Trends in Nonfatal Falls and Fall-Related Injuries Among Adults Aged ≥65 Years — United States, 2012–2018

Falls are the leading cause of injury among adults aged ≥65 years (older adults) in the United States. In 2018, an estimated 3 million emergency department visits, more than 950,000 hospitalizations or transfers to another facility (e.g., trauma center), and approximately 32,000 deaths resulted from fall-related injuries among older adults.* Deaths from falls are increasing, with the largest increases occurring among persons aged ≥85 years (1). To describe the percentages and rates of nonfatal falls by age group and demographic characteristics and trends in falls and fall-related injuries over time, data were analyzed from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) and were compared with data from 2012, 2014, and 2016. In 2018, 27.5% of older adults reported falling at least once in the past year, and 10.2% reported an injury from a fall in the past year. The percentages of older adults reporting a fall increased between 2012 and 2016 and decreased slightly between 2016 and 2018. Falls are preventable, and health care providers can help their older patients reduce their risk for falls. Screening older patients for fall risk, assessing modifiable risk factors (e.g., use of psychoactive medications or poor gait and balance), and recommending interventions to reduce this risk (e.g., medication management or referral to physical therapy) can prevent older adult falls (https://www.cdc.gov/steadi).

Using 2018 BRFSS data, percentages and rates were calculated by age group for demographic (sex and race/ethnicity) and geographic (urban/rural status) characteristics. Functional characteristics (blind/difficulty seeing, difficulty dressing/ bathing, difficulty walking/climbing stairs, difficulty doing errands alone, and difficulty concentrating/making decisions) also were compared, as were self-reported health status and data on taking part in any physical activity/exercise in the past month. Analysis was restricted to respondents aged ≥65 years residing in the 50 states and DC. Any respondents with missing values or responses of "Don't know/Not sure" or "Refused" for falls or fall-related injuries were excluded. Overall, 4.8% of respondents were excluded from the analysis of falls, leaving 142,834; and 4.9% were excluded from the analysis of fallrelated injuries, leaving 142,591. Two-sample t-tests were used to compare percentages across characteristics. Linear trend tests were conducted for age group and self-reported health status. BRFSS data from 2012, 2014, 2016, and 2018 were used to examine trends in the percentages of adults aged ≥65 years who had fallen or had a fall-related injury and rates of falls overall and by age group. Polynomial linear regression was used to assess linearity of trends (2). Where nonlinear trends were detected, two-sample t-tests with Bonferroni adjustments for multiple comparisons were performed to determine differences between years (2). Because the BRFSS questions about falls differed in three states (Michigan, Oregon, and Wisconsin) for 2012, compared with other years, the trend analysis was limited to 47 states and DC. All results presented are weighted to represent the U.S. population. Analysis was conducted using SAS-callable SUDAAN (version 11; RTI International) to account for the complex survey design.
In 2018, 27.5% of adults aged ≥65 years reported at least one fall in the past year (Table 1), and 10.2 % of adults aged ≥65 years reported at least one fall-related injury ( Table 2). In the preceding year, an average of 714 falls (Table 1) and an average of 170 fall-related injuries were reported per 1,000 older adults (Table 2), or approximately 35.6 million falls and 8.4 million fall-related injuries. The percentage of adults aged ≥65 years reporting a fall or a fall-related injury increased with age (p<0.001). Among adults aged ≥85 years, 33.8% reported a fall (Table 1) and 13.9% reported a fall-related injury (Table 2). Overall, a higher percentage of women reported at least one fall (29.1%; p<0.001) or fall-related injury (11.9%; p<0.001)   Abbreviation: CI = confidence interval. * Weighted number of falls per 1,000 adults aged ≥65 years. † Weighted number of adults aged ≥65 years reporting at least one fall in the past year. Because of varying question-specific nonresponse, sample sizes might vary among questions. § Weighted percentage of adults aged ≥65 years reporting at least one fall in the past year. ¶ Whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and others/unknown were non-Hispanic; Hispanics could be of any race. ** Dashes indicate sample size <50 or relative standard error >30%.

TABLE 1. (Continued) Number of falls, percentages of adults reporting a fall, and rates* of self-reported falls in the past year among adults aged ≥65 years, by age group and selected characteristics (unweighted n = 142,834) -Behavioral Risk Factor Surveillance System, United States, 2018
than did men in the past year (25.5% reported a fall and 7.9% reported a fall-related injury). However, when stratified by age group, the percentages of adults aged ≥85 years reporting a fall (32.8% of women and 35.7% of men; p = 0.184) or fall-related injury (14.3% of women and 13.4% of men; p = 0.553) did not differ significantly by sex. A lower percentage of blacks (22.5%; p<0.001) and Asian/Pacific Islanders (15.6%; p<0.001) reported a fall than did whites (28.3%) ( Table 1), and a higher percentage of American Indian/Alaska Natives (15.2%) reported a fall-related injury than did whites (10.2%; p = 0.008) ( Table 2). The percentages of older adults reporting a fall decreased as health status improved (p<0.001) ( Table 1). Overall, a higher percentage of older adults living in rural areas (29.5%) reported a fall compared with those living in urban areas (27.0%; p<0.001); however, when stratified by age group, this was only true for persons aged 65-74 years ( Table 1). Regardless of age group, older adults reporting difficulties with functional abilities reported a higher percentage of falls and fall-related injuries than did those without these difficulties (p<0.001). A lower percentage of older adults who reported any physical activity in the past month reported a fall (24.9%) compared with those who did not report physical activity (33.1%; p<0.001), regardless of age group.
Among states in which falls and fall injuries were consistently reported across years (excluding Michigan, Oregon, and Wisconsin where data in 2012 were reported differently than in other years), the percentage of those older adults reporting a fall increased from 27.9% in 2012 to 29.6% in 2016 (p<0.001) and decreased to 27.4% in 2018 (p<0.001) (Figure). The rates of falls and fall-related injuries and the percentages of older adults reporting a fall-related injury did not significantly change from 2012 to 2018.   Abbreviation: CI = confidence interval. * Weighted number of fall-related injuries per 1,000 older adults. † Weighted number of adults aged ≥65 years reporting at least one fall-related injury in the past year. Because of varying question-specific nonresponse, sample sizes might vary among questions. § Weighted percentage of older adults reporting at least one fall-related injury in the past year. ¶ Whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and others/unknown were non-Hispanic; Hispanics could be of any race. ** Dashes indicate sample size <50 or relative standard error >30%.

Discussion
The percentage of older adults reporting a fall increased from 2012 to 2016, followed by a modest decline from 2016 to 2018. Although statistically significant, these changes were small. Even with this decrease in 2018, older adults reported 35.6 million falls. Among those falls, 8.4 million resulted in an injury that limited regular activities for at least a day or resulted in a medical visit. In the United States, health care spending on older adult falls has been approximately $50 billion annually (3). In 2018, approximately 52 million adults were aged ≥65 years § by 2030, this number will increase to approximately 73 million. ¶ Despite no significant changes in the rate of fallrelated injuries from 2012 to 2018, the number of fall-related § https://www2.census.gov/programs-surveys/popest/tables/2010-2018/counties/ asrh/PEPAGESEX.pdf. ¶ https://www.census.gov/data/tables/2017/demo/popproj/2017-summarytables.html. injuries and health care costs can be expected to increase as the proportion of older adults in the United States grows.
Adults aged ≥85 years were more likely to report a fall or fall-related injury in the preceding year than were those aged <85 years. Currently, adults aged ≥85 years account for <2% of the population; by 2050 this proportion is projected to increase to 5%. Many fall risk factors increase with age, including chronic health conditions related to falls, increased use of medications, and functional decline (4). More research is needed to determine how fall risk factors differ among persons aged ≥85 years and to identify targeted interventions that could adequately address the needs of these adults.
The findings in this report are subject to at least five limitations. First, because BRFSS data are self-reported, they are subject to recall bias, especially for falls that did not result in injury or that occurred several months before the survey (5). Second, this survey is cross-sectional. Although functional abilities, health status, and physical activity were all associated with falls and fall-related injuries, it is not possible to determine whether these factors preceded the fall or resulted from a fall. Third, BRFSS does not include older adults living in nursing homes, which might have led to an underestimation of falls and fall-related injuries, especially among adults aged ≥85 years (6). Fourth, the response rate (median response rate of 49.9%) could result in non-response bias, however BRFSS data are weighted to adjust for some of this bias. Finally, the results of the trend analyses were derived from only four time points. Future analyses with more time points might describe these trends with more certainty.

Summary
What is already known about this topic?
Falls are the leading cause of injury among adults aged ≥65 years, who in 2014 experienced an estimated 29 million falls, resulting in 7 million fall-related injuries.
What is added by this report?
In 2018, 27.5% of adults aged ≥65 years reported at least one fall in the past year (35.6 million falls) and 10.2% reported a fall-related injury (8.4 million fall-related injuries). From 2012 to 2016, the percentages of these adults reporting a fall increased, and from 2016 to 2018, the percentages decreased.
What are the implications for public health practice?
Falls and fall-related injuries are highly prevalent but are preventable. Health care providers play a crucial role and can help older adults reduce their risk for falls.
Regardless of age group, higher percentages of older adults who reported no physical activity in the past month or reported difficulty with one or more functional characteristics (difficulty walking up or down stairs, dressing and bathing, and performing errands alone) reported falls and fall-related injuries. These risk factors are frequently modifiable suggesting that, regardless of age, many falls might be prevented. Older adults of any age can, together with their health care providers, take steps to reduce their risk for falls. CDC created the Stopping Elderly Accidents, Deaths & Injuries (STEADI) initiative, which offers tools and resources for health care providers to screen their older patients for fall risk, assess modifiable fall risk factors, and to intervene with evidence-based fall prevention interventions (https://www.cdc.gov/steadi). These include medication management, vision screening, home modifications, referral to physical therapists who can address problems with gait, strength, and balance, and referral to effective communitybased fall prevention programs. As the proportion of older adults living in the United States continues to grow, so too will the number of falls and fall-related injuries. However, many of these falls are preventable. To help keep older adults living independently and injury-free, reducing fall risk and fall-related injuries is essential.