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Falls in the institutionalized elderly in Japan
Arch. Geranto£ Geriatr., 5 (1986) 1-9 Elsevier AGG 00130
Falls in the institutionalized elderly in Japan Hiroshi Haga a . , Hiroshi Shibata b Keiko Shichita a Toshihisa Matsuzaki a and Shuichi Hatano c o Department of Epidemiology and b Department of Project Research, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan; ¢ Department of Epidemiology, The Institute of Public Health, Tokyo, Japan (Received 18 July 1985: accepted 20 September 1985)
Summary Falls can be considered a vital factor in impeding successful aging in the elderly. The purpose of the study is to know rates of falls per year among the elderly, to observe the situations when falls occurred, and to clarify the association of falls with physical deterioration. The survey was carried out in 1406 residents aged 65 and over of the Tokyo Metropolitan Home for the Elderly in 1982. The rate of subjects who fell more than once during a one-year period was 14.5~$. Females had a higher rate than males. Sixty per cent of all the falls occurred indoors. As for the cause of the falls, extrinsic factors were accounted three times as much as intrinsic factors. Among injuries sustained by the falls, fracture was more frequent in females than in males. Length of time of standing on one le8 was shorter for railers than for non-railers in both sexes. However, the differences were not significant when age was controlled. Fall is attributed not only to physical factors but also to environmental factors. Therefore, it should be encouraged to design an environment with devices. falls: the elderly: rate: cause: injury
Introduction Accident is a frequent cause of death among the elderly. According to the Vital Statistical of Japan (Ministry of Health and Welfare, 1983) in 1981, approximately one-third of all deaths caused by accidents occurred in the aged of 65 years and over. The death rate due to accident among those of 65 and over was 82.5 per 100000. Of these, death by fall was the second most frequent cause, traffic fatalities being the first in number. This observation suggests that many elderly fall, though without fatal result. Fall is not only a cause of death (Hogue, 1982; Wild et al., 1981); repeated falls, or injuries sustained as a result of a fall (e.g. hip fracture) may diminish the quality of life among the elderly by putting limitations to their mobility and life style, in other words, fall can be considered a vital factor in impeding * Correspondence and requests for reprints should be addressed to Mr. Hag& Department of Epidemiology, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakaecho, Itabashi, Tokyo 173. Japan. 01674943/86/$03.50 © 1986 Elsevier Science Publishers B.V. (Biomedical Division)
successful aging in the elderly. Though a great amount of technology and knowledge is necessary to prevent falls among the elderly, there is at present in Japan almost no study or research being done on the subject. The purpose of the present study is three-fold: (1) to know the rate of fall over a 1-year period among residents of a home for the elderly according to age and sex group; (2) to observe the cause, time and location of a fall, and then to observe the site and degree of injury suffered, and (3) to clarify the association of fall and degree of physical decline, as indicated by time of standing on one leg.
Materials and Methods
The present survey was carried out in 1982. Subjects were all the residents aged 65 years and over of the Tokyo Metropolitan Home for the Elderly (excluding those then hospitalized). Of a total of 1 406 subjects, 552 were males (39.370) and 854 were females (60.770); average age was 74.8 and 77.1, respectively (Table I). The Home surveyed is an institution for elderly who are independently carrying out their daily activities but who are, for one reason or another (insufficient means, no living relations etc.), unable to live on their own. The subjects were questioned on falls, and the times of standing on one leg were measured. The questionnaire included the following: sex, age, history of falls during the past year, time of fall, location of fail, cause of fail, site of injury, and degree of injury. In cases where the subject had fallen more than twice in a year, there were questions regarding the fall that resulted in the most serious injury. Three classifications of cause of fall were proposed: due to environmental factors (extrinsic), due to the subject him/herself (intrinsic), and origin unknown. Extrinsic cause includes such things as tripping, slipping, colliding with obstacles, loss of footing on a staircase. Intrinsic cause includes dizziness, vertigo, and drop attack. Standing on one leg was adopted as a general indicator of the muscle strength of the lower extremities, the function of the central nervous system, and the sense of equilibrium. Standing on one leg was done with the eyes open, one leg raised and bent at the knee at an angle of approximately 90 degrees. The duration of time when
TABLE i Age distribution of subjects by sex Age
Males
(years)
number
Females
65-69 70-74 75 -79 80- 84 85-
120 148 154 88 42
21.7 26.8 27.9 15.9 7.6
117 202 222 208 105
13.7 23.7 26.0 24.4 12.3
237 350 376 296 147
16.9 24.9 26.7 21.1 10.5
Total
552
100.0
854
100.0
1406
100.0
•
number
Both sexes %
number
this posture can be maintained was measured. However, the test was stopped at 60 sec at maximum. Statistical methods used were the chi-square test for rate of fall and analysis of variance for the time of standing on one leg,
Results The rate of subjects who fell more than once during a 1-year period is shown according to age and sex in Table It. Females showed a significantly higher rate of falls than males, 16.2% to 12.0% (p--0.035). This tendency towards a high rate among females was observed in all age groups with the exception of the group aged 80-84. Rate of falls by age group was as follows: 70-74 showed the lowest rate: age groups 75-79, 80-84 showed a rise in the rate accompanying aging; age group 85 and over showed a slight decrease. Rate of falls for the youngest group, age 65-69, was located intermediate between that of ages 70-74 and 75-79. The significant difference of the rate by age group was found in males (p -~ 0.037) and in both sexes combined ( p = 0.035). The most common time of falls was in the afternoon, followed by the morning. Approximately two-thirds of all falls occurred during these periods (Table lit). The time.s of falling were slightly different between males and females. Males tended to fall during the period from afternoon to evening, while females tended 1o fall from before breakfast until the morning. Fall at night was the least common, 4.5~ for males and 4.3% for females. Table IV shows the distribution of the location of falls. Fall indoors was more frequent than fall outdoors. Among indoor locations, fall in the hallway, living room, on the stairs, or in the vestibule was relatively frequent. Among outdoor locations, fall on flat roads and in the garden was frequent. These characteristics were almost the same for both males and females. Further, falls among the youngest age group occurred more frequently outdoors (51.6%) than indoors (48.4%). On the other hand, falls among the oldest group were more likely to occur indoors (68.0%) than outdoors (32.0%).
TABLE !! Annual rate of falls by age and sex
Age
Males
(years)
number
%
Females
65-69 70-74 75-79 80-84 85-
12 13 16 19 6
10.0 8.8 10.4 21.6 14.3
19 25 37 38 19
16.2 12.4 16.7 18.3 18.1
31 38 53 57 25
13.1 10.9 14.1 19.3 17.0
Total
66
i 2.0
138
16.2
204
14.5
"number
Both sexes %
number
%
4
TABLE Iii Relative frequency of falls by the time of day Time of day
Males
Females
(No.) Before breakfast in the morning In the afternoon In the evening At nisht All falls
~
9.1 27.3 47.0 12.1 4.5 100.0
Both sexes
(No.)
~o.)
19.6 36.2 32.6 7.2 4.3 (66)
100.0
16.2 33.3 37.3 8.8 4.4
(138)
100.0
(204)
F o r cause o f falls, extrinsic factors were accounted three times as much as intrinsic factors (Table V). Almost no differences were observed between males and females in this respect. Table VI shows the degree o f injury suffered at a fall. Subjects w h o suffered from some sort of injury as a result of falls were 68.1~ of the total w h o experienced fall. Injury was classified in two categories, major injury and minor injury. Major injury refers to an injury that required the immediate attention o f a physician. The relative frequency o f major and minor injuries was 17.6~ and 50.5~, respectively. Major injury was more c o m m o n in males than in females; however, a m o n g major injuries, females surpassed males in the category of fracture. T h e relation of degree o f injury
T A B L E IV Location of falls
Location
Males
Indoor vestibule living room toilet bath room washing room dining room hallway stairs
53.0
Outdoor garden road slope step other All falls
(35)
6.2 9.2 3.1 3.1 3.1 3.1 15.4 6.2
other
47.0 12.3 23.1 1.S 0.0 9.2
~
(No.)
63.0
(87)
7.2 12.3 3.6 1A 2.9 3.6 13.8 9.4 8.7
4,6
100.0
Both sexes
Females
(No.)
(31)
37.0
100.0
(No.)
59.8
(122)
6.9 11.4 3.4 2.0 3.0 3.4 14.3 8.4 7.4
(5|)
7.2 23.2 2.9 0.7 2.9 (66)
~
40.2
(82)
8.9 23.2 2.5
0.5 4.9 (138)
100.0
(204)
TABLE V Cause of falls Cause
Females
Males
(No.) Extrinsic Intrinsic Unknow
71.2 24.2 4.6
All falls
100.0
Both sexes
%
(No.)
75.4 23.9 0.7
(No.)
74.0 24.0 2.0
100.0
(66)
~
(138)
100.0
(204)
TABLE Vi Injury caused by falls
(No.) No injury
30.3
Minor injury wound twist bruise other
48.5
Major injury fracture trauma unconsciousness
21.2
All falls
Both sexes
Females
Males
~
(20)
32.6
(32)
51.5
18.2 10.6 18.2 1.5
(45)
31.9
(71)
50.5
13.8 10.9 26.1 0.7 (14)
15.9
7.6 9.1 4.5 100.0
(No.)
(No.)
(65) (103) 15.2 10.8 23.5 1.0
(22)
17.6
10.1 2.9 2.9 (66)
100.0
(36) 9.3 4.9 3.4
(138)
100.0
(204)
TABLE Vii Injury by ase and location of falls No injury
Minor injury
Major injury
All falls
(No.) Ase (years) 65-69 70-74 75-79 80-84 85-
32.3 31.6 35.8 26.3 36.0
48.4 52.6 47.2 54.4 48.0
19.4 15.8 17.0 19.3 16.0
100.0 100.0 100.0 100.0 100.0
(31) (38) (53) (57) (25)
Location of falls indoor outdoor
31.1 32.9
54.1 45.1
14.8 22.0
100.0 100.0
(122) (82)
6
TABLE VIII Site of injury by sex Site
Males
7o Head and face Breast Shoulder Elbow Wrist and fingers Upper extremities Back Low back Buttocks Hip Knee Lower extremities Ankle and toes Other Total
Both sexes
Females
(No.)
28.3 4.3 2.2 4.3 15.2 2.2 0.0 4.3 0.0 4.3 8.7 6.5 6.5 13.0
7o
(No.)
7~
13.6 6.3 3.1 1.0 3.1 4.2 5.3 15.8 3.1 1.1 20.0 3.1 10.5 7.4
100.0
(46)
100.0
(No.)
18.7 5.8 2.9 2.2 7.2 3.6 3.6 12.2 2.2 2.2 16.5 4.3 9.4 5.0 (93)
100.0
(139)
suffered in a fall to age o r l o c a t i o n o f fall is given in T a b l e VII. M a j o r injury was the lowest a m o n g the age g r o u p o f 7 0 - 7 4 years. A rise in m a j o r injury a c c o m p a n y i n g a g i n g was found, except in age g r o u p 85 a n d over. A g e s 85 a n d over showed a decrease. T h e rate o f m a j o r injury in the y o u n g e s t g r o u p was o b s e r v e d to b e as high as t h a t of age g r o u p 8 0 - 8 4 . M a j o r injury, in "general, occurred m o r e frequently o u t d o o r s t h a n indoors. T h e site o f injuries suffered in falls was a n a l y z e d a c c o r d i n g
TABLE IX Average time (SE) of standing on one leg by age and sex Failer
Non-failer
sec.
mean SE
Males 65-69 70--74 75-79 80-84 85Total
13.7 14.6 9.6 4.8 3.5 9.3
(5.3) (6.6) (5.0) (2.3) (2.5) (2.1)
Females 65-69 70-74 75-79 80-84 85Total
24.1 15.9 7.8 3.5 2.7 9.3
(5.6) (4.3) (2.4) (1.0) (1.1) (1.4)
No.
Total
see.
mean SE
No.
sec.
mean SE
No.
12 11 16 18 6 63
26.0 16.5 14.0 8.6 6.7 16.0
(2.5) (1.9) (1.7) (1.9) (2.3) (1.0)
103 129 135 66 36 469
24.7 16.3 13.5 7.8 6.2 15.2
(2.3) (1.8) (1.6) (1.6) (1.9) (0.9)
115 140 151 84 42 532
16 22 36 36 18 128
25.3 19.5 8.6 6.2 4.6 12.3
(2.6) (1.6) (0.9) (0.8) (1.2) (0.7)
85 167 175 167 84 678
25.1 19.1 8.4 5.7 4.3 11.8
(2.3) (1.5) (0.9) (0.7) (1.1) (0.6)
101 189 211 203 102 806
to sex (Table Vlll). Among males, the most common site was the head and face, followed by the wrist and fingers, and the knee. Females most commonly injured the knee, the low back, the head and face, and the ankle and toes. As these figures show, males characteristically were injured from the hips up, while females tended to suffer injuries from the hips down. Table IX shows the average time for standing on one leg for both railers and non-fallen. The average time declined significantly with aging in both males and females ( p < 0.001). Regardless of sex, the duration of standing on one leg showed a tendency to be shorter among railers than among non-railers, in all age groups. Difference in average time between all railers and non-railers was significant only in males ( p -- 0.005). However, the difference between railers and non-railers in males did not reach a significant level when the effects of age were controlled using analysis of variance ( p ffi 0.081).
Discussion
The present survey of persons aged 65 years and over, living in a Home, found 14.5~ of railers among all the subjects during a year. Campbell et al. (1981) and Prudham and Evans (1981) reported rates of fall during a 1-year period among elderly aged 65 years and over, living in a community, of 34~ and 28~, respectively. The rate of the present survey is lower than that of the above reports, and this difference exists even when viewed from the point of age specifically. The difference may be derived from a difference of samples; the subjects of the present survey lived in a Home, while those of the other surveys rived in a community. A Home for the elderly is designed with the prospect to decrease the possibility of falls; this is not always true in the case of a private home. Further, older people riving in a community may have a higher level of activity, both indoors and outdoors, than those in a home, and so may be more liable to falls. There might be a basic difference in the rates of falls between Japan and a western country. However, as no survey of the elderly living in a community has yet been undertaken in Japan, this remains debatable. Females had a higher rate of fails than males, and this tendency corresponds with the data of other researchers (Prudham and Evans, 1981; Gryfe et al., 1977) Stout (1978) suggests that the reason why females are more prone to fall than males is due to muscle weakness. The present survey found that, excluding the age group 65-74, females were inferior to males in duration of standing on one leg. The rates of falls according to age group revealed an increase accompanying aging in the age range 70-84 for both males and females. However, there was a slight decrease in age group 85 and over. The youngest group, ages 65-69, showed an even higher frequency than age group 70-74. The relatively high rate of the youngest group may reflect a particular characteristic of this subpopulation; in other words, those entering a Home while still young possess an unusual amount of physical, emotional, and social disability (Gryfe et al., 1977). The reason for the low rate of falls in the hiahest aae arouo. 85 and over. is considered due to memory
decline which affects their reporting, and to lessened likelihood of encountering a potentially dangerous situation as a result of a diminished sphere of activity. Classification of time of falls: before breakfast, in the morning, in the afternoon, in the evening, were adopted because the elderly have difficulty in remembering precise time. Roughly 70~ of all falls occurred during the active time of morning and afternoon. Rodstein (1964) reported that the active time period of the day is when falls are most likely to occur. On the other hand, among groups older than those observed in the present survey, the rate of falls was found to be similar between active time and inactive time (Ashley et al., 1977). Sixty per cent of all falls occurred indoors in the present survey. Ashley et al. (1977) reported a rate of 94~ in indoor falls. These data suggest the need to design an environment with devices for preventing falls. The cause of falls is difficult to assess. Tideiksaar (1984) states that "the fall results from a combination of the 'normal' aging process, pathologic status, medications, and environmental conditions". The present survey adopted the rough classifications of extrinsic, intrinsic, and cause unknown. These classifications were considered to be the limits of the present survey on the basis of retrospective method. A prospective survey is necessary in order to obtain more precise data. This means obtaining information on the fall as soon as possible after the fall, not only from the failer, but also from eyewitnesses and the staff of the Home. Further, it is vital to obtain information from the failer's family physician as to the failer's normal state of health and use of medication. Degree of injury resulting from falls showed percentages of 32 for no-injury, of 50 for minor injury, and of 18 for major injury, in the present study. The relative frequency corresponds to that given by Gryfe et al. (1977). However, Kalchthaler et al. (1978) found a frequency rate of 38~ of major injury in their survey of a nursing home. The above two surveys found the highest rate of major injury among the oldest group; however, the present survey found the highest rate among the youngest group. As stated previously, this is probably due to the poor health condition of the youngest group. The length of time of standing on one leg is an indicator of the muscle strength of the lower extremities, the function of the central nervous system, and the sense of equilibrium. The value declined with age. In both males and females, length of time was shorter for railers than for non-railers, however, the significant difference was found only in males. The difference among males was not significant when age was controlled by using analysis of variance. Physical deterioration as reflected by time of standing on one leg probably contributes to falls among the elderly, however, one cannot explain falls as due only to physical factors, because many other factors must be related to fall in the elderly.
Acknowledgments The authors are grateful for the help of Mrs. Nagai H. and Mr. Suyama Y. in the Department of Epidemiology, Tokyo Metropolitan Institute of Gerontology.
References Ashley M.J., Oryfe C.I. and Amies A. (1977): A Ionsitudinal study of falls in an elderly population. 11. some circumstances of falling. Ase Ageing. 6, 211-220. Campbell AJ., Reinken, J., Allen B.C. and Martinez G.S. (1981): Fall in old abe: a study of frequency and related clinical factors. ABe Ageing. 10, 264-270. Gryfe C.I., Amies A. and Ashley M.J. (1977): A Ionsitudinal study of falls in an elderly population: 1. Incidence and morbidity. ABe Ageing. 6, 201-210. Hogue C.C. (1982): Injury in late life. Part I, Epidemiolosy. J. Am. Geriatr. Soc., 30, 183-190. Kalchthaler, T., Bascon R.A. and Quintos v. (1978): Falls in the institutionalized elderly. J. Am. Geriatr. Sot., 26, 424-428. Ministry of Health and Welfare (1983): Vital Statistics 1981 Japan. Tokyo, Vol. 3, 272 pp. Prudham D, and Evans J.G. (1981): Factors associated with falls in the elderly: a community study. Age Ascing . 10, 141-146. Rodstein M. (1964): Accidents amon8 the aged: incidence, causes and prevention. J. Chron. Dis., 17, 515-526. Stout R.W. (1978): Falls and disorders of postural balance. ABe Ageing. 7, Suppl., 134-136. Tideiksaar R. (1984): An assessment form for falls. J. Am. Geriatr. Soc., 32, 538-539. Wild D., Nayak U.S.L. and isaacs B. (1981): How danserous are falls in old people at home.'?Br. Med. J., 282, 266-268.
Falls in the institutionalized elderly in Japan Hiroshi Haga a . , Hiroshi Shibata b Keiko Shichita a Toshihisa Matsuzaki a and Shuichi Hatano c o Department of Epidemiology and b Department of Project Research, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan; ¢ Department of Epidemiology, The Institute of Public Health, Tokyo, Japan (Received 18 July 1985: accepted 20 September 1985)
Summary Falls can be considered a vital factor in impeding successful aging in the elderly. The purpose of the study is to know rates of falls per year among the elderly, to observe the situations when falls occurred, and to clarify the association of falls with physical deterioration. The survey was carried out in 1406 residents aged 65 and over of the Tokyo Metropolitan Home for the Elderly in 1982. The rate of subjects who fell more than once during a one-year period was 14.5~$. Females had a higher rate than males. Sixty per cent of all the falls occurred indoors. As for the cause of the falls, extrinsic factors were accounted three times as much as intrinsic factors. Among injuries sustained by the falls, fracture was more frequent in females than in males. Length of time of standing on one le8 was shorter for railers than for non-railers in both sexes. However, the differences were not significant when age was controlled. Fall is attributed not only to physical factors but also to environmental factors. Therefore, it should be encouraged to design an environment with devices. falls: the elderly: rate: cause: injury
Introduction Accident is a frequent cause of death among the elderly. According to the Vital Statistical of Japan (Ministry of Health and Welfare, 1983) in 1981, approximately one-third of all deaths caused by accidents occurred in the aged of 65 years and over. The death rate due to accident among those of 65 and over was 82.5 per 100000. Of these, death by fall was the second most frequent cause, traffic fatalities being the first in number. This observation suggests that many elderly fall, though without fatal result. Fall is not only a cause of death (Hogue, 1982; Wild et al., 1981); repeated falls, or injuries sustained as a result of a fall (e.g. hip fracture) may diminish the quality of life among the elderly by putting limitations to their mobility and life style, in other words, fall can be considered a vital factor in impeding * Correspondence and requests for reprints should be addressed to Mr. Hag& Department of Epidemiology, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakaecho, Itabashi, Tokyo 173. Japan. 01674943/86/$03.50 © 1986 Elsevier Science Publishers B.V. (Biomedical Division)
successful aging in the elderly. Though a great amount of technology and knowledge is necessary to prevent falls among the elderly, there is at present in Japan almost no study or research being done on the subject. The purpose of the present study is three-fold: (1) to know the rate of fall over a 1-year period among residents of a home for the elderly according to age and sex group; (2) to observe the cause, time and location of a fall, and then to observe the site and degree of injury suffered, and (3) to clarify the association of fall and degree of physical decline, as indicated by time of standing on one leg.
Materials and Methods
The present survey was carried out in 1982. Subjects were all the residents aged 65 years and over of the Tokyo Metropolitan Home for the Elderly (excluding those then hospitalized). Of a total of 1 406 subjects, 552 were males (39.370) and 854 were females (60.770); average age was 74.8 and 77.1, respectively (Table I). The Home surveyed is an institution for elderly who are independently carrying out their daily activities but who are, for one reason or another (insufficient means, no living relations etc.), unable to live on their own. The subjects were questioned on falls, and the times of standing on one leg were measured. The questionnaire included the following: sex, age, history of falls during the past year, time of fall, location of fail, cause of fail, site of injury, and degree of injury. In cases where the subject had fallen more than twice in a year, there were questions regarding the fall that resulted in the most serious injury. Three classifications of cause of fall were proposed: due to environmental factors (extrinsic), due to the subject him/herself (intrinsic), and origin unknown. Extrinsic cause includes such things as tripping, slipping, colliding with obstacles, loss of footing on a staircase. Intrinsic cause includes dizziness, vertigo, and drop attack. Standing on one leg was adopted as a general indicator of the muscle strength of the lower extremities, the function of the central nervous system, and the sense of equilibrium. Standing on one leg was done with the eyes open, one leg raised and bent at the knee at an angle of approximately 90 degrees. The duration of time when
TABLE i Age distribution of subjects by sex Age
Males
(years)
number
Females
65-69 70-74 75 -79 80- 84 85-
120 148 154 88 42
21.7 26.8 27.9 15.9 7.6
117 202 222 208 105
13.7 23.7 26.0 24.4 12.3
237 350 376 296 147
16.9 24.9 26.7 21.1 10.5
Total
552
100.0
854
100.0
1406
100.0
•
number
Both sexes %
number
this posture can be maintained was measured. However, the test was stopped at 60 sec at maximum. Statistical methods used were the chi-square test for rate of fall and analysis of variance for the time of standing on one leg,
Results The rate of subjects who fell more than once during a 1-year period is shown according to age and sex in Table It. Females showed a significantly higher rate of falls than males, 16.2% to 12.0% (p--0.035). This tendency towards a high rate among females was observed in all age groups with the exception of the group aged 80-84. Rate of falls by age group was as follows: 70-74 showed the lowest rate: age groups 75-79, 80-84 showed a rise in the rate accompanying aging; age group 85 and over showed a slight decrease. Rate of falls for the youngest group, age 65-69, was located intermediate between that of ages 70-74 and 75-79. The significant difference of the rate by age group was found in males (p -~ 0.037) and in both sexes combined ( p = 0.035). The most common time of falls was in the afternoon, followed by the morning. Approximately two-thirds of all falls occurred during these periods (Table lit). The time.s of falling were slightly different between males and females. Males tended to fall during the period from afternoon to evening, while females tended 1o fall from before breakfast until the morning. Fall at night was the least common, 4.5~ for males and 4.3% for females. Table IV shows the distribution of the location of falls. Fall indoors was more frequent than fall outdoors. Among indoor locations, fall in the hallway, living room, on the stairs, or in the vestibule was relatively frequent. Among outdoor locations, fall on flat roads and in the garden was frequent. These characteristics were almost the same for both males and females. Further, falls among the youngest age group occurred more frequently outdoors (51.6%) than indoors (48.4%). On the other hand, falls among the oldest group were more likely to occur indoors (68.0%) than outdoors (32.0%).
TABLE !! Annual rate of falls by age and sex
Age
Males
(years)
number
%
Females
65-69 70-74 75-79 80-84 85-
12 13 16 19 6
10.0 8.8 10.4 21.6 14.3
19 25 37 38 19
16.2 12.4 16.7 18.3 18.1
31 38 53 57 25
13.1 10.9 14.1 19.3 17.0
Total
66
i 2.0
138
16.2
204
14.5
"number
Both sexes %
number
%
4
TABLE Iii Relative frequency of falls by the time of day Time of day
Males
Females
(No.) Before breakfast in the morning In the afternoon In the evening At nisht All falls
~
9.1 27.3 47.0 12.1 4.5 100.0
Both sexes
(No.)
~o.)
19.6 36.2 32.6 7.2 4.3 (66)
100.0
16.2 33.3 37.3 8.8 4.4
(138)
100.0
(204)
F o r cause o f falls, extrinsic factors were accounted three times as much as intrinsic factors (Table V). Almost no differences were observed between males and females in this respect. Table VI shows the degree o f injury suffered at a fall. Subjects w h o suffered from some sort of injury as a result of falls were 68.1~ of the total w h o experienced fall. Injury was classified in two categories, major injury and minor injury. Major injury refers to an injury that required the immediate attention o f a physician. The relative frequency o f major and minor injuries was 17.6~ and 50.5~, respectively. Major injury was more c o m m o n in males than in females; however, a m o n g major injuries, females surpassed males in the category of fracture. T h e relation of degree o f injury
T A B L E IV Location of falls
Location
Males
Indoor vestibule living room toilet bath room washing room dining room hallway stairs
53.0
Outdoor garden road slope step other All falls
(35)
6.2 9.2 3.1 3.1 3.1 3.1 15.4 6.2
other
47.0 12.3 23.1 1.S 0.0 9.2
~
(No.)
63.0
(87)
7.2 12.3 3.6 1A 2.9 3.6 13.8 9.4 8.7
4,6
100.0
Both sexes
Females
(No.)
(31)
37.0
100.0
(No.)
59.8
(122)
6.9 11.4 3.4 2.0 3.0 3.4 14.3 8.4 7.4
(5|)
7.2 23.2 2.9 0.7 2.9 (66)
~
40.2
(82)
8.9 23.2 2.5
0.5 4.9 (138)
100.0
(204)
TABLE V Cause of falls Cause
Females
Males
(No.) Extrinsic Intrinsic Unknow
71.2 24.2 4.6
All falls
100.0
Both sexes
%
(No.)
75.4 23.9 0.7
(No.)
74.0 24.0 2.0
100.0
(66)
~
(138)
100.0
(204)
TABLE Vi Injury caused by falls
(No.) No injury
30.3
Minor injury wound twist bruise other
48.5
Major injury fracture trauma unconsciousness
21.2
All falls
Both sexes
Females
Males
~
(20)
32.6
(32)
51.5
18.2 10.6 18.2 1.5
(45)
31.9
(71)
50.5
13.8 10.9 26.1 0.7 (14)
15.9
7.6 9.1 4.5 100.0
(No.)
(No.)
(65) (103) 15.2 10.8 23.5 1.0
(22)
17.6
10.1 2.9 2.9 (66)
100.0
(36) 9.3 4.9 3.4
(138)
100.0
(204)
TABLE Vii Injury by ase and location of falls No injury
Minor injury
Major injury
All falls
(No.) Ase (years) 65-69 70-74 75-79 80-84 85-
32.3 31.6 35.8 26.3 36.0
48.4 52.6 47.2 54.4 48.0
19.4 15.8 17.0 19.3 16.0
100.0 100.0 100.0 100.0 100.0
(31) (38) (53) (57) (25)
Location of falls indoor outdoor
31.1 32.9
54.1 45.1
14.8 22.0
100.0 100.0
(122) (82)
6
TABLE VIII Site of injury by sex Site
Males
7o Head and face Breast Shoulder Elbow Wrist and fingers Upper extremities Back Low back Buttocks Hip Knee Lower extremities Ankle and toes Other Total
Both sexes
Females
(No.)
28.3 4.3 2.2 4.3 15.2 2.2 0.0 4.3 0.0 4.3 8.7 6.5 6.5 13.0
7o
(No.)
7~
13.6 6.3 3.1 1.0 3.1 4.2 5.3 15.8 3.1 1.1 20.0 3.1 10.5 7.4
100.0
(46)
100.0
(No.)
18.7 5.8 2.9 2.2 7.2 3.6 3.6 12.2 2.2 2.2 16.5 4.3 9.4 5.0 (93)
100.0
(139)
suffered in a fall to age o r l o c a t i o n o f fall is given in T a b l e VII. M a j o r injury was the lowest a m o n g the age g r o u p o f 7 0 - 7 4 years. A rise in m a j o r injury a c c o m p a n y i n g a g i n g was found, except in age g r o u p 85 a n d over. A g e s 85 a n d over showed a decrease. T h e rate o f m a j o r injury in the y o u n g e s t g r o u p was o b s e r v e d to b e as high as t h a t of age g r o u p 8 0 - 8 4 . M a j o r injury, in "general, occurred m o r e frequently o u t d o o r s t h a n indoors. T h e site o f injuries suffered in falls was a n a l y z e d a c c o r d i n g
TABLE IX Average time (SE) of standing on one leg by age and sex Failer
Non-failer
sec.
mean SE
Males 65-69 70--74 75-79 80-84 85Total
13.7 14.6 9.6 4.8 3.5 9.3
(5.3) (6.6) (5.0) (2.3) (2.5) (2.1)
Females 65-69 70-74 75-79 80-84 85Total
24.1 15.9 7.8 3.5 2.7 9.3
(5.6) (4.3) (2.4) (1.0) (1.1) (1.4)
No.
Total
see.
mean SE
No.
sec.
mean SE
No.
12 11 16 18 6 63
26.0 16.5 14.0 8.6 6.7 16.0
(2.5) (1.9) (1.7) (1.9) (2.3) (1.0)
103 129 135 66 36 469
24.7 16.3 13.5 7.8 6.2 15.2
(2.3) (1.8) (1.6) (1.6) (1.9) (0.9)
115 140 151 84 42 532
16 22 36 36 18 128
25.3 19.5 8.6 6.2 4.6 12.3
(2.6) (1.6) (0.9) (0.8) (1.2) (0.7)
85 167 175 167 84 678
25.1 19.1 8.4 5.7 4.3 11.8
(2.3) (1.5) (0.9) (0.7) (1.1) (0.6)
101 189 211 203 102 806
to sex (Table Vlll). Among males, the most common site was the head and face, followed by the wrist and fingers, and the knee. Females most commonly injured the knee, the low back, the head and face, and the ankle and toes. As these figures show, males characteristically were injured from the hips up, while females tended to suffer injuries from the hips down. Table IX shows the average time for standing on one leg for both railers and non-fallen. The average time declined significantly with aging in both males and females ( p < 0.001). Regardless of sex, the duration of standing on one leg showed a tendency to be shorter among railers than among non-railers, in all age groups. Difference in average time between all railers and non-railers was significant only in males ( p -- 0.005). However, the difference between railers and non-railers in males did not reach a significant level when the effects of age were controlled using analysis of variance ( p ffi 0.081).
Discussion
The present survey of persons aged 65 years and over, living in a Home, found 14.5~ of railers among all the subjects during a year. Campbell et al. (1981) and Prudham and Evans (1981) reported rates of fall during a 1-year period among elderly aged 65 years and over, living in a community, of 34~ and 28~, respectively. The rate of the present survey is lower than that of the above reports, and this difference exists even when viewed from the point of age specifically. The difference may be derived from a difference of samples; the subjects of the present survey lived in a Home, while those of the other surveys rived in a community. A Home for the elderly is designed with the prospect to decrease the possibility of falls; this is not always true in the case of a private home. Further, older people riving in a community may have a higher level of activity, both indoors and outdoors, than those in a home, and so may be more liable to falls. There might be a basic difference in the rates of falls between Japan and a western country. However, as no survey of the elderly living in a community has yet been undertaken in Japan, this remains debatable. Females had a higher rate of fails than males, and this tendency corresponds with the data of other researchers (Prudham and Evans, 1981; Gryfe et al., 1977) Stout (1978) suggests that the reason why females are more prone to fall than males is due to muscle weakness. The present survey found that, excluding the age group 65-74, females were inferior to males in duration of standing on one leg. The rates of falls according to age group revealed an increase accompanying aging in the age range 70-84 for both males and females. However, there was a slight decrease in age group 85 and over. The youngest group, ages 65-69, showed an even higher frequency than age group 70-74. The relatively high rate of the youngest group may reflect a particular characteristic of this subpopulation; in other words, those entering a Home while still young possess an unusual amount of physical, emotional, and social disability (Gryfe et al., 1977). The reason for the low rate of falls in the hiahest aae arouo. 85 and over. is considered due to memory
decline which affects their reporting, and to lessened likelihood of encountering a potentially dangerous situation as a result of a diminished sphere of activity. Classification of time of falls: before breakfast, in the morning, in the afternoon, in the evening, were adopted because the elderly have difficulty in remembering precise time. Roughly 70~ of all falls occurred during the active time of morning and afternoon. Rodstein (1964) reported that the active time period of the day is when falls are most likely to occur. On the other hand, among groups older than those observed in the present survey, the rate of falls was found to be similar between active time and inactive time (Ashley et al., 1977). Sixty per cent of all falls occurred indoors in the present survey. Ashley et al. (1977) reported a rate of 94~ in indoor falls. These data suggest the need to design an environment with devices for preventing falls. The cause of falls is difficult to assess. Tideiksaar (1984) states that "the fall results from a combination of the 'normal' aging process, pathologic status, medications, and environmental conditions". The present survey adopted the rough classifications of extrinsic, intrinsic, and cause unknown. These classifications were considered to be the limits of the present survey on the basis of retrospective method. A prospective survey is necessary in order to obtain more precise data. This means obtaining information on the fall as soon as possible after the fall, not only from the failer, but also from eyewitnesses and the staff of the Home. Further, it is vital to obtain information from the failer's family physician as to the failer's normal state of health and use of medication. Degree of injury resulting from falls showed percentages of 32 for no-injury, of 50 for minor injury, and of 18 for major injury, in the present study. The relative frequency corresponds to that given by Gryfe et al. (1977). However, Kalchthaler et al. (1978) found a frequency rate of 38~ of major injury in their survey of a nursing home. The above two surveys found the highest rate of major injury among the oldest group; however, the present survey found the highest rate among the youngest group. As stated previously, this is probably due to the poor health condition of the youngest group. The length of time of standing on one leg is an indicator of the muscle strength of the lower extremities, the function of the central nervous system, and the sense of equilibrium. The value declined with age. In both males and females, length of time was shorter for railers than for non-railers, however, the significant difference was found only in males. The difference among males was not significant when age was controlled by using analysis of variance. Physical deterioration as reflected by time of standing on one leg probably contributes to falls among the elderly, however, one cannot explain falls as due only to physical factors, because many other factors must be related to fall in the elderly.
Acknowledgments The authors are grateful for the help of Mrs. Nagai H. and Mr. Suyama Y. in the Department of Epidemiology, Tokyo Metropolitan Institute of Gerontology.
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