H. Alsaleh1, S. AlObaidi2, A. Alsaber3
1. Department of Physiotherapy, Alrazi Orthopedic Hospital, Ministry of Health, Kuwait City, Kuwait; 2. Department of Physical Therapy, Dar Al Shifa Hospital, Kuwait; 3. The American University of Kuwait, Kuwait
Corresponding Author: H. Alsaleh, Department of Physiotherapy, Alrazi Orthopedic Hospital, Ministry of Health, Kuwait City, Kuwait; Email: golden_land85@hotmail.com Tel: +96565064141
J Frailty Aging 2024;in press
Published online October 14, 2024, http://dx.doi.org/10.14283/jfa.2024.76
Abstract
BACKGROUND: Falls among the older population have attracted global attention, with a specific emphasis on the regional contexts of falls. This study reports the incidence and characteristics of falls in the State of Kuwait, where there is currently no national fall prevention strategy.
METHODOLOGY: A prospective, cross-sectional study reported on 420 individuals aged 55 years and above admitted to Alrazi Orthopaedic Hospital in Kuwait City due to falls between March 2022 and February 2023. ICD-10 codes were used to classify the fall causes. The National Database of Nursing Quality Indicators injury severity classification was used to classify the fall-related injuries. Structured interviews were used to identify 10 main fall risk factors. Annual fall-rate was calculated and fall-related injuries were reported in frequencies and percentages. Chi-square tests and multinomial logistic regression models were used to examine the cross-sectional associations between fall severity and risk factors to determine the factors that could predict more severe fall-related injuries.
RESULTS: Fall-related injuries comprised 24.1% of the total hospital admissions, with 4% mortality rate. Around 31.6% of the falls led to temporary impairment injuries, 23.5% resulted in long-term impairment injuries, and 44.8% created potentially fatal injuries. The results of this study show that being between 55 and 74 years of age, having no history of falls, suffering from at least one illness, with no polypharmacy effect, and possessing fair vision are significantly associated with the severity of fall injuries. Being male (odds ratio [OR] = 3.38), being over 65 years of age (OR = 3.46), having a history of falls (OR = 2.49), and limitations in visual acuity predict more severe fall injuries among older individuals.
CONCLUSION: The severity of fall injuries is significantly associated with more capable older people. Government officials should immediately design and implement culture-specific fall-prevention strategies tailored to the targeted population.
Key words: Falls, older people, severity of injuries.
Abbreviations: NDNQI: National Database of Nursing Quality Indicators; ICD-10: International Classification of Diseases, 10th edition; WHO: world Health Organization; ADL: Activity of Daily Living.
Introduction
Falls are common among older adults and place a burden on healthcare services at both the community and individual levels (1, 2). Annually, about 20–33% of adults aged 65 years and over fall, resulting in serious injury, inactivity, loss of independence or even death (1-4). Identifying those at risk of falling as early as possible is important so that proper preventative care strategies can be implemented. Globally, we are witnessing rapid growth in the older population aged 65+ years (4), which increased from 6.7% in 2000 to 8.7% in 2017 (5). With a population of 4.6 million living in Kuwait, the proportion of people aged 65 and above is expected to reach 4.9% and 17.9% by 2025 and 2050, respectively (6). This merits government fall prevention strategies, which have not yet been implemented.
Falls are the leading cause of morbidity and mortality among older people (1-6). However, the rate of falls among those aged 65 years or older varies across the globe. In Canada and the USA, the fall rates are estimated to be 20.1% and 28.7%, respectively (7, 8). In Ecuador, the rate is estimated at around 11.4% (9). Santiago has demonstrated a high fall rate, at 34.0% (10). In Africa, the estimated rates vary between 23% and 41%; for example, Nigeria reported a 23% fall rate in one year (11). A much higher rate was reported for Malawi, at 41% for the same age group (12). Similarly, high fall rates of 34%–57.7% have been reported among the older population in the Arabian Gulf countries (13).
Many factors contribute to the risk of falling, including one’s biological, physiological, environmental, and medical history (14-17). Biologically, age-related changes in the nervous system, including deteriorated audiovisual acuity, proprioception impairment, poor neuromuscular coordination, slow walking speed, and lack of balance, increase the risk of falling (18). Other contributors include environmental hazards, health status, cognitive decline, physical inactivity history of previous falls, and the use of multiple medications (18). In the Arabian Gulf countries, fall prevalence is significantly associated with physical inactivity and comorbidities (13, 19-21).
Hip fractures are the most serious and costly consequence of falls among older individuals (22, 23). Studies from Kuwait have reported an increased incidence of both bone (24, 25) and hip fractures (26) among individuals aged 50 years and above. Ibrahim and AlAsoomi (27) reported a higher rate of femur fractures (79.6%) among people aged 65 and above and admitted to the hospital due to falls; a significantly higher incidence among females (5.6%) compared to males (3.6%); and a significant association between fall incidence and fractures, surgical procedures and longer hospital stays.
Despite the higher precipitating and predisposing fall factors in Kuwait, there is still missing information about fall epidemiology and severity in the older population. Such information is needed in light of the regional health conditions, older adult lifestyles, and the cross-cultural differences of older individuals. Therefore, this study aimed to estimate the national prevalence of falls that led to tertiary care admission, the causes of fall-related injuries, and associated risk factors among older adults.
Methods
Study design
A prospective, cross-sectional, observational study. Data were collected at Alrazi Orthopaedic Hospital, known as the only specialist tertiary orthopedic hospital in Kuwait City.
Data collection
Data of the study were obtained between March 2022 and February 2023; the hospital’s database was monitored daily for fall-related admissions among older adults. The data were compiled as reported in the hospital’s information system. During the study period, 1,736 older individuals were admitted, 24.1% (420) of whom reported falls, with a mortality rate of 4% (16). The final study population that met the World Health Organization (WHO) definition of a fall alive comprised 404 individuals aged 55 years and above. All patients were screened and interviewed to determine their eligibility for the study. In addition, phone interviews were conducted with patients who were discharged before being interviewed.
Causes and consequences of falls
Diagnoses of fall-related injuries were coded according to the International Classification of Diseases, 10th edition (ICD-10). ICD-10 codes W00 to W19 were used to indicate additional information about the primary causes of the fall-related admissions or the patients’ own explanations for their falls. The severity of each fall injury was classified based on the National Database of Nursing Quality Indicators (NDNQI) classification system (28).
Intrinsic and extrinsic fall risk factors
Information on intrinsic fall risk factors was obtained by consulting each patient’s demographic data, premorbid health status, self-reported falls, polypharmacy, visual acuity, urinary incontinence, health behaviour, and premorbid functional status. The demographic factors included age and sex. Premorbid health status was determined by the existence of co-morbidities. The patients’ medical histories were flagged if they were diagnosed with any of the following conditions prior to the fall: coronary or ischaemic heart disease, diabetes, hypertension, arthritis, asthma, osteoporosis, Alzheimer’s disease or dementia, cancer, stroke, or Parkinson’s disease.
Self-reported falls in the previous 12 months with and without injury were also reported. The number of medications taken per day was noted, with five or more medications indicating polypharmacy. Self-reported visual impairment was used, which was found to be suitable for older people (29), and classified into three categories by asking the patient to rate their sight (with glasses if used) as excellent, fair, or blind. Urinary incontinence was rated by asking the patient if they had lost control over their urine within the last 12 months and was categorised as yes or no. Health behaviour was assessed based on the patient’s level of engagement in physical activity according to the Rapid Assessment of Physical Activity questionnaire (30). Premorbid functional status included the patient’s self-reported level of independence in activities of daily living (ADLs) and was classified as either ADL independent or completely dependent on caregivers for basic ADLs.
The extrinsic fall risk factors included environmental hazards associated with the occurrence of falls. The patients were questioned about the reasons for their falls and whether environmental hazards were associated with the fall; the answers included steps or stairs, an uneven or slippery floor, furniture or other obstacles, and poor light.
Statistical methodology
Jamovi statistical analysis software (version 2.3.21) was used for data analysis (31-37). The annual fall rate was calculated by dividing the total number of older adults’ reported fall-related admissions by the total number of all older people’s admissions between March 2022 and February 2023. The severity of falls was categorised under three classes: Temporary impairment (Major A), long-term impairment (Major B), and potentially fatal (Major C) (28). The death cases were excluded from the study as the main interest of this research is to inform the management of those to be discharged from the hospital. Patient characteristics are displayed as frequencies and percentages. Chi-square tests were used to examine the cross-sectional associations between fall severity and risk factors. Additionally, a multinomial logistic regression model was used to determine the factors associated with fall severity (with p < .05 indicating a significant association).
Results
Most falls (67.1%) were among native Kuwaitis, while 32.9% were sustained by those of other nationalities. Female patients sustained 66.5%, while male patients sustained 33.5% of the reported falls. Among the 404 participants, 35.3% belonged to the 65–74-year-old age group, 32.7% were between 55 and 64 years, 24.6% were between 75 and 84 years, and only 7.4% were 85 or above. Around 81.5% of the fallers reported a sedentary lifestyle, while only 18.5% were active. Furthermore, 83.5% of the fallers were independent, while only 16.5% were dependent on their ADLs.
According to the ICD-10 classification, slipping, tripping, and stumbling were the causes for the majority of the falls (66.6%), while 15.5% were described by the patients as caused by general weakness or dizziness (Table 1). In the NDNQI classification, 31.6% of falls caused temporary impairment injuries, 23.5% led to long-term impairment injuries and 44.8% resulted in potentially fatal injuries. Fractures of the proximal femoral comprised the largest class of the most severe injuries (44.8%).
* Reported by the participants
Table 2 displays the results of the association between the severity of falls and intrinsic fall risk factors. The results indicate a significant association between fall severity and age group, fall history in the last year, having a medical history of chronic condition, visual acuity, and taking 0–4 medications (p < .05). Most falls resulted in temporary impairment injuries (53.8%) and long-term impairment injuries (40.5%) in the 55–64 age group, while those aged 65–74 suffered more severe injuries (potentially fatal = 39.6%).
1. Pearson’s chi-squared test
However, it was interesting to observe that fall severity was significantly associated with having no history of falls (temporary impairment: 82.4%, long-term impairment: 61.2%, and potentially fatal: 56.0%) and fair vision (temporary impairment: 53.8%, long-term impairment: 69.4% and potentially fatal: 81.3%). The results also indicate a significant association between fall severity and history of medical issues (p > 0.05). A higher proportion of individuals in the potentially fatal (89%) class reported a history of medical problems compared to participants classified under long-term impairment (84.3%) and temporary impairment (72.5%). Most individuals were taking between 0 and 4 medications daily, which indicates no polypharmacy effect and this was significantly associated with injury severity across all types of injuries.
Table 3 displays the results of the association between fall severity and extrinsic fall risks. This table indicates a significant association between environmental hazards and fall severity. Uneven or slippery floors represented the most common hazard associated with falls resulting in major injuries (temporary impairment: 53.3%, long-term impairment: 50.8%, and potentially fatal: 50%).
Multinomial logistic regression
Table 4 presents the results of a multinomial logistic regression analysis examining the predictors of fall severity, comparing long-term impairment (Major B) and potentially fatal injuries (Major C) to injuries with temporary impairment (Major A, lower severity injuries) as the reference category. For the long-term impairment vs. temporary impairment comparison, having a fall history in the last year significantly increased the odds of experiencing a long-term impairment injury after a fall (Odds Ratio (OR) = 2.56, 95% CI: [1.2759, 5.138], p = 0.008), while other predictors such as polypharmacy status, medical history, age group, gender, and vision did not show significant associations. For the potentially fatal vs. temporary impairment injuries comparison, several predictors were significant. Older age groups had significantly higher odds of experiencing a potentially fatal injury compared to the 55-64 age group: OR = 3.459, 95% CI: [1.7437, 6.861], p < 0.001 for ages 65-74; OR = 5.078, 95% CI: [2.119, 12.168], p < 0.001 for ages 75-84; and OR = 11.406, 95% CI: [2.3384, 55.632], p = 0.003 for ages 85+. Males were more likely to experience potentially fatal injuries compared to females (OR = 3.384, 95% CI: [1.7376, 6.592], p < 0.001). Additionally, having a fall history in the last year (OR = 2.494, 95% CI: [1.2638, 4.923], p = 0.008) and poor vision compared to excellent vision (OR = 2.51, 95% CI: [1.2408, 5.078], p = 0.01) significantly increased the odds of a fall with potentially fatal injuries. This analysis highlights that age, gender, fall history, and vision are significant predictors of more severe falls.
Discussion
The results of this study are in general agreement with the global research on falls among older adults. However, our results confirm the existence of variations in fall prevalence rates by geographical location, reflecting various cultural and behavioural risk factors; particularly in countries where fall prevention services are primarily lacking. To our knowledge, this study is the first to explore the characteristics of falls among older individuals in the State of Kuwait.
The results of this study showed that most falls (67.1%) were among native Kuwaitis, while 32.9% were sustained by those of other nationalities. Environment, living arrangements, culture, awareness, and knowledge are some factors that might explain the cause of this variation in fall incidence rate, as it either increases or decreases fall risk factors. However, the results of this study resemble the Ministry of Health statistics that state that the Kuwaitis use the health care facilities more than the non-Kuwaitis (38).
According to the NDNQI, all reported fall admissions resulted in major injuries that ranged from temporary impairment to potentially fatal injuries. Fractures of the proximal femoral comprised the majority of the injuries (44.8%), reflecting similar trends reported elsewhere (18, 27, 39). The alarming rate of fall-related fractures places a significant economic burden on governmental services by overloading medical and surgical staff, overusing ancillary services, and increasing lengths of stay in hospitals (39, 40). In addition, fractures disrupt physical independence, restrict activities, and potentially contribute to further falls (22, 23, 41). Additionally, some studies have observed changes in functional status after hospitalisation and difficulty performing ADLs; individuals with decreased motor mobility demonstrate higher mortality and falling risk (42-44). Long hospital stays are associated with a higher likelihood of persistent self-reported disability and loss of independence in ADLs (45, 46). Establishing fall prevention programmes would surely reduce the undesired consequences of falls;
Our results confirm that the highest rate of falls was among those reported to be independent (83.4%), while a lower rate of falling was found among the older age group (7.4% aged 85+). Usually, it is the older age group who are more dependent on caregivers, who must ensure the application of fall-prevention measures for their clients, which can eventually reduce the fall rate among the older age group (47).
Surprisingly, our findings indicated a higher fall rate among individuals from 55–64 (32.7%) and 65–74 (35.3%) years old, who appeared younger in age but might have had significantly accelerated age-related changes in health. Older adults are vulnerable to the physical, sensory and cognitive changes associated with ageing (17, 18, 43). These changes can silently and progressively affect balance, strength and, eventually, mobility, the deterioration of which can not only increase the risk of a fall but also increase the severity of falls (17, 18, 41). In addition, the existence of several associated risk factors, such as high physical inactivity levels (81.5%) and prevalent environmental hazards (81.3%) could lead to more severe future falls among relatively young, independent older people (48- 50).
This interpretation was further supported by the statistically significant association found, which confirmed that more competent older people aged 55–74, those with no fall history, patients with a medical history of a chronic condition, individuals with fair vision and those with no polypharmacy effect were found to be significantly associated with fall-related injury severity.
This may be related to a combination of environmental, ethnic, cultural as well as social factors that may cause variation in the protection and precautions taken by the families for their elderly individuals (51). For example, culturally and ethnically; older adults in Kuwait are treated with upmost respect, are highly cared for throughout the day and are under constant watched and received upmost help when needed. Thus, being in such family support system and attitudes may have lessen the falling rate among older individuals in this study and limits the history of falls. Nevertheless, even one fall could be severe enough to cause adverse outcomes and history of fall still found to be a predictor of future falls with more severe injury. The result of this study would draw the stakeholder’s attention to empower family caregivers role in the management and reduction of the risk of falling in older adults to those lack a strong family support while highlighting the important risk factors that we should consider when developing culturally specific interventions (52) (e.g. focusing on age, rather than falls history, and other risk factors that may predispose individuals to the risk of falling). We strongly believe that a cross cultural social and ethnicity merit future investigation.
Furthermore, giving further specification to the type and severity of the pre-existing health condition and type of medication taken could justify the co-occurrence of the association between the severity of falls injury and the pre-existing chronic condition with the lack of this association with polypharmacy. For example, some medications might be with beneficial effect in the treatment of osteoporosis and/or potentially decrease the risk of falling and fractures might also be included in the concept of polypharmacy (53). Around 81.3% of all severity was significantly associated with environmental hazards, such as uneven or slippery floors. This should highlight the importance of prioritizing the efforts of raising public awareness of the importance of environmental modifications to prevent falls especially within the context of limited fall prevention services.
The multinomial logistic regression revealed that being aged 55 and above could predict more severe injury following a fall. Despite the higher fall rate among females which was also reported in several studies of reported falls (22, 23, 48, 54), our study found that older male individuals are 3.3 times likelier to have more severe injuries if they fall. Furthermore, having a previous fall history is a predictor of more severe future falls. This finding should direct governmental attention to developing a preventive strategy among older individuals.
Adequately identifying the target population at higher risk of falling and sustaining severe injuries should be the key element on which public health policies and programmes should focus. Therefore, interventions should focus on raising health awareness among all age groups while focusing on competent people in the transitional stage to older adulthood.
This study has some limitations. Given the variation in contexts, levels of national representation and methodologies employed in previously reported fall studies, it is difficult to productively compare their results to our findings. Moreover, the registration system in Kuwait relies on a manual fall recording system, where the word ‘fall’ is manually added to the records; hence, some falls may have been missed because the presentation was not recorded as a fall.
Another limitation was the inability to account for the recurrence of falls among older adults and determine their causes, as such data were not included in the recording system. Therefore, a more rigorous recording system is needed. Finally, the data collected in this study were obtained from only one major orthopaedic hospital in Kuwait City and therefore do not account for falls in other hospitals or falls occurring elsewhere in the community that did not lead to medical care.
Conclusion
The results of this study quantify the incidence of reported falls observed at a specialist orthopaedic tertiary care hospital in Kuwait City for the first time. This study highlights the need to implement intervention programmes that prevent falls and fall-related injuries in the clinical setting within the wider package of health and social care for older people. Preventing falls should be a government priority, as it can provide longer-term quality of life to the older population, reduce costs to the healthcare system and lighten the burden on families.
Ethical approval: This study is approved by the Ministry of Health-Kuwait (Project ID: 1869/2021).
Funding: This research did not grant any external fund and was self-funded by the authors
Acknowledgment: The authors thank Dr. Matteo Cesari, scientist (geriatric and gerontology) Ageing and Health Unit, Department of Maternal, New borne, Child and Adolescent Health and Aging, World Health Organization (WHO) for helpful comments and valuable edits on this work. We also thank Hessa Bokhowa, Shaimaa Alnashmi Lolwa Allahdan and J.Wincy Rubarani for their valuable effort in facilitating and contributing to collecting the data of this research.
Conflicts of Interest: The named authors of this research have no conflicts of interest to declare.
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