JAMA. 2019;321(21):2131-2133. doi:10.1001/jama.2019.4185
Klaas A. Hartholt, MD, PhD1; Robin Lee, PhD, MPH2; Elizabeth R. Burns, MPH2; et al Ed F. van Beeck, MD, PhD3
The word VITAMIN does not occur once in the study
Vitamin D prevents falls, prevents fractures and speeds up the healing from fractures
- Preventing Falls in Older Adults – Vitamin D combination is the best - JAMA Meta-analysis Nov 2017
- Vitamin D prevents falls – majority of meta-analyses conclude – meta-meta analysis Feb 2015
- Vitamin D and fractures – 24 meta-analyses and counting – Dec 2014
- 1 in 3 died after hip fracture but only 1 in 14 if add Vitamin D and exercise – RCT April 2017
- Hip fracture recovery best with home exercise plus Vitamin D – RCT Dec 2018
- Fracture 4.8 X more likely if low vitamin D, Falls 2.7 X were more likely if low D – Oct 2017
- Deaths due to falls doubled in just a decade (age-adjusted, perhaps decreased vitamin D) – June 2019
- Death of older hip fracture patients at least 1.6X more likely if low vitamin D – May 2018
- Risk of death after bone fracture was 6.6 X higher if less than 10 ng of vitamin D – June 2017
- Vitamin D In Older Women - Fractures, Frailty and Mortality – Buchebner thesis 2017
- Vitamin D and exercise after hip fracture surgery – far fewer deaths – July 2016
- Fewer heart attacks, hip fractures and deaths if more skin cancer – Sept 2013
Falls and Fractures category contains the following summary
213 items in FALLS and FRACTURES
- see also Overview Seniors and Vitamin D
- Overview Fractures and Falls and Vitamin D
- Search VitaminDWiki for "HIP FRACTURE" 1310 items as of April 2019
In the United States, an estimated 28.7% of adults aged 65 years or older fell in 2014.1 Falls result in increased morbidity, mortality, and health care costs.1,2 Risk factors for falls include age, medication use, poor balance, and chronic conditions (ie, depression, diabetes).1 Fall prevention strategies are typically recommended for adults older than 65 years. In several European countries, an increase in mortality from falls has been observed since 2000, particularly among adults older than 75 years.3,4 This age group has the highest fall risk and potential for cost-effective interventions. We report trends in mortality from falls for the US population aged 75 years or older from 2000 to 2016.
Deaths from falls were extracted from the US National Vital Statistics System mortality files. These data are deidentified and publicly available; therefore, neither consent nor institutional review board review was required according to US federal regulations. Falls, defined as the underlying cause of death, were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes W00-W19. Unintentional deaths from falls for persons aged 75 years or older were collected between 2000 and 2016. Numbers of deaths from falls were specified for age and sex. Age-specific mortality rates were calculated in 5 age groups (75-79, 80-84, 85-89, 90-94, and ≥95 years). Age adjustment was performed by direct standardization to the 2000 US Census population and corrected for demographic changes throughout the study period. The mortality rate was expressed as cases per 100 000 persons aged 75 years or older. Age-specific population estimates overall and by sex, which are produced by the US Census Bureau each year, were used to calculate mortality rates.5 The annual percentage change (APC) in mortality from falls was modeled using a linear regression model with Poisson error and log link. A P < .05 (2-sided testing) was considered statistically significant. The analyses were performed using SPSS statistical software version 17.0.0 (IBM).
The absolute number of deaths from falls among US adults aged 75 years or older increased from 8613 in 2000 to 25 189 in 2016 (Table). The crude mortality rate increased from 51.6 (95% CI, 50.5-52.7) per 100 000 persons in 2000 to 122.2 (95% CI, 120.7-123.7) per 100 000 persons in 2016 (Table). Age-adjusted mortality rates among adults aged 75 years or older increased significantly from 60.7 (95% CI, 58.8-62.7) per 100 000 men in 2000 to 116.4 (95% CI, 113.7-119.1) per 100 000 men in 2016 and from 46.3 (95% CI, 45.0-47.6) per 100 000 women in 2000 to 105.9 (95% CI, 103.9-107.8) per 100 000 women in 2016 (Figure). Mortality rates increased by age group. In 2016, persons aged 75 to 79 years old experienced a rate of 42.1 deaths (95% CI, 40.7-43.5) per 100 000 compared with 590.7 deaths (95% CI, 566.0-615.3) per 100 000 in persons aged 95 years or older. The APC for adults aged 75 years or older was 5.1% (95% CI, 5.0%-5.2%) and increased with age from 3.5% (95% CI, 3.3%-3.7%) in adults aged 75 to 79 years to 6.4% (95% CI, 6.2%-6.7%) in those aged 95 years or older (Table).
An increasing age-adjusted trend in mortality from falls was observed among older US adults from 2000 to 2016. Mortality rates increased with age and throughout the study period. The APCs were highest among the oldest age groups. These finding are consistent with European data,3,4 although the mortality rates from falls were lower among the oldest old population in the United States compared with the Netherlands.3 This might be explained by differences between those countries in both the demographic composition (eg, the population share of non-Hispanic whites) and activity patterns (eg, rates of outdoor activities such as walking and cycling) of the older population.
The current study is based on nationally representative vital statistics. However, limitations exist. The age-adjusted rates were based on information from the US Census Bureau, which reports it might undercount persons aged 65 years or older; this could result in an overestimation of death rates. Misclassification or incomplete recording of cause of death is another concern that could overestimate or underestimate deaths from falls.6
The circumstances behind the increasing trends in mortality from falls are not fully understood. Future studies should focus on explaining the recent increase in mortality from falls, especially among the oldest age groups and what can be done to tailor interventions for these older age cohorts.
JAMA. 2019;321(21):2080-2081. doi:10.1001/jama.2019.6569
Marco Pahor, MD1
In this issue of JAMA, Liu-Ambrose and colleagues report the results of a randomized clinical trial testing the ability of a home-based exercise program to prevent falls in older persons presenting for treatment after a prior fall.1 Over a mean follow-up time of 338 days (0.92 years), those randomized to the exercise group experienced a significantly lower number of self-reported falls (236 falls among 172 participants) compared with those in the usual care group (366 falls among 172 participants). The estimated incidence rates of falls per person-year were 1.4 in the exercise group vs 2.1 in the usual care group (absolute difference, 0.74; 95% CI, 0.04-1.78), suggesting that just 1.2 participants had to be treated per year to prevent 1 fall event. However, the study did not show differences in the number of participants who experienced 1 or more falls (105 participants in the exercise group vs 104 in the usual care group) or those who experienced fall-related fractures (15 in the exercise group vs 12 in the usual care group).
The results of the study conducted by Liu-Ambrose et al add to growing clinical trial evidence that physical activity programs are highly effective for prevention of falls among older persons living in the community.2,3 This trial used the widely available home-based Otago program, which was individually delivered to those in the intervention group by a physical therapist and consisted of strengthening, balance, and walking exercises. Participants in the control (“usual care”) group received fall prevention care provided by a geriatrician. Other randomized clinical trials have shown that physical exercise programs reduce injurious falls and the number of older persons experiencing a fall.3 Among different types of interventions, including multifactorial interventions, vitamin D, and physical exercise, physical exercise was consistently the most efficacious in preventing falls and injurious falls.2,3 The 2018 Physical Activity Guidelines Advisory Committee Scientific Report highlights the strong evidence that physical exercise improves physical function and reduces risk of falls and fall-related injuries while also preventing disability in older persons.4,5
In the study by Liu-Ambrose et al, the home-based exercise program reduced the number of falls without improving physical performance measures, including the Short Physical Performance Battery and the Timed Up and Go Test, suggesting that the reduction in fall risk was mediated by mechanisms other than detectable improvements in muscle strength or physical function. Other factors not measured in this trial, such as improvements in self-efficacy and self-controlled coping awareness, may have played a role.6 The health benefits of physical exercise are well established4; however, the molecular mechanisms by which exercise produces health benefits are poorly understood. A multidisciplinary consortium funded by the National Institutes of Health, named Molecular Transducers of Physical Activity,7 has initiated a large discovery multicenter trial linked with animal studies to address this gap in evidence.
Not all older persons benefit from physical exercise interventions, partly because of difficulty with adherence linked to inability or unwillingness to engage in regular exercise. Thus, future studies should address novel sustainable behavioral approaches to target risk factors for falls, such as obesity and prolonged sitting time, in addition to pain, fatigue, sleep, and depression.8 A cluster-randomized pragmatic effectiveness trial of a multifactorial fall injury prevention strategy named Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) was recently completed,9 and data analyses are ongoing. The intervention consists of multifactorial risk assessments and individualized care plans developed by a nurse, including surveillance, follow-up evaluation, and intervention strategies. However, no randomized clinical trials have specifically targeted obesity or sitting time for prevention of falls.
Approximately 1 in 3 persons aged 65 years or older falls every year.10 Falling is a potentially catastrophic and life-threatening event for older persons. Falls are frequent causes of disability, institutionalization, and mortality and are the primary causes of traumatic injury among older persons in the United States. Also in this issue of JAMA, Hartholt et al11 report data on fall-related mortality from the National Vital Statistics System in years 2000 to 2016 among persons aged 75 years or older. The absolute number of fall deaths almost tripled, from 8613 in 2000 to 25 189 in 2016, and the age-adjusted fall-related mortality rate virtually doubled in both men and women, from 60.7 to 116.4 per 100 000 men and from 46.3 to 105.9 per 100 000 women.
In another report in this issue of JAMA, Montgomery et al12 analyzed the Medicare and Medicaid claims for acute hospitalization from 2008 through 2014 for persons aged 65 years or older using a nationally representative 20% sample. Traumatic injury was among the most frequent primary indications for hospitalization. Average annual payments for hospitalization, readmission, and postacute care within 90 days of discharge for traumatic injury in this 20% sample were estimated at $2.76 billion, which was significantly greater than payments for other common primary causes of hospitalization, including congestive heart failure ($1.81 billion), pneumonia ($1.45 billion), stroke ($1.16 billion), and acute myocardial infarction ($1.11 billion). The cost of hospitalizations related to traumatic injury among older persons is considerable, and falls are among the most frequent causes of traumatic injuries in older people.
Florence et al10 recently estimated that in 2015 the total medical costs attributable to fatal and nonfatal falls was nearly $50 billion. Virtually 99% of this cost was attributable to care for nonfatal falls paid by Medicare ($28.9 billion), Medicaid ($8.7 billion), and other payers ($12.0 billion). The estimated overall medical expenditures attributable to falls among older adults are substantial, and such costs are expected to further increase in the near future with the rapid expansion of the older population in the United States.
Among older persons who fall, only one-third seek medical care,13 and thus, two-thirds of those who have fallen at least once are unlikely to seek and take advantage of fall prevention services. One explanation for not seeking medical care for fall prevention is likely insufficient public awareness regarding the importance of fall prevention and the availability of fall prevention programs. A recent survey of a random sample of 1050 older persons living in Ottawa, Ontario, found major gaps in knowledge and awareness of risk factors for falls, and there was poor adherence to the national recommendations for fall prevention.14 Although 76% of those surveyed agreed that falling was a concern, only 63% agreed that falls could be prevented and 44% were aware that taking more than 4 medications increased the risk of falling. In addition, only 50% met aerobic physical activity recommendations and 38% met strength exercise recommendations.
Efficacious fall prevention strategies are available, and fall prevention programs are reimbursed by multiple insurance companies, including by Medicare as part of the Medicare annual wellness visit.15 Several tools and resources are accessible online and in local communities for both physicians and patients. For example, the Centers for Disease Control and Prevention (CDC) has developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) initiative to assist physicians in preventing falls by implementing an algorithm to aid in implementing the American Geriatrics Society/British Geriatrics Society guidelines.16 STEADI covers 3 main areas: screening for risk of falling, assessing individual risk factors for falls that are potentially modifiable, and interventions to reduce the risk of falling by means of proven clinical and community-based strategies. The CDC is also working with electronic medical record developers to integrate fall screening and assessment in patients’ medical records. The National Council on Aging provides online information for the general public regarding fall prevention strategies and availability of prevention programs in local communities.17 Other resources are available on social media, such as Facebook, Twitter, and Instagram.
Despite these efforts and continued research advancements, fall prevention remains an uncharted territory for too many people. Substantial improvements in fall prevention among older adults can be achieved both from initiatives for the general public and clinicians’ interventions to enhance prevention and treatment.
Corresponding Author: Marco Pahor, MD, Department of Aging and Geriatric Research, University of Florida, 2004 Mowry Rd, PO Box 100107, Gainesville, FL 32611 (firstname.lastname@example.org).
1. Liu-Ambrose T, Davis JC, Best JR, et al. Effect of a home-based exercise program on subsequent falls among community-dwelling high-risk older adults after a fall: a randomized clinical trial [published June 4, 2019]. JAMA. doi:10.1001/jama.2019.5795
2. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019;1:CD012424.PubMedGoogle Scholar
3. Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018;319(16):1705-1716. doi:10.1001/jama.2017.21962
4. Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020-2028. doi:10.1001/jama.2018.14854
5. Pahor M, Guralnik JM, Ambrosius WT, et al; LIFE Study Investigators. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE Study randomized clinical trial. JAMA. 2014;311(23):2387-2396. doi:10.1001/jama.2014.5616
6. Loft CC, Jones FW, Kneebone II. Falls self-efficacy and falls incidence in community-dwelling older people: the mediating role of coping. Int Psychogeriatr. 2018;30(5):727-733. doi:10.1017/S1041610217002319PubMedGoogle ScholarCrossref
7. The Molecular Transducers of Physical Activity Consortium. https://www.motrpac.org/. Accessed May 9, 2019. 8. Mitchell RJ, Lord SR, Harvey LA, Close JC. Obesity and falls in older people: mediating effects of disease, sedentary behavior, mood, pain and medication use. Arch Gerontol Geriatr. 2015;60(1):52-58. doi:10.1016/j.archger.2014.09.006PubMedGoogle ScholarCrossref
9. Bhasin S, Gill TM, Reuben DB, et al. Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE): a cluster-randomized pragmatic trial of a multifactorial fall injury prevention strategy: design and methods. J Gerontol A Biol Sci Med Sci. 2018;73(8):1053-1061. doi:10.1093/gerona/glx190PubMedGoogle ScholarCrossref
10. Florence CS, Bergen G, Atherly A, Burns E, Stevens J, Drake C. Medical costs of fatal and nonfatal falls in older adults. J Am Geriatr Soc. 2018;66(4):693-698. doi:10.1111/jgs.15304PubMedGoogle ScholarCrossref
11. Hartholt KA, Lee R, Burns ER, van Beek EF. Mortality from falls among US adults aged 75 years or older, 2000-2016 [published June 4, 2019]. JAMA. doi:10.1001/jama.2019.4185
12. Montgomery JR, Cain-Nielson AH, Jenkins PC, Regenbogen SE, Hemmila MR. Prevalence and payments for traumatic injury compared with common acute diseases by episode of care in Medicare beneficiaries, 2008-2014 [published June 4, 2019]. JAMA. doi:10.1001/jama.2019.1146
13. Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged Medicare population. Am J Prev Med. 2012;43(1):59-62. doi:10.1016/j.amepre.2012.03.008PubMedGoogle ScholarCrossref
14. Russell K, Taing D, Roy J. Measurement of fall prevention awareness and behaviours among older adults at home. Can J Aging. 2017;36(4):522-535. doi:10.1017/S0714980817000332PubMedGoogle ScholarCrossref
15. Moncada LVV, Mire LG. Preventing falls in older persons. Am Fam Physician. 2017;96(4):240-247.PubMedGoogle Scholar
16. Lee R. The CDC’s STEADI initiative: promoting older adult health and independence through fall prevention. Am Fam Physician. 2017;96(4):220-221.PubMedGoogle Scholar
17. National Council on Aging. Falls prevention. https://www.ncoa.org/healthy-aging/falls-prevention/. Accessed May 9, 2019. See More About
Geriatrics Trauma and Injury
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