This study analyzes the demographics and clinical characteristics of fall related injuries observed in male and female geriatric population presented to a Level I trauma center in Westchester County, New York. This is a unique study with a large sample size that emphasizes the impact of gender on the incidence and outcome of fall from height among older adults.
This study shows that fall-related injuries represent 43% of the total trauma admissions and nearly 60% of them are of age 60 and above. Almost half of older adults sustained fall-related injury at age ≥80 years old. Approximately three-quarter of older adults sustained a home related fall. Across the study period from 2012 to 2016, there were no significant changes in the proportions of falls among different age groups; however, mortality decreased from 10% to 5.6%. This drop in mortality could be in part explained by the higher mean ISS in 2012 (13±8) in comparison to 10±7.6 in 2016; in addition to the improvement in the health care system. Of note, mortality in females decreased from 7.5% in 2012 to 1.2% in 2016 (p=0.02), whereas it varied in males from 12.4% in 2012 to 11.1 in 2016 with a peak in 2014 (14.4%). The mean age, ISS and GCS did not show significant changes per year in female gender and therefore it could not explain the drop in mortality between 2012 and 2016. The risk of fall increases significantly with the increase in age with an OR of 3.4 in patients aged 80 and above. Furthermore, our study shows that female gender is associated with increased risk of fall regardless of the age. The mortality was greater in males by 2 times, which could be related to the higher ISS, head AIS , height of fall and NISS and lower GCS in addition to the greater frequency of having DM, alcohol consumption, smoking habit, and rib fractures.
Prior data reported that almost one third of the older adults population fall at least once per year [21-24], however, our study reported one fifth of older adults falls once per year.
Our data shows that women between 60 and 79 years old sustain more fall injury, however, at age of 80 and above, men fell more than women. Prior reports conducted on emergency department visits showed that women experienced fall-related injury more than men [17,25-28]. In contrary, two studies reported that men comprised a more proportion of fall-related emergency visits [29-30]. Recently, Galet et al [24] evaluated WHO mortality and readmission database between 2010 and 2014 among older adults. The authors observed 1.4 and 2% increase in the fall-related mortality and readmission for a subsequent fall, respectively. Fall was the most common mechanism of injuries in women who required hospitalization and the majority of fall patients readmitted within 30 days were also women [24].
It is difficult to establish the factors affecting mortality in falls [23]. The WHO database showed that older adults with uncomplicated and complicated diabetes mellitus were at 16% and 31% increased risk of being admitted for fall injury, respectively [24]. Also it was observed that anemic patients had a 21% increased risk of being admitted for a fall injury. Alcohol consumption and diabetes mellitus were reported in 11% and 25% of our study cohort, respectively.
In the present study, SI and male gender were independent predictors of mortality among elder patients who fell down after adjustment for age, diabetes mellitus, GCS, ISS, height of fall and need for blood transfusion. Pandit et al [31] studied 217,190 geriatric trauma patients and found that SI is an accurate and specific predictor of significant bleeding and mortality in geriatric trauma patients. Higher SI after trauma in older adults prerequisites transfer to a Level 1 trauma center [31].
In 2010, Bennett et al [32] studied the outcomes in 422 patients ≥80 years old vs 898 patients aged 60-79 years old after traumatic injury. The first group had significantly higher risk-adjusted in-hospital mortality (OR 1.94; 95% CI 1.14, 3.31). In our study this elderly group who sustained fall injury after adjustment for gender and GCS had a higher mortality with OR 2.871;95% CI 1.97-4.19).
In the United States, falls from the standing height are considered the second cause of death due to unintentional injuries in the older adults [33]. Based on the present study; home related falls were the most common falls in older adults. In 2011 Rapp et al [34] analyzed nearly 70,000 elderly for falls that occurred in residences in Germany and observed a higher frequency of falls among male patients, and approximately 75% of the events occurred in the bedroom or bathroom. A previous study with a small sample size showed that elderly who sustained falls-related injury at bathroom were significantly associated with the female gender and high mortality rate [35].
Limitations: The limitations of this study include the use of a retrospective design and the lack of availability of data regarding the risk factors, other than diabetes and alcoholism, such as pulmonary, cardiac and stroke in addition to the circumstances of the mechanism of injury and readmissions. Although we intended to include all fall-related injuries in older adults, selection bias cannot be ignored. We did not intend to study those who brought in dead (BID) or died at the scene as these data were not available for this analysis. There is a significant number of patients with missing information regarding the location of fall (home, workplace or public). Additionally, our single center study is not a representative of the entire population of United States and our results may therefore not be generalizable. When comparing census data of Westchester County to the U.S. in general, there is a higher percentage of Hispanic or Latino, in Westchester County. The U.S. has an average of 18.1% versus 24.9% in Westchester County. Westchester County is slightly more racially diverse than that of the rest of the United States, on average. Additionally, Westchester has slightly older adults than the average of the United States, where Westchester had 16.6% over aged 65, the U.S. in general has 15.6%. However, we do not have data of county origin of patients. Another limitation of our study is the lack of data on anticoagulants, antihypertensive, hypoglycemic agents and polymedications. Most recently, the frailty index has become a popular tool in predicting outcomes in older adults trauma patients, however it was lacking in our data [36].