WHAT IS ALREADY KNOWN ON THIS TOPIC

Fall-related fractures are a major public health burden in older adults.

Previous research reported stable emergency department visits for fall-related fractures in U.S. older women between 2001 and 2008.

WHAT THIS STUDY ADDS

The estimated number of EDs visits for fall-related fractures increased in U.S. older adults from 2001 to 2020.

Age-adjusted fall-related fracture rates decreased in women from 2016 onward.

Hospitalizations for fall-related fractures progressively increased during the study period.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYIntroductionBackground

Falls in older adults represent a major public health burden associated with increased morbidity, mortality, and healthcare costs.1 2 Of fall-related injury visits to the emergency department (EDs) in older adults, fractures account for 37.8% of women’s and 28.3% of men’s injuries.3 Moreover, fractures in older adults are associated with long-term disability and poor health-related quality of life.4 5 In the U.S, about 5 million EDs visits for fall-related fractures occurred among older adults between 2001 and 2008. Of those, adults aged 80 years and older, women, and trunk fractures (lumbar spine, pelvis, and hip) accounted for most of these injuries.6

Notably, EDs visits for fall-related injuries among U.S. older adults increased on average by 2% per year from 2001 to 2012. Moreover, it was projected that about 5.7 million EDs visits for fall-related injuries will occur by 2030.7 Similarly, Drew et al,8 in a recent analysis of the National Health Interview Survey (NHIS) demonstrated that self-reported fall-related injuries in U.S. older adults increased by 42% between 2004 and 2017. Although EDs visits for fall-related fractures among U.S. older adults was reported to increase in men and remain stable in women between 2001 and 2008,6 whether fall-related fracture rates have changed over the past decade is undetermined. Given the adverse health consequences of low impact fractures among older adults, the present study aimed to examine temporal trends in EDs visits for fall-related fractures in U.S. adults aged 65 years and older between 2001 and 2020.

MethodsStudy population

The National Electronic Injury Surveillance System All Injury Programme (NEISS-AIP) is a collaborative effort by the National Centre for Injury Prevention and Control and the Consumer Product Safety Commission designed to provide national incidence estimates of all types and external causes of non-fatal injuries visits to the EDs. A detailed description of the NEISS-AIP methods and analytic guidelines can be found at: https://www.icpsr.umich.edu/web/ICPSR/search/studies?q=NEISS-AIP.

The present analysis was limited to EDs visits for unintentional fall-related fractures in adults aged 65 years and older between 2001 and 2020. Age-adjusted fall-related fracture rates by sex and primary body parts were calculated using the direct method and adjusted to the 2000 U.S. standard population. Moreover, the percentage of older adults hospitalised for fall-related fractures according to body parts was examine over time.

Statistical analysis

Joinpoint trend analysis software, V.4.9.1.0, (https://surveillance.cancer.gov/joinpoint/) was used to examine the average annual percent change (AAPC) in rates. This summary measure describes the average annual percent changes over a period of multiple years, which is valid even if the model indicates that changes in trend occurred over time. Moreover, the annual percent change (APC) in fracture rates was calculated if changes in trends was seen during the study period.9 A maximum of 2 joinpoints were allowed for each analysis. All statistical analyses were performed using SPSS Complex Sample software, V.25 (SPSS Inc, Chicago, Illinois, USA) to incorporate sampling weights and obtain nationally representative estimates from the NEISS-AIP sampling design.

Results

An estimated 15.8 million visits to the EDs for unintentional fall-related fractures occurred in U.S. older adults between 2001 and 2020. Of those, women accounted for 73.2% of the cases. Overall, 55% of fall-related fractures occurred at home, and lower trunk fractures were the most frequently affected body part. The estimated number of EDs visits for fall-related fractures in older adults increased from 574 000 in 2001 to 9 84 000 in 2020. Similarly, the percentage of older adults hospitalised for these injuries increased from 41.6% in 2001 to 51.5% in 2020.

As shown in figure 1, fall-related fracture rates progressively increased on average by 1.3% (95% CI: 0.9%, 1.7%) per year in adults aged 65–74 years. From 2001 to 2016. fracture rates did not significantly change among those aged 75–84 and increased on average by 2.2% (95% CI: 0.6%, 3.7%) per year in subjects 85 years and older. From 2016 onward, annual rates significantly decreased by −5.6% in both age-groups.

Figure 1

Trends in EDs Visits for fall-related fractures by age-groups.

As shown in figure 2, the age-adjusted incidence of fall-related fractures in women increased annually by 1.1% (95% CI: 0.4%, 1.7%) between 2001 and 2012. Thereafter, a non-significant annual increase in rates by 4.2% (95% CI: −0.8%, 9.5%) was seen between 2012 and 2016. Notably, a marked decrease in fracture rates by −5.0% (95% CI: −7.9%, −2.0%) per year occurred in older women during 2016–2020. In men, fracture rates also increased by 1.3% (95% CI: 0.4%, 2.2%) per year between 2001 and 2016. Moreover, a non-significant upward trend in rates by 5.4% (95% CI: −1.5%, 12.7%) per year was seen during the period 2012–2016. Subsequently, fracture rates did not significantly decrease by −3.0 (95% CI: −7.1%, 1.2%) per year from 2016 onward.

Figure 2

Trends in ED visits for fall-related fractures in men and women.

Table 1 shows trends in age-adjusted EDs visits for fall-related fractures according to affected body parts. Head/neck fractures increased on average by 4.4% (95% CI: 3.1%, 5.8%) and upper trunk fractures by 2.1% (95% CI: 1.6%, 2.6%) per year during the study period. Similarly, lower trunk and leg/foot fractures significantly increased by 1.4% (95% CI: 0.6%, 2.2%) and 2.1% (95% CI: 0.0%, 4.3%) per year from 2001 to 2016, respectively. From 2016 onward lower trunk fractures did not significantly change. Notably, arm/hand fractures also decreased by −6.2% (-9.4%, −2.8%) during 2016–2020.

Table 1

Trends in emergency department visits for fall-related fractures according to body parts

Table 2 shows trends in hospitalisation for fall-related fractures according to body parts affected. Overall, lower trunk fractures accounted for about 59% of the fractures. Moreover, upward trends in hospitalisation were mostly attributed to increasing head/neck, upper trunk, and leg/foot fractures in older adults.

Table 2

Trends in hospitalisation for fall-related fractures according to body parts

Discussion

In a nationally representative sample of EDs visits for injuries, the estimated number of fall-related fractures increased in U.S. older adults between 2001 and 2020. After adjusting for age, fall-related fracture rates in men and women increased annually on average by 1.3% and 1.1% from 2001 to 2012, respectively. Moreover, a non-significant increase in fracture rates was seen in men and women during the period 2012–2016. From 2016 onward, fracture rates decreased annually by 5% in older women, but did not significantly change in men. These findings were particularly attributed to similar trends in fall-related fractures of the arm/hand, lower trunk, and among subjects aged 75 years and older.

Baiden et al 10 reported that EDs visits for geriatric fractures decreased in U.S. women by 2.5% between 2004 and 2014. The authors also described downward trends in the incidence of upper and lower trunk fractures during the 11 year period. These contradictory results may be related to the characteristic of the NEISS for consumer product-related injuries database, which do not report falls as an external cause of injury. Therefore, it is possible that EDs visits for geriatric fractures might have been underestimated in that latter study. Indeed, a secondary analysis of the National Hospital Ambulatory Medical Care Survey demonstrated that EDs visits for a fall or fall-related injury increased among U.S. older adults by 27% between 2003 and 2010.11 Similarly, the incidence of self-reported fall, minor injury, and severe injuries in U.S. older adults increased by 42%, 88.7, and 45.7% between 2004 and 2017, respectively.6

A recent report from the Behavioural Risk Factor Surveillance System demonstrated that the percentage of U.S. older adults who self-reported a fall or fall-related injury decreased between 2016 and 2018, which is consistent with the present results.12 The precise reason for recent downward trends in fall-related fractures in older women remains undetermined. However, it is unlikely to be associated with adequate management of osteoporosis. In fact, the treatment of osteoporosis significantly decreased in U.S. postmenopausal women from 2007 to 2008 through 2017–2018.13 It is possible that interventions for preventing fall-related fractures in community-dwelling older adults such as exercise and basic fall risk assessment may partly explain the decrease in fall-related fractures rates among U.S. older adults from 2016 onward.14

Notably, the percentage older adults hospitalised for fall-related fractures increased during the study period, which was particularly attributed to an increase in head/neck, upper trunk, and leg/foot fractures. Previously, Hartholt et al reported that fall-related hospitalisation rates increased in U.S. older adults between 2001 and 2008.15 Similarly, age-adjusted hospitalisation rates for fall-related injuries in older adults increased annually by 4% between 2001 and 2012, which is consistent with the present results.7 In contrast, Reider et al recently demonstrated that the incidence of fall-related extremity fractures decreased by 13.6% and 4.6% in older women and men between 2003 and 2017. This downward trend was associated to a decline in femur fractures which accounted for 65% of all fracture hospitalizations.16

The present study has several limitations that should be mentioned. First, trends in fall-related fractures may have been underestimated because they represented only older adults treated in EDs. Second, fall-related fractures may have been missed because the NEISS-AIP reports the principal diagnosis and primary body part affected during the initial injury visit. In cases with multiple injuries, data for the most severe injury are recorded. Third, the NEISS-AIP coding system has a fixed number of categories for the primary body part affected. Therefore, specific fractures such as hip fracture may not be accurately identified.6 9 Despite these limitations, the present findings may be generalised to the U.S. older population.

In conclusion, EDs visits and hospitalisation for fall-related fractures increased in U.S. older adults over the past two decades. However, after accounting for the demographic changes of the population, the incidence of EDs visits for fall-related fractures in women significantly decreased from 2016 onward.

Ethics statementsPatient consent for publication

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