Comparison of injury pattern and clinical outcomes between young adults and elderly patients with alcohol-related injury in South Korea 2011–2016

Introduction

Injury is a public health problem accounting for 16% of the global disease burden. Alcohol is an important contributing factor to injury-related emergency department (ED) visits and is the most commonly used and abused substance in the United States. It accounts for one in 10 deaths among adults aged 20–64 years (Fernandez et al., 2019). Several studies have suggested that alcohol consumption is independently associated with injury complications and severity (Draus Jr et al., 2008; Plurad et al., 2011; Rehm et al., 2003).

South Korea has a rapidly aging population. In 2015, 13.2% of South Korea’s population was determined to be ≥65 years old. KOSIS (2016) Park reported that age affects fatality in injury patients (Park et al., 2016). The importance of the association between alcohol use and injury in elderly patients has been recognized (Kowalenko et al., 2013; Selway, Soderstrom & Kufera, 2008).

The role of alcohol in injury patients visiting EDs has not been clearly defined. This study aimed to examine the association of age and alcohol with injury severity and clinical outcomes.

Materials and Methods

Results

During the study period, there were 1,537,617 injured patients in the registry, of whom 54,492 patients who visited the ED more than 48 h after injury were excluded; the drinking status of 87,856 patients were not known, and 498,969 were aged <18 years. We also excluded patients who were unknown whether they were admitted to hospital (1,921 patients) and whose EMR-ISS (6,667 patients) were unknown. Finally, we analyzed the data of 887,712 patients. Figure 1 shows the study flow diagram of enrolled patients.

Injury characteristics in the elderly and non-elderly groups who consumed alcohol (Table 4, Figs. 2 and 3)

Table 4 compares the mechanism, place, kind of activity, intentionality, and time of ED presentation between non-elderly and elderly group who consumed alcohol. Fall and slips are the most common injury mechanism (37.9%) in these patients (36.3% non-elderly/58.40% elderly).

Table 3:

General characteristics of injury patients in the elderly and non-elderly groups who consumed alcohol.

	Non-elderly (<65 yrs)	Elderly (≥65 yrs)	Total	p-value
No. of patients	131,708 (93.0)	9,906 (7.0)	141,614 (100)
Age	38.98 ± 12.62	71.50 ± 5.36	41.25 ± 14.80	<0.001
Sex				<0.001
Male	97,176 (73.8)	8,493 (85.7)	105,669 (74.6)
Female	34,532 (26.2)	1,413 (14.3)	35,945 (25.4)
Mode of arrival
Walk-in (include car, foot, etc.)	65,227 (49.5)	2,524 (25.5)	67,751 (47.8)	<0.001
119	57,773 (43.9)	6,047 (61.0)	63,820 (45.1)	<0.001
Private ambulance	7,570 (5.7)	1,280 (12.9)	8,850 (6.2)	<0.001
Police	925 (0.7)	28 (0.3)	953 (0.7)	<0.001
Air	93 (0.1)	19 (0.2)	112 (0.1)	<0.001
Others	88 (0.1)	5 (0.1)	93 (0.1)	0.540
Unknown	32 (0.0)	3 (0.0)	35 (0.0)	0.715
Insurance
National health insurance	103,975 (78.9)	8,064 (81.4)	112,039 (79.1)	<0.001
Self-pay (uninsured)	12,702 (9.6)	596 (6.0)	13,298 (9.4)	<0.001
Vehicle	8,193 (6.2)	434 (4.4)	8,627 (6.1)	<0.001
Medicaid beneficiary	6,299 (4.8)	789 (8.0)	7,088 (5.0)	<0.001
Private insurance	24 (0.0)	3 (0.0)	27 (0.0)	0.402
Work accident	23 (0.0)	1 (0.0)	24 (0.0)	0.587
Others	416 (0.3)	16 (0.2)	432 (0.3)	0.007
Unknown	76 (0.1)	3 (0.0)	79 (0.1)	0.265

DOI: 10.7717/peerj.7704/table-3

Table 4:

Injury characteristics in the elderly and non-elderly groups who consumed alcohol.

	Non-elderly (<65 yrs)	Elderly (≥65 yrs)	Total	p-value
Mechanism
Fall, slip	47,861 (36.3)	5,789 (58.4)	53,650 (37.9)	<0.001
Collision	41,992 (31.9)	1,048 (10.6)	43,040 (30.4)	<0.001
Traffic accident	13,658 (10.4)	1,073 (10.8)	14,731 (10.4)	0.146
Penetration	12,576 (9.5)	238 (2.4)	12,814 (9.0)	<0.001
Substance exposure	9,077 (6.9)	1,292 (13.0)	10,369 (7.3)	<0.001
Overuse	1,236 (0.9)	33 (0.3)	1,269 (0.9)	<0.001
Drowning, hanging, asphyxia	836 (0.6)	62 (0.6)	898 (0.6)	0.915
Thermal injury	751 (0.6)	18 (0.2)	769 (0.5)	<0.001
Machine	60 (0.0)	8 (0.1)	68 (0.0)	0.123
Natural disaster	5 (0.0)	0 (0.0)	5 (0.0)	0.540
Others	1,499 (1.1)	71 (0.7)	1,570 (1.1)	<0.001
Unknown	2,157 (1.6)	274 (2.8)	2,431 (1.7)	<0.001
Place
Road	48,487 (36.8)	4,026 (40.6)	52,513 (37.1)	<0.001
Commercial facilities	41,254 (31.3)	1,176 (11.9)	42,430 (30.0)	<0.001
House	28,506 (21.6)	3,349 (33.8)	31,855 (22.5)	<0.001
Outdoor, river, sea	3,434 (2.6)	342 (3.5)	3,776 (2.7)	<0.001
Amusement, cultural public facilities	2,533 (1.9)	200 (2.0)	2,733 (1.9)	0.504
Transportation area except road	1,747 (1.3)	378 (3.8)	2,125 (1.5)	<0.001
Residential facilities	1,127 (0.9)	119 (1.2)	1,246 (0.9)	<0.001
Factory, industrial facilities	591 (0.4)	28 (0.3)	619 (0.4)	0.016
Farm	298 (0.2)	50 (0.5)	348 (0.2)	<0.001
School, education facilities	322 (0.2)	3 (0.0)	325 (0.2)	<0.001
Sport facilities	302 (0.2)	12 (0.1)	314 (0.2)	0.027
Medical facilities	157 (0.1)	36 (0.4)	193 (0.1)	<0.001
Others	99 (0.1)	9 (0.1)	108 (0.1)	0.585
Unknown	2,851 (2.2)	178 (1.8)	3,029 (2.1)	0.015
Activity
Leisure activities	41,853 (31.8)	3,486 (35.2)	45,339 (32.0)	<0.001
Daily living activities	25,840 (19.6)	2,789 (28.2)	28,629 (20.2)	<0.001
Unpaid labor	13,987 (10.6)	1,235 (12.5)	15,222 (10.7)	0.129
Work	1,345 (1.0)	117 (1.2)	1,462 (1.0)	<0.001
Exercise	286 (0.2)	10 (0.1)	296 (0.2)	0.015
Travel	187 (0.1)	8 (0.1)	195 (0.1)	0.113
Hospital treatment	53 (0.0)	15 (0.2)	68 (0.0)	<0.001
Education	48 (0.0)	3 (0.0)	51 (0.0)	0.755
Others	46,538 (35.3)	2,053 (20.7)	48,591 (34.3)	<0.001
Unknown	1,571 (1.2)	190 (1.9)	1761 (1.2)	<0.001
Intentionality
Unintentional	86,063 (65.3)	7,913 (79.9)	93,976 (66.4)	<0.001
Assault	31,201 (23.7)	618 (6.2)	31,819 (22.5)	<0.001
Self-harm, suicide	12,825 (9.7)	1,192 (12.0)	14,017 (9.9)	<0.001
Others	328 (0.2)	37 (0.4)	365 (0.3)	0.018
Unknown	1,291 (1.0)	146 (1.5)	1,437 (1.0)	<0.001
Day of presentation				<0.001
Weekday (Mon-Thu)	63,372 (48.1)	5,233 (52.8)	68,605 (48.4)
Weekend (Fri-Sun)	68,336 (51.9)	4,673 (47.2)	73,009 (51.6)
Time of presentation
Day (7∼14 h)	17,291 (13.1)	1,555 (15.7)	18,846 (13.3)	<0.001
Evening (15∼22 h)	31,941 (24.3)	6,019 (60.8)	37,960 (26.8)	<0.001
Night (23∼6 h)	82,468 (62.6)	2,332 (23.5)	141,606 (59.9)	<0.001

DOI: 10.7717/peerj.7704/table-4

Place of injury was the roads (40.6%), around the house (33.8%), and commercial facilities (11.9%) in elderly patients and roads (36.8%), commercial facility (31.3%), and around the house (21.6%) in non-elderly patients. Activities that led to injury was leisure activities (35.2%) and daily living activities (28.2%) in elderly patients and leisure activities (31.8%) and daily living activities (19.6%) in non-elderly patients. On the intentionality of injury, self-harm and suicide rates were 12.0% in elderly and 9.7% in non-elderly patients.

Injury was more common in weekdays (52.8%) in elderly patients and in weekends (52.9%) in non-elderly patients. The monthly incidence of injury showed no significant difference between elderly and non-elderly patients (Fig. 2). With respect to the time of injury, evening (60.8%) was the most common in elderly and night (62.6%) in non-elderly patients (Fig. 3).

Discussion

This study shows that alcohol-related injury had serious clinical outcomes in elderly patients. The relationship between alcohol consumption and injury has already been revealed by various studies and analyses. Acute alcohol consumption, even in small amounts, increases the risk of injury (Cherpitel, 2007). Globally, 10%–18% of injuries that result in ED visits have been reported to be related to alcohol consumption (WHO, 2007). In the elderly population, injury has important public health implications. Injured elderly patients have a higher mortality rate than younger adults (Champion et al., 1989), and it has been reported that relatively mild mechanisms may cause injury in the elderly (Giannoudis et al., 2009). This study aimed to investigate the relationship between alcohol consumption and injury in elderly patients and to analyze the effect of alcohol on injury severity.

The rate of alcohol consumption among elderly patients with injury was 7.0% (Table 1). Ekeh et al. (2014) reported that 11.1% of injury patients aged ≥65 years who visited the level 1 trauma center showed positive blood alcohol content (BAC). In another study, the BAC of 12.6% of injury patients aged ≥65 years who visited the ED was >100 mg/dl. (Rivara et al., 1993) The difference between previous studies and the present study is probably due to the different alcohol-drinking behaviors of each region and cultures.

The number of males in the alcohol injury elderly group was higher than that in the younger adult group (Table 3). This is thought to be due to differences in alcohol-drinking behavior based on age and sex. According to Kim’s analysis of data from the Korea National Health and Nutrition Examination Survey, prevalence of intermediate risk drinking (alcohol use disorder identification test score of ≥8) was 23.1%, 13.5%, and 4.2% for females aged 19–44 years, 45–64 years, and ≥65 years, respectively, and 59.7%, 60.1%, and 36.7%, respectively, for males (Hong, Noh & Kim, 2017). In elderly females, the drinking rate was significantly lower; this explains why the proportion of males in the elderly alcohol injury patients is significantly higher. It can also be seen that the rate of alcohol consumption is closely related to the occurrence of alcohol-related injury.

The rate of using 119 in the alcohol injury elderly group was higher than that in the total elderly injury group (Tables 1 and 3). A total of 119 of Korea, regardless of the severity, sends the patient to a hospital free of charge, if they request the emergency medical system. For this reason, 119 is more likely to be used when patients cannot move by themselves or in poor economic conditions. This tendency is prominent in the elderly. (Kang, 2015) Besides, the higher use of 119 in the drinking elderly group than in the total elderly injury group can be attributed to the increased severity of injury due to alcohol (Tables 4 and 5). At a time when the society is rapidly aging, this will lead to an increase in medical costs.

The percentage of falls and slips in the elderly alcohol group was higher than that in the total elderly injury group. Falls and slips are the most common and one of the major mechanisms in elderly injury. They can result in fractures, immobility, and reduced daily living activities, even leading to death (WHO, 2017). Risk factors for elderly falls include age, drug use, cognitive impairment, and sensory deficit (Fuller, 2000). Even though there are various opinions as to whether alcohol is a risk factor in elderly falls (Adams & Jones, 1998), studies have suggested that alcohol is a risk factor for the occurrence of and mortality due to elderly falls (Schick et al., 2018; Sorock et al., 2006). In this study, the incidence of falls and slips was higher in the elderly alcohol group, suggesting that alcohol contributes to the occurrence of falls.

In this research, intentional injury in patients who consumed alcohol was higher than in total injury patients. A total of 9.9% of patients who consumed alcohol had intentions of self-harm or suicide, whereas 12.0% of elderly patients who consumed alcohol attempted suicide and self-harm. Darvishi et al. (2015) reported that alcohol use significantly increases the risk of suicidal ideation, suicide attempt, and completed suicide. Compared with the total elderly injury group, intentional injury (assault, self-harm/suicide) accounted for a large proportion of the alcohol elderly injury group (Tables 2 and 4). Therefore, alcohol can be seen as one of the factors causing intentional injury. In the alcohol injury group, the ratio of unintentional injury and self-harm/suicide was higher in the elderly group than in the younger group. This is because of the higher rate of violence in the younger alcohol group. According to Dinh et al. (2014), the proportion of alcohol-related assault patients who visited the trauma center was 3%, 52%, and 21% in those aged ≥65 years, 24–44 years, and 45–64 years old, respectively.

ED visits in elderly injury patients were the most frequent during the evening, followed by day, then night (Table 2). On the other hand, the order was evening, night, and day in elderly alcohol injury patients (Table 4). This is related to the time of day when alcohol drinking occurs. In the younger alcohol injury group, visits were the highest during the night, (Table 4) suggesting a difference in the time zone in which alcohol consumption is done in different age groups.

With regard to injury severity, age and drinking were found to have interaction effects. Injury severity was positively correlated with age and alcohol consumption. Particularly, this was observed in ICU care rate and EMR-ISS score of ≥25 in severely injured patients (Tables 5 and 6). Although there is no doubt that alcohol is a risk factor in causing damage, various studies have shown whether alcohol consumption is related to the severity of the damage. Some studies have reported that alcohol consumption and injury severity are not significantly correlated (Ahmed & Greenberg, 2019; Schneiders et al., 2017). There was a difference according to the mechanism of damage. (Valdez et al., 2016) It has also been reported that the effect of alcohol is different depending on whether the BAC is 400 or more (Afshar et al., 2016). While positive BACs have been shown to reduce mortality rate in trauma patients (Yaghoubian et al., 2009), drinking has been reported to be related to injury severity (Elshiere, Noorbhai & Madiba, 2017; Swearingen et al., 2010). This study showed that age and drinking had an interaction effect and were associated with the occurrence of severe injury.

There are some limitations. This study used data obtained from the Emergency Department-Based Injury In-depth Surveillance conducted by the Korea Centers for Disease Control and Prevention at 23 EDs to prevent injury. However, one of the limitations of this study is that information on alcohol consumption behavior required to understand the relationship between injury and drinking is limited, and the exact time interval between alcohol consumption and injury is unknown. Additionally, the fact that alcohol consumption was based on the patient’s self-report was a limitation to objectively determine whether the patient was drinking or not. In England, alcohol screening with referral or intervention is becoming part of routine practice. And the rate of alcohol identification and intervention in ED has had improvements (Patton & Green, 2018). However, there is no system for alcohol screening and intervention in Korea. 23 EDs supported by KCDC gather the information whether the injury patients drink or not. Korean EDs need to screen alcohol with appropriate tools such as AUDIT score for future study and public health.

Tests to reveal blood alcohol level were not performed. Zautcke et al. (2002) also reported that falls are the most common mechanism of injury in elderly patients who under the influence of alcohol. They performed blood alcohol level test in 5.2% of geriatric patients and obtained positive results for 49.7% (Zautcke et al., 2002). Csipke et al. (2007) reported a low correlation with BAC and alcohol questionnaire results. This suggests that not only alcohol screening but also an objective BAC measurement should be performed. Alcohol screening and BAC information should be included in the future study. And More prospective studies are needed to investigate true alcohol level. Also, there is a possibility of selection biases due to unknown data on alcohol use, admission rate, and EMR-ISS.

Conclusions

Elderly alcohol injury patients increased the incidence of falls, the most common injury mechanism in elderly, and increased the utilization rate of 119. Moreover, age and alcohol were risk factors for ICU care and EMR-ISS score of ≥25. Alcohol screening and intervention is required in geriatric trauma patients because alcohol use is significantly prevalent in trauma (Ekeh et al., 2014). This study shows that alcohol-related injury had serious clinical outcomes. Therefore, alcohol screening and intervention in ED are needed to prevent alcohol-related injury in the elderly.