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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:M686-M692 (2001)
© 2001 The Gerontological Society of America

Do the Risks and Consequences of Hospitalized Fall Injuries Among Older Adults in California Vary by Type of Fall?

Arthur A. Ellisa and Roger B. Trenta

a Injury Surveillance and Epidemiology Section, Epidemiology and Prevention for Injury Control Branch, California Department of Health Services, Sacramento

Arthur A. Ellis, Department of Health Services, Epidemiology and Prevention for Injury Control Branch, Injury Surveillance and Epidemiology Section, 611 N. 7th Street, MS 39A, PO Box 942732, Sacramento, CA 94234-7320 E-mail: aellis{at}dhs.ca.gov.

Decision Editor: John E. Morley, MB, BCh


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Research on fall injuries in older persons generally does not examine different types of falls separately. (The main types are same level, from one level to another, and on or from stairs and steps.) There is no a priori reason to believe that various types of falls have similar demographic risk factors and consequences. Therefore, we examined patterns in types of falls, place of falls, and consequences of fall injuries as Californians move through their later decades.

Methods. We analyzed all computerized patient discharge records for all adults 20 years and over hospitalized with a fall as the principal external cause of injury in California nonfederal acute care hospitals, from 1995 through 1997 (N = 242,166). Older-adult age groups were compared with all younger adults. Place of fall, hospital charges, and disposition at discharge were analyzed by type of fall.

Results. The three main types of fall injury increase with age, but each type shows variation by age and sex. Women have the highest rates for the main types but not for the less common types. Hospitalized falls vary by place of fall. Mean hospital charges ($17,086) vary by type of fall, with falls from one level to another having the largest mean hospital charge ($19,632). Disposition at discharge does not vary by type of fall.

Conclusions. We found significant variation in demographic factors, place of fall, and mean hospital charges for falling by type of fall, suggesting that future research should focus on individual types of falls rather than on aggregated falls.

FALLS, common at any age, are endemic among older adults (1)(2)(3)(4)(5). Each year, one in three Americans over 65 years of age falls (6)(7). In California in 1995, 688 people 65 years and older died because of falls, and another 53,312 were hospitalized, a ratio of 1:77. Among injuries, falls were the leading cause of hospitalization in this age group, dwarfing the second leading cause (car crash injuries) by 60-fold (unpublished data).

Although most falls among older adults (90%) do not cause injury or death (8), research shows that many are medically and personally serious (4)(6)(7)(9)(10)(11)(12)(13)(14)(15)(16). Older adults who suffer a fall injury become heavy users of medical resources (15)(17). Fractures are a common consequence of falls among older adults, and hip fractures produce the greatest morbidity and mortality (18)(19)(20).

Falls are the most costly injury among older persons in the United States (21)(22)(23). The total annual cost of falls was estimated to be $75 to $100 billion, according to an earlier report (24). However, the projected costs for slip and trip injuries and deaths for persons aged 75 years and older are expected to increase at a substantially higher rate (59%) than for the population in general (27%) (25). Hospitalization costs are higher for women than men, rise dramatically with age (15), and increase with fall frequency and severity (21).

Falls among elderly persons have distinct age and sex patterns. The risk of suffering a fall injury rises sharply with age (4)(17)(19)(25)(26). Our earlier (unpublished) data for California show that fall injuries start rising at about age 55. Women have a higher hospitalization rate from falls (3)(4)(15)(17).

The literature on falls among the elderly population is large, but no study has analyzed serious older-adult fall injuries by type (e.g., from slipping or tripping). Most studies aggregate types of fall, and some focus on one type. There is no empirical or a priori reason to believe that various types of falls have similar demographic risk factors and consequences.

Research has shown that the largest proportion of falls among older adults occurs at home and indoors (25)(26)(27)(28)(29)(30). However, no one has documented whether the various types of falls take place mainly at home. Inasmuch as a common fall prevention approach is to reduce fall hazards, such as obstacles and slippery surfaces, it is important to know where various types of falls occur.

This study describes older-adult fall injuries in California by type of fall. We use a large hospitalized injury data set to examine patterns in types of falls, place of falls, and consequences of fall injuries as people move through their later decades. Specifically, our study addresses the following questions: (i) Do particular types of falls account for the large increase in fall injuries that come with age? (ii) Does the typical place of fall vary with type of fall and change as people age? and (iii) Do medical outcomes vary with type of fall and become more adverse with age?


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Data Source
We obtained computerized hospital discharge summaries for 1991 through 1997 from the California Office of Statewide Health Planning and Development (OSHPD). As required by law, all nonfederal acute care hospitals report discharges to the OSHPD. All injury records contain an external cause of injury (E-) code (31). Only the first hospitalization for a fall injury is E-coded, permitting us to look at incident cases and avoid duplication of counts for patients re-admitted in the same year for the same fall. California hospital discharge data appear reliable, as demonstrated by the OSHPD's reabstraction studies of hospital records. Computerized edits and analyst review are performed on every record. The OSHPD allows an error tolerance level of 0.1% for E-codes (32).

For denominator populations, we used California Department of Finance population estimates by age, sex, and the following race/ethnicity categories: white, black, Hispanic, Asian, and Native American. No "other" category is given for persons not included in the previous categories or for persons of mixed race.

Case Definition
This study includes all adults, aged 20 years and older, hospitalized with a fall injury as the principal external cause of injury in California nonfederal acute care hospitals. Older adults were stratified by age group for analyses (55–64 years, 65–74 years, 75–84 years, and 85 years and older) and were compared with all younger adults (20–54 years). We selected three recent years of patient discharge data—1995 through 1997—to increase the size of the population analyzed. Hospitalized falls and fall injury rates (per 100,000) rose significantly each year (Table 1 ).


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  		Table 1. Hospitalized Falls and Fall Injury Rates (per 100,000) Among California Residents, 1995–1997

 
We identified older-adult fall injuries by using the International Classification of Diseases, Ninth Revision E-code series "Accidental Falls," E880 through E888, with the exception of E887 (fracture, cause unspecified). Because this code probably contains some (unidentifiable) nonfalls, we excluded 4704 (1.9% of E880–E888 cases) to avoid including as cases patients who did not fall (5).

Variables
We used the following patient discharge data set variables: age, type and place of fall injury (both derived from E-codes), sex, race, disposition at discharge, hospital charges (billed charges only, not revenue, excluding professional fees), and length of stay (days between admission and discharge).

Place of fall was determined for cases admitted because of one E-coded fall injury (n = 219,402 or 91% of all falls). Multiple fall cases (n = 7292) were disregarded because place of occurrence cannot be determined uniquely.

Analysis
To determine risk, we calculated average age-specific crude incidence rates per 100,000 California population per year (rate = mean fall injuries for 1995–1997/California population, July 1, 1996 x 100,000). Rates based on numerators less than 20 are unstable and are not shown. Statistically significant differences between rates were determined by nonoverlapping confidence intervals at the 95% level. All rate comparisons cited in the text are statistically significant at p < .05. Rate increases by age and sex were described by fitting the rates to an exponential curve using Prism Release 3.0 software (Prism Software Corp., Lake Forest, CA). Statistical Analysis System for Windows, Release 6.12 (SAS Institute, Inc., Cary, NC) was used for all other analyses.


   Results
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 Abstract
 Methods
 Results
Discussion
 References
 
Trends, Incidence, and Population Characteristics
Falls are a major public health problem in California, with 268,181 fall injuries requiring hospitalization during the 1995 through 1997 study period. Table 2 illustrates how the risk of falling rises dramatically with age, with women falling more frequently than men starting at age 50. The average annual rate of falls was 276/100,000 (all ages). For 1995 through 1997, there were 242,166 hospitalized falls among all adult residents of California (aged 20 years and older), an average annual rate of 358.


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  		Table 2. Hospitalized Fall Injury Rates (per 100,000) by Gender and Age Among California Residents, 1995–1997

 
Table 3 shows demographic risk factors and types of falls for California adults from 1995 through 1997. Women have an elevated rate, nearly double that of men (457 vs 258). Fall risk shows a 2.5- to 3-fold increase between each successive age group. The rate difference between adults aged 20 to 54 years and 85 years and older is 57-fold. The increase in rates across age for both men and women is exponential (data not shown). Whites are at the most risk, with a rate double that of Blacks, followed by Hispanics, Asian/Pacific Islanders, and Native Americans. Fall injuries from slipping, tripping, and stumbling on the same level are clearly most common among adults, followed by injuries from falling from one level to another and from falling on or from stairs and steps. These three types of falls represent 91% of all fall injuries with type known (excluding other and unspecified). Among fall injuries from one level to another, falls from a bed or chair are particularly common.


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  		Table 3. Hospitalized Fall Injuries, Percentages, and Rates (per 100,000) by Gender, Age, Race/Ethnicity and Type of Fall Among California Residents Aged 20 and Older, 1995–1997

 
Incidence Rates by Type of Fall Injuries and Age
The risk of injury from falling varies by type of fall, age, and sex (Table 4 ). For the three main types of falls, rates jump dramatically with age. The increase between younger adults aged 20 to 54 and older adults aged 85 and older was 76-fold for fall injuries from slipping, tripping, and stumbling on the same level (31 vs 2383), 33-fold for fall injuries from one level to another (17 vs 556), and 19-fold for fall injuries on or from stairs and steps (7 vs 132).


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  		Table 4. Hospitalized Falls, Rates (per 100,000)* by Gender and Age, and Type of Fall Among California Residents Aged 20 and Older, 1995–1997

 
Women have higher rates for the three leading types, whereas men have higher rates for all less common types. The risk for women increases with age for fall injuries from slipping, tripping, and stumbling (from 33 for ages 20–54 to 2690 for ages 85 and older) and those from stairs and steps (from 8 to 144). For fall injuries from one level to another, men have higher rates until age 64, and women have higher rates thereafter.

Place of Fall Injury by Type of Fall and Age
Nearly two thirds of all hospitalized falls occur at home, with the proportion increasing with age (from 39% for ages 20–54 to 70% for ages 85+) (Table 5 ). A residential institution is the second leading place for fall injuries (with 14%), and the proportion increases with age (from 7% for ages 20–54 to 21% for ages 85+). For all other specified places, fall injury becomes less frequent with age. The place of fall injury also varies by type of fall injury. For example, more than two thirds of fall injuries from slipping, tripping, and stumbling occur at home, but only one half of those from one level to another occur at home.


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  		Table 5. Hospitalized Falls and Percentage of Distribution by Age, Type, and Place of Fall Among California Residents Aged 20 and Older, 1995–1997

 
Fall Injury Outcomes and Consequences by Age
Hospital charges, which are partly a function of length of stay, do not rise with age for older adult fall injuries (Table 6 ). However, hospital charges for older adult fall injuries are about $2000 higher than charges for the age 20 through 54 comparison group. Hospital charges for all fall injuries amounted to $4.1 billion for 1.7 million hospital days for the study period. Mean charges came to $17,086, and the mean stay was 7 days. Mean charges and length of stay vary by type of fall injury, with those from one level to another having the largest means (charges = $19,632, and length of stay = 8 days).


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  		Table 6. Hospitalized Falls and Mean Hospital Charges by Type of Fall and Age Among California Residents Aged 20 and Older 1995–1997

 
Fig. 1 shows that disposition at discharge varies by age. However, examination revealed that it does not vary by type of fall injury. Transfer from hospital to long-term nursing care, the most common discharge destination for older adults with fall injuries, is typically an adverse outcome. Nearly 67% of those aged 85 years and older were transferred to long-term care, compared with only 5% of those in the 20 to 54 age group. The percentage of fall injury patients dying in the hospital also rose consistently with age (from 1% for ages 20–54 to 4% for ages 85 and older). In contrast, the percentage of patients experiencing a routine discharge and returning home was strongly inversely related to age (decreasing from 83% for ages 20–54 to 14% for ages 85 and older).



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  		Figure 1. Hospitalized falls and percentage distribution of disposition at discharge from acute care facilities among California residents aged 20 and older, 1995 through 1997. Source: patient discharge data, California Office of Statewide Health Planning and Development.

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Unlike falls in general, types of fall injuries have not been widely studied. Taking advantage of California's large population, we were able to see how fall injuries—and major fall types—change as people age. The increase in rate with age is remarkable. From age 50 on, the increase is exponential. By age 90, the rate reaches 7058 per 100,000.

Like recent studies in Finland (33) and the United States (34), we found an upward trend in rates among older adults. The reasons for the rising trend among older adults are unclear, but the implications for health care are serious. In California, demographers have forecasted that the population of those 55 and older will increase from 18% of the total population in 1999 to 26% in 2040 (35).

All major types of fall injuries climbed significantly with age in our study, but same-level falls from slipping, tripping, and stumbling accounted for the majority. Most of these occur at the patient's home, as the literature has shown (26)(27)(29)(30). Exposure is key: Older adults may have less chance of falling in places they are presumably less likely to visit as they get older, such as recreation and industrial places.

The consequences of older-adult fall injuries are extreme and increase with age. Falls are the most costly injury among older adults (21)(22). Hospital charges alone amounted to $4.1 billion for 1.7 million hospital days during our study period. We found that hospital charges do vary by type of fall, with falls from one level to another having the largest charges.

Disposition at discharge varied radically by age but not by type of fall. Transfers to long-term care in nursing homes increased with age, and this was the most typical discharge destination for older adults with fall injuries, as other studies report (4)(36). Among very old fall patients, long-term care becomes the norm. This pattern suggests high morbidity and high costs.

The following caveats should be kept in mind when interpreting our data. We include only serious adult fall injuries requiring hospitalization and, therefore, do not consider falls that cause death before admission or fall injuries treated in outpatient settings. Although there is little ambiguity as to what constitutes a hospitalized fall injury, the decision to hospitalize a person who falls is made by thousands of physicians in nearly 600 acute care hospitals in California. However, hospital records do not identify type of fall for 89,841 (37%) cases. Whether these missing data are distributed so as to bias our findings cannot be determined, although age–sex patterns of unidentified falls are very similar to those of identified falls (data not shown). Intrinsic risk factors are not included in California hospital discharge records and could not be studied. For example, we do not know which patients took medications that affect balance.

Given the extremely high rates of older-adult fall injuries, the aging of our population, and possibly increasing rates, the prevention of falls among older adults should be a top public health priority. The potential cost benefit of programs to prevent morbidity from falls is believed to be very large (21)(37). We encourage prevention workers to take note of our findings that demographic factors, place of fall, and mean hospital charges all vary by type of fall. These findings suggest that future research should focus on individual types of falls rather than on aggregated falls.


   Acknowledgments
 
The California Department of Health Services supported this research.

Received September 5, 2000

Accepted September 14, 2000


   References
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 Abstract
 Methods
 Results
 Discussion
 References
 

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