Unintentional injuries among older adults in the capital region of Iceland in 2011-2012

A retrospective observational incidence study

María Guðnadóttir

Thesis for the degree of Master of Public Health Sciences University of Iceland Faculty of Medicine

Centre of Public Health Sciences School of Health Sciences

Slys aldraðra á höfuðborgarsvæðinu á Íslandi á árunum 2011-2012

Afturskyggn nýgengnisrannsókn

María Guðnadóttir

Ritgerð til meistaragráðu í lýðheilsuvísindum

Leiðbeinandi: Edda Björk Þórðardóttir

Meistaranámsnefnd: Brynjólfur Mogensen og Þórdís Katrín Þorsteinsdóttir

Læknadeild

Námsbraut í lýðheilsuvísindum

Heilbrigðisvísindasvið Háskóla Íslands

Júní 2015

Unintentional injuries among older adults in the capital region of Iceland in 2011-2012

A retrospective observational incidence study

María Guðnadóttir

Thesis for the degree of Master of Public Health

Supervisor: Edda Björk Þórðardóttir

Masters committee: Brynjólfur Mogensen and Þórdís Katrín Þorsteinsdóttir

Faculty of Medicine

Department of Public Health Sciences

School of Health Sciences

June 2015

Ritgerð þessi er til meistaragráðu í lýðheilsuvísindum og er óheimilt að

afrita ritgerðina á nokkurn hátt nema með leyfi rétthafa.

© María Guðnadóttir 2015

Prentun: Háskólaprent ehf.

Reykjavík, Ísland 2015

3

Ágrip

Bakgrunnur: Fyrri rannsóknir benda til að slys séu leiðandi orsök meiðsla á meðal aldraðra og að

tíðni slysa aukist með aldri. Slys geta haft alvarlegar afleiðingar í för með sér, bæði líkamlegar og

andlegar. Á Íslandi er skortur á faraldsfræðilegum rannsóknum um slysatíðni meðal aldraðra ásamt

áhættuþáttum fyrir slys meðal þessa aldurshóps.

Markmið: Kannað var hver árlegur fjöldi koma á bráðamóttöku Landspítala háskólasjúkrahúss

(LSH) vegna meiðsla af völdum slysa væri á meðal aldraðra á árunum 2011-2012. Áhættuþættir fyrir

slysum t.d. aldur og kyn, voru skoðaðir, ásamt orsökum og afleiðingum slysa.

Aðferðir: Rannsóknarhópurinn samanstóð af einstaklingum 67 ára og eldri, búsettum á

höfuðborgarsvæðinu, sem komu á bráðamóttöku LSH á árunum 2011 og 2012. Gagna var aflað úr

komuskráningarkerfi NOMESCO og rafrænni sjúkraskrá SÖGU um allar komur vegna slysa, aðstæður

slyss og ICD-10 greiningu. Lýsandi tölfræði var notuð til að skoða gögnin. Tengsl milli breyta voru

könnuð með kí-kvaðrat prófi og auk þess var Poisson aðhvarfsgreining notuð til að greina hvort það

væri munur á fjölda koma á milli áranna 2011 og 2012, aldursflokka og kynja.

Niðurstöður: Alls voru 4.469 komur aldraðra á bráðamóttöku LSH á tímabilinu. Af hverjum 1.000

íbúum 67 ára og eldri leituðu að meðaltali 106 til bráðamóttökunnar á þessu tímabili vegna meiðsla.

Slysatíðni jókst línulega með hækkandi aldri (p<0.001) og var mest í aldurshópnum 90 ára og eldri

(193 slys per 1.000 íbúa). Fleiri konur en karlar leituðu á bráðamóttöku LSH á tímabilinu í öllum

aldursflokkum af hverjum 1.000 íbúum (RR = 1,19, 95% CI 1,11-1,26). Flest slysanna eða 73%

(3.283/4.469) gerðust á heimili eða í næsta nágrenni þess. Helstu orsakir slysanna voru föll

(3.302/4.469; 74%), bæði á meðal kvenna (2.207/2.776; 80%) og karla (1.095/1.693; 65%).

Algengustu meiðslin voru brot (1.508/4.922; 31%)

Ályktanir: Niðurstöður gefa til kynna að slysavarnir aldraðra þurfi að beinast að heimilum og leggja

áherslu á inngrip sem koma í veg fyrir föll á meðal aldraðra. Auk þess þurfa inngrip að beinast að

konum og þeim elstu innan þessa aldurshóps.

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Abstract

Background: Previous studies have found that unintentional injuries represent a common public

health problem for older adults and that the incidence of injuries increases with age. Unintentional

injuries can have a substantial impact on the lives of older adults and may result in both physical and

psychological consequences. In Iceland there is a lack of epidemiological studies on the incidence and

risk factors of injuries among older adults.

Objective: To investigate the yearly frequency of injuries at the emergency department of

Landspitali University Hospital (LUH) among adults 67 years and older, along with risk factors such as

gender and age as well as causes and consequences of injuries.

Methods: The primary data source of the study was arrivals of adults 67 and older living in the

capital region in Iceland, to the emergency department of LUH, in the years 2011 and 2012. Data on

injuries was obtained from registries at Landspitali University Hospital, the Nordic Medico-Statistical

Committee (NOMESCO) database and the International Classification of Diseases (ICD-10) coding

systems. To assess the differences between groups a chi-square test was used for categorical data.

Poisson regression was used to assess the accident rate with regard to age and gender as well as the

differences in accident rate between the years 2011-2012.

Results: There were a total of 4,469 visits among adults 67 years and older to the emergency

department of LUH in the study period. The yearly incidence rate for injuries was 106 per 1,000

population. Injury rates increased with age (test for linear trend p<0.001) and were highest in the age

group 90 years and older (193 per 1,000 inhabitants ≥ 90 years old). Injury rates per 1,000 women

were higher than those per 1,000 men in all the age groups (RR = 1.19, 95% CI 1.11-1.26; p<0.001).

The most frequent place of occurrence was in or around homes (3,283/4,469; 73%). Falls were the

reason for most injuries (3,302/4,469; 74%) among both women (2,207/2,776; 80%) and men

(1,095/1,693; 65%). Fractures were the most common consequences of injuries (1,508/4,922; 31%).

Conclusions: Findings suggest that preventive measures need to focus on accidents occurring in

homes and their surroundings and focus on interventions to prevent falls among the elderly. In

addition, interventions should target women and the oldest in the elderly population.

5

Acknowledgements

I am grateful to all of those who have made my thesis possible. First of all I would like to give

special thanks to my supervisor Edda Björk Þórðardóttir, a PhD student at the Centre for Public Health

at the University of Iceland, for her encouragement and guidance through this process. Her kindness

and support were much appreciated.

Sincere thanks for the members of my masters committee, on behalf of the Research Institute in

Emergency Care: Þórdís Katrín Þorsteinsdóttir, PhD, assistant professor at the Faculty of Nursing at

the University of Iceland and Brynjólfur Mogensen, MD and PhD, associate professor in Emergency

Medicine at the Faculty of Medicine at the University of Iceland and Director of the Research Institute

in Emergency Medicine at Landspitali University Hospital and University of Iceland. Their knowledge,

guidance and kind words throughout the process were extremely helpful. I would like to thank Ingibjörg

Richter, system analyzer at Landspitali University Hospital for her assistance in providing the data.

Furthermore, thanks go to Thor Aspelund, MS, PhD, associate professor in the Department of

Medicine, Center of Public Health, for his advice on the statistical analysis. Thanks to Hildur Björk

Sigbjörnsdóttir, MPhil Project Manager at the Directorate of Health for information about the data.

Thanks go to the medical secretaries at Landspitali University Hospital for reflections on the matter.

Furthermore, thanks and hugs to my fellow students for discussions on the subject.

Finally I thank my amazing family and friends for cheering me on throughout the process. A special

thanks to my brother Valur and my parents Adda and Guðni, for all their endless support, patience and

motivation. Their smiles and positive attitude made this process a lot easier. Finally, a sincere thanks

to my grandparents Alla and Brynjar who never seize to inspire me with their enthusiasm.

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Table of contents

Ágrip ........................................................................................................................................................ 3Abstract ................................................................................................................................................... 4Acknowledgements ................................................................................................................................. 5Table of contents ..................................................................................................................................... 6Tables ..................................................................................................................................................... 7List of abbreviations ................................................................................................................................ 81 Introduction ....................................................................................................................................... 9

1.1 Types of unintentional injuries ................................................................................................. 101.1.1 Falls .................................................................................................................................. 101.1.2 Other causes of injuries .................................................................................................... 10

1.2 Risk factors .............................................................................................................................. 111.2.1 Gender .............................................................................................................................. 111.2.2 Age ................................................................................................................................... 12

1.3 Consequences of injuries ......................................................................................................... 131.4 Prevention ................................................................................................................................ 141.5 Place of occurrence ................................................................................................................. 141.6 Status in Iceland ...................................................................................................................... 15Introduction ........................................................................................................................................ 19Methods ............................................................................................................................................. 20Results .............................................................................................................................................. 21Discussion ......................................................................................................................................... 23Conclusions ....................................................................................................................................... 26Acknowledgements ........................................................................................................................... 27

References ............................................................................................................................................ 28Tables ................................................................................................................................................... 32Appendix A - Study approvals ............................................................................................................... 35

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Tables

Table 1. Number of accidents by gender and age in the study period (2011-2012) ........................ 32Table 2: Place of occurrence and mechanism of injury by gender in the study period (2011-2012) 33Table 3. Type of injury by gender in the study period (2011-2012) .................................................. 34

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List of abbreviations

CDC Centers for Disease Control and Prevention

DALY Disability-adjusted life years

ED Emergency department

EU European Union

EUNESE European Network for Safety among Elderly

ICD International Classification of Diseases

LUH Landspitali University Hospital

NCHS National Center for Health Statistics

NOMESCO Nordic Medico-Statistical Committee

U.S. United States

WHO World Health Organization

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1 Introduction In modern society people are living longer than ever before. While fewer children are being born, more

people advance into old age and older adults are the most rapidly growing age group in the world (1).

Older adults are generally defined as individuals with the chronological age of 65 years and older (2).

Worldwide, adults 65 years and older comprised 8% of the population in 2009 and by 2050 this is

estimated to have doubled to 16% (1). Currently, 17% of people in Europe are older than 65 years (3)

and this ratio is predicted to have reached 29% by the year 2050 (4). In Iceland, a country with

approximately 330,000 inhabitants, the ratio of people 65 years and older is expected to increase from

11% in 2008 to almost 25% in 2050 (5). To put this in perspective, according to the World Health

Organization (WHO), within the next couple of years the number of adults 65 years and older

worldwide will have outnumbered children under 5 years old and by 2050 older adults will have

outnumbered children under 14 years old (6).

Consequently there is an urgent necessity for the health care system to address the health

problems of older adults. Previous research around the world has shown that with ageing there are

increasing odds of suffering from various health problems, such as chronic diseases and physical and

mental disabilities (7). Worldwide, injuries caused by accidents represent a common public health

problem for older adults (8). A report on injury statistics in the European Union, found that injuries

were the leading cause of both fatal and non-fatal injuries among older adults in the period 2008-2010

(9). According to a data brief by the National Center for Health Statistics (NCHS) in the United States

(U.S.) injury rates among older adults in 2009 and 2010 increased with age (10). In Iceland, injury

rates among older adults in 2012 were higher than among younger adults (11). Additionally, a

retrospective analysis of emergency department (ED) data in a 10 year period (1999 to 2009) in

Australia, found that following an unintentional injury, older adults were considerably more likely to

stay for longer periods of time in emergency departments than younger adults (12). Furthermore, in

2002, the World Health Organization published the Injury Chart Book, a graphical overview of the

global burden of injuries, which stated that fatality was higher in adults over the age of 60 years

compared to younger persons (13). Falls have been found to be the cause of most unintentional

injuries among older adults (14, 37). The Centers for Disease Control and Prevention (CDC) in the

U.S. reported that in 2013 other common causes of injuries, caused by accidents among older adults,

were injuries involving struck by or against something, overexertion, cuts and pierce wounds (15).

Unintentional injuries can have a substantial impact on the lives of older adults, such as declines in

physical activity or functional status (16). According to a report on injuries in the European Union, an

estimated 6,7 million adults 60 years and older are treated for an injury in hospitals every year. Of

them, about one third will need to be admitted for an extended hospital stay (9). In addition to causing

physical and psychological consequences for older adults, unintentional injuries also take an

enormous toll on the economy (17). According to a report on total medical costs of injury in Europe in

2004, coordinated by the Consumer Safety Institute in Amsterdam, almost 50% of the total costs of

hospital inpatients were linked to individuals older than 65 years (18). A study by Meerding et al. on

health care costs as a result of injury in the Netherlands, found that among older adults, the total cost

10

of injuries per patient was higher among women than men. Furthermore, findings showed that the

costs per patient for both genders rose steadily by age and were highest among adults 65 years and

older (19).

1.1 Types of unintentional injuries

1.1.1 Falls Worldwide, falls have been found to be the most common reasons for both fatal and non-fatal

unintentional injuries among older adults (14, 20, 37), accounting for up to 75% of visits from older

adults to the emergency department (21). According to WHO, falls have been defined as “an event

which results in a person coming to rest inadvertently on the ground or floor or other lower level” (22).

According to a report by the United States Consumer Product Safety Commission (CPSC), on

emergency department injuries among adults 65 and older from 1991 to 2002, fall-related injuries

accounted for 59% of visits from older adults in the age group 65-74 years and 77% of visits from

older adults 75 years and older (23). A report by the Directorate of Health in Iceland on unintentional

injuries among people 65 year and older, found that 67% of all injuries among older adults in 2003

resulted from an unintentional falls (24).

Research indicates that falls are a serious health concern for older adults. Several of the earliest

studies on falls, in the nineteen eighties, reported that one third of community-dwelling older adults

suffered a fall each year (25). Among the most notable of these studies were those of Campbell et al.

from 1981 (26) and Blake et al. from 1988 (27). In a retrospective study by Campbell et al., a stratified

population sample of 553 individuals older than 65 years was analyzed and the results found that 34%

of the participants had fallen once or more in the last year. In the study fall rates increased with age

and were 45% for those in the age range 80-89 years and 56% for those 90-99 years old (26). Similar

rates were reported by Blake et al. in a retrospective study of 1042 adults older than 65 years, where

35% of the participants had experienced one or more fall the previous year (27). More recent studies

that have been done since Campbell's and Blake's work have shown similar results. A prospective

cohort study by Tromp et al. on 1,285 community-dwelling older adults in the Netherlands, aged 65

years and over, found that 33% of the participants had experienced one or more fall in the previous

year (28). A prospective study by Hausdorff et al. on community-dwelling adults, 70 years and older,

found that in a 12 month follow up period, almost 40% of the participants reported falling (29).

Additionally, many older adults who fall do so more than once and about two-thirds of those who

experience an unintentional fall will experience another fall in the next 6 months (30).

1.1.2 Other causes of injuries Injuries other than falls, such as being struck by or against something, overexertion, cuts and pierce

wounds, seem to be much less common than falls among older adults (15). The struck by or struck

against injuries are defined as injuries that result from contact made between a person and another

human, animal or inanimate object such as furniture (31). These types of injuries were the second

leading cause of non-fatal injuries treated in EDs in the U.S. in 2013 among people 65 years and older

11

(15). The struck by or struck against injuries were also the second leading cause of non-fatal injuries

treated in the emergency department in Iceland in 2003, accounting for 16% of all injuries (24).

Overexertion is defined by WHO as an injury caused by overexertion and strenuous or repetitive

movements (32), such as lifting, pulling or pushing (31). It was the third leading cause of non-fatal

injuries treated in emergency departments in the U.S. in 2013 among people 65 years and older (15).

Overexertion was the fourth leading cause for non-fatal visits to the emergency department in Iceland

in 2003 among people 65 years and older and accounted 4% of all injuries (24).

The cut or pierce injuries are defined as injuries resulting from cutting or piercing objects or

instruments (e.g. knives, rocks, stiff paper) (33). They were the fifth leading cause of non-fatal injuries

treated in EDs in the U.S. in 2013 among people 65 years and older and represented 4% of all

unintentional injuries within this age group (15). The cut or pierce injuries were the third leading cause

for non-fatal visits to the emergency department in Iceland in 2003 among people 65 years and older

and accounted for 7% of the injuries (24). The majority of cut or pierce injuries are non-fatal and do not

require hospital admission (34).

1.2 Risk factors Previous studies have shown that there is a complex interaction of factors that leads to unintentional

injuries among older adults (35) with both gender and age being key risk factors (22).

1.2.1 Gender Research indicates that there is a gender difference in unintentional injuries during the lifespan.

Men are more likely to sustain unintentional injuries than women up until the age of 65, after which the

roles are reversed and women sustain more injuries (9, 36). A retrospective study by Saveman and

Björnstig on unintentional injuries among older adults in northern Sweden, found that out of all visits

(n=1,753) admitted to Umeå University Hospital in 2006, two thirds (64%) of those injured were

women (37). This is in line with an Icelandic report on visits to the emergency department in 2003,

which showed that out of all visits (n=1,827), 60% of those admitted were women. Additionally, injury

rates were significantly higher among older women than men, irrespective of age (ranging from 65

years to 90 years and older) (24).

Since falls are the most common injuries that older adults suffer many studies have assessed

gender differences with regard to falls. Women have been found to be more likely to sustain

unintentional falls than men, with women accounting for up to 70% of fall-related visits to the

emergency department (38). A prospective study by Campbell et al. on 761 community-dwelling older

adults found that after controlling for sociological and physical variables, women were 50% more likely

to fall than men (39). According to a study by Stevens and Sogolow, based on data on 22,590 older

adults admitted to the emergency department for fall-related injuries, women’s fall-related injury

prevalence was 40-60% higher than men of the same age. Also, the hospitalization rates among

women as a result of falling were 80% higher than among men. The fracture rate among women

resulting from an injurious fall was twice as high as among men (38). These findings are in line with a

previous study on fracture rates among older adults which found that women have two times higher

12

rates of fall-related fracture than men (40). Additionally, women are more likely to suffer non-fatal falls

while men are more likely to die as a result of a fall (41).

Gender differences have also been reported in other types of injuries. A report on incidence of

injuries in the U.S. found that among 65-74 year old adults the incidence and hospitalizations of struck

by or struck against injuries were more common among men than women. On the other hand, in the

age group 75 years and older, the rate of struck by or struck against injuries was almost five times

higher among women than among men of the same age (34). An Australian report on injury

hospitalizations during 1999-2009 showed that over the ten year period, men between 65 and 75

years of age were more likely to be hospitalized of struck by or struck against injuries than women of

the same age. On the other hand women 75 years of age and older were more likely to be

hospitalized after sustaining such injuries than men. The report also found that among adults 65 years

and older, the rates of hospitalization after having sustained cut or pierce injuries was more common

among men than women (33).

1.2.2 Age The annual non-fatal injury rate among older adults appears to increase with age. A retrospective

study on visits to the emergency department at Umeå Hospital in Sweden in 2006 found that the injury

rates were 54 per 1,000 individuals for the age group 65-74, 92 per 1,000 individuals in the age group

75-84 and 170 per 1,000 individuals in the oldest age group 85 years and older (37). These rates are

higher than those found in an Icelandic report from 2003, on visits to the emergency department at

Landspitali University Hospital (LUH), where the injury rates were a total of 54 per 1,000 population

among adults 65 years and older (24).

Age is one of the leading risk factors for falls, and adults older than 65 years of age have the

highest risk of both injurious and fatal falls compared to other adults (22). Fall rates increase with age

for both men and women although the increase is greater for women. In a study by Stevens et al. from

2006, the non-fatal fall rates increased steadily with age for both genders although women’s rates

exceeded those of the men’s in all the age groups (42).

Physical health status has been found to deteriorate with age, leading to impaired vision,

deterioration of the vestibular and the somatosensory system along with loss of strength and balance

problems (43). These impairments increase the odds of unintentional injuries, such as falling (44).

Visual acuity declines with age, usually beginning at the age of fifty. Impaired vision contributes to loss

of balance by lessening people’s ability to judge distances and affecting the capacity to perceive

spatial relationship. Therefore impaired vision can be an independent risk factor of falling among older

people (45). The vestibular system contributes to balance and the sense of spatial orientation (43) and

the function of the vestibular system deteriorates with age. Any changes in the balance system can

lead to dizziness (46) which is a possible risk factor for falls (47).

Compared to those younger, older adults have an increasing likelihood of having multiple chronic

conditions including arthritis, cataracts, heart disease, osteoporosis, hypertension and diabetes (48).

Rising disease burden is associated with the risk of falling among older adults (49).

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1.3 Consequences of injuries Fractures, contusions, bruises and wounds have been found to be among the most common

consequences of unintentional injuries among older adults. A study on visits among adults, 65 years

and older to the emergency departments in a well-defined geographical area in northern Sweden,

found that the most common injuries were fractures (41%), followed by contusions and bruises (27%),

open wounds (15%) and dislocations (7%) (37). Another retrospective study on 34,454 visits of adults,

65 years and older to emergency departments in Nova Scotia, Canada, found that out of all visits due

to injuries 31% were due to a fracture, 18% were due to dislocations, sprains and strains of joints and

muscles, 14% due to open wounds and 18% to other injuries (e.g. contusions, wounds, burns) (50).

Since most of the injuries older adults suffer from are falls there is a large body of literature on falls

and their consequences. Although most falls are non-fatal they can lead to serious injury (41). The risk

of non-fatal injuries arising from unintentional falls increases with age and compared to younger

adults, adults 65 years and older have the highest risk of an injury following a fall (51). Not all falls

among older adults result in injury but around 30% of adults older than 65 years who fall sustain

injuries that requires medical attention (52). Approximately 5% to 10% of falls among adults 65 years

and older result in serious injury (53). According to a statistical brief published by the U.S. Agency for

Healthcare Research and Quality, on fall-related visits among adults 65 years and older to the

emergency department in 2006, fractures were the most common (41%), followed by superficial or

contusion injuries (22%) and open wounds (21%) (54).

WHO estimated in the year 2000 that the most common types of fractures among older adults were

those of the hip, vertebral (spine), distal forearm (wrist) and proximal humerus (upper arm) (55). This

is in line with a study on the epidemiology of fractures among 35-90 year olds in Iceland between

1989-2008, which found that among women, the most common fractures were those of the distal

forearm, hip and vertebrae. Among men, the most common fractures were hand and rib fractures. In

the study, there were not many fractures before the age of 50 but after that fractures happened much

more frequently (56). The most serious of the fractures that older adults suffer are hip fractures and

research indicates that up to 97% of all hip fractures result from an unintentional fall (57). Hip fractures

are generally classified into three major types: femoral neck fractures (ICD-10 code S72.0),

intertrochanteric fractures (ICD-10 code S72.1) and subtrochanteric fractures (ICD-10 code S72.2)

(58). Out of all hip fractures, intertrochanteric fractures have been found to account for 49%, femoral

neck fractures for 37%, and subtrochanteric for 14% (59). Hip fractures have been found to be more

common among women than men. A study on visits to the emergency department of LUH between

2008-2012 found that 72% of those who sustained a hip fracture were women (60). This is in line with

a literature review by Curran et al. that found the incidence of hip fractures to be twice as high among

women than men (61). Additionally, hip fractures are the leading type of fractures that result in

hospitalization after being treated in EDs for fall-related injuries (62). In addition, Bonar et al. found

that out of 151 community-dwelling older adults who had undergone surgery for a fractured hip, one

third of them were admitted to a nursing home facility and never moved home again (63).

Falls do not only cause physical injuries but also lead to restrictions in activity. Based on a study of

204 community dwelling older adults, Stel et al. reported that as a consequence of falling, 68% of

14

older people suffered physical injury, of whom 35% reported a decline in functional status, 17%

reported a decline in social activities and 15% reported a decline in physical activity (16).

Fall-induced injuries are responsible for a substantial amount of disability-adjusted life years

(DALYs) lost, (41) which are expressed as the number of years that are lost to ill-health (64). In

addition, roughly half of older adults who fall will not return to their former level of mobility (30) and

function after having sustained a fall (65). Therefore older adults, who suffer fall injuries, are at a great

risk for an extended hospital stay or being institutionalized (66, 67). Additionally, fall injuries have been

found to be a contributing factor for 40% of nursing homes admissions (68).

The consequences arising from unintentional injuries, such as falls, are not only physical but also

psychological. Research indicates that after falls individuals are at risk of suffering from fear of falling

(66, 67) and experience symptoms of depression (22). Fear of falling is defined as the exaggerated

concern of falling and is a common result of unintentional falls. Women have been found to be more

likely to experience fear of falling than men (69). Fear of falling can also precede falls. With increasing

age, there are increasing odds of experiencing gait and balance abnormalities, along with poor

physical and cognitive function. These factors can increase the likelihood that the individual becomes

afraid of falling (70). Moreover, older adults who restrict their activities may experience complications

such as reduced strength and poor balance. That may lead to increased disability among these

individuals and increase their fall risk. Therefore those who experience fear of falling are at greater risk

of falling (71).

1.4 Prevention Most non-fatal injuries among older people are falls and they are both predicable and preventable

(22). Evidence shows that a combination of factors is effective in reducing falls among older people

living in the community. These factors include assessment of homes and screening of living

environments, aimed to identify risk factors for falls, in addition to providing interventions based on the

assessment. These interventions include prescribing appropriate assistive devices such as canes and

walkers that can address both sensory and physical impairments, managing visual problems and

providing education and training programs (22). A systematic review of 159 trials on fall prevention by

Gillespie et al. found that the training programs that have been proven effective in reducing falls

usually contain both balance and strength training exercises (72).

1.5 Place of occurrence Nearly half of all non-fatal unintentional injuries among older people have been found to occur in the

residential home environment. A report on injuries in the European Union in 2008-2010 revealed that

among people 60 years of age and older, 47% of all non-fatal injuries occurred in or around the home,

19% in unspecified locations, 17% in transport areas, 5% in a residential institution and the remaining

12% in other locations such as commercial areas or the countryside (9). These findings are similar to

an Australian study on 657 community-dwelling adults 65 years and older, which found that

approximately 80% of all non-fatal injuries happened inside or outside of homes (73). This proportion

15

of injuries that happened inside or around the homes is higher than found in an Icelandic report, where

66% of all non-fatal injuries among adults 65 years and older happened in or around homes (24).

Since falls are the reason for most injuries among older adults there have been several studies on

the place of occurrence of fall-related injuries. A number of studies have reported that fall related

injuries are most likely to happen in or around the homes. A Canadian report from 2014, on falls

among adults aged 65 years of age and older in 2009-2010, indicated that half of fall-related injuries

occurred in or around the home. The other half of fall-related injuries happened in unspecified places

(19%), in a residential institution (17%) and the remaining 14% in other locations (74). A study by

Stevens et al. on fall-related injuries among 465 community-dwelling adults in Wisconsin aged 65 and

older, showed that two thirds of falls occurred inside the home. The majority of falls that occurred

inside the home happened in the living room (26%) or the bedroom (23%). About 13% happened in

the bathroom and 10% in the kitchen. The remaining 28% of falls occurred in hallways, stairs, and

other indoor locations or in locations not specified (75). These results are similar to those of Campbell

et al. who found that 27% of falls occur in the living room, 21% in the bedroom and 19% in the kitchen

(76).

Previous studies have shown that there are gender differences in place of occurrence in fall-related

injuries. Women have been shown to be more likely to fall inside their homes than men (65% vs. 44%

respectively) and men are more likely than women to fall outside the homes, such as in their gardens

(25% versus 11% respectively) (76). A study by Duckham et al. suggested that the rates of indoor falls

did not differ with regard to gender. However, women had significantly lower outdoor fall rates than

men (77). These studies suggest that preventive measures on injuries might need to address the

gender differences in injury locations.

1.6 Status in Iceland In October of 2001, the Directorate of Health in Iceland established the Accident Registry, a

centralized data bank on accidental injuries. The registration of accidents began with the aim of

collecting and coordinating the registration of all accidents taking place throughout Iceland to be able

to obtain an overall picture of the circumstances of the accidents. Since the beginning of the

registration, the number of participating institutions submitting data to the registry has increased

rapidly (78) and in 2010 there were a total of 21 institutions submitting data to the registry, including

hospitals, clinics, the police and insurance companies. The information registered on the accident is

the date, time, type of accident, municipality and the place of accident. The personal information

registered is the personal identification number (a proxy for age) and gender (79).

Statistics from the Accident Registry are published regularly on the website of the Directorate of

Health, in addition to a monthly newsletter. The newsletter provides information on health statistics,

which includes statistics on injuries (78). In 2005 the Directorate of Health published a report on

injuries among older adults in Iceland. The report is the only one that the Directorate has published on

injuries among this age group in Iceland (24). There have been studies published on the incidence of

distal radius fractures (80) and the epidemiology of fractures (56), but there seem to be no published

epidemiological studies on the incidence of injuries among older adults in Iceland.

16

Domestic- and leisure time accidents are the most common type of accidents in Iceland (81) and

since the registration of accidents in Iceland began they have been the most common type of accident

among adults, 65 years and older (82). According to the Directorate of Health’s newsletter, there was

a notable increase of domestic- and leisure-time injuries among older adults in Iceland between 2003

and 2012. This increase was especially alarming among women aged 80 years and over, where

injuries have increased from 62 accidents per 1,000 inhabitants in 2003 to 80 accidents per 1,000

inhabitants in 2012. In the newsletters, data on injuries was only obtained from LUH (82).

Thus far, the circumstances and consequences of unintentional injuries among older adults in

Iceland have not been investigated in detail. Currently there is a large amount of important and

detailed data in electronic registries in Iceland, which provides an unique opportunity for register-

based research. There is a lack of studies on the subject and considering the fact that injury is an

important health problem for older adults, this study is necessary to understand the scope of the

problem in Iceland.

17

Article

To be submitted to Age and Ageing

Unintentional injuries among older adults in the capital region in Iceland in 2011-2012

María Guðnadóttir (1), Þórdís Katrín Þorsteinsdóttir (3,4), Brynjólfur Mogensen (3,5), Thor Aspelund (1,6), Edda Björk Þórðardóttir (1,2)

1) Centre of Public Health Sciences, University of Iceland, Reykjavik, Iceland

2) Faculty of Psychology, University of Iceland, Reykjavik, Iceland

3) Research Institute in Emergency Care, The University Hospital of Iceland

4) Faculty of Nursing, University of Iceland, Reykjavik, Iceland

5) Faculty of Medicine, University of Iceland, Reykjavik, Iceland

6) Icelandic Heart Association

Correspondence: María Guðnadóttir, Centre of Public Health Sciences, University of Iceland, Stapi v/Hringbraut, 101 Reykjavík, Iceland

mag85@hi.is

18

Abstract

Background: Unintentional injuries represent a common public health problem for older adults. In

Iceland there is a lack of epidemiologic studies assessing the incidence and risk factors of injuries

among the elderly.

Objective: To investigate the yearly frequency of injuries at the emergency department of

Landspitali University Hospital among adults 67 years and older, as well as the risk factors, causes

and consequences of injuries.

Methods: The primary data source of the study was arrivals of adults 67 and older, living in the

capital region in Iceland, to the emergency department of Landspitali University Hospital in 2011 and

2012. Data on injuries was obtained from registries at the hospital.

Results: The yearly incidence rate for injuries was 106 per 1,000 adults 67 years and older. Injury

rates increased with age (test for linear trend p<0.001) and were highest in the age group 90 years

and older (193 per 1,000). Injury rates per 1,000 women were higher than those per 1,000 men in all

the age groups (RR = 1.19, 95% CI 1.11-1.26; p<0.001). The most frequent place of occurrence was

in or around homes (3,283/4,469; 73%). Falls were the reason for most injuries (3,302/4,469; 74%)

and fractures were the most common consequences of injuries (1,508/4,922; 31%).

Conclusions: In line with previous studies, our findings suggest that preventive measures need to

focus on accidents occurring in homes and their surroundings and focus on interventions to prevent

falls among the elderly. In addition, preventive measure should focus on women and the oldest group

in the elderly population.

19

Introduction Worldwide, injuries caused by accidents are a common public health problem for older adults (8) and

are the leading cause of both fatal and non-fatal injuries in this age group (9). Approximately 6.7

million adults 60 years and older are treated for injuries in hospitals in the European Union every year

and about one third of them will need to be admitted for an extended hospital stay (9). Injuries can

have a substantial impact on the lives of older adults, such as declines in physical activity or functional

status (16). Furthermore, injuries take an enormous toll on the economy, both by health care costs

arising from disability, hospitalization and premature death (22).

Previous research has found gender to be a key risk factor for injuries among this age group with

women 65 years and older being more prone to suffering injuries than men of the same age (22, 38).

Age has also been found to be a main risk factor for injuries among older adults and from 65 years of

age the annual injury rate increases steadily (22, 37). Older adults older than 70 have also been found

to be more likely to have to remain for longer periods of time in Emergency Departments (ED) after

unintentional injuries compared to younger adults (12).

Falls have been found to be the most common reasons for unintentional injuries among older

adults (14, 20, 37), accounting for up to 80% of visits to the EDs (23). Research indicates that one

third of community-dwelling older adults fall each year and that fall rates among them increase with

age (25). Other common causes for injuries among older adults include being struck by or against

something, as well as cuts and pierce wounds (15). Roughly half of older adults who suffer injuries,

such as falls, will not return to their former level of mobility and function (30, 65). The European Injury

Database (IDB) estimates that one third of older adults who are admitted to emergency departments

for injuries will have an extended hospital stay (9).

Previous Nordic research has found fractures to be the most common consequences of injuries

among older adults, accounting for up to 40% of the injuries (37). The most common types of fractures

are fractures of the hip, lower end of radius, rib and humerus (83, 84). The most serious of these

fractures are hip fractures (57), which most often result from falls (62). Other consequences of injuries

among older adults are dislocations, sprains and strains of joints and muscles, superficial wounds,

contusions and open wounds (50). Nearly half of all injuries among older adults occur in the residential

home environment (83). Other places of occurrence include residential care facilities, health care

settings and transport areas (37).

This is the first published epidemiological study assessing visits to the ED among older adults in

Iceland to the best of our knowledge. The aim of this study was to assess the rate and risk factors for

injuries among older adults admitted to the ED of the Landspitali University Hospital (LUH) in Iceland

in 2011-2012 using registry based data. Based on the literature reviewed above, we hypothesized that

the rate of injuries among older adults would increase with age and that injuries would be more

common among women than men. Furthermore, we hypothesized that falls would be the most

common reason for occurrence and that the most common place of occurrence of injuries would be in

or around residential areas. Lastly, based on previous findings we hypothesized that the most

common type of injuries would be fractures.

20

Methods Study context and data source

The context for the study was the capital region in Iceland, which is a well-defined area. The capital

region is the most populated region in Iceland with over 200,000 inhabitants. Data on injuries was

obtained from registries at LUH, the only hospital in the region, the Nordic Medico-Statistical

Committee (NOMESCO) database (85) and the International Classification of Diseases (ICD-10) (86)

coding systems. The registries provide reliable data on unintentional injuries in the capital region in

Iceland. The primary data source of the study was arrivals of adults, aged 67 and older, to the ED of

LUH, in the years 2011 and 2012. In this study older adults were defined as people aged 67 and older,

based on the general retirement age in Iceland. Therefore, the cohort in our study was all Icelanders

67 years old and older, living in the capital region of Iceland. Disease diagnosis in relation to trauma

diagnosis on discharge from LUH was used.

Exposure and outcome

The independent variables of interest were obtained from NOMESCO: gender, age, place of

residence, place of occurrence, mechanism of injury and type of injury. Age was coded into the

following six groups; 67-69, 70-74, 75-79, 80-84, 85-90, >90 years.

In our study we used the following NOMESCO categories for the place of occurrence variable (85):

school, institutional area and public premises; transport area; retail, commercial and service area. We

split the NOMESCO category for residential area into two categories: inside of a residential area;

outside of a residential area. We combined the NOMESCO categories amusement, entertainment and

park area and open nature. Furthermore, we combined the categories for sea, lake and river,

production and workshop area and sports area categories with place, other and unspecified.

In our study we used the following NOMESCO categories for the mechanism of injury variable (85):

struck, hit by fall; struck, hit by contact with other object, person or animal; crushing, cutting, piercing;

foreign body in natural orifice; acute overexertion of body or part of body. We combined the

NOMESCO category: chemical effect with thermal effect. Finally, we combined the NOMESCO

categories suffocation and electric/radiation and effect of other energy-waves with mechanism of

injury, other and unspecified.

Statistical analysis

Analyses were conducted using the statistical software R Studio for Mac (version 3.1.2.). Age-

adjusted incidence of injuries was calculated for each year during the study period, in 2011 and 2012,

along with the overall incidence. To assess the differences between groups a chi-square test was used

for categorical data. Population data was collected from Statistics Iceland, using the annual midyear

population, and used to calculate the age-specific incidence of arrivals to the ED per 1,000 population.

Poisson regression analyses, using these population numbers as offset, was conducted to assess the

accident rate with regard to age and gender as well as the differences in accident rate between the

years 2011 and 2012.

21

Results Demographics

There were a total of 4,469 visits among older adults due to unintentional injuries to the ED of LUH in

the study period. Specifically, there were 2,180 visits in the year 2011 and 2,289 visits in the year

2012. The age of the injured older adults ranged from 67 to 107 years (! = 79; SD 7.5). The average

age of men and women was 78 (SD 7.2) and 79 (SD 7.7), respectively. Out of the 4,469 visits, a total

of 3,459 individuals were injured once and 505 individuals had two visits. The majority of injured

individuals were women or 62%.

Distribution of injuries by age and gender

Overall, the yearly incidence rate for visits among adults 67 years and older was 106 per 1,000

population. Poisson regression analysis revealed no difference in injury rate between the years 2011

and 2012 (RR = 1.02, 95% CI 0.96-1.08). Furthermore, injury rates increased with age (test for linear

trend p<0.001). The injury rates were highest for adults 90 years and older compared to adults in other

age groups. Injury rates increased with age for both genders. Among men, the injury rate was lowest

at 63 per 1,000 population in the youngest age group and highest at 185 per 1,000 population in the

oldest age group. Among women the injury rate was lowest at 71 per 1,000 population in the youngest

age group and highest at 196 per 1,000 population in the oldest age group (Table 1). With regard to

gender, injury rates per 1,000 women were higher than those per 1,000 men in all age groups (RR =

1.19, 95% CI 1.12-1.26; p<0.001). Women were significantly more likely to sustain injuries than men in

the age groups 75-79, 80-84 and 85-89 years (p<0.05). No difference in injury rate was found with

regard to gender in other age groups (Table 1).

Place of occurrence

The most common place of occurrence was in or around the homes, with 47% (2,089/4,469) of

injuries happening inside the homes and 27% (1,194/4,469) of injuries occurring outside the homes.

Women were significantly more likely to suffer injuries inside the homes (p<0.05), while men were

significantly more likely to suffer injuries outside of the homes (p<0.05). Compared to men, women

were significantly more likely to suffer injuries in nursing homes or hospitals than men (p<0.05).

Compared to women, men were significantly more likely to be injured in the group “other and

unspecified”, as well as transport areas and parks and open countryside (p<0.05) (Table 2).

Mechanism of Injury

Table 2 shows the mechanism of injuries among older adults. Falls were the mechanism for 74% of

the injuries in the study period. Significantly more women than men suffered falls (80% vs. 65%

respectively; p<0.05). Significantly more men than women were hit by contact with other object,

person or animal, suffered crushing, cutting or piercing and had foreign body in natural orifice (p<0.05)

(Table 2).

Consequences of injuries

Among the 4,469 visits there were a total of 4,922 ICD-10 diagnoses. As seen in Table 3, fractures

were the most common consequences of injuries (31%), followed by open wounds (16%), sprain and

strain injuries (13%), contusions (9%) and superficial injuries (9%). The group "other" injuries

22

accounted for 19% of all injuries. Other consequences (dislocations, foreign body, muscle injuries,

burns) were less frequent. Women were significantly more likely to suffer fractures than men (p<0.05).

Men were significantly more likely to suffer open wounds, superficial injuries, foreign body injuries and

muscle injuries than women (p<0.05). No difference was found with regard to gender in the other

groups (Table 3).

23

Discussion In our study assessing visits of older adults to the ED of the national hospital in Iceland in 2011-2012,

we found older age and female gender to be associated with increased risk of injuries. The most

frequent place of occurrence of injuries was in or around homes and the most common reason for

occurrence were falls. With regard to injuries, the most common type was fractures among both

women and men.

In accordance with previous research, we found that injury rates increased with age and were

highest in the oldest age group, 90 years and older (37, 87). A potential explanation for this is that

physical and mental health status has been found to deteriorate with age, leading to multiple problems

such as impaired vision, loss of strength and balance problems (43). These problems have been

found to increase the odds of unintentional injuries, such as falling (44). Haanes et al. carried out a

study on adults 80 years and older who received encouragement and advice on how to improve their

vision, hearing, and indoor lighting conditions in the home. The results showed that these factors,

including improving lighting conditions in the homes could have positive effects on peoples vision (88).

Therefore, prevention programs that deal with these physiological problems may lead to reduction in

injuries among the oldest age groups.

Consistent with previous research, we found that injuries were more common among women than

men (19, 37, 50). Nearly two thirds of visits in our study to the ED belonged to women. Women have

been found to be at more risk of falling than men (38). Lower extremity strength has been shown to be

a risk factor for falling (20). A study by Oman et al. (89) found that among older adults, men had more

lower extremity strength than women. Therefore differences in lower extremity strength may explain

the gender differences in injury rates to some degree, as falls are the leading cause for injuries among

older adults. Based on our results preventive measures should place special emphasis on

interventions targeting older women.

Our results are in line with previous studies that have found the most common reasons for injuries

among older adults to be falls (90). The next most common reasons for injuries in our study were

collisions with objects or other people and injuries resulting from crushing, cutting and pierce wounds,

which is similar to what previous studies have found (37, 50). The fall rates in our study were

significantly higher among women than men which has also been found in other studies (38). This can

partly be explained by the fact that on average, compared to men, women live longer lives (91). With

increasing age, adults suffer several physical health changes, such as age-related declines in bone

mineral density (BMD). The annual loss in BMD has been found to be greater in older women than in

men (92) and declines in BMD have been linked to increased risk of falls (44). Furthermore, in light of

the fact that older women have less bone mass than men of the same age, we suggest a possibility of

underreporting of fall rates among men. Falling among men might be less likely to lead to fractures

and severe injuries, therefore they might be less likely to seek medical assistance for their injuries

than women.

Prior research has found that the majority of injuries among older adults occur in or around homes

(9, 73, 83), which is consistent with our study results, in which 74% of the injuries happened in or

around the. Based on these findings it seems necessary for preventive work in Iceland to focus on

24

home-based preventions. We found women to be more likely to be injured in nursing homes and

hospitals than men. With increasing age older adults are more likely to be admitted to nursing homes.

On average, women live longer than men and are therefore more likely to be admitted to such homes

(93).

According to a recent review of interventions for preventing falls in older adults living in the

community (94), several interventions have been found to be significantly effective in reducing fall rate

and risk of falls among these older adults. The review found that home safety assessment and

modification interventions as well as multiple-component group exercises were especially effective.

Multi-component exercises focus on balance and strength training that improve function as well as the

ability to control movement. Therefore it is possible that such interventions could not only reduce risk

factors for injuries and fall rates but also reduce the risk of other injuries.

The most common types of injuries in our study were fractures. Our results are in line with previous

studies (37, 38). A study by Röding et al. (87) on injuries among older adults, treated at the ED of a

Swedish medical center, found that fractures accounted for almost a quarter of all of the visits.

Nonvertebral fractures, such as hip fractures, fractures of the leg, upper arms and forearms, have

been estimated to account for up to 70% of fractures adults 50 years and older suffer from (95). Of

these fractures, hip fractures are considered to be the most serious fractures, contributing to both

disability and mortality. There are a number of interventions to prevent hip fractures and our results

emphasize the importance that such interventions be implemented to ensure better quality of life

among older adults (96).

We found no significant difference in injury rate between the years 2011 and 2012 which is not

surprising considering that these are two consecutive years. In Iceland there is a lack of epidemiologic

studies on the incidence and risk factors of injuries among older adults. To our knowledge the only

data on the subject is a report on injuries among older adults in Iceland published by the Directorate of

Health in 2003. The report is the only one that the Directorate has published on injuries among this

age group in Iceland. Therefore there is a lack of earlier data from Iceland that we can compare our

results to (24).

The main strength of our study is that using registry-based data from LUH we were able to include

all visits to the ED from inhabitants of the capital region. Another strength of this study is that in LUH,

detailed injury data is collected and classified according to NOMESCO classification system. A

limitation to our study is that it lacks information on those who might have visited other outpatient

settings or physicians' offices in the region. Despite that, is considered likely that almost all older

adults who suffered severe injuries were admitted to the ED and only those with minor injuries visited

outpatient settings or physicians' offices.

As the population of older adults is predicted to increase over the span of the next years (1), we

can expect that in the coming years injuries will account for more hospitalizations and deaths along

with a higher share of health care costs among older adults. Previous research has shown that the

majority of injuries are predicable and preventable (22). Prevention strategies should be implemented

in the older adult population to a higher degree, focusing on the risk factors identified in our study.

These risk factors include gender and age, along with the home environment. Focusing on these

25

factors while planning prevention strategies might lead to a reduction in the frequency of injuries

among older adults.

26

Conclusions In this first published study assessing injuries among older adults treated at the ED of LUH we

found that unintentional injuries were more common among women than men and that injury rates

increased with age. In our study falls were the main reason for injury and fractures were the most

frequent type of injury. Our results indicate that there is a need to address these risk factors while

keeping in mind that the most prevalent place of occurrence for unintentional injuries among older

adults is in the home.

27

Acknowledgements We thank Ingibjörg Richter, system analyzer at LUH for her assistance in providing the data.

28

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