For this assignment, your instructor will provide you with an epidemiological research article to review. Using the information in Chapter 14 of the textbook as a guide, summarize and critique the article based on the epidemiological methods and concepts covered in the course.
By Day 7
Once you have reviewed the article, click the Module 6 Article Critique tab. You will be given a set of 15 randomly-selected questions to answer. These questions are short answer questions about the critique of the article. You will have 3 hours from the time you open your critique questions until you must have the answers submitted in Blackboard. While you may open and close the questions in Blackboard, the timer will not stop once it is started. You may complete the questions any time during Module 6, and they must be completed and submitted before the end of Module 6 (and within 3 hours of when you opened them). Make sure to answer in complete sentences and address all parts of each question. These questions will be worth 5 points each, for a total of 75 points. They will be graded by your instructor and partial credit is possible.
Please see the article critique
oup_ajepid_kwx XXXXXXXXXX ++
American Journal of Epidemiology
© The Author(s XXXXXXXXXXPublished by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:
creativecommons.org/licenses
y-nc/4.0), which permits non-commercial re-use, distribution, and reproduction in any medium,
provided the original work is properly cited. For commercial re-use, please contact XXXXXXXXXX.
Vol. 186, No. 9
DOI: XXXXXXXXXX/aje/kwx170
Advance Access publication:
May 23, 2017
Original Contribution
Sex Differences in the Association Between Pain and Injurious Falls in Olde
Adults: A Population-Based Longitudinal Study
Anna-KarinWelmer*, Debora Rizzuto, Amaia Calderón-La
añaga, and Kristina Johnell
*Co
espondence to Dr. Anna-KarinWelmer, Aging Research Center, Department of Neurobiology, Care Sciences and Society,
Karolinska Institutet, Gävlegatan 16, S XXXXXXXXXXStockholm, Sweden (e-mail: XXXXXXXXXX).
Initially submitted September 14, 2016; accepted for publication December 20, 2016.
We investigated whether there are sex differences in the association between pain and incident injurious falls. A
total of 2,934 people (ages ≥60 years) from the population-based Swedish National Study on Aging and Care in
Kungsholmen (2001–2004) participated. Participants were followed up for 3 and 10 years for falls leading to hospi-
talization or outpatient care. Data were analyzed with flexible parametric survival models that adjusted for potential
confounders. During the first 3 years of follow-up, 67 men and 194 women experienced an injurious fall, and ove
10 years of follow up, 203 men and 548 women experienced such a fall. In men, the presence of pain, having pain
that was at least mild, having pain that affected several daily activities, and having daily pain all significantly
increased the likelihood of incu
ing an injurious fall during the 3-year follow-up period. The multivariate-adjusted
hazard ratios ranged from XXXXXXXXXX% confidence interval: 1.00, 3.15) for the presence of pain to XXXXXXXXXX% confi-
dence interval: 1.41, 5.93) for several daily activities’ being affected by pain. Results for the 10-year follow-up
period were similar. No significant associations were detected in women. Although pain is less prevalent in men
than in women, its impact on risk of injurious falls seems to be greater in men.
aged; falls; injury; pain; sex factors
A
eviation: SD, standard deviation.
Injurious falls are a major public health concern and are
associated with risk of disability, nursing home admissions,
and death in older people. They also lead to considerable costs
for society (1). Injurious falls have been associated with highe
isk of disability and nursing home admissions than othe
conditions (e.g., diseases) that lead to hospitalization (2). The
prevention of injurious falls should therefore be a high prior-
ity in society.
Successful preventive interventions depend on identifying
and managing risk factors for falls. Pain is common in the
older population and is a major cause of mobility limitation
and disability (3–5). Studies of older adults have shown that
pain also increases the likelihood of falls (4, 6–11). However,
few studies have investigated whether the increased risk of
falls in older people with pain also translates to an increased
isk of fall-related injuries. One study found that pain of at
least moderate intensity increased the likelihood of falls but
not fractures in older men (12). Another study suggested that
widespread pain of moderate-to-high intensity was associated
with falls and fractures in older women with disabilities (7).
Previous studies have shown that the incidence of (13), risk
factors for (14, 15), and consequences of (16) falls may diffe
in men and women. For instance, older women fall more fre-
quently than older men and have a higher risk of experiencing
injurious falls, possibly because older women have poorer physi-
cal function and a higher prevalence of osteoporosis than olde
men (13, 16). In addition, studies have shown that the prevalence
of pain is higher in women than in men (17, 18) and that women
may be more likely than men to experience severe pain (19).
However, studies have not yet established whether the association
etween pain and injurious falls differs in older men and women
(8). Therefore, our objective in this study was to examine whethe
there were sex differences in the associations between pain charac-
teristics (location, intensity, frequency, and interference with daily
activities) and incident injurious falls in older adults during
short (3 years) and long (10 years) periods of observation.
1049 Am J Epidemiol. 2017;186(9):1049–1056
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METHODS
Study population
Participants comprised people aged 60 years or older from
a population-based study, the Swedish National Study on
Aging and Care in Kungsholmen (SNAC-K XXXXXXXXXXThe study
used stratified sampling. The population of Kungsholmen, an
island in central Stockholm, was first stratified by age, and then
a random sample of individuals was selected from each age
cohort. A total of 11 age cohorts were chosen, with 6-year in-
tervals between the younger cohorts (ages 60, 66, and 72 years)
and 3-year intervals between the older cohorts (ages 78, 81, 84,
87, 90, 93, 96, and ≥99 years). Baseline data were collected
from 2001 through 2004.
A total of 5,111 people were initially selected to participate.
Two hundred died before the start of the study, contact infor-
mation was unavailable for 262 people, 32 had moved, 23 did
not speak Swedish, and 4 were deaf. Of the remaining 4,590
people, 3, XXXXXXXXXX%) participated in the baseline examina-
tion. In this study, we excluded an additional 349 people who
had dementia (diagnosed in accordance with the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition,
criteria) or who lived in an institution, because self-reported
pain is difficult to measure in these groups (21). Of the remain-
ing 3,014 people, pain questionnaire data were missing for 35
and outcome data for 45. The analytical sample (n = 2,934)
was significantly younger (mean age = 73.1 (standard devi-
ation (SD), 10.3) years vs. mean age = 86.3 (SD, 10.2)
years; P < 0.01) than the group of eligible nonparticipants
and included fewer women (62.6%women vs. 80.2%women;
P < 0.01).
The Swedish National Study on Aging and Care in Kung-
sholmen was approved by the Regional Ethical Review Board
in Stockholm, Sweden. Written informed consent was col-
lected from participants. If the person could not answer (e.g.,
was cognitively impaired), consent was obtained from a proxy
(usually a close family member).
Data collection
Data on demographic, health, and lifestyle factors were
collected at our research center via interviews, clinical exam-
inations, and testing by trained staff. Home visits were con-
ducted with persons who agreed to participate but were unable
or unwilling to come to the center.
An injurious fall was defined as hospitalization for or receipt
of outpatient care because of a fall (22). International Classifi-
cation of Diseases, Tenth Revision, discharge diagnoses as-
signed from the date of the baseline examination to the last
available date (December 31, 2011) were used. These included
the external-cause codes W00, W01, W05–W10, and W17–
W19: falls on the same level (codes W00, W01, and W18);
falls from furniture, wheelchairs, etc. (codes W05–W09); falls
from one level to another (e.g., from stairs) (codes W10 and
W17); and unspecified falls (code W19). We did not include
injurious falls caused by other people or by falling from
heights, because these were considered extreme events (e.g.,
code W12: falling from scaffolding). Information on falls was
etrieved from the National Patient Register, which includes
data from inpatient care and specialized outpatient care, and
from the Local Outpatient Register, which includes data from
primary care given in the Stockholm County Council area
(23). Outcome status was determined by linking each partici-
pant’s personal identification number to the registers. Because
of the personal identification number, these data are highly
eliable (24). Previous injurious falls were defined as falls
occu
ing up to 3 years before the baseline examination.
Information about the vital status of the participants up to
December 31, 2011, was obtained from the Swedish Cause of
Death Registry.
We assessed pain characteristics that have been described as
important in the assessment of pain by the American Geriatrics
Society, including the location, intensity, and frequency of pain
and its interference with daily activities (25). Pain characteris-
tics were determined with a questionnaire that asked about pain
experienced during the previous 4 weeks (26). The presence of
pain was assessed with the question, “In the last 4 weeks, have
you experienced pain?”. Response alternatives were “yes” and
“no.” The location of pain was determined with a 9-item ques-
tion that ascertained whether the person had pain in the head,
neck, back, joints, shoulders/upper extremities, lower extremi-
ties/feet, chest, abdomen, or genitals. We classified pain loca-
tion by the number of pain sites: no pain, pain at a single
location, and pain at 2 or more locations (6, 27). People with
pain in their joints were classified as having pain at 2 or more
locations. The intensity of pain was assessed with the question,
“In the last 4 weeks, how much pain have you had?”. Response
options were “none,” “very mild,” “mild,” “moderate,” “severe,”
and “very severe” (6). In the analyses, we categorized pain
intensity as no pain (“none”) or very mild pain, mild-to-
moderate pain, and severe or very severe pain. Interference
with daily activities/conditions was determined via the 6-item
question, “In the last 4 weeks, how much