PREVALENCE OF FALLS AND ASSOCIATED FACTORS IN VIETNAMESE ELDERLY

It could be said that falls may be a common health problem among Vietnamese elderly, but data about this type of health issue is incomprehensive explored. Several studies showed that the elderly have highest injury incidence ratecompared with other agegroup and falls, which took place in the home, represented a major proportion of injuries among the elderly(Chuan et al., 2001; Hanh, 1999; Hoang, 2004). A recent study found that falls are common injuries among older adults and accountfor the highest proportion of economic costs for their family (Nguyen et al., 2013). However, no study on associated factors for falls within older population has been conducted recently (To et al., 2014).

3.1 ………

3.1.1 ………

3.1.2 Definition of Terms………

3.2 Research Hypotheses………

Chapter 4: Material and Methods 4.1 Study Design………

4.2 Sampling and Setting………

4.3 Research Instruments………

4.4 Research Progress………

4.4.1 Training the Observers………

4.4.2 Pilot study………

4.4.3 Validity and Reliability………

4.4.4 Data Collection ………

4.5 Data Analysis………

4.5.1 Data Screening and Recoding ………

4.5.2 StatisticAnalyses………

4.6 Ethical Consideration………

PREVALENCE OF FALLS AND ASSOCIATED FACTORS

IN VIETNAMESE ELDERLY

Chapter 1: Introduction

1.1 Statement of the Problem

With the rapid ageing of the world’s populations, falls in older adults are asignificant public health issue More than one third of persons 65 years of age orolder fall each year, and in half ofsuch cases the falls are recurrent(Nevitt,Cummings, Kidd, & Black, 1989; Tinetti, Speechley, & Ginter, 1988).The risk offalling and fall-related injury proportionately increases as older adults age Indeed,

it is estimated that about 28-35% of people aged of 65 and over fall each year(Blake & et al, 1988), whereas 32-42% of older over 70 years of age experiencefalling in their life (Downton & Andrews, 1991; Stalenhoef & et al, 2002) The rate

of falling is vary from 20% in Japanese older (Yoshida & Kim, 2006) to 21.6% inBarbados and 34% in Chile (Reyes-Ortiz, Al-Snih, & Markides, 2005)

Falls among older adults cause serious consequences to their health andquality of life and shoulder heavier costs of health care onto their family as well.Approximately 1 in 10 falls results in a seriousinjury, such as hip fracture, otherfracture, subdural hematoma, other serious softtissue injury, or head injury(Nevitt,Cummings, & Hudes, 1991; Sattin, 1992; Tinetti, Doucette, Claus, & Marottoli,1995).Falls account for approximately 10 percent of visits tothe emergencydepartment and 6 percent of urgent hospitalizations among elderly persons(Runge,1993; Sattin, 1992) Many longitudinal studies indicated that elderly with fall-relate hospitalization have to pay higher health care cost than nonfallers(Bohl etal., 2010 ; Craig et al., 2013 ; Dubey, Koval, & Zuckerman, 1998; Finkelstein &Miller, 2006; Hartholt et al., 2011 )

1.2 Problem: Background and Significance

Although recognized as a young population, Vietnam is now enter the

“aging phase” in its population growth Historically, only 3.71 million older adultsover 60 years was reported in 1979, but the number increased by the time from4.64 million in 1989 to 7.8 million in 2006 (General Statistics Office, 2007) Theprojected number of elderly in 2020 will be more than 12 million and theproportion of older population is estimated to be 26.1% by 2050 (United Nations,2007b)

Like any older individual in other countries, Vietnamese elderly have tosuffer not only physical impairment due to their old age but also illnesses,especially non-communicable diseases Most of the elderly have to cope with non-contagious and chronic diseases such as joint degradation, cardiac problems andblood pressure, prostate, and urination disorders (United Nations, 2007a) Inaddition, risks of disability are also high for the Vietnamese elderly, particularly interms of vision and hearing

It could be said that falls may be a common health problem amongVietnamese elderly, but data about this type of health issue is incomprehensiveexplored Several studies showed that the elderly have highest injury incidenceratecompared with other age-group and falls, which took place in the home,represented a major proportion of injuries among the elderly(Chuan et al., 2001;Hanh, 1999; Hoang, 2004) A recent study found that falls are common injuriesamong older adults and accountfor the highest proportion of economic costs fortheir family (Nguyen, Ivers, Jan, Martiniuk, & Pham, 2013) However, no study onassociated factors for falls within older population has been conducted recently (To

et al., 2014)

1.3 Statement of Purpose

To provide more data on fall prevalence and associated factors for fallsamong older adults, I conduct this study There are two objectives must beachieved in this study:

1 Evaluating the fall prevalence among institutionalized older adults

2 Identifying associated factors involving to falls among institutionalized olderadults

Chapter 2: Literature Review

2.1 Definition of fall

Falls are commonly defined as inadvertently coming to rest on the ground,floor or other lower level, excluding intentional change in position to rest infurniture, wall or other objects.The adoption of a definition is an importantrequirement when studying falls as many studies fail to specify an operationaldefinition, leaving room for interpretation to study participants This results inmany different interpretations of falls(Zecevic & et al, 2006) For example, olderpeople tend to describe a fall as a loss of balance, whereas health care professionalsgenerally refer to events leading to injuries and ill health Therefore, theoperational definition of a fall with explicit inclusion and exclusioncriteria ishighly important

2.2 Epidemiology of falls among elderly

2.2.1 The prevalence and mortality offall among older age

Among older adults, the risk of falling and fall-related injury is known toincrease withincreasing age Approximately 28-35% of people aged of 65 and overfall each year (Blake & et al, 1988)increasing to 32-42% for those over 70 years ofage(Downton & Andrews, 1991; Stalenhoef & et al, 2002) Approximately 30-50%

of people living in long-term care institutions fall each year, and 40% of themexperienced recurrent falls (Tinetti, 1987)

Given incidence of falls it varies among countries The annual incidence offalls in China was estimated to 6-31% (Gang & Sufang, 2006; Liang, Y., & X.,2004)while in Japan was 20%(Yoshida & Kim, 2006) Some countries in region ofthe Americas reported the proportion of elderly feltannually ranging from 21.6% inBarbados to 34% in Chile (Reyes-Ortiz et al., 2005)

2.2.2 The consequences of falls among elderly

Falls among older adults represent a major public healthproblem associatedwith increased morbidity, mortality, and health care costs Approximately 10%-15% of falls resultin a major injury such as a fracture, serious soft tissueinjury, ortraumatic brain injury (Orces, 2014; Tinetti & Williams, 1997) Previous studieshavedemonstrated that fall-related fractures treated in hospitalemergencydepartments and hospitalizations for fall-relatedinjuries are increasing among olderadults in developedcountries (Hartholt, Stevens, Polinder, van Der Cammen, &Patka, 2011; Hartholt, van der Velde, Looman, & et al, 2010; Orces, 2013).Overall, 44.2% of adults aged 65 years orolder with fall-related fractures requirehospitalization andhip fractures account for 48% of the hospitalizations forfallrelated injuries among women (Hartholt et al., 2010; Orces, 2013).Falls are alsoassociated with restricted mobility; a decline in the ability to carry out activitiessuch as dressing, bathing, shopping, or housekeeping; and an increased risk ofplacement in a nursing home(Kosorok, Omenn, Diehr, & et al, 1992; Tinetti &Williams, 1998)

The mortality of falls varies widely among countries Fall fatality rate forpeople aged 65 and older in United States is 36.8 per 100,000 population(Stevens

& et al, 2007)whereas in Canada mortality rate for the same age group is 9.4 per10,000 population (Division of Aging and Seniors & PHAC Canada, 2005).Rates

of fatal falls among men exceed that of women for all age groups and this isattributed to the fact that men suffer from more co-morbid conditions than women

of the same age (Stevens & et al, 2007) One study found that men reported poorerhealth and a greater number of underlying conditions than women, whichsubstantially increased the impact of hip fracture and consequently increased therisk ofmortality (Fransen & al, 2002)

Not only causing injuries and mortality in elderly, falls also cause highhealthcare cost to older patients A longitudinal analysis of total 3-year healthcarecosts for older adults who experience a fall requiring medical care showed thatfallers are sought resulted in higher costs than for nonfallers for up to 12 monthsafter a fall, particularly for falls requiring hospitalization(Bohl et al., 2010 ) Astudy conducted in Scotland found that the health care cost for falling elderly wereover £470 million, with 60% incurred by social services, mainly providing long-term care Cost per person falling was over £1720, rising to over £8600 for thoseseeking medical assistance A hip fracture admission cost £39,490, compared with

£21,960 for other falls-related admissions(Craig et al., 2013 ) In Dutch, fallsamong older adults led to a total healthcare cost of €474.4 million, whichrepresents 21% of total healthcare expenses due to injuries(Hartholt et al.,

2011 ).In American, the direct medical costs associated with fall-relatedinjurieswere approximately $19 billion (Finkelstein & Miller, 2006) and are projectedtorise as the population ages (Dubey et al., 1998)

2.2.3 Main risk factors for falls

Although a few falls have a single cause, the majority occur as a result of acomplex interaction of risk factors.The risk of falling consistently increases as thenumber of these risk factors increases(Nevitt et al., 1989; Tinetti et al., 1988).Therisk of falling increased in a cohort of elderly persons living in the community,forexample, from 8 percent among those with no risk factors to 78 percent amongthosewith four or more risk factors(Tinetti et al., 1988) Those are categorized intofivedimensions: biological, behavioural, environmental, personal andsocioeconomic factors(World Health Organization, 2007)

Biological risk factors

Biological factors embrace characteristics of individuals that are pertaining

to the human body For instance, age, gender and race are non-modifiablebiological factors These are also associated with changes due to ageing such as thedecline of physical, cognitive and affective capacities, and the co-morbidityassociated with chronic illnesses

Women are more likely than men to fall and sustain fracture (Stevens & et

al, 2006), resulting in twice more hospitalizations and emergency department visitsthan men (Hendrie & et al, 2003) The reasons for these differences may comefrom gender-related factors such as women being inclined to make greater use ofmultiple medications and living alone (Ebrahim & Kalache, 1996), women'smuscle mass declines faster than that of men, especially in the immediate fewyears after menopause, and to some extent women are less likely to engage into thepractice of muscular building physical activities (e.g sports, exercises) though thelife course

On the other hand, fall-related mortality disproportionately affects men morethan women That is attributed from health seeking behavior differs according togender Generally, men are not try to seek medical care until a condition becomessevere, resulting in substantial delay to the access to prevention and management

of diseases In addition, men are more likely to be engaged in intense anddangerous physical activity and risky behaviors – such as climbing high ladders,cleaning roofs or ignoring the limits of their physical capacity

Although the relationship between falls and ethnicity and race remainswidely open for research, Caucasians living in the USA have higher risk of falling

In addition, the rate of hospitalization for fall-related injuries is two to four timeshigher among the Whites than Hispanics and Asians/Pacific Islanders, and about20% higher than African-Americans (Ellis & Trent, 2001) It is also clear

differences observed between Singaporeans of Chinese, Malay and Indian ethnicorigins, and between native Japanese older community dwellers and Japanese-Americans and Caucasians Native Japanese people have much lower rates of fallsthan Japanese-Americans and Caucasians.

Cognitive impairment has been identified as a fall riskfactor in clinicalpractice guidelines

Behavioral risk factors

Behavioral risk factors include those concerning human actions, emotions ordaily choices They are potentially modifiable For example, risky behavior such asthe intake of multiple medications, excess alcohol use, and sedentary behavior can

be modified through strategic interventions for behavioral change

Medications may be appropriately recommended for the treatment of adisease,but they also have adverse effects; falling is oneof themostcommonadverseeventsrelatedto drugs(Field, Gurwitz, Avorn, & et al, 2001; Gray, Mahoney, &Blough, 1999; Hanlon, K.E., Koronkowski, & et al, 1997).Manyelderlypatientshaveseveralchronic conditions for which multiple medicationsare prescribed,furtherincreasingtheassociatedrisks, including falling Althoughthere is a clear relation between falling and the use of a higher numberofmedications, the risks associated with individual classes of drugs have been morevariable(Leipzig, Cumming, & Tinetti, 1999).To date, serotonin-reuptakeinhibitors, tricyclicantidepressants, neurolepticagents, benzodiazapines,anticonvulsants, and class IA antiarrhythmic medicationshave been shown to havethe strongest link to an increased risk of falling(Leipzig et al., 1999; Thapa,Gideon, Cost, Milam, & Ray, 1998)

It is believed that moderate physical activities and exercises lowers risk offalls and fall-related injuries in older age based on the evidence that these activitiescould control weight and contribute to healthy bones, muscles, and joints (Gardner,

Robertson, & Campbell, 2000) One study showed that regular participation inmoderate physical activities could increase bone mineral density ofpostmenopausal women and individuals aged 70 years and over (Day & et al,2002) Activities such as outdoor walking or mall walking indoors is the mostfeasible and accessible way of exercising that improves strength, balance andflexibility leading to a reduction on the risk of falling

Eating is a behavioral risk factor that could be contributable for fallingamong older population Deficiencies in consumption of protein, calcium, essentialvitamins and water could result in weakness, poor fall recovery and increase risk ofinjuries Numerous evidence supports dietary calcium and vitamin D intakeimproves bone mass among persons with low bone density and that it reduces therisk of osteoporosis and falling (Tuck & Francis, 2002) Older persons with lowdietary intake of calcium and vitamin D may be at risk for falls and thereforefractures resulting from them (Division of Aging and Seniors & PHAC Canada,2005).No dairy and fish consumption were also associated with a higher risk offalling Use of excessive alcohol has been shown to be a risk factor of falls.Consumption of14 or more drinks per week is associated with an increased risk offalls in older adults (Division of Aging and Seniors & PHAC Canada, 2005)

Non-adherence or not taking medication is now considered as a risk factor offalling Effects of uncontrolled medical conditions and of medication because ofnon-adherence can provoke or generate altering alertness, judgement, andcoordination; dizziness; altering the balance mechanism and the ability torecognize and adapt to obstacles; and increased stiffness or weakness (Division ofAging and Seniors & PHAC Canada, 2005)

Some other risk-taking behaviors increase the risk of falling in older age aswell Those behaviors include climbing ladders, standing on unsteady chairs orbending while performing activities of daily living, rushing with little attention to

the environment or not using mobility devices prescribed to them such as a cane orwalker (Gallagher & Brunt, 1996) Wearing poor fitting shoes or walking in sockswithout shoes or in slippers without a sole increase the risk of slipping indoor.

Environmental risk factors

Physical environment plays a significant role in many falls in older age.Factors related to the physical environment are the most common cause of falls inolder people, responsible for between 30 to 50% of them (Rubenstein, 2006) Anumber of hazards in the home and public environment that interact with other riskfactors contribute to falls and fall-related injuries A high particular risk to fallswas found in homes including irregular sidewalks to the residence, loose carpets onthe kitchen and bathroom floors, loose electrical wires, and inconvenient doorsteps.Poor surroundings around home such as garden paths and walks that are cracked orslippery from rain, snow or moss are also dangerous Entrance stairs and poor nightlighting can also pose risks.Factors related to the public environment are alsofrequent causes of fall in older age Most problematic factors are cracked oruneven sidewalks, unmarked obstacles, slippery surfaces, poor lighting and lengthydistances to sitting areas and public restrooms

Socioeconomic risk factors

Culturally driven expectations affect how people view older persons andfalls in older age In some cultures, social participation in older age is not seen as avirtue: the perception is that old people are meant “to rest” In practice, this results

in some older people adopting sedentary life often in isolation due to theresignation from social, economic and cultural participation, with a resultingincrease in the risk of falling Furthermore, in many societies, falls in older age areperceived as "an inevitable natural part of ageing" or "unavoidable accidents" Allthese contribute to falls prevention not to be considered as a matter of priority ongovernmental agendas-leading to a loss of financial provisions required to develop

surveillance systems, appropriate interventions and clinical diagnostic techniques,

as well as treatment regimens for falls and fall-related injuries

Cultural preferences are also reflected in the design of public and privatespaces–such as shining floors and steps or staircases without appropriaterailings.Culture also contributes to the stigma ofrequesting help where that isneeded or even unavoidable–for instance, where negotiating architectonic barriersthat should not be there in the first place but, if they are, asking for help shouldcome naturally rather than a reason for embarrassment

Falls in older age has been a neglected public health problem in manysocieties, particularly in the developing world Many health and social servicesproviders are unprepared to prevent and manage falls in older age as they lacksufficient knowledge to treat the conditions that predispose their consequences andcomplications.Falls in older age are often iatrogenic conditions – that is, induced

by incorrect diagnoses and treatments Examples include over-prescription ofmedications that cause side effects and interactions among the drugs, inadequatedosage and lack of warning to make older people aware about their effects

Appropriate training programmes covering knowledge and skills in fallsprevention and management should be a priority in primary heath care (PHC)settings, where increasing number of patients are older people PHC practitionersshould be well versed in the diagnosis and management of falls and fall-relatedinjuries In addition, social services that ensure the accessibility of older people tofalls prevention programmes are critical

Isolation and loneliness are commonly experiences by older peopleparticularly among those who lose their spouse or live alone They are much morelikely than other groups to experience disability and the physical, cognitive, andsensory limitations that increase the risk of falls.Isolation and depression triggered

by lack of social participation increase fear of falling, and vice versa Fear of

falling can increase the risk of falls through a reduction in social participation andloss of personal contact - which in turn increase isolation and depression.Providing social support and opportunities for older people to participate in socialactivities to help maintain active interaction with others may decrease their risk offalls.

Studies have shown that there is a relationship between socioeconomicstatus and falls Lower income is associated with increased risk of falling (Reyes &

et al, 2004) Older people, especially those who are female, live alone or in ruralareas with unreliable and insufficient incomes face an increased risk of falls Poorenvironment in which they live, their poor diet and the fact of not being able toaccess health care services even when they have acute or chronic illnessexacerbates the risk of falling The negative cycle of poverty and falls in older age

is particularly evident in rural areas and in developing countries The fallrelatedburden to health system will keep increasing unless resources and money areallocated in order to provide proper PHC and opportunities to older people forsocial participation It is never too late to break this vicious cycle

Personal factors

Older people's attitudes greatly influence whether they will avoid fall-relatedrisktaking behaviours when they participate in activities of daily living If olderpeople perceive falls as a normal consequence ofageing expressed as "seniors willalways fall" their attitudes may halt preventive measures

Attitudes of policy-makers determine to a large extent the amount ofresources allocated to falls prevention and development and enforcement of relatedpolicies Awareness and attitudes of health professionals to falls are essential toincreased incentive in providing appropriate services for preventing and managingfalls in older age

Professionals who design public transportations, such as buses and subwaysystems, often do not make them age-friendly, neglecting the risk of falls for olderpeople For example, in some developing countries, buses are designed with notenough seats and rails and the steps to climb into them are too high As aconsequence, older people incur the risk of falling because they have to stand or donot have the strength to climb into the buses in the first place and cannot properlyhold on for support Moreover, the steps on the public buses are often too high toolder people and they might fall when getting into the bus.

Fear of falling is frequently reported by older persons Older people areusually under the fear of falling again, being hurt or hospitalized, not being able toget up after a fall, social embarrassment, loss of independence, and having to movefrom their homes Fear can positively motivate some seniors to take precautionsagainst falls and can lead to gait adaptations that increase stability For others, fearcan lead to a decline in overall quality of life and increase the risk of falls through

a reduction in the activities needed to maintain self-esteem, confidence, strengthand balance In addition, fear can lead to maladaptive changes in balance controlthat may increase the risk of falling People who are fearful of falling also tend tolack confidence in their ability to prevent or manage falls, which increases the risk

of falling again (Division of Aging and Seniors & PHAC Canada, 2005)

The ability of coping with falls of both older people and health professionalscan lower the risk and consequences of falling Falls are particularly difficult tomanage in PHC settings because health professionals lack enough knowledge andskills Building coping skills of health professionals to prevent and manage fallsneeds to be emphasized For example, health professionals are recommended toteach patients at risk of falling how to get up from the floor; unfortunately clinicalexperience suggests that this is rarely done (Simpson & Salkin, 1993).Physical andmental management of falls by older people and their family members is also

important Therefore, training older people at high risk of falling needs to beencouraged.

2.3 Older population in Vietnam

2.3.1 Health status of Vietnamese elderly

Over time, thanks to improved living standards and a better healthcaresystem, the health status of the Vietnamese elderly has improved, and thus thepercentage of the elderly with fair/good health has increased, while the percentage

of those with ill health has subsequently diminished However, there continue to be

a number of serious health challenges for the elderly in Vietnam The elderly have

to live with the burden of disease due to the natural occurrence of such at anadvanced age; on the other hand, they also are exposed to new diseases resultingfrom socio-economic change According to United Nation country statement(2007a) there were about 95% of elderly people suffer from a disease with anaverage of 2.6 diseases suffered per elderly person

Most of the elderly have to cope with non-contagious and chronic diseasessuch as joint degradation, cardiac problems and blood pressure, prostate, andurination disorders (United Nations, 2007a) There are 53.1% of the participantsreported a bone and joint related disease, making it the most common disease Thesecond most common disease was cardiovascular disease (38.5%) and the thirdmost common disease was blood pressure (23.2%) Other diseases had much lowerrates of occurrence, with few differences across regions In terms of marriagestatus, single elderly had higher disease rates than the married couples Forexample, cardiovascular disease was found in 33.3% of legally separated elderly,32.0% of widowed elderly, and 21.7% of still married elderly

Risks of becoming disabled are also high for the Vietnamese elderly,particularly in terms of vision and hearing Disabilities make the elderlyuncomfortable, unconfident, and less socially interactive Data from the Population

and Housing Census 2009 indicate that the percentage of elderly suffering fromdisabilities increases with age.

2.3.2 Fall prevalence and associated factors for fall among Vietnamese elderly

It could be said that falls may be a common health problem among Vietnameseelderly, but data about this type of health issue is incomprehensive explored.Several studies showed that the elderly have highest injury incidence ratecomparedwith other age-group and falls, which took place in the home, represented a majorproportion of injuries among the elderly(Chuan et al., 2001; Hanh, 1999; Hoang,2004) A recent study found that falls are common injuries among older adults andaccountfor the highest proportion of economic costs for their family (Nguyen et al.,2013) However, no study on associated factors for falls within older populationhas been conducted recently (To et al., 2014)

Chapter 3: Conceptual Framework

3.1 Framework Development

According to 2007 WHO report, falls occur as a result of a complexinteraction of risk factors The main risk factors reflect the multitude of healthdeterminants that directly or indirectly affect well-being(World HealthOrganization, 2007) Those are categorized into fourdimensions: biological,behavioral, environmental and socioeconomic factors Biological factors such asage, gender and race embrace characteristics of individuals that are pertaining tothe human body Behavioral risk factors include those concerning human actions,emotions or daily choices Several behavioral factors that could be listed here arepolypharmacy, alcohol abuse, smoking and regular physicalactivity.Environmental factors encapsulate the interplay of individuals' physicalconditions and the surrounding environment, including home hazards such asnarrow steps, slippery surfaces of stairs, looser rugs and insufficient lighting andhazardous public environment such as poor building design, slippery floor, cracked

or uneven sidewalks, and poor lightening in public places Socioeconomic riskfactors are those related to influence social conditions and economic status ofindividuals as well as the capacity of the community to challenge them Thesefactors include: low income, low education, inadequate housing, lack of socialinteraction, limited access to health and social care especially in remote areas, andlack of community resources (World Health Organization, 2007)

However, 2007 WHO report also mentioned to determinants related topersonal factors (World Health Organization, 2007) Older people's attitudesgreatly influence whether they will avoid fall-related risk-taking behaviors whenthey participate in activities of daily living In addition, attitudes of policy-makers,health professionals, and transportation stakeholders also determine to a large

extent the amount of resources allocated to falls prevention and development andenforcement of related policies Apart from attitudes, fear of falling and knowledge

of management of falls play an important role in preventing falls among olderadults (Division of Aging and Seniors & PHAC Canada, 2005; Simpson & Salkin,1993)

3.2 The study framework

Based on 2007 WHO report and numerous studies on falls among elderly(Blake & et al, 1988; Reyes-Ortiz et al., 2005; Reyes & et al, 2004; Rubenstein,2006; World Health Organization, 2007; Yoshida & Kim, 2006), we build up astudy framework for this study There are five groups of factors related to falls will

be explore in the study They include biological, behavioral, environmentalsocioeconomic and personal factors

For biological factors, 7selected factors will be examined including age, sex,balance and gait status, comorbidities, general health, and clinical characteristics.Although race or ethnicity is an important factor that influences fall likelihood ofelderly(Blake & et al, 1988; Downton & Andrews, 1991; Hartholt et al., 2010;Liang et al., 2004; Nevitt et al., 1991), we do not examine it since there are solelytwo groups of ethnicity living in Ho Chi Minh City where we are going to conductthis study Other factors are chosen on the basis of previous studies

Seven factors including multiple medication use, insufficient sleep, smokinghabit, alcohol consumption, physical activity, dietary and routine physicalexamination are included in the group of behavioral factors Strong evidenceshowed that these factors play important role in preventing and managing fallsamong older adults (Blake & et al, 1988; Downton & Andrews, 1991; Hartholt etal., 2010; Liang et al., 2004; Nevitt et al., 1991) Inappropriate footwear issuggested in WHO model as a behavioral factor, but this behavior is not popularamong Vietnamese elderly so we exclude from the study

In the terms of environmental factors, we select factors suggested by WHOmodel including material made of floors, walking problems in home and walkingsafety outside home (World Health Organization, 2007) Although there are nodata about these hazards involving in fall probability among Vietnamese elderly,

we supposed that they may have high impact on the ways of falling within olderpopulation

Socioeconomic factors those suggested in WHO model included low incomeand education levels, inadequate housing, lack of social interactions, limited access

to health and social services and lack of community resources Inadequate housingmay be a significant factor related to falls in other countries, but it is notconsidered as an important issue in Vietnamese settings where most of elderly livewith their children or other relatives (Giang & Pfau, 2007) Instead we chooseliving arrangement as one of socioeconomic factors that needs to be explored in thestudy Three factors including lack of social interactions, limited to health andsocial services and lack of community resources are not chosen as interestedfactors for similar reasons Instead, we choose marital status, area of residence(rural/urban) are two factors may have significant impacts on falls likelihood ofelderly Thus, five socioeconomic factors exploring in this study are marital status,household arrangement, education level, area of residence and household income For personal factors, we examine three factors including attitudes ofparticipant toward falls, fear of falling and knowledge about falls prevention andmanagement of falls These factors may be contributable to the risk of fallingamong elderly (Simpson & Salkin, 1993; Tinetti et al., 1988; Yoshida & Kim,2006)

Five groups of factors as described in WHO model have interactionrelationships and they all contribute to cause falls in older adults (World HealthOrganization, 2007) With the aim of cross-sectional description of fall prevalence

and associated factors, we however solely describe the associations between fivegroups of factors and falls occurrence among participants Thus, the studyframework will be described in followed diagram.

Diagram 1.The study framework for falls prevalence and associated factors

Falls prevalence

Environmental factors

Poor building design,

slippery floors and

stairs, looser rugs,

Biological factors

Age, gender, balance and

gait status, comorbidities,

general health, and clinical

characteristics

Behavioral factors

Multiple medication use, insufficient sleep, smoking habit, alcohol consumption and physical activity

Chapter 4: Material and Methods

4.1 Study Design

This cross-sectional study is conducted from1 January, 2015 until 28February, 2015

4.2 Sampling and Setting

This study was conducted ina tertiary center in the East Coast of Peninsular Malaysia (Hospital UniversitiSains Malaysia)

Falls were defined asunintentionally coming to the ground or some lowersurfaceand not as a consequence of sustaining a violent blow,loss of consciousnessand sudden paralysis as in a strokeincident or epileptic seizure In this study, fallswere definedas having at least one history of falling in the past one yearfrom theinterview date, and frequent falls were defined asexperiencing two or more falls inthe past one year fromthe interview date

The elderly is defined as those over 60years of age, adopting the criteria set

at the World Assemblyon Aging in Vienna in 1982 (Ministry of National UnityandSocial Development, 1996)

Nonambulatory patientsand those unable to stand unassisted for a minimumofoneminutewereexcludedfromthestudy

Polypharmacywas defined as using four or more types of medications

Patients were given questionnaire on sociodemographicdetails to fill inwhich consists of questions to assessage, ethnicity, gender, marital status,educational status,occupational status, smoking status, and livingarrangement.Then, physical examinations were performed on the subjectsby thedoctor The physical examination includes measurement of height, weight, bloodpressure during standingand sitting, and Tinetti Balance and Gait Assessment.Review of patients’ hospitalrecords for medications usage, laboratoryinvestigationsresults, and medical illnesses were done.

stepwise procedure All possible 2-way interactionswere checked, and thosesignificant variables were includedin the model The independent variables werefitted intomultiple logistic regression, and variance inflation factorswere obtained

to check for multicollinearity Fitness of modelwas tested by Hosmer-Lemeshowgoodness of fit test, theclassification table and receiver operator characteristiccurve

4.6 Ethical Consideration

The protocol was approved by the Research and Ethical Committee,School

of Medical Sciences, UniversitiSains Malaysia onMarch 22, 2007

Table 5.1 Age and sex distribution of participants (n=306)

Hypertens

ion

Respirato

13.07 21.9

2.61 7.84

13.07 0.33

39.54

Proportion (%)

Firgure 5.2 Co-morbid frequency among participants (n=306)

Among co-morbidities, hypertension was the most common one (71.9%),followed by cataract (39.54%) and arthritis (37.91%)

No co

rmob

id es

1 se e

2 se es

3 se es

4 se es

5 se es 0

Figure 5.1 Number of comorbidities of participants (n=306)

There were 36.6% patients who had two comorbidities and 27.45% had onecomorbidity The number of patients who had four or more than four comorbidities

was relative low

The mean balance score of participants was of 10.46 ± 4.30 with a rangevaries from 0 to 16 points The mean gait score of participants was of 7.14 ± 2.18and the range of 0 to 11 points The mean Tinetti score of patients was 17.60 ±6.28.

Table 5.2 Balance and gait score of participants (n=306)

From Tinetti score, 58.82% patients were classified as high risk of falls (≤

18 points) and 13.07% were felt into moderate risk of falls (19-23%)

High risk of falls Moderate risk of falls Low risk of falls 0

Figure 5.2 Risk of fall among participants on the basis of Tinetti score

There were 67.97% patients thought that their health just at average level, while only 13.07% thought their health good or very good

Very good Good Average Bad 0

Figure 3 Self-report health of participants (n=306)

From the clinical records, BMI, blood pressure and biochemical indexeswere collected The results showed that all biochemical indexes are in normalrange

Table 5.3 Clinical characteristics of participants

Physical activity with low intensity was the most choice of participants(78.10%) Nearly all patients (97.06%) ate less than 5 servings of vegetables andfruits and 81.7% patient had physical examination in the last month.

Table 5.4 Behavior factors of participants (n=306)