The Association between Doctor-Diagnosed Arthritis
and Falls and Fall Injuries among Middle-Aged and
Older Adults
LCDR Kamil E. Barbour, PhD, MPH, MS
Arthritis Program
Centers for Disease Control and Prevention
USPHS Symposium (Scientist Category Day): Tuesday, May 19, 2015
National Center for Chronic Disease Prevention and Health Promotion
Division of Population Health
Presenter Disclosures
All authors have no relationships to disclose.
PUBLIC HEALTH BURDEN OF FALLS
• Among older adults (≥65 years), falls are the leading
cause of
• Injury-related morbidity and mortality
• More than 1 in 3 older adults fall each year1
• Hip fractures, traumatic brain injuries
• Decline in functional abilities
• Reduced social and physical activities
• Direct medical costs almost $30 billion annually2
1Information
2Stevens
available at www.cdc.gov/injury/wisqars
JA, et al. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12:290-5
ARTHRITIS AND FALLS
• Major risk factor is poor neuromuscular function (i.e., walking
speed, balance)
•
Common among people with arthritis
• Association between arthritis and increased falls risk among older
adults is well documented
•
Meta-analysis of seven studies showed that persons with arthritis have more
than a two-fold increased risk for falls1
• Little is known about arthritis and falls among middle-aged adults
(45-64 years)
•
1Rubenstein
Prevalence of arthritis and falls is 30%2 and 26%3, respectively
LZ, Josephson KR. Falls and their prevention in elderly people What does the evidence show? Med Clin North Am 2006;90:807–24.
KE , et al. Prevalence of doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2010-2012. MMWR. November 8,
2013 / 62(44);869-873
3Barbour KE, et al. Falls and fall injuries among adults with arthritis—United states, 2012. MMWR. May 2, 2014 / 63(17);379-383
2Barbour
FINDINGS FROM 2014 MMWR ON
STATE-SPECIFIC PREVALENCE OF FALLS
AND FALL INJURIES AMONG ADULTS
WITH ARTHRITIS AGED 45 YEARS OR
OLDER
BARBOUR KE, ET AL. FALLS AND FALL INJURIES AMONG ADULTS WITH
ARTHRITIS—UNITED STATES, 2012. MMWR. MAY 2, 2014 / 63(17);379-383
Median age-standardized1 state prevalence of falls and
fall injury by arthritis status for 50 states and DC
25
[VALUE]*
20
15
[VALUE]*
[VALUE]
12.1
9
10
6.5
5
0
1 Fall
≥2 Falls
Arthritis
1The
*For
Fall injury
No arthritis
standard population used for direct age-adjustment was derived from the 2000 U.S. Census.
each state and DC, those with arthritis had a significantly higher prevalence of ≥2 falls and fall injuries
Median age-standardized state prevalence of falls and
fall injury by arthritis status
40
[VALUE]*
35
30
25
20
21
[VALUE]*
15
10
6.3
5
0
≥1 Fall
Arthritis
1The
*For
Fall injury
No arthritis
standard population used for direct age-adjustment was derived from the 2000 U.S. Census.
each state and DC, those with arthritis had a significantly higher prevalence of ≥1 falls and fall injuries

STUDY OBJECTIVE
• Determine the association between doctordiagnosed arthritis and falls and fall injuries
among middle-aged and older adults
STUDY HYPOTHESIS
• We hypothesize that older or middle-aged adults
with doctor-diagnosed arthritis will have a
significantly higher prevalence of falls and fall
injuries than those without arthritis
METHODS
•
Data source: Behavioral Risk Factor Surveillance System




•
BRFSS: random-digit–dialed landline and cellphone survey
Representative of non-institutionalized adults aged ≥18 years
State-Based survey; also includes DC, Puerto Rico, and Guam
Analytic Sample (n=338,734 respondents, age ≥45 years).
Definition of arthritis
 “Have you ever been told by a doctor or other health professional
that you have some form of arthritis, rheumatoid arthritis, gout,
lupus, or fibromyalgia?”
METHODS - 2
•
Fall
 "In the past 12 months, how many times have you fallen?”
 “By a fall, we mean when a person unintentionally comes to rest on
the ground or on another lower level.
 Categorized as any fall (0 or >1) and 0,1, ≥2 falls
•
Fall injury (asked of those who fell)
 “How many of these falls caused an injury?”
 “By an injury, we mean the fall caused you to limit your regular
activities for at least a day or to go see a doctor.”
 Categorized as any (yes) or none (no)
METHODS - 3
Statistical analyses:
• Log binomial and multinomial regression models were used to
estimate prevalence ratios (PRs) and 95% confidence intervals
(CIs).
•
All regression models adjusted for self-report age, sex, race,
education, body mass index (BMI), health status, physical activity,
heart disease, and stroke.
Baseline Characteristics by Falls
Age 45-64 years
Age ≥65 years
No Falls
% (95% CI)
One or more
Falls
% (95% CI)
No Falls
% (95% CI)
One or more
Falls
% (95% CI)
Arthritis
28.8 (28.3, 29.3)
49.2 (48.3, 50.1)
49.8 (49.1, 50.4)
64.1 (63.1, 65.0)
Obese (BMI ≥30 kg/m2 )
30.7 (30.2, 31.2)
39.3 (38.4, 40.2)
24.6 (24.0 , 25.1)
29.9 (28.9, 30.8)
Some high school
12.1 (11.6, 12.5
15.3 (14.5, 16.1)
17.7 (17.0, 18.2)
19.9 (18.8, 20.7)
Poor/fair health
16.7 (16.3, 17.2)
36.4 (35.5, 37.3)
22.6 (22.0, 23.1)
36.9 (35.9, 37.9)
2.1 (2.0, 2.2)
6.5 (6.0, 7.0)
6.2 (5.9, 6.5)
11.1 (10.5, 11.7)
6.3 (6.0, 6.6)
12.1 (11.5, 12.7)
17.2 (16.7, 17.7)
23.7 (22.9, 24.6)
23.0 (22.5, 23.5)
31.4 (30.6, 32.3)
29.2 (28.7, 29.8)
38. 0 (37.1, 39.0)
2012 Behavioral Risk
Factor Surveillance
System: N=336, 831
Stroke
Heart disease
Physical inactivity
Baseline Characteristics by Fall Injuries
Age 45-64 years
Age ≥65 years
No Fall
Injuries
% (95% CI)
One or more
Fall Injuries
% (95% CI)
No Fall
Injuries
% (95% CI)
One ore more
Fall Injuries
% (95% CI)
Arthritis
31.1 (30.6, 31.5)
59.0 (57.6, 60.4)
51.8 (51.2, 52.3)
68.7 (67.2, 70.2)
Obese (BMI ≥30 kg/m2 )
31.9 (31.4, 32.3)
41.6 (40.2, 43.0)
25.2 (24.7 , 25.7)
31.1 (29.7, 32.6)
Some high school
12.7 (12.2, 13.1)
18.0 (16.7, 19.4)
18.2 (17.7, 18.8)
20.6 (19.2, 22.0)
Poor/fair health
19.2 (18.8, 19.6)
47.9 (46.5, 49.3)
24.8 (24.3, 25.3)
43.9 (42.4, 45.5)
2.6 (2.5, 2.8)
8.7 (7.9, 9.6)
7.0 (6.7, 7.3)
12.6 (11.7, 13.6)
6.9 (6.6, 7.1)
16.0 (15.0, 17.1)
18.2 (17.8, 18.6)
25.8 (24.5, 27.1)
24.1 (23.6, 24.5)
38.0 (36.6, 39.4)
30. 7 (30.2, 31.2)
42.0 (40.5, 43.6)
2012 Behavioral Risk
Factor Surveillance
System: N=336, 831
Stroke
Heart disease
Physical inactivity
Association between Doctor-Diagnosed Arthritis and Falls
and Fall Injuries among Middle-Aged and Older Adults
2012 Behavioral Risk
Factor Surveillance
System: N=336, 831
One or more
falls**
PR (95% CIs)
Two or more
falls**
PR (95% Cis)
One or more
Fall Injuries**
PR (95% CIs)
1.58 (1.53, 1.63)
1.92 (1.82, 2.02)
2.10 (1.97, 2.23)
1.38 (1.34, 1.45)
1.69 (1.59, 1.80)
1.63 (1.52, 1.75)
Middle-Aged (45-64 years)
Arthritis*
Older Adults (≥ 65 years)
Arthritis *
*Reference category is no arthritis
**All models adjusted for age, sex, race, education, BMI, health, physical activity, heart disease, stroke
Analyses used SAS-Callable SUDAAN Version 9.3
Taylor Linearization used to estimate variance.
Summary

Among middle-aged or older adults, those with arthritis
had a significantly higher prevalence of falls and fall
injuries than those without arthritis.

The association between arthritis and falls and fall
injuries was significantly more robust among middleaged adults compared with older adults.

Our findings on fall injuries were corroborated recently
using data from the National Health Interview Survey1

Odds of a fall injury was significantly higher in middle-aged vs. older adults, 91 vs. 36%, respectively
Sheu, Y, et al. The association between arthritis and fall-related injuries among adults aged 45 and older.
2015 Society for Advancement of Violence and Injury Research (SAVIR) conference March 11-13 in New Orleans.
Strengths

Large sample size (N=336, 831)

Used a validated case definition for arthritis1

Controlled for many potential confounders

Used PRs instead of odds ratios (ORs) to measure the
magnitude of the associations
 PRs are more interpratable than ORs and are a more accurate
measure of the association when outcome is common
1Sacks JJ, et al. Validation of a surveillance case definition for arthritis. J Rheumatol 2005;32:340-7
Limitations

Self-report can lead to recall bias and missclassification
of the arthritis, falls, and other variables




The temporal sequence of arthritis and falls could not
be established


However, arthritis question shown to be sufficiently sensitive and specific
Falls prevalence may be underestimated due to recall bias
Conversely, the broad definition of a fall injury might have led participants to
report minor falls as injurious, resulting in an overestimate.
Nonetheless, severallongitudinal studies show that persons with
arthritis have an increased risk for falls
No BRFSS questions assess the severity, location, or
type of arthritis, which might affect falls and fall
injuries differently.
Conclusions

Arthritis was associated with falls and fall injuries in
middle-aged and older adults
 Association was strongest in middle-aged adults

Future increases in numbers of older adults and people
with arthritis underscore the need for falls prevention

Falls prevention: exercise or PT to improve gait, balance,
and lower body strength

Greater dissemination of arthritis management and fall
prevention programs in clinical and community practice
Fall Prevention Strategies
•
Improving strength and balance
• EnhanceFitness
• Fit and Strong
• Tai Chi




Treat chronic diseases that increase fall risk
Reducing polypharmacy
Environmental hazard reduction
Improving vision
Thank you
Questions?
For more information please contact
Kamil E. Barbour
Centers for Disease Control and Prevention
Division of Population Health
Arthritis Program
[email protected]
770-488-5145
Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or
www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the
Centers for Disease Control and Prevention.
National Center for Chronic Disease Prevention and Health Promotion
Division of Population Health in this space
RESULTS
Age-Standardized median state prevalence * among adults > 45
years
• Arthritis
 1 fall
15.5%, range: 10.7-20.1
 >2 falls
21.3%, range: 7.7-30.6
 Fall injury
16.2%, range: 8.5-22.1
• No arthritis
 1 fall
12.1%, range: 7.7-15.1
 >2 falls
9.0%, range: 4.1-14.6
 Fall injury
6.5%, range: 2.7-9.0
* Age-Standardized prevalence for 50 states and DC