Fall-related injuries among Canadian seniors, 2005–2013: an analysis of the Canadian Community Health Survey - HPCDP: Volume 35-7, September 2015

Volume 35 · Number 7 · September 2015

Correspondence: Minh T. Do, Injury Section, Surveillance and Epidemiology Division, Public Health Agency of Canada, 785 Carling Avenue, Ottawa, ON  K1A 0K9; Tel: 613-946-6958; Fax: 613-941-2057; Email: minh.t.do@phac-aspc.gc.ca

Abstract

Introduction: We describe the epidemiology and trends of fall-related injuries among Canadian seniors aged 65 years and older by sex and age, as well as the circumstances and consequences of their injuries.

Methods: We analyzed nationally representative data from the 2005, 2009/2010 and 2013 samples of the Canadian Community Health Survey to calculate the number and rates of fall-related injuries for each survey year. Where possible, we combined data from two or more samples to estimate the proportion of fall-related injuries by type of injury, part of body injured, type of activity and type of treatment.

Results: The rate of fall-related injuries among seniors increased from 49.4 to 58.8 per 1000 population between 2005 and 2013, during which the number of fall-related injuries increased by 54% overall. Women had consistently higher rates than men across all survey years, while rates increased with advancing age. The upward trend in fall-related injury rates was more prominent among women and younger age groups. The most common type of injury was broken or fractured bones (37%), and the shoulder or upper arm (16%) was the most commonly injured body part. Many fall-related injuries occurred while walking on a surface other than snow or ice (45%). Over 70% of seniors seeking treatment for their injuries visited a hospital emergency department.

Conclusion: Given the increase in both the number and rates of fall-related injuries over time, there is a need to continue monitoring trends and injury patterns associated with falls.

Keywords: falls, unintentional injuries, seniors, Canada

Rates and trends

Figure 1 shows the estimated numbers and rates of fall-related injuries among Canadian seniors across all survey years. In 2005, 194 135 Canadians aged 65 years or older reported being injured due to a fall in the previous 12 months. This number increased to 256 011 in 2009/2010 and 299 769 in 2013, with an overall increase of 54% from 2005 to 2013. A similar upward trend was observed in the rate of fall-related injuries, from 49.4 (95% CI: 45.5-53.3) per 1000 population in 2005 to 57.5 (95% CI: 52.6-62.3) per 1000 in 2009/2010 and 58.8 (95% CI: 53.0-64.6) per 1000 in 2013. Compared to 2005, the rate estimate was significantly higher in 2013 (p =.01). Of note, while the increase in rate between 2005 and 2009/2010 was statistically significant (8.1 per 1000, p =.01), the rate appeared to level off, with only a small and non-significant increase between 2009/2010 and 2013 (1.3 per 1000, p =.72).

FIGURE 1. Numbers and rates of fall-related injuries, ≥ 65 years, Canada, CCHS 2005, 2009/2010, 2013

Source: Canadian Community Health Survey (2005, 2009/2010, 2013), Statistics Canada.

Abbreviation: CCHS, Canadian Community Health Survey.

Notes: Numbers and rates (per 1000 population) of fall-related injuries were calculated using sampling weights. Error bars represent 95% confidence intervals of rates of fall-related injuries, computed using the bootstrap technique.

*Significantly different from the 2005 estimate ( p < .05) based on the z-test for proportions.

Figure 2 shows rates of fall-related injuries by sex and survey year. Based on non-overlapping CIs, women had significantly higher rates of fall-related injuries than men across all survey years, with female-to-male ratios ranging from 1.4 to 1.7. Fall-related injury rates for women increased steadily from 61.0 (95% CI: 55.2–66.9) per 1000 in 2005 to 72.4 (95% CI: 63.9–80.9) per 1000 in 2013 (p = .03 for 2013 vs. 2005). On the other hand, whereas men experienced a marked increase between 2005 and 2009/2010, from 34.9 (95% CI: 30.2–39.6) per 1000 to 46.3 (95% CI: 39.5–53.1) per 1000 (p =.007), there was a small but non-significant decrease between 2009/2010 and 2013, to a rate of 42.7 (95% CI: 35.0–50.4) per 1000 in 2013. Unlike for women, the difference in rates between the 2005 and 2013 samples was not statistically significant for men (p = .10).

FIGURE 2. Rates of fall-related injuries by sex, ≥ 65 years, Canada, CCHS 2005, 2009/2010, 2013

Source: Canadian Community Health Survey (2005, 2009/2010, 2013), Statistics Canada.

Abbreviation: CCHS, Canadian Community Health Survey.

Notes: Rates of fall-related injuries were calculated per 1000 population using sampling weights. Error bars represent 95% confidence intervals computed using the bootstrap technique.

*Significantly different from the 2005 estimate ( p < .05) based on the z-test for proportions.

Figure 3 shows rates of fall-related injuries by 5-year age groups and survey year. In general, the rate of fall-related injuries increased with advancing age in all survey years, with a larger increase from the 80–84 to the 85–89 age group. From 2005 to 2013, a significant upward trend was seen among those aged 65–69 and 70–74 years (p = .02 for both), while a non-significant decline was noted in the oldest age group (i.e. ≥ 90 years). Moreover, in 2005, the rate of fall-related injuries among seniors aged 90 years or older was 2.5 times that among those aged 65 to 69 years (102.8 vs. 40.6 per 1000), but this ratio decreased to 2.0 in 2009/2010 (100.6 vs. 49.8 per 1000) and 1.5 in 2013 (83.8 vs. 55.4 per 1000).

FIGURE 3. Rates of fall-related injuries by age group, ≥ 65 years, Canada, CCHS 2005, 2009/2010, 2013

Source: Canadian Community Health Survey (2005, 2009/2010, 2013), Statistics Canada.

Abbreviation: CCHS, Canadian Community Health Survey.

Notes: Rates of fall-related injuries were calculated per 1000 population using sampling weights. Error bars represent 95% confidence intervals computed using the bootstrap technique.

E : Estimates for the 2009/2010 and 2013 samples are associated with high sampling variability (i.e. coefficient of variation is between 16.6% and 33.3%) – interpret with caution.

* Significantly different from the 2005 estimate ( p < .05) based on the z-test for proportions.

Injury characteristics

Based on combined data from the 2005, 2009/2010 and 2013 samples, Figures 4 and 5 show the proportion of fall-related injuries by type of injury and part of body injured, respectively. The majority of fall-related injuries involved broken or fractured bones (37%), sprains or strains (27%) and scrapes, bruises or blisters (17%). The body parts that were most frequently affected were shoulder or upper arm (16%), knee or lower leg (13%) and ankle or foot (11%). Although the wording in the 2009/2010 and 2013 questionnaires changed slightly from that in 2005 (e.g. the “sprain or strain” category was given more details in 2009/2010 and 2013: “sprain or strain, including torn ligaments and muscles”), we did not observe any meaningful differences in proportions across survey years because of these changes (data not shown).

FIGURE 4. Proportion of fall-related injuries by type of injury, ≥ 65 years, Canada, CCHS 2005, 2009/2010, 2013

Source: Canadian Community Health Survey (2005, 2009/2010 and 2013 combined), Statistics Canada.

Abbreviation: CCHS, Canadian Community Health Survey.

Note: There were slight wording changes for some categories in the 2009/2010 and 2013 questionnaires compared to 2005 (see below), but no meaningful differences were observed in the proportions of these categories across survey years.

a : Stated as “sprain or strain” in 2005 and “sprain or strain (including torn ligaments and muscles)” in 2009/2010 and 2013.

b : Stated as “scrape, bruise, blister” in 2005 and “scrape(s), bruise(s), blister(s) (including multiple minor injuries)” in 2009/2010 and 2013.

c : Stated as “multiple injuries” in 2005 and “multiple serious injuries (excluding multiple minor injuries)” in 2009/2010 and 2013.

E : Estimate is associated with high sampling variability (i.e. coefficient of variation is between 16.6% and 33.3%) – interpret with caution.

FIGURE 5. Proportion of fall-related injuries by part of body injured, ≥ 65 years, Canada, CCHS 2005, 2009/2010, 2013

Source: Canadian Community Health Survey (2005, 2009/2010 and 2013 combined), Statistics Canada.

Abbreviation: CCHS, Canadian Community Health Survey.

Note: Wording for some categories in the 2009/2010 and 2013 questionnaires changed from 2005 (see below), but no meaningful differences were observed in the proportions of these categories across survey years.

a : Stated as "head (excluding eyes)" in 2005 and "head (including facial bones)" in 2009/2010 and 2013.

b : Stated as "eyes" in 2005 and "eyes (excluding fracture of facial bones around the eye)" in 2009/2010 and 2013.

E : Estimate is associated with high sampling variability (i.e. coefficient of variation is between 16.6% and 33.3%) – interpret with caution.

Figure 6 shows the proportion of fall-related injuries by type of activity associated with the fall using combined data from the 2009/2010 and 2013 samples (the 2005 sample was excluded due to differences in the categorization of activity types). The largest proportions of fall-related injuries resulted from slipping, tripping, stumbling or loss of balance while walking on a surface other than snow or ice (45%), while walking on snow or ice (16%) and while going up or down stairs or steps (12%). Others reported falling due to health problems (e.g. fainting, weakness, dizziness, hip/knee giving out, seizure) (7%), from furniture or while rising from furniture (e.g. bed, chair) (6%), while engaged in sport or physical exercise (5%) or from an elevated position (4%).

FIGURE 6. Proportion of fall-related injuries by type of activity, ≥ 65 years, Canada, CCHS 2009/2010, 2013

Source: Canadian Community Health Survey (2009/2010 and 2013 combined), Statistics Canada.

Abbreviation: CCHS, Canadian Community Health Survey.

Note: Data from the 2005 CCHS sample were not included in the analysis due to differences in the categorization of activity types compared to the 2009/2010 and 2013 surveys.

a : Examples include fainting, weakness, dizziness, hip/knee giving out and seizure.

b : Includes skating, skiing and snowboarding.

Of those seniors with a fall-related injury in the 2005 sample, 133 958 (69%) reported seeking medical attention from a health professional in the 48 hours following the injury. This number increased to 163 571 in 2009/2010 and 198 164 in 2013, although the proportions were slightly lower (64% in 2009/2010 and 66% in 2013). Based on combined data from the three survey years, the majority of those seeking treatment for a fall-related injury visited a hospital emergency department (71%), a doctor's office (15%), a clinic (6%) and a hospital outpatient clinic (5%). Less than 5% reported seeking medical treatment at a community health centre or at the site where the injury occurred. In addition, more than one-quarter of those who reported a medically attended fall-related injury were hospitalized overnight. Similar patterns were observed across all survey years (data not shown).

Discussion

Using population-based data from the 2005, 2009/2010 and 2013 CCHS, we provide an updated national profile of injuries resulting from falls among Canadians aged 65 years or older and examine trends over time.

From 2005 to 2013, the number of Canadian seniors who sustained a fall-related injury increased by over 50%, which corresponds to the demographic shift towards an older population.^{Footnote 21} Moreover, the increase in fall-related injury rates is consistent with that reported for the period 2003 to 2009/2010 in Canada^{Footnote 7} as well as with trends observed in the United States,^{Footnote 29Footnote 30} the Netherlands^{Footnote 31} and Australia.^{Footnote 32Footnote 33} Of note, while the majority of these studies were restricted to injuries treated in emergency departments or that required hospitalization, our study shows time trends of self-reported fall-related injuries regardless of whether medical treatment was sought.

As with other studies,^{Footnote 29Footnote 30Footnote 31Footnote 32Footnote 33Footnote 34Footnote 35Footnote 36} we found significantly higher rates of fall-related injuries among older women compared to older men across all survey years. Loss of bone mineral density following menopause may predispose women to a higher risk of fracture.^{Footnote 37Footnote 38Footnote 39} The gender disparity in fall-related injury rates may also reflect differences between men and women in the strength of their lower extremities, chronic health conditions and lifestyle or behavioural factors.^{Footnote 40}

A study that used data from the CCHS – Healthy Aging survey showed that men and women have different sets of socio-demographic, lifestyle/behavioural and medical risk factors for falls.^{Footnote 41} For example, being widowed, separated or divorced, having a higher level of education and having an eye disorder were associated with elevated risk of falls in men, whereas older age, lower income, alcohol consumption, medication use and having diabetes, osteoporosis or a higher number of comorbid conditions increased the risk of falls in women.^{Footnote 41} Note that although women are at higher risk for falls and fall-related injuries, mortality rates from falls are higher among men,^{Footnote 7Footnote 42Footnote 43} who may be more severely injured due to the circumstances or events of their fall.^{Footnote 35}

While the rate of fall-related injuries increased steadily for women over time, we observed a peak among men in 2009/2010, followed by a small but non-significant decline in the most recent year, which may have partially accounted for the levelling off of the overall rate. This differs from the trends observed between 2003 and 2009/2010, during which there was a consistent increase in rates in both sexes.^{Footnote 7}

Although making direct comparisons is difficult due to differences in data sources and time periods examined, studies in other countries have shown either similar upward trends for both sexes^{Footnote 29Footnote 30} or a sharper increase in men than in women.^{Footnote 31Footnote 32Footnote 33} The reasons for the recent decline (or levelling off) that we observed among men are unclear and may be associated with changes in risk-taking behaviour and risk perception (e.g. taking extra caution when climbing ladders and paying greater attention to surroundings while walking).^{Footnote 6Footnote 7Footnote 44} However, more years of data are needed to assess longer-term trends and to determine whether fall-related injury rates are truly decreasing for older men in Canada.

The increase in fall risk with age is well-documented^{Footnote 29Footnote 30Footnote 31Footnote 34Footnote 35Footnote 36} and can be attributed to age-induced declines in physical, sensory and cognitive function, as well as increases in comorbidities.^{Footnote 43Footnote 45} Moreover, our results indicate that, although older seniors (i.e. ≥ 85 years) continue to experience higher rates of fall-related injuries compared to younger seniors, the gap between the younger and the older age groups appears to be a closing over time. A possible explanation is that younger seniors have been leading more active lifestyles than in the past, spending more time pursuing activities that could increase their chances of falling.^{Footnote 29Footnote 46} However, the trends we observed most likely involved a complex interplay of fall risk factors, including age-related shifts in lifestyle and behaviour, health conditions and medication use.^{Footnote 47} In addition, recent declines in fall-related injury rates have also been reported in the older senior population (≥ 80 years) in Finland^{Footnote 48} and may reflect improvements in the functional ability and living environments of older seniors, although further assessment of trends is warranted. In contrast, studies in the USA^{Footnote 30} and Australia^{Footnote 33} have reported notably sharper increases in rates among older rather than younger age groups.

Our finding that fractures account for the greatest proportion of fall-related injuries is consistent with studies examining hospitalized^{Footnote 31Footnote 32} or emergency department–treated^{Footnote 35} fall-related injuries. It also suggests the importance of bone health in preventing fall-related fractures among seniors, especially given the high prevalence of osteoporosis in older women.^{Footnote 7Footnote 49} In addition, the circumstances surrounding fall-related injuries among seniors are similar to those reported in the USA,^{Footnote 36} as the majority involved slipping, tripping, stumbling or loss of balance while walking. However, of concern is the relatively large proportion of fall-related injuries among seniors that resulted from walking on ice or snow, highlighting the role of weather conditions in contributing to fall risk in Canada.^{Footnote 7Footnote 50} Our results also demonstrate the burden of fall-related injuries on the health care system. Specifically, over two-thirds of Canadian seniors who sustained fall-related injuries sought medical treatment, most commonly at a hospital emergency department. With an aging population, health care utilization resulting from fall-related injuries and associated costs are expected to increase substantially over the next decades.

Strengths and limitations

To our knowledge, this is the first peer-reviewed study that examines trends of self-reported fall-related injuries among Canadian seniors over time.

A major strength of this study is our use of a well-validated population-based survey, which provided a national picture of fall-related injuries representative of the entire community-dwelling senior population in Canada. Instead of restricting observations only to injuries involving hospitalization or emergency department visits, our study shows estimates and trends for a wider spectrum of fall-related injuries.

Our study also has several limitations that should be taken into consideration when interpreting the findings. First, based on the way the questions were designed in the CCHS, data were only collected for the most serious injury experienced by the respondent during the previous year. In other words, falls resulting in less serious injuries compared to other causes of injuries (e.g. traffic collisions) occurring in the same time period would not have been captured, likely leading to underestimated numbers and rates of fall-related injuries. Similarly, the survey did not collect information on multiple falls experienced by the same individual.

Second, since the CCHS does not collect data annually on injuries from all provinces and territories of Canada, our examination of national trends is limited to only several data points (i.e. 2005, 2009/2010 and 2013). As a result, potential changes in trends during the gap periods may have been missed. Nevertheless, we demonstrated a generally increasing trend of fall-related injuries consistent with that reported previously.^{Footnote 7}

Third, due to the self-reported nature of the CCHS, our results may be subject to measurement bias and misclassification. For example, questions about injuries may be interpreted differently by different respondents. There may also be the issue of underreporting of falls due to social desirability bias (i.e. an unwillingness to admit falling) or difficulty recalling, particularly among an older population.^{Footnote 51}

Fourth, low response rates, particularly in the most recent survey year (i.e. 66.8% in 2013), could have resulted in limited generalizability of study findings. However, to minimize potential bias associated with total non-response (i.e. refusal to participate or inability to contact the selected household or individual), Statistics Canada has adjusted the survey weights by redistributing weights of non-responding households or people to responding households or people with similar characteristics (e.g. geographic information, collection period, time and number of contact attempts).^{Footnote 24}

Finally, our findings may only be generalized to a relatively healthy population of seniors living in the community and do not apply to residents of care facilities, who may have a distinct risk profile for falls and very different circumstances and outcomes of fall-related injuries compared to the general population.^{Footnote 52}

Conclusion

As in other developed nations, fall-related injuries among seniors in Canada have been increasing over the past decade. Recent data also suggest differences in trends by sex and age, with a sharper increase among women and among younger seniors. As our population is rapidly aging, it remains essential to monitor trends and patterns of fall-related injuries along with the associated burdens on the health care system.

References