Fall-Induced Injuries and Deaths Among Older Adults

ORIGINAL CONTRIBUTION

Pekka Kannus, MD, PhD Context Although various fall-induced injuries and deaths among older adults are Jari Parkkari, MD, PhD increasing, little is known about the epidemiology of these events. Seppo Koskinen, MD, PhD Objective To determine the trends in the number and incidence of fall-induced injuries and deaths of older adults in a well-defined white population. Seppo Niemi Design and Setting Secular trend analysis of the population of Finland, using the Mika Palvanen, MD Finnish National Hospital Discharge Register and the Official Cause-of-Death Statis- Markku Ja¨rvinen, MD, PhD tics of Finland. Ilkka Vuori, MD, PhD Participants All persons aged 50 years or older who were admitted to hospitals in Finland for primary treatment of a first fall-induced injury from the years of 1970 to ALL-INDUCED INJURIES AND 1995, and for comparison, all fall-induced deaths in the same age group from the years deaths among older adults are 1971 to 1995. a major public health problem, Main Outcome Measure The number and the age-specific and age-adjusted incidence especially in developed societ- rate (per 100 000 persons) of fall-induced injuries and deaths in each year of the study. Fies that have aging populations.1-5 As the Results For the study period, both the total and population-adjusted number (per number of older adults in these popu- 100 000 persons) of Finns aged 50 years or older with fall-induced injury increased lations continues to increase, the num- substantially. Total fall-induced injuries increased from 5622 in 1970 to 21 574 in 1995, ber of fall-related injuries and result- a 284% increase, and the rate increased from 494 to 1398 per 100 000 persons, a ing deaths is also likely to increase. 183% increase. The age-adjusted incidence also increased in both women (from 648 About one third of 65-year-old or in 1970 to 1469 in 1995, a 127% increase) and men (from 434 in 1970 to 972 in older persons living in the community 1995, a 124% increase). Moreover, the number of deaths due to falls in the overall population increased from 441 in 1971 to 793 in 1995, an 80% increase, and the rate and more than half of those living in increased from 38 in 1971 to 51 in 1995, a 34% increase. However, after age adjust- institutions fall every year, and about ment the incidence of fall-induced death did not show a clear upward trend. half of those who fall do so repeat- edly.1,2 Both the incidence of falls and Conclusions In a well-defined white population, the number of older persons with fall-induced injuries is increasing at a rate that cannot be explained simply by demo- the severity of complications increase graphic changes. Preventive measures should be adopted to control the increasing bur- with age and increased disability and den of these injuries. Fortunately, the age-adjusted incidence of the fall-induced deaths functional impairment.2,3 Not all falls shows no increasing trend over time. of older persons are injurious and life- JAMA. 1999;281:1895-1899 www.jama.com threatening, but about 5% of them result in a fracture, and other serious in- deaths of older adults has been con- Discharge Register (NHDR) of Fin- juries occur in 5% to 11% of falls.1-5 ducted. Therefore, we determined the land. This statutory register contains Injury is the fifth leading cause of death secular trends in the absolute number data on age, sex, place of residence, hos- in older adults, and most of these fatal and age-specific and age-adjusted inci- pital number and department, place and injuries are related to falls.1-5 In the dence rates of fall-induced injuries and cause of injury, diagnosis, day of ad- United States, falls, occurring primar- deaths among persons aged 50 years or ily among older adults, were the sec- older in Finland, a country with approxi- Author Affiliations: Accident & Trauma Research Cen- ond leading cause of deaths due to un- mately 5 million inhabitants between the ter and the Tampere Research Center of Sports Medi- 5 years of 1970 and 1995 (deaths were in- cine, President Urho Kaleva Kekkonen Institute for intentional injuries in 1994. Health Promotion Research, Tampere, Finland (Drs Despite these facts, to our knowl- cluded beginning in 1971). Kannus, Parkkari, Palvanen, and Vuori and Mr Ni- edge, no epidemiologic study on the emi); National Public Health Institute, Helsinki, Fin- METHODS land (Dr Koskinen); and the Medical School and the secular trends of fall-induced injuries and Department of Surgery, Tampere University and Uni- Fall-Induced Injuries versity Hospital, Tampere, Finland (Dr Ja¨ rvinen). Data for the fall-induced injuries were Corresponding Author and Reprints: Pekka Kannus, See also Patient Page. MD, PhD, UKK Institute, Kaupinpuistonkatu 1, FIN- obtained from the National Hospital 33500 Tampere, Finland (e-mail: [email protected]).

Downloaded from www.jama.com by LauraCooper, on September 11, 2006 FALL-INDUCED INJURIES AND DEATHS IN OLDER ADULTS mission and discharge, and place of fur- Fall-Induced Deaths due to injuries and their cause-of-death ther treatment. The register has been Data were obtained from the Official codes are verified further by autopsies operating since 1967 and is updated and Cause-of-DeathStatistics(OCDS)ofFin- performed in 94% to 97% of these monitored for quality by the Depart- land.13 This statutory register has been cases.13,14 The death data for this study ment of Registers and Statistics, Na- computer-based since 1971, and from were drawn from the entire population tional Research and Development Cen- the beginning, the Cause-of-Death Bu- of Finland. ter for Welfare and Health, Helsinki, reau at the Central Statistical Office of Finland. Finland(currentlyStatisticsFinland)has Age-Specific and In this study, we defined fall- updated it and has maintained quality Age-Adjusted Incidence induced injuries as having been in- control. Annual mid year population figures for curred by adults aged 50 years or older The Finnish OCDS contains data on each 5-year age group, ranging from 50 who as a consequence of a fall (ie, an age,sex,maritalstatus,placeofresidence, to more than 90 years during the years unexpected, sudden descent from an and place, cause, and time of death of from1970through1995weretakenfrom upright, sitting, or horizontal posi- the deceased. In the Finnish system of the Official Statistics of Finland.16 In each tion, the descent height being Յ1m) death certification, the basic reason for age group, the fall-induced injury and were hospitalized (emergency depart- thedeathisclarifiedbythephysicianwho deathincidenceswerecalculatedforboth ment visits not requiring hospitaliza- certified the death and who wrote the of- sexes and expressed as the number of tion were not included). Similar crite- ficial death certificate. In injury-related cases per 100 000 persons each year. In ria have been used in epidemiological deaths, an autopsy is required and per- calculating the age-adjusted incidences, studies of osteoporotic fractures of the formed almost without exception in 94% ageadjustmentwasperformedseparately elderly.6-8 Thus, all Finns aged 50 years to 97% of these deaths to verify that the for women and men by means of direct or older who were admitted to hospi- death was indeed injury induced.13,14 standardization using the mean popu- tals for primary treatment of a fall- The main OCDS categories for unin- lation between 1970 and 1995 as the induced injury in the years between tentional injuries are those caused by standard population. 1970 and 1995 were selected from the road traffic and water traffic collisions, NHDR. The date of the injury and falls, drownings, and poisonings.13 For RESULTS unique personal identification num- the current study, all Finns aged 50 years Fall-Induced Injuries ber system of Finnish citizens allowed or older whose deaths were due to a fall- Numbers and Incidences. The number us to focus our analysis on each sub- induced injury from 1971 through 1995 of older persons with fall-induced injury ject’s first recorded admission. The fall- were selected. increasedconsiderablybetweentheyears induced injuries were classified as In practice, the Finnish OCDS re- 1970 and 1995: from 5622 to 21 574 bone fractures, soft tissue bruises and views 100% of Finnish deaths, since each overall (a 284% increase) and from 3659 contusions, head injuries other than death certificate and the correspond- to 14 764 in women and from 1963 to fractures, joint distortions and dislo- ing decedant information in the popu- 6810 in men (FIGURE 1, A). The aver- cations, soft tissue wounds and lacera- lation register are cross-checked.13 For age annual increases for women and men tions, and other injuries. example, in 1994 only 4 death certifi- were 12.1% and 9.9%, respectively. In The Finnish NHDR is the oldest es- cates of the 47 938 deceased were not is- both sexes, the overall incidence curve tablished nationwide discharge regis- sued before the deadline and publica- also showed a clearly increasing trend, ter in the world, and the data pro- tion of the 1994 statistics.13,15 although the Finnish population of per- vided by this register are well suited to The accuracy of the data of the OCDS sonsaged50yearsorolderincreased36% epidemiologic purposes: the register has is maximized by triple-checking each (from 1.1 million to 1.5 million) during been shown to cover the acute inju- code of the death certificate issued by the this 25-year period (Figure 1, B). Inci- ries of the population adequately (an- physician who certified the death.13 The dence increased from 494 to 1398 per nual coverage of injuries is 95%- first check is made by the local popula- 100 000 persons, a 183% increase. Even 100%) and record them accurately tion authority for accuracy of the popu- after age-adjustment, the incidence (annual accuracy of the NHDR injury lation data of the deceased, the second curves showed a clear increase in the diagnoses is higher than 95%).9-12 by the legal medical officer at the county number of women injured, increasing The injury data were drawn from the administration for accuracy and to en- from 648 in 1970 to 1469 in 1995, a entire population of Finland. In other sure that the cause-of-death codes and 127% increase, and the number of men words, the absolute and relative num- the original death certificate are consis- injured, increasing from 434 in 1970 to bers of Finns aged 50 years or older with tent, and the third by Statistics Finland, 972 in 1995, a 124% increase (Figure 1, fall-induced injuries were not cohort- a computer-driven check of the logic of C). A more detailed examination of these based estimates but complete popula- the entire database through a cross- curves showed that the injury develop- tion results, and, therefore, statistical tabulation of statistical variables. The ac- ment actually consisted of 2 phases: the analyses were not used. curacy of our death certificates for deaths number and incidence of injuries slightly

Downloaded from www.jama.com by LauraCooper, on September 11, 2006 FALL-INDUCED INJURIES AND DEATHS IN OLDER ADULTS decreased between 1970 and 1977 and creased during the study period, from older increased by 36% during this sharply and steadily increased thereafter. 67.3 years in 1970 to 73.0 years in 1995. period (Figure 2, B). However, after age- Comparing the secular changes of the In women, the mean age increased from adjustment (Figure 2, C), these inci- older adults’ fall-induced injuries with 69.2 to 75.3 years; in men, it increased dence curves do not show a clear trend those of people younger than 50 years or from 63.6 to 68.0 years. and they show larger annual variation with those whose injuries were induced Injury Distribution by Type. Of all than the corresponding injury curves by means other than falling reveals that injuries,bonefracturesrepresentthelarg- (see Figure 1, C). In women, the age- thetrendsaregreatestamongfallsinolder est injury group and their proportion re- adjusted incidence of fall-induced deaths adults. For all injuries in Finland (ie, all mained constant (68%) over time in both decreased between 1971 and 1975, after age groups and all causes for injuries in- 1970 and 1995. Soft tissue bruises and which it stayed relatively stable, while cluded), the proportion of the study contusions, the second largest injury in men this incidence rate increased group’s injuries increased from 12% in group, increased slightly over time, from slightly from 1971 to 1995 (Figure 2, C). 1970 to 26% in 1995. Within the study 9% in 1970 to 11% in 1995. A slight in- The number of deaths due to falls group population, this proportion rose crease also occurred in joint distortions decreased in women from 64.9 in 1971 from 36% to 56%. Of all persons treated anddislocations(6%to9%,respectively), to 37.5 in 1995 and increased in men in hospitals for fall-induced injuries, the soft tissue wounds and lacerations (3.5% from 40.5 in 1971 to 47.6 in 1995. proportion of older adults increased to 4%, respectively), and other injuries When comparing secular trends of steadilyfrom46%in1970to59%in1995. (0.5% to 1.5%, respectively). The only in- fall-induced deaths among persons aged Age-Specific Incidences. Age- jurycategorythatdecreasedovertimewas 50 years or older with the other cat- specific incidence curves showed that the head injuries other than fractures, which egories of the unintentional injury incidence of fall-induced injuries, re- declinedfrom13%in1970to7%in1995. deaths, the increasing relative impor- gardless of sex, increased by age and time tance of the fall-induced deaths is evi- and that in both absolute and relative Fall-Induced Deaths dent. For all unintentional injury deaths numbers, the incidence increases were Numbers and Incidences. The num- among all age groups in Finland, the higher in older age groups than in ber of deaths due to falls in older adults proportion of deaths due to falls among younger age groups (data not shown). also increased from 441 to 793, an 80% those aged 50 years or older steadily in- For example, the incidence of fall- increase overall. The rate increased from creased, from 15% in 1971 to 30% in induced injuries (per 100 000 persons) 38 in 1971 to 51 in 1995, a 34% increase. 1995. Within the population aged 50 experienced by women aged 50 to 54 Stratified by sex, numbers increased years or older, this proportion rose from years increased from 264 in 1970 to 596 among women from 279 in 1971 to 441 33% to 47%, respectively. in 1995, a 126% increase. Similarly, the in 1995 and from 162 to 352 in men dur- Age-Specific Incidences. The lim- incidence of fall-induced injuries expe- ing the same years (FIGURE 2, A). The ited number of fall-induced deaths per rienced by women aged 90 years or older average annual increases were 2.4% and year and age group allowed reasonable increased from 2760 in 1970 to 7880 in 4.9%, respectively. In both sexes, the examination of the age-specific inci- 1995, a 186% increase. overall incidence curve also showed an dence curves of the fall-induced deaths Mean Age. The mean age of older per- increasing trend, although the Finnish in 4 age groups that span 10 years: 50 to sons with a fall-induced injury also in- population of persons aged 50 years or 59, 60 to 69, 70 to 79, and 80 years or

Figure 1. Trends in Fall-Induced Injuries of Older Adults

16 000 1800 1600 A B Women C Men 14 000 1600 1400

1400 12 000 1200 1200 10 000 1000 1000 8000 800 800 6000 600 600 4000 400 No. of Fall Induced Injuries 400 Incidence of Fall Induced Injuries 2000 200 200

0 0 Age-Adjusted Incidence of Fall Induced Injuries 0 1970 1975 1980 1985 1990 1995 1970 1975 1980 1985 1990 1995 1970 1975 1980 1985 1990 1995 Year Year Year

Data represent Finnish persons aged 50 years or older injured due to falls from 1970 through 1995. Incidences are reported as number of injured patients per 100 000.

Downloaded from www.jama.com by LauraCooper, on September 11, 2006 FALL-INDUCED INJURIES AND DEATHS IN OLDER ADULTS older. In both women and men, the age- countries with predominantly white portion of all injuries that were due to specific incidence of fall-induced deaths population. falls from 36% in 1970 to 56% in 1995 increased by age, being clearly highest Theoretically, it is possible that the ob- would not be explained by an in- in the oldest age group (Ն80 years), but servation that the absolute and relative creased rate of hospitalization. Third, none of these incidence curves showed number of older Finnish persons with within specific injury categories, we re- a clearly and consistently increasing time fall-induced injuries increased in the cently studied severe fall-induced head trend (data not shown). years from 1970 to 1995 (Figure 1, pan- traumas and found that while the age- els A, B, and C) is a result of changes in adjusted incidence of these injuries COMMENT the hospitalization policy of the injured has clearly increased among older Our study showed that the absolute as older persons over time rather than a true adults during recent decades, it has re- well as the relative number (patients per increase in the number of injured per- mained stable among a randomly se- 100 000 persons) of older persons with sons in the population. For several rea- lected younger reference group, people fall-induced injury increased consider- sons, this possibility is, however, very aged 30 to 39 years.18 Finally, a simi- ably in Finland between 1970 and 1995: unlikely. larly increasing trend has been seen in from 5622 and 494 in 1970, to 21 574 First, the increases were so large that the number and age-adjusted inci- and 1398 in 1995, respectively. This in- it is unlikely that they would have oc- dence of hip fractures of Finns aged 50 crease occurred in both women and men curred as a result of a change in the hos- years or older,19 and these injuries have and after age adjustment. The trend was pitalization policy of older patients only. always resulted in hospital admission. greatest in persons aged 80 years or Any trends in hospitalization policy Our findings on fall-induced injuries older. The overall number and inci- would have favored outpatient care be- among older persons are alarming for 2 dence of fall-induced deaths among this cause in Finland, as elsewhere, the eco- reasons. First, not only is the incidence population also increased during the nomic mandate calls for reductions in oftheseinjuriesincreasing,butthepopu- study period, but as in the age-adjusted health care costs.17 Such a trend would lation at risk is constantly expanding and figures, the incidence curves did not mean that our data would underesti- will grow more rapidly in the near fu- show definite trends over time. mate rather than overestimate the true ture. Second, the increasing mean age A major strength of this study was that incidence of fall-induced injuries among of the patients presenting with a fall- the data of fall-induced injuries and older adults. Second, the steady in- induced injury is likely to mean more deaths were taken from 2 registers (the crease in the relative number of fall- difficulties in the treatment of these in- Finnish NHDR and OCDS) both of induced injuries in older adults com- juries and increasing rates of general which are with highly accurate and have pared with younger adults, trends in morbid conditions and, indirectly, death excellent coverage,9-15 and that both reg- other mechanisms of injury, and the of the patients. In this respect, it was en- isters included the entire population of proportion of fall-induced injuries that couragingthattheage-adjustedincidence Finland. On the other hand, these trends occurred in older adults support the of fall-induced deaths did not show a of fall-induced injuries and deaths can- view that the number and incidence of clear increase over time (Figure 2, C), notbedirectlygeneralizedtootherpopu- fall-induced injuries among the el- which is most likely due to improved lations in the world, although it is likely derly Finns indeed increased between treatment, rehabilitation, and average that trends are similar in other western 1970 and 1995. The increase in the pro- health of injured older adults.20,21

Figure 2. Trends in Fall-Induced Deaths of Older Adults

500 60 70 A B Women C Men 60 50 400 50 40 300 40 30 30 200 20 20 No. of Fall-Induced Deaths 100

Incidence of Fall-Induced Deaths 10 10

0 0 Age-Adjusted Incidence of Fall-Induced Deaths 0 1971 1975 1980 1985 1990 1995 1971 1975 1980 1985 1990 1995 1971 1975 1980 1985 1990 1995 Year Year Year

Data represent Finnish persons aged 50 years or older who died due to a fall between 1971 and 1995. Incidences are reported as deaths per 100 000 persons.

Downloaded from www.jama.com by LauraCooper, on September 11, 2006 FALL-INDUCED INJURIES AND DEATHS IN OLDER ADULTS

The precise reasons for the increas- adults has increased during recent de- largest Finnish age groups will not reach ing age-adjusted incidence of fall- cades, and in England, Wales, 24 and the the average age of the patients in this induced injuries in Finnish older adults United States,25 no deterioration in the study until the year 2020, and thus the are not known. In the fall-related frac- average health of these people has been number of these injuries would be tures of the hip and proximal humerus, observed. expected to increase particularly rap- fractures for which a similar secular trend Older adults who are in the young- idly during that time (about 61 000 has been reported,8,19 deterioration in the old age group (eg, 65-75 years) have im- patients with fall-induced injury per age-adjusted bone density and strength proved average health and functional year by 2030). For this reason, vigor- and an increase in the age-adjusted inci- capacity compared with past co- ous preventive measures, such as reduc- dence of falls in the older adults have horts,24,25 and they may engage in more ing the number and severity of falls of been the most commonly offered expla- activities that place them at risk of falls. older persons, should be implemented nations.19,22,23 In the fall-induced inju- An increasingly mobile lifestyle may to control the increasing burden of these ries other than fractures, only the latter thus predispose these persons to inju- age-related injuries. Fall-prevention explanation is plausible. ries due to falls.26,27 In addition, the in- interventions have given convincing evi- Among very old adults (persons aged creased average consumption of alco- dence that strength and balance train- 80 years or older), the suspected in- hol, psychotropic drugs, and related ing of older adults,28,29 as well as more creasing average propensity for falls has substances among the younger Finn- multifactorial preventive programs been explained by such factors as in- ish groups of older adults may have in- including simultaneous assessment and creased occurrence of coexisting medi- creased the risk of falling.26,27 reduction of many of the individual’s cal problems, poorer mobility and neu- Assuming that the observed rather predisposing and situational risk fac- romuscular function, and more frequent linear development in the injury inci- tors for falls,30,31 can significantly use of drugs and related substances that dence continues (Figure 1, B) and that decrease the risk of falling. Such pro- increase the risk of falling.1-5,19 Also, in- the size of the population of older per- grams should be implemented on a creased survival of ill and frail older sons increases as predicted, the annual broader scale to reduce the likelihood individuals may increase the tendency number of 50-year-old or older Finns of falls in older adults. to falls and injuries in this population. experiencing fall-induced injury can be Funding/Support: This study was funded by the Medi- On the other hand, no study has been estimated to increase from 21 600 cal Research Fund of Tampere University Hospital, Tampere, Finland. published to confirm that the age- (1995) to about 25 000 and 36 000 in Acknowledgment: We thank the Finnish Ministry of adjusted incidence of falls of the older the years 2000 and 2010. However, the Health and Statistics Finland for their cooperation.

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