J Community Health DOI 10.1007/s10900-014-9852-8

REVIEW

Exploring Ethnic and Racial Differences in Falls Among Older Adults Benjamin H. Han • Rosie Ferris • Caroline Blaum

Ó Springer Science+Business Media New York 2014

Abstract Falls are common events that threaten the independence and health of older adults. Studies have found a wide range of fall statistics in different ethnic and racial groups throughout the world. These studies suggest that fall rates may differ between different racial and ethnic groups. Studies also suggest that the location of falls, circumstances of falls, and particular behaviors may also be different by population. Also migration to new locations may alter an individual’s fall risk. However, there are few studies that directly compare ethnic and racial differences in falls statistics or examine how known fall risk factors change based on race and ethnicity. This paper reviews the existing literature on how falls may differ between different racial and ethnic groups, highlights gaps in the literature, and explores directions for future research. The focus of this paper is community dwelling older adults and immigrant populations in the United States.

(both physical and behavioral) and their environment [2]. Multiple prospective cohort studies have consistently identified several risk factors for falls, including female gender, older age, cognitive impairment, gait difficulties, psychotropic medication use, and past history of falls [3– 5]. Several studies and cohorts have shown a variation of fall statistics by ethnicity and race. While ethnic and racial differences have been explored in osteoporosis and fractures [6], little is known on the influences of race, ethnicity, and culture on falls, particularly in the United States. This review presents a summary of the literature regarding the influence of race and ethnicity on falls in older adults, with an emphasis on community dwelling older adults. Furthermore, it will explore future research directions in this area.

Search Strategy and Criteria Keywords disparities

Falls  Geriatrics  Ethnic groups  Health

Introduction Unintentional falls are a common event in older adults and a significant cause of morbidity and mortality associated with a decline in functional status, disability, and nursing home admissions [1]. The causes of a fall are a complex interaction of multiple domains between the individual

B. H. Han (&)  R. Ferris  C. Blaum Division of Geriatric Medicine and Palliative Care, New York University School of Medicine, 550 First Avenue, BCD612, New York, NY 10016, USA e-mail: [email protected]

A search was conducted using Medline, EMBase, and Web of Science for peer-reviewed studies that addressed falls, ethnicity, and race. The Medical Subject Heading (MESH) terms used for Medline were ‘‘Accidental Falls’’[Mesh] AND ‘‘Ethnic Groups’’[Mesh] as well as searches with ‘‘Accidental Falls’’[Mesh] AND (‘‘incidence’’[mesh] OR ‘‘prevalence’’[mesh]). The terms falls and ethnic groups were used for EMBase and Web of Science. A secondary review of references of reviewed studies was also examined, and relevant articles reviewed. Given the wide differences in study design, fall measurement, follow up, and how results were reported it was determined that a systematic meta-analysis was not possible. Also only English language articles were reviewed, limiting a review of all international studies. The search was concluded in December 2013.

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International Studies Several studies have been conducted with varying study designs, fall ascertainment methods, and standardizations to examine fall prevalence and/or incidence rates in different countries throughout the world [7–11]. These investigations provide a wide range of statistics that are difficult to compare between countries, races, and ethnicities due to such variation. However, some evidence of comparable statistics on falls between countries and thus, race and ethnicity, is from the Osteoporotic Fractures in Men (MrOS) Study [12]. This was a multi-centered study of community-dwelling men over the age of 65 with several international cohorts: Hong Kong (100 % Chinese ethnicity), the United States (90.7 % Caucasian, 4.2 % African American, 3.3 % Asian, 2.2 % Hispanic, and \1.0 % Native American), and Sweden (participants were 99 % Caucasian). The number of falls for each study participant was obtained through questionnaire regarding the previous 12 months. There were significant (P \ 0.001) differences in prevalence between the three cohorts; with the USA the highest at 21.2 %; Sweden with 16.5 % and Hong Kong with the lowest rate of 15.4 %. Among the three cohorts there were no significant differences between those who fell and those who did not in terms of age, height, weight, and BMI. While this multi-centered study used similar protocols for inclusion and exclusion criteria, it is impossible to assert what influence race and ethnicity specifically had on these different fall prevalence rates. Interestingly, differences in physical function based on physical performance tests between the groups did not explain the difference in fall prevalence. A recently published follow-up paper examining fall rates in the MrOS study compared prevalence rates of falls between men living in different countries, but of the same ethnic group [13]. The statistically significant difference found was between white men in the United States and white men Sweden, but not between Asian men living in Hong Kong and in the United States. There were also no differences in the prevalence rates of falls in the Unites States between different ethnicities. This led the authors to conclude that the location of residence influences fall rates more than ethnicity. A systematic review by the Falls and Balance Research Group from the Neuroscience Research Australia evaluated twenty-one studies on incident falls in varying Chinese populations in China, Hong Kong, Macao, Singapore and Taiwan, noting a fall rate range between 14.7 and 34 % per year with a median of 18 % [14]. The authors noted that this rate was well below commonly stated fall rates in Caucasian older populations. These studies used varying sampling methods and different exclusion criteria. The authors also examined the location of falls and noted a

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higher percentage of falls outside the home as well as a higher proportion of fall-sustaining injuries and fractures compared to Caucasian populations. However, the Caucasian populations that were used as reference ranges appear to be heterogeneous. The same research group did a more direct comparison between Chinese and Caucasian populations in a multicohort, prospective study with 12–24 month follow up [15]. The study examined fall rates of four cohorts of patients, aged 65 and older and living independently in the community: Chinese in Tainan City; Taiwan; Hong Kong; and Sydney, Australia and Caucasians in Sydney Australia. Age and sex standardized annual fall rates were determined for each cohort. The three Chinese cohort rates (0.26 ± 0.47 in Taiwan, 0.21 ± 0.57 in Hong Kong, and 0.36 ± 0.80 in Australia) were significantly lower than the Caucasian cohort (0.70 ± 1.15). Risk factors were explored and the Chinese cohorts appeared to have more concern about falling using the Falls Efficacy Scale-International score. Also, the two cohorts in Asia (Taiwan and Hong Kong) had significantly lower fall rates than that of the Australian Chinese cohort, which suggests that there may be a migration effect on fall risk. However, little is characterized regarding the Chinese cohort in Australia in terms of location of birth or level of acculturation. Another prospective study in Australia compared two cohorts of men older than 70—Australian-born and Italianborn immigrants living in the community [16]. They found that the incidence rates of two or more falls in older male Italian-born immigrants were roughly half of their Australian-born counterparts. After adjustment for age, education, dementia, alcohol use, medications, timed chair stand and height, Italian born men remained significantly less likely to fall (IRR = 0.57, 95 % CI 0.39–0.85). Interestingly, the lower education level of Italian-born men appeared to have a protective effect for falls, which has been noted elsewhere in the literature [17, 18].

US: Based Studies In the United States, there is a paucity of prospective studies that directly compare fall incidence rates between different racial and ethnic groups. Much of what we can extrapolate regarding the influence of race and ethnicity in varying rates of falls are based on nationally collected data and from cohort studies designed to study other outcomes, as well as small cohorts with varying study design. The Centers for Disease Control and Prevention makes available the US data on injury-related deaths with information on unintentional fall mortality collected from death certificate information recorded by the National Vital Statistics System through their Web-based Injury Statistics

6. Chinese participants in Sydney, Australia (n = 211), mean age 74.5

Cross-sectional retrospective study design

1993–1998

Study years:

Women’s Health Initiative (WHI) [22]

Prospective longitudinal study design

2005–2007

Study years:

Concord Health and Ageing in Men Project (CHAMP) [16]

4. Asian/Pacific Islander n = 4,192

3. Hispanic n-6,512

2. Black n = 14,627

Women aged 50–79 and postmenopausal. 1. White n = 133,533

2. Australian-born men C70 (n = 848)

1. Italian-born Australian men C70 (n = 335).

7. White participants in Sydney, Australia (n = 764), mean age 77.6

Taiwan: 0.26 ± 0.47

5. Hong Kong (n = 201), mean age 74.9

Study years: not specified

Prospective longitudinal study design

Chinese in Australia: 0.36 ± 0.80

4. Tainan City, Taiwan (n = 280), mean age 74.9.

Chopstix Fall Risk Study [15]

White = 6.7 %

Hispanic = 5.0 %

Black = 5.1 %

Asian/Pacific Islander = 4.4 %

Cross-sectional prevalence rates of number of [2 falls in last year:

Italian-born men with a 43 % lower fall rate (IRR = 0.57, 95 % CI 0.39–0.85)

Incident rates of two or more falls after adjustment for fall risk factors:

Italian-born men = 11 %

Australian-born men = 22 %

Unadjusted fall rates:

Hong Kong: 0.21 ± 0.57 White in Australia: 0.70 ± 1.15

Age and sex standardized annual fall rates:

3. Sweden (99 % Caucasian), n = 3,014, men aged 69–81

P \ 0.001

United States (21.2 %)

Sweden (16.5 %)

Cross-sectional retrospective study design

2. United States (90.7 % Caucasian, 4.2 % African American, 3.3 % Asian, 2.2 % Hispanic, \1.0 % Native American), n = 5,995, men aged 65–100

Cross-sectional prevalence rates: Hong Kong (15.4 %)

1. Hong Kong (100 % Chinese ethnicity), n = 2,000, men aged 65–92.

Osteoporotic Fractures in Men (MrOS Study) [12, 13]

Study years: 2001–2004

Results

Participants

Study/cohort

Table 1 Studies that directly compare fall statistics between different ethnic/racial cohorts

Questionnaire regarding previous 12 months

Participants phoned at 4-month intervals regarding preceding 4 months. Mean follow up was 26.7 months

Monthly telephone calls for 1–2 years. Follow up ranged from 1 to 2 years

No difference between fallers and nonfallers in age, height, weight, BMI between ethnic groups

Questionnaire regarding previous 12 months

Not age-adjusted

Lower education level of Italian-born men appeared to have a protective effect for falls

The Falls Efficacy Scale International Score was used to evaluate concern about falling, and revealed a significant interaction

Fallers C70 performed worse in physical performance tests, and C85 in grip strength in the USA and Sweden, but not in Hong Kong

Findings/notes

Method of fall ascertainment/ follow up

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Fall circumstances differed by ethnicity

Race not a significant predictor of multiple falls. Increased age and education, arthritis, and diabetes were significant risk factors

Prospective longitudinal study design

Caucasian = 24.7 %

African American = 27.4 % African American women C65 (n = 156)

Age-adjusted fall rates nonsignificantly higher in Caucasians (RR 1.30, 95 % CI 0.93–1.83 %) 1993–1998

Study years:

Unadjusted fall rates: 1. Caucasian women C65 (n = 1,665)

Prospective longitudinal study design Study of Osteoporotic Fractures [25]

1986–1990

Study years:

African American = 20.2 % 6. African Americans C65 (n = 1,049)

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Caucasian = 23.2 %

Unadjusted fall rates: 5. Caucasians C65 (n = 1,947)

Duke Established Populations for Epidemiologic Studies of the Elderly [24]

Multivariable analysis: African Americans less likely than whites to have any fall (adjusted OR 0.77, 95 % CI 0.62–0.94)

Participants sent postcards or phoned every 4 months for 5.4 years (Caucasian) and 3.8 years (African American)

In-home interview asked about fall in the past 12 months at the 3 year follow up from enrollment

Results Participants Study/cohort

Table 1 continued

Method of fall ascertainment/ follow up

Findings/notes

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Query and Reporting System (WISAQRS) [19]. A study examining unintentional falls mortality in adults older than 65 using these data from 2003 to 2007 found age-adjusted rates of fall mortality per 100,000 per year among Caucasians to be higher compared to Blacks (43.04 vs. 18.83; P = 0.01). Mortality rates for other ethnic groups included American Indians (29.81 per 100,000), Asian Pacific (28.70 per 100,000), and Hispanic (27.95 per 100,000) [20]. These data are limited in that they represent only fall mortality reported through the National Vital Statistics System. Data do exist through the WISQARS on unintentional nonfatal fall rates. However, due to the small sample size rates by ethnicity and race these are not computed [19]. Differences in fall rates between racial and ethnic groups are also seen in other large US population data, although with a wide variety of rates. A retrospective study of hospital discharge summaries for 1995–1997 from nonfederal acute care hospitals in California showed significant differences (for all ages) in admission rates for falls per 100,000 (Caucasians 161, Blacks 64, Hispanics 43, and Asian 35) [21]. Such significant ranges are also seen in other large cohort studies, such as the Women’s Health Initiative [22] and The Osteoporotic Fractures in Men (MrOS) Study [12, 13, 23], see Table 1. Differences in fall rates between Caucasian Americans and African Americans have been studied with mixed results. An analysis of the Duke Established Populations for Epidemiologic Studies of the Elderly cohort found African Americans were less likely to have any falls compared to Caucasians with an adjusted OR of 0.77, 95 % CI 0.62–0.94), but there was no significant difference for multiple falls [24]. However, a prospective analysis of incident falls between Caucasian and African American women enrolled in the Study of Osteoporotic Fractures in 1993–1994 and followed for 5.7 years found non-significantly higher age-adjusted fall rates in Caucasians than African Americans (RR = 1.30, 95 % CI 0.93–1.83 %) [25]. However, the analysis of fall circumstances found that Caucasian women were significantly more likely to fall outdoors, laterally, and were less likely to fall on their hand/wrist compared to African American women. This suggests that fall circumstance, which may vary by race or ethnicity, has an association with fracture risk. A handful of studies have examined falls in Hispanic populations in the United States. A prospective cohort study of 152 community-dwelling Mexican–American women aged 59 years or older found that 41 % reported falling in the first year [26]. The authors concluded that this is similar to Caucasian reported rates with independent risk factors of age, history of arthritis, hyperthyroidism, fainting in the past year, psychotropic medications, and walking less than five blocks a day. Another cohort of

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Mexican Americans, the Hispanic Established Population for the Epidemiological Study of the Elderly, found that among 1,391 participants, 31.8 % fell one or more times in the previous 12 months, which the authors acknowledge is similar to Caucasian prevalence rates. This study found significant risk factors for falls to be age, female, diabetes, arthritis, depression and impairments in instrumental activities of daily living [27]. Similarly, a cross-sectional study of 103 older Latino adults in Milwaukee County, Wisconsin found that 54 % of its participants had fallen in the past year with 21 % of those needed medical care [28]. These studies, while not age-adjusted, suggest that fall rates may be similar in Hispanic older adults compared to Caucasian fall rates. These results are in contrast to CDC data from the Web-based Injury Statistics Query and Reporting System (WISAQRS) which shows that Hispanic ethnicity was associated with a reduced risk of fatal falls across all age and gender subgroups [29, 30]. Thus, while Hispanic fall rates may be similar, the circumstances of these falls may be different leading to different risk of fatal falls. As discussed previously, there have been several studies examining falls in Asian communities internationally; however there are little published research on falls for Asian Americans. A prospective study of falls in community dwelling men and women of Japanese ancestry living in Hawaii done within the Hawaii Osteoporosis Study [31] found Japanese Hawaiians had fall rates for males being 139 per 1,000 person-years (95 % CI 111–167) and females 267 per 1,000 person-years (95 % CI 235–299). They concluded that these were lower fall rates compared to published Caucasian fall rates from Canada, Finland, and New Zealand. The study identified previous falls, female gender and daytime hours to be associated with an increase in falls in this population. No other articles were found that specifically examined Asian American fall rates or risk.

Discussion The population in the United States is not only getting older, but also becoming increasingly diverse [32]. Understanding how race and ethnicity influences important geriatric-related syndromes, such as falls, can help identify groups at risk and effectively tailor interventions. Fall risk is not well-understood or described for different races or ethnic groups in the United States. However, due to the complexity and multi-factorial causes of falls it proves difficult to study and identify the influence of race and ethnicity on fall rates. This review revealed that there is a lack of studies that directly compare racial and ethnic differences in fall rates,

and that existing studies are difficult to compare due to widely variable data and methodology. Many studies examine fall rates in a specific racial or ethnic group, and then compare to them ‘‘Caucasian’’ fall rates that are often derived from studies conducted in a wide range of cultural and geographical locations, and often decades apart. The use of these standard ‘‘Caucasian’’ fall rates makes direct comparisons between different groups impossible. More prospective studies are needed that enroll patients from a wide range of racial and ethnic backgrounds within a single geographical location, including Caucasians, for a more direct comparison of fall rates. There also appears to be a lack of studies that explore the different impact of known risk factors, such as age, cognitive impairment, and medication use, by different races or ethnicities. Little is also known about the influence of race and ethnicity on falls by disease. For example, diabetes has been associated with an increase in falls in older women [33], however the cohort study that found such an association was nearly all Caucasian. An association was also found in a cohort of African American inner city diabetics aged 70 and older [34]. However, a crosssectional study did not find significant differences in falls between ethnicities in adults over 65 years old with diabetes in rural North Carolina in a multiethnic population [35]. Further studies are needed to examine the influence of race and ethnicity, if any, for older patients with diabetes and other chronic diseases. This review also reveals that the literature suggests that there may be differences in fall circumstances and location between racial and ethnic groups. It appears that Caucasian populations may have higher rates of falls outside the home compared to African Americans [25], but not Chinese cohorts [14]. Also noted were that Chinese cohorts fall more often in the daytime hours [14], and that there may be differences in how Caucasians fall compared to African Americans [25]. The specifics of location and circumstances of falls may explain why subsequent mortality [19] and hip fractures [6] may differ based on race and ethnicity. There is very little research that examines how fall rates change based on migration to a new geographic location. The studies by Kwan et al. [15] not only showed that fall rates were higher for Australian Chinese compared to Chinese in Asia, but also interestingly suggest that Chinese cohorts may lose protective behaviors that reduce fall risk after migration [36]. This highlights the possibility of the role of culture underlying some of the differences in fall risk between ethnicities. An example is certain groups may participate in activities that are culturally-based that could decrease their risk for falls, such as tai-chi [37]. This and other beliefs regarding falling may be rooted in culture that can change with time, migration, and globalization. An

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J Community Health Table 2 Research questions regarding falls in different ethnic and racial groups 1. How do risk factors for falls differ based on race or ethnicity? 2. Are locations of falls (indoor vs outdoor) or time of fall (daytime vs night) different for certain groups? 3. How do fall circumstances change by particular groups? 4. How does level of acculturation change fall risk in immigrant populations? 5. What cultural behaviors may change fall risk? 6. Do types of family structures or social supports influence fall risk? 7. How does migration change fall risk? 8. What diseases may change fall risk in particular groups? 9. Does acceptability of fall interventions change based on race or ethnicity? 10. Are current fall interventions culturally competent/relevant?

example is the finding that Chinese cohorts appeared to have more concern or fear about falling that was associated with their decreased risk for falls [15]. Further studies that explore the role of culture on fall risk and describe how levels of acculturation changes fall risk are needed. In particular community-based studies of specific immigrant groups in the United States would help to specifically understand fall risks in different populations. Table 2 lists key research questions to further explore ethnic and racial difference in falls among older adults. Future studies should attempt to understand the role of culture, behavior, biological factors, and the environment in falls. Migrant study designs and community-based studies may be useful to understand these differences. Further examination is needed to understand how risk factors for falls differ by race and ethnicity. Ideally such research questions should be answered using similar data gathering and statistical techniques, as well as measures of association, to allow for accurate comparison between studies. While fall prevention should be targeted to all ethnicities and races, understanding why and how specific groups fall may help identify those at particular risk for falls.

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Exploring ethnic and racial differences in falls among older adults.

Falls are common events that threaten the independence and health of older adults. Studies have found a wide range of fall statistics in different eth...
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