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

1. Characteristics and risk factors of fall injury in Taiwan in 1999 vs 2007 Yih-Jian Tsai* MD, MSc, PhD candidate LSHTM 140 th APHA 4275.0 International Health and Aging and Healthcare Policy 2:54-3:06 pm, Moscone Convention Center West, San Francisco, CA * Section Chief, Adult and Elderly Health Division, Bureau of Health Promotion, Department of Health, Taiwan, ROC

2. Outline • Introduction • Subjects and Methods • Results • Discussion • Conclusions

3. Introduction • Falls are one of the leading causes of global burden of disease (Barss et al., 1998) • Fallers are more likely to be admitted into hospitals, nursing homes, and to consume more medical care resources, and to have more functional limitations in ADLs and IADLs (Kiel et al., 1991) • Among fallers of injury fall events, 42.3％ need hospitalization, and 37.0％ of those hospitalised have to move into nursing homes after discharge (Sattin et al., 1990)

4. Emergency Department Visits Ref: Owens PL, Russo CA, Spector W, Mutter R. Emergency Department Visits for Injurious Falls among the Elderly, 2006: Statistical Brief #80. <http://www.ncbi.nlm.nih.gov/pubmed/21452495> Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Health Care Policy and Research (US); 2006 Feb-. • In 2006, 10.5 % of all ED visits among the elderly in the US were claimed by injurious falls, of which • about seven tenth was released from the ED; • the remaining three tenths resulted in hospital admission. • The overall rate of ED visits for injurious falls was 57.4 visits per 1000 person 65 years and older.

5. The elderly top the other age groups in the prevalence of injurious falls Chang FC, Tsai YJ, Wu SL. Nonfatal unintentional injuries in Taiwan. Taiwan J Public Health 2003;22:492-500. [in Chinese]

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

7. Subjects and Methods • Elderly participants of • 1999 and 2007 Taiwan Longitudinal Study on Ageing (TLSA) :Survey of Health and Living Status of the Middle Aged and Elderly • Tool of measurement: structured questionnaires • Data collection: face-to-face interview • Population base: registered ≧65y living in non-mountainous regions • Sampling :Three-stage stratified sampling • It was not until 1999 that fall-related items were incorporated into the TLSA series.

8. Chronological sample size of respondents by age

9. Fall • C8. During the past one year, have you fallen down (including falling while walking, due to a slippery surface, while sitting down or standing up, due to fainting, or while trying to lie down, no matter if there was injury or not)? ___ 1 Yes ___0 No [Skip to C13]

10. Injurious falls: Did that fall cause a bone fracture or hairline fracture, sprain or dislocation? ___0 No [Skip to C11] ___1 Yes Injurious falls, Fall Injury • Fall Injury: Where (i.e., what part of the body) was the fracture, hairline fracture, sprain or dislocation? [Can choose more than one.] • Head, Neck, Spine, Lower limb, Upper limb, Hip, Trunk, Other

11. Medical care utilization • C10b. Where did you go for treatment? [Can choose more than one.] • ___1 Didn’t go for treatment; respondent treated it himself/herself (self care) • ___2 Bone-setting clinic or healing martial arts center • __3 Chinese medicine hospital or clinic • ___4 Western medicine hospital or clinic • ___5 Other (please explain):_______

12. Study framework Body site injured • Socio-demographic factors: • Age • Sex • ADL • IADL Medical factors, Physical and Mental function: • Sleeping pills or sedative use • Vision • Walk aid use • Exercise • No. of chronic diseases • Incontinence • Body pain • Depressive symptoms • Cognitive function 1999、2007 TLSA Injurious falls Medical care utilization

13. Socio-demographic factors 13

14. Medical factors, Physical function 14

15. Medical factors, Physical function 15

16. Mental function

17. Data analysis • To compare the 1999 with 2007 surveys in terms of: • Prevalence of falls/of injurious falls • Type of injury, injury rate • Body site injured • Consequent medical care utilization • Risk factors: • Uni- & bi-variate analyses: chi square test for categorical variables • Multi-variate logistic regression model adjusted for • age, sex, IADL dependency, • walk aid use, exercise, sleeping pills or sedative use, vision, No. of chronic conditions, cognitive impairment

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

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

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

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

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

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

24. Main findings • During 1999 and 2007, • prevalence of falls↑ • prevalence of injurious falls ↑ • injury rate of fallers↓ • multiple injuries ↑ • a rising utilization rate for Western medicine care↑ • a decreasing utilization rate for Chinese medicine care, and for bone setting clinic/healing martial arts center ↓ • The top three body sites injured were lower limb , upper limb and hip. 2014/10/15 24

25. Discussion • Demographic transition: with a rapidly ageing population, female elderly will have 1.24 times the population size of male counterpart by 2025, when the share of elderly population will be more than 20% as a whole. • Epidemiologic transition: • Prevalence of chronic diseases • Morbidity expansion: • a selectively beneficial effect on old-age survival of those who had severe functional limitations (climbing stairs, walking) between 1993-1996-1999* under full coverage of the National Health Insurance program launched in 1995?. *Zimmer, Martin & Chang. Population Studies 2002;56:265-276

26. Toward an Age-friendly society? • Filial piety decayed? • Health Inequality? • Age-friendly environments?

27. From 1999 to 2007, a rising utilization rate for Western medical care was found among injured fallers, • Probably due to competitive use of a variety of medical care, especially since the launch of NHI program.

28. The risk factors of injurious identified in multiple regression model were compatible with preceding study? • Advanced age:Sattin, Lamber Huber, DeVito et al. 1990, O’Loughlin et al. 1993; Yasumura et al., 1994 • Female: weakness quadriceps, indoor stay (Yasumura et al., 1996; Schultz, Ashton-Miller & Alexander, 1997; Lord, Sambrook, Gilbert et al., 1994) • IADL dependency: Nourhashémi, Andrien, Gillette-Guyonnet et al. (2001),Lin et al.(2002) • Walk aid use:Tinetti, Williams, Mayewski et al., 1986b; Stalenhoef et al., 1997 • but not for other risk factors: such as taking sleeping pills or sedative, vision, chronic conditions, cognitive impairment, exercise • Probably due to relatively fewer number of injurious fallers 2014/10/15 28

29. Strength • The 1999 & 2007 TLSA data • National representative • Large sample size • Quality assurance of data collection • Interviewers’ training • Questionnaire validity • Stable estimates for prevalence of injurious falls

30. Limitations • Cross-sectional survey on falls • Recall bias • Just association, instead of causal relationship • No further verification with medical record

31. Thanks for your attention