Hrev_master [page 85] [Emergency Care Journal 2014; 10:4708] A multicenter retrospective study on falls in elderly population. Epidemiology and impact on hospital workload in two Emergency Departments of Northern Italy Gianfranco Cervellin,1 Francesca Montali,2 Giovanna Campaniello,2 Mario Benatti,1 Roberto Fiorini,3 Gianni Rastelli3 1Emergency Department, Parma University Hospital; 2Clinical Governance, Risk Management, Quality and Accreditation Unit, Parma University Hospital; 3Emergency Department, Vaio Hospital, Fidenza, Italy Abstract Aims of this study were to evaluate the inci- dence of falls in subjects aged ≥65 years in Parma Province (Northern Italy), and the bur- den of fall-related hospitalizations. All the Emergency Department (ED) visits for domes- tic or trivial falls were retrieved from the data- base of the two EDs of Parma Province during 2013. All cases were classified according to age and gender. Out of 129,898 total ED visits, 3720 (2.9%) were related to trivial falls in patients aged ≥65 years. Females accounted for 2648 visits and males for 1072. The absolute num- ber of visits due to falls increased with age in both genders, with a peak between 80 and 84 yrs. When related with the actual number of residents by age groups, females showed a continuous increase, peaking at age >100 yrs, and males a continuous increase, peaking at age 95-99 yrs. Of these patients, 963 (25.9%) needed hospitalization, 605 in the orthopedic ward, 342 in medical wards, and 16 in special- ist surgical units. In conclusion, falls represent a major cause of morbidity in the elderly in Northern Italy, representing 13.3% of the ED visits for people aged ≥65, with a high impact on hospital workload. Introduction It is generally acknowledged that falls are a major public health concern, mainly affecting people aged ≥65 years. It has been estimated that approximately 424,000 fatal falls occur each year around the globe, which makes them the second cause of death due to accidental injury after road traffic collisions.1 Approximately 37.3 million falls per year, although non fatal, are serious enough to seek medical attention.1 It has been reported that approximately 30% of community living people aged ≥65 years experiment a fall each year, and that single and repeated falls represent an important health concern in this group.2 With age advancement, many people have an increased risk of fall for a variety of reasons, including gait problems, and vision or cognitive impair- ment.3,4 According to recent European surveys, at least 20% of people aged ≥ 65 years suffers at least one fall per year.5,6 Up to 15% of falls in subjects living in the community2 and 20% of falls in institutionalized ones7 result in a sig- nificant injury. Falls are associated with several and often negative health outcomes, accounting for 40% of all injury deaths and leading to 20-30% of mild to severe injuries (from soft tissue injuries to fractures).8,9 A fall also carries sev- eral negative psycho-social consequences such as reduced physical activity,10 at least partially due to the fear of falling,11,12 and thus resulting in a global impairment of the quality of life.13 As such, even when non fatal in the short term, falls are often followed by functional limita- tions, high healthcare costs, along with medi- um-term high mortality.14,15 In Italy, according to the Informative National System for Injuries in Domestic Environment (SINIACA) database (promoted by the Italian Public Health Institute), the average cost for fall-related hospitalization was estimated to approximately € 395 million per year in 2007.16 Surprisingly, only one study investigated the epidemiology of falls among the elderly belong- ing to a single study population17 and the hos- pital workload induced by falls in specific geo- graphical areas. Therefore, the main aim of this study was to evaluate the incidence rate of falls in subjects aged ≥65 years admitted to the Emergency Departments (EDs) of a Northern Italian Province, and their relationship with age. The secondary aim was to evaluate the burden of fall-related hospitalizations. Materials and Methods All the ED visits for domestic or trivial falls were retrieved from the database of the two EDs of Parma Province (about 447,000 inhabi- tants) during the year 2013, with exclusion of injuries related to sports, car accidents and all high-energy trauma. Since the number of vis- its in the two EDs was substantially stable in the last five years, and due to the high number of cases, we chose the year 2013 as represen- tative of the trend. The University Hospital of Parma is a 1250-bed teaching general hospital, serving a population of about 340,000 inhabi- tants. This hospital is a level 2 Trauma Center, and a referral center for stroke and myocardial infarction. The Hospital of Vaio-Fidenza is a 240-bed community hospital, with medical wards, general surgery and orthopaedic units. The elderly population of this area in 2013 is described in Table 1. According to our study design, only patients aged ≥65 years were con- sidered. All cases were then classified into groups, according to age (5-year ranges) and gender. The individual reports of the visits were analyzed separately to evaluate where and how the patient fell, the type of injury, the need for hospitalization and the ward of admission (i.e., Medicine/Geriatrics, Orthopedics, Neurosurgery). We have then analyzed i) the incidence rate of falls in all subjects; ii) the incidence in relationship with age, also calculating the relative risk (RR); iii) the burden of fall-related hospitalizations in the considered age groups. The distribution of falls rate was analyzed with Pearson’s c2 sta- tistic, using Analyse-it (Analyse-it Software Ltd, Leeds, UK). Due to the retrospective nature of the study and the maintenance of anonymity of all the subjects, the consensus of the ethical commit- tee was not requested. The study was per- formed in accordance with the Declaration of Emergency Care Journal 2014; volume 10:4708 Correspondence: Gianfranco Cervellin, Emergency Department, Parma University Hospital, via Gramsci 14, 43126 Parma, Italy. Tel. +39.0521.703800 - Fax: +39.0521.703144. E-mail: gcervellin@ao.pr.it Key words: falls, elderly, hospitalization, frac- tures, frailty. Conflict of interests: the authors declare no potential conflict of interests. Acknowledgements: the authors acknowledge Drs. Marco Brambilla and Marco Mignani of the University Hospital of Parma, and Dr. Paolo Iannone of the Hospital of Vaio, Fidenza, for their kind support in extracting data from electronic databases of the two Institutions. Note: the results of this study have been partly presented during the Academy of Emergency Medicine and Care (AcEMC) Congress Geriatric Emergency Medicine, held in Verona, Italy, on May 16th-17th, 2014. Received for publication: 16 September 2014. Revision received: 19 November 2014. Accepted for publication: 19 November 2014. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright G. Cervellin et al., 2014 Licensee PAGEPress, Italy Emergency Care Journal 2014; 10:4708 doi:10.4081/ecj.2014.4708 Non co mmerc ial us e o nly [Emergency Care Journal 2014; 10:4708] [page 86] Helsinki, under the terms of relevant local leg- islation. Results A total number of 129,898 ED visits was recorded during 2013, of whom 92,981 in the University Hospital, and 37,007 in the Community Hospital. Males accounted for 52.1% and females for 47.9% of the whole sam- ple. According to gross age groups, patients aged <30 years accounted for 34.4%, those aged 31-60 years for 34.85, and those aged ≥61 years for 30.75% of the total. During the same study period, 3720 ED visits were related to domestic falls in patients aged ≥65 years (i.e., 2.9% of the total visits), occurring at home or in nursing-home. In the same period, 828 patients aged ≥65 years, involved in sport acci- dents, car accidents and high-energy trauma have been excluded. No patients were missed, due to the nature of the hospital database. As many as 2533 visits were made in the University Hospital, and 1187 in the Community Hospital. During the same period 3300 patients were visited for a fall only once, whereas 183 patients were visited twice, 15 patients three times, 1 patient four times and 1 patient five times. Accordingly, the two EDs recorded 3720 visits for 3500 patients. Overall, females accounted for 2648 visits (71.2%) and males for 1072 (28.8%), respectively (Table 2). In both females and males the absolute num- ber of visits for falls increased with age, peak- ing in the 80-84 yrs age group and then pro- gressively decreasing in older ages (Figure 1). The lowest rate of falls was observed in the 65- 69 age range for both females (0.018%) and males (0.012%). Nevertheless, when the number of falls was related to the actual number of residents by age groups, females displayed a continuous increase [Pearson’s c2 statistic 825; degree of freedom (DF) 8; P<0.001 for trend], peaking at age >100 yrs, whereas males also displayed a continuous increase, but the peak was reached between 95 and 99 yrs, and then decreased in the group aged >100 yrs (Pearson’s c2 statis- tic 716; DF 8; P<0.001 for trend) (Figure 2). The RR of falls comparing the age range with the highest prevalence (>100 yrs in females and 95-99 yrs in males, respectively) with the age range exhibiting the lowest prevalence (65-69 yrs in both genders) was 6.9 (95% CI, 4.5 to 10.5; P<0.001) in females and 10.4 (95% CI, 7.1 to 15.5; P<0.001) in males, respectively. The age-distribution of falls was also signifi- cantly different between genders (Pearson’s c2 statistic 43; DF 8; P<0.001 for trend). This dif- ference is probably attributable to the negligi- ble number of males in the group >100 yrs (n=2), which may decrease the statistical sig- nificance of our analysis. Only 6% of patients were living in nursing home, thus reflecting the social reality of Parma Province, in which traditional familiar environment is still strong enough to allow the majority of elderly people to live at home. A total number of 963 (i.e., 25.9%) of patients needed to be hospitalized, 605 of whom in Orthopaedic ward due to frac- tures (9.9% for femur neck fractures), and 342 in Medical wards (including Geriatrics, Cardiology, and Neurology) due to non-surgi- cal brain injury, abdominal or chest trauma, or comorbidity. Ten patients were admitted to the Neurosurgical unit for an acute subdural hematoma, two patients to Maxillo-facial Surgery for severe facial injuries, two patients to Thoracic Surgery for severe chest trauma, two to the Intensive Care Unit for multiple severe injuries. Due to the higher prevalence of falls among Article Table 1. Inhabitants aged ≥65 years of the Province of Parma, year 2013. Age group (years) Females Males N % N % 65-69 12,623 21.7 11,580 27.1 70-74 12,964 22.3 11,101 26.0 75-79 11,141 19.2 8793 20.6 80-84 9679 16.7 6170 14.4 85-89 7369 12.7 3618 8.5 90-94 3293 5.7 1226 2.9 95-99 829 1.4 200 0.5 >100 166 0.3 30 0.1 Total 58,064 100.0 42,718 100.0 Figure 1. Absolute number of Emergency Department visits due to falls in 2013. Figure 2. Number of Emergency Department visits due to falls in 2013, divided per number of inhabitants of the same age group. Non co mmerc ial us e o nly [page 87] [Emergency Care Journal 2014; 10:4708] women, the need for hospitalization was over- all higher in the females’ group (694 vs 272). Discussion The present study shows that in a medium size province in Northern Italy the falls repre- sent an important cause of morbidity in the elderly population, representing up to 2.9% of the whole ED workload, and up to 13.3% of the visits for patients aged ≥65. These results hence show that the hospital workload induced by falls is globally impressive, roughly corre- sponding to the whole activity of a medical or orthopaedic ward, in terms of number of admitted patients per year. A potential limitation of the study is its ret- rospective nature, and the consequent risk of including subjects non-epidemiologically relat- ed to the sample. However, since only two EDs exists in the Province of Parma, it is reason- able to assume that the vast majority of patients admitted to these healthcare facilities are represented by residents, with the excep- tion of a negligible number of subjects occa- sionally present for tourism. An Italian study has estimated an average cost of € 5479.09 for fall-related hospitaliza- tion in patients aged ≥75 years, that could be translated into an annual direct overall expen- diture of € 1,621,810.21 for the specific single hospital of the research.18 According to data provided by this investigation, the overall cost burden of hospitalizing patients for falls in our two hospitals could hence be estimated at € 5,276,363.67 for 2013. Since the causes of falls are essentially multi-factorial (environment-, person- and activity-related) and at least in part preventa- ble, more efforts should be done to prevent falls in the elderly, for both persons living at home as well as for community-dwelling indi- viduals. Gait instability has been identified as a rel- atively consistent risk factor for falls,19 and inactivity and comorbidity are strong predic- tors for falls in older individuals compared to active, ostensibly healthy age-matched con- trols.20 Some underlying medical conditions, such as stroke and arthritis, are also recog- nized risk factors for falls.21-23 In addition, drugs, most notably psychotropic drugs, anti- hypertensive drugs, or multiple medications have been clearly associated with risk of falling.24-27 Conclusions Considering the social and economic bur- den of such a high rate of hospitalization, pre- ventive strategies should be planned to improve gait ability through exercise pro- grams, general and bone health through ade- quate dietary and drug delivery, optimizing of antihypertensive, antidiabetic and psychotrop- ic therapy, minimizing the risk of falls. 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