Characteristics and outcomes of older patients presenting to the
emergency department after a fall: a retrospective analysis
Anthony J Bell, Janet K Talbot-Stern and Annemarie Hennessy
MJA 2000; 173: 179-182
For editorial comment, see Close & Glucksman
More articles on Emergency medicine
Objectives: To study older patients presenting to
the emergency department after a fall -- factors associated with the
fall, injuries sustained and outcome.|
Design: A retrospective analysis using the Emergency
Department Information System (EDIS), the Trauma Registry and the
patient information database (CCIS), in addition to the patient's
emergency and inpatient medical records.
department of a major inner city teaching hospital, 1 June - 30
Patients: All patients over 65 years presenting to the
emergency department (ED) after a fall, for whom complete medical
records were available.
Results: Of 803 patients over 65 years presenting to the ED
after a fall, complete records were available for 733 (91.3%) (283 men
and 450 women). Extrinsic (accidental) causes were implicated in
more than a third of falls (313 patients [42.7%]). A high proportion of
the patients were living at home (520; 70.9%) and walking unaided
(389; 53.1%). Although absolute numbers of women increased with age,
men were as likely as women to present after a fall. Many patients had
fallen before -- 39% of the men (111/283) and 24% of the women
(110/450). In 78 patients (10.6%), alcohol misuse may have been a
direct cause of the fall. The overall injury rate was 70.5% (517/733
patients), the most common injury being an isolated fracture
(269/517 patients; 52.0%). In all, 419 patients (57.2%) were
admitted to hospital, 48% (200/419) with a fracture and 52% (219/419)
for investigation of the medical cause of the fall. The median length
of hospital stay was 6 days (mean, 10.4 days; range, 1-129 days); 35%
(146/419) of patients were in hospital for more than 10 days.
Conclusion: Older patients presenting to the ED after a
fall had high injury rates, high admission rates and often prolonged
hospitalisation. About a third had fallen before. Patients at risk
can be identified in the ED and referred to falls prevention
Census data for 1996 show that 12.1% of Australians are aged 65 years or
This proportion is expected to double in the next
with major implications for healthcare costs.
Alone, the cost of falls in patients over 70 years in Australia was
estimated to be $398 million in 1989.3|
In the United States, trauma causes a considerable proportion of
presentations (and subsequent hospital admissions) of older
patients. Falls account for most of these presentations.4 The annual
incidence of all falls increases from 25% at age 70 years to 35% after
the age of 75; the risk increases with age and is higher among those
living in long-stay institutions.5 Up to 10%-15% of falls result
in serious injury, of which at least half are fractures. Even falls not
resulting in injury may have serious psychological
consequences.5,6 The "postfall anxiety
and fear of falling leads to decreased
activity,8 and ultimately an increased
risk of future falls.9 Patients have reported
continued disability two months after a fall.10
No Australian report has been published specifically about patients
in this age group presenting to the emergency department (ED) after
falls, although previous studies have looked at older people
presenting to the ED.11,12 Our aim was therefore
to focus on patients over 65 years who presented to our ED as a result of a
fall. Several features were of interest: why the patients fell; what,
if any, injuries were sustained; what proportion of patients
required admission to hospital; and what morbidity and mortality
resulted from the fall.
Royal Prince Alfred Hospital is a 700-bed tertiary referral centre
with 60 000 admissions and 45 000 ED attendances per year. A
retrospective review of attendances for the six-month period June -
November 1997 was undertaken. All older patients who had fallen were
eligible for the study.
Data were obtained from the sources below and thereafter patients
- EDIS: Patients eligible for the study were
identified by a search of the EDIS (Emergency Department Information
System) for "falls" in the age group chosen. EDIS is a computerised
database in the ED with demographic information, presenting
complaint, diagnosis and disposition for each patient.
- Medical records: A predetermined dataset was
recorded from the medical record for each patient presenting to the
ED. This included medical record number, age, sex, type of residence
(home, hostel or nursing home), prefall mobility, nature of fall,
alcohol misuse, recurrent fall, referral status, triage category,
injury score, specific area of the body injured, fracture,
admission, specialty, length of stay, mortality, and discharge
disposition. Prefall mobility was further defined as unaided versus
aided (use of a stick, frame, crutches, assistance by another person)
- Trauma Registry: Additional data were obtained
from the hospital's Trauma Registry. An Injury Severity Score (ISS)
is calculated for patients requiring admission after trauma. ISS is
the sum of the squares of the highest Abbreviated Injury Scores (an
anatomical system classifying injuries by body region on a scale of 1
[minor] to 6 [serious]) for the three most seriously injured body
regions. ISS ranges from 1 (minor injury) to 75 (severe
- CCIS: For patients transferred to an affiliated
geriatric and rehabilitation hospital, the patient information
database (CCIS [Central Sydney Area Health Service Clinical
Information System]) was accessed for the length of stay. None of the
patients in our study were transferred to non-affiliated geriatric
and rehabilitation hospitals.
- Population data: The Australian Bureau of
Statistics supplied population data for the hospital's catchment
- Fall: "Inadvertently coming to rest on the ground or
other lower level with or without loss of consciousness."15
- Extrinsic (accidental) causes: Environmental
factors (eg, rugs, steps, uneven floors). Falls as a result of
external trauma, such as motor vehicle accidents and violence, were
- Intrinsic (non-accidental) causes: Syncope,
dizziness or vertigo, postural drop, central nervous system lesion
(haemorrhage or infarct), drop attack, and balance or gait
- Alcohol misuse: A history of alcohol misuse related
temporally to the event, a record of alcohol on the breath, or a
statement in the ED record about the patient's being intoxicated.
We used Minitab Statistical Software16 for statistical analysis
and performed χ2 tests. Analysis was based on
age group or sex and compared with a number of variables: presentation
as a result of a fall, nature of the fall, outcome of a fracture, and
admission status. A multivariate analysis was performed on four
aspects of the falls considered to be related to place of residence or
mobility: extrinsic cause, recurrent falls, fracture/no fracture
and admission. Odds ratios (95% CI) were calculated for each of these
groups. Multivariate analysis was also used to calculate odds ratios
(95% CI) for whether alcohol use contributed to selected outcomes:
admission (yes/no), extrinsic or recurrent falls versus other
falls, and age under or over 80 years.
Of a total of 22 782 patients presenting to the ED during the six-month
study period, 4489 (19.7%) were patients older than 65 years and 803
(17.8%) of these patients presented as a direct consequence of a fall.
Of these patients, 733 (91.3%) had medical records available for
review at the time of analysis and complete for the purposes of the
- Age and sex: The average age was 78.6 years
(range, 65-101 years) and the median age was 79 years: 263 patients
were aged 65-74 years, 279 were 75-84 years and 191 were 85 years or
older. Increasing age of the patients was associated with presenting
to the ED as a result of a fall (χ2 test for trend, P <
0.001) (Box 1). There were 283 men and 450 women. However, the
number of men and women presenting to the ED after a fall reflected the
age and sex distribution within the catchment population (Box 2).
Thus, men were as likely as women to present as a result of a fall.
- Residence: At the time of the fall, 83% (211/253)
of the 65-74 year olds, 74% (200/269) of the 75-84 year olds and
57% (109/191) of those over 85 years were living in their own homes.
Thus, the proportion of those living in either a hostel or a nursing
home increased with advancing age. In 20 patients residence could not
- Previous falls: 39% of the men (111/283) and 24%
of the women (110/450) had fallen before.
- Mobility: Patients were classified according
to mobility: walking aided or unaided. As expected, as the patients
aged the use of a walking aid increased.
Cause of fall|
- Extrinsic or intrinsic: Overall, extrinsic causes
for the fall accounted for 42.7% of patients presenting to the ED. In
the age group 65-74 years extrinsic causes accounted for 49.4% of
falls, which is more than expected when compared with the proportion
in the older age groups (39.0% and 38.7%, respectively). Intrinsic
causes were more likely with advancing age (χ2 test; P =
0.018) and accounted for 50.5% (95% CI, 45%-57%), 60.9% (95% CI,
55%-67%) and 64.2% (95% CI, 54%-68%) of falls in the respective age
groups. The breakdown of all causes for falls presenting to the ED is
shown in Box 3. Despite extensive review of the medical records we were
unable to classify 23% of falls as either extrinsic or intrinsic.
- Alcohol misuse: This was documented in 78 patients
(10.6%): 18% of the 65-74 year olds, 10% of the 75-84 year olds, and was
not a factor in those over 85 years (χ2 test; P = 0.001).
Sixty-five (83%) of these patients were living in their own homes.
Multivariate analysis for alcohol misuse at the time of fall showed it
to be significantly associated with an increased risk of both
accidental and recurrent falls (Box 4).
- Injury: 517 (70.5%) patients sustained an injury as
a result of the fall: 73.3% (379/517) had an ISS of 4 or less (a score of 9
correlated with a femoral fracture); 13 patients had scores between
15 and 25, with all of these patients (except one with spinal cord
compression) sustaining intracranial injury. The most common
injuries were fractures (36.7%), soft tissue injuries (16%),
lacerations and skin tears (14.5%).
- Fracture: 269 patients (36.7%) sustained a
fracture: 36% (98/269) of which were neck-of-femur fractures, 16%
fractured wrists, 12% fractured humeral neck and 5% pelvic
fractures. The breakdown of fractures in each group is shown in Box 5.
Women sustained both neck-of-femur and all fractures more
frequently than men (χ2 test; P < 0.001):
64% (63/98) of femoral-neck fractures and 73% (125/171) of all other
fractures (95% CI, 66%-80%). Interestingly, in women, the
proportion of fractured neck of femur to all fractures was 33.5%
(63/188) (95% CI, 27%-40%), whereas in men it was 43% (35/81) (95% CI,
32%-54%). Fracture rate overall was not found to be related to
advancing age in either sex.
- Admission: The total number of patients
admitted to hospital was 419, or 57.2% of all older patients with falls
(representing 38% of all older patients admitted during the study
period). Sixty-three per cent of those 85 years or older were
admitted, compared with 60% of the 75-84 year olds and 50% of the 65-74
year olds (χ2 test; P = 0.009). Of
the 269 patients with fractures, 200 (74%) were admitted. There was no
statistically significant difference in the fracture admission
rate across the age groups (χ2 test; P =
0.53). Of the 200 patients admitted, in 49% the cause of the fracture
Patients admitted to hospital after a fall had a mean length of stay of
10.4 days (95% CI, 10.2-10.6) and a median stay of 6 days (range, 1-129
days). Hospitalisation for more than 10 days was necessary in 35%
(146/419) of patients.
- Deaths: Thirty-two patients died in hospital,
representing 4.4% of all patients presenting to the ED after a fall:
half of those who died were over 85 years of age and half were from
nursing homes. In those who died, the cause of the fall was intrinsic
rather than extrinsic (27/32), and the most common injury was a
fracture of the neck of the femur (10/32).
- Data analysis: Multivariate analysis of place of
residence or mobility and extrinsic cause, recurrent falls,
fracture/no fracture and admission showed no significant
We found that older patients presenting to the ED after a fall had a high
injury rate (71%), high admission rates (57%) and often prolonged
hospitalisation (> 10 days in about a third of those admitted).
Our study complements others performed in Australia and elsewhere on
older patients who fall, particularly those who present to an
Some studies have found that women in the community fall more
frequently than men,17 and others, as we did,
found no difference.18 Institutionalised
patients have been reported to have higher fall rates than patients
living at home,17,19
but most of our patients lived at home and walked
Falls may be caused by an environmental hazard alone or a simple
syncopal event, or there may be a complex interaction of environment,
physical illness, and type of activity. Changes in vision,
vestibular function and proprioception affect physical stability,
and musculoskeletal changes affect gait. Postural hypotension from
dehydration, drug effects or autonomic dysfunction may be involved.
Additionally, acute illness such as respiratory tract infection,
arrhythmias, carotid sinus hypersensitivity,20 cardiac
failure and neurological problems (eg, Parkinson's disease) may
increase the risk of falling. All these intrinsic factors may be
compounded by environmental hazards.5,6,17 We found gait
disturbance, syncope, central nervous system lesion, postural
hypotension and dizziness to be the most common intrinsic causes, and
these were statistically more likely to be the underlying reason for a
fall as age increased.
The proportion of patients with falls in association with alcohol
misuse contrasts with the findings of Adams et al.21 They surveyed
older patients over an eight-week period for alcohol use, and found a
negative relationship between alcohol use and falls. A high
proportion of our patients with alcohol misuse lived at home, with
perhaps easy access to alcohol. These patients had a greater risk of
extrinsic and recurrent falls, a potential relationship that
warrants further study.
A UK study found that most falls in the community do not result in
serious injury.17 We found that patients
presenting to the ED after a fall have a high rate of injuries,
consistent with previous reports,17,22 but the rate was
significantly higher than that found by Tinetti et al.23
We found women to be statistically more likely to suffer a fracture
than men. Grisso et al,10 in an older inner-city
population in the United States, found that women generally had
higher rates of fall injury than men. In addition, they found that
injury rates increased with advancing age, a finding that we could not
There were fewer hip fractures in older men than older women in our
study, confirming previous findings.24 This is probably related
to the higher prevalence of osteoporosis in women. Previous reports
have shown that older men with hip fracture have higher mortality
rates than age-matched women.23
The high admission rate in our study, which increased in older
patients, is only slightly higher than that found by
Richardson,11 but this was in patients
over 75 years, in whom a higher admission rate is expected. A UK study
found admission was needed in only 34% of patients.22 Admission
rates for patients with a fracture did not vary significantly across
our three age groups, nor were they different according to place of
residence or prefall mobility. Length of hospital stay similarly did
not depend on place of residence or prefall mobility, differing from
the Richardson study, in which a significant relationship was found
between accommodation status and outcome at 90 days.11
US studies report that 75% of deaths after a fall occur in patients over
65 years.6 We found that the single most
important factor associated with death was hip fracture, a finding
similar to that in previous studies.7,11
Modification of the environment and dealing with intrinsic problems
such as drug side effects and gait dysfunction can reduce
hospitalisation26 and shorten length of
stay.15 If 95% of problems can be
identified from the history and physical examination alone, as
suggested by Rubenstein et al,15 the emergency physician
is well able to identify those patients at risk of further falls.
Intrinsic causes can be treated and the patient's general
practitioner or specific falls prevention programs can then proceed
to modify the risk of recurrence.
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(Received 10 Aug 1999, accepted 29 May 2000)
Department of Emergency Medicine, Royal Prince Alfred Hospital,
Anthony J Bell, MB BS, Emergency Medicine Registrar.
Janet K Talbot-Stern, MD, FACEM, FACEP, Director, Emergency
Department; and Clinical Senior Lecturer, Department of Surgery,
University of Sydney.
Department of Medicine, University of Sydney, Sydney, NSW.
Annemarie Hennessy, MB BS, PhD, Senior Lecturer.
Reprints will not be available from the authors.
Correspondence: Dr A
J Bell, Department of Emergency Medicine, Royal Prince Alfred
Hospital, Missenden Road, Camperdown, NSW 2050.
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