Consumer products and fall-related injuries in seniors.
Griffith, Lauren E. ; Sohel, Nazmul ; Walker, Kathryn 等
Approximately 23-35% of people aged 65 and older fall each year.
(1-3) Falls in seniors account for 40% of injury-related deaths4 and
over 80% of all injury admissions to hospital. (5,6) Numerous reviews
identifying risk factors for falls and strategies for fall prevention
have been published since 2000. (4,7-19) Intrinsic and extrinsic risk
factors include demographic characteristics, social and environmental
factors, co-morbidity, cognitive impairment, functional capacity, and
medication use, with complex interactions among these factors.
The role of consumer products in fall-related injuries in seniors
has not been comprehensively studied. Of the review articles, only Akyol
(14) enumerated the most important environment hazards of which some,
such as electrical cords in pathways, throw rugs, and low chairs, were
consumer products. Theoretically, environmental factors, such as the use
of consumer products, can be modified more easily than other intrinsic
risk factors related to falling. Thus, identifying classes of consumer
products related to injuries could have an important public health
impact.
As in other countries, there is little population-based data to
examine the association between consumer products and fall-related
injuries. In the 2008-2009 Canadian Community Health Survey on Healthy
Aging, a module on falls was administered to a representative sample of
Canadian seniors. This module included information on one particular
type of consumer products, assistive devices (AD). We therefore took
this opportunity to explore the available Canadian data. The objectives
of this study were to: 1) conduct an environmental scan to identify the
scope and summarize the intelligence of the literature on consumer
products and injuries in seniors, and 2) fill some of the information
gaps identified in the environmental scan by exploring the relationship
between AD and fall-related injuries in seniors using data from the
Canadian Community Health Survey on Healthy Aging.
MATERIALS AND METHODS
Environmental scan
The World Health Organization definition of a fall (20) as "an
event which results in a person coming to rest inadvertently on the
ground or floor or other lower level" was used. A consumer product
was defined as "any article produced or distributed for sale to a
consumer for use in or around a household or residence, a school, in
recreation, or otherwise". (21) An AD was defined as any device or
system that allows an individual to perform a task that they would
otherwise be unable to do, or increases the ease and safety with which
the task can be performed.
Literature search
Review articles, primary and grey literature were identified by a
research librarian. Medline and EMBASE databases were searched using
terms for "consumer products" and "falls OR
injuries". Reference lists of included articles were reviewed to
identify additional literature. Grey literature was identified using the
same terms in Google and consumer product safety sites in the US,
Canada, the UK, and Australia. These results were supplemented by
searches to identify literature for key types of consumer products:
ladders, floor coverings, rugs, carpets, bathroom products.
Screening and data abstraction
Articles including information on at least one consumer product and
injuries in older adults ([greater than or equal to]45 years) were
included. Abstracts were screened by a single reviewer (KW). Any
questions regarding inclusion were resolved by a second reviewer (LG,
PR). Study design, population, type of consumer products, injury
characteristics, and whether the study included primary or secondary
data were abstracted from each included article.
Canadian Community Health Survey (CCHS)--Healthy Aging
The CCHS-Healthy Aging includes community-dwelling people aged 45
years and over living in the ten Canadian provinces. Excluded from the
sample were residents of the three territories; persons living on Indian
reserves, Crown lands or in institutions; full-time members of the
Canadian Forces; and residents of some remote regions. Data collection
took place in participants' homes from December 1, 2008 through
November 30, 2009 using computer-assisted personal interviewing.
The content of the CCHS-Healthy Aging was developed collaboratively
by Statistics Canada and researchers from the Canadian Longitudinal
Study on Aging (CLSA). (22) As part of the Statistics Canada-CLSA
collaboration, CCHS participants were asked whether their survey data
could be shared with the CLSA. This article includes data from CCHS
participants who were between the ages of 45 and 85 years and who agreed
to share their data with the CLSA, henceforth referred to as the
CCHS-CLSA sample.
Measurement
Participants aged 65 years and older were asked whether they had
sustained a fall in the previous 12 months in which they were hurt
enough to limit some of their normal activities. Those reporting a fall
were asked about the severity, nature, consequent health care resource
utilization resulting from their fall, and whether they were using an AD
at the time of their fall. If a participant had more than one fall, they
were asked to describe their most "serious injury or problem due to
a fall". Fallers were asked whether they were concerned about
future falls and if, as a result of this concern, they had stopped doing
some activities.
Regression analyses were adjusted for a core set of
socio-demographic factors (age, sex, marital status, education, and
household income) and whether a participant reported having had more
than one fall in the previous 12 months. These are known risk factors of
falling and could be related to AD use. (23) Socio-demographic factors
were categorized according to Statistics Canada documentation, (24)
although some categories were collapsed due to low cell frequencies. Age
was represented by five-year groups (65-69, 70-74, 75-79, and 80-85),
marital status was represented as three categories (married/common-law,
widowed/divorced/separated, and single/never married), education was
categorized into post-secondary versus <post-secondary, and income
was included as <$30,000 CDN vs. [greater than or equal to]$30,000
CDN.
Clinical frailty has also been shown to be associated with
morbidity, institutionalization and mortality in people 65 years of age
and older. (25) Because frailty would also be associated with AD use, we
examined whether there was an independent effect of AD use after
adjusting for frailty. Three frailty variables represented the domains
of the clinical frailty scale developed by Rockwood et al. (25): level
of physical activity, medical problems, and activity limitations. The
Physical Activity Scale for the Elderly (PASE) was used to characterize
physical activity. (26) The PASE scale incorporates leisure time,
household, and work-related activities carried out in the previous week.
Medical problems were characterized as the number of self-reported
health professional-diagnosed chronic conditions. The CCHS collected
information on 26 respiratory, musculoskeletal, cardiovascular,
neurological, vision-related, and mental health conditions and cancer. A
cut-point of 5 or more was used to represent a higher level of
co-morbidities. Activity limitations were characterized using the
instrumental and basic activities of daily living (ADL). (27) We
categorized participants as having any versus no functional impairment.
Statistical analysis
The CCHS used a multistage stratified cluster design to select
participants. To correct the potential bias resulting from this complex
survey design, we used bootstrapping of all tests according to a set of
replicate weights supplied by Statistics Canada for the CCHSCLSA sample.
Similarly, statistics dependent on standard errors are adjusted for
survey design effects (i.e., the ratio of an estimated variance based on
the survey to a comparable estimated variance from a random sample of
the population).
Using a bootstrap method, sampling weights were used to estimate
the prevalence and 95% confidence interval of having at least one fall
serious enough to limit some normal activities in the previous 12 months
for the Canadian population between the ages 65-85 years. Estimates were
also provided for subgroups of the populations based on
socio-demographic and health status factors. Weighted logistic
regression was used to examine the relationship between AD use at the
time of the fall and socio-demographic and frailty indicators, and the
relationship between AD use at the time of the fall and the type of
health services utilized and psychological consequences of the fall.
Dependent variables included: whether medical attention was received,
hospitalization, whether follow-up care was received, worry about future
falls, and limiting activities due to this worry. For each dependent
variable, an unadjusted OR, an OR adjusted for socio-demographic
factors, and an OR adjusted for demographic and frailty variables were
estimated. All reported p-values are two-sided. Analyses were conducted
using SAS version 9.2. (28)
Regression analyses were limited to participants with complete data
for all variables. Because the majority of missing data were for income,
we conducted sensitivity analyses in which the median income was imputed
for missing cases. Participants with missing income data were
categorized in the [greater than or equal to]$30,000 CDN group.
RESULTS
Environmental scan
The literature search yielded 40 citations, of which 21 directly
addressed the association of consumer products with injuries in older
adults (Table 1; Supplemental Table 1). The majority of the articles
reported secondary database sources. (29-45) Two included both primary
and secondary data, (46,47) and one collected primary data. (48) Of the
three studies in which primary data were collected, one used an
adaptation of the Nordic Medico-Statistical Committee (NOMESCO)
classification (46) of products, (47) one used a list of product codes
developed by the Council of Ministries of the European Union, (49) and
one developed their own survey tool to collect information on consumer
products. (48)
Most of the reports (57.1%) presented national or international
data. All studies included either hospital and/or emergency department
admissions; eight studies (29,31,32,35,41,42,45,49) (38.1%) also
included mortality data, and one study included information on injuries
that required time off work. (48) Of the 21 studies, 10 focused on
ladders and/or steps and stairs, (33-35,37,39-43,50) one focused on
wheelchairs and adult walkers, (39) one included only sports products,
(38) and one included only bathroom products. (30) The remaining
articles (29,31,32,36,45,47-49) described the mortality and morbidity
associated with a broad spectrum of consumer products. The most commonly
identified consumer products related to injuries were floors/flooring,
stairs/steps, beds, chairs, rugs/carpets, ladders, footwear, outdoor
structures, and housing/building materials. Only one study (48) reported
the characteristics of the injury event and whether product fault was
the cause of the accident.
CCHS-CLSA data
In total, 30,865 people aged 45 years and over participated in
CCHS-Healthy Aging. The overall response rate was 74.4%; the response
rate in participants 65-84 was 75.4%. (51) Of these respondents, 26,248
(85.0%) met the additional CLSA eligibility criterion of being between
45-85 years old, and 20,087 (76.5%) agreed to share their data with the
CLSA. Of these participants, 9,108 (45.3%) were 65-85 years of age and
9,106 (99.9%) completed the Falls module.
Complete data were available for 7,712 (84.7%) participants.
Compared to those with incomplete data, participants with complete data
were more likely male (45% vs. 33.7%), slightly younger (73.4[+ or -]5.9
vs. 74.4[+ or -]6.0), and reported no functional impairments (80.5% vs.
75.9%). The groups did not differ with respect to marital status,
education level, or number of chronic conditions.
The data from these participants represent approximately 4.0
million Canadians aged between 65-85 years, of whom almost 800,000 (20%)
experienced a fall in the previous 12 months. About two thirds of the
falls were serious enough to limit normal activities. Over one third of
participants reported more than one fall in the previous 12 months. The
12-month prevalence of falls differed by demographic characteristics
(Table 2). A higher prevalence of falls was associated with being
female, older, widowed, separated or divorced, earning less money, and
having more chronic conditions.
About 6% of the fallers reported using an AD at the time of their
fall. The odds of using an AD at the time of the fall were higher for
participants who had ADL limitations (OR 4.16, 95% CI: 2.07-8.36), and
for those with a lower level of physical activity (OR 0.87, 95% CI:
0.79-0.97 for a difference of 20 points PASE score).
The unadjusted ORs were statistically significant for
hospitalization for injury (OR 3.70, 95% CI: 1.54-8.9), worried about
re-injury (OR 2.81, 95% CI: 1.56-5.01), and limiting activities due to
worry about re-injury (OR 3.79, 95% CI: 2.09-6.86) (Table 3). After
adjusting for the socio-demographic factors, the magnitude of the ORs
was slightly attenuated but still statistically significant. After
adjusting for the frailty variables, AD use at the time of the fall was
no longer statistically significant. The sensitivity analyses in which
median income was imputed for participants not reporting income did not
result in qualitatively different results (results not shown).
DISCUSSION
In our environmental scan, we found a dearth of information on the
association between consumer products and injuries in older adults. The
current literature lacks a clear link between consumer products, the
product's influence on a given injury, and the age of the subject
when a given injury occurred. At present, most of the data available
come from administrative databases, which have non-specific coding of
consumer products and little information on the role of the consumer
product in the injury. There are very little data for the 45-64 year age
group. (29,49)
Using the CCHS-CLSA sample, it was estimated that about 48,000
(6.1%) Canadians 65-85 years of age were using an AD at the time of
their reported fall. In a prospective case series study, Zecevic et al.
(52) used the Seniors Falls Investigation Methodology to investigate
falls in 15 community-dwelling seniors in London, Ontario. Although it
was not a random sample, they reported that 3 of the 15 fallers (20%)
were using an AD at the time of their fall. The Health and Activity
Limitation Study (HALS) indicated that 35% of Canadians 75 years of age
and older used an AD. (53) In the CCHS, AD-use data were not collected
outside of the falls questions, thus we do not know how many people who
regularly use an AD were not using it at the time of their fall.
We found AD use at the time of a fall was associated with
hospitalization, worry about re-injury, and limiting one's
activities due to this worry, even after adjustment for
socio-demographic variables. When frailty variables were included in the
model, however, AD use was no longer statistically significant. AD use
in the fully adjusted model predicting limiting one's activities
due to a fall has a p-value of 0.07. Although not statistically
significant, it is important that we not completely ignore these
results, as the fear of falling has been shown to have a negative impact
on physical, psychological, and social functioning. (54) For example,
restricting one's activities can in turn lead to social isolation.
These findings underscore the need to pay more attention to the
prevention of falls among those most vulnerable.
This is a relatively new area of research, thus we used a
two-pronged approach of conducting an environmental scan to identify
consumer product and injury literature and then analyzing the CCHS-CLSA
data to help fill some of the information gaps. This study draws upon a
large-scale national population-based cohort with a high participation
rate. The large sample size allowed adjustment for a number of important
confounders. We did, however, limit our sample to those participants
with complete data. This group differed in sex, age, and functional
limitations compared to those who did not have complete data. The most
common reason for incomplete data was failure to report income, which we
thought would be an important control variable as it could be associated
with the quality of an AD. Our sensitivity analyses in which the median
income was imputed for those not reporting their income did not result
in qualitatively different results.
We are also limited by the specificity of the questions asked in
the CCHS-Healthy Aging. There was a question asking whether an AD was
being used at the time of the fall, but it was not clear if and how the
AD contributed to the fall. As well, there was not a question regarding
regular AD use such that one could determine if a person who normally
used an AD was not using it at the time of their fall. Furthermore, as
these data are restricted to people aged 65-85 years, it is likely that
the relationship between consumer products and falls could be different
in adults <65 years old.
The CCHS-CLSA data provide some preliminary information on the
relationship between AD use and fall-related outcomes, however, the
current data are not sufficient to draw specific conclusions. It is
clear that a substantial number of people were using an AD at the time
of their fall, but it is less clear if the ineffective use, misuse, or
use of an AD contributed to the fall. It could be that ADs that
contributed to injuries had design flaws, were less well maintained or
did not provide sufficient instructions or training for their use. More
detailed questions regarding the regular use of ADs and if and how the
AD contributed to the injury would help to provide a richer
understanding of this relationship. Attention should also be given to
other consumer products and injuries, particularly to the contribution
of design and maintenance to falls in seniors. Learning more about the
relationship between consumer products and injuries can provide
important information that might make using consumer products safer for
Canadian seniors.
Acknowledgements: The Canadian Community Health Survey--Healthy
Aging survey content was developed by the Health Statistics Division at
Statistics Canada in consultation with Health Canada, the Public Health
Agency of Canada (PHAC), and experts conducting the Canadian
Longitudinal Study on Aging (CLSA). Consultations included stakeholders
from Human Resources and Social Development Canada and provincial and
territorial health ministries. The Canadian Institutes of Health
Research (CIHR) provided funding for the CLSA; and the CLSA--Mobility
Initiative--An Emerging Team in Mobility and Aging, the Canada
Foundation for Innovation (CFI), provided infrastructure support for the
CLSA. Funding for this study was provided by PHAC.
Conflict of Interest: None to declare.
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Received: March 7, 2012
Accepted: July 18, 2012
Lauren E. Griffith, PhD, [1] Nazmul Sohel, PhD, [1] Kathryn Walker,
MSc PT, [1] Ying Jiang, MD, MSc, [2] Yang Mao, PhD, [2] Doug Hopkins,
[2] Parminder S. Raina, PhD [1]
Author Affiliations
[1.] Department of Clinical Epidemiology and Biostatistics,
McMaster University, Hamilton, ON
[2.] Centre for Chronic Disease Control and Prevention, Public
Health Agency of Canada, Ottawa, ON
Correspondence: P. Raina, Department of Clinical Epidemiology and
Biostatistics, MIP-309A, McMaster University, 175 Longwood Rd S.,
Hamilton, ON L8P 0A1, Tel: 905-525-9140, Fax: 905-522-7681, E-mail:
[email protected]
Table 1. Summary of Literature Identified in Environmental Scan
Characteristic N (%) Notes
Geographic Scope
International 2 (9.5) International: Comparison of
Australia, US, UK and the
Netherlands and countries
within the European Union
National 10 (47.6) National: Australia, Canada,
US, Ireland
Regional 2 (9.5) Regional: Atlantic Provinces
(Canada), Vastmanland County
(Sweden)
State/Provincial 6 (28.6) State/Provincial: Victoria
(Australia), Massachusetts
(US), Ontario (Canada)
City 1 (4.8) City: Dublin (Ireland)
Type of Data Analyzed
Primary 1 (4.8) Primary Data: Telephone
survey, questionnaires
Secondary 18 (85.7) Secondary Data: Hospital
discharge data, emergency
department data, mortality
records, retrospective
chart review
Both 2 (9.5)
Data Sources
Mortality data 8 (38.1) Injury Surveillance Systems:
Many injury surveillance
databases included data from
multiple administrative
Hospital discharge 17 (81.0) databases (mortality data,
data hospital discharge data, and
emergency department data)
Emergency department 16 (76.2)
data
Time off work 1 (4.8) Time off work: Self-reported
questionnaire data
Injury Type
All unintentional 8 (38.1) Injuries: All reported
injuries injuries associated with
a consumer product
Falls 12 (57.1) Falls: All fall-related
injuries associated with
a consumer product
Both (comparison) 1 (4.8) One study compared falls
vs. other non-fall injuries
Consumer Products
General 8 (38.1) The most commonly identified
consumer products related to
injuries: Floors/flooring,
stairs/steps, beds, rugs/
Ladders and/or steps 10 (47.6) carpets, ladders, footwear,
and stairs outdoor structures, and
housing/building materials
Sports equipment 1 (4.8)
Wheelchairs and adult 1 (4.8) Only one study reported the
walkers characteristics of the injury
event, including whether
product fault was the cause of
Bathroom products 1 (4.8) the accident
Table 2. Weighted Prevalence of Falls Serious Enough to Limit
Some Normal Activities in the Previous 12 Months in Relation to
Socio-demographic Factors for Canadians Aged 65-85 Years
Variable Weighted 95% Confidence P-value for
Prevalence Interval Difference
Overall 0.20 (0.19-0.21)
Sex
Male 0.18 (0.16-0.20) <0.001
Female 0.22 (0.20-0.24)
Age (years) <0.001
65-69 0.18 (0.16-0.20)
70-74 0.18 (0.16-0.20)
75-79 0.22 (0.20-0.24)
80-85 0.24 (0.21-0.27)
Marital status <0.001
Married/Common-law 0.18 (0.17-0.20)
Widowed/separated/ 0.23 (0.22-0.25)
divorced
Single 0.20 (0.15-0.25)
Education 0.39
Less than post- 0.20 (0.18-0.22)
secondary
Post-secondary 0.20 (0.18-0.22)
graduation
Income 0.004
<$30,000 0.22 (0.20-0.24)
$30,000-$49,999 0.19 (0.18-0.21)
Number of Chronic <0.001
Conditions
<5 0.17 (0.16-0.19)
[greater than 0.28 (0.26-0.31)
or equal to]5
CCHS = Canadian Community Health Survey; CLSA = Canadian Longitudinal
Study on Aging; CI = confidence interval.
Table 3. Weighted Logistic Regression Results Examining
the Association of Assistive Device Use at the Time of
the Fall and Fall-related Health Care and Psychological
Consequences in Canadians 65-85 Years of Age
Unadjusted
Outcome OR (95% CI) P-value
Received medical 1.64 (0.88-3.02) 0.12
attention
Hospitalized for 3.70 (1.54-8.90) 0.003
injury
Follow-up care 1.02 (0.47-2.21) 0.95
from a health
professional
Worried about re- 2.81 (1.56-5.07) <0.001
injury
Limits activities 3.79 (2.09-6.86) <0.001
due to worry
about re-injury
Adjusted for
Socio-demographic Factors *
Outcome OR (95% CI) P-value
Received medical 1.54 (0.82-2.87) 0.18
attention
Hospitalized for 3.36 (1.26-8.92) 0.02
injury
Follow-up care 0.98 (0.45-2.12) 0.96
from a health
professional
Worried about re- 2.43 (1.31-4.49) 0.005
injury
Limits activities 3.22 (1.69-6.12) <0.001
due to worry
about re-injury
Adjusted for Socio-demographic
and Frailty Factors ([dagger])
Outcome OR (95% CI) P-value
Received medical 1.24 (0.65-2.38) 0.51
attention
Hospitalized for 1.87 (0.72-4.86) 0.20
injury
Follow-up care 0.64 (0.28-1.45) 0.28
from a health
professional
Worried about re- 1.50 (0.73-3.07) 0.27
injury
Limits activities 1.91 (0.94-3.90) 0.07
due to worry
about re-injury
* Analyses adjusted for age, sex, income, marital status,
education, >1 fall in previous 12 months.
([dagger]) Analyses adjusted for age, sex, income, marital
status, education, >1 fall in previous 12 months, 5 or more
chronic conditions, any ADL/IADL impairment, and physical
activity level.
OR = odds ratio; CI = confidence interval.
