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Geriatr Gerontol Int 2015
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Ten-year mortality in older patients attending the emergency department after a fall Maw Pin Tan,1,2 Shahrul Bahyah Kamaruzzaman,1,2 Mohd Idzwan Zakaria,2,3 Ai-Vyrn Chin1,2 and Philip Jun Hua Poi1,2 1
Division of Geriatric Medicine, Department of Medicine, 2Aging and Age-Associated Disorders Research Group, and 3Academic Unit of Trauma and Emergency Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
Aim: To determine the dependency scores, long-term mortality and factors associated with mortality in older people presenting to the emergency department (ED) with a fall. Methods: Information on sociodemographics, dependency using the Barthel index and fall characteristics were collected from consecutive patients attending the ED over a 6-month period. Barthel score was reassessed at 12 months. Ten-year mortality data were obtained through the National Registry Department. Results: A total of 198 participants, with a mean age (standard deviation) of 76.2 years (6.3 years) and 74% women, were recruited. Of these, 70% sustained falls indoors, while 49% of falls occurred between 06.00 to 12.00 hours. Total Barthel scores were significantly lower at 1-year follow up compared with baseline (median [interquartile range], 20 [2] vs 18 [5], P < 0.001). Age ≥75 years was significantly associated with mortality at 1, 3, 5 and 10 years (HR 3.12, 95% CI 1.48–6.56; HR 2.32, 95% CI 1.37–3.92; HR 1.87, 95% CI 1.21–2.88; and HR 2.25, 95% CI 1.60–3.17, respectively). Indoor falls (HR 2.54, 95% CI 1.07–6.06; HR 2.01, 95% CI 1.10–3.69), hospital admission (HR 2.16, 95% CI 1.14–4.10; HR 1.84, 95% CI 1.11–3.07) and Barthel ≤18 (HR 2.99, 95% CI 1.39–6.44; HR 2.47, 95% CI 1.40–4.33) were significantly associated with 1-year and 3-year mortality. Hospital admission (HR 1.94, 95% CI 1.24–3.01; HR 1.53, 95% CI 1.06–2.23) and Barthel ≤18 (HR 2.27, 95% CI 1.41–3.66; HR 1.85, 95% CI 1.27–2.68) remained significantly associated with increased mortality at 5 and 10 years. Conclusion: Functional ability is significantly reduced at 1 year after an initial presentation to the ED with a fall. Mortality is increased at 1 and 3 years in fallers who experienced indoor falls. The excess mortality associated with hospital admission and lower disability scores is persistent at 5 and 10 years. The results of the present study are invaluable in prognostication and healthcare decision-making for this group of frail older patients. Geriatr Gerontol Int 2015; ••–••. Keywords: accidental falls, aged, disability, fractures, mortality.
Introduction Falling is a common problem among older people, and fall-related deaths are a leading cause of mortality among older individuals. Recent reports have suggested that fall-related deaths are increasing.1,2 However, statistics of falls mortality only include deaths directly associated with accidental falls rather than the mortality rate of individuals who have fallen, but did not necessarily Accepted for publication 14 November 2014. Correspondence: Dr Maw Pin Tan MD, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Email: [email protected]
© 2015 Japan Geriatrics Society
succumb to fall-related physical injuries.3 Previous reports have reported excess mortality even after 5 years in older patients who had sustained hip fractures compared with non-fracture cohorts.4,5 Although hip fractures are considered a common and serious complication of falls in older individuals, the majority of fallers do not sustain hip fractures. Statistics on longer-term mortality of individuals who have presented with an index fall to the emergency department (ED) remain limited. Falls are associated with increasing physical frailty and mental decline, which in turn are associated with increased risk of susceptibility to disease and death.6 Major risk factors for falls include muscle weakness, polypharmacy, orthostatic hypotension, cardiac doi: 10.1111/ggi.12446
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arrhythmias, cognitive decline and cerebrovascular disease.7 Orthostatic hypotension, cognitive decline and muscular weakness might occur as a result of serious illness, such as infection or gastrointestinal bleeding, or underlying malignancy. The individual might therefore present with a fall as the initial presentation of their illness, consistent with the non-specific presentation of illness that is well described in geriatric medicine. Subsequent disability and mortality in individuals presenting with a fall might therefore result not directly from the consequences of the incident fall itself. Instead, functional decline and mortality could occur as a result of a pre-existing physical or mental condition that predisposes the individual to the fall. Nearly 40% of individuals over the age of 50 years who present to the ED do so because of a fall.8 A better understanding of factors associated with mortality in individuals presenting with falls to medical services will assist with triage and management, leading to better utilization of resources and timely, life-saving interventions. We, therefore, carried out a 10-year follow-up study of patients attending the emergency department after a fall to determine the functional dependence, mortality rate and factors associated with mortality in these individuals.
Methods Study population Consecutive patients attending the ED at the University of Malaya Medical Center, Kuala Lumpur, Malaysia, over a 6-month period in 2002 were recruited into the study. Written informed consent was obtained from all participants or their next-of-kin. The present study received ethical approval from the University of Malaya Medical Center medical ethics committee.
10-year mortality data 10-year mortality was determined by submitting the unique identity card numbers and registered name of participants to the National Registration Department (NRD). Prior written approval was obtained from the NRD before the exchange of personal information. The confidentiality of all research participants was ensured throughout the process. The vital status and exact date of death if the participant had died were provided for cases that provided a match to the national identity card number.
Data analysis Data analysis was carried out using SPSS 20.0 (SPSS, Chicago, IL, USA). Continuous data were presented as mean with standard deviation (SD) for parametric data and median with interquartile range (IQR) for nonparametric data. Categorical data were presented as numbers with percentages in parenthesis. As comparisons for the Barthel index were only possible for survivors at 1 year, only the Barthel index of the survivors was compared between baseline and 1-year follow up. Data from deceased patients at 1 year were excluded for this part of the analysis. The Barthel index scores were compared between baseline and 1 year using the Wilcoxon sign-rank test for paired, non-parametric data. Hazard ratios (HR) with 95% confidence intervals (CI) were determined for different variables for mortality at 1 year, 3 years, 5 years and 10 years, and potential confounders controlled for using the Cox-proportional hazards analysis to determine factors associated with short-, medium- and long-term mortality.
Results
Baseline information
Study population
Baseline social demographics, time of presentation, characteristics of falls and injuries associated with falls were recorded in detail. Premorbid function was measured using the Barthel index.9 The Barthel index is a 10-item scale that assesses the activities of daily living and functional mobility within the domains of feeding, bathing, transferring to and from a toilet, walking, going up and down stairs, dressing, and continence of the bowels and bladder. The maximal score is 20, with 0 indicating full dependence in all activities of daily living, and 20 indicating full independence with all basic activities of daily living.
A total of 198 participants, with a mean age (SD) of 76.2 years (6.3 years) and 74% women, were recruited into the study at baseline. The sociodemographic information of the patients is summarized in Table 1. Of the participants, 61% were ethnic Chinese. Marital status and living arrangements were available for 175 participants. A total of 65% were widowed, single or divorced, but just 4% lived alone, and 6% lived in nursing or residential homes.
One-year follow up Patients were followed-up at 1 year through telephone calls or home visits, and their Barthel index score was re-assessed. 2
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Falls characteristics The characteristics of falls among our participants are summarized in Table 2. Time of injury was available for 178 participants. Of the 178 participants, 87 (49%) sustained their falls between the hours of 06.00 and12.00. The location of the falls was available for all © 2015 Japan Geriatrics Society
Ten-year ED falls mortality
Table 1 Sociodemographics of older fallers attending the emergency room Characteristics
n
n (%)
Age (years) Female, n (%) Ethnicity, n (%) Chinese Malay Indian Marital status, n (%) Widowed Married Single Divorced Living arrangements, n (%) Family Spouse Nursing home Alone
198 198 198
76.3 (7.2)† 146 (74)
†
129 (61) 23 (12) 47 (24) 175 94 (54) 62 (35) 14 (8) 5 (3) 172 116 (67) 39 (23) 10 (6) 7 (4)
Mean (standard deviation) for age.
198 participants. A total of 139 (70%) sustained their falls indoors, with 71 of 139 (51%) indoor falls occurring either in the bedroom or bathroom. Information on injuries was not available for one patient. A total of 72 of 197 (37%) patients sustained fractures. Of the 197 fallers, 49 (25%) sustained injuries in the head region, while 59 of 197 (30%) sustained injuries in the lower limbs. No obvious precipitants for falls were reported by 88 of 194 (45%) of our fallers, information on precipitants was missing for four patients. A total of 81 of all 198 patients (41%) required admission to the observation ward or hospital, and 114 of 198 (58%) were discharged home directly from the ED.
Table 2 Characteristics of falls Characteristics
n
Time of injury 06.00–12.00 hours 12.00–18.00 hours 18.00–00.00 hours 00.00–06.00 hours Location of fall Indoors Bathroom Bedroom Kitchen Stairs Others Outdoors Garden Others Fractures Soft tissue injury Site of injury Head Upper limb Femur Lower limb Trunk/vertebral Others Precipitants None Lost balance Slipped/tripped Outcome at ED Discharged Hospital admission Observation Ward
178
n (%) 87 (49) 39 (22) 28 (16) 24 (13)
198 139 139 139 139 139 198 37 37 197 197 197
139 (70) 38 (27) 33 (24) 12 (9) 12 (9) 44 (32) 37 (19) 21 (57) 16 (43) 72 (37) 90 (46) 49 (25) 40 (20) 32 (16) 27 (14) 20 (10) 29 (15)
194 88 (45) 21 (11) 63 (32) 198 198 198
114(58) 51 (26) 30 (15)
ED, emergency department.
Functional dependence The baseline Barthel index score was available for 157 out of 198 patients. Of these, 122 patients were available for interview at 1-year follow up, as 41 were deceased at follow up and 35 were uncontactable or declined follow up. Baseline data was missing for seven individuals. Comparisons were possible for 115 patients. The detailed Barthel scores collected at baseline and 1-year follow up are shown in Table 3. Participants showed increased dependency in all activities of daily living, with a significantly lower total Barthel score at 1-year follow up compared with baseline (median [interquartile range], 20 [2] vs 18 [5], P < 0.001).
Mortality The vital status of 183 out of 198 patients (93%) was established using death registry records. The remaining © 2015 Japan Geriatrics Society
15 patients had either no matching information or incomplete personal data. Unadjusted hazard ratios were calculated for age, whereas the hazard ratios for the remaining variables were calculated after adjustment for age differences for 1-, 3-, 5- and 10-year mortality. Figure 1 shows the Kaplan–Meier survival curve demonstrating survival of the 183 patients over 10 years.
One-year mortality A total of 40 (21.9%) of the 183 older fallers had died within 1 year of their initial presentation to the ED. There was a significant association between older age (age ≥75 years; HR 3.12, 95% CI 1.48–6.56; P < 0.01) and mortality. After adjustment for age differences, indoor falls (HR 2.54, 95% CI 1.07–6.06; P < 0.05), being admitted to hospital or the observation ward (HR |
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MP Tan et al.
Table 3 Dependency level of fallers pre-fall and at 1-year follow up
Bowel incontinence, n (%) Constant Occasional Bladder incontinence, n (%) Constant Occasional Grooming, n (%) Toileting, n (%) Fully dependent Needs assistance Feeding, n (%) Unable Needs help Transfer, n (%) Unable Major help Minor help Mobility, n (%) Immobile Wheelchair Support with one Dressing, n (%) Dependent Assistance Stairs, n (%) Unable With assistance Bathing, n (%) Dependent Total Barthel score, median (IQR)
Baseline (n = 115)
Follow up (n = 115)
1 (0.9) 0 (0.0)
7 (6.1) 7 (6.1)
2 (1.7) 4 (3.5) 7 (6.1)
9 (7.8) 7 (6.1) 15 (13.0)
1 (0.9) 11 (9.6)
8 (7.0) 19 (16.5)
0 (0.0) 9 (7.8)
4 (3.5) 17 (14.8)
0 (0.0) 2 (1.7) 8 (7.0)
4 (3.5) 6 (5.2) 14 (12.2)
1 (0.9) 1 (0.9) 8 (7.0)
3 (2.6) 7 (6.1) 18 (15.7)
3 (2.6) 7 (6.1)
12 (10.4) 12 (10.4)
33 (28.7) 7 (6.1)
56 (48.7) 2 (1.7)
10 (8.7) 20 (2)
31 (27.0) 18 (5)
P-value
65 years who sustained low-velocity falls had significantly higher 30-day mortality if they fell between the hours of midnight and 08.00.17 The present study found no increase in 1-year or longer-term mortality in individuals who fell between midnight and 0.600 hours in the morning, refuting the results of the previous study. Although over 50% of our fallers fell between 06.00 hours and 12.00 noon, mortality did not appear to be influenced by the time of fall. The presence of fractures also did not appear to increase the risk of mortality. Previous reports concentrated on patients with hip fractures. A recent study in Singapore evaluating mortality rates of hip fractures has suggested a crude 5-year mortality rate of 37% for older individuals after a hip fracture.5 Although our overall 5-year mortality rate of 49% in individuals with and without fractures appears higher, direct comparisons should not be made because of potential differences between the two populations that have not been controlled for. The present study, however, does suggest that the mortality rate of fallers attending ED is increased regardless of whether they sustained a fracture, and despite the majority being independent of basic activities of daily living at presentation. This suggests that the excess mortality in fallers who present to ED is independent of fracture complications, and could instead be due to factors not previously accounted for. The extent and completeness of data collectable in the ED setting is limited, because of the busy and often chaotic setting of the ED, where delivery of clinical care takes priority. Subsequent data collection on functional abilities was limited by the high 1-year mortality among our patient population. Nevertheless, the difficulty in collecting information in the ED setting is likely to be reflected by the paucity of published data on presentation and outcomes of fallers attending the ED. The findings of the present study therefore provide valuable new knowledge on the disability and mortality outcomes of fallers attending the ED, and highlights important areas for future research, which will focus on the identification of risk factors that increase the risk of adverse outcomes in fallers attending ED, as well as evaluating the potential benefits of interventions in reducing adverse outcomes after the initial presentation to the ED. © 2015 Japan Geriatrics Society
Ten-year ED falls mortality
There is a female and ethnic Chinese preponderance among fallers attending the ED. Fallers are significantly more dependent at 1 year after their initial presentation. The 1-, 3-, 5- and 10-year mortality rates among our fallers were 22%, 37%, 49% and 80%, respectively. Older age, hospital admission and increased disability were associated with increased short- and long-term mortality, whereas indoor falls were associated with increased mortality at 1 and 3 years only. The results of the present study provide crucial information for resource planning and healthcare decisions. Future research should be directed at determining factors underlying the excess mortality among fallers and identifying potential solutions to improve outcomes among fallers attending the ED.
Acknowledgments The authors of this paper are currently funded by the Ministry of Science, Technology and Innovation Science Fund grant [SF017-2013], the University of Malaya Research Grant [RP-010-2012A] and the Department of Education High Impact Research Grant [UM.C/625/1/HIRMOHE/ASH/0]. MPT, SBK, AVC, PP, IZ were involved with methodological design. MPT and PP were involved in data collection. MPT and SBK were involved in statistical analysis. All authors were involved with writing the manuscript and had approved the final manuscript before submission.
Disclosure statement The authors declare no conflict of interest.
References 1 Alamgir H, Muazzam S, Nasrullah M. Unintentional falls mortality among elderly in the United States: time for action. Injury 2012; 43: 2065–2071. 2 Kannus P, Parkkari J, Niemi S, Palvanen M. Fall-induced deaths among elderly people. Am J Public Health 2005; 95: 422–424. 3 Koehler SA, Weiss HB, Shakir A et al. Accurately assessing elderly fall deaths using hospital discharge and vital statistics data. Am J Forensic Med Pathol 2006; 27: 30–35.
© 2015 Japan Geriatrics Society
4 Haentjens P, Magaziner J, Colon-Emeric CS et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med 2010; 152: 380– 390. 5 Koh GC, Tai BC, Ang LW, Heng D, Yuan JM, Koh WP. All-cause and cause-specific mortality after hip fracture among Chinese women and men: the Singapore Chinese Health Study. Osteoporos Int 2013; 24: 1981–1989. 6 Ensrud KE, Ewing SK, Cawthon PM et al. A comparison of frailty indexes for the prediction of falls, disability, fractures, and mortality in older men. J Am Geriatr Soc 2009; 57: 492–498. 7 Panel on Prevention of Falls in Older Persons AGS, British Geriatrics S. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011; 59: 148–157. 8 Richardson DA, Bexton RS, Shaw FE, Kenny RA. Prevalence of cardioinhibitory carotid sinus hypersensitivity in patients 50 years or over presenting to the accident and emergency department with “unexplained” or “recurrent” falls. Pacing Clin Electrophysiol 1997; 20: 820–823. 9 Mahoney FI. Functional assessment: the Barthel index. MD Med J 1965; 14: 61–65. 10 Department of Statistics M. Population Distribution and Basic Demographic Characteristic Report 2010. In: Statistics Do, ed. Putrajaya, 2011. 11 Department of Statistics M. Abridged Life Tables. Putrajaya, 2012; 10. 12 Sekaran NK, Choi H, Hayward RA, Langa KM. Fallassociated difficulty with activities of daily living in functionally independent individuals aged 65 to 69 in the United States: a cohort study. J Am Geriatr Soc 2013; 61: 96–100. 13 Gill TM, Murphy TE, Gahbauer EA, Allore HG. Association of injurious falls with disability outcomes and nursing home admissions in community-living older persons. Am J Epidemiol 2013; 178: 418–425. 14 Bujang MA, Abdul Hamid AM, Zolkepali NA, Hamedon NM, Mat Lazim SS, Haniff J. Mortality rates by specific age group and gender in Malaysia: trend of 16 years, 1995– 2010. J Health Inform Dev Count 2012; 6: 521–529. 15 Yu W-Y, Hwang H-F, Hu M-H, Chen C-Y, Lin M-R. Effects of fall injury type and discharge placement on mortality, hospitalization, falls, and ADL changes among older people in Taiwan. Accid Anal Prev 2013; 50: 887–894. 16 Kelsey JL, Berry SD, Procter-Gray E et al. Indoor and Outdoor Falls in Older Adults Are Different: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc 2010; 58: 2135–2141. 17 McMahon CG, Kenny RA, Bennett K, Bouamra O, Lecky F. Diurnal variation in mortality in older nocturnal fallers. Age Ageing 2012; 41: 29–35.
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Geriatr Gerontol Int 2015
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Ten-year mortality in older patients attending the emergency department after a fall Maw Pin Tan,1,2 Shahrul Bahyah Kamaruzzaman,1,2 Mohd Idzwan Zakaria,2,3 Ai-Vyrn Chin1,2 and Philip Jun Hua Poi1,2 1
Division of Geriatric Medicine, Department of Medicine, 2Aging and Age-Associated Disorders Research Group, and 3Academic Unit of Trauma and Emergency Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
Aim: To determine the dependency scores, long-term mortality and factors associated with mortality in older people presenting to the emergency department (ED) with a fall. Methods: Information on sociodemographics, dependency using the Barthel index and fall characteristics were collected from consecutive patients attending the ED over a 6-month period. Barthel score was reassessed at 12 months. Ten-year mortality data were obtained through the National Registry Department. Results: A total of 198 participants, with a mean age (standard deviation) of 76.2 years (6.3 years) and 74% women, were recruited. Of these, 70% sustained falls indoors, while 49% of falls occurred between 06.00 to 12.00 hours. Total Barthel scores were significantly lower at 1-year follow up compared with baseline (median [interquartile range], 20 [2] vs 18 [5], P < 0.001). Age ≥75 years was significantly associated with mortality at 1, 3, 5 and 10 years (HR 3.12, 95% CI 1.48–6.56; HR 2.32, 95% CI 1.37–3.92; HR 1.87, 95% CI 1.21–2.88; and HR 2.25, 95% CI 1.60–3.17, respectively). Indoor falls (HR 2.54, 95% CI 1.07–6.06; HR 2.01, 95% CI 1.10–3.69), hospital admission (HR 2.16, 95% CI 1.14–4.10; HR 1.84, 95% CI 1.11–3.07) and Barthel ≤18 (HR 2.99, 95% CI 1.39–6.44; HR 2.47, 95% CI 1.40–4.33) were significantly associated with 1-year and 3-year mortality. Hospital admission (HR 1.94, 95% CI 1.24–3.01; HR 1.53, 95% CI 1.06–2.23) and Barthel ≤18 (HR 2.27, 95% CI 1.41–3.66; HR 1.85, 95% CI 1.27–2.68) remained significantly associated with increased mortality at 5 and 10 years. Conclusion: Functional ability is significantly reduced at 1 year after an initial presentation to the ED with a fall. Mortality is increased at 1 and 3 years in fallers who experienced indoor falls. The excess mortality associated with hospital admission and lower disability scores is persistent at 5 and 10 years. The results of the present study are invaluable in prognostication and healthcare decision-making for this group of frail older patients. Geriatr Gerontol Int 2015; ••–••. Keywords: accidental falls, aged, disability, fractures, mortality.
Introduction Falling is a common problem among older people, and fall-related deaths are a leading cause of mortality among older individuals. Recent reports have suggested that fall-related deaths are increasing.1,2 However, statistics of falls mortality only include deaths directly associated with accidental falls rather than the mortality rate of individuals who have fallen, but did not necessarily Accepted for publication 14 November 2014. Correspondence: Dr Maw Pin Tan MD, Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Email: [email protected]
© 2015 Japan Geriatrics Society
succumb to fall-related physical injuries.3 Previous reports have reported excess mortality even after 5 years in older patients who had sustained hip fractures compared with non-fracture cohorts.4,5 Although hip fractures are considered a common and serious complication of falls in older individuals, the majority of fallers do not sustain hip fractures. Statistics on longer-term mortality of individuals who have presented with an index fall to the emergency department (ED) remain limited. Falls are associated with increasing physical frailty and mental decline, which in turn are associated with increased risk of susceptibility to disease and death.6 Major risk factors for falls include muscle weakness, polypharmacy, orthostatic hypotension, cardiac doi: 10.1111/ggi.12446
|
1
MP Tan et al.
arrhythmias, cognitive decline and cerebrovascular disease.7 Orthostatic hypotension, cognitive decline and muscular weakness might occur as a result of serious illness, such as infection or gastrointestinal bleeding, or underlying malignancy. The individual might therefore present with a fall as the initial presentation of their illness, consistent with the non-specific presentation of illness that is well described in geriatric medicine. Subsequent disability and mortality in individuals presenting with a fall might therefore result not directly from the consequences of the incident fall itself. Instead, functional decline and mortality could occur as a result of a pre-existing physical or mental condition that predisposes the individual to the fall. Nearly 40% of individuals over the age of 50 years who present to the ED do so because of a fall.8 A better understanding of factors associated with mortality in individuals presenting with falls to medical services will assist with triage and management, leading to better utilization of resources and timely, life-saving interventions. We, therefore, carried out a 10-year follow-up study of patients attending the emergency department after a fall to determine the functional dependence, mortality rate and factors associated with mortality in these individuals.
Methods Study population Consecutive patients attending the ED at the University of Malaya Medical Center, Kuala Lumpur, Malaysia, over a 6-month period in 2002 were recruited into the study. Written informed consent was obtained from all participants or their next-of-kin. The present study received ethical approval from the University of Malaya Medical Center medical ethics committee.
10-year mortality data 10-year mortality was determined by submitting the unique identity card numbers and registered name of participants to the National Registration Department (NRD). Prior written approval was obtained from the NRD before the exchange of personal information. The confidentiality of all research participants was ensured throughout the process. The vital status and exact date of death if the participant had died were provided for cases that provided a match to the national identity card number.
Data analysis Data analysis was carried out using SPSS 20.0 (SPSS, Chicago, IL, USA). Continuous data were presented as mean with standard deviation (SD) for parametric data and median with interquartile range (IQR) for nonparametric data. Categorical data were presented as numbers with percentages in parenthesis. As comparisons for the Barthel index were only possible for survivors at 1 year, only the Barthel index of the survivors was compared between baseline and 1-year follow up. Data from deceased patients at 1 year were excluded for this part of the analysis. The Barthel index scores were compared between baseline and 1 year using the Wilcoxon sign-rank test for paired, non-parametric data. Hazard ratios (HR) with 95% confidence intervals (CI) were determined for different variables for mortality at 1 year, 3 years, 5 years and 10 years, and potential confounders controlled for using the Cox-proportional hazards analysis to determine factors associated with short-, medium- and long-term mortality.
Results
Baseline information
Study population
Baseline social demographics, time of presentation, characteristics of falls and injuries associated with falls were recorded in detail. Premorbid function was measured using the Barthel index.9 The Barthel index is a 10-item scale that assesses the activities of daily living and functional mobility within the domains of feeding, bathing, transferring to and from a toilet, walking, going up and down stairs, dressing, and continence of the bowels and bladder. The maximal score is 20, with 0 indicating full dependence in all activities of daily living, and 20 indicating full independence with all basic activities of daily living.
A total of 198 participants, with a mean age (SD) of 76.2 years (6.3 years) and 74% women, were recruited into the study at baseline. The sociodemographic information of the patients is summarized in Table 1. Of the participants, 61% were ethnic Chinese. Marital status and living arrangements were available for 175 participants. A total of 65% were widowed, single or divorced, but just 4% lived alone, and 6% lived in nursing or residential homes.
One-year follow up Patients were followed-up at 1 year through telephone calls or home visits, and their Barthel index score was re-assessed. 2
|
Falls characteristics The characteristics of falls among our participants are summarized in Table 2. Time of injury was available for 178 participants. Of the 178 participants, 87 (49%) sustained their falls between the hours of 06.00 and12.00. The location of the falls was available for all © 2015 Japan Geriatrics Society
Ten-year ED falls mortality
Table 1 Sociodemographics of older fallers attending the emergency room Characteristics
n
n (%)
Age (years) Female, n (%) Ethnicity, n (%) Chinese Malay Indian Marital status, n (%) Widowed Married Single Divorced Living arrangements, n (%) Family Spouse Nursing home Alone
198 198 198
76.3 (7.2)† 146 (74)
†
129 (61) 23 (12) 47 (24) 175 94 (54) 62 (35) 14 (8) 5 (3) 172 116 (67) 39 (23) 10 (6) 7 (4)
Mean (standard deviation) for age.
198 participants. A total of 139 (70%) sustained their falls indoors, with 71 of 139 (51%) indoor falls occurring either in the bedroom or bathroom. Information on injuries was not available for one patient. A total of 72 of 197 (37%) patients sustained fractures. Of the 197 fallers, 49 (25%) sustained injuries in the head region, while 59 of 197 (30%) sustained injuries in the lower limbs. No obvious precipitants for falls were reported by 88 of 194 (45%) of our fallers, information on precipitants was missing for four patients. A total of 81 of all 198 patients (41%) required admission to the observation ward or hospital, and 114 of 198 (58%) were discharged home directly from the ED.
Table 2 Characteristics of falls Characteristics
n
Time of injury 06.00–12.00 hours 12.00–18.00 hours 18.00–00.00 hours 00.00–06.00 hours Location of fall Indoors Bathroom Bedroom Kitchen Stairs Others Outdoors Garden Others Fractures Soft tissue injury Site of injury Head Upper limb Femur Lower limb Trunk/vertebral Others Precipitants None Lost balance Slipped/tripped Outcome at ED Discharged Hospital admission Observation Ward
178
n (%) 87 (49) 39 (22) 28 (16) 24 (13)
198 139 139 139 139 139 198 37 37 197 197 197
139 (70) 38 (27) 33 (24) 12 (9) 12 (9) 44 (32) 37 (19) 21 (57) 16 (43) 72 (37) 90 (46) 49 (25) 40 (20) 32 (16) 27 (14) 20 (10) 29 (15)
194 88 (45) 21 (11) 63 (32) 198 198 198
114(58) 51 (26) 30 (15)
ED, emergency department.
Functional dependence The baseline Barthel index score was available for 157 out of 198 patients. Of these, 122 patients were available for interview at 1-year follow up, as 41 were deceased at follow up and 35 were uncontactable or declined follow up. Baseline data was missing for seven individuals. Comparisons were possible for 115 patients. The detailed Barthel scores collected at baseline and 1-year follow up are shown in Table 3. Participants showed increased dependency in all activities of daily living, with a significantly lower total Barthel score at 1-year follow up compared with baseline (median [interquartile range], 20 [2] vs 18 [5], P < 0.001).
Mortality The vital status of 183 out of 198 patients (93%) was established using death registry records. The remaining © 2015 Japan Geriatrics Society
15 patients had either no matching information or incomplete personal data. Unadjusted hazard ratios were calculated for age, whereas the hazard ratios for the remaining variables were calculated after adjustment for age differences for 1-, 3-, 5- and 10-year mortality. Figure 1 shows the Kaplan–Meier survival curve demonstrating survival of the 183 patients over 10 years.
One-year mortality A total of 40 (21.9%) of the 183 older fallers had died within 1 year of their initial presentation to the ED. There was a significant association between older age (age ≥75 years; HR 3.12, 95% CI 1.48–6.56; P < 0.01) and mortality. After adjustment for age differences, indoor falls (HR 2.54, 95% CI 1.07–6.06; P < 0.05), being admitted to hospital or the observation ward (HR |
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Table 3 Dependency level of fallers pre-fall and at 1-year follow up
Bowel incontinence, n (%) Constant Occasional Bladder incontinence, n (%) Constant Occasional Grooming, n (%) Toileting, n (%) Fully dependent Needs assistance Feeding, n (%) Unable Needs help Transfer, n (%) Unable Major help Minor help Mobility, n (%) Immobile Wheelchair Support with one Dressing, n (%) Dependent Assistance Stairs, n (%) Unable With assistance Bathing, n (%) Dependent Total Barthel score, median (IQR)
Baseline (n = 115)
Follow up (n = 115)
1 (0.9) 0 (0.0)
7 (6.1) 7 (6.1)
2 (1.7) 4 (3.5) 7 (6.1)
9 (7.8) 7 (6.1) 15 (13.0)
1 (0.9) 11 (9.6)
8 (7.0) 19 (16.5)
0 (0.0) 9 (7.8)
4 (3.5) 17 (14.8)
0 (0.0) 2 (1.7) 8 (7.0)
4 (3.5) 6 (5.2) 14 (12.2)
1 (0.9) 1 (0.9) 8 (7.0)
3 (2.6) 7 (6.1) 18 (15.7)
3 (2.6) 7 (6.1)
12 (10.4) 12 (10.4)
33 (28.7) 7 (6.1)
56 (48.7) 2 (1.7)
10 (8.7) 20 (2)
31 (27.0) 18 (5)
P-value
65 years who sustained low-velocity falls had significantly higher 30-day mortality if they fell between the hours of midnight and 08.00.17 The present study found no increase in 1-year or longer-term mortality in individuals who fell between midnight and 0.600 hours in the morning, refuting the results of the previous study. Although over 50% of our fallers fell between 06.00 hours and 12.00 noon, mortality did not appear to be influenced by the time of fall. The presence of fractures also did not appear to increase the risk of mortality. Previous reports concentrated on patients with hip fractures. A recent study in Singapore evaluating mortality rates of hip fractures has suggested a crude 5-year mortality rate of 37% for older individuals after a hip fracture.5 Although our overall 5-year mortality rate of 49% in individuals with and without fractures appears higher, direct comparisons should not be made because of potential differences between the two populations that have not been controlled for. The present study, however, does suggest that the mortality rate of fallers attending ED is increased regardless of whether they sustained a fracture, and despite the majority being independent of basic activities of daily living at presentation. This suggests that the excess mortality in fallers who present to ED is independent of fracture complications, and could instead be due to factors not previously accounted for. The extent and completeness of data collectable in the ED setting is limited, because of the busy and often chaotic setting of the ED, where delivery of clinical care takes priority. Subsequent data collection on functional abilities was limited by the high 1-year mortality among our patient population. Nevertheless, the difficulty in collecting information in the ED setting is likely to be reflected by the paucity of published data on presentation and outcomes of fallers attending the ED. The findings of the present study therefore provide valuable new knowledge on the disability and mortality outcomes of fallers attending the ED, and highlights important areas for future research, which will focus on the identification of risk factors that increase the risk of adverse outcomes in fallers attending ED, as well as evaluating the potential benefits of interventions in reducing adverse outcomes after the initial presentation to the ED. © 2015 Japan Geriatrics Society
Ten-year ED falls mortality
There is a female and ethnic Chinese preponderance among fallers attending the ED. Fallers are significantly more dependent at 1 year after their initial presentation. The 1-, 3-, 5- and 10-year mortality rates among our fallers were 22%, 37%, 49% and 80%, respectively. Older age, hospital admission and increased disability were associated with increased short- and long-term mortality, whereas indoor falls were associated with increased mortality at 1 and 3 years only. The results of the present study provide crucial information for resource planning and healthcare decisions. Future research should be directed at determining factors underlying the excess mortality among fallers and identifying potential solutions to improve outcomes among fallers attending the ED.
Acknowledgments The authors of this paper are currently funded by the Ministry of Science, Technology and Innovation Science Fund grant [SF017-2013], the University of Malaya Research Grant [RP-010-2012A] and the Department of Education High Impact Research Grant [UM.C/625/1/HIRMOHE/ASH/0]. MPT, SBK, AVC, PP, IZ were involved with methodological design. MPT and PP were involved in data collection. MPT and SBK were involved in statistical analysis. All authors were involved with writing the manuscript and had approved the final manuscript before submission.
Disclosure statement The authors declare no conflict of interest.
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© 2015 Japan Geriatrics Society
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