SeniorS' FallS In Canada - Public Health Agency Of Canada
Seniors’ Fallsin CanadaSECOND ReportProtecting Canadians from Illness
To promote and protect the health of Canadians through leadership, partnership,innovation and action in public health.—Public Health Agency of CanadaÉgalement disponible en français sous le titre :Chutes chez les aînés au Canada: deuxième rapportTo obtain additional copies, please contact:Public Health Agency of CanadaAddress Locator 0900C2Ottawa, ON K1A 0K9Tel.: 613-957-2991Toll free: 1-866-225-0709Fax: 613-941-5366TTY: 1-800-465-7735E-mail: publications@hc-sc.gc.caThis publication can be made available in alternative formats upon request. Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2014This publication may be reproduced for personal or internal use only without permission provided the source is fully acknowledged.PrintCat.: HP25-1/2014EPDFISBN: 978-1-100-23261-4Pub.: 130592Cat.: HP25-1/2014E-PDFISBN: 978-1-100-23262-1Pub.: 130593
Seniors’ Falls in Canada: second Report ISeniors’ Falls in CanadaSECOND Report
II Seniors’ Falls in Canada: second Report
Seniors’ Falls in Canada: second Report IIIExecutive SummaryInjury in Canada is a serious public health concern.It is a leading cause of hospitalization for children,young adults and seniors, and it is a major cause ofdisability and death. Falls remain the leading causeof injury-related hospitalizations among Canadianseniors, and between 20% and 30% of seniors falleach year. Falls and associated outcomes not onlyharm the injured individuals but also affect family,friends, care providers and the health care system.However, we do know that these personal andeconomic costs can be avoided through injuryprevention activities.To this end, this report provides policy makers,researchers, community programmers andpractitioners with current national information toprevent falls among seniors. It offers an update ofour knowledge of falls, injuries and hospitalizationsamong Canadian adults aged 65 and over, andprovides a picture of changes over time. The dataused in this report were taken from the CanadianCommunity Health Survey, the Hospital MorbidityDatabase and Canadian Vital Statistics.31, 159,160The data show a continued, but also increasing, needfor effective falls interventions initiatives targeted atolder adults. Among Canadian seniors, falls remainthe leading cause of injury-related hospitalizations,and absolute numbers are on the rise. Falls can leadto negative mental health outcomes such as fear offalling, loss of autonomy and greater isolation,confusion, immobilization and depression. In additionto the negative physical and mental health consequencesof falling, there are significant associated financialcosts, estimated at 2 billion annually, a value 3.7times greater than that for younger adults.156Results from the data analysis indicate thatself-reported injuries due to falls are increasing,specifically by 43% between 2003 and 2009/2010.The majority of falls resulted in broken or fracturedbones, and over one third of fall-related hospitalizationsamong seniors were associated with a hip fracture.Fracture-induced physical limitations augment theneed for support on the part of older adultsthemselves and their caregivers, and increasespressure on Canadian health care systems.When hospitalization data are examined, the resultsshow that seniors who are hospitalized for a fall remainin hospital an average of nine days longer than thosehospitalized for any cause. This discrepancy highlightsthe disproportionate health care costs of fall-relatedinjuries in comparison to other causes of hospitalization.Even more worrying is that the number of deaths dueto falls increased by 65% from 2003 to 2008.The report also presents risk factors for falls amongseniors, which are numerous, complex and interactive.These factors are categorized as biological/intrinsic,behavioural, environmental and social/economic.Each older person may face a unique combination ofrisk factors according to his or her life circumstances,health status, health behaviours, economic situation,social supports and environment. Factors that putseniors at risk of falls include chronic and acute healthconditions, balance or gait deficits, sensory factors,inadequate nutrition, social isolation, as well asfactors related to the built and social environment.
IV Seniors’ Falls in Canada: second ReportEvidence shows that preventing falls requiresinterventions that target more than one risk factor.Specifically, the evidence supports comprehensiveindividual assessment followed by multifactorial,evidence-based practices. Fall prevention guidelinesmay be useful to assess individual risks, behavioursand challenges, and to establish standards thatminimize the number and impact of falls. Further,interventions need to be tailored to the individual’shealth status, situation and environment.The research literature on risk factors for falls and onbest practices in fall prevention reveals a numberof research gaps. In particular, there is a lack ofknowledge around the efficacy of fall preventionpractices for subpopulations of Canadian seniors.Given that 50% of falls that result in hospitalizationoccur in the home and the same percentage ofseniors are discharged to a home setting, the reportalso serves to highlight the importance of developingand evaluating tools for seniors and their families toplan for safely aging in place.Falls among seniors are preventable; however, theirmultifactorial nature means that addressing thisgrowing public health problem is a shared responsibility.Progress in the prevention of falls and their resultinginjuries requires continued multisectoral collaboration,including governments, health care providers,non-government organizations, care associations andservices, as well as Canadians themselves. Over theyears, Canada has laid a foundation for good healthand well-being across the life course.123 However, asour population ages, focused efforts on fall preventionwill be required to maintain and improve the qualityof life and well-being of seniors and to ensure thatthey continue to contribute and participate in society.The Public Health Agency of Canada (PHAC) has ahistory of playing a strong coordinating role withrespect to fall prevention among seniors in Canada.Working collaboratively with stakeholders, PHACaims to increase the capacity of those who work withseniors to plan, implement and evaluate evidencebased injury prevention programs. To target theunique needs of seniors in preventing injuriesdue to falls, PHAC has undertaken several activitiesin public education, community-based programmingand policy development. Examples include numerouspublications aimed at helping seniors and their familiesto reduce the occurrence and impact of falls. PHAChas also advanced the Age-Friendly Communitiesconcept in Canada and internationally as a way tofacilitate healthy and supportive environments forolder adults.In Canada, there is an increased understandingof what puts seniors at risk of falling and what kindof fall prevention interventions work, for whomand in what setting. Healthy aging is about creatingconditions for individuals to make choices andengage in behaviours that prevent falls. GivenCanada’s aging population, it is anticipated that fallswill continue to be a public health problem, especiallyif collaborative action is not taken. In stepping up ourcoordinated efforts against falls, Canadians are workingtogether to create a healthier environment in whichto live and thrive.
Seniors’ Falls in Canada: second Report VTable of ContentsExecutive Summary. IIIPreface: How this report is organized.11.0 Introduction.21.1 Seniors’ falls – definitions.32.0 The scope of the problem.32.1 What seniors report about falls and related injuries .32.1.1 Definitions and data.42.1.2 Findings .42.1.3 Summary.122.2 What hospitalization data tell us about seniors’ falls.132.2.1 Definitions and data.132.2.2 Findings .142.2.3 Summary .182.3 What hospitalization data tell us about falls among seniors in residential care.182.3.1 Definitions and data.192.3.2 Findings.192.3.3 Summary .222.4 What mortality data tell us about deaths due to falls.222.4.1 Definitions and data.222.4.2 Findings.232.4.3 Summary .253.0 Risk factors for falls and fall-related injuries among seniors.253.1 Risk factors – complex and interactive.253.2 Biological or intrinsic risk factors.263.3 Behavioural risk factors.273.4 Social and economic risk factors.293.5 Environmental risk factors.293.6 Summary.30
VI Seniors’ Falls in Canada: second Report4.0 Best practices for the prevention of falls.314.1 Initial risk assessment.314.1.1 Components of a comprehensive assessment.324.2 Multifactorial interventions.324.2.1 Components of successful multifactorial approaches for community-based settings .324.2.2 Components of successful multifactorial approaches for residential care settings .344.2.3 Components of successful multifactorial approaches for acute care settings.354.3 Summary .355.0 Stepping up fall prevention in Canada.355.1 Why is an updated report on falls needed?.355.2 Examining the findings.365.3 Managing the risk factors.375.4 Identified research gaps.385.5 Working together to build strength.395.6 Summary.41Appendices.42Appendix A: Distribution of CCHS sample with injury related to afall by key demographic variables, age 65 , Canada, 2005 and 2003.42Appendix B: Factors associated with an increased risk of falling among older adults.44References.45
Seniors’ Falls in Canada: second Report 1Preface: How this report isorganizedChapter 1Introduction, presents the report’s objectives, definitions and main data sources used.Chapter 2The scope of the problem, offers a comprehensive overview of data on fall-related injuries, hospitalizations anddeaths among Canadians aged 65 and over.Chapter 3Risk factors for falls and fall-related injuries among seniors, provides the latest evidence regarding risks of fallsfrom widely adopted guidelines, and it reviews recent studies on the prevention of falls. The information isorganized under biological/intrinsic, behavioural, environmental and social/economic risk factors.Chapter 4Best practices for the prevention of falls, summarizes current guidelines and best practices for the preventionof falls and fall-related injuries with a focus on multifactorial approaches.Chapter 5Stepping up fall prevention in Canada, discusses national activities to reduce falls among seniors and areasfor potential improvement and further collaboration.
2 Seniors’ Falls in Canada: second Report1.0 IntroductionUnintentional injuries represent a significant publichealth issue for Canadians at all stages of the lifecourse. Injury is a leading cause of hospitalization forchildren, young adults and seniors, and it is a majorcause of disability and death in Canada.156 Injuriesand associated outcomes not only harm the afflictedindividuals, but also affect family, friends, careproviders and the health care system. In 2004, forexample, the total economic burden of injury inCanada was estimated at 19.8 billion.156 We doknow that these personal and economic costs canbe avoided, however, through injury preventionactivities.Falls remain the leading cause of injury-relatedhospitalizations among Canadian seniors.28 It isestimated that between 20% and 30% of seniorsfall each year. For example, data from the CanadianCommunity Health Survey – Healthy Aging indicatethat 20% of seniors living in the community reporteda fall, with a higher prevalence among older seniors,i.e., over 80 years.162 Research suggests that falls arethe direct cause of 95% of all hip fractures, leading todeath in 20% of cases.78, 81,178 Falls also appear to be acatalyst for the transition to long-term care. Researchshows that over one third of seniors who are hospitalizedfor a fall are discharged to long-term care, which isalmost double the proportion who were living in thatkind of care when they fell.147 Falls can also lead tonegative mental health outcomes, such as fear offalling, loss of autonomy and greater isolation,confusion, immobilization and depression. In additionto the negative physical and mental healthconsequences of falling, there are significantassociated financial costs. In 2004, the direct costsassociated with falls among seniors in Canada wereestimated at over 2 billion. The cost of falls forCanadian seniors (per capita) was 3.7 times greaterthan that for individuals between the ages of 25 and64 years.156In 2011, an estimated 5 million Canadians, or 15% ofthe population, were 65 years of age or older.161 Thisnumber is expected to double in the next 25 yearsand reach 10.47 million seniors by 2036. Given thisshift towards an older demographic, the release ofthis report is timely, as it presents data on the rates offalls, information on risk factors, and evidence-basedinterventions to prevent falls among seniors.This report is an update of the Report on Seniors’Falls in Canada125 and provides policy makers,researchers, community programmers andpractitioners with current national information toprevent falls among seniors. Specifically, it updatesour knowledge of the nature and severity of fallsamong Canadian adults aged 65 and over, andprovides a picture of changes over time. The reportalso re-examines risk factors for falls and fall-relatedinjuries in older adults and reviews the effectivenessof multifactorial interventions to prevent falls.National information is provided through analysis ofthe following data: Epidemiological evidence on seniors’ falls focusingon self-reported data from Statistics Canada –Canadian Community Health Survey159; Hospitalization data from the Canadian Institutefor Health Information – Hospital MorbidityDatabase31; and Mortality data from Statistics Canada – CanadianVital Statistics160.The following content is also included in the report: Information on multifaceted risks for falls amongseniors; Evidence-based best practices for the preventionof falls and injury from falls; and Considerations that will have an impact onnational fall prevention efforts.
Seniors’ Falls in Canada: second Report 31.1 Seniors’ falls – definitionsAll statistics and information reported in thisdocument refer to Canadians aged 65 and overunless otherwise stated. Terms such as senior, olderadult and older person all refer to this age group.A fall is often defined as a sudden and unintentionalchange in position resulting in an individual landingat a lower level such as on an object, the floor, or theground, with or without injury.170 Different data setsdefine falls in various ways. These are describedunder each section.Age standardization for this report was calculated byproportionally adjusting annual figures to the standard1991 Canadian population aged 65 and over.2.0 The scope of theproblemA comprehensive description of the magnitude andnature of seniors’ falls and related injuries in Canadawas derived from an analysis of three data sources: Epidemiological evidence on falls highlightingseniors’ self-reported data from the CanadianCommunity Health Survey (CCHS);159 Hospitalization data from the Canadian Institutefor Health Information (CIHI) Hospital MorbidityDatabase (HMDB) for all seniors, then morespecifically for seniors in residential care;31 and Mortality data from Statistics Canada’s CanadianVital Statistics.160The reader should be cautious when comparing dataon falls among data sources as each data sourceanalyzed for this report has its own definition of whatconstitutes a fall. These definitions are influenced bythe nature of the data collection methods, forexample, self-report versus hospital records. Itis equally important to recognize the limitationsassociated with any data source, including theinherent potential for data errors and the impact ofchanges in the International Classification of Diseaseson hospitalization and mortality data.2.1 What seniors report about fallsand related injuriesThis section provides national estimates based ondata from the CCHS from seniors aged 65 and overwho indicated that they had had at least one injury inthe previous 12 months that was both serious enoughto limit normal activities the day after the injuryoccurred and was the result of a fall. Included areestimates of the number of cases and rates of injuriousfalls, types of injury, types of activity and places wheretreatment was sought. Where sample size permitted,results are presented by sex and age group.The Canadian Community Health Survey159,162The CCHS is a cross-sectional survey that collectsinformation about health status, health careutilization and health determinants, representingapproximately 98% of the population aged 12 andolder. The CCHS collects data from householdresidents in Canada’s provinces and territories.People living on Indian reserves or Crown lands,residents of institutions, full-time members of theCanadian Armed Forces and residents of certainremote regions are excluded. Coverage is lowerin the north where the population is more likelyto be living in remote regions not captured by theCCHS.159 The exclusion of institutional residentsshould be noted as particularly pertinent forthis analysis. Data are collected from a complex,multi-stage stratified sample of approximately65,000 individuals annually from across Canada(Statistics Canada, 2010)a. The data for this reportare based on three cycles of CCHS data – cycle2.1 (2003), cycle 3.1 (2005) and data for the period2009/2010b.aPrior to 2007, CCHS data were collected over a single fiscal year andreleased every two years. Currently, every two years a file is released,which combines data collected over a two-year period.bQuestions in the injuries module were included as optional contentfor the 2007/08 CCHS. Only two provinces opted to include thesequestions for their residents (British Columbia and Nova Scotia). Giventhat the purpose of this report was to provide details regarding selfreported injuries for the Canadian population aged 65 and over, itwas decided not to include data from the 2007/08 cycle.
4 Seniors’ Falls in Canada: second Report2.1.1 Definitions and dataWith regard to the CCHS data, a fall is “defined” bythe respondents when they indicate, first, that theysuffered an injury in the previous year serious enoughto limit their normal activities and, second, that theinjury was the result of a fall.The CCHS collects data about only the most seriousinjury resulting from a fall in the previous 12 months,thus information about individuals who experiencedmore than one fall or who fell but were not injured isnot captured.The term cases referred to in this section refers to thenumber of persons reporting a fall-related injury inthe previous 12 months. The term rate refers to thenumber of persons who reported a fall-related injuryin the previous 12 months per 1,000 persons in thepopulation (of those aged 65 and over).2.1.2 FindingsOf the total CCHS sample aged 65 and over, Table 1compares those who did not report an injury relatedto a fall in the previous 12 months with those who didreport such an injury. Presented in these data arepopulation estimates, the proportion of respondentswithin a series of key demographic variables and the95% confidence interval (CI) for the proportionsc.cConfidence intervals represent a range of values within which the truevalue in the population is likely to fall. Statistical significance can bedetermined by examining whether confidence intervals around twocomparable estimates overlap.In 2009/2010, 256,011 older Canadians reportedexperiencing a fall-related injury. In comparison tothose without a fall-related injury, they were morelikely to be female (63.6% compared with 54.3%)and less likely to be aged 74 or younger (47.5%compared with 57.7%). There were also statisticallysignificant differences found by marital status. Amongthose with a fall-related injury, 55.9% were married,compared with 63.6% without a fall-related injury.Additionally, 31.0% of those with a fall-related injurywere widowed, compared with 23.6% of thosewithout a fall-related injury. Difference in maritalstatus is likely tied to differences in age, in that olderindividuals were more likely to be widowed.Education was only significantly different amongthose with less than secondary school graduation.A total of 30.0% of those with an injury related toa fall were in this education group, compared with34.1% of those without an injury related to a fall.There were no differences observed in theproportions by household income group.Data from 2003 and 2005 are presented in Appendix A.
Seniors’ Falls in Canada: second Report 5Table 1: Distribution of CCHS sample, age 65 , by key demographic variables, Canada, 2009/10159Without a fall-related injuryPop.Estimated%With a fall-related injury95% ConfidenceIntervalLowerUpperfPop.Estimate%95% 952.958.8*Age90 Marital 17.011.2Single, 026.733.2*Secondary 9.2Some t statedgEducationhLess than secondaryschool graduationPost-secondarygraduationNot statedHousehold IncomeiLess than 15,000 15,000- 29,999921,97322.021.322.656,34422.018.825.2 30,000- 49,999949,72122.621.823.552,05520.316.823.9 50,000- 79,999694,47716.515.817.344,55617.413.821.0 80,000 or more513,70912.211.413.034,59313.510.116.9Not Numbers in this table have been extrapolated to the Canadian population from the 2009/10 CCHS sample aged 65 and over of 28,379.eAsterisk denotes a statistically significant difference (p 0.05) between proportions without an injury related to a fall and those with an injury related to a fall.fE denotes cells with estimates that meet minimal Statistics Canada guidelines for reportability. Because of small samples or large coefficients of variation,data for these groups should be interpreted with caution.gNot stated included all responses categorized as “don’t know”, as a refusal and not stated.hHighest level of education of the respondent collapsed into four levels.iTotal household income from all sources.
6 Seniors’ Falls in Canada: second ReportFigure 1 presents estimates of cases and rates of fall-related injuries based on self-reports from CCHS samplesfor 2003, 2005 and 2009/2010. The data show that in 2003, there were 178,755 older Canadians who reported aninjury related to a fall, which translates to a rate of 47.2 per 1,000 population (95% CI 43.0 to 51.5). In 2009/2010,this number had increased significantly to 256,011 with a rate of 57.5 per 1,000 (95% CI 52.5 to 62.4). Thisrepresents a 43% increase in the number of individuals who reported a fall-related injury from 2003 to 2009/2010.Figure 1: Estimated cases and rates (per 1,000) of injuries resulting from a fall,age 65 , Canada, 2003, 2005, 2009/2010 (95% CIs 4,135256,011200320052009/100Number of fall-related injuriesRate per 1,000Figure 2 shows rates of self-reported injuries related to a fall by sex and survey year. The data indicatedsignificantly higher rates among females than males for each survey year. A significant increase in the rateof fall-related injuries among older males was observed in 2009/2010 in comparison to previous years.Figure 2: Estimated rates (per 1,000) of injuries resulting from a fallby sex, age 65 , Canada, 2003, 2005, 2009/10 (95% CIs 20032005Male Rate per 1,0002009/10Female Rate per 1,0000Rate per 1,000Number of Persons300,000
Seniors’ Falls in Canada: second Report 7Figure 3 shows the general trend of increasing rates of self-reported injuries due to falls with age. In 2009/10,the rates among Canadians aged 85 to 89 and 90 and older were significantly higher than among Canadiansaged 65 to 69.Figure 3: Estimated rates (per 1,000) of injuries resulting from a fallby age group, age 65 , Canada, 2009/10 (95% CIs 61.560.475-7980-84402002009/1085-8990 pa
To promoTe and proTecT The healTh of canadians Through leadership, parTnership, innovaTion and acTion in public healTh. —Public Health Agency of Canada Également disponible en français sous le titre : Chutes chez les aînés au Canada: deuxième rapport To obtain additional copies, please contact: Public Health Agency of Canada
Front / Rear Winch Rope No. of Falls and Lifting Load Hook Capacity ( t ) Maximum Rated Load ( t ) 10 Falls 9 Falls 8 Falls 7 Falls 6 Falls 5 Falls 4 Falls 3 Falls 2 Falls 1 Fall 70 70 58.5 52 45.5 39 32.5 26 19.5 13 -
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Slips Trips and Falls. Slips, trips, and falls make-up . about . 20% of all work-related . injuries. More than 500,000 falls every year require hospital . care. 300,000 falls . every year . result in a disabling injury. 250,00 falls . every year . result in death. The majority of falls are due to a "human factor," for example visual
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