At-a-glance – Temporal trends and characteristics of fall-related deaths, hospitalizations and emergency department visits among older adults in Canada

Abstract

Falls among older adults (aged 65 years and older) are a public health concern in Canada. Fall-related injuries can cause a reduction in quality of life among older adults, and death. They also entail substantial health care costs. It is essential to monitor fall-related injuries and deaths among older adults to better understand temporal trends and characteristics and to evaluate fall prevention strategies. We used the most up-to-date data from the Canadian Vital Statistics–Death database, Discharge Abstract Database and National Ambulatory Care Reporting System to analyze the temporal trends of fall-related mortality, hospitalizations and emergency department (ED) visits among older adults in Canada over more than a decade. Age and sex characteristics were also examined. In 2022, 7189 older adults died due to a fall in Canada (excluding Yukon). From 2010 to 2022, deaths due to falls generally increased in both number and rates. In fiscal year 2023/24, there were 81 599 fall-related hospitalizations in Canada (excluding Quebec) and 212 570 fall-related ED visits in Ontario and Alberta. From fiscal year 2010/11 to 2023/24, even though the overall trend of the rates of fall-related hospitalizations and ED visits did not increase, the numbers generally rose year by year except in 2020/21, the early stage of the COVID-19 pandemic. As for the age and sex characteristics, the rates for deaths, hospitalizations and ED visits rose with advancing age for both men and women. With the aging population, continuous monitoring of the trends is crucial for fall prevention.

Keywords: accidental falls, aged, death, mortality, hospitalization, emergency room visits, men, women

Introduction

Falls among older adults (aged 65 years and older) are a public health concern worldwide. According to the WHO, about a third of older adults fall each year.^{Footnote 1} In Canada, 5581 older adults died due to falls in 2019, representing a crude mortality rate of 84.6 per 100 000 older adults. The age-standardized mortality rate increased by 111% from 2001 to 2019. Between fiscal years 2008/09 and 2019/20, the annual number of fall-related hospitalizations (FRHs) among older adults increased by 47% from 49 152 to 72 392 (Quebec data not available). However, the age-standardized FRH rate was relatively stable during this time period, at approximately 15 per 1000 older adults. FRHs represented 87% of all injury-related hospitalizations among older adults in Canada (excluding Quebec).^{Footnote 2}

Falls and their resulting injuries cause loss of life, reduce quality of life and entail substantial health care costs. In 2018, the annual direct cost of injurious falls among older Canadian adults was estimated at CAD 5.6 billion, which was more than twice the cost associated with falls among those aged 25 to 64 years.^{Footnote 3}

Older adults are projected to represent over a fifth of the Canadian population by 2068.^{Footnote 4} Therefore, it is essential to monitor trends in falls among this population and the associated burden on those injured, their families and the health care system, which is important for effective management and prevention. The objective of this study was to use the most recent data available to provide the temporal trends and characteristics of fall-related mortality, hospitalizations and emergency department (ED) visits among older adults in Canada.

Methods

Our data sources were the Canadian Vital Statistics–Death database^{Footnote 5} for deaths due to falls, the Discharge Abstract Database (DAD)^{Footnote 6} for FRHs and the National Ambulatory Care Reporting System (NACRS)^{Footnote 7} for fall-related ED visits.

We used ICD-10/ICD-10-CA^{Footnote 8Footnote 9}codes W00–W19 (unintentional fall) to identify fall cases. For deaths due to falls, we used the underlying cause, that is, the disease or external cause of injury that initiated the sequence of events leading directly to death, or the circumstances of the incident that produced the fatal injury. A fall-related hospitalization is defined as a hospitalization in acute care containing W00–W19 in the diagnosis fields (maximum of 25) in the DAD record.^{Footnote 2Footnote 10} The analysis was based on episodes of care. If a patient was transferred for care to another health facility, all discharges were counted as a single case (or episode).^{Footnote 2Footnote 11Footnote 12} We merged DAD records with an exact match on (1) encrypted health card number; (2) health card issuing province; and (3) year of birth.^{Footnote 2Footnote 11Footnote 12} Fall-related ED visits were identified by any one of the diagnoses (maximum of 10) containing W00–W19 in the NACRS ED records.^{Footnote 2} A similar analysis based on episodes of care and linking methodology was also conducted for ED visits.

We used SAS Enterprise Guide version 7.1^{Footnote 13} to compile the pooled and stratified (by sex and age) counts. Population estimates from Statistics Canada^{Footnote 14} were used for rate calculation. We used the 2011 Canadian population for direct age standardization. To quantify temporal trends, we used Joinpoint software version 5.0.2^{Footnote 15} to compile annual percent changes (APCs) of age-standardized rates. Considering the interruption in hospitalizations and ED visits caused by the COVID-19 pandemic, as of fiscal year 2020/21, APC was calculated by the difference in hospitalization or ED visit rates between two continuous years divided by the first year. We checked the autocorrelation in the data and used the corresponding setting in Joinpoint to run the program. A p value threshold of 0.05 was used to determine statistical significance.

Results

Temporal trends in deaths, hospitalizations and ED visits

Figure 1 shows the temporal trends in deaths due to falls, and fall-related hospitalizations and ED visits over more than a decade. Annual numbers and crude and standardized rates are presented.

Figure 1 : Descriptive text

Figure 1A: Number of deaths and mortality rates due to falls, Canada, 2010–2022

Year	Number of deaths	Mortality rate (crude rate per 100 000 older adults)	Mortality rate (age-standardized rate per 100 000 older adults)
2010	3652	76.01974598	76.54813838
2011	3802	76.72693626	76.72693626
2012	4055	78.66245504	78.69148198
2013	4173	77.95653377	78.33199312
2014	4383	79.08232031	79.79008228
2015	4274	74.69106924	75.62385346
2016	4252	71.812582	72.64725397
2017Footnote a	4752	77.51408164	78.35576731
2018Footnote a	5282	83.17163258	84.38983508
2019Footnote a	5812	88.13000176	89.89714809
2020Footnote a	6169	90.20591045	92.4908548
2021Footnote a	6579	92.97973991	95.86888286
2022Footnote a	7189	98.16265562	102.0081651

Figure 1B: Number and rates of fall-related hospitalizations, Canada (Quebec not included), 2010/11–2023/24

Year	Number of fall-related hospitalizations	Hospitalization rate (crude rate per 1000 older adults)	Hospitalization rate (age-standardized rate per 1000 older adults)
2010/11	53347	14.73879643	14.57230724
2011/12	54837	14.66260918	14.52358929
2012/13	57464	14.75164488	14.70815982
2013/14	61268	15.13538297	15.20215659
2014/15	62633	14.94169844	15.08754902
2015/16	63224	14.5930006	14.81397035
2016/17	65614	14.6226577	14.8830543
2017/18	66803	14.37476868	14.68872184
2018/19	69302	14.38814269	14.7749847
2019/20	71721	14.3369627	14.80508219
2020/21	68759	13.25894896	13.76418542
2021/22	73916	13.76154048	14.30812591
2022/23	77170	13.85566764	14.44748353

Figure 1C: Number and rates of fall-related emergency department (ED) visits, Ontario and Alberta combined, 2010/11–2023/24

Year	Number of fall-related emergency department visits	Emergency department visitation rate (crude rate per 1000 older adults)	Emergency department visitation rate (age-standardized rate per 1000 older adults)
2010/11	129825	57.84700853	57.76033105
2011/12	133912	57.67174325	57.58112948
2012/13	140650	58.07411934	58.18625777
2013/14	152802	60.65393454	60.96804723
2014/15	157015	60.19539783	60.665795
2015/16	163052	60.5099548	61.08737023
2016/17	175214	62.7944374	63.40279804
2017/18	180186	62.33690213	63.01766955
2018/19	191684	63.97533957	64.78124726
2019/20	189669	60.93372013	61.92438593
2020/21	163026	50.53950846	51.50545324
2021/22	191830	57.40977555	58.55978185
2022/23	200823	57.88026843	59.13997099

In Canada (all provinces and territories), the annual number of deaths due to falls rose between 2010 (3652) and 2014 (4383) with decreases in 2015 (4274) and 2016 (4252). From 2017 to 2022, in Canada (excluding Yukon), the annual number of deaths due to falls rose more steeply, reaching 7189 in 2022 (crude rate: 98.2/100 000 older adults). The age-standardized rate increased annually at 1.7% from 2010 to 2013, decreased annually at 2.8% from 2013 to 2016, and increased again annually at 6.8% from 2017 to 2019 and 4.1% from 2019 to 2022.

For FRHs (excluding Quebec), the annual numbers steadily rose from fiscal year 2010/11 (53 347) to 2023/24 (81 599) except in 2020/21 (68 759), the year of the early stage of the COVID-19 pandemic. The number of hospitalizations in 2023/24 was 53.0% higher than in 2010/11. The trend in crude rates for hospitalizations showed different results and was highest in 2013/14 (15.1/1000 older adults); the rate was 14.1 per 1000 older adults in 2023/24. The age-standardized rate increased annually at 1.4% from 2010/11 to 2013/14 and decreased annually at 0.4% from 2013/14 to 2019/20. The 2020/21 rate showed a decrease (7.0%) compared to the pre-COVID-19 year 2019/20. After 2020/21, the age-standardized rate increased: 4.0% higher in 2021/22 compared to 2020/21, 1.0% higher in 2022/23 compared to 2021/22 (not significant) and 2.1% higher in 2023/24 compared to 2022/23.

In Ontario and Alberta, two provinces where full data coverage is available, the annual number of fall-related ED visits continuously rose from fiscal year 2010/11 (129 825) to 2018/19 (191 689) with a slight decrease in 2019/20 (189 669). The number greatly decreased in 2020/21 (163 026) but rose again, above all the previous years, with 212 570 visits in 2023/24. The crude rate was 58.9 per 1000 older adults in 2023/24 and highest in 2018/19 (64.0/1000 older adults). The age-standardized rate increased annually at 1.6% from 2010/11 to 2017/18. The 2020/21 rate showed a sharp decrease (16.8%) compared to the pre-COVID-19 2019/20. After 2020/21, the age-standardized rate greatly increased in 2021/22, 13.7% higher compared to 2020/21. The 2022/23 rate was 1.0% higher than that of 2021/22 and the 2023/24 rate was 2.1% higher than that of 2022/23.

Age and sex characteristics

Figure 2 shows the age-specific number and rates by sex for 2022 for deaths and fiscal year 2023/24 for fall-related hospitalizations and ED visits.

Figure 2 : Descriptive text

Figure 2A: Age-specific number of deaths and mortality rates due to falls, by sex, Canada (Yukon not included), 2022

Age group	Number of deaths, men	Number of deaths, women	Mortality rate of men (per 100 000)	Mortality rate of women (per 100 000)
65–69	144	109	12.89388	9.17073
70–74	273	216	30.44663	22.00758
75–79	400	379	61.84847	51.64487
80–84	592	580	151.4682	119.0154
85–89	712	874	328.9747	279.0032
90+	942	1968	829.2181	826.9151
Total (65 years and older)	3063	4126	90.6	104.7

Figure 2B: Age-specific number and rates of fall-related hospitalizations, by sex, Canada (Quebec not included), fiscal year 2023/24

Age group	Number of fall-related hospitalizations, men	Number of fall-related hospitalizations, women	Hospitalization rate of men (per 1000 older adults)	Hospitalization rate of women (per 1000 older adults)
65–69	3771	4653	4.288307	4.948021
70–74	4568	6269	6.574639	8.174255
75–79	5395	8305	10.34197	14.06204
80–84	5669	9681	18.15777	25.14591
85–89	5634	10441	33.04864	42.77696
90+	4977	12236	55.87865	66.97721
Total (65 years and older)	30014	51585	11.3	16.6

Figure 2C: Age-specific number and rates of fall-related emergency department (ED) visits, by sex, Ontario and Alberta combined, fiscal year 2023/24

Age group	Number of fall-related emergency department visits, men	Number of fall-related emergency department visits, women	Emergency department visitation rate of men (per 1000 older adults)	Emergency department visitation rate of women (per 1000 older adults)
65–69	14711	22850	26.76835	38.82581
70–74	14051	22440	32.96515	47.1711
75–79	14613	23641	45.39073	64.17959
80–84	13347	22472	68.6726	92.52382
85–89	11786	20857	109.1397	133.4754
90+	9703	22099	170.7433	187.9454
Total (65 years and older)	78211	134359	47.2	68.9

In 2022, 7189 older adults (3063 men and 4126 women) died due to a fall in Canada (excluding Yukon). The age-specific mortality rates rose with advancing age for both men and women. Men had higher rates than women across all age groups even though more women than men died from falls.

In fiscal year 2023/24, there were 81 599 FRHs (excluding Quebec) among older adults, almost two-thirds of which (51 585) occurred among women. The age-specific rates were higher at successively older ages, and numbers and rates for FRHs in women consistently exceeded those of men.

In fiscal year 2023/24, there were 212 570 fall-related ED visits in Ontario and Alberta among older adults, almost two-thirds of which (134 359) occurred among women. Similar to FRHs, the age-specific rates were higher at successively older ages, and the numbers and rates for women consistently exceeded those of men.

Discussion

We used the most up-to-date data to analyze the temporal trends and characteristics of deaths due to falls, and fall-related hospitalizations and ED visits for older adults in Canada, spanning over a decade. From 2010 to 2022, deaths due to falls for those aged 65 years and over generally increased in both numbers and rates. From fiscal year 2010/11 to 2023/24, even though the overall trend of the rates of fall-related hospitalizations and ED visits did not increase, the numbers generally rose year by year, except in 2020/21, the early stage of the COVID-19 pandemic. As for age and sex characteristics, the rates for deaths, hospitalizations and ED visits rose with advancing age for both men and women.

We observed a difference between the trends for mortality and morbidity. The overall trend of the rates of fall-related hospitalizations and ED visits has been relatively steady (except in 2020/21), with the numbers increasing. This indicates that the overall risk of going to the ED or being hospitalized because of a fall remains relatively stable, and that the rise in numbers is probably mostly due to the aging population. However, the mortality due to falls has increased in both rates and numbers. Further research is needed to explain this, such as the trend in the nature of injuries resulting from falls, and comorbidities.

The results of this paper demonstrate that falls among older adults remain an important public health concern in Canada despite prevention efforts. Risks associated with falls stem from a number of biological, behavioural, socioeconomic and environmental factors.^{Footnote 16} Older adults have a particularly high risk of falling compared to the younger population. This risk can be attributed to a number of factors, which can include decreased mobility and balance, muscle weakness, visual impairment and medication side effects.^{Footnote 16}

Fall prevention efforts generally entail a multifaceted approach. At the individual level, for instance, participating in balance and strength exercises and managing medications and their side effects are strategies that may reduce the risk of falls among older adults. At the community level, providing educational opportunities to older adults on fall prevention strategies (i.e. exercise programs, fall prevention skills and social connection), installing handrails and grab bars, and removing hazards such as snow and ice from public walkways are examples of broader-scale approaches.^{Footnote 17Footnote 18} Continued research to address knowledge gaps and assess promising practices will strengthen the evidence base, lessen the consequences of falls for older adults and promote healthy aging.

Strengths and limitations

The strengths of this study include the timeliness of data, the analysis of both mortality and morbidity related to falls among older adults and the quantification of the temporal trends over a decade.

Our results are subject to the limitations existing in the data sources we used. The Canadian Vital Statistics–Death database does not include information from Yukon as of 2017; the mortality counts in years 2019 to 2022 are to be considered preliminary. With respect to hospitalizations, Quebec data were not included. Additionally, data for ED visits came from Ontario and Alberta only. All of these limitations pose a difficulty in presenting a complete national picture in Canada.

Conclusion

The health care burden of falls (deaths due to falls, fall-related hospitalizations and ED visits) among older adults in Canada increased from 2010 to 2022. The information presented in this paper is essential for understanding the temporal trends in falls and patient characteristics and evaluating fall prevention strategies among older adults in Canada. As Canada’s population ages, continuous monitoring will be crucial.

Conflicts of interest

All authors declare no conflicts of interest.

Authors’ contributions and statement

• XY: conceptualization, formal analysis, methodology, writing—original draft.
• AC: writing—review and editing.
• SM: writing—review and editing.
• WT: writing—review and editing, supervision.

The content and views expressed in this article are those of the authors and do not necessarily reflect those of the Government of Canada.

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