Prevalence of Falls and Its Characteristics among Malaysian Older Adults: A Review

Full text

Med & Health Jun 2020; 15(1): 18-33
REVIEW ARTICLE
18
https://doi.org/10.17576/MH.2020.1501.03
Address for correspondence and reprint requests: Muhammad Iqbal Shaharudin. Physiotherapy
Programme, Faculty of Health Sciences, Universiti Teknologi MARA, Cawangan Pulau Pinang, Kampus
Bertam, 13200 Kepala Batas, Pulau Pinang, Malaysia. Tel: +604-562 3444 (ext 3501) Email: iqbal90shahar@
yahoo.com
Prevalence of Falls and Its Characteristics among
Malaysian Older Adults: A Review
MUHAMMAD IQBAL S, BAHMAN J, ASLINDA CM
Physiotherapy Programme, Faculty of Health Sciences, Universiti Teknologi MARA,
Cawangan Pulau Pinang, Kampus Bertam, 13200 Kepala Batas, Pulau Pinang, Malaysia.
ABSTRAK
Kejatuhan adalah isu kesihatan yang sering dikaitkan dengan warga emas di
seluruh dunia. Kejatuhan boleh menyebabkan kesan negatif pada individu dan
juga menyebabkan kematian dalam kes tertentu. Kajian semasa kejatuhan adalah
amat terhad di Malaysia. Tujuan kajian ini adalah untuk merumuskan kajian
semasa yang dijalankan di Malaysia yang mengenai prevalens dan ciri-cirinya.
Artikel telah dikenalpasti melalui menggunakan pangkalan data elektronik berikut:
EBSCOhost, ClinicalKey, ScienceDirect, Wiley Online Library, SpringerLink dan
Google Scholar. Pemilihan artikel adalah terhad kepada artikel bahasa Inggeris
yang diterbitkan antara tahun 2013 hingga 2019. Kajian ini menilai golongan warga
emas yang berumur 60 tahun ke atas; sama ada di kediaman, komuniti atau institut
perubatan. Sembilan artikel yang berkaitan telah dikenalpasti dan disiasat. Hasil
kajian menunjukkan variasi yang ketara dengan julat 4-74 % dalam prevalens
kejatuhan di kalangan warga emas di Malaysia. Salah satu kajian yang dijalankan
dalam komuniti menunjukkan prevalens kejatuhan yang lebih rendah. Majoriti
peristiwa kejatuhan berlaku pada waktu pagi seperti yang dilaporkan oleh tiga
kajian iaitu sebanyak 49%-64.7%. Kejatuhan dalam kawasan bangunan adalah
jumlah tertinggi lokasi jatuh dengan 50-87% manakala di luar bangunan adalah
13-49.3%. Lokasi di bilik mandi / tandas mempunyai peratusan kejatuhan tertinggi
dalam bangunan. Kejatuhan yang menyebabkan kecederaan adalah antara 47%
-82%. Perubahan pada prevalens kejatuhan dalam warga emas ditentukan oleh
faktor-faktor seperti lokasi dan keadaan kesihatan. Maklumat yang dikumpulkan
dalam kajian ini menunjukkan terdapat kekurangan alat ukur piawai bagi mengkaji
ciri-ciri kejatuhan di Malaysia. Kajian prospektif diperlukan untuk menubuhkan
prevalens dan hubungan faktor-kesan kejatuhan di Malaysia.
Kata kunci: ciri-ciri, kecederaan, kejatuhan, Malaysia, prevalens, warga emas

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Fall Characteristics among Malaysian Older Adults Med & Health Jun 2020;15(1): 18-33
ABSTRACT
Falls are major public health issues which highly associated with older adults
worldwide. Falls can cause a negative debilitating effect on the individual and
may lead to fatal injury in certain cases. Current studies on falls characteristics are
limited in Malaysia. The aim of this study was to pool the current studies conducted
in Malaysia regarding the fall and its characteristics. Articles were identified by
using the following electronic databases; EBSCOhost, ClinicalKey, ScienceDirect,
Wiley Online Library, SpringerLink and Google Scholar. Article identification was
limited to English language which were published between 2013 to 2019. This
study looked into older adults aged 60 years old and above; conducted either in
a residential, community-dwelling or medical institute. A total of nine articles was
identified and investigated. Studies indicate a huge variation in the prevalence
falls among older adults in Malaysia ranging between 4-74%. A study that was
conducted in the community indicated lower prevalence of falls. Majority of the
falls occurred in the morning as reported by three studies which covered and
ranged between 49-64.7%. Indoor accounted as the highest number of falls in
term of location and ranged between 50-87% while outdoor falls were between
13-49.3%. Location in bathroom and toilet had the highest percentage of indoor
falls. Fallers that sustained injury ranged between 47-82%. A variation on the fall
prevalence among older adults was determined by factors such as location and
existing medical conditions. Pooled information in our study indicates that there is
lack of standardised measuring tools for falls characteristics in Malaysia. There is a
need for large scale longitudinal prospective study to establish the prevalence and
the causal-effect relationship of falls in Malaysia.
Keywords: characteristics, falls, injury, Malaysia, older adults, prevalence
and may lead to fatal injury in certain
cases (World Health Organization,
2007). Other implications of falling
such financial burden (Cotter et al.
2005), depression (Iaboni & Flint 2013),
injuries such as a fracture (Pi et al. 2015)
and physical inactivity (Assantachai et
al. 2003). Depression and fear of falling
are associated with the impairment
of gait and balance. This association
mediated through cognitive, sensory,
and motor pathways. The management
of depression in fall-prone individuals
INTRODUCTION
Falls were major public health issues
which highly associated with older
adults worldwide (Hill et al., 2018),
although most are from Western
countries. According to the World
Health Organization (2018), falls were
defined as “an event which results in
a person coming to rest inadvertently
on the ground or floor or other lower-
level.” Falls can cause a negative
debilitating effect on the individual

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Med & Health Jun 2020;15(1): 18-33 Muhammad Iqbal S. et al.
is challenging since antidepressant
medications like selective serotonin
reuptake inhibitors can increase the
risk falls and fragility fractures. There
is lack of information regarding the
effect of fall rehabilitation programs on
clinically significant depression. There
was also an increase in the risk of falls
as to the age increased (Kim 2016).
In the United States, fall prevalence
among older adults aged 65 and
above was around 28.2-36.3% (Cigolle
et al. 2015). A study in Germany
indicates there was 25.7-37.4% of falls
prevalence in females and 16.3-28.9%
in males (Rapp et al. 2014). Similarly, a
longitudinal study in United Kingdom
indicates fall prevalence between 20.8-
33.2% in males but higher in females
participant between 26.6-35.1% (Gale
et al. 2016). In general, there was a
lower prevalence of fall reported in
Asian countries compared to Western
countries (World Health Organization,
2007). A study in China reported
prevalence of fall among older adults
aged 60-year-old and above was
19.28% (Wu & Ouyang 2017). An
epidemiology study that conducted
across 10 states in India reported a 14%
of fallers (Krishnaswamy & Usha 2006).
A comparable report from Singapore
also reported a fall prevalence of less
than 15% (Dai et al. 2018).
Study on the characteristics of
falls was scarce in Malaysia. It is
important to understand the probable
consequences and the nature of the falls
especially for prevention, management
measure and resource allocation.
Knowing fall characteristics could help
physiotherapist and other healthcare
professionals to be well-informed and
empowered better healthcare decision
making. Thus, substantial research
on falls characteristics needs to be
conducted to fully understand and
rectify the falls issues among older
adult.
The aim of this study was to
review the prevalence of falls and
characteristics in current studies
conducted in Malaysia regarding fall
prevalence and its characteristics. This
study looked into older individuals
aged 60 years and above; summarised
the fall prevalence either from a
residential, community-dwelling or
medical institute. This information
collected is useful for fall preventive
measures, in order to reduce falls
related injuries among older adults.
MATERIALS AND METHODS
Search Strategy
Articles were identified using the
electronic databases EBSCOhost
(CINAHL Complete, MEDLINE
Complete & Academic Search
Complete), ClinicalKey, ScienceDirect,
Wiley Online Library, SpringerLink,
and Google Scholar. The search
management was conducted using the
following primary search terms; falls
OR fall. The search strategy continued
using the individual search term;
AND Malaysia AND older adult AND
elderly. All the electronic databases
were conducted using a similar search
strategy.
Study Selection
Study selection was divided into a
three-stage process, where first stage

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Fall Characteristics among Malaysian Older Adults Med & Health Jun 2020;15(1): 18-33
was involved the articles identification
to include only those which were
written in English language articles
and that published between 2013 to
2019. Articles were identified through
systematic searching of the database
according to their titles and abstracts
which help in retrieving a substantial
number of 1445 of articles. The second
stage was used to screen and eliminate
those articles not related to falls,
duplicated, subject aged below 60
years, not related to fall characteristics
and not conducted in Malaysia. The
third stage where eligibility checking
for the relevant articles were taken
into consideration before final papers
selection for full-text review. All articles
were screened accordingly based on
the requirement listed in Table 1.
Data Extraction
All articles were screened
independently by the author through
systematic searching of the database.
Relevant information was retrieved
from the articles including participant
information (age, number of subjects,
location), fall prevalence, standardised
1. Are these participants over 60 years old of
age?
2. Are these studies about falls in older adults?
3. Are these studies conducted in Malaysia?
4. Are these studies about falls characteristics?
Table 1: Assessment form to choose
articles
Figure 1: Study selection flowchart of published articles between the year 2013 to 2019

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Med & Health Jun 2020;15(1): 18-33 Muhammad Iqbal S. et al.
assessment tool, fall characteristics,
result, recommendation, limitation and
strength. In this study, appraisal tool to
score study quality was not used as it is
not a compulsory criterion for scoping
a review (Colquhoun et al. 2014).
Study Identification
A total of 1445 articles were identified
through systematic searching of
database where 521 articles from
EBSCOhost, 8 from Web of Science,
24 from ClinicalKey, 72 articles from
ScienceDirect, 172 from Wiley Online
Library, 67 from SpringerLink and
581 from Google Scholar. Studies
were eliminated if not fulfil criteria as
stated in Table 1. Nine studies were
included in our review after excluding
duplicated articles and articles that
do not fulfil inclusion and exclusion
criteria as indicated in Figure 1.
RES U LTS
Articles retrieved from the electronic
database preceding nine years between
2011 to 2019. Total of nine articles was
identified and investigated regarding
falls and its characteristics among older
adults in Malaysia as indicated in Table
2. Seven of the studies were conducted
among community-dwelling older
adults (Azidah et al. 2012; Goh et
al. 2016; Kadir & Hasim 2011; Romli
et al. 2017; Tan et al. 2016; Yeong
et al. 2016; Zia et al. 2016) and the
remaining two studies were conducted
among residential older adults (Ghazi
et al. 2017; Kioh & Rashid 2018).
Majority of the fall prevalence studies
were evaluated in clear definition of
fall and three studies (Azidah et al.
2012; Goh et al. 2016; Kadir & Hasim
2011) in conditioned-specific (stroke
and diabetic) older adults population.
Total of two studies (Romli et al. 2017;
Tan et al. 2016) were conducted in
longitudinal studies and the rest in
cross-sectional studies. Fall prevalence
was defined as retrospective falls
occurred in the preceding 12 months
except for one study (Tan et al. 2016)
in the preceding six months.
Prevalence of Fall
Studies indicated a huge variation in
prevalence of fall among older adults
in Malaysia, ranging between 4-74%
(Azidah et al. 2012; Ghazi et al. 2017;
Goh et al. 2016; Kadir & Hasim 2011;
Kioh & Rashid 2018; Romli et al. 2017;
Tan et al. 2016; Yeong et al. 2016;
Zia et al. 2016). Study that conducted
in community indicated a lower
prevalence of fall of 4.07% (Yeong et
al. 2016) and 22.6% (Romli et al. 2017),
as compared to residential older adults
with 32.8% (Kioh & Rashid 2018) and
30% (Ghazi et al. 2017), and 12-74%
for medical institution (Azidah et al.
2012; Goh et al. 2016; Kadir & Hasim
2011; Tan et al. 2016; Zia et al. 2016).
Prevalence of fall among condition-
specific older adults was between
12.9-29% (Azidah et al. 2012; Goh et
al. 2016; Kadir & Hasim 2011) where
well-defined older adults population
was 4-74% (Ghazi et al. 2017; Kioh &
Rashid 2018; Romli et al. 2017; Tan et
al. 2016; Yeong et al. 2016; Zia et al.
2016).
Location

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Fall Characteristics among Malaysian Older Adults Med & Health Jun 2020;15(1): 18-33
No Studies Participants
(Age, N,
location)
Prevalence
of falls (%)
Standardised
Assessment
tool
Falls Characteristics Results Recommendation Limitation and
Strength
1. Ta n et
al. 2016
Aged
(mean+SD)
(76.2+6.3 years,
N = 198 female
Location
Emergency
Department at
the University
of Malaya
Medical Center,
Malaysia
74% fema l e
in the
preceding 6
months
Barthel Index
(10 items scale)
Time of injury (%)
- 06.00-12.00 (49%)
- 12.00-18.00 (22%)
- 18.00-00.00 (16%)
- 00.00-06.00 (13%)
Location of falls
-Indoor (70%)
Bathroom (27%),
Bedro om (24%),
Kitchen (9%), Stairs (9%),
Othe r (32%).
-Outdoor (19%)
Garden (57%), Others
(43%).
Sustained injury
(82%)
Type of injury
- Fractures (37%)
- Soft Tissues (46%)
Site of injury
- Head (25%), Upper
- limb (20%)
- Femur (16%)
- Lower limb (14%)
- Trunk/ vertebral (10%)
- Others (15%)
Hospital Admission:
(26%)
Age ≥≥75 years
was significantly
associated with
mortality at 1, 3, 5
and 10 years.
Indoor falls and
Barthel≤≤18 were
significantly
associated with
1-year and 3-year
mo r talit y.
Future research
should be
directed at
determining factors
underlying the
excess mortality
among fallers
and identifying
potential solutions
to improve
outcomes among
fallers attending
the Emergency
Department.
Strength
The results
provide crucial
information for
resource planning
and healthcare
decisions.
Limitation
Subjects
predominantly
from women and
Chinese ethnicity.
Table 2: Summary of reviewed studies related to falls prevalence and its characteristics among Malaysian older adults

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Med & Health Jun 2020;15(1): 18-33 Muhammad Iqbal S. et al.
No Studies Participants
(Age, N,
location)
Prevalence
of falls (%)
Standardised
Assessment tool
Falls Characteristics Results Recommendation Limitation and
Strength
2. Goh et
al. 2016
Aged
(mean+SD)
(66+7 years,
N = 125
Location
Primary
Teaching
Hospital,
Malaysia
29% in the
preceding
12 months.
1. Fall Efficacy
Scale-
International
2. Berg Balance
Scale
3. Functional
Ambulation
Category
4. Fatigue Severity
Scale
5. Montreal
Cognitive
Assessment
6. Patient Healthy
Questionnaire-9
7. Fu g l -M ey e r
Motor Assessment
Falls frequency in the
preceding 12 months
1: ( 61%)
≥≥ 2: (39%)
Location of falls
Indoor: (60%)
Outdoor: (40%)
Sustained Injury
(47. 2% )
Hospital Admission
(25%)
Stroke was significantly
more likely to
experience recurrent
falls and fear of falling.
Participants with
stroke reported greater
concern for falling than
did non-stroke control
participants (P <.01).
FES-I score >27 points
(high concern for falling)
was greater in the stroke
group than in the non-
stroke group (P < .01).
Future investigations
should consider the
inclusion of fear
avoidance behaviour as
an outcome because it
may be the intermediate
modulator for fear of
falling and falls.
Limitation
Small sample
size and
cross-sectional
design; causal
relationships
could not be
established.
effects of risk
factors of falling.
Strength
The study
reported
information on
post-stroke falls
and fear of falls.
3. Kadir &
Hasim
20 11
Aged
(mean+SD)
(67. 5+5.6
years,
N = 131
Location
Diabetic
Clinic
Universiti
Sains
Malaysia
Hospital.
12.9%
in the
preceding
12 months.
1. Barthel’s index
2. Tinetti Balance
Falls frequency in the
preceding 12 months
1: (60.7%)
≥ 2: (39.3%)
Timing of falls
Morning (64.7%)
Location of falls
-Indoor (87%)
-Outdoor (13%)
Type of injury
Mild or soft tissue
injuries (76.4%)
Majority of falls
had no eye witness
(52.9%)
Multivariate analysis
indicates falls among
older adult’s men
with diabetics showed
that increasing age,
neuropathy and
orthostatic hypotension
are associated with a
higher risk of falls.
High balance and
gait scoring were
significantly associated
with reduced risk of falls
in older adults men with
diabetes.
Future study to focus
more on diabetic men’s
health concerns which
have been relatively
neglected.
Multi-component
intervention
programmes which
combine medical,
rehabilitative and
environmental
component can
minimise the risk
of falling without
compromising the
mobility and functional
independence in the
older adults.
Limitation
The retrospective
design of this
study prone to
recalled bias
and causal
relationships
could not be
established.

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Fall Characteristics among Malaysian Older Adults Med & Health Jun 2020;15(1): 18-33
No Studies Participants
(Age, N,
location)
Prevalence
of falls (%)
Standardised
Assessment tool
Falls Characteristics Results Recommendation Limitation and
Strength
2. Goh et
al. 2016
Aged
(mean+SD)
(66+7 years,
N = 125
Location
Primary
Teaching
Hospital,
Malaysia
29% in the
preceding
12 months.
1. Fall Efficacy
Scale-
International
2. Berg Balance
Scale
3. Functional
Ambulation
Category
4. Fatigue Severity
Scale
5. Montreal
Cognitive
Assessment
6. Patient Healthy
Questionnaire-9
7. Fu g l -M ey e r
Motor Assessment
Falls frequency in the
preceding 12 months
1: ( 61%)
≥≥ 2: (39%)
Location of falls
Indoor: (60%)
Outdoor: (40%)
Sustained Injury
(47. 2% )
Hospital Admission
(25%)
Stroke was significantly
more likely to
experience recurrent
falls and fear of falling.
Participants with
stroke reported greater
concern for falling than
did non-stroke control
participants (P <.01).
FES-I score >27 points
(high concern for falling)
was greater in the stroke
group than in the non-
stroke group (P < .01).
Future investigations
should consider the
inclusion of fear
avoidance behaviour as
an outcome because it
may be the intermediate
modulator for fear of
falling and falls.
Limitation
Small sample
size and
cross-sectional
design; causal
relationships
could not be
established.
effects of risk
factors of falling.
Strength
The study
reported
information on
post-stroke falls
and fear of falls.
3. Kadir &
Hasim
20 11
Aged
(mean+SD)
(67. 5+5.6
years,
N = 131
Location
Diabetic
Clinic
Universiti
Sains
Malaysia
Hospital.
12.9%
in the
preceding
12 months.
1. Barthel’s index
2. Tinetti Balance
Falls frequency in the
preceding 12 months
1: (60.7%)
≥ 2: (39.3%)
Timing of falls
Morning (64.7%)
Location of falls
-Indoor (87%)
-Outdoor (13%)
Type of injury
Mild or soft tissue
injuries (76.4%)
Majority of falls
had no eye witness
(52.9%)
Multivariate analysis
indicates falls among
older adult’s men
with diabetics showed
that increasing age,
neuropathy and
orthostatic hypotension
are associated with a
higher risk of falls.
High balance and
gait scoring were
significantly associated
with reduced risk of falls
in older adults men with
diabetes.
Future study to focus
more on diabetic men’s
health concerns which
have been relatively
neglected.
Multi-component
intervention
programmes which
combine medical,
rehabilitative and
environmental
component can
minimise the risk
of falling without
compromising the
mobility and functional
independence in the
older adults.
Limitation
The retrospective
design of this
study prone to
recalled bias
and causal
relationships
could not be
established.
No Studies Participants
(Age, N,
location)
Prevalence
of falls (%)
Standardised
Assessment
tool
Falls Characteristics Results Recommendation Limitation and
Strength
4. Azidah
et al.
2012
Aged
(mean+SD)
(66.9+5.81
years,
N = 288
Location
Tertiary
centre in the
East Coast of
Peninsular
Malaysia.
18.8%
in the
preceding
12 months.
1. Bar t hel ’s
Index
2. Tinetti
Balance
3. Semmes-
Weinstein
Monofilament
Timing of falls
- Morning (57.4%)
- Afternoon (38.9%)
- Evening (3.7%)
Location of falls
- Indoor (87%)
- Bathroom (38.9%)
- Bedroom (22.2%), Living
- Room (25.9%),
- Others (13.0%).
Out d o o r (13 %)
Type of injury
- Mild Bruises (79.6%)
- Muscle Pain (14.8%)
- Fracture Limb (5.5%)
Fallers (Gender)
- Males (31.5%)
- Females (68.5%)
Diabetes, female
sex, age group
more than 75 years
old, the presence
of retinopathy
and orthostatic
hypotension are
factors that are
associated with a
higher risk for falls
among older adults.
Nil. Limitation
The retrospective
design of this study
prone to recall
bias and may
underestimate the
actual number and
seriousness of falls.
The cognitive ability
not accessed in this
study hence poor
memory subjects
are more likely
subjected to recall
bias.
5. Yeong
et al.
2016
Aged
(mean+SD)
(70. 21+7.2 4
years,
N = 811
Location
Districts in the
state of Perak,
Malaysia.
4.07%
in the
preceding
12 months.
International
Physical
Activity
Questionnaire
(I PAQ)
Location of falls
- Indoor (75.8%)
- Bathroom (20%)
- Bedroom (8%)
- Kitchen (20%)
- Stairs (8%)
- Living room (16%), -
Outside compound (28%)
Outdoor (24.2%)
Indigenous older
adults (Adjusted odd
ratio, AOR = 6.06,
95% CI = 1.10–33.55,
p = 0.039) and living
alone (AOR = 2.60,
95% CI = 1.04–6.50,
p = 0.042) were
shown to be factors
associated
with falls.
Social support
and provision of
health education to
increase awareness
among older adults.
Primary care
physicians
can provide
comprehensive
geriatric assessment
for older adults.
Limitation
The study was
cross-sectional
in design; causal
relationships could
not be established
and the possibility
of recall bias for
cognitive testing.

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Med & Health Jun 2020;15(1): 18-33 Muhammad Iqbal S. et al.
No Studies Participants
(Age, N,
location)
Prevalence
of falls (%)
Standardised
Assessment
tool
Falls
Characteristics
Results Recommendation Limitation and
Strength
6. Kioh &
Rashid
2018
Aged
(≥60 years)
N = 357
Location
Nursing homes
in the state
of Penang,
Malaysia.
32.8%
in the
preceding
12 months.
1. Fall Risk
Assessment
Tool (F R AT )
2. The
Geriatric
Depression
Scale (GDS)
Falls frequency in
the preceding 12
months
1: (58 .6%)
2: (41.4%)
Depression and the presence
of respiratory illnesses are
strongly associated with the
prevalence of falls.
Higher history of falls was
also at higher risk of falls
Anti-depression
medications
consumed should
be monitored and
the replacement of
pharmacologic to
non-pharmacologic
therapy among
older adults who are
depressed should be
considered where
feasible.
Limitation
Lack of temporality
and convenience
sampling methods
increases the
probability of
obtaining a biased
sample leading to
the possibility of
over representation
Recall bias is
another possibility
considering the
participants were
asked about
previous falls past
12 months.
7. Romli et
al. 201
Aged
(mean+SD)
(68.71+0.39
years,
N = 1489
Location
Older adult
population
residing in
greater Kuala
Lum pur.
22.6%
in the
preceding
12 months.
1. Katz Index
2. Lawton–
Brody scales
3. Home Falls
and Accidents
Screening Tool
(HOM E FAS T)
Falls frequency in
the preceding 12
months
1: (65 .7%)
2: (34.3%)
Location
Indoor (65.7%)
Outdoor (45.1%)
Hazards were frequently
identified (>30%) in the toilet
and bathroom areas (no
grab rail, no non-slip mat,
distant toilet), slippery floors,
no bedside light access and
inappropriate footwear.
Lower educational
attainment, traditional
housing, Chinese ethnicity,
the greater number of home
occupants, lower monthly
expenditure, poor vision and
younger age were the factors
independently associated
with home hazards.
Identify home
hazards and
recommend home
modifications after
the older person falls
in order to prevent
fall recurrence.
A prospective study
using prospective
reporting of falls,
such as using a
fall diary or falls
notification through
phone calls or
postcards.
Limitation
A cross-sectional
design, the
limitation is
expected of where
any causal-and
effect relationship
is unable to be
determined.

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Fall Characteristics among Malaysian Older Adults Med & Health Jun 2020;15(1): 18-33
No Studies Participants
(Age, N,
location)
Prevalence
of falls (%)
Standardised
Assessment tool
Falls Characteristics Results Recommendation Limitation and
Strength
8. Ghazi
et al.
2017
Aged
(mean+SD)
(80+1.24
years,
N = 50
Location
Old folks
home
in Kuala
Lump ur,
Malaysia.
30% in the
preceding 6
months.
Katz Index Reasons for falling
- Tripped (20%)
- Slipped (26.7%)
- Loss of balance (6.7%)
- Legs gave way (26.7%)
- Not sure (20%)
Location of falls
- On one Level (40%)
- Bathroom (26.6%)
- Bedroom (26.7%),
- Garden (6.7)
Sustained injury (66.7%)
Type of injury
- Fractures (40%)
- Bruises (30%)
- Cuts (20%)
- Back Pain (20%)
Hospital Admission (50%)
There is no association
between the
sociodemographic
activity of daily
living, number of
comorbidities and
number of medication
with falls.
Nil. Limitation
Small sample
size
and the
communication
barrier between
researcher and
participants,
prevent them
from obtaining
accurate
information.
9. Zia et
al. 2016
Aged
(≥65 years)
N = 428
Location
Emergency
Department,
Primary Care
clinics and
Geriatric
clinics,
Malaysia.
61.4%
in the
preceding
12 months.
1. Anticholinergic
cognitive burden
(ACB) scale
2. Timed Up and
Go (TUG)
3. Functional
Reach (FR)
4. Grip Strength
(GS)
Location
- Indoor: (50.7%)
- Outdoor: (49.3%)
Sustained Injury
(49.4%)
Univariate analysis
indicates a significant
association bet ween
an ACB score of ≥1
with falls (OR, 1.8;
95% CI; 1.1–3.0; p =
0. 01).
Multivariate analysis
indicates a significant
association bet ween
TUG, FR, GS and falls
after adjusting for age,
gender and number of
comorbidities
Future studies
should also
include adequately
sensitive
assessments of
higher mental
function as well
as lower limb
function.
Limitation
A cross-
sectional
study; causal
relationships
could not be
established.

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Med & Health Jun 2020;15(1): 18-33 Muhammad Iqbal S. et al.
A total of 50 to 1489 older adult’s
participant aged 60-year-old and
above enrolled in these local Malaysian
studies. There were five studies
conducted in a medical institution
(hospital and clinic) (Azidah et al. 2012;
Goh et al. 2016; Kadir & Hasim 2011;
Tan et al. 2016; Zia et al. 2016), two
studies in the residential home (Ghazi
et al. 2017; Kioh & Rashid 2018) and
two studies in community-dwelling
older adults. Note that, all studies were
conducted in Peninsular Malaysia.
Falls Characteristics
Majority of the falls occurred in the
morning as reported by three studies
which contributed to 49-64.7% of
prevalence (Azidah et al. 2012; Kadir &
Hasim 2011; Tan et al. 2016), followed
by afternoon as stated in two studies for
22% and 38.9% of prevalence (Azidah
et al. 2012; Tan et al. 2016). Indoor fall
accounted for the most number of fall
location ranging from 50-87% while
outdoor fall was between 13-49.3%
(Azidah et al. 2012; Goh et al. 2016;
Kadir & Hasim 2011; Romli et al. 2017;
Tan et al. 2016; Yeong et al. 2016; Zia
et al. 2016). Two studies indicated that
location in the bathroom/ toilet has the
highest percentage of indoor falls (Tan
et al. 2016; Yeong et al. 2016). Fallers
that sustained injury were around
47-82% (Ghazi et al. 2017; Goh et
al. 2016; Kadir & Hasim 2011; Tan et
al. 2016; Zia et al. 2016). Sustained
injury including soft tissue injuries
and fracture accounted for 46-94.4%
(Azidah et al. 2012; Ghazi et al. 2017;
Kadir & Hasim 2011; Tan et al. 2016)
and 5.5-40% , respectively (Azidah
et al. 2012; Ghazi et al. 2017; Tan et
al. 2016). One study had reported the
fall-related site of anatomical injury;
including head (25%), upper Limb
(20%), femur (16%), lower Limb (14%),
vertebral (10%) and others (15%) (Tan
et al. 2016). Hospital admission had
been reported in three studies with
prevalence between 25-50% (Ghazi
et al. 2017; Goh et al. 2016). The
retrospective study had reported a 58-
61% of single fall freaquency and 39-
41.4% of two or more falls frequency
(Goh et al. 2016; Kadir & Hasim 2011;
Kioh & Rashid 2018).
Standardised Assessment Tools
Standardised assessment tools that
employed in these studies can be
grouped into falls risk measure, physical
performance measure, functional
measure, cognitive measure and other
outcome measures. The tools under
fall risk measure are including Fall
Efficacy Scale-International (FES-I),
Fall Risk Assessment Tool (FRAT) and
Home Falls and Accidents Screening
Tool (HOME FAST) (Goh et al. 2016;
Kioh & Rashid 2018; Romli et al. 2017).
The physical performance measure-
related tools are Fugl-Meyer Motor
Assessment, Berg Balance Scale,
Tinetti Balance, Semmes-Weinstein
Monofilament, Timed Up and Go
(TUG), Functional Reach (FR) and Grip
Strength (GS) (Azidah et al. 2012; Goh
et al. 2016; Kadir & Hasim 2011; Zia et
al. 2016). The functional measure tools
consist of Barthel Index, Functional
Ambulation Category, Katz Index
and Lawton-Brody Scales (Azidah
et al. 2012; Ghazi et al. 2017; Goh et

29
Fall Characteristics among Malaysian Older Adults Med & Health Jun 2020;15(1): 18-33
al. 2016; Kadir & Hasim 2011; Romli
et al. 2017; Tan et al. 2016). Cognitive
measure tools are Montreal Cognitive
Assessment and Anticholinergic
Cognitive Burden (ACB) scale (Goh
et al. 2016; Zia et al. 2016). Another
standardised outcome measure-tool
like Fatigue Severity Scale, Patient
Healthy Questionnaire-9, International
Physical Activity Questionnaire (IPAQ)
and The Geriatric Depression Scale
(GDS) are also being employed (Goh
et al. 2016; Kioh & Rashid 2018; Yeong
et al. 2016).
Recommendation
Eight out of nine studies had
recommended various fall-related
assessments, intervention or future
studies. Fall assessments had been
recommended by three studies
which include a comprehensive
geriatric assessments by a physician
for older adults (Yeong et al. 2016),
identification of home hazards to
prevent falls recurrence (Romli et al.
2017) and inclusion a higher sensitivity
assessments for mental function and
lower limb (Zia et al. 2016). Intervention
for falls had been mentioned in
three studies which include multi-
component intervention with a
combination of medical, rehabilitation
and environmental (Kadir & Hasim
2011); social support and provision of
health education (Yeong et al. 2016);
and anti-depression drugs provision
among residential older adults (Kioh
& Rashid 2018). Future studies are
recommended to focus on prospective
falls report (Romli et al. 2017), those
factors for excessive mortality among
fallers and identifying solution to
improve the outcome among fallers
(Tan et al. 2016); inclusion of fear-
avoidance behaviour as an outcome
for fear of falling and falls (Goh et
al. 2016) and the study on the male
diabetic patients (Kadir & Hasim 2011).
Summary of Findings
Older age was significantly associated
with prevalence of falls as reported
in three studies (Azidah et al. 2012;
Kadir & Hasim 2011; Tan et al. 2016).
Two studies had shown a correlation
between older adults with diabetes
and orthostatic hypotension with a
higher fall risk (Azidah et al. 2012; Kadir
& Hasim 2011). Indigenous people
(Yeong et al. 2016), higher falls history
(Kioh & Rashid 2018), an older adult
with respiratory illness (Kioh & Rashid
2018) and history of stroke (Goh et al.
2016) also significantly associated with
falls.
Outcomes measure that applied
in two studies had reported a low
Barthel index of faller older adults
was significantly associated with fall
(Goh et al. 2016; Tan et al. 2016).
Physical performance test such as
TUG, Functional Reach, Gait Speed
and Tinetti balance in multivariate and
univariate analysis also revealed an
association with falls (Kadir & Hasim
2011; Zia et al. 2016). Other outcomes
measure such as Fall FES-I (Goh et al.
2016), GDS (Kioh & Rashid 2018) and
ACB scale score of ≥1 had demostrated
a significant association with falls in
univariate analysis (Zia et al. 2016).

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Med & Health Jun 2020;15(1): 18-33 Muhammad Iqbal S. et al.
DISCUSSION
The aim of the study is to identify
the current prevalence of falls and
also identify the fall characteristics
among Malaysia older adults. Nine
relevant articles were identified in the
prevalence of falls and its characteristic
either among residential or community-
dwelling older adults in Malaysia.
Currently, there is no any fall study had
been conducted in East Malaysia. All
articles retrieved were retrospective
in nature; observation in design with
no intervention similar to a previous
review study in Malaysia (Shaharudin
et al. 2018). The advantages of
prospective studies as compared to
retrospective studies where it minimise
the recall bias and the possibility to
under estimate the population at risk
(Sedgwick, 2014).
There was a huge variation of falls
prevalence among Malaysian older
adults due to a different location in data
collection. The higher prevalence was
reported on the residential area (Ghazi
et al. 2017). Parallel with previous
study, there was a higher percentage
of fall risk among residential older
adults (Rapp et al. 2012; Singh et al.
2014). Thus, more future study should
be conducted among residential older
adults with larger sample size. The
prospective study was recommended
as it can prevent recall bias in reporting
fall prevalence.
This review also summarised that
most fall occurs indoor (Azidah et al.
2012; Goh et al. 2016; Kadir & Hasim
2011; Romli et al. 2017; Tan et al. 2016;
Yeong et al. 2016; Zia et al. 2016). This
finding was supported by another study
where a higher prevalence of indoor
falls was detected among older adults
(Duckham et al. 2013). A prospective
longitudinal study from South Korea
also reported there was a higher indoor
fall prevalence among older adults
(Kim 2016). Falls usually happened in
the morning (Azidah et al. 2012; Kadir
& Hasim 2011; Tan et al. 2016) with
most activities were conducted which
may explain the higher fall prevalence
among older adults.
Bathroom/toilet was associated
with the highest number of falls
occurrence (Tan et al. 2016; Yeong et
al. 2016). A systematic review study
had explained that the urgency of
going to the toilet, the anxiety of not
able to reach the toilet on time and
cognitive ability to perform multiple
tasks (walking, negotiating household
obstacles and hold bladder) could
lead to high risk of falls within vicinity
of bathroom/ toilet (Chiarelli et al.
2009). Other consideration of higher
falls prevalence is due to slippery
bathroom/toilet surfaces (Chiarelli et al.
2009). Bathroom location was twice
likely a person to sustain an injury as
compared to other places (Stevents et
al. 2014).
Falls participants that sustained an
injury was 47-82% (Ghazi et al. 2017;
Goh et al. 2016; Kadir & Hasim 2011;
Tan et al. 2016; Zia et al. 2016). A higher
percentage of faller that sustained
injury was recorded in India, at about
67% (Tripathy et al. 2015). This result
was supported by an epidemiology
study in Australia, wherev about 60%
of older adults were sustained an injury
after falling. In this review, soft tissue
injuries due to fall was accounted for

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Fall Characteristics among Malaysian Older Adults Med & Health Jun 2020;15(1): 18-33
46-94.4% (Azidah et al. 2012; Ghazi
et al. 2017; Kadir & Hasim 2011; Tan
et al. 2016); while fracture was 5.5-
40% (Azidah et al. 2012; Ghazi et al.
2017; Tan et al. 2016). This is coherent
with a longitudinal fall prospective
study, where the soft tissue injuries was
accounted for 50.6% while fracture was
37.4% (Pohl et al. 2014). This review
also reported a hospital admission-
related fall which was 25-50% (Ghazi
et al. 2017; Goh et al. 2016). This is
supported by some epidemiology
studies where about 30% of fallers
underwent hospitalisation and
resulting medical cost up to 50 billion
dollars annually (Centers for Disease
Control and Prevention 2017; Florence
et al. 2018).
This study only included articles
published in English with full-text
availability. Electronic database only
limited to EBSCOhost, ClinicalKey,
ScienceDirect, Wiley Online Library,
SpringerLink and Google Scholar.
CONCLUSIONS
In summary, a variation on the fall
prevalence was determined by
several factors such as location and
existing medical condition. Pooled
information in our study indicates
that there still a lack of standardised
measuring tools for falls characteristics
in Malaysia. There is a need for
large scale longitudinal prospective
study to determine the prevalence
and the causal-effect relationship of
falls, as well as suggestion to include
psychological assessments to delve
further into faller psyche and mental
health in Malaysia. Findings on falls
prevalence and its characteristics
will help the physiotherapists and
healthcare providers to reduce the
impact of falling especially among the
elderly population is rapidly increasing.
ACKNOWLEDGEMENT
The authors would like to thank
Universiti Teknologi MARA, Cawangan
Pulau Pinang, Kampus Bertam, for the
support given for this study.
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Received: 2 Dec 2019
Accepted: 3 Mar 2020