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Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014


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Gwen Bergen, PhD1; Mark R. Stevens, MA, MSPH2; Elizabeth R. Burns, MPH1 (View author affiliations)

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Summary

What is already known about this topic?

Falls are the leading cause of fatal and nonfatal injuries among persons aged ≥65 years (older adults).

What is added by this report?

In 2014, 28.7% of older adults reported falling at least once in the preceding 12 months, resulting in an estimated 29.0 million falls. Of those who fell, 37.5% reported at least one fall that required medical treatment or restricted their activity for at least 1 day, resulting in an estimated 7.0 million fall injuries.

What are the implications for public health practice?

Although falls are common, approximately half of older adults who fall do not discuss it with their health care provider. However, older adult falls are largely preventable. Health care providers can play an important role in fall prevention by 1) screening older adults for fall risk, 2) reviewing and managing medications linked to falls, and 3) recommending vitamin D where appropriate for improved bone, muscle, and nerve health.

Falls are the leading cause of fatal and nonfatal injuries among adults aged ≥65 years (older adults). During 2014, approximately 27,000 older adults died because of falls; 2.8 million were treated in emergency departments for fall-related injuries, and approximately 800,000 of these patients were subsequently hospitalized.* To estimate the numbers, percentages, and rates of falls and fall injuries among older adults by selected characteristics and state, CDC analyzed data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) survey. In 2014, 28.7% of older adults reported falling; the estimated 29.0 million falls resulted in 7.0 million injuries. Known effective strategies for reducing the number of older adult falls include a multifactorial clinical approach (e.g., gait and balance assessment, strength and balance exercises, and medication review). Health care providers can play an important role in fall prevention by screening older adults for fall risk, reviewing and managing medications linked to falls, and recommending vitamin D supplements to improve bone, muscle, and nerve health and reduce the risk for falls.

BRFSS is an annual, random-digit–dialed telephone survey of the noninstitutionalized U.S. civilian population aged ≥18 years conducted annually in all 50 states, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands. Detailed information regarding the survey is available online. The median response rate for 2014 was 47.0%.

In 2014, survey respondents were asked, “In the past 12 months, how many times have you fallen?” If the response was one or more times, they were asked, “How many of these falls caused an injury? By an injury, we mean the fall caused you to limit your regular activities for at least a day or to go see a doctor.” This analysis was limited to adults aged ≥65 years in all 50 states and the District of Columbia who were asked the questions about falls.

The first question was used to estimate the percentage of older adults who reported one or more falls and the total number of falls; the second question was used to estimate the number of fall injuries. Response options ranged from zero to 76 or more with reported means of 0.67 falls and 0.16 fall injuries. The percentages and numbers of falls and fall injuries included all adults aged ≥65 years in the denominator. Adults with responses of “Don’t know/Not sure,” “Refused,” or “Not asked or missing” for questions about falls, fall injuries, or demographic characteristics were excluded, reducing the sample to 147,319 adults.§

The percentages and numbers were compared across the following subgroups: sex, age group, race/ethnicity, marital status, education, annual household income, health status, and state of residence. Orthogonal polynomial contrasts and pairwise t-tests were used to identify significant increases or decreases where appropriate. The 2014 BRFSS data were weighted by iterative proportional fitting (raking) to represent state-level population estimates and aggregated to represent a nationwide estimate. All results presented are weighted. Analyses were conducted using statistical software to account for the complex sampling design.

In 2014, 28.7% of older adults reported falling at least once in the preceding 12 months, resulting in an estimated 29.0 million falls (Table 1). Of those who fell, 37.5% reported at least one fall that required medical treatment or restricted activity for at least 1 day, resulting in 7.0 million fall injuries. Women (30.3%) were more likely to report falling than men (26.5%) (p<0.01) and were more likely to report a fall injury (12.6% compared with 8.3%; p<0.01). The percentage of older adults who fell increased with age (p<0.01), from 26.7% among persons aged 65–74 years, to 29.8% among persons aged 75–84 years, to 36.5% among persons aged ≥85 years. The percentage of older adults who fell was higher among whites (29.6%) and American Indian/Alaska Natives (AI/ANs) (34.2%) than among blacks (23.1%) and Asian/Pacific Islanders (19.8%). The percentage of older adults who reported a fall injury also increased with age (p<0.01), from 9.9% among persons aged 65–74 years to 11.4% among persons aged 75–84 years, to 13.5% among persons aged ≥85 years. AI/ANs were more likely to report a fall-related injury (16.8%) than were whites (10.9%), Hispanics (10.7%), and blacks (7.8%). The rate of fall-related injuries was significantly higher in the population reporting poor health (480 per 1,000) than the population reporting excellent health (69 per 1,000).

Among states and the District of Columbia, the percentage of older adults who reported a fall ranged from 20.8% in Hawaii to 34.3% in Arkansas. Several states had either significantly higher or lower percentages of reported falls among older adults compared with the national average (Figure) (Table 2). The percentage of older adults experiencing fall injuries ranged from 7.0% in Hawaii to 12.9% in Missouri.

Discussion

In 2014, 28.7% of older adults in the United States reported an estimated 29.0 million falls in the preceding 12 months. Older adult falls can result in death, serious injury, and loss of independence (1,2). This analysis found that an estimated 7 million falls required medical treatment or caused restricted activity for at least 1 day. Women and those in older age groups were at higher risk for falling and being injured in a fall. Reduced muscle strength is a risk factor for falls, and aging and female sex are associated with reduced muscle mass (1,2). Women have been found to be more likely to report falls than men (3). Aging also is associated with changes in gait and balance, increased inactivity, more severe chronic conditions, and more prescription medication use, all of which are risk factors for falls (1). Limited research exists on the causes for racial/ethnic differences, but these differences might be related to differences in health and behavior (4,5). Reasons for state differences are unknown; however, even in Hawaii, the state with the lowest incidence, 20.8% of older adults reported a fall.

Annual Medicare costs for older adult falls have been estimated at $31.3 billion (6), and the older adult population is expected to increase 55% by 2030.** Applying the number of falls from this analysis to the projected 2030 population would result in an estimated 48.8 million falls and 11.9 million fall injuries, unless effective interventions are implemented nationwide.

The findings in this report are subject to at least four limitations. First, BRFSS data are self-reported and subject to recall bias. Second, BRFSS does not include persons in long-term care facilities who are at higher risk for falls (7). Third, the broad definition of fall injury for this analysis might have resulted in a higher estimate of injurious falls compared with other reports. Finally, the response rate (median = 47%) could have resulted in nonresponse bias; however, weighting and survey methodology are used to adjust the estimates and reduce the effect of nonresponse bias.

Older adult falls are largely preventable, and health care providers (e.g., physicians, nurses, nurse practitioners, physician assistants, pharmacists, physical therapists, and occupational therapists) can play an important part by discussing falls with older adult patients and providing appropriate interventions (8). The American and British Geriatrics Societies (AGS/BGS) Clinical Practice Guideline recommends that health care providers use a multifactorial approach to prevent falls that includes activities such as asking about falls, assessing gait and balance, reviewing medications, and prescribing interventions such as strength and balance exercises, or taking vitamin D.†† This type of approach has been estimated to be capable of reducing falls by 24% (8). Based on the AGS/BGS guidelines, CDC has developed the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) initiative§§ to provide resources to help health care providers incorporate fall prevention into primary care (3). STEADI stresses three initial steps that can be completed in one patient visit: 1) ask patients if they have fallen in the past year, feel unsteady, or worry about falling; 2) review medications and stop, switch, or reduce the dosage of drugs that increase fall risk; and 3) recommend daily vitamin D supplementation for improved bone, muscle, and nerve health (with dosage of vitamin D and decision on whether to co-supplement with calcium to be determined based on the patient’s history).

Health care providers should discuss fall prevention with their patients because approximately half of older adults who fall do not discuss it with their health care provider, often because they fear this will lead to a loss of independence (9). Health care providers cite limited time and cost as barriers to incorporating preventive services, such as those proposed by STEADI, into their clinical practice (10). However, the Centers for Medicare & Medicaid Services (CMS) now provides incentives for health care providers to conduct fall prevention activities through payment and delivery reforms (e.g., Welcome to Medicare Visit, Medicare Annual Wellness Visit, and the Medicare Shared Savings Accountable Care Organization Program).¶¶ CMS also links health care provider incentives to fall prevention quality measures through the Physician Quality Reporting System (PQRS) in the Merit-Based Incentive Program. PQRS includes two quality measures for falls: Falls Risk Assessment and Falls Plan of Care.*** Mechanisms such as payment and delivery reforms and quality reporting measures are opportunities to make fall prevention a routine part of clinical practice and reduce the barriers to providing services that can prevent falls among older adults.

Acknowledgments

Susan Dugan, Hilary Eiring, MPH, Robin Lee, PhD, Judy A. Stevens, PhD, National Center for Injury Prevention and Control, CDC.


Corresponding author: Gwen Bergen, gbergen@cdc.gov, 770-488-1394.

1Division of Unintentional Injury, National Center for Injury Prevention and Control, CDC; 2Division of Analysis, Research and Practice Integration, National Center for Injury Prevention and Control, CDC.

References

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Return to your place in the textTABLE 1. Percentages and rates* of falls and fall injuries in the preceding 12 months reported by adults aged ≥65 years (N = 147,319), by selected characteristics — Behavioral Risk Factor Surveillance System, United States, 2014
Characteristic No. reporting a fall§ % (95% CI) No. of falls reported (millions) Rate (95% CI) No. reporting a fall injury % (95% CI) No. of fall injuries reported (millions) Rate** (95% CI)
Overall 43,958 28.7 (28.2–29.1) 29.0 672 (648–695) 16,083 10.7 (10.4–11.0) 7.0 164 (156–171)
Sex
Men 15,668 26.5 (25.8–27.2) 12.4 657 (620–694) 4,731 8.3 (7.9–8.8) 2.4 127 (118–136)
Women 28,290 30.3 (29.7–31.0) 16.5 683 (653–714) 11,352 12.6 (12.1–13.0) 4.6 192 (181–203)
Age group (yrs)
65–74 23,859 26.7 (26.2–27.3) 16.2 650 (619–680) 8,650 9.9 (9.5–10.3) 3.8 154 (146–163)
75–84 14,379 29.8 (29.0–30.7) 9.5 669 (634–703) 5,267 11.4 (10.8–12.1) 2.4 170 (155–185)
≥85 5,720 36.5 (35.0–38.0) 3.3 820 (705–935) 2,166 13.5 (12.4–14.6) 0.8 199 (172–226)
Race/Ethnicity
White 38,180 29.6 (29.1–30.0) 23.3 683 (661–706) 13,869 10.9 (10.6–11.2) 5.6 163 (156–170)
Black 2,204 23.1 (21.5–24.8) 1.8 487 (432–542) 795 7.8 (6.9–8.8) 0.4 115 (93–137)
American Indian/Alaska Native 542 34.2 (29.6–39.2) 0.4 1,322 (838–1,805) 234 16.8 (13.0–21.3) 0.1 441 (233–649)
Asian/Pacific Islander 271 19.8 (14.0–27.1) ††
Hispanic 1,191 26.4 (23.8–29.2) 1.8 655 (483–827) 489 10.7 (9.0–12.7) 0.4 164 (132–196)
Multiple/Other 844 33.5 (29.5–37.8) 0.5 971 (734–1,208) 340 15.4 (12.5–18.7) 0.2 314 (171–456)
Marital status
Married 19,241 26.2 (25.6–26.8) 14.2 597 (570–624) 6,491 9.3 (8.9–9.8) 3.3 140 (129–150)
Divorced 6,582 32.7 (31.3–34.1) 4.3 825 (741–908) 2,613 13.3 (12.3–14.4) 1.1 209 (190–229)
Widowed 15,062 31.7 (30.9–32.6) 8.0 703 (669–736) 5,858 12.2 (11.6–12.8) 2.1 182 (169–194)
Separated 491 30.2 (25.5–35.3) 0.5 928 (709–1,148) 208 12.8 (9.8–16.4) 0.1 275 (172–378)
Never married 2,116 29.6 (27.3–31.9) 1.3 813 (641–986) 743 10.7 (9.4–12.3) 0.3 177 (136–218)
Member of unmarried couple 318 32.8 (26.5–39.8) 0.1 291 (138–445)
Education
Less than high school graduate 4,439 30.2 (28.7–31.7) 5.6 810 (724–896) 1,728 11.9 (10.9–12.9) 1.3 193 (172–215)
High school graduate 13,317 27.2 (26.5–28.0) 8.1 600 (572–628) 4,856 9.9 (9.4–10.4) 1.9 143 (134–152)
Some college 11,614 29.9 (29.0–30.9) 8.9 721 (669–772) 4,438 11.9 (11.1–12.6) 2.3 189 (171–207)
College graduate or more 14,460 28.1 (27.3–28.8) 6.2 607 (577–636) 5,005 9.6 (9.1–10.1) 1.4 139 (129–149)
Annual household income ($)
<15,000 4,832 34.9 (33.1–36.7) 4.0 987 (893–1,080) 2,119 15.1 (13.8–16.5) 1.1 277 (243–312)
15,000–24,999 8,726 30.7 (29.6–31.8) 6.2 802 (746–858) 3,438 12.3 (11.6–13.1) 1.5 198 (181–216)
25,000–34,999 5,480 30.2 (28.9–31.6) 3.5 665 (619–712) 1,920 10.6 (9.8–11.5) 0.8 157 (139–175)
35,000–49,999 6,054 28.0 (26.9–29.2) 3.9 647 (592–702) 2,084 10.0 (9.2–10.9) 0.9 145 (130–160)
50,000–74,999 5,007 26.1 (24.9–27.3) 3.1 587 (511–663) 1,728 9.4 (8.6–10.2) 0.7 129 (116–143)
≥75,000 5,911 24.8 (23.7–25.9) 3.7 532 (461–604) 1,885 8.6 (7.8–9.4) 0.8 119 (104–134)
Health status
Excellent 3,922 19.2 (18.1–20.3) 1.8 340 (307–374) 1,136 5.9 (5.2–6.6) 0.4 69 (60–77)
Very good 11,089 23.7 (22.9–24.4) 5.7 457 (410–505) 3,479 7.9 (7.4–8.4) 1.2 101 (92–109)
Good 14,481 28.3 (27.4–29.1) 8.3 578 (547–608) 5,055 10.1 (9.5–10.7) 2.0 138 (125–151)
Fair 9,285 36.7 (35.5–37.9) 7.4 979 (918–1,040) 3,883 15.3 (14.4–16.2) 1.9 253 (232–275)
Poor 4,936 47.3 (45.3–49.3) 5.5 1771 (1,619–1,923) 2,440 22.1 (20.6–23.6) 1.5 480 (430–530)

Abbreviation: CI = confidence interval.
* Number of falls in the preceding 12 months.
An injury caused by a fall in the preceding 12 months that caused respondents to limit their regular activities for ≥1 days or to go see a doctor.
§ Unweighted number of older adults reporting a fall. Because of varying question-specific nonresponse, sample sizes vary among questions.
Number of falls per 1,000 adults aged ≥65 years.
** Number of fall injuries per 1,000 adults aged ≥65 years.
†† Sample size <50 or relative standard error >30%.

Return to your place in the textFIGURE. Percentages of falls and fall injuries* in the preceding 12 months reported by adults aged =65 years (N = 147,319) — Behavioral Risk Factor Surveillance System, United States, 2014
The figure above is a pair of maps showing percentages of falls and fall injuries in the preceding 12 months reported by adults aged ≥65 years (N = 147,319) in the United States during 2014.

* Injuries resulting from falls that caused respondents to limit their regular activities for =1 days or to go see a doctor.

Return to your place in the textTABLE 2. Percentages and rates* of falls and fall injuries in the preceding 12 months reported by adults aged ≥65 years (N = 147,319), by states ranked by percentage of older adults reporting ≥1 fall — Behavioral Risk Factor Surveillance System, United States, 2014
State No. reporting a fall§ % (95% CI) No. of falls reported (thousands) Rate (95% CI) No. reporting a fall injury % (95% CI) No. of fall injuries reported (thousands) Rate** (95% CI)
Overall 43,958 28.7 (28.2–29.1) 29,000 672 (648–695) 16,083 10.7 (10.4–11.0) 7,000 164 (156–171)
Arkansas 727 34.3 (31.6–37.0)†† 377 868 (725–1011)†† 275 11.5 (9.9–13.4) 79 183 (148–218)
Alaska 324 32.9 (29.0–37.0)†† 65 940 (683–1197)†† 114 11.9 (9.4–15.0) 12 178 (128–227)
Michigan 901 32.6 (30.5–34.8)†† 1,216 810 (671–949) 323 11.4 (10.0–13.0) 265 177 (137–217)
Missouri 865 32.4 (29.9–35.0)†† 741 823 (639–1008) 326 12.9 (11.2–14.9)†† 187 208 (150–266)
Montana 908 32.2 (29.7–34.7)†† 137 824 (670–977) 351 12.1 (10.5–13.9) 27 163 (139–187)
Kentucky 1,174 32.1 (29.7–34.6)†† 473 770 (660–880) 445 11.9 (10.3–13.6) 108 176 (145–208)
Wyoming 836 32.1 (29.7–34.5)†† 65 831 (668–994) 276 10.5 (9.1–12.2) 15 196 (122–270)
Indiana 1,272 31.8 (29.9–33.7) †† 685 762 (659–864) 441 11.0 (9.8–12.3) 156 174 (142–207)
Oregon 626 31.8 (29.4–34.4)†† 495 822 (684–960)†† 251 12.3 (10.6–14.2) 145 241 (125–357)
Vermont 561 31.7 (29.2–34.3)†† 78 777 (646–909) 197 11.1 (9.5–12.9) 15 151 (126–177)
Iowa 887 31.5 (29.5–33.7) †† 322 686 (604–767) 289 9.9 (8.7–11.3) 70 149 (118–179)
Washington 1,120 31.2 (29.3–33.2)†† 813 840 (652–1028) 406 10.5 (9.3–11.8) 150 155 (131–179)
Oklahoma 920 30.9 (28.9–32.9)†† 488 891 (706–1075)†† 322 11.1 (9.9–12.6) 120 219 (122–315)
California 613 30.7 (28.0–33.5) 3,134 801 (631–970) 225 12.4 (10.4–14.8) 807 207 (156–257)
Kansas 1,321 30.5 (28.9–32.0)†† 292 735 (619–851) 455 10.4 (9.4–11.4) 76 191 (106–275)
Texas 1,504 30.2 (27.9–32.7) 1,906 654 (563–745) 551 11.4 (9.9–13.2) 476 164 (136–191)
Tennessee 600 30.1 (27.5–32.8) 685 737 (614–860) 213 11.4 (9.6–13.4) 166 179 (131–228)
Ohio 1,209 30.1 (28.0–32.3) 1,210 688 (610–767) 452 10.4 (9.1–11.9) 259 147 (124–171)
District of Columbia 427 30.1 (26.9–33.4) 51 687 (548–826) 155 11.7 (9.5–14.3) 13 175 (121–230)
Maine 1,014 29.9 (27.9–31.9) 195 836 (640–1032) 327 9.3 (8.1–10.5)§§ 35 151 (116–185)
Idaho 586 29.9 (27.2–32.8) 154 697 (600–794) 201 10.6 (8.8–12.7) 37 170 (131–209)
Utah 1,049 29.6 (27.8–31.6) 192 668 (591–744) 383 10.5 (9.3–11.8) 43 149 (126–172)
Alabama 925 29.4 (27.3–31.6) 524 733 (630–836) 342 10.7 (9.4–12.3) 121 170 (134–206)
South Carolina 1,097 29.2 (27.4–31.1) 553 749 (623–874) 431 11.4 (10.2–12.8) 155 211 (140–281)
Massachusetts 1,591 28.6 (26.8–30.5) 588 611 (532–689) 613 10.6 (9.5–11.9) 146 152 (127–177)
Pennsylvania 1,083 28.6 (26.7–30.5) 1,208 588 (524–651)§§ 380 9.9 (8.7–11.2) 271 132 (114–151)§§
Georgia 615 28.6 (26.2–31.1) 769 649 (560–738) 227 10.5 (8.9–12.2) 190 160 (124–196)
South Dakota 720 28.5 (25.6–31.6) 74 577 (473–681) 242 9.7 (8.0–11.8) 18 143 (103–183)
Nebraska 2,235 28.2 (26.8–29.6) 187 701 (614–789) 751 9.9 (9.0–10.9) 39 146 (120–172)
Delaware 441 28.1 (25.4–31.0) 97 660 (495–826) 160 10.0 (8.3–12.0) 21 143 (112–175)
Mississippi 457 28.1 (25.3–31.0) 282 674 (526–822) 163 8.9 (7.4–10.6)§§ 55 133 (98–167)
North Carolina 642 28.0 (25.9–30.2) 868 616 (543–688) 234 10.0 (8.7–11.6) 237 168 (132–205)
New Hampshire 619 28.0 (25.5–30.6) 131 649 (530–768) 228 9.6 (8.2–11.3) 33 162 (108–217)
New Mexico 828 27.8 (25.5–30.2) 190 661 (567–755) 294 10.2 (8.7–11.9) 46 158 (125–192)
Wisconsin 505 27.8 (24.9–30.9) 496 690 (470–911) 192 10.1 (8.3–12.2) 104 145 (111–179)
New York 547 27.7 (25.2–30.3) 1,598 584 (507–661)§§ 205 10.7 (9.1–12.6) 422 154 (126–183)
Arizona 1,722 27.5 (26.0–29.1) 676 707 (591–824) 677 10.4 (9.4–11.5) 142 148 (130–167)
Illinois 457 27.4 (24.7–30.3) 1,058 610 (485–736) 178 11.1 (9.3–13.2) 277 160 (125–195)
North Dakota 732 27.2 (24.8–29.7) 71 677 (539–815) 264 9.5 (8.1–11.2) 15 145 (101–188)
Colorado 1,107 27.1 (25.4–28.8) 374 601 (515–688) 395 9.4 (8.4–10.5)§§ 85 137 (115–158)§§
Nevada 386 26.9 (23.6–30.5) 233 605 (475–735) 141 9.8 (7.8–12.2) 76 198 (124–272)
Rhode Island 550 26.8 (24.4–29.3) 90 566 (457–674) 219 10.2 (8.6–12.0) 24 150 (113–186)
West Virginia 536 26.6 (24.4–28.9) 208 642 (533–751) 206 9.9 (8.5–11.6) 48 149 (121–177)
Connecticut 661 26.5 (24.2–29.0) 263 496 (425–567)§§ 266 10.3 (8.8–12.1) 79 149 (117–182)
Minnesota 1,185 26.1 (24.5–27.6)§§ 448 591 (514–669) 415 9.0 (8.0–10.1)§§ 105 139 (114–164)
Virginia 700 25.6 (23.5–27.8)§§ 602 534 (468–600)§§ 265 9.9 (8.5–11.4) 154 137 (112–162)§§
Florida 1,060 25.1 (23.4–26.9)§§ 2,087 599 (513–686) 440 10.4 (9.3–11.7) 526 151 (129–174)
Maryland 1,179 25.1 (23.1–27.2)§§ 405 506 (437–576)§§ 418 8.1 (7.0–9.3)§§ 93 116 (98–134)§§
Louisiana 530 24.9 (22.7–27.1)§§ 365 591 (511–670) 193 8.6 (7.3–10.1)§§ 92 150 (108–191)
New Jersey 937 23.6 (21.6–25.7)§§ 653 525 (421–629)§§ 397 10.2 (8.9–11.8) 187 151 (111–190)
Hawaii 467 20.8 (18.5–23.4)§§ 85 399 (331–467)§§ 169 7.0 (5.6–8.6)§§ 18 83 (66–101)§§

Abbreviation: CI = confidence interval.
* Number of falls in the preceding 12 months.
An injury caused by a fall in the preceding 12 months that caused respondents to limit their regular activities for ≥1 days or to go see a doctor.
§ Unweighted number of older adults reporting a fall. Because of varying question-specific nonresponse, sample sizes vary among questions.
Number of falls per 1,000 adults aged ≥65 years.
** Number of fall injuries per 1,000 adults aged ≥65 years.
†† Significantly higher than the overall percentage or rate.
§§ Significantly lower than the overall percentage or rate.

Suggested citation for this article: Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:993–998. DOI: http://dx.doi.org/10.15585/mmwr.mm6537a2.

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