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Correlates of Falls among Community-Dwelling Elderly in Thailand

Correlates of Falls among Community-Dwelling Elderly in Thailand Hindawi Journal of Aging Research Volume 2018, Article ID 8546085, 10 pages https://doi.org/10.1155/2018/8546085 Research Article Correlates of Falls among Community-Dwelling Elderly in Thailand 1 1 2 Titaporn Worapanwisit, Somkid Prabpai, and Ed Rosenberg Health Promotion and Health Education, Faculty of Education, Kasetsart University, Bangkok 10903, "ailand Department of Sociology, Appalachian State University, Boone, NC 28608, USA Correspondence should be addressed to Ed Rosenberg; rosenberge@appstate.edu Received 24 January 2018; Accepted 7 May 2018; Published 24 May 2018 Academic Editor: Barbara Shukitt-Hale Copyright © 2018 Titaporn Worapanwisit et al. -is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Nearly every nation is experiencing rapid population aging. One area of major concern is health; a major health risk for older adults is falling, and there are multiple negative consequences of falling. -is is a global concern yet is underresearched in many nations. -is study examines demographic, health, and environmental correlates of falling among community-dwelling -ai elderly. Data were collected from a sample of 406 adults aged 60–69. Significant (p< 0.05) fall correlates were urban residence, older age, greater BMI, impaired and uncorrected vision, chronic health conditions, medication use and medication side effects, poor muscle tone, and hazardous indoor and outdoor home environments. Results lead to recommendations for interventions to reduce fall risk that are both evidence-based and culturally acceptable. Population aging has serious implications for 1. Introduction individuals, families, communities, and nations. -e faster In the twenty-first century, most nations are experiencing the aging, the more quickly and severely the challenges rapid growth of their older populations, both in number and arrive, and the more difficult it is for governments to react as a percent of the population. -is growth is largely at- effectively. Large-scale proactive initiatives, if and where tributable to decreasing mortality due to advances in they exist, seem the exception that proves the under- medicine and health promotion, and to fertility declines. -e preparedness rule. portion of the world’s population aged 60+, 12% in 2015, is Adapting health care for an aging population is one such projected to rise to 22%, to 2.1 billion, by 2050. major challenge. As people live longer, all else equal, they will live longer with illness and other impairments. -e older adult growth rate is not uniform across na- tions: less-developed nations will experience more rapid Extending healthy life expectancy is more difficult than growth. While those aged 60+ in developed countries grew extending life expectancy, and the “rectangularization of the by 29% from 2000 to 2015, less-developed countries can survival curve” [3], where we live a long, healthy life ending expect a 60–71% increase by 2030. By 2050 nearly 80% of the in a brief, precipitous terminal drop, remains the Holy Grail world’s older population will live in these less-developed of life extension. countries. Many Asian nations are in this latter category. By One typology of causes of death is composed of non- 2030, 60% of Asians will be 60+ and Asia will be home to communicable diseases, communicable disease, and injuries. more than half of the world’s oldest-old persons (aged 80+) -e World Health Organization [4] believes the distribution [1]. of noncommunicable disease deaths will remain relatively In this context, -ailand is typical of Asian nations. -e constant, while communicable disease deaths will decrease. In contrast, deaths due to injuries—the focus of this World Health Organization [2] estimates that those aged 60+ will comprise 29.6% of the -ai population in 2050. research—will grow through 2030. Injury-related deaths are 2 Journal of Aging Research reported that prescription medications can contribute to fall a large burden on society, financially and otherwise, but many of these deaths are preventable [5]. Unintentional- risk. Jung et al. [32] found that mobility impairments (transferring, gait imbalance, and lack of equilibrium) in- injury deaths, the five leading causes of which are falls, motor vehicle traffic crashes, suffocation, poisoning, and fire [6], crease fall risk. Guzman et al. [33] related nonuse of assistive focus the current study further. devices to increased odds of falling. In a -ai study, A fall is “an unexpected event in which the participant Kuhirunyaratn et al. [34] reported that elderly who use comes to rest on the ground, floor, or lower level” [7]. psychotropic medications are almost twice as likely to fall as Similarly, Bekibele and Gureje [8] described a fall as an those who do not (see also [35, 36]). Gait disturbance, visual unintentional loss of balance, causing one to make un- impairment, and depression also doubled fall risk, and in- appropriate indoor environment (cluttered rooms, slippery expected or unprepared contact with the ground or floor. Weir and Culmer [9] noted that a fall results from a complex floors, nonadapted bathrooms, and dim lighting) nearly tripled the risk of falling. combination of individual factors operating alone or in association with precipitating environmental factors. Still, measures to reduce fall risk can be taken, especially at the individual and community levels. Fall-reduction Falls are by far the most common cause of injury and unintentional-injury death among older persons in the improvements can be made inside and outside the home United States [10], accounting for more than one-half (55%) [37], often inexpensively. of the total; in contrast, the second most common cause, Since falls incidence and prevalence rise with age, since motor vehicle accidents, accounts for only 14% [11]. Both nearly every nation is experiencing rapid population ag- the NCHS and the Centers for Disease Control and Pre- ing, and since the health, economic, and quality of life vention [12] report that the rank of falls as a cause of impacts of falls are significant on both micro- and mac- rolevels, there is a need for evidence-based research on unintentional-injury death rises with age, from tenth among those aged 25–34 to first for those aged 60+. effective fall prevention strategies and programs that re- duce fall risks. Fortunately, many such studies exist, Falls also have greater consequences for older adults compared to younger adults. Elderly falls may cause serious, looking at the efficacy of both single- and multi-factor interventions to reduce risk factors and fall incidence. perhaps fatal injuries such as fractures, joint dislocation, and/or head trauma. But even if falls have no lasting impact Exercise is the most common intervention used to reduce on older adults’ physical health, they can have significant fall risk factors in community-dwelling older adults. effects on psychosocial health, including greater fear of Balance, gait, and strength training have been shown to be falling that can lead to social isolation [13]. It is difficult to effective methods to reduce and prevent falls among determine the definitive risk factors for falling [14]. community-dwelling older adults [38]. For example, a Nonetheless, fall risk factors can be trichotomized as follows: study of older adults [39] found that fall evaluation, balance training, home hazard management, fall pre- (1) intrinsic risk factors related to normal age changes, gender, race, physical problems, medical conditions, cog- vention education, exercise, and home visitations resulted in significant fall reduction. Other multifaceted inter- nitive impairment, and degree of physical inactivity, (2) extrinsic risk factors, such as outdated vision correction, ventions, such as exercise plus dietary supplements [40] taking multiple prescribed medications, improper footwear, and exercise plus fall prevention education [41], yielded and nonuse of assistive devices, and (3) environmental risk reduced fall rates among older adults. factors, such as loose carpet, lack of grab bars in the Overall, falls are the leading cause of unintentional- bathroom, poor lighting, unsafe stairs, and uneven or injury deaths and can result from multiple causes, either slippery surfaces. Over one-third of elderly fall at least once singly or in combination. -e risk of such death rises with annually due to various intrinsic and extrinsic risk factors age. Even nonfatal falls have more serious consequences for [15]; 30–50% of falls among community-dwelling elderly are older adults than younger age groups. Major findings in- clude (1) compared to time spent outside the home, older due to environmental factors [16]. Each year, more than one-third of the American elderly adults are disproportionately likely to fall there, often due to lack of familiarity and uneven surfaces; (2) prescription fall, with outdoor falls comprising nearly half the total— about 45%—of all elderly falls [17]. Outdoor falls com- medications, mobility impairments, and nonuse of assistive prise nearly half the total—about 48%—of all elderly falls devices are associated with greater likelihood of falling; (3) [18]. Since Americans spend only 7% of their time outdoors lower perceived fall risk is related to higher likelihood of [19], this is greatly disproportionate. -e same is true in falling; and (4) many evidence-based fall-reduction in- -ailand, where the Health Insurance System Research terventions exist. Some of these findings have been dem- Office (HISRO) [20] reported that -ai women and men onstrated to have cross-cultural application. It is utopian to believe fall-related injuries can be aged 60–69 are more likely to fall in public settings than in the home. eradicated, but one can realistically hope to reduce fall in- cidence and prevalence, even as nations’ population age and, Most outdoor falls are precipitated by environmental factors, such as uneven surfaces and tripping or slipping on as they do, the risk of falls increase. -e aim of this research, by reporting demographic, health, and behavioral correlates objects and usually occur on sidewalks, curbs, and streets [21]. -is finding has cross-cultural support from studies in of falls for community-dwelling -ai elderly, was to add to Canada [22], England [23], Norway [24], Finland [25, 26], the knowledge base of universal versus culture-specific fall- Israel [27], and Japan [28]. Several researchers [29–31] reduction knowledge, attitudes, and practices. For older Journal of Aging Research 3 falls in the past three months, general cause of falls people, there seem to be cross-cultural commonalities in risk of falling. But there is likely variation in preventive or in- (e.g., medication side effects, hazardous home environ- ment), specific cause of falls (e.g., footwear, drowsiness, poor tervention activities; these can depend on aspects like a society’s view of aging and older people and the cultural lighting), general (indoors and outdoors), and specific (e.g., acceptability of a proposed intervention (thus the impor- kitchen, sidewalk, temple) locations of falls, fall-related tance of properly framing the intervention). health problems, and treatment (if any) after falling. Two types of relationships are of interest: those that support prior research and those that vary from prior re- 2.2. Data Analysis. Descriptive statistics (mean, median, search. -e latter case may merely reflect methodological standard deviation, frequency, and percentage distributions) variance from prior studies but also could indicate the were used to describe the demographic, health, and falls impact of cultural variation on the risk of falls. In both cases, history data of the sample. Data were analyzed using SPSS the findings could help identify fall prevention strategies that version 17. Due to most variables being measured at the could reduce falls among community-dwelling older adults, nominal level, including the dependent variable (falls promote safe, independent, healthy aging, and be culturally measured as yes/no or never/ever), chi-square was calcu- appropriate. lated, and p< 0.05 was chosen to indicate statistical sig- nificance. In some cross tabulations, a cell had a frequency of 2. Methods zero; these instances related never/ever fall to muscle weakness, medical condition/lack of assistive devices, haz- 2.1. Sampling, Sample, and Data Collection. -ailand, ardous home environment, footwear/clothing, and a country in Southeast Asia, comprises 77 provinces and is indoor/outdoor area. In these cases, the Fisher Exact Test divided into four regions: North, Central, Northeast, and was calculated; p< 0.001 was chosen to indicate statistical South. For this study, one province—Surat -ani—was significance [42]. randomly chosen from the Southern region due to the residence of the lead author (“researcher”). -e province has 19 districts containing a total of 131 subdistricts. Ten dis- 2.3. Research Ethics. -is study was approved by the ethics tricts were randomly selected, and from each, a convenience committee at Boromarajonani College of Nursing, Surat sample of one subdistrict was chosen. Convenience criteria -ani, -ailand. It was also approved by the Ethics Com- were ease of access by the researcher (transportation and mittee of the Provincial Public Health Office in -ailand for relative proximity), researcher safety, and ease of access to the research involving human subjects. -e purpose of the older adults. Each subdistrict has a hospital. -e researcher research was explained to participants, as were voluntary met with each hospital’s director; with the director’s consent, participation, identity protection (confidentiality), and re- the researcher then met with the hospital’s Health Pro- searcher contact information. Informed consent was ob- motion Director to obtain a list of older adults. In each tained from all participants. Survey data were entered into subdistrict, a list of all older adults was extracted from a password-protected database on the first author’s secured a database made available by public health officers. Each computer. resulting list contained 80–200 older adults; the total for all ten subdistricts was 2203. 3. Results A random sample of 50 was drawn from each list. -e 500 randomly selected -ai older adults then had to meet the -e demographic characteristics of the sample are presented following inclusion criteria: aged 60–69, voluntary partici- in Table 1. -ere were 406 community-dwelling older adults pation, neither a current psychiatric diagnosis nor a history aged 60–69 (M � 64.60, SD � 3.20), with slightly more of such diagnoses, and sufficiently literate to complete (52.2%) in the older category. -ere were slightly more a questionnaire with minimal assistance. Some were ex- females (56.0%) than males. About two-thirds (63.85%) were cluded due to being older than 69, and some chose not to living in towns, the rest in cities. Nearly half (46.8%) were participate. Nine older adults with a current psychiatric married, with another 31% self-identifying as part of diagnosis or history of psychiatric diagnoses were excluded a couple; 12.1% were single, with smaller percentages sep- from the sample. No one was excluded due to illiteracy. arated or divorced. Over half (53.9%) had primary school After exclusions, a sample contained 406 older adults. education or less. Just over one-quarter (27.9%) considered Demographic, health, and falls history data were collected themselves working (merchant or employee), with the rest via surveys administered at participants’ homes or other reporting themselves as unemployed, pensioners, or gar- convenient locations (e.g., senior clubs, temples) between 15 deners. Four of five (80.5%) lived in their own homes, with June and 31 October 2017. Demographic variables were age, another 12.3% living with relatives. gender, marital status, residential location, education, oc- -e number of family members in the household where cupational status, residence type, number of family members the participant lived ranged from 1 to 9 persons, with two- in household, living arrangement, income, main source of thirds of participants living in households with 2–5 family income, and health service provider. Health variables were members. Seventy percent lived with spouses and/or body mass index, vision, hearing, chronic condition di- children; another 22% were living with nephews or nie- agnosis, medication use, and alcohol use. Fall history var- ces. Hardly any older -ais (1.2%) lived alone. Partici- iables were falls since turning 60, falls in the past six months, pants’ mean income was 10,953 -ai baht per month 4 Journal of Aging Research Table 1: Demographic characteristics of the sample. Table 1: Continued. Number Number Variable Percent Variable Percent (n � 406) (n � 406) Age Government support 219 30.7 60–64 194 47.8 Working 190 26.6 65–69 212 52.2 Health service provider Mean: 64.6 years Government hospital 405 99.8 Standard deviation: 3.2 years Private hospital 1 0.2 Gender Male 175 43.1 Female 231 56.9 Residential location (about US$ 335). A bit less than one-third (30.7%) came City 147 36.2 from government support, followed by employment Town 259 63.8 (26.6%) and children (25.4%). -ai elderly in the sample Marital status had, essentially, no savings. All but one of the 406 par- Single 49 12.1 ticipants received health care from the government Couple 126 31.0 Married 190 46.8 hospital. Divorced 14 3.4 Data on participants’ health status are presented in Separated 27 6.7 Table 2. Body mass index (BMI) showed well over half Education (63.3%) to be overweight or obese. About three-fifths Uneducated 24 5.9 (61.3%) had normal vision. Of those with vision prob- Primary school 195 48.0 lems, more than four-fifths were diagnosed with presbyopia Some secondary school 71 17.5 or blurry vision. Nine of ten participants had normal High school graduate 43 10.6 hearing; of those who did not, less than one in five used any Vocational education 22 5.4 type of hearing aid. -e majority (60.1%) of participants had Bachelor’s degree 6 1.5 a diagnosed medical condition, with the primary ones being Master’s degree 45 11.1 hypertension, hyperlipidemia, diabetes mellitus, benign Occupational status prostate hypertrophy, or heart disease. Two-thirds (66.0%) Unemployed 143 35.2 used medications to help with their medical conditions, with Pensioner 36 8.9 the most common being antihypertensive drugs, anti- Merchant 62 15.3 hyperlipidemia drugs, and antihyperglycemic drugs. Nine of Employee 51 12.6 Gardener 114 28.1 ten participants (92.1%) reported not drinking alcohol. Participants’ fall history is described in Table 3. About Residence Own house 327 80.5 three-quarters (73.9%) of the sample reported no falls since Relative’s house 50 12.3 age 60, with the rest acknowledging one or more falls. Of the Rental house 29 7.1 26.1% reporting falls, most (21.1%) reported falling one or Number of family members two times since turning 60. Only about one in ten had fallen in household in the six months preceding the study; even fewer had fallen Range: 1–9 in the preceding three months. Mean: 3.51 Although the great majority of the sample did not Standard deviation: 1.53 identify specific causes for their falls, some of the attributed Living arrangement causes, such as a hazardous home environment, were more Alone 9 1.2 common than others. Physical weakness, medication side Spouse 268 35.1 effects, and lack of assistive devices were also reported. Children 265 34.9 Regarding specific causes, improper footwear and “contact Nephew/niece 168 22.0 falls” (losing one’s balance due to being jostled, bumping Cousin 26 3.4 into furniture, etc.) were the most commonly mentioned. Others 26 3.4 More participants fell outdoors (65.1%) than indoors; Income (-ai baht per month, about one in ten (11.3%) reported falls in both locations. As 1000 baht � US$ 30–31) one might expect, the majority of outdoor falls (69.3%) Minimum: 500 occurred in the area surrounding the house. Indoor falls Maximum: 112,000 Mean: 10,953 were most common in frequently used areas: kitchen, Standard deviation: 12,520 bedroom, and living room. Main source of income For -ai elderly, a fall comes with physical consequences; Children 181 25.4 nearly all (97.2%) reported fall-related health problems. Of Spouse 68 9.5 those reporting physical consequences, fortunately, most cited Cousin 17 2.4 relatively minor problems: swelling/bruising, pain, and Pension 38 5.3 abrasions comprised 85.7% of reported consequences. More Journal of Aging Research 5 Table 2: Health status of the sample. (4) overweight and obese (measured by BMI) elderly compared to normal weight and underweight elderly; Number Variable Percentage (5) those with visual impairment compared to those with (n � 406) normal vision; (6) those with a chronic health condition; Body mass index 2 (7) those using medications versus those who do not; (8) Underweight (<17.50 kg/m ) 3 0.7 those reporting muscle weakness compared to those Normal weight (17.50–22.99 kg/m ) 146 36.0 claiming no muscle weakness; (9) those reporting side effects Overweight (23.00–27.99 kg/m ) 192 47.3 from medications; (10) those with physical impairments who Obese (≥28 kg/m ) 65 16.0 Minimum: 15.56 kg/m lack assistive devices; (11) those reporting a hazardous home Maximum: 43.75 kg/m environment; and (12) those using footwear or clothing that Mean: 24.60 kg/m can contribute to falling. Standard deviation: 4.15 kg/m Vision 4. Discussion Normal 249 61.3 Abnormal 157 38.7 -e sample of 406 community-dwelling -ai adults aged Presbyopia 98 51.9 60–69 had many traits that imply representativeness of the Blurry vision 64 33.9 -ai population and, in fact, make this sample similar to Cataract 12 6.3 those of other studies. -ere were more females than males, Glaucoma 3 1.6 more in rural than urban areas, most were living in their own Pterygium 12 6.3 residences, and nearly all received health care from gov- Hearing ernment facilities. Normal 367 90.4 On the other hand, three-quarters of the -ai sample Abnormal 39 9.6 were married or cohabiting, educational attainment was low Hearing aids 6 17.1 Deaf 29 82.9 (over half had not attended secondary school), nearly all (about 19 of 20) lived with immediate or extended family, Diagnosis of chronic condition No 162 39.9 and over one-quarter reported their main source of income Yes 244 60.1 as their children (31% reported “government support”). Diabetes 76 19.2 In addition, nearly two-thirds (63.3%) were overweight Heart 18 4.6 or obese based on BMI; a solid majority (61.3%) reported Hypertension 167 42.3 normal vision, and 90.4% reported normal hearing. Six in Hyperlipidemia 99 25.1 ten had a chronic condition diagnosis, and two-thirds were Benign prostate hypertrophy 35 8.9 taking one or more medications. As might be expected in Medication use a heavily Buddhist nation, over nine in ten (92.1%) reported No 138 34.0 not drinking alcohol. Yes 268 66.0 Regarding falls history, only one-quarter (26.1%) of the Antianalgesic drugs 51 11.0 sample reported one or more falls since turning 60 (com- Bone and joint medicine 15 3.21 pared to the one-third of American elderly who fall in Antidiuretic drugs 6 1.3 a given year); however, the maximum age in the sample was Antihyperglycemic drugs 77 16.6 Cardiac medications 16 3.4 69, and it can be expected that falls incidence and prevalence Antihypertensive drugs 168 36.2 will rise as the sample lives into its 70s, 80s, and 90s. Despite Antihyperlipidemia drugs 96 20.7 the disproportionate likelihood of falling outside (versus Antidepressive 1 0.2 inside the home) based on percent of time spent outside, the Sleeping pill 14 3.0 most commonly attributed cause of falls was indoors: Others 20 4.3 a “hazardous home environment.” Alcohol drinking Bivariate analyses found several factors were associated No 374 92.1 with higher fall risk: age, urban residence, low or high Yes 32 7.9 educational attainment, being overweight or obese, impaired vision, chronic health conditions, medication use and side serious outcomes, such as lacerations, fractures, dislocations, effects, muscle weakness, nonuse of assistive devices, or head injuries, were far less common, accounting for 14.3% a hazardous home environment, and certain types of of reported problems. Treatment behavior was quite varied: footwear/clothing. about one-quarter went to the hospital, another quarter One counterintuitive finding was the high percent obtained medications from a pharmacy, and another quarter (35.6%) of the sample with master’s degrees (n � 45) used no treatment whatsoever. reporting ever falling (Table 4). In general, the percent Table 4 reports bivariate analyses of likelihood of falling reporting a fall declined as education increased. -is could and several independent variables. For community-dwelling result from increasing educational attainment leading to less -ais aged 60–69, falls are significantly more likely to occur physical and physically risky jobs, better health education and among (1) city residents versus residents of towns; (2) older health promotion opportunities, and better overall health. -e participants; (3) those with the least or the most education; literature on the education-falls relationship reaches no 6 Journal of Aging Research Table 3: Falls history. Table 3: Continued. Number Number Event Percentage Event Percentage (n � 406) (n � 406) Falls since 60 years old In a hurry to void 8 1.7 None 300 73.9 Foot numbness 7 1.5 Some 106 26.1 General numbness 6 1.3 1 time 57 14.0 Poor lighting 5 1.1 2 times 29 7.1 Stairs 5 1.1 3 times 11 2.7 Muscle tension 3 0.6 4 times 5 1.2 High-heeled shoes 3 0.6 5 times 2 0.5 Skewness 2 0.4 6 times 1 0.2 Falls location 10 times 1 0.2 Outdoor 69 65.1 Falls in previous 6 months Indoor 25 23.6 None 360 88.7 Both 12 11.3 Some 46 11.3 Indoor falls location 1 time 33 8.1 Kitchen 22 30.6 2 times 9 2.2 Bedroom 14 19.4 3 times 3 0.7 Living room 11 15.3 4 times 1 0.2 Terraces 11 15.3 Falls in previous 3 months Bathroom 7 9.7 None 376 92.6 Stairs 6 8.3 Some 30 7.4 Roof 1 1.4 1 time 22 5.4 Outdoor falls location 2 times 7 1.7 House surroundings 52 69.3 3 times 1 0.2 Footpath/sidewalk 12 16.0 Attributed general causes of falls Street/road 4 5.3 Muscle weakness Hospital/clinic 2 2.7 No 339 83.5 Sky walk/overpass 2 2.7 Yes 67 16.5 Mall/supermarket 1 1.3 Medication side effect -eatre 1 1.3 No 334 82.3 Temple 1 1.3 Yes 72 17.7 Falls-related health problems Medical condition/lack of None 3 2.8 assistive devices Some 103 97.2 No 357 87.9 Physical consequences Yes 49 12.1 Swelling/bruising 63 50.0 Hazardous home environment Pain 30 23.8 No 309 76.1 Abrasion 15 11.9 Yes 97 23.9 Fracture/dislocation 10 7.9 Specific causes of falls Laceration 6 4.8 Slippery shoes 51 10.8 Head injury 2 1.6 Contact with other person/object 47 10.0 Treatment Slippery floor 40 8.5 Buying drugs at pharmacy 29 27.4 Fatigue 39 8.3 Hospital 28 26.4 Headache 25 5.3 No treatment 26 24.5 Blurry vision 24 5.1 Resting at home for 1-2 days 14 13.2 Muscle pain 24 5.1 Resting for “a while” 6 5.7 Muscle weakness 22 4.7 Clinic 3 2.8 Presbyopia 20 4.2 Dizziness 17 3.6 Slope/uneven ground 15 3.2 consensus: studies from Australia and Finland found the Cramp 13 2.8 logically expected inverse relationship [26, 43], while other Numb leg 13 2.8 studies found a positive ([44], in America) or insignificant Hard heeled shoes 13 2.8 ([45], in Turkey) relationship between educational attainment Flushing toilet 12 2.5 Slippery bathroom 11 2.3 and falls among older adults. Additional cross cultural and Foot abnormality 10 2.1 multivariate studies are needed to understand the relation- Long dress or sarong 10 2.1 ship, if any, between educational attainment and falls among Stumbling 9 1.9 older adults. Cesspool 9 1.9 In some ways, -ai culture can affect the risk and rate of Drowsiness 8 1.7 elderly falls. -ai culture, historically and even today, is Journal of Aging Research 7 Table 4: Likelihood of falling by selected factors. Table 4: Continued. Falling, number (%) Falling, number (%) Variable p value Variable p value Never Ever Never Ever Residential location <0.001 Vision 0.001 City 88 (59.9) 59 (40.1) Normal 198 (79.5) 51 (20.5) Town 212 (81.9) 47 (18.1) Abnormal 102 (65.0) 55 (35.0) Presbyopia 63 (64.3) 35 (35.7) Gender 0.19 Blurry vision 41 (64.1) 23 (35.9) Male 135 (77.1) 40 (22.9) Cataract 7 (58.3) 5 (41.7) Female 165 (71.4) 66 (28.6) Glaucoma 3 (100.0) 0 Age 0.029 Pterygium 7 (58.3) 5 (41.7) 60–64 153 (78.9) 41 (21.1) Hearing 0.065 65–69 147 (69.3) 65 (30.7) Normal 276 (75.2) 91 (24.8) Marital status 0.9 Abnormal 24 (61.5) 15 (38.5) Single 34 (69.4) 15 (30.6) Hearing aids 5 (83.3) 1 (16.7) Couple 97 (77.0) 29 (23.0) Deaf 17 (58.6) 12 (41.4) Married 138 (72.6) 52 (27.4) Diagnosis of chronic Divorced 10 (71.4) 4 (28.6) <0.001 condition Separated 21 (77.8) 6 (22.2) No 144 (88.9) 18 (11.1) Education 0.009 Yes 156 (63.9) 88 (36.1) Uneducated 19 (79.2) 5 (20.8) Diabetes 53 (69.7) 23 (30.3) Primary school 137 (70.3) 58 (29.7) Heart 12 (66.7) 6 (33.3) Secondary school 60 (84.5) 11 (15.5) Hypertension 105 (62.9) 62 (37.1) High school graduate 38 (88.4) 5 (11.6) Hyperlipidemia 64 (64.6) 35 (35.4) Vocational education 12 (54.5) 10 (16.7) Benign prostate 21 (60.0) 14 (40.0) Bachelor’s degree 5 (83.3) 1 (16.7) hypertrophy Master’s degree 29 (64.4) 16 (35.6) Medication use <0.001 Residence 0.45 No 125 (90.6) 13 (9.4) Own house 241 (73.7) 86 (26.3) Yes 175 (65.3) 93 (34.7) Relative’s house 35 (70.0) 15 (30.0) Antianalgesic drugs 29 (56.9) 22 (43.1) Rental house 24 (82.8) 5 (17.2) Bone and joint medicine 5 (33.3) 10 (66.7) Number of family members Antidiuretic drugs 1 (16.7) 5 (83.3) 0.13 in household Antihyperglycemic drugs 53 (68.8) 24 (31.2) 1 person 9 (52.9) 8 (47.1) Cardiac medications 13 (81.3) 3 (18.8) 2–4 persons 228 (75.0) 76 (25.0) Antihypertensive drugs 108 (64.3) 60 (35.7) 5+ persons 63 (74.1) 22 (25.9) Antihyperlipidemia drugs 62 (64.3) 34 (35.4) Antidepressive 1 (100.0) 0 Living arrangement 0.08 Sleeping pill 11 (78.6) 3 (21.4) Spouse 203 (75.7) 65 (24.3) Others 12 (60.0) 8 (40.0) Children 199 (74.8) 67 (25.2) Nephew/niece 118 (70.2) 50 (29.8) Alcohol drinking 0.051 Cousin 16 (61.5) 10 (38.5) No 281 (75.1) 93 (24.9) Others 20 (76.9) 6 (23.1) Yes 19 (59.4) 13 (40.6) Alone 5 (55.6) 4 (44.4) Muscle weakness <0.001 Occupation 0.59 No 300 (88.5) 39 (11.5) Unemployed 99 (69.2) 44 (30.8) Yes 0 67 (100.0) Pensioner 27 (75.0) 9 (25.0) Weak 22 (33.8) Merchant 48 (77.4) 14 (22.6) Fatigue 39 (60.0) Employee 41 (80.4) 10 (19.6) Cramp 13 (20.0) Gardener 85 (74.6) 29 (25.4) Numb leg 13 (20.0) Numb foot 7 (10.8) Income 0.5 Muscle tension 3 (4.6) Below poverty line 33 (70.2) 14 (29.8) (<2,647 baht/month) Medication side effect <0.001 Above poverty line No 319 (95.5) 15 (4.5) 267 (74.4) 92 (25.6) (2,647+ baht/month) Yes 42 (58.3) 30 (41.7) BMI 0.046 Headaches 25 (34.2) Blurry vision 24 (32.9) Underweight (<17.50 kg/m ) 3 (100) 0 Drowsiness 8 (11.0) Normal weight 115 (78.8) 31 (21.2) Diuretic 8 (11.0) (17.50–22.99 kg/m ) Muscle aches 24 (32.9) Overweight 142 (74.0) 50 (26.0) Numbness 6 (8.2) (23.00–27.99 kg/m ) Dizziness 17 (23.3) Obese (≥28 kg/m ) 40 (61.5) 25 (38.5) 8 Journal of Aging Research Table 4: Continued. However, the effects of modernization on the lived expe- rience of older adults can be and are mediated by culture. Falling, number (%) Variable p value For example, in -ailand, China, and other Asian na- Never Ever tions including highly modernized Japan, there is a strong Medical condition/lack cultural norm of filial piety that (adult) children will honor <0.001 of assistive devices their aging parents by caring for them, even to the point of No 300 (84.0) 57 (16.0) doing as much as they can for them. Regarding the focus of Yes 0 49 (100.0) this research, this operationalization of filial piety can in- Myopia 18 (36.7) clude activities the aging parents might still be quite capable Presbyopia 20 (40.8) of doing themselves, leading to less physical activity, less Skewness 2 (4.1) muscle tone, and thus increased fall risk. Abnormal foot 10 (20.4) -e data suggest recommendations to reduce fall risk for Home hazard environment <0.001 older -ais. First, the interior home environment could be No 300 (97.1) 9 (2.9) Yes 0 97 (100.0) modified, often at little or no cost, to reduce the risk of falling. Slippery floor 40 (41.2) Examples include better lighting, nonskid flooring, and grab Slope/uneven ground 15 (15.5) bars/handrails in the bathrooms and on stairs. Second, the Stumbling 9 (9.3) external environment could be modified, given the dispro- Contact with other portionate number of falls that occur outside and the 70% that 47 (48.5) person/object occur on the “house surroundings.” Smoothing/repairing Poor lighting 5 (5.2) uneven surfaces, and adding handrails on outside stairs or Stairs 5 (5.2) replacing stairs with ramps are examples of such modifica- Flushing toilet 12 (12.4) tions. Older adults could be strongly encouraged to maintain Cesspool 9 (9.3) Slippery bathroom 11 (11.3) a healthy weight, to seek treatment for vision problems, to learn about and practice chronic disease self-management, Footwear/clothing <.0001 No 300 (89.6) 35 (10.4) and maintain regular physical activity. When it comes to Yes 0 71 (100.0) clothing and footwear, safety should be a greater concern than Slippery shoes 51 (71.8) vanity. High-heeled shoes 3 (4.2) As is well known, the physical and psychosocial con- Hard-heeled shoes 13 (18.3) sequences of elderly falls are significant and negative, a drain Long dress/sarong 10 (14.1) on the time, energy, and resources of the older adult and Indoor area <0.001 his/her family. But these consequences, and thus the rec- No 300 (85.2) 52 (14.8) ommendations above, pertain to more macrolevels as Yes 0 54 (100.0) well—the community and the nation. -e World Health Bedroom 14 (25.5) Organization, on a global level, and national organizations Kitchen 22 (40.0) like AARP in the United States have developed guides to age- Living room 11 (20.0) friendly homes, communities, and societies. Many of their Terraces 11 (20.0) assessments and recommendations are relevant and appli- Stairs 6 (10.9) Bathroom 7 (12.7) cable cross culturally. New regulations for construction of Roof 1 (1.8) home and business environments, subsidization of age- Outdoor area <0.001 friendly renovations, and macrolevel initiatives to pro- No 300 (86.7) 46 (13.3) mote physical activity, fight obesity, and manage chronic Yes 0 60 (100.0) health conditions can be implemented on community and Home surrounding 52 (82.5) national levels and adapted for cultural acceptability as Foot path 12 (19.0) necessary. Department store 1 (1.6) Sky walk/overpass 2 (3.2) Street/road 4 (6.3) 5. Conclusions -eatre 1 (1.6) Temple 1 (1.6) Globally and nationally, populations are aging. Rising life Hospital/clinic 2 (3.3) expectancy is due mainly to advances in medical science and technology (especially in reducing infant and child mor- tality). -e rapid increase in the percent of older adults is due collectivistic and family oriented. In a more individualistic also to decades-long declines in fertility. -e world and and independent culture, such as in the United States, the nations are aging, quickly and permanently, and this must be government often provides economic, health care and other planned for. supports for older adults based on the assumption that the Falling has significant and negative consequences for older family will not or cannot do this. Within any given nation, adults and their families, communities, and societies. -ese this shift from a more communal to a more individualistic consequences affect families, communities, and societies along society tends to occur with modernization [46, 47]. several dimensions, including economic, psychosocial, and Journal of Aging Research 9 [4] World Health Organization, "e Global Burden of Disease: health care. Age is strongly related to falling; as populations 2004 Update, World Health Organization, Geneva, Switzerland, age, it is more important than ever to take evidence-based steps to change knowledge, attitudes, and behaviors to reduce fall [5] G. Bergen, L. H. Chen, M. Warner, and L. A. Fingerhut, Injury risk at home, in the community, and in society. in the United States: 2007, National Center for Health Sta- Data in this study came from a nonrepresentative sample tistics, Hyattsville, MD, USA, 2008. of older -ai adults in one province of southern -ailand. [6] Department of Health and Human Services, Office of Disease -us, generalizability is limited. Replication in the three Prevention and Health Promotion. Healthy People 2020, 2013, other regions of -ailand would help assess both validity and http://www.healthypeople.gov/2020. reliability; more representative samples would also be [7] L. D. Gillespie, M. Robertson, W. Gillespie et al., “In- advantageous. terventions for preventing falls in older people living in the Some results of this study of community-dwelling older community,” Cochrane Database of Systematic Reviews, vol. 2, -ais support prior research in other nations and thus add to 2009. [8] C. O. Bekibele and O. Gureje, “Fall incidence in a population the knowledge base of falls, fall risk, and fall-reduction of elderly persons in Nigeria,” Gerontology, vol. 56, no. 3, strategies that have cross-cultural applicability. At the pp. 278–283, 2010. same time, some results vary from prior research and show [9] E. Weir and L. Culmer, “Fall prevention in the elderly the necessity of cultural awareness. It is only through such population,” CMAJ, vol. 171, no. 7, p. 724, 2004. awareness that some questions—for example, why are the [10] N. R. Hooyman and H. A. Kiyak, Social Gerontology: A least- and most-educated -ai elderly more likely to fall?— Multidisciplinary Perspective, Allyn and Bacon, Boston, MA, will find answers, and only through such awareness can USA, 9th edition, 2011. evidence-based interventions be developed to adapt to en- [11] National Center for Health Statistics, Mortality Multiple sure cultural acceptability. Cause Files, 2000–2013, 2013, http://www.cdc.gov/nchs/data_ access/vitalstatsonline.htm. [12] Centers for Disease Control and Prevention, Ten Leading Data Availability Causes of Injury Deaths by Age Group Highlighting Un- intentional Injury Death, Centers for Disease Control and Data availability inquiries should be addressed to the first Prevention, Atlanta, GA, USA, 2014. author. [13] M. Rogerson and C. Emes, “Fostering resilience within an adult day support program,” Activities, Adaptation and Aging, Conflicts of Interest vol. 32, no. 1, pp. 1–18, 2008. [14] R. A. Newton, “Maximizing independence: reducing/ -e authors declare that they have no conflicts of interest. preventing falls,” Geriatric Care Management Journal, vol. 12, no. 2, pp. 16–19, 2002. [15] K. Frick, J. Kung, J. Parrish, and M. Narrett, “Evaluating the Authors’ Contributions cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults,” Journal of the All authors have contributed significantly to the research American Geriatrics Society, vol. 58, no. 1, pp. 136–141, concept, literature review, and objectives. -ey all are in agreement with the content of the manuscript. All authors [16] G. Feder, C. Cryer, S. Donovan, and Y. Carter, “Guidelines for approved the manuscript and this submission. the prevention of falls in older people,” BMJ, vol. 321, no. 7267, pp. 1007–1011, 2000. [17] M. E. Tinetti, “Clinical practice. 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Correlates of Falls among Community-Dwelling Elderly in Thailand

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Hindawi Journal of Aging Research Volume 2018, Article ID 8546085, 10 pages https://doi.org/10.1155/2018/8546085 Research Article Correlates of Falls among Community-Dwelling Elderly in Thailand 1 1 2 Titaporn Worapanwisit, Somkid Prabpai, and Ed Rosenberg Health Promotion and Health Education, Faculty of Education, Kasetsart University, Bangkok 10903, "ailand Department of Sociology, Appalachian State University, Boone, NC 28608, USA Correspondence should be addressed to Ed Rosenberg; rosenberge@appstate.edu Received 24 January 2018; Accepted 7 May 2018; Published 24 May 2018 Academic Editor: Barbara Shukitt-Hale Copyright © 2018 Titaporn Worapanwisit et al. -is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Nearly every nation is experiencing rapid population aging. One area of major concern is health; a major health risk for older adults is falling, and there are multiple negative consequences of falling. -is is a global concern yet is underresearched in many nations. -is study examines demographic, health, and environmental correlates of falling among community-dwelling -ai elderly. Data were collected from a sample of 406 adults aged 60–69. Significant (p< 0.05) fall correlates were urban residence, older age, greater BMI, impaired and uncorrected vision, chronic health conditions, medication use and medication side effects, poor muscle tone, and hazardous indoor and outdoor home environments. Results lead to recommendations for interventions to reduce fall risk that are both evidence-based and culturally acceptable. Population aging has serious implications for 1. Introduction individuals, families, communities, and nations. -e faster In the twenty-first century, most nations are experiencing the aging, the more quickly and severely the challenges rapid growth of their older populations, both in number and arrive, and the more difficult it is for governments to react as a percent of the population. -is growth is largely at- effectively. Large-scale proactive initiatives, if and where tributable to decreasing mortality due to advances in they exist, seem the exception that proves the under- medicine and health promotion, and to fertility declines. -e preparedness rule. portion of the world’s population aged 60+, 12% in 2015, is Adapting health care for an aging population is one such projected to rise to 22%, to 2.1 billion, by 2050. major challenge. As people live longer, all else equal, they will live longer with illness and other impairments. -e older adult growth rate is not uniform across na- tions: less-developed nations will experience more rapid Extending healthy life expectancy is more difficult than growth. While those aged 60+ in developed countries grew extending life expectancy, and the “rectangularization of the by 29% from 2000 to 2015, less-developed countries can survival curve” [3], where we live a long, healthy life ending expect a 60–71% increase by 2030. By 2050 nearly 80% of the in a brief, precipitous terminal drop, remains the Holy Grail world’s older population will live in these less-developed of life extension. countries. Many Asian nations are in this latter category. By One typology of causes of death is composed of non- 2030, 60% of Asians will be 60+ and Asia will be home to communicable diseases, communicable disease, and injuries. more than half of the world’s oldest-old persons (aged 80+) -e World Health Organization [4] believes the distribution [1]. of noncommunicable disease deaths will remain relatively In this context, -ailand is typical of Asian nations. -e constant, while communicable disease deaths will decrease. In contrast, deaths due to injuries—the focus of this World Health Organization [2] estimates that those aged 60+ will comprise 29.6% of the -ai population in 2050. research—will grow through 2030. Injury-related deaths are 2 Journal of Aging Research reported that prescription medications can contribute to fall a large burden on society, financially and otherwise, but many of these deaths are preventable [5]. Unintentional- risk. Jung et al. [32] found that mobility impairments (transferring, gait imbalance, and lack of equilibrium) in- injury deaths, the five leading causes of which are falls, motor vehicle traffic crashes, suffocation, poisoning, and fire [6], crease fall risk. Guzman et al. [33] related nonuse of assistive focus the current study further. devices to increased odds of falling. In a -ai study, A fall is “an unexpected event in which the participant Kuhirunyaratn et al. [34] reported that elderly who use comes to rest on the ground, floor, or lower level” [7]. psychotropic medications are almost twice as likely to fall as Similarly, Bekibele and Gureje [8] described a fall as an those who do not (see also [35, 36]). Gait disturbance, visual unintentional loss of balance, causing one to make un- impairment, and depression also doubled fall risk, and in- appropriate indoor environment (cluttered rooms, slippery expected or unprepared contact with the ground or floor. Weir and Culmer [9] noted that a fall results from a complex floors, nonadapted bathrooms, and dim lighting) nearly tripled the risk of falling. combination of individual factors operating alone or in association with precipitating environmental factors. Still, measures to reduce fall risk can be taken, especially at the individual and community levels. Fall-reduction Falls are by far the most common cause of injury and unintentional-injury death among older persons in the improvements can be made inside and outside the home United States [10], accounting for more than one-half (55%) [37], often inexpensively. of the total; in contrast, the second most common cause, Since falls incidence and prevalence rise with age, since motor vehicle accidents, accounts for only 14% [11]. Both nearly every nation is experiencing rapid population ag- the NCHS and the Centers for Disease Control and Pre- ing, and since the health, economic, and quality of life vention [12] report that the rank of falls as a cause of impacts of falls are significant on both micro- and mac- rolevels, there is a need for evidence-based research on unintentional-injury death rises with age, from tenth among those aged 25–34 to first for those aged 60+. effective fall prevention strategies and programs that re- duce fall risks. Fortunately, many such studies exist, Falls also have greater consequences for older adults compared to younger adults. Elderly falls may cause serious, looking at the efficacy of both single- and multi-factor interventions to reduce risk factors and fall incidence. perhaps fatal injuries such as fractures, joint dislocation, and/or head trauma. But even if falls have no lasting impact Exercise is the most common intervention used to reduce on older adults’ physical health, they can have significant fall risk factors in community-dwelling older adults. effects on psychosocial health, including greater fear of Balance, gait, and strength training have been shown to be falling that can lead to social isolation [13]. It is difficult to effective methods to reduce and prevent falls among determine the definitive risk factors for falling [14]. community-dwelling older adults [38]. For example, a Nonetheless, fall risk factors can be trichotomized as follows: study of older adults [39] found that fall evaluation, balance training, home hazard management, fall pre- (1) intrinsic risk factors related to normal age changes, gender, race, physical problems, medical conditions, cog- vention education, exercise, and home visitations resulted in significant fall reduction. Other multifaceted inter- nitive impairment, and degree of physical inactivity, (2) extrinsic risk factors, such as outdated vision correction, ventions, such as exercise plus dietary supplements [40] taking multiple prescribed medications, improper footwear, and exercise plus fall prevention education [41], yielded and nonuse of assistive devices, and (3) environmental risk reduced fall rates among older adults. factors, such as loose carpet, lack of grab bars in the Overall, falls are the leading cause of unintentional- bathroom, poor lighting, unsafe stairs, and uneven or injury deaths and can result from multiple causes, either slippery surfaces. Over one-third of elderly fall at least once singly or in combination. -e risk of such death rises with annually due to various intrinsic and extrinsic risk factors age. Even nonfatal falls have more serious consequences for [15]; 30–50% of falls among community-dwelling elderly are older adults than younger age groups. Major findings in- clude (1) compared to time spent outside the home, older due to environmental factors [16]. Each year, more than one-third of the American elderly adults are disproportionately likely to fall there, often due to lack of familiarity and uneven surfaces; (2) prescription fall, with outdoor falls comprising nearly half the total— about 45%—of all elderly falls [17]. Outdoor falls com- medications, mobility impairments, and nonuse of assistive prise nearly half the total—about 48%—of all elderly falls devices are associated with greater likelihood of falling; (3) [18]. Since Americans spend only 7% of their time outdoors lower perceived fall risk is related to higher likelihood of [19], this is greatly disproportionate. -e same is true in falling; and (4) many evidence-based fall-reduction in- -ailand, where the Health Insurance System Research terventions exist. Some of these findings have been dem- Office (HISRO) [20] reported that -ai women and men onstrated to have cross-cultural application. It is utopian to believe fall-related injuries can be aged 60–69 are more likely to fall in public settings than in the home. eradicated, but one can realistically hope to reduce fall in- cidence and prevalence, even as nations’ population age and, Most outdoor falls are precipitated by environmental factors, such as uneven surfaces and tripping or slipping on as they do, the risk of falls increase. -e aim of this research, by reporting demographic, health, and behavioral correlates objects and usually occur on sidewalks, curbs, and streets [21]. -is finding has cross-cultural support from studies in of falls for community-dwelling -ai elderly, was to add to Canada [22], England [23], Norway [24], Finland [25, 26], the knowledge base of universal versus culture-specific fall- Israel [27], and Japan [28]. Several researchers [29–31] reduction knowledge, attitudes, and practices. For older Journal of Aging Research 3 falls in the past three months, general cause of falls people, there seem to be cross-cultural commonalities in risk of falling. But there is likely variation in preventive or in- (e.g., medication side effects, hazardous home environ- ment), specific cause of falls (e.g., footwear, drowsiness, poor tervention activities; these can depend on aspects like a society’s view of aging and older people and the cultural lighting), general (indoors and outdoors), and specific (e.g., acceptability of a proposed intervention (thus the impor- kitchen, sidewalk, temple) locations of falls, fall-related tance of properly framing the intervention). health problems, and treatment (if any) after falling. Two types of relationships are of interest: those that support prior research and those that vary from prior re- 2.2. Data Analysis. Descriptive statistics (mean, median, search. -e latter case may merely reflect methodological standard deviation, frequency, and percentage distributions) variance from prior studies but also could indicate the were used to describe the demographic, health, and falls impact of cultural variation on the risk of falls. In both cases, history data of the sample. Data were analyzed using SPSS the findings could help identify fall prevention strategies that version 17. Due to most variables being measured at the could reduce falls among community-dwelling older adults, nominal level, including the dependent variable (falls promote safe, independent, healthy aging, and be culturally measured as yes/no or never/ever), chi-square was calcu- appropriate. lated, and p< 0.05 was chosen to indicate statistical sig- nificance. In some cross tabulations, a cell had a frequency of 2. Methods zero; these instances related never/ever fall to muscle weakness, medical condition/lack of assistive devices, haz- 2.1. Sampling, Sample, and Data Collection. -ailand, ardous home environment, footwear/clothing, and a country in Southeast Asia, comprises 77 provinces and is indoor/outdoor area. In these cases, the Fisher Exact Test divided into four regions: North, Central, Northeast, and was calculated; p< 0.001 was chosen to indicate statistical South. For this study, one province—Surat -ani—was significance [42]. randomly chosen from the Southern region due to the residence of the lead author (“researcher”). -e province has 19 districts containing a total of 131 subdistricts. Ten dis- 2.3. Research Ethics. -is study was approved by the ethics tricts were randomly selected, and from each, a convenience committee at Boromarajonani College of Nursing, Surat sample of one subdistrict was chosen. Convenience criteria -ani, -ailand. It was also approved by the Ethics Com- were ease of access by the researcher (transportation and mittee of the Provincial Public Health Office in -ailand for relative proximity), researcher safety, and ease of access to the research involving human subjects. -e purpose of the older adults. Each subdistrict has a hospital. -e researcher research was explained to participants, as were voluntary met with each hospital’s director; with the director’s consent, participation, identity protection (confidentiality), and re- the researcher then met with the hospital’s Health Pro- searcher contact information. Informed consent was ob- motion Director to obtain a list of older adults. In each tained from all participants. Survey data were entered into subdistrict, a list of all older adults was extracted from a password-protected database on the first author’s secured a database made available by public health officers. Each computer. resulting list contained 80–200 older adults; the total for all ten subdistricts was 2203. 3. Results A random sample of 50 was drawn from each list. -e 500 randomly selected -ai older adults then had to meet the -e demographic characteristics of the sample are presented following inclusion criteria: aged 60–69, voluntary partici- in Table 1. -ere were 406 community-dwelling older adults pation, neither a current psychiatric diagnosis nor a history aged 60–69 (M � 64.60, SD � 3.20), with slightly more of such diagnoses, and sufficiently literate to complete (52.2%) in the older category. -ere were slightly more a questionnaire with minimal assistance. Some were ex- females (56.0%) than males. About two-thirds (63.85%) were cluded due to being older than 69, and some chose not to living in towns, the rest in cities. Nearly half (46.8%) were participate. Nine older adults with a current psychiatric married, with another 31% self-identifying as part of diagnosis or history of psychiatric diagnoses were excluded a couple; 12.1% were single, with smaller percentages sep- from the sample. No one was excluded due to illiteracy. arated or divorced. Over half (53.9%) had primary school After exclusions, a sample contained 406 older adults. education or less. Just over one-quarter (27.9%) considered Demographic, health, and falls history data were collected themselves working (merchant or employee), with the rest via surveys administered at participants’ homes or other reporting themselves as unemployed, pensioners, or gar- convenient locations (e.g., senior clubs, temples) between 15 deners. Four of five (80.5%) lived in their own homes, with June and 31 October 2017. Demographic variables were age, another 12.3% living with relatives. gender, marital status, residential location, education, oc- -e number of family members in the household where cupational status, residence type, number of family members the participant lived ranged from 1 to 9 persons, with two- in household, living arrangement, income, main source of thirds of participants living in households with 2–5 family income, and health service provider. Health variables were members. Seventy percent lived with spouses and/or body mass index, vision, hearing, chronic condition di- children; another 22% were living with nephews or nie- agnosis, medication use, and alcohol use. Fall history var- ces. Hardly any older -ais (1.2%) lived alone. Partici- iables were falls since turning 60, falls in the past six months, pants’ mean income was 10,953 -ai baht per month 4 Journal of Aging Research Table 1: Demographic characteristics of the sample. Table 1: Continued. Number Number Variable Percent Variable Percent (n � 406) (n � 406) Age Government support 219 30.7 60–64 194 47.8 Working 190 26.6 65–69 212 52.2 Health service provider Mean: 64.6 years Government hospital 405 99.8 Standard deviation: 3.2 years Private hospital 1 0.2 Gender Male 175 43.1 Female 231 56.9 Residential location (about US$ 335). A bit less than one-third (30.7%) came City 147 36.2 from government support, followed by employment Town 259 63.8 (26.6%) and children (25.4%). -ai elderly in the sample Marital status had, essentially, no savings. All but one of the 406 par- Single 49 12.1 ticipants received health care from the government Couple 126 31.0 Married 190 46.8 hospital. Divorced 14 3.4 Data on participants’ health status are presented in Separated 27 6.7 Table 2. Body mass index (BMI) showed well over half Education (63.3%) to be overweight or obese. About three-fifths Uneducated 24 5.9 (61.3%) had normal vision. Of those with vision prob- Primary school 195 48.0 lems, more than four-fifths were diagnosed with presbyopia Some secondary school 71 17.5 or blurry vision. Nine of ten participants had normal High school graduate 43 10.6 hearing; of those who did not, less than one in five used any Vocational education 22 5.4 type of hearing aid. -e majority (60.1%) of participants had Bachelor’s degree 6 1.5 a diagnosed medical condition, with the primary ones being Master’s degree 45 11.1 hypertension, hyperlipidemia, diabetes mellitus, benign Occupational status prostate hypertrophy, or heart disease. Two-thirds (66.0%) Unemployed 143 35.2 used medications to help with their medical conditions, with Pensioner 36 8.9 the most common being antihypertensive drugs, anti- Merchant 62 15.3 hyperlipidemia drugs, and antihyperglycemic drugs. Nine of Employee 51 12.6 Gardener 114 28.1 ten participants (92.1%) reported not drinking alcohol. Participants’ fall history is described in Table 3. About Residence Own house 327 80.5 three-quarters (73.9%) of the sample reported no falls since Relative’s house 50 12.3 age 60, with the rest acknowledging one or more falls. Of the Rental house 29 7.1 26.1% reporting falls, most (21.1%) reported falling one or Number of family members two times since turning 60. Only about one in ten had fallen in household in the six months preceding the study; even fewer had fallen Range: 1–9 in the preceding three months. Mean: 3.51 Although the great majority of the sample did not Standard deviation: 1.53 identify specific causes for their falls, some of the attributed Living arrangement causes, such as a hazardous home environment, were more Alone 9 1.2 common than others. Physical weakness, medication side Spouse 268 35.1 effects, and lack of assistive devices were also reported. Children 265 34.9 Regarding specific causes, improper footwear and “contact Nephew/niece 168 22.0 falls” (losing one’s balance due to being jostled, bumping Cousin 26 3.4 into furniture, etc.) were the most commonly mentioned. Others 26 3.4 More participants fell outdoors (65.1%) than indoors; Income (-ai baht per month, about one in ten (11.3%) reported falls in both locations. As 1000 baht � US$ 30–31) one might expect, the majority of outdoor falls (69.3%) Minimum: 500 occurred in the area surrounding the house. Indoor falls Maximum: 112,000 Mean: 10,953 were most common in frequently used areas: kitchen, Standard deviation: 12,520 bedroom, and living room. Main source of income For -ai elderly, a fall comes with physical consequences; Children 181 25.4 nearly all (97.2%) reported fall-related health problems. Of Spouse 68 9.5 those reporting physical consequences, fortunately, most cited Cousin 17 2.4 relatively minor problems: swelling/bruising, pain, and Pension 38 5.3 abrasions comprised 85.7% of reported consequences. More Journal of Aging Research 5 Table 2: Health status of the sample. (4) overweight and obese (measured by BMI) elderly compared to normal weight and underweight elderly; Number Variable Percentage (5) those with visual impairment compared to those with (n � 406) normal vision; (6) those with a chronic health condition; Body mass index 2 (7) those using medications versus those who do not; (8) Underweight (<17.50 kg/m ) 3 0.7 those reporting muscle weakness compared to those Normal weight (17.50–22.99 kg/m ) 146 36.0 claiming no muscle weakness; (9) those reporting side effects Overweight (23.00–27.99 kg/m ) 192 47.3 from medications; (10) those with physical impairments who Obese (≥28 kg/m ) 65 16.0 Minimum: 15.56 kg/m lack assistive devices; (11) those reporting a hazardous home Maximum: 43.75 kg/m environment; and (12) those using footwear or clothing that Mean: 24.60 kg/m can contribute to falling. Standard deviation: 4.15 kg/m Vision 4. Discussion Normal 249 61.3 Abnormal 157 38.7 -e sample of 406 community-dwelling -ai adults aged Presbyopia 98 51.9 60–69 had many traits that imply representativeness of the Blurry vision 64 33.9 -ai population and, in fact, make this sample similar to Cataract 12 6.3 those of other studies. -ere were more females than males, Glaucoma 3 1.6 more in rural than urban areas, most were living in their own Pterygium 12 6.3 residences, and nearly all received health care from gov- Hearing ernment facilities. Normal 367 90.4 On the other hand, three-quarters of the -ai sample Abnormal 39 9.6 were married or cohabiting, educational attainment was low Hearing aids 6 17.1 Deaf 29 82.9 (over half had not attended secondary school), nearly all (about 19 of 20) lived with immediate or extended family, Diagnosis of chronic condition No 162 39.9 and over one-quarter reported their main source of income Yes 244 60.1 as their children (31% reported “government support”). Diabetes 76 19.2 In addition, nearly two-thirds (63.3%) were overweight Heart 18 4.6 or obese based on BMI; a solid majority (61.3%) reported Hypertension 167 42.3 normal vision, and 90.4% reported normal hearing. Six in Hyperlipidemia 99 25.1 ten had a chronic condition diagnosis, and two-thirds were Benign prostate hypertrophy 35 8.9 taking one or more medications. As might be expected in Medication use a heavily Buddhist nation, over nine in ten (92.1%) reported No 138 34.0 not drinking alcohol. Yes 268 66.0 Regarding falls history, only one-quarter (26.1%) of the Antianalgesic drugs 51 11.0 sample reported one or more falls since turning 60 (com- Bone and joint medicine 15 3.21 pared to the one-third of American elderly who fall in Antidiuretic drugs 6 1.3 a given year); however, the maximum age in the sample was Antihyperglycemic drugs 77 16.6 Cardiac medications 16 3.4 69, and it can be expected that falls incidence and prevalence Antihypertensive drugs 168 36.2 will rise as the sample lives into its 70s, 80s, and 90s. Despite Antihyperlipidemia drugs 96 20.7 the disproportionate likelihood of falling outside (versus Antidepressive 1 0.2 inside the home) based on percent of time spent outside, the Sleeping pill 14 3.0 most commonly attributed cause of falls was indoors: Others 20 4.3 a “hazardous home environment.” Alcohol drinking Bivariate analyses found several factors were associated No 374 92.1 with higher fall risk: age, urban residence, low or high Yes 32 7.9 educational attainment, being overweight or obese, impaired vision, chronic health conditions, medication use and side serious outcomes, such as lacerations, fractures, dislocations, effects, muscle weakness, nonuse of assistive devices, or head injuries, were far less common, accounting for 14.3% a hazardous home environment, and certain types of of reported problems. Treatment behavior was quite varied: footwear/clothing. about one-quarter went to the hospital, another quarter One counterintuitive finding was the high percent obtained medications from a pharmacy, and another quarter (35.6%) of the sample with master’s degrees (n � 45) used no treatment whatsoever. reporting ever falling (Table 4). In general, the percent Table 4 reports bivariate analyses of likelihood of falling reporting a fall declined as education increased. -is could and several independent variables. For community-dwelling result from increasing educational attainment leading to less -ais aged 60–69, falls are significantly more likely to occur physical and physically risky jobs, better health education and among (1) city residents versus residents of towns; (2) older health promotion opportunities, and better overall health. -e participants; (3) those with the least or the most education; literature on the education-falls relationship reaches no 6 Journal of Aging Research Table 3: Falls history. Table 3: Continued. Number Number Event Percentage Event Percentage (n � 406) (n � 406) Falls since 60 years old In a hurry to void 8 1.7 None 300 73.9 Foot numbness 7 1.5 Some 106 26.1 General numbness 6 1.3 1 time 57 14.0 Poor lighting 5 1.1 2 times 29 7.1 Stairs 5 1.1 3 times 11 2.7 Muscle tension 3 0.6 4 times 5 1.2 High-heeled shoes 3 0.6 5 times 2 0.5 Skewness 2 0.4 6 times 1 0.2 Falls location 10 times 1 0.2 Outdoor 69 65.1 Falls in previous 6 months Indoor 25 23.6 None 360 88.7 Both 12 11.3 Some 46 11.3 Indoor falls location 1 time 33 8.1 Kitchen 22 30.6 2 times 9 2.2 Bedroom 14 19.4 3 times 3 0.7 Living room 11 15.3 4 times 1 0.2 Terraces 11 15.3 Falls in previous 3 months Bathroom 7 9.7 None 376 92.6 Stairs 6 8.3 Some 30 7.4 Roof 1 1.4 1 time 22 5.4 Outdoor falls location 2 times 7 1.7 House surroundings 52 69.3 3 times 1 0.2 Footpath/sidewalk 12 16.0 Attributed general causes of falls Street/road 4 5.3 Muscle weakness Hospital/clinic 2 2.7 No 339 83.5 Sky walk/overpass 2 2.7 Yes 67 16.5 Mall/supermarket 1 1.3 Medication side effect -eatre 1 1.3 No 334 82.3 Temple 1 1.3 Yes 72 17.7 Falls-related health problems Medical condition/lack of None 3 2.8 assistive devices Some 103 97.2 No 357 87.9 Physical consequences Yes 49 12.1 Swelling/bruising 63 50.0 Hazardous home environment Pain 30 23.8 No 309 76.1 Abrasion 15 11.9 Yes 97 23.9 Fracture/dislocation 10 7.9 Specific causes of falls Laceration 6 4.8 Slippery shoes 51 10.8 Head injury 2 1.6 Contact with other person/object 47 10.0 Treatment Slippery floor 40 8.5 Buying drugs at pharmacy 29 27.4 Fatigue 39 8.3 Hospital 28 26.4 Headache 25 5.3 No treatment 26 24.5 Blurry vision 24 5.1 Resting at home for 1-2 days 14 13.2 Muscle pain 24 5.1 Resting for “a while” 6 5.7 Muscle weakness 22 4.7 Clinic 3 2.8 Presbyopia 20 4.2 Dizziness 17 3.6 Slope/uneven ground 15 3.2 consensus: studies from Australia and Finland found the Cramp 13 2.8 logically expected inverse relationship [26, 43], while other Numb leg 13 2.8 studies found a positive ([44], in America) or insignificant Hard heeled shoes 13 2.8 ([45], in Turkey) relationship between educational attainment Flushing toilet 12 2.5 Slippery bathroom 11 2.3 and falls among older adults. Additional cross cultural and Foot abnormality 10 2.1 multivariate studies are needed to understand the relation- Long dress or sarong 10 2.1 ship, if any, between educational attainment and falls among Stumbling 9 1.9 older adults. Cesspool 9 1.9 In some ways, -ai culture can affect the risk and rate of Drowsiness 8 1.7 elderly falls. -ai culture, historically and even today, is Journal of Aging Research 7 Table 4: Likelihood of falling by selected factors. Table 4: Continued. Falling, number (%) Falling, number (%) Variable p value Variable p value Never Ever Never Ever Residential location <0.001 Vision 0.001 City 88 (59.9) 59 (40.1) Normal 198 (79.5) 51 (20.5) Town 212 (81.9) 47 (18.1) Abnormal 102 (65.0) 55 (35.0) Presbyopia 63 (64.3) 35 (35.7) Gender 0.19 Blurry vision 41 (64.1) 23 (35.9) Male 135 (77.1) 40 (22.9) Cataract 7 (58.3) 5 (41.7) Female 165 (71.4) 66 (28.6) Glaucoma 3 (100.0) 0 Age 0.029 Pterygium 7 (58.3) 5 (41.7) 60–64 153 (78.9) 41 (21.1) Hearing 0.065 65–69 147 (69.3) 65 (30.7) Normal 276 (75.2) 91 (24.8) Marital status 0.9 Abnormal 24 (61.5) 15 (38.5) Single 34 (69.4) 15 (30.6) Hearing aids 5 (83.3) 1 (16.7) Couple 97 (77.0) 29 (23.0) Deaf 17 (58.6) 12 (41.4) Married 138 (72.6) 52 (27.4) Diagnosis of chronic Divorced 10 (71.4) 4 (28.6) <0.001 condition Separated 21 (77.8) 6 (22.2) No 144 (88.9) 18 (11.1) Education 0.009 Yes 156 (63.9) 88 (36.1) Uneducated 19 (79.2) 5 (20.8) Diabetes 53 (69.7) 23 (30.3) Primary school 137 (70.3) 58 (29.7) Heart 12 (66.7) 6 (33.3) Secondary school 60 (84.5) 11 (15.5) Hypertension 105 (62.9) 62 (37.1) High school graduate 38 (88.4) 5 (11.6) Hyperlipidemia 64 (64.6) 35 (35.4) Vocational education 12 (54.5) 10 (16.7) Benign prostate 21 (60.0) 14 (40.0) Bachelor’s degree 5 (83.3) 1 (16.7) hypertrophy Master’s degree 29 (64.4) 16 (35.6) Medication use <0.001 Residence 0.45 No 125 (90.6) 13 (9.4) Own house 241 (73.7) 86 (26.3) Yes 175 (65.3) 93 (34.7) Relative’s house 35 (70.0) 15 (30.0) Antianalgesic drugs 29 (56.9) 22 (43.1) Rental house 24 (82.8) 5 (17.2) Bone and joint medicine 5 (33.3) 10 (66.7) Number of family members Antidiuretic drugs 1 (16.7) 5 (83.3) 0.13 in household Antihyperglycemic drugs 53 (68.8) 24 (31.2) 1 person 9 (52.9) 8 (47.1) Cardiac medications 13 (81.3) 3 (18.8) 2–4 persons 228 (75.0) 76 (25.0) Antihypertensive drugs 108 (64.3) 60 (35.7) 5+ persons 63 (74.1) 22 (25.9) Antihyperlipidemia drugs 62 (64.3) 34 (35.4) Antidepressive 1 (100.0) 0 Living arrangement 0.08 Sleeping pill 11 (78.6) 3 (21.4) Spouse 203 (75.7) 65 (24.3) Others 12 (60.0) 8 (40.0) Children 199 (74.8) 67 (25.2) Nephew/niece 118 (70.2) 50 (29.8) Alcohol drinking 0.051 Cousin 16 (61.5) 10 (38.5) No 281 (75.1) 93 (24.9) Others 20 (76.9) 6 (23.1) Yes 19 (59.4) 13 (40.6) Alone 5 (55.6) 4 (44.4) Muscle weakness <0.001 Occupation 0.59 No 300 (88.5) 39 (11.5) Unemployed 99 (69.2) 44 (30.8) Yes 0 67 (100.0) Pensioner 27 (75.0) 9 (25.0) Weak 22 (33.8) Merchant 48 (77.4) 14 (22.6) Fatigue 39 (60.0) Employee 41 (80.4) 10 (19.6) Cramp 13 (20.0) Gardener 85 (74.6) 29 (25.4) Numb leg 13 (20.0) Numb foot 7 (10.8) Income 0.5 Muscle tension 3 (4.6) Below poverty line 33 (70.2) 14 (29.8) (<2,647 baht/month) Medication side effect <0.001 Above poverty line No 319 (95.5) 15 (4.5) 267 (74.4) 92 (25.6) (2,647+ baht/month) Yes 42 (58.3) 30 (41.7) BMI 0.046 Headaches 25 (34.2) Blurry vision 24 (32.9) Underweight (<17.50 kg/m ) 3 (100) 0 Drowsiness 8 (11.0) Normal weight 115 (78.8) 31 (21.2) Diuretic 8 (11.0) (17.50–22.99 kg/m ) Muscle aches 24 (32.9) Overweight 142 (74.0) 50 (26.0) Numbness 6 (8.2) (23.00–27.99 kg/m ) Dizziness 17 (23.3) Obese (≥28 kg/m ) 40 (61.5) 25 (38.5) 8 Journal of Aging Research Table 4: Continued. However, the effects of modernization on the lived expe- rience of older adults can be and are mediated by culture. Falling, number (%) Variable p value For example, in -ailand, China, and other Asian na- Never Ever tions including highly modernized Japan, there is a strong Medical condition/lack cultural norm of filial piety that (adult) children will honor <0.001 of assistive devices their aging parents by caring for them, even to the point of No 300 (84.0) 57 (16.0) doing as much as they can for them. Regarding the focus of Yes 0 49 (100.0) this research, this operationalization of filial piety can in- Myopia 18 (36.7) clude activities the aging parents might still be quite capable Presbyopia 20 (40.8) of doing themselves, leading to less physical activity, less Skewness 2 (4.1) muscle tone, and thus increased fall risk. Abnormal foot 10 (20.4) -e data suggest recommendations to reduce fall risk for Home hazard environment <0.001 older -ais. First, the interior home environment could be No 300 (97.1) 9 (2.9) Yes 0 97 (100.0) modified, often at little or no cost, to reduce the risk of falling. Slippery floor 40 (41.2) Examples include better lighting, nonskid flooring, and grab Slope/uneven ground 15 (15.5) bars/handrails in the bathrooms and on stairs. Second, the Stumbling 9 (9.3) external environment could be modified, given the dispro- Contact with other portionate number of falls that occur outside and the 70% that 47 (48.5) person/object occur on the “house surroundings.” Smoothing/repairing Poor lighting 5 (5.2) uneven surfaces, and adding handrails on outside stairs or Stairs 5 (5.2) replacing stairs with ramps are examples of such modifica- Flushing toilet 12 (12.4) tions. Older adults could be strongly encouraged to maintain Cesspool 9 (9.3) Slippery bathroom 11 (11.3) a healthy weight, to seek treatment for vision problems, to learn about and practice chronic disease self-management, Footwear/clothing <.0001 No 300 (89.6) 35 (10.4) and maintain regular physical activity. When it comes to Yes 0 71 (100.0) clothing and footwear, safety should be a greater concern than Slippery shoes 51 (71.8) vanity. High-heeled shoes 3 (4.2) As is well known, the physical and psychosocial con- Hard-heeled shoes 13 (18.3) sequences of elderly falls are significant and negative, a drain Long dress/sarong 10 (14.1) on the time, energy, and resources of the older adult and Indoor area <0.001 his/her family. But these consequences, and thus the rec- No 300 (85.2) 52 (14.8) ommendations above, pertain to more macrolevels as Yes 0 54 (100.0) well—the community and the nation. -e World Health Bedroom 14 (25.5) Organization, on a global level, and national organizations Kitchen 22 (40.0) like AARP in the United States have developed guides to age- Living room 11 (20.0) friendly homes, communities, and societies. Many of their Terraces 11 (20.0) assessments and recommendations are relevant and appli- Stairs 6 (10.9) Bathroom 7 (12.7) cable cross culturally. New regulations for construction of Roof 1 (1.8) home and business environments, subsidization of age- Outdoor area <0.001 friendly renovations, and macrolevel initiatives to pro- No 300 (86.7) 46 (13.3) mote physical activity, fight obesity, and manage chronic Yes 0 60 (100.0) health conditions can be implemented on community and Home surrounding 52 (82.5) national levels and adapted for cultural acceptability as Foot path 12 (19.0) necessary. Department store 1 (1.6) Sky walk/overpass 2 (3.2) Street/road 4 (6.3) 5. Conclusions -eatre 1 (1.6) Temple 1 (1.6) Globally and nationally, populations are aging. Rising life Hospital/clinic 2 (3.3) expectancy is due mainly to advances in medical science and technology (especially in reducing infant and child mor- tality). -e rapid increase in the percent of older adults is due collectivistic and family oriented. In a more individualistic also to decades-long declines in fertility. -e world and and independent culture, such as in the United States, the nations are aging, quickly and permanently, and this must be government often provides economic, health care and other planned for. supports for older adults based on the assumption that the Falling has significant and negative consequences for older family will not or cannot do this. Within any given nation, adults and their families, communities, and societies. -ese this shift from a more communal to a more individualistic consequences affect families, communities, and societies along society tends to occur with modernization [46, 47]. several dimensions, including economic, psychosocial, and Journal of Aging Research 9 [4] World Health Organization, "e Global Burden of Disease: health care. Age is strongly related to falling; as populations 2004 Update, World Health Organization, Geneva, Switzerland, age, it is more important than ever to take evidence-based steps to change knowledge, attitudes, and behaviors to reduce fall [5] G. Bergen, L. H. Chen, M. Warner, and L. A. Fingerhut, Injury risk at home, in the community, and in society. in the United States: 2007, National Center for Health Sta- Data in this study came from a nonrepresentative sample tistics, Hyattsville, MD, USA, 2008. of older -ai adults in one province of southern -ailand. [6] Department of Health and Human Services, Office of Disease -us, generalizability is limited. Replication in the three Prevention and Health Promotion. Healthy People 2020, 2013, other regions of -ailand would help assess both validity and http://www.healthypeople.gov/2020. reliability; more representative samples would also be [7] L. D. Gillespie, M. Robertson, W. 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