Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014
Gwen Bergen, PhD1; Mark R. Stevens, MA, MSPH2; Elizabeth R. Burns, MPH1
Summary
What is already known about this topic?Falls are the leading cause of fatal and nonfatal injuries among persons aged ≥65 years (older adults).
What is added by this report?In
2014, 28.7% of older adults reported falling at least once in the
preceding 12 months, resulting in an estimated 29.0 million falls. Of
those who fell, 37.5% reported at least one fall that required medical
treatment or restricted their activity for at least 1 day, resulting in
an estimated 7.0 million fall injuries.
What are the implications for public health practice?Although
falls are common, approximately half of older adults who fall do not
discuss it with their health care provider. However, older adult falls
are largely preventable. Health care providers can play an important
role in fall prevention by 1) screening older adults for fall risk, 2)
reviewing and managing medications linked to falls, and 3) recommending
vitamin D where appropriate for improved bone, muscle, and nerve health.
Falls
are the leading cause of fatal and nonfatal injuries among adults aged
≥65 years (older adults). During 2014, approximately 27,000 older adults
died because of falls; 2.8 million were treated in emergency
departments for fall-related injuries, and approximately 800,000 of
these patients were subsequently hospitalized.* To estimate the numbers,
percentages, and rates of falls and fall injuries among older adults by
selected characteristics and state, CDC analyzed data from the 2014
Behavioral Risk Factor Surveillance System (BRFSS) survey. In 2014,
28.7% of older adults reported falling; the estimated 29.0 million falls
resulted in 7.0 million injuries. Known effective strategies for
reducing the number of older adult falls include a multifactorial
clinical approach (e.g., gait and balance assessment, strength and
balance exercises, and medication review). Health care providers can
play an important role in fall prevention by screening older adults for
fall risk, reviewing and managing medications linked to falls, and
recommending vitamin D supplements to improve bone, muscle, and nerve
health and reduce the risk for falls.
BRFSS is an annual, random-digit–dialed telephone survey of the
noninstitutionalized U.S. civilian population aged ≥18 years conducted
annually in all 50 states, the District of Columbia, Guam, Puerto Rico,
and the U.S. Virgin Islands. Detailed information regarding the survey
is available online.† The median response rate for 2014 was 47.0%.
In 2014, survey respondents were asked, “In the past 12 months, how
many times have you fallen?” If the response was one or more times, they
were asked, “How many of these falls caused an injury? By an injury, we
mean the fall caused you to limit your regular activities for at least a
day or to go see a doctor.” This analysis was limited to adults aged
≥65 years in all 50 states and the District of Columbia who were asked
the questions about falls.
The first question was used to estimate the percentage of older
adults who reported one or more falls and the total number of falls; the
second question was used to estimate the number of fall injuries.
Response options ranged from zero to 76 or more with reported means of
0.67 falls and 0.16 fall injuries. The percentages and numbers of falls
and fall injuries included all adults aged ≥65 years in the denominator.
Adults with responses of “Don’t know/Not sure,” “Refused,” or “Not
asked or missing” for questions about falls, fall injuries, or
demographic characteristics were excluded, reducing the sample to
147,319 adults.§
The percentages and numbers were compared across the following
subgroups: sex, age group, race/ethnicity, marital status, education,
annual household income, health status, and state of residence.
Orthogonal polynomial contrasts and pairwise t-tests were used to
identify significant increases or decreases where appropriate. The 2014
BRFSS data were weighted by iterative proportional fitting (raking) to
represent state-level population estimates and aggregated to represent a
nationwide estimate.¶ All results presented are weighted.
Analyses were conducted using statistical software to account for the
complex sampling design.
In 2014, 28.7% of older adults reported falling at least once in the
preceding 12 months, resulting in an estimated 29.0 million falls (Table 1).
Of those who fell, 37.5% reported at least one fall that required
medical treatment or restricted activity for at least 1 day, resulting
in 7.0 million fall injuries. Women (30.3%) were more likely to report
falling than men (26.5%) (p<0.01) and were more likely to report a
fall injury (12.6% compared with 8.3%; p<0.01). The percentage of
older adults who fell increased with age (p<0.01), from 26.7% among
persons aged 65–74 years, to 29.8% among persons aged 75–84 years, to
36.5% among persons aged ≥85 years. The percentage of older adults who
fell was higher among whites (29.6%) and American Indian/Alaska Natives
(AI/ANs) (34.2%) than among blacks (23.1%) and Asian/Pacific Islanders
(19.8%). The percentage of older adults who reported a fall injury also
increased with age (p<0.01), from 9.9% among persons aged 65–74 years
to 11.4% among persons aged 75–84 years, to 13.5% among persons aged
≥85 years. AI/ANs were more likely to report a fall-related injury
(16.8%) than were whites (10.9%), Hispanics (10.7%), and blacks (7.8%).
The rate of fall-related injuries was significantly higher in the
population reporting poor health (480 per 1,000) than the population
reporting excellent health (69 per 1,000).
Among states and the District of Columbia, the percentage of older
adults who reported a fall ranged from 20.8% in Hawaii to 34.3% in
Arkansas. Several states had either significantly higher or lower
percentages of reported falls among older adults compared with the
national average (Figure) (Table 2). The percentage of older adults experiencing fall injuries ranged from 7.0% in Hawaii to 12.9% in Missouri.
Discussion
In 2014, 28.7% of older adults in the United States reported an
estimated 29.0 million falls in the preceding 12 months. Older adult
falls can result in death, serious injury, and loss of independence (1,2).
This analysis found that an estimated 7 million falls required medical
treatment or caused restricted activity for at least 1 day. Women and
those in older age groups were at higher risk for falling and being
injured in a fall. Reduced muscle strength is a risk factor for falls,
and aging and female sex are associated with reduced muscle mass (1,2). Women have been found to be more likely to report falls than men (3).
Aging also is associated with changes in gait and balance, increased
inactivity, more severe chronic conditions, and more prescription
medication use, all of which are risk factors for falls (1).
Limited research exists on the causes for racial/ethnic differences, but
these differences might be related to differences in health and
behavior (4,5). Reasons for state differences are unknown;
however, even in Hawaii, the state with the lowest incidence, 20.8% of
older adults reported a fall.
Annual Medicare costs for older adult falls have been estimated at $31.3 billion (6),
and the older adult population is expected to increase 55% by 2030.**
Applying the number of falls from this analysis to the projected 2030
population would result in an estimated 48.8 million falls and 11.9
million fall injuries, unless effective interventions are implemented
nationwide.
The findings in this report are subject to at least four limitations.
First, BRFSS data are self-reported and subject to recall bias. Second,
BRFSS does not include persons in long-term care facilities who are at
higher risk for falls (7). Third, the broad definition of fall
injury for this analysis might have resulted in a higher estimate of
injurious falls compared with other reports. Finally, the response rate
(median = 47%) could have resulted in nonresponse bias; however,
weighting and survey methodology are used to adjust the estimates and
reduce the effect of nonresponse bias.
Older adult falls are largely preventable, and health care providers
(e.g., physicians, nurses, nurse practitioners, physician assistants,
pharmacists, physical therapists, and occupational therapists) can play
an important part by discussing falls with older adult patients and
providing appropriate interventions (8). The American and British
Geriatrics Societies (AGS/BGS) Clinical Practice Guideline recommends
that health care providers use a multifactorial approach to prevent
falls that includes activities such as asking about falls, assessing
gait and balance, reviewing medications, and prescribing interventions
such as strength and balance exercises, or taking vitamin D.†† This type of approach has been estimated to be capable of reducing falls by 24% (8). Based on the AGS/BGS guidelines, CDC has developed the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative§§ to provide resources to help health care providers incorporate fall prevention into primary care (3).
STEADI stresses three initial steps that can be completed in one
patient visit: 1) ask patients if they have fallen in the past year,
feel unsteady, or worry about falling; 2) review medications and stop,
switch, or reduce the dosage of drugs that increase fall risk; and 3)
recommend daily vitamin D supplementation for improved bone, muscle, and
nerve health (with dosage of vitamin D and decision on whether to
co-supplement with calcium to be determined based on the patient’s
history).
Health care providers should discuss fall prevention with their
patients because approximately half of older adults who fall do not
discuss it with their health care provider, often because they fear this
will lead to a loss of independence (9). Health care providers
cite limited time and cost as barriers to incorporating preventive
services, such as those proposed by STEADI, into their clinical practice
(10). However, the Centers for Medicare & Medicaid Services
(CMS) now provides incentives for health care providers to conduct fall
prevention activities through payment and delivery reforms (e.g.,
Welcome to Medicare Visit, Medicare Annual Wellness Visit, and the
Medicare Shared Savings Accountable Care Organization Program).¶¶
CMS also links health care provider incentives to fall prevention
quality measures through the Physician Quality Reporting System (PQRS)
in the Merit-Based Incentive Program. PQRS includes two quality measures
for falls: Falls Risk Assessment and Falls Plan of Care.*** Mechanisms
such as payment and delivery reforms and quality reporting measures are
opportunities to make fall prevention a routine part of clinical
practice and reduce the barriers to providing services that can prevent
falls among older adults.
Acknowledgments
Susan Dugan, Hilary Eiring, MPH, Robin Lee, PhD, Judy A. Stevens, PhD, National Center for Injury Prevention and Control, CDC.
1Division of Unintentional Injury, National Center for Injury Prevention and Control, CDC; 2Division
of Analysis, Research and Practice Integration, National Center for
Injury Prevention and Control, CDC.
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