The COVID-19 pandemic has been studied to show negative effects on older adults in particular conditions such as nutrition, physical activity-fitness, mobility, sleep, mood, and quality of life [9, 20-23]. Results of presentations with falls to the ED are diverse reporting higher [12] or lower numbers during the pandemic period [13-16]. In our study, we showed that the number of geriatric fall presentations to ED, comorbidity burden, consultations, and LOS at the ED in those patients was lower, but direct costs were higher in the pandemic period than pre-pandemic period. Additionally, hospitalizations plus mortality in ED, and costs were higher, particularly for COVID-19 positive older patients admitted to ED with falls than in COVID-19 negative older patients during the pandemic period, and the pre-pandemic period.
The risk of falls was predicted to increase in older individuals because of the negative effects of the COVID-19 pandemic [7,10,24,25]. However, presentations with falls have decreased during the pandemic period in the studies carried out in EDs and other settings [13-16, 27-29]. It is considered that approximately half of all falls occur outside the home [30], and in Turkey, there were strict stay-at-home restrictions for older adults at the beginning of the pandemic. So, it could be expected that there would be a decrease in the number of falls for older adults. Accordingly, in the present study covering older adults admitted to the ED because of a fall two years before and during the first year of the COVID-19 pandemic, our results showed that the total number of patients presenting at ED, the number of patients aged ≥65 years, and the number of older adults presenting because of a fall decreased during the pandemic. During the pandemic, presentations to hospitals and healthcare facilities were significantly less for all adults, particularly older people because of all kinds of restrictions (lock-downs, continuing to stay at home with own preference and encouragement by policies, unavailability of hospitals, ED, inadequate services) and COVID-19 anxiety, also individuals postponed all kinds of health needs. Besides, lower application to EDs has been reported to be due to a decreased need for emergency healthcare services by society during the COVID-19 pandemic as there were fewer serious trauma cases [27-28,31].
Examining according to months, after the start of the pandemic except for July, the number of older adults who fell was lower than in the previous pre-pandemic year in our study whereas a greater number of fall cases occurred in the summer period during the pandemic as it would be expected because of increased outdoor activities, with a peak in October. In accordance with those findings in a study on older adults participating in the Ambulatory Blood Pressure in Older Adults cohort; fall rates in August, September, and October 2020 (reopening) were higher during the pandemic than the pre-pandemic previous year, and fall rates during the shelter-in-place policy period were lower than the pre-pandemic year expressing the importance of changes in community mobility [32]. Falls outside the home are generally shown in active, younger older adults, and falls at home in the frail older age group [33]. In a study investigating ED presentations among older adults during the COVID-19 pandemic, the older (75–84) and oldest old (>85 years) had the greatest decline in visit counts initially [13]. However, we could not show such significant differences between the pre-pandemic and pandemic periods in terms of the mean age of older patients admitted to ED with falls. Additionally, the distribution of age groups in both periods was similar.
The rate of requested consultations decreased during the pandemic compared to the pre-pandemic period whereas GCS, triage classifications, and injury region and types which indicate the need for emergency interventions as well as LOS in the hospital, and patient outcomes in the ED were similar in the pandemic and pre-pandemic periods. This can be explained by the increased workload because of COVID-19, and probable decision differences. As far as we could determine in the literature search, this data was not reported in previous studies. On the other hand, a decrease in the consultation rates was revealed in all age groups at the beginning of the pandemic, least with the oldest reaching to same rates after three months for older adults in primary healthcare centers [34]. Though the triage categories of the patients in both groups were similar in our study, in a recent study from Italy on all age group trauma cases before the pandemic and during a period of lockdown, there was a decrease in non-urgent and urgent but not critical cases, and an increase in life-threatening and extremely critical cases [35]. The difference in the results might be due to the inclusion of all trauma cases in all age groups. If it is assumed that falls during the pandemic would have occurred mostly at home because of the restrictions, it might be expected that there would be fewer injuries. However, in a study among all age groups from the Netherlands aiming to determine the impact of the first lockdown on the number and type of all trauma-related injuries presenting to ED, more frequent injuries due to a fall were reported [36]. In a study carried out on high-risk, community-dwelling older people, it was reported that injury status was similar in the pandemic and pre-pandemic periods among older adults who have fallen [15]. Likewise, injury type and regions were similar in the present study at both periods. The rate of fractures to the head, neck, and forearm was lower during the pandemic compared to the pre-pandemic period in our study whereas the other fractures were similar. We could not find other studies investigating all fracture types related to falls among older patients regarding pre-pandemic and pandemic periods. In studies investigating all types of fractures in all age groups, and fall-related injuries during COVID-19; it was reported that the number of fractures decreased [37], and hip fractures did not change [38] or decreased [13]. No study could be found in the literature on the state of consciousness of older patients presenting with falls in comparison with pandemic and pre-pandemic periods which was found to be similar in the current study. In the study by Ilhan et al., in a tertiary-level trauma center, there was no change during the pandemic period regarding the need for surgery, ICU, or admission to wards, though there was a decrease in visit frequency of adult trauma patients during the pandemic period [39].
Length of hospital stay was reported to be similar during the pandemic period in a retrospective study on senior citizens for hip fractures due to a fall [40]. Likewise, the LOS in the hospital, and hospitalization/mortality rates in the ED were similar in the pandemic (25.8%) and pre-pandemic periods (22.8%) in the present study whereas mortality rates in ED at both periods were quite low. In a study from Ireland, there were reductions in admissions, and compliance with many of the Irish Hip Fracture Standards, LOS during the pandemic, but in-hospital mortality was similar in pre-pandemic and pandemic periods [41]. In contrary, in a meta-analysis, it was shown that COVID-19 increased the risk of mortality in patients with hip fractures [42]. On the other hand, the mean LOS in ED decreased in our study. The decrease in the LOS for older patients in the ED might have occurred due to lower number of patients admitted to the ED, and the COVID-19 infection risk in the ED. The lowest LOS in ED was among COVID-19 negative patients of the pandemic period than the pre-pandemic and COVID-19 positive patients. COVID-19 anxiety might have shortened the time spent for those patients. We could not find any research on how the LOS in the ED changed in older patients admitted with falls. However, it was reported that LOS in ED for the admitted and discharged patients were significantly higher in the COVID-19 period, though there was a decrease in the number of patients in a recent research among all age groups [43]. In another study by Guo et al., the length of resuscitation area stay was shown to be incresed in the pandemic, variable for different departments [44]. The differences regarding the LOS in ED might be due to factors such as present resources (i.e. healthcare professionals), and the impact of the pandemic in that area or country. The direct costs increased for the older adults presenting at ED because of a fall during the pandemic period compared to the pre-pandemic period whereas the highest costs were for COVID-19 positive patients. No other study could be found in the literature that has investigated the costs for older adults presenting at the hospital because of a fall during the COVID-19 pandemic. In a study that examined the economic costs of hospital presentations due to COVID-19, the costs were much higher [45] than in our study as those costs were whole hospitalization costs. Application Notice of Public Healthcare Services Price Tariffs for Turkey was examined for 2019-2021, and no price increase was reported. So, the difference in costs between the two periods might be due to the costs associated with COVID-19. Hospitalization/mortality rates were the highest for COVID-19 positive patients (77.2%) in comparison with pre-pandemic (22.8%) and COVID-19 negative patients (4.6%) in the present study, though the pandemic period in total and the pre-pandemic period’s rates were similar with decreased number of patients admitted in the pandemic. Herein, median CCI for older patients admitted to the ED with falls was lower in the pandemic period in our study. This might reflect that older patients with multiple morbidity and falls did not apply to the ED of the hospital despite a higher risk of mortality. Non-COVID patients were unlikely to be hopitalized during the pandemic. Hospitalizations were reported to be lower during the COVID-19 pandemic period from the ED in a study from Italy in older patients with chronic conditions [46]. On the other hand, in another study on trauma cases over the age of 15, it was shown that the rate of hospitalizations increased [31]. Determinants such as demand for ED, supply for care need further investigation on those subjects [46]. It has also been reported that a fall is an atypical COVID-19 finding [47]. However, from the present data of our study, it was not possible to comment on.
One of the limitations of this study is that this is a single-center study. Some data were not reached because of the retrospective design of the study for the ED such as the location of the fall (i.e. at home), and mortality in the hospital, and in long-term. Besides, a cost analysis was not performed, only a comparison of direct treatment costs was performed in TRY. The strength of this study is that it is designed for a specific patient, and age group presented at ED at a tertiary level hospital in the third largest city in Turkey over a two- years period before the pandemic and during the pandemic.