INTRODUCTION
Falls were major public health issues which highly associated with older adults worldwide (Hill et al., 2018), although most are from Western countries. According to the World Health Organization (2018), falls were defined as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower-level.” Falls can cause a negative debilitating effect on the individual and may lead to fatal injury in certain cases (World Health Organization, 2007). Other implications of falling such financial burden (Cotter et al. 2005), depression (Iaboni & Flint 2013), injuries such as a fracture (Pi et al. 2015) and physical inactivity (Assantachai et al. 2003). Depression and fear of falling are associated with the impairment of gait and balance. This association mediated through cognitive, sensory, and motor pathways. The management of depression in fall-prone individuals is challenging since antidepressant medications like selective serotonin reuptake inhibitors can increase the risk falls and fragility fractures. There is lack of information regarding the effect of fall rehabilitation programs on clinically significant depression. There was also an increase in the risk of falls as to the age increased (Kim 2016).
In the United States, fall prevalence among older adults aged 65 and above was around 28.2-36.3% (Cigolle et al. 2015). A study in Germany indicates there was 25.7-37.4% of falls prevalence in females and 16.3-28.9% in males (Rapp et al. 2014). Similarly, a longitudinal study in United Kingdom indicates fall prevalence between 20.8- 33.2% in males but higher in females participant between 26.6-35.1% (Gale et al. 2016). In general, there was a lower prevalence of fall reported in Asian countries compared to Western countries (World Health Organization, 2007). A study in China reported prevalence of fall among older adults aged 60-year-old and above was 19.28% (Wu & Ouyang 2017). An epidemiology study that conducted across 10 states in India reported a 14% of fallers (Krishnaswamy & Usha 2006). A comparable report from Singapore also reported a fall prevalence of less than 15% (Dai et al. 2018).
Study on the characteristics of falls was scarce in Malaysia. It is important to understand the probable consequences and the nature of the falls especially for prevention, management measure and resource allocation. Knowing fall characteristics could help physiotherapist and other healthcare professionals to be well-informed and empowered better healthcare decision making. Thus, substantial research on falls characteristics needs to be conducted to fully understand and rectify the falls issues among older adult.
The aim of this study was to review the prevalence of falls and characteristics in current studies conducted in Malaysia regarding fall prevalence and its characteristics. This study looked into older individuals aged 60 years and above; summarised the fall prevalence either from a residential, community-dwelling or medical institute. This information collected is useful for fall preventive measures, in order to reduce falls related injuries among older adults.
MATERIALS AND METHODS
Search Strategy
Articles were identified using the electronic databases EBSCOhost (CINAHL Complete, MEDLINE Complete & Academic Search Complete), ClinicalKey, ScienceDirect, Wiley Online Library, SpringerLink, and Google Scholar. The search management was conducted using the following primary search terms; falls OR fall. The search strategy continued using the individual search term; AND Malaysia AND older adult AND elderly. All the electronic databases were conducted using a similar search strategy.
Study Selection
Study selection was divided into a three-stage process, where first stage was involved the articles identification to include only those which were written in English language articles and that published between 2013 to 2019. Articles were identified through systematic searching of the database according to their titles and abstracts which help in retrieving a substantial number of 1445 of articles. The second stage was used to screen and eliminate those articles not related to falls, duplicated, subject aged below 60 years, not related to fall characteristics and not conducted in Malaysia. The third stage where eligibility checking for the relevant articles were taken into consideration before final papers selection for full-text review. All articles were screened accordingly based on the requirement listed in Table 1.
Data Extraction
All articles were screened independently by the author through systematic searching of the database. Relevant information was retrieved from the articles including participant information (age, number of subjects, location), fall prevalence, standardised assessment tool, fall characteristics, result, recommendation, limitation and strength. In this study, appraisal tool to score study quality was not used as it is not a compulsory criterion for scoping a review (Colquhoun et al. 2014).
Study Identification
A total of 1445 articles were identified through systematic searching of database where 521 articles from EBSCOhost, 8 from Web of Science, 24 from ClinicalKey, 72 articles from ScienceDirect, 172 from Wiley Online Library, 67 from SpringerLink and 581 from Google Scholar. Studies were eliminated if not fulfil criteria as stated in Table 1. Nine studies were included in our review after excluding duplicated articles and articles that do not fulfil inclusion and exclusion criteria as indicated in Figure 1.
RESULTS
Articles retrieved from the electronic database preceding nine years between 2011 to 2019. Total of nine articles was identified and investigated regarding falls and its characteristics among older adults in Malaysia as indicated in Table 2. Seven of the studies were conducted among community-dwelling older adults (Azidah et al. 2012; Goh et al. 2016; Kadir & Hasim 2011; Romli et al. 2017; Tan et al. 2016; Yeong et al. 2016; Zia et al. 2016) and the remaining two studies were conducted among residential older adults (Ghazi et al. 2017; Kioh & Rashid 2018). Majority of the fall prevalence studies were evaluated in clear definition of fall and three studies (Azidah et al. 2012; Goh et al. 2016; Kadir & Hasim 2011) in conditioned-specific (stroke and diabetic) older adults population. Total of two studies (Romli et al. 2017; Tan et al. 2016) were conducted in longitudinal studies and the rest in cross-sectional studies. Fall prevalence was defined as retrospective falls occurred in the preceding 12 months except for one study (Tan et al. 2016) in the preceding six months.
Prevalence of Fall
Studies indicated a huge variation in prevalence of fall among older adults in Malaysia, ranging between 4-74% (Azidah et al. 2012; Ghazi et al. 2017; Goh et al. 2016; Kadir & Hasim 2011; Kioh & Rashid 2018; Romli et al. 2017; Tan et al. 2016; Yeong et al. 2016; Zia et al. 2016). Study that conducted in community indicated a lower prevalence of fall of 4.07% (Yeong et al. 2016) and 22.6% (Romli et al. 2017), as compared to residential older adults with 32.8% (Kioh & Rashid 2018) and 30% (Ghazi et al. 2017), and 12-74% for medical institution (Azidah et al. 2012; Goh et al. 2016; Kadir & Hasim 2011; Tan et al. 2016; Zia et al. 2016). Prevalence of fall among condition-specific older adults was between 12.9-29% (Azidah et al. 2012; Goh et al. 2016; Kadir & Hasim 2011) where well-defined older adults population was 4-74% (Ghazi et al. 2017; Kioh & Rashid 2018; Romli et al. 2017; Tan et al. 2016; Yeong et al. 2016; Zia et al. 2016).
Location
A total of 50 to 1489 older adult’s participant aged 60-year-old and above enrolled in these local Malaysian studies. There were five studies conducted in a medical institution (hospital and clinic) (Azidah et al. 2012; Goh et al. 2016; Kadir & Hasim 2011; Tan et al. 2016; Zia et al. 2016), two studies in the residential home (Ghazi et al. 2017; Kioh & Rashid 2018) and two studies in community-dwelling older adults. Note that, all studies were conducted in Peninsular Malaysia.
Falls Characteristics
Majority of the falls occurred in the morning as reported by three studies which contributed to 49-64.7% of prevalence (Azidah et al. 2012; Kadir & Hasim 2011; Tan et al. 2016), followed by afternoon as stated in two studies for 22% and 38.9% of prevalence (Azidah et al. 2012; Tan et al. 2016). Indoor fall accounted for the most number of fall location ranging from 50-87% while outdoor fall was between 13-49.3% (Azidah et al. 2012; Goh et al. 2016; Kadir & Hasim 2011; Romli et al. 2017; Tan et al. 2016; Yeong et al. 2016; Zia et al. 2016). Two studies indicated that location in the bathroom/ toilet has the highest percentage of indoor falls (Tan et al. 2016; Yeong et al. 2016). Fallers that sustained injury were around 47-82% (Ghazi et al. 2017; Goh et al. 2016; Kadir & Hasim 2011; Tan et al. 2016; Zia et al. 2016). Sustained injury including soft tissue injuries and fracture accounted for 46-94.4% (Azidah et al. 2012; Ghazi et al. 2017; Kadir & Hasim 2011; Tan et al. 2016) and 5.5-40% , respectively (Azidah et al. 2012; Ghazi et al. 2017; Tan et al. 2016). One study had reported the fall-related site of anatomical injury; including head (25%), upper Limb (20%), femur (16%), lower Limb (14%), vertebral (10%) and others (15%) (Tan et al. 2016). Hospital admission had been reported in three studies with prevalence between 25-50% (Ghazi et al. 2017; Goh et al. 2016). The retrospective study had reported a 58-61% of single fall freaquency and 39-41.4% of two or more falls frequency (Goh et al. 2016; Kadir & Hasim 2011; Kioh & Rashid 2018).
Standardised Assessment Tools
Standardised assessment tools that employed in these studies can be grouped into falls risk measure, physical performance measure, functional measure, cognitive measure and other outcome measures. The tools under fall risk measure are including Fall Efficacy Scale-International (FES-I), Fall Risk Assessment Tool (FRAT) and Home Falls and Accidents Screening Tool (HOME FAST) (Goh et al. 2016; Kioh & Rashid 2018; Romli et al. 2017). The physical performance measure-related tools are Fugl-Meyer Motor Assessment, Berg Balance Scale, Tinetti Balance, Semmes-Weinstein Monofilament, Timed Up and Go (TUG), Functional Reach (FR) and Grip Strength (GS) (Azidah et al. 2012; Goh et al. 2016; Kadir & Hasim 2011; Zia et al. 2016). The functional measure tools consist of Barthel Index, Functional Ambulation Category, Katz Index and Lawton-Brody Scales (Azidah et al. 2012; Ghazi et al. 2017; Goh et al. 2016; Kadir & Hasim 2011; Romli et al. 2017; Tan et al. 2016). Cognitive measure tools are Montreal Cognitive Assessment and Anticholinergic Cognitive Burden (ACB) scale (Goh et al. 2016; Zia et al. 2016). Another standardised outcome measure-tool like Fatigue Severity Scale, Patient Healthy Questionnaire-9, International Physical Activity Questionnaire (IPAQ) and The Geriatric Depression Scale (GDS) are also being employed (Goh et al. 2016; Kioh & Rashid 2018; Yeong et al. 2016).
Recommendation
Eight out of nine studies had recommended various fall-related assessments, intervention or future studies. Fall assessments had been recommended by three studies which include a comprehensive geriatric assessments by a physician for older adults (Yeong et al. 2016), identification of home hazards to prevent falls recurrence (Romli et al. 2017) and inclusion a higher sensitivity assessments for mental function and lower limb (Zia et al. 2016). Intervention for falls had been mentioned in three studies which include multi-component intervention with a combination of medical, rehabilitation and environmental (Kadir & Hasim 2011); social support and provision of health education (Yeong et al. 2016); and anti-depression drugs provision among residential older adults (Kioh & Rashid 2018). Future studies are recommended to focus on prospective falls report (Romli et al. 2017), those factors for excessive mortality among fallers and identifying solution to improve the outcome among fallers (Tan et al. 2016); inclusion of fear-avoidance behaviour as an outcome for fear of falling and falls (Goh et al. 2016) and the study on the male diabetic patients (Kadir & Hasim 2011).
Summary of Findings
Older age was significantly associated with prevalence of falls as reported in three studies (Azidah et al. 2012; Kadir & Hasim 2011; Tan et al. 2016). Two studies had shown a correlation between older adults with diabetes and orthostatic hypotension with a higher fall risk (Azidah et al. 2012; Kadir & Hasim 2011). Indigenous people (Yeong et al. 2016), higher falls history (Kioh & Rashid 2018), an older adult with respiratory illness (Kioh & Rashid 2018) and history of stroke (Goh et al. 2016) also significantly associated with falls.
Outcomes measure that applied in two studies had reported a low Barthel index of faller older adults was significantly associated with fall (Goh et al. 2016; Tan et al. 2016). Physical performance test such as TUG, Functional Reach, Gait Speed and Tinetti balance in multivariate and univariate analysis also revealed an association with falls (Kadir & Hasim 2011; Zia et al. 2016). Other outcomes measure such as Fall FES-I (Goh et al. 2016), GDS (Kioh & Rashid 2018) and ACB scale score of ≥1 had demostrated a significant association with falls in univariate analysis (Zia et al. 2016).
DISCUSSION
The aim of the study is to identify the current prevalence of falls and also identify the fall characteristics among Malaysia older adults. Nine relevant articles were identified in the prevalence of falls and its characteristic either among residential or community-dwelling older adults in Malaysia. Currently, there is no any fall study had been conducted in East Malaysia. All articles retrieved were retrospective in nature; observation in design with no intervention similar to a previous review study in Malaysia (Shaharudin et al. 2018). The advantages of prospective studies as compared to retrospective studies where it minimise the recall bias and the possibility to under estimate the population at risk (Sedgwick, 2014).
There was a huge variation of falls prevalence among Malaysian older adults due to a different location in data collection. The higher prevalence was reported on the residential area (Ghazi et al. 2017). Parallel with previous study, there was a higher percentage of fall risk among residential older adults (Rapp et al. 2012; Singh et al. 2014). Thus, more future study should be conducted among residential older adults with larger sample size. The prospective study was recommended as it can prevent recall bias in reporting fall prevalence.
This review also summarised that most fall occurs indoor (Azidah et al. 2012; Goh et al. 2016; Kadir & Hasim 2011; Romli et al. 2017; Tan et al. 2016; Yeong et al. 2016; Zia et al. 2016). This finding was supported by another study where a higher prevalence of indoor falls was detected among older adults (Duckham et al. 2013). A prospective longitudinal study from South Korea also reported there was a higher indoor fall prevalence among older adults (Kim 2016). Falls usually happened in the morning (Azidah et al. 2012; Kadir & Hasim 2011; Tan et al. 2016) with most activities were conducted which may explain the higher fall prevalence among older adults.
Bathroom/toilet was associated with the highest number of falls occurrence (Tan et al. 2016; Yeong et al. 2016). A systematic review study had explained that the urgency of going to the toilet, the anxiety of not able to reach the toilet on time and cognitive ability to perform multiple tasks (walking, negotiating household obstacles and hold bladder) could lead to high risk of falls within vicinity of bathroom/ toilet (Chiarelli et al. 2009). Other consideration of higher falls prevalence is due to slippery bathroom/toilet surfaces (Chiarelli et al. 2009). Bathroom location was twice likely a person to sustain an injury as compared to other places (Stevents et al. 2014).
Falls participants that sustained an injury was 47-82% (Ghazi et al. 2017; Goh et al. 2016; Kadir & Hasim 2011; Tan et al. 2016; Zia et al. 2016). A higher percentage of faller that sustained injury was recorded in India, at about 67% (Tripathy et al. 2015). This result was supported by an epidemiology study in Australia, wherev about 60% of older adults were sustained an injury after falling. In this review, soft tissue injuries due to fall was accounted for 46-94.4% (Azidah et al. 2012; Ghazi et al. 2017; Kadir & Hasim 2011; Tan et al. 2016); while fracture was 5.5-40% (Azidah et al. 2012; Ghazi et al. 2017; Tan et al. 2016). This is coherent with a longitudinal fall prospective study, where the soft tissue injuries was accounted for 50.6% while fracture was 37.4% (Pohl et al. 2014). This review also reported a hospital admission-related fall which was 25-50% (Ghazi et al. 2017; Goh et al. 2016). This is supported by some epidemiology studies where about 30% of fallers underwent hospitalisation and resulting medical cost up to 50 billion dollars annually (Centers for Disease Control and Prevention 2017; Florence et al. 2018).
This study only included articles published in English with full-text availability. Electronic database only limited to EBSCOhost, ClinicalKey, ScienceDirect, Wiley Online Library, SpringerLink and Google Scholar.
CONCLUSIONS
In summary, a variation on the fall prevalence was determined by several factors such as location and existing medical condition. Pooled information in our study indicates that there still a lack of standardised measuring tools for falls characteristics in Malaysia. There is a need for large scale longitudinal prospective study to determine the prevalence and the causal-effect relationship of falls, as well as suggestion to include psychological assessments to delve further into faller psyche and mental health in Malaysia. Findings on falls prevalence and its characteristics will help the physiotherapists and healthcare providers to reduce the impact of falling especially among the elderly population is rapidly increasing.
ACKNOWLEDGEMENT
The authors would like to thank Universiti Teknologi MARA, Cawangan Pulau Pinang, Kampus Bertam, for the support given for this study.