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RESEARCH AND PRACTICE |
Wenjun Li and Jennifer L. Kelsey are with the Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester. Theresa H. M. Keegan is with the Northern California Cancer Center, Fremont, Calif. Kelsey and Keegan are also with the Department of Health Research and Policy, Stanford University School of Medicine, Stanford, Calif. Barbara Sternfeld, Stephen Sidney, and Charles P. Quesenberry, Jr, are with the Division of Research, Kaiser Permanente Medical Care Program, Oakland, Calif.
Correspondence: Requests for reprints should be sent to Wenjun Li, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, Shaw Building, SH–230, 55 Lake Ave N, Worcester, MA 01655 (e-mail: wenjun.li{at}umassmed.edu).
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ABSTRACT |
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Objectives. Although risk factors for indoor falls among older individuals have been well studied, little is known about the etiology of outdoor falls. We examined risk factors for outdoor falls among middle-aged and older adults.
Methods. We analyzed data on the most recent fall during the past year among participants aged 45 years and older in the control group (N=2193) of a case–control study of fractures. The study was conducted at 5 Northern California Kaiser Permanente Medical Centers between 1996 and 2001.
Results. Falls occurred outdoors more often than indoors among most age groups. Study participants who reported more leisure-time physical activity had a higher risk for outdoor falls, and participants who were in poorer health had a greater risk for indoor falls. Most outdoor falls (73%) were precipitated by environmental factors, such as uneven surfaces and tripping or slipping on objects, and usually occurred on sidewalks, curbs, and streets. Walking (47.3%) was the most common fall-related activity.
Conclusions. Outdoor falls among adults aged 45 years and older were frequently attributable to modifiable environmental factors. With the widespread promotion of active lifestyles among older people, improvements in their outdoor environment are urgently needed.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Many studies have identified home hazards and personal risk factors for falls.8–13 North-ridge et al.8 showed the importance of home hazards in falls among active versus inactive elderly persons, and they noted that measures are needed to prevent falls among the active elderly. To date, little research or public attention has been focused on outdoor falls; however, outdoor falls occur at least as often as indoor falls among older adults.14–17 Indoor falls tend to occur among frail individuals,15–17 but outdoor falls tend to occur among more active people and are heavily influenced by characteristics of the outdoor environment.15–17
In an era when active living is promoted by numerous international and national health agencies,18–20 a better understanding of how the outdoor environment influences the risk for falls is important. Although increased physical activity is associated with decreased risk for chronic conditions such as obesity and cardiovascular disease, and although some national reports and guidelines suggest that physical activity may reduce an older person’s risk for falling,21,22 little empirical evidence exists about the association between physical activity, particularly outdoor activity, and the occurrence of falls.
Detailed data on falls and the people who experience them from the control group of a case–control study of fractures in Northern California provided an opportunity for examining this issue. We investigated the circumstances of outdoor falls, identified environmental and personal risk factors for outdoor falls, compared the frequency of self-reported outdoor and indoor falls among older adults, and examined differences in the characteristics of outdoor and indoor falls and the people who experienced them.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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85 years) and were randomly ordered within each gender/age group; the first 34 women and 7 men within each group were then selected. All who belonged to a minority group or were of unknown race/ethnicity, 39% of White women, and 78% of White men within each age group were randomly chosen. Sixty-five percent of those persons selected for the control group participated; study participants who required proxy respondents because they were unable to answer the questionnaire themselves (n= 74) were excluded from our analyses. Persons in the control group who had a recent fracture or a previous fracture since age 45 years were included in our analyses.
Falls and Potential Risk Factors for Falls
Data about falls and possible risk factors for falls and fractures were obtained with a standardized structured questionnaire that was administered in either English or Spanish by trained interviewers. During the first 3 years of the study, most of the interviews were face-to-face; after November 15, 2000, most interviews were conducted by telephone to increase the response rate and the sample size. Mode of interview was controlled for in the multivariate analyses.
During the interview, all participants were asked how many times they had fallen during the past year. Those who had fallen at least once were asked for details about their most recent fall, including the place, circumstances, activity in which they were engaged, height from which they fell, direction in which they fell, type of surface on which they landed, whether they were wearing visual or hearing aids, and whether they took any medication or consumed alcohol before the fall.
Each respondent was classified as a non-faller (did not fall during the past year), an indoor faller (most recent fall was indoors), or an outdoor faller (most recent fall was outdoors). An outdoor fall was defined as occurring outside a building or in a parking garage, and an indoor fall was defined as occurring inside any building other than a parking garage.
Potential risk factors for falls included demographic characteristics; weight and height, which were used to calculate body mass index (BMI); overall health status compared with others of similar age; history of practitioner-diagnosed medical conditions; self-reported foot problems; history of certain neuromuscular symptoms during the past year; history of using selected medications at least once a week for at least 1 year; recent use of medications for sleeping, calming nerves, or lifting mood; cigarette smoking; and alcohol consumption. To measure physical functioning, respondents were asked to report level of difficulty performing various tasks. Ability to perform activities of daily living during the past month was assessed with an approach similar to that used by Schwartz et al.27
Leisure-time physical activity was assessed with a modified Physical Activity History questionnaire,28 which included questions about past-year frequency and duration of walking/hiking, gardening, exercise classes, swimming, bicycling, tennis, calisthenics/weight training, social dancing, jogging, bowling, golfing, stretching exercises/yoga, tai chi, and heavy housework. Each activity was assigned an appropriate metabolic equivalent value,29 and a summary variable for total physical activity in metabolic equivalent hours of exercise per month was obtained by multiplying intensity by frequency by duration and then summing across all activities.
Approximately 10% of participants (n= 198) agreed to a slightly abbreviated interview that did not include questions about some or all of the following variables: physical activity, cigarette smoking, and part of the medication history. Because of the reduction in number of respondents for these variables, analyses that included those variables were based on slightly smaller numbers than analyses that did not include them.
Statistical Analysis
Data were analyzed with Stata SE 9.0 software (Stata Corp, College Station, TX). Frequency and characteristics of falls were stratified by age and gender into the following categories: men aged 45 to 64 years (middle-aged men), men aged 65 years and older (older men), women aged 45 to 64 years (middle-aged women), and women aged 65 years and older (older women). Associations of indoor and outdoor falls with potential risk factors were assessed using unconditional multinomial logistic regression; nonfallers were the referent category, and indoor fallers and outdoor fallers were treated as mutually exclusive categories. For both types of falls, the same predictors were included in the models, making it possible for us to examine whether the risk factor profiles differed between those who fell outdoors and those who fell indoors. A risk factor was included in the model if it was statistically significant (P<0.10). Likelihood ratio tests evaluated the statistical significance of categorical risk factors. In all regression models, age in years, self-reported race/ethnicity (White, Native American, or other; Asian/Pacific Islander; Black; Hispanic), and mode of interview were included to account for possible confounding from these variables. The analysis was conducted with and without probability sampling weights. The impact of weighting was negligible; therefore, the unweighted results are presented.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Outdoor falls occurred most often on sidewalks, curbs, and streets (Table 1
). Gardens, patios, yards, decks or porches, parks and recreational areas, parking garages and parking lots, and outdoor stairs also were frequently cited. Among all groups except middle-aged men, the highest percentage of outdoor falls occurred when participants were walking (Table 1). Among middle-aged men, an outdoor fall was most likely to have occurred while engaging in a vigorous activity. Study participants reported that approximately three quarters of outdoor falls were precipitated by 1 or more (not mutually exclusive) environmental causes, including an uneven surface, a wet surface, and tripping and/or slipping on an object (Table 1). Among those who fell outdoors, more than 70% landed on a hard surface (concrete, asphalt, tile, marble, stone, or a wood floor), and almost half fell forward. Falls on sidewalks, curbs, or streets were often attributed to 1 or more environmental causes, particularly uneven surfaces and tripping on something.
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compares characteristics of outdoor and indoor fallers. Outdoor fallers were more likely to be men, younger, White, and more educated compared with both indoor fallers and nonfallers. On average, outdoor fallers had a higher level of leisure-time physical activity during the past year compared with indoor fallers and nonfallers. Additionally, outdoor fallers had better health and a higher level of physical functioning. Outdoor fallers were less likely to be obese and more likely to smoke cigarettes and drink alcohol than nonfallers. Outdoor falls were more likely to have been precipitated by environmental causes compared with indoor falls. Higher proportions of outdoor fallers landed on a hard surface and fell in a forward direction.
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shows adjusted odds ratios for several factors associated with falling outdoors or indoors compared with having not fallen. After adjusting for gender, age, race/ethnicity, education, and mode of interview, odds for outdoor falls—but not indoor falls—were strongly associated with more leisure-time physical activity. Cigarette smoking was associated with both outdoor and indoor falls, but the odds were lower and not statistically significant for indoor falls. Foot problems, lower-extremity neuromuscular symptoms, use of a walking aid, and alcohol consumption were associated with increased odds for both outdoor and indoor falls. Attributes associated with increased odds for an indoor fall—but only slightly or not at all associated with an outdoor fall—included various indicators of poor health, underweight (BMI<18.5) or obesity (BMI>30), and current use of sleep-inducing medications. Number of medications was somewhat associated with increased odds for both types of falls.
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shows multivariate adjusted odds ratios for falling both outdoors and indoors, with each variable adjusted for all other variables in the table. Differential risk factor profiles between those who fell outdoors and those who fell indoors remained evident. Higher level of leisure-time physical activity was still an independent predictor of outdoor but not indoor falls, whereas more health problems and more physical difficulties were independent predictors of indoor but not outdoor falls. Independent risk factors for both outdoor and indoor falls included lower-extremity neuromuscular symptoms, use of walking aids, cigarette smoking, and alcohol consumption during the past year.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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We also found that the risk profile for outdoor falls differed from indoor falls. Higher leisure-time physical activity was associated with outdoor but not indoor falls, and a greater number of physical difficulties and indicators of poor health were associated with indoor but not outdoor falls. These findings are consistent with results from other studies.14–17 As noted by Northridge et al.,8 fall prevention programs should not overlook the active elderly population, whose risk factors for falls may differ from those of the frail elderly population.
Our study adds to the results of the few previous studies on outdoor falls by providing more information about specific outdoor hazards. Sidewalks, curbs, and streets were the most frequent site of outdoor falls. Simple yet effective preventive measures include cleaning sidewalks and streets frequently, installing ramps at intersections, painting/marking curbs, fixing cracks or removing bumps, providing better lighting, and timely removal of construction debris and snow. Public works departments can implement these measures, which should be given high priority in areas where there are high concentrations of older people. A sizable proportion of outdoor falls occurred in parking lots and garages, particularly from tripping over the short curbs often placed at the end of parking spaces (data not shown). Despite the limited time older adults spend in these facilities, the relatively high frequency of falls shows that these settings need to be built and maintained not only for the benefit of motor vehicle drivers but also for pedestrians. Lack of designated walkways in parking lots and garages also may contribute to the increased risk for falls.
As noted in other studies,15,17,30 the highest proportion of outdoor falls occurred while walking. Walking is the most common type of reported physical activity across all racial/ethnic, income, and age groups35–39: 45% of older adults report walking for leisure-time physical activity,38 and nearly 70% of physically active older adults report walking as their predominant choice of physical activity. Increased walking has been promoted by various health organizations as an important way of lowering risk for chronic diseases,7 yet little has been done to make walking safe for older adults. Streets, roads, and sidewalks are most often used by older adults for leisure-time physical activity,40,41 but our results suggest that walking on sidewalks or roads may be dangerous because of uneven surfaces, litter, and other hazards. Elevated risk for falls associated with increasing physical activity may in part offset the lowered risk for chronic diseases, because the consequences of falls may result in older adults becoming homebound or institutionalized. Furthermore, fear of falling can become a significant barrier to physical activity42,43 and thus lead to decreased independence and mobility.44 Activity-related risk for falls among older adults is therefore a timely public health concern and should be thoroughly evaluated, because relatively easy environmental modifications can substantially reduce the risk for falls. We recommend that future trials evaluate the effectiveness of such environmental improvements as a means of reducing the occurrence of falls and fractures.
In a 2005 comprehensive review of intervention trials for preventing falls among the elderly, Gillespie et al.45 reported that none of the 62 intervention trials included modification to or maintenance of the outdoor environment as an intervention component. The only published study on modifications to the outdoor environment for preventing falls among older adults, including lighting in public spaces and the conditions of roads and walkways, was conducted in Motala, Sweden, 20 years ago.46 The lack of studies on outdoor falls may be the result of a common perception that the elderly spend little time outdoors, and therefore outdoor falls are less important than indoor falls. However, as documented in our study and several other reports,14,16,17,33,47 outdoor falls are more common than indoor falls in almost all age groups, despite the limited amount of time most people spend outdoors.
Experts on fall-related research have long recognized the lack of studies on outdoor environmental hazards.1,4,5,48,49 As they have noted, assessing environmental influences is problematic because of a lack of standardized methods for evaluating environmental hazards and because of the difficulty associating falls with specific environmental hazards that are dynamic over space and time. During the past 20 years, several techniques have been developed for studying the health impact of the built environment on falls. Such studies are possible because of the fast growth of spatial statistics, geographic information systems (GIS), and public databases. The knowledge accumulated in this research area should be applied to studies on falls among the elderly. For example, municipal GIS units and public works or transportation departments can develop spatial databases that monitor environmental changes, identify high-risk locales, and prioritize maintenance in neighborhoods where there are high concentrations of older people. Research into the impact of the built environment on falls requires multidisciplinary efforts and a joint framework that connects public health, behavioral research, health economics, transportation, and urban design. Several recent publications provide stepping-stones in this emerging field.50–55
Our study has strengths and limitations. The data came from a large probability sample that was drawn from a defined community-based population. Data about falls includes place, circumstance, direction, and activity at the time of fall. Many known and potential risk factors for falls and fractures were collected during the study, enabling us to control for many potentially confounding variables. On the other hand, the study was conducted in 1 geographic area, Northern California, where people may spend more time outdoors compared with other geographic areas. Although the sociodemographic characteristics of Kaiser patients were generally similar to those of the general population, except for underrepresentation of the very rich and the very poor,56 participants in our study tended to be well-educated and relatively active. People who were recovering from previous serious injuries were probably less likely to participate. The focus of the original study was on the etiology of fractures rather than falls and the study was conducted on the basis of self-reported data on falls and potential risk factors for falls. It is likely that the frequency of falls was underreported, because the data were obtained on the basis of past-year recall, and only the most recent fall was queried in detail. Previous studies have shown that past-year falls are likely to be underreported by 13% to 32%.57 After we accounted for this extent of underreporting, the frequency of falls in our control group was consistent with other studies. However, there are no data to show whether recall error differs between outdoor and indoor falls. Some errors also may have occurred when reporting the circumstance of the fall. Our findings need to be replicated by other investigators.
Outdoor falls are an important but neglected public health problem. Many of the environmental risk factors associated with outdoor falls appear to be preventable through better design and maintenance of sidewalks, curbs, walkways, streets, outdoor parks and recreational places, and parking lots and garages. In this decade of worldwide promotion of Active Living and Active Aging,19,58 efforts have begun at the national, state, municipal, and community levels to improve the built environment, including making neighborhoods more walkable. Preventing falls among older persons should be included in these efforts.
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Acknowledgments |
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Human Participant Protection
The study was approved annually by the institutional review boards of the Kaiser Permanente Division of Research and the Stanford University School of Medicine.
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Footnotes |
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Contributors
J.L. Kelsey originated the study, W. Li conducted the data analysis, and W. Li and J.L. Kelsey led the writing. J.L. Kelsey was the principal investigator of the study from which from these data were obtained. T.H.M. Keegan assisted with preparation of the analytic data set, data analysis, and writing the article. B. Sternfeld had primary responsibility for measuring physical activity on the questionnaire and assisted with writing the article. S. Sidney and C.P. Quesenberry assisted with the study design, and S. Sidney was the principal investigator of the Kaiser Permanente component of the study.
Accepted for publication February 4, 2006.
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References |
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