CDC's research portfolio in older adult fall prevention: a review of progress, 1985-2005, and future research directions

PROBLEM: Falls are a leading cause of mortality and morbidity among adults age 65 and older. Population models predict steep increases in the 65 and older population bands in the next 10-15 years and in turn, public health is bracing for increased fall rates and the strain they place on health care systems and society. To assess progress in fall prevention, the Centers for Disease Control and Prevention conducted a research portfolio review to examine the quality, relevance, outcomes and successes of the CDC fall prevention program and its impact on public health. METHODS: A peer review panel was charged with reviewing 20 years of funded research and conducting a SWOT (strengths, weaknesses, opportunities, and threats) analysis for extramural and intramural research activities. Information was collected from grantees (via a survey instrument), staff were interviewed, and progress reports and products were reviewed and analyzed. RESULTS: CDC has invested over $24,900,000 in fall-related research and programs over 20 years. The portfolio has had positive impacts on research, policies and programs, increasing the public health injury prevention workforce, and delivering effective fall prevention programs. DISCUSSION: Public health agencies, practitioners, and policy makers recognize that while there are some evidence-based older adult fall prevention interventions available, many remain unused or are infeasible to implement. Specific recommendations across the public health model, include: additional research in gathering robust epidemiologic data on trends and patterns of fall-related injuries at all levels; researching risk factors by setting or sub-population; developing and testing innovative interventions; and engaging in translation and dissemination research on best practices to increase uptake and adoption of fall prevention strategies. CDC has responded to a number of suggestions from the portfolio review including: funding translation research of a proven Tai Chi fall intervention; beginning to address gaps in gender, ethnic, and racial differences in falls; and collaborating with partner organizations who share in CDC's mission to improve public health by preventing falls and reducing fall-related injuries. IMPACT ON INDUSTRY: Industry has an opportunity to develop more accessible and usable devices to reduce injury from falls (for example, hip protectors and force reducing flooring). By implementing effective, evidence-based interventions to prevent falls and reduce injuries from falls, significant decreases in health care costs can be expected.     

Geospatial distribution of fall-related hospitalization incidence in Texas

IntroductionWith the rapid growth of the aging U.S. population, the incidence of falls and fall-related injuries is expected to rise. We examined incidence and characteristics of fall-related hospitalizations (falls) among Texans aged 50 and older, by geography and across time.MethodWe calculated fall-related hospitalization incidence rates (65 and older), identified fall ‘hot spots,’ and examined availability of fall-prevention programming.ResultsThe incidence of fall-related hospitalizations for older adults increased by nearly 20% from 2007 to 2011. There were clusters of ‘hot spot’ counties throughout the state, many of which lack fall prevention programs.ConclusionsIncreased efforts are needed to identify older adults at elevated risk for falling and develop referral systems for promoting evidence-based fall prevention programs at multiple levels accounting for geographic settings.Practical applicationsGeospatial investigations can inform strategic planning efforts to develop clinical-community partnerships to offer fall prevention programming in high risk areas.     

Fall-related traumatic brain injury deaths and hospitalizations among older adults--United States, 2005

PROBLEM: Among older adults, both unintentional falls and traumatic brain injuries (TBI) result in significant morbidity and mortality; however, only limited national data on fall-related TBI are available. METHOD: To examine the relationship between older adult falls and TBI deaths and hospitalizations, CDC analyzed 2005 data from the National Center for Health Statistics' National Vital Statistics System and the Agency for Healthcare Research and Quality's Nationwide Inpatient Sample. RESULTS: In 2005, among adults>or=65 years, there were 7946 fall-related TBI deaths and an estimated 56,423 hospitalizations for nonfatal fall-related TBI in the United States. Fall-related TBI accounted for 50.3% of unintentional fall deaths and 8.0% of nonfatal fall-related hospitalizations. SUMMARY: These findings underscore the need for greater dissemination and implementation of evidence-based fall prevention interventions.     

Seasonal variation in fall-related emergency department visits by location of fall – United States, 2015

Introduction: In the United States, fall-related emergency department (ED) visits among older adults (age 65 and older) have increased over the past decade. Studies document seasonal variation in fall injuries in other countries, while research in the United States is inconclusive. The objectives of this study were to examine seasonal variation in older adult fall-related ED visits and explore if seasonal variation differs by the location of the fall (indoors vs. outdoors), age group, and sex of the faller. Methods: Fall-related ED visit data from the National Electronic Injury Surveillance System-All Injury Program were analyzed by season of the ED visit, location of the fall, and demographics for adults aged 65 years and older. Results: Total fall-related ED visits were higher during winter compared with other seasons. This seasonal variation was found only for falls occurring outdoors. Among outdoor falls, the variation was found among males and adults aged 65 to 74 years. The percentages of visits for weather-related outdoor falls were also higher among males and the 65–74 year age group. Conclusions: In 2015, there was a seasonal variation in fall-related ED visits in the United States. Weather-related slips and trips in winter may partially account for the seasonal variation. Practical Implications: These results can inform healthcare providers about the importance of screening all older adults for fall risk and help to identify specific patients at increased risk during winter. They may encourage community-based organizations serving older adults to increase fall prevention messaging during winter.     

Unintentional injuries treated in hospital emergency departments among persons aged 65 years and older,United States, 2006–2011

IntroductionWith the aging of the United States population, unintentional injuries among older adults, and especially falls-related injuries, are an increasing public health concern.MethodsWe analyzed emergency department (ED) data from the Nationwide Emergency Department Sample, 2006–2011. We examined unintentional injury trends by 5-year age groups, sex, mechanism, body region, discharge disposition, and primary payer. For 2011, we estimated the medical costs of unintentional injury and the distribution of primary payers, plus rates by injury mechanisms and body regions injured by 5-year age groups.ResultsFrom 2006 to 2011, the age-adjusted annual rate of unintentional injury-related ED visits among persons aged ≥ 65 years increased significantly from 7987 to 8163, per 100,000 population. In 2011, 65% of injuries were due to falls. Rates for fall-related injury ED visits increased with age and the highest rate was among those aged ≥ 100. Each year, about 85% of unintentional injury-related ED visits in this population were expected to be paid by Medicare. In 2011, the estimated lifetime medical cost of unintentional injury-related ED visits among those aged ≥ 65 years was $40 billion.ConclusionIncreasing rates of ED-treated unintentional injuries, driven mainly by falls among older adults, will challenge our health care system and increase the economic burden on our society. Prevention efforts to reduce falls and resulting injuries among adults aged ≥ 65 years have the potential to increase well-being and reduce health care spending, especially the costs covered by Medicare.Practical applicationsWith the aging of the U.S. population, unintentional injuries, and especially fall-related injuries, will present a growing challenge to our health care system as well as an increasing economic burden. To counteract this trend, we must implement effective public health strategies, such as increasing knowledge about fall risk factors and broadly disseminating evidence-based injury and fall prevention programs in both clinical and community settings.     

The direct costs of fatal and non-fatal falls among older adults — United States

IntroductionThis study sought to estimate the incidence, average cost, and total direct medical costs for fatal and non-fatal fall injuries in hospital, ED, and out-patient settings among U.S. adults aged 65 or older in 2012, by sex and age group and to report total direct medical costs for falls inflated to 2015 dollars.MethodIncidence data came from the 2012 National Vital Statistics System, 2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, 2012 Health Care Utilization Program National Emergency Department Sample, and 2007 Medical Expenditure Panel Survey. Costs for fatal falls were derived from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System; costs for non-fatal falls were based on claims from the 1998/1999 Medicare fee-for-service 5% Standard Analytical Files. Costs were inflated to 2015 estimates using the health care component of the Personal Consumption Expenditure index.ResultsIn 2012, there were 24,190 fatal and 3.2 million medically treated non-fatal fall related injuries. Direct medical costs totaled $616.5 million for fatal and $30.3 billion for non-fatal injuries in 2012 and rose to $637.5 million and $31.3 billion, respectively, in 2015. Fall incidence as well as total cost increased with age and were higher among women.ConclusionMedically treated falls among older adults, especially among older women, are associated with substantial economic costs.Practical applicationWidely implementing evidence-based interventions for fall prevention is essential to decrease the incidence and healthcare costs associated with these injuries.     

Projections of hospitalised fall-related injury in NSW, Australia: impacts on the hospital and aged care sectors

Projections of the number, rate and cost of fall-related hospitalised injuries for individuals aged 65 years and older in New South Wales (NSW), Australia were estimated to 2051 for two scenarios: (1) demographic change only using 2008 admission rates; and (2) modelled change using negative binominal regression taking into account current trends in admission rates. Based on demographic change alone, the number and cost of fall injury hospitalisations among older people is expected to increase almost three-fold by 2051. Transfers to permanent residential aged care will also increase 3.2 fold. However, if the fall-related hospitalisation rate sustains its current trend, these increases are projected to be more than ten-fold by 2051. Even with demographic change alone, there will be a significant impact on the resources required to care for older people suffering a fall injury hospitalisation over the next forty years in NSW. The impact on the hospital and aged care sectors will be considerable unless significant improvements occur in the prevention and treatment of fall-related injury in older people.     

The National Falls Free™ Initiative, working collaboratively to affect change

Introduction

Since 2004 the National Council on Aging (NCOA) has been working in collaboration with a growing number of national, state, and local organizations through the Falls Free^© Initiative to address the growing public health issue of falls and fall-related injuries among older adults. Through collaborative leadership, evidence-based interventions, practical lifestyle adjustments, and community partnerships we are working to reduce the number of older adult falls.

Impact on industry

The many activities of the national and state coalitions have brought recognition to the issue of fall prevention, education, and training to providers and greater investment in programs and services resulting in tremendous momentum and community activism. While we have yet to realize an impact on rates of falls, this strategic investment in building the infrastructure needed to affect change is the first step toward reducing the growing number of falls among older adults.     

Aging without injury in the United States requires action today

Introduction: In 2017, unintentional injuries were the seventh leading cause of death among older adults (age ≥ 65), resulting in over 55,000 deaths. Falls accounted for more than half of these deaths. Given that older adults are the fastest growing age group in the United States, we can anticipate that injuries will become an even greater health concern in the near future. Methods: Aging without injury is possible. There are evidence-based strategies that can reduce falls. However, older adults may not realize that falls can be prevented or they may be afraid to admit their fear of falling or difficulty with walking as these issues may signal their inability to live independently. Results: In this commentary, we will highlight what the Centers for Disease Control and Prevention is doing to prevent older adult falls. We also highlight the importance of broadening older adults' awareness about falls to successfully empower them to begin contemplating and preparing to adopt fall prevention strategies that can help them age in place. Conclusions: Older adult falls are common and can result in severe injury and death but they can be prevented. Broadening older adults' awareness about falls can empower them to take the actions necessary to reduce their fall risk. Practical applications: Increasing awareness about falls can help older adults, healthcare providers, and local and state health departments take steps to reduce fall risk.     

Fall-related emergency department visits involving alcohol among older adults

Problem: Falls are the leading cause of injury deaths among adults aged 65 years and older. Characteristics of these falls may vary with alcohol use. Objective: Describe and compare characteristics of older adult fall-related emergency department (ED) visits with indication of alcohol to visits with no indication. Methods: Using nationally-representative 2015 National Electronic Injury Surveillance System-All Injury Program data, we compared demographic characteristics for fall-related ED visits by indication of alcohol consumption. Alcohol-indicated ED visits were matched on age group, sex, treatment month, and treatment day to ED visits with no alcohol indication using a 1:4 ratio and injury characteristics (i.e., diagnosis, body part injured, disposition) were compared. Results and discussion: Of 38,640 ED records, 906 (1.9%) indicated use of alcohol. Fall-related ED visits among women were less likely to indicate alcohol (1.0%) compared to ED visits among men (3.8%). ED visits indicating alcohol decreased with age from 4.1% for those 65–74 years to 1.5% for those 75–84 and <1% for those 85+. After controlling for age-group, sex, and month and day of treatment, 17.0% of ED visits with no alcohol indication had a traumatic brain injury compared to 34.8% of alcohol-indicated ED visits. Practical applications: Alcohol-indicated fall ED visits resulted in more severe head injury than those that did not indicate alcohol. To determine whether alcohol use should be part of clinical risk assessment for older adult falls, more routinely collected data and detailed information on the amount of alcohol consumed at the time of the fall are needed.     

Falls prevention through community intervention – A Swedish example

In order to control and reduce fall-related injuries, particularly among women over the age of 55, a safety management and falls prevention campaign was structured and implemented during 2006–2007 in the small industrial town of Södertälje, Sweden. A local campaign was launched to recruit falls prevention agents, to inform key target groups in the local community, and to educate older people about fall risks. A survey showed that the campaign had a greater impact among professionals with a special relation to fall risk than among the general population. Medical records were used in the evaluation of the outcomes. The results show that between 2005 and 2007 there was a drop of fractures related to falls in the council: an overall drop of 16.7% in the population; among men 55 or older a drop of 12%, among women 55 or older a drop of 15%, among home-dwelling women 55 or older a drop of 5.7% and among women in special accommodation a drop of 44.4%. Expressed in terms of years lost to disability (YLD), the overall drop in hip fractures treated at the local hospital between 2005 and 2007 was 48%. A comparison with National medical records for the same period shows the drop for the intervention area to be much larger than that for Sweden as a whole, although the effect was not statistically significant. The study demonstrates the advantages of a broad, community-based approach to injury prevention.     

A cost–benefit analysis of three older adult fall prevention interventions

IntroductionOne out of three persons aged 65 and older falls annually and 20% to 30% of falls result in injury. The purpose of this cost–benefit analysis was to identify community-based fall interventions that were feasible, effective, and provided a positive return on investment (ROI).MethodsA third-party payer perspective was used to determine the costs and benefits of three effective fall interventions. Intervention effectiveness was based on randomized controlled trial results. National data were used to estimate the average annual benefits from averting the direct medical costs of a fall. The net benefit and ROI were estimated for each of the interventions.ResultsFor the Otago Exercise Program delivered to persons aged 65 and older, the net benefit was $121.85 per participant and the ROI was 36% for each dollar invested. For Otago delivered to persons aged 80 and older, the net benefit was $429.18 and the ROI was 127%. Tai chi: Moving for Better Balance had a net benefit of $529.86 and an ROI of 509% and Stepping On had a net benefit of $134.37 and an ROI of 64%.ConclusionsAll three fall interventions provided positive net benefits. The ROIs showed that the benefits not only covered the implementation costs but also exceeded the expected direct program delivery costs. These results can help health care funders and other community organizations select appropriate and effective fall interventions that also can provide positive returns on investment.     

Fall-related traumatic brain injury in children ages 0–4 years

Introduction: Falls are the leading cause of traumatic brain injury (TBI) for children in the 0–4 year age group. There is limited literature pertaining to fall-related TBIs in children age 4 and under and the circumstances surrounding these TBIs. This study provides a national estimate and describes actions and products associated with fall-related TBI in this age group. Method: Data analyzed were from the 2001–2013 National Electronic Injury Surveillance System–All Injury Program (NEISS–AIP), a nationally representative sample of emergency departments (ED). Case narratives were coded for actions associated with the fall, and product codes were abstracted to determine fall location and product type. All estimates were weighted. Results: An estimated 139,001 children younger than 5 years were treated annually in EDs for nonfatal, unintentional fall-related TBI injuries (total = 1,807,019 during 2001–2013). Overall, child actions (e.g., running) accounted for the greatest proportion of injuries and actions by others (e.g., carrying) was highest for children younger than 1 year. The majority of falls occurred in the home, and involved surfaces, fixtures, furniture, and baby products. Conclusions: Fall-related TBI in young children represents a significant public health burden. The majority of children seen for TBI assessment in EDs were released to home. Prevention efforts that target parent supervision practices and the home environment are indicated. Practical applications: Professionals in contact with parents of young children can remind them to establish a safe home and be attentive to the environment when carrying young children to prevent falls.     

Winter storm-related injuries in Oklahoma, January 2007

Introduction

A January 2007 ice storm occurred in Oklahoma, causing power outages and hazardous travel conditions. The objective of this investigation was to describe the nature of winter storm-related injuries among Oklahoma residents, to determine populations at risk, and to inform prevention-planning personnel.

Methods

Winter storm-related injuries were a temporarily reportable condition; all acute-care hospitals and the state medical examiner logged storm-related injuries and deaths during January 12 − 30, 2007. Medical records were retrospectively abstracted.Risk of injury was described by demographic group, injury type, and mechanism.

Results

Among 6,047 persons experiencing winter storm-related injuries, 74% were injured in falls, 13% in motor-vehicle collisions (MVCs), 8% while sledding, 1% by unintentional carbon monoxide poisoning, 1% in cleanup activities, and 3% by other mechanisms. Median age of injured persons was 39 years. Persons aged ≥ 40 years were 1.4 times more likely to experience falls as the cause of injury than those aged < 40 years, and falls were twice as likely as other mechanisms to cause fractures among persons aged ≥ 40 years. Injured persons aged < 40 years were 2.2 times more likely to experience MVC-related injuries, and 19 times more likely to experience sledding-related injuries than persons aged ≥ 40 years.

Conclusions

Younger persons were more likely injured in MVCs and sledding incidents, whereas older persons were more likely to experience falls and fractures.

Impact on industry

Prevention messages for winter storm-related injuries should target winter-driving safety tips to younger adults and precautions regarding falls to older adults.     

Disability among adults injured in motor-vehicle crashes in the United States

INTRODUCTION: Little population-based information exists about the long-term effects of motor-vehicle crash-related injuries. METHOD: We analyzed data from the 1995 National Health Interview Survey Disability (NHIS-D) Supplement to estimate the prevalence of crash-related disability among noninstitutionalized U.S. adults aged 18 years and older. RESULTS: More than 1.2 million adults were living in their homes with the disabling effects of motor-vehicle crash-related injuries in 1995. The prevalence of crash-related disability was highest for persons in their mid-life years, ages 35-64. Half of the respondents had sustained the injuries more than 5 years before the interview. Forty-one percent of working-aged individuals reported being unable to work because of their disability. CONCLUSIONS: Because crash-related disability is most prevalent during the mid-life years, quality of life and productivity may be affected for decades. These findings highlight the personal and societal burden associated with motor-vehicle crash-related disability in the United States.     

Dogs and cats as environmental fall hazards

Problem

Falls are the leading cause of non-fatal injuries in the United States. This study assessed the prevalence of fall injuries associated with cats and dogs in the United States and describes the types of injuries sustained, the location, activity, and circumstances under which they occurred.

Methods

Data were from a nationally representative sample of emergency department visits from January 1, 2001 to December 31, 2006, available through the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP).

Results

Based on 7,456 cases, an estimated 86,629 fall injuries each year were associated with cats and dogs, for an injury rate of 29.7. There were 7.5 times as many injuries involving dogs as cats and females were 2.1 times more likely to be injured than males. Injury rates were highest among people aged ≥ 75, but pets were a fall hazard for all ages. Fractures and contusions or abrasions were the most common injuries; the highest rates were for injuries to the extremities. About 66.4% of falls associated with cats and 31.3 % of falls associated with dogs were caused by falling or tripping over the pet. An additional 21.2% of falls related to dogs were caused by being pushed or pulled.

Summary

Although pets were associated with fall injuries, this risk can be reduced by increasing public awareness about situations that can lead to falls, such as dog-walking and chasing pets, and by calling attention to the importance of obedience training for dogs to minimize hazardous behaviors such as pulling and pushing.

Impact on industry

Fall injuries represent a burden to individuals, our society and our health care system. Increasing public awareness and implementing basic prevention strategies can help people of all ages enjoy their pets, reduce their chances of experiencing pet-related falls, and lessen the impact of fall injuries on our health care system.     

Fall-related fracture trends among elderly in Sweden – exploring transitions among hospitalized cases

ProblemFall-related injuries have been a cause of worry during the end of the 20th century with increasing trends among the elderly.MethodUsing data from the Swedish National Patient Register (NPR) based on hospital admissions, this study explores the trends in fall-related fractures between 1998 and 2010.ResultsThe data shows a decreasing trend in fall-related fractures in all age- and sex-specific groups apart from men 80 years and above. While hip fracture incidence rates decreased in all age- and sex-specific groups, both central fractures and upper extremity fractures have increased in all age- and sex-specific groups apart from women 65–79 years. Lower extremity fractures have increased in the older age groups and decreased in the younger. Discussion: The differences found between the groups of fractures and by age- and sex-specific groups indicate a possible transition where more serious fractures are decreasing while less serious fractures increase among hospitalized cases.SummaryPerhaps due to a focus on hip fracture prevention, this study shows that while the incidence rate of hospitalized hip fractures has decreased, other fall-related hospitalized fractures have increased.Impact on industryPotentially, this could be indicative of a healthier younger elderly, coupled with a frailer older elderly requiring more comprehensive healthcare also for less serious injuries. Further research is needed to confirm our results.     

Older Adults at Increased Risk as Pedestrians in Victoria,Australia: An Examination of Crash Characteristics and Injury Outcomes

Objectives: Engaging in active transport modes (especially walking) is a healthy and environmentally friendly alternative to driving and may be particularly beneficial for older adults. However, older adults are a vulnerable group: they are at higher risk of injury compared with younger adults, mainly due to frailty and may be at increased risk of collision due to the effects of age on sensory, cognitive, and motor abilities. Moreover, our population is aging, and there is a trend for the current cohort of older adults to maintain mobility later in life compared with previous cohorts. Though these trends have serious implications for transport policy and safety, little is known about the contributing factors and injury outcomes of pedestrian collision. Further, previous research generally considers the older population as a homogeneous group and rarely considers the increased risks associated with continued ageing.

Method: Collision characteristics and injury outcomes for 2 subgroups of older pedestrians (65–74 years and 75+ years) were examined by extracting data from the state police–reported crash dataset and hospital admission/emergency department presentation data over the 10-year period between 2003 and 2012. Variables identified for analysis included pedestrian characteristics (age, gender, activity, etc.), crash location and type, injury characteristics and severity, and duration of hospital stay. A spatial analysis of crash locations was also undertaken to identify collision clusters and the contribution of environmental features on collision and injury risk.

Results: Adults over 65 years were involved in 21% of all pedestrian collisions. A high fatality rate was found among older adults, particularly for those aged 75 years and older: this group had 3.2 deaths per 100,000 population, compared to a rate of 1.3 for 65- to 74-year-olds and 0.7 for adults below 65 years of age. Older pedestrian injuries were most likely to occur while crossing the carriageway; they were also more likely to be injured in parking lots, at driveway intersections, and on sidewalks compared to younger cohorts. Spatial analyses revealed older pedestrian crash clusters on arterial roads in urban shopping precincts. Significantly higher rates of hospital admissions were found for pedestrians over the age of 75 years and for abdominal, head, and neck injuries; conversely, older adults were underrepresented in emergency department presentations (mainly lower and upper extremity injuries), suggesting an increased severity associated with older pedestrian injuries. Average length of hospital stay also increased with increasing age.

Conclusion: This analysis revealed age differences in collision risk and injury outcomes among older adults and that aggregate analysis of older pedestrians can distort the significance of risk factors associated with older pedestrian injuries. These findings have implications that extend to the development of engineering, behavioral, and enforcement countermeasures to address the problems faced by the oldest pedestrians and reduce collision risk and improve injury outcomes.