 9), uneven surfaces (n = 5), and inadequate lighting (n = 5). Older adults with multiple falls (>1 fall in 12 month period) had non-significantly higher injury rate (71%, 34/48) as compared to those with history of one fall (64%, 28/44) (p 0.6). Those with multiple falls were admitted to hospital non-significantly less often (4%, 2/48) compared to those with one fall (11%, 5/44) (p 0.4). However, disabilities were significantly less common (4%, 2/48) among those who had multiple fall than those who had single fall (25%, 11/44) (p 0.01). The association of socio-demographic and health conditions with falls is presented in Table 4. Female sex, poor body balance, and intake of four or more medicines were significantly associated with falls. Age and body mass index did not have significant association with falls. The multivariable logistic regression analysis presented in Table 5 shows that the multiple medication use and poor body balance are the predictors of falls in this community. Discussion To the best our knowledge, this is the first community-based study on falls among older adults in India which is conducted in a representative population. We achieved high participation rate. On an average fall occurrence rate was 0.67 episodes/person/year. Other population-based studies have reported falls rate varying from 0.3 to 1.6 per person annually among older people (age >65 years) living in different community settings [10]. Similar to earlier reports, most of falls did not result into serious injury. Though most of the falls do not lead to an injury but falls do impact the quality of life of the older adults. Fall has been reported to lead to ‘‘post falls syndrome’’ which is associated with loss of confidence and immobility [11]. Several participants in our study (14%, 13/92) experienced restricted mobility and self-care issues after the fall. We observed falls to be significantly higher among women as has also been reported in previous studies. Worldwide, among older ages, women are more likely than men to be injured due to fall [3,12]. Some of the other factors which have been reported in previous studies globally and also in India are – increased rate of fall with age [6,10,13], homes as the most common setting for fall [3,5,6,12], and same level falls while doing an activity of daily living [2,4,6]. Our findings are in coherence with previous research.
Table 2 Characteristics of last fall during 12 month period among older adults (>60 years) in Chandigarh, India. Variable
Time of fall Morning (6 am–11 am) Afternoon (12 pm–4 pm) Evening (5 pm–8 pm) Night (9 pm–5 am) Activity preceding fall Walking Working Sports Activities of daily livingb Others Injury Yes No a b
Location of fall
All (N = 92) N (%)
Homea (N = 63)
Work place (N = 2)
Road/street (N = 24)
Public building (N = 3)
29 15 7 12
0 1 1 0
7 4 12 1
2 1 0 0
38 21 20 13
(41) (23) (22) (14)
9 4 2 44 4
0 2 0 0 0
21 1 0 1 1
2 0 0 0 1
32 7 2 45 6
(35) (8) (2) (49) (6)
37 26
2 0
22 2
1 2
62 (67) 30 (33)
Home includes garden and courtyard outside of the house also. While involved in performing activities such as toileting, bathing, sleeping, and eating.
Please cite this article in press as: Tripathy NK, et al. Epidemiology of falls among older adults: A cross sectional study from Chandigarh, India. Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.04.037
G Model
JINJ-6185; No. of Pages 5 N.K. Tripathy et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
4
Table 3 Nature of injuries sustained due to the most recent fall among older adults (>60 years) in Chandigarh, India. Fracture N=5
Variable
Location Home Work place Road/street Public building Body part injured Head/neck Trunk Spine Upper extremities Lower extremities Treatment type Emergency room Hospital admission Allopathic doctor Ayurveda/homoeopathy Home/self-treatment No treatment Disability Yes No
Dislocation/sprain N = 16
Falls/total
a
Reference.
All N = 62 N (%)
8 0 8 0
4 0 4 0
20 2 10 1
37 2 22 1
(60) (3) (35) (2)
0 0 1 2 2
0 0 3 8 5
2 2 1 1 2
7 2 3 7 14
9 4 8 18 23
(15) (6) (13) (29) (37)
1 2 1 0 0 1
2 3 7 0 2 2
0 2 3 2 0 1
4 0 16 4 3 6
7 7 27 6 5 10
(11) (11) (44) (10) (8) (16)
4 1
6 10
3 5
0 33
13 (21) 49 (79)
Table 4 Association of socio-demographic and biological factors with falls among older adults (60 years) in Chandigarh, India. Variable
Cut/bruise/abrasion N = 33
5 0 0 0
People living in slum areas had higher incidence rate of fall. Socio-demographic gradient has also been reported in other studies [14,15]. The increased risk in slums and rural area may be mediated through poor home environment, poor nutrition and lower health status. A Thai study found that lack of electricity in the house and ‘bad’ or ‘fairly bad’ health was associated with falls [16]. Poor social status could lead to poor household environment and it may also be associated with other health issues like untreated vision problems or nutritional related conditions like anaemia and other disorders which are associated with falls [17,18]. We also observed association of falls with poor body balance. Co-morbidities may impair the body structure and function. Further the medications used for management of comorbidities could affect the body balance, a predisposing factor for fall. Cross-sectional research, such as this study, rely on history of fall and related injuries. This study design has the limitation to generally under-estimate fall incidence as falls which do not result
Residence place Rural 11/40 Urban 81/260 Age (years) 60–79 80/270 80–99 12/30 Sex Male 40/160 Female 52/140 Body mass index (kg/m2)
