Public Health and Aging: Nonfatal Fall-Related Traumatic Brain Injury Among Older Adults --- California, 1996--1999

In the United States, falls are the second leading cause of traumatic brain injury (TBI) hospitalizations overall and the leading cause of TBI hospitalizations among persons aged >65 years (1). In 1995, TBIs resulted in an estimated $56 billion in direct and indirect costs in the United States (2). In California, during 1999, a total of 61,475 hospitalizations from falls were reported among persons aged >65 years (3). Risk factors for falling among older persons included arthritis; impairments in balance, gait, vision, and muscle strength; and the use of four or more prescription medications (2,4). As part of CDC's program of state-based TBI surveillance, California hospital discharge data were collected and analyzed to describe fall-related TBIs. This report summarizes the results of that analysis, which support previous findings that persons aged >65 years are at risk for hospitalization for a fall and that same-level falls are far more common among persons aged >65 years than falls from a higher level (e.g., a ladder, chair, or stair) (1,2,5). Defining the circumstances of fall injuries and recognizing the type of fall leading to TBI hospitalizations among older persons can help health-care providers conduct risk assessment and management of falls in this population.

All nonfederal, acute care hospitals in California are required to report hospital discharges to the Office of Statewide Health Planning and Development. All first admissions with an injury diagnosis must be coded for external cause of injury (E-code); E-codes are listed in >99% of these records (5). For this report, cases were limited to first admissions. Hospitalization records of transfers, fatal cases, and out-of-state residents were excluded by matching sex, date of birth, and a record linkage number (i.e, an encrypted social security number). Hospital discharge records were coded according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) (6). TBI cases were defined by the most recent CDC surveillance definition, in which any of the 25 diagnoses include one of the following nature-of-injury diagnosis codes: 800.0--801.9 (fracture of the vault of the skull), 803.0--804.9 (other and unqualified skull fracture), 850.0--854.1 (intracranial injury including concussion, laceration, and hemorrhage), or 959.01 (head injury, unspecified). The primary cause of injury for falls (E880--E886, E888) was analyzed by mechanism.* Age was categorized into one younger comparison group (aged 0--64 years) and three older groups (aged 65--74 years, 75--84 years, and >85 years). Incidence rates were calculated per 100,000 population by using mid-year population estimates of California residents for each year (Epidemiology and Prevention for Injury Control, California Department of Health Services, unpublished data, 1996--1999).

During 1996--1999, a total of 29,761 fall-related TBI hospitalizations were reported; of these, 28,009 (94%) patients were discharged, and 1,752 were deceased. A total of 1,252 (71%) of fatal fall-related TBI hospitalizations were among those aged >65 years. Overall, the nonfatal fall-related TBI hospitalization rate was 21.1 per 100,000 population (95% confidence interval = 20.8--21.3) (Table 1). Hospitalization rates increased with age; the highest rate (223.0) was among persons aged >85 years. Compared with persons aged 0--64 years, the rate ratio of hospitalizations was 3.1 for persons aged 65--74 years, 7.6 for those aged 75--84 years, and 16.4 for those aged >85 years. Overall, males were hospitalized more frequently (59%) than females. Although 70% of hospitalizations among those aged <65 years were among males, females accounted for 56% of hospitalizations among those aged >65 years. For those aged >65 years, whites represented 78% of hospitalizations and had the highest rate (25.4) among all racial/ethnic populations.

In 9,364 (33%) hospitalizations, the type of fall was coded "other and unspecified" (E888). Among the 18,645 specified falls, the pattern differed by age group (Table 2). Among persons aged 0--64 years, 75% of falls were from at least one level. Among persons aged >65 years, 60% of falls were on the same level. For the three older population groups, the proportion of specified falls on the same level also varied: 52% among persons aged 65--74 years, 61% among those aged 75--84 years, and 66% among those aged >85 years. By race/ethnicity for all age groups, the proportion of specified falls on the same level was 40% for whites, 31% for blacks, 23%^† for Hispanics, 36% for Asians/Pacific Islanders, and 33% for American Indians/Alaska Natives.

Among persons aged 0--64 years, 13,792 (86%) were discharged with only self-care or unskilled care provided. The remainder were sent to another facility or discharged with in-home health services or outpatient rehabilitation. Among persons aged >65 years, the number discharged was 4,927 (41%). The proportion of persons discharged home decreased with increasing age. For those aged >85 years, the number discharged was 1,071 (30%) compared with 2,083 (41%) for those aged 75--84 years and 1,773 (54%) for those aged 65--74 years.

Reported by: J Cross, PhD, R Trent, PhD, Epidemiology and Prevention for Injury Control, California Dept of Health Svcs. N Adekoya, DrPH, Div of Surveillance Systems and Informatics, Epidemiology Program Office, CDC.

Editorial Note:

In California, fall-related TBIs have a substantial impact on the health-care delivery system. Among those aged >85 years, three out of five hospitalizations resulted in a discharge to a residential facility with skilled nursing or to an in-home health service with outpatient rehabilitation services. Among older persons, an estimated annual average of 3,000 nonfatal falls results in hospitalizations for TBI at an estimated cost of $50 million^§. Studying the nature of these injuries and demographic risk factors might inform intervention strategies. However, few reports have been published regarding hospitalizations for fall-related TBIs (1,2).

The overall rate of hospitalized TBI falls observed in California (21.1) is similar to the combined incidence rate of hospitalized TBI falls (23.3) reported by Colorado, Missouri, Oklahoma, and Utah (1). Although the number of patients who returned to their pre-injury level of functioning is unknown, TBI often results in lifelong neurologic, psychological, and cognitive conditions requiring rehabilitation therapy and other treatment (7). This study indicates that for older adults, these injuries often result in death or impairment.

Rates of fall-related TBI are historically higher in males (8). In this study, rates observed in males also exceeded those of females in every age group, compared with all fall injury rates (i.e., those including other injuries in addition to TBI), which usually are higher for females (5). The reasons for this difference are unclear.

Adults aged >65 years have elevated TBI hospitalization rates (1). Older persons are at increased risk for fall-related TBI hospitalizations for at least three reasons. First, older persons are more likely to have chronic diseases and to use more medications whose adverse effects can lead to falls (4,9,10). Certain medications (e.g., sedatives, benzodiazepines, anticonvulsants, and antihypertensives) might cause dizziness, drowsiness, and postural hypotension (4,10). Second, even without medication effects, older adults might have impaired balance, slower reaction times, and decreased muscle strength, all of which can lead to more frequent falls. Finally, older adults who fall often sustain more severe head injuries than their younger counterparts (5). Falls are a major cause of intracranial lesion among older persons because of their greater susceptibility to acute subdural hematoma (10).

The findings in this report are subject to at least four limitations. First, because TBI cases were identified when any of the 25 diagnoses included a TBI diagnosis code, TBI might not be the primary reason for hospital admission or even the most serious problem. In this report, 21,593 (77%) of cases had TBI as the primary diagnosis. Second, the data source did not include intrinsic risk factors such as medications, co-morbidities, or physical condition. Third, one third of TBI patients did not specify the type of fall, making it difficult to characterize what type of falls cause TBI. Finally, hospitalization records were not reviewed to validate the E-codes for fall-related TBI.

Falls are a major cause of TBI in older persons. As the population of older persons in the United States continues to grow, the number of TBIs also is likely to grow. Recent clinical trials have identified fall prevention strategies that are effective in reducing the number of falls (e.g., balance and gait training, strength exercise programs, discontinuation of psychotropic medication, and reduction in home hazards after hospitalization) (4). Integration of these strategies into public health programs might reduce TBI-related morbidity and health-care costs.

References

1. CDC. Traumatic brain injury---Colorado, Missouri, Oklahoma, and Utah, 1990--1993. MMWR 1997;46:8--11.
2. Thurman DJ. The epidemiology and economics of head trauma. In Miller L, Hayes R, eds. Head Trauma Therapeutics: Basic, Preclinical and Clinical Aspects. New York, New York: John Wiley and Sons, 2001.
3. California Department of Health Services. Injuries in California. Available at http://www.dhs.ca.gov/EPICenter.
4. Tinetti ME. Preventing falls in elderly persons. N Engl J Med 2003;348:42--9.
5. Ellis AA, Trent RB. Do the risks and consequences of hospitalized fall injuries among older adults in California vary by type of fall? Journals of Gerontology Series A- Biological Sciences and Medical Sciences 2001;56:686--92.
6. U.S. Department of Health and Human Services. International Classification of Diseases, 9th Revision, Clinical Modification, 6th ed. (ICD-9-CM). Washington, DC: Department of Health and Human Services, 1996.
7. Thurman DJ, Alverson C, Browne D, et al. Traumatic brain injury in the United States: a report to Congress (December 1999). Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 1999.
8. Adekoya N, Thurman DJ, White D, Webb K. Surveillance for traumatic brain injury deaths---United States, 1989--1998. In: CDC surveillance summaries (December 6) 51(No. SS-10):1--16.
9. Grossman MD, Miller D, Scaff DW, Arcona S. When is an elder old? Effect of preexisting conditions on mortality in geriatric trauma. J Trauma 2002;52:242--6.
10. Sasser HC, Hammond FM, Lincourt AE. To fall or not to fall: brain injury in the elderly. N C Med J 2001;62:369--72.

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