Risk factors associated with visiting or not visiting the accident & emergency department after a fall
© Scheffer et al.; licensee BioMed Central Ltd. 2013
Received: 20 April 2012
Accepted: 22 July 2013
Published: 26 July 2013
Little is known about the prevalence of modifiable risk factors of falling in elderly persons with a fall-history who do not visit the Accident and Emergency (A&E) Department after one or more falls. The objective of this study was to determine the prevalence of modifiable risk factors in a population that visited the A&E Department after a fall (A&E group) and in a community-dwelling population of elderly individuals with a fall history who did not visit the A&E Department after a fall (non-A&E group).
Two cohorts were included in this study. The first cohort included 547 individuals 65 years and older who were visited at home by a mobile fall prevention team. The participants in this cohort had fall histories but did not visit the A&E Department after a previous fall. These participants were age- and gender-matched to persons who visited the A&E Department for care after a fall. All participants were asked to complete the CAREFALL Triage Instrument.
The mean number of modifiable risk factors in patients who did not visit the A&E Department was 2.9, compared to 3.8 in the group that visited the A&E Department (p<0.01). All risk factors were present in both groups but were more prevalent in the A&E group, except for the risk factors of balance and mobility (equally prevalent in both groups) and orthostatic hypotension (less prevalent in the A&E group). The risk factors of polypharmacy, absence of orthostatic hypotension, fear of falling, impaired vision, mood and high risk of osteoporosis were all independently associated with visiting the A&E Department.
All modifiable risk factors for falling were found to be shared between community-dwelling elderly individuals with a fall history who visited the A&E Department and those who did not visit the Department, although the prevalence of these factors was somewhat lower in the A&E group. Preventive strategies aimed both at patients presenting to the A&E Department after a fall and those not presenting after a fall could perhaps reduce the number of recurrent falls, the occurrence of injury and the frequency of visits to the A&E Department.
KeywordsOlder persons Falls Risk factors A&E Department Mobile fall prevention unit
Falls are a major health problem among older adults because they are frequent and may have severe consequences [1–4]. Approximately 30% of the community-dwelling persons aged 65 years and older fall at least once a year, and approximately 15% fall two or more times per year [1, 5–7]. In the Netherlands, 2.6 million inhabitants are aged 65 years or older. Every year, almost 100,000 older persons are treated in hospital emergency rooms for fall-related injuries [8, 9]. The consequences of falls, such as injury and disability, are a major threat to the independence and well-being of these individuals [1, 10, 11]. Fall-related injuries are the third leading cause of years lived with disability, according to the World Health Organization’s report ‘Global burden of disease’ . In addition, falls can have considerable psychological consequences, leading to a fear of falling, depression and social isolation . In older persons, a high incidence of falls is associated with a high susceptibility to injury. This susceptibility is based on the prevalence of co-morbid disease and age-related physiological deterioration and could cause serious consequences to result from a mild fall . In addition, older persons who have sustained a fall are at risk of falling again and of osteoporotic fractures. Because of these consequences, both primary and secondary prevention of falls is crucial. Over the last several decades, many studies have been published regarding the prevention of secondary falls and fractures, and contradictory results have been found . This disparity may have been due to differences in the populations and strategies used in these studies, and other triage strategies might therefore be useful.
Programs for the identification of modifiable risk factors and secondary prevention of falls are most often aimed at those patients presenting to the Accident & Emergency (A&E) Department after a fall [16–18]. However, little is known about the prevalence of modifiable risk factors and their association with falling in older persons with a fall history who do not visit the A&E Department after one or more falls. In this population, secondary fall prevention and primary fracture prevention should be conducted to prevent falls and their harmful sequelae . Preventive activities adapted and tailored to each individual might be advisable.
The first objective of this study was to compare the prevalence of modifiable risk factors for falling in two groups of older persons with a fall history. The first group consisted of persons who did not come to the A&E Department after a fall (A&E group) and the second group included those who did visit the Department after a fall (non-A&E group). The second objective was to find modifiable risk factors related to a higher likelihood of presenting to the A&E Department after a fall.
For this observational cohort study, two groups of subjects aged 65 years or older were included. The individuals in the first group were invited by mail to participate in a touring, mobile fall prevention and intervention program between July 1, 2007 and March 5, 2009. This program consisted of a mobile van, which was equipped as a small mobile diagnostic centre and was taken to visit the participants at their home addresses. If participants were interested in the program, they received a visit from a fall prevention team, during which time home care nurses assessed the modifiable risk factors for falling. Within this program, the participants were presented with an intervention program based on their identified modifiable risk factors for recurrent falling. This initiative was supported by an unrestricted grant, which was part of an innovative care project of a large, nationwide active health insurance company in the Netherlands. Individuals who had never sustained a fall were excluded from this study.
The second group consisted of patients who presented to the A&E Department of the Academic Medical Center (AMC), a university teaching hospital in Amsterdam, after a fall. The patients were selected between February 1, 2004 and July, 31, 2010. The exclusion criteria for the second group included cognitive impairment, admittance to the ICU or Department of Neurology, language problems, death within 24 hours after the fall, living in a nursing home, falls resulting from external violence or having been sent the Carefall Triage Instrument (CTI) aftert a previous visit to the A&E Department.
The CAREFALL triage instrument (CTI)
The CTI consists of 44 questions to determine patient characteristics (age, gender, social status, living arrangements, physical activity and self-reported health), characteristics and possible cause(s) of the fall (accidental fall, fainting, or otherwise), and modifiable risk factors for falling. This self-reported fall history questionnaire was designed to identify modifiable risk factors for falling in older persons [16, 18] and has proven to be reliable and valid in assessing the potential modifiable risk factors in older patients presenting to the A&E Department after a fall . The CTI was also used to collect socio-demographic data.
The definitions of the eight modifiable risk factors
Modifiable risk factor
● Use of three or more medications, independent of their types and/or
● Use of sedative, psychoactive, anti-hypertensive, or diuretic medications
One or more of the nine questions concerning orthostatic hypotension were answered positively on the CTI
Balance and mobility
● Difficulties in walking and/or
● Use of an aid for walking and/or
● A lack of balance and/or
● Pain in the feet or legs and/or
● Reduced feeling in the feet or legs and/or
● Reduced strength in one or both feet and/or
● Stiffness of the joints
Fear of falling
A score of 5 or more on the scale from 1 (no fear of falling) to 10 (a very large fear of falling) on the question: “are you afraid to fall?”
● Unable to read the newspaper, even with magnifying glasses or a loupe, and/or
● Substantially reduced eyesight in the past 6 months
● Daily problems with urinary incontinence and/or
● Need to get out of bed twice or more per night to visit the toilet
● Feeling down or depressed and/or
● Loss of interest
Both within the last month
High risk of osteoporosis
Patients with a fracture after the age of 50 and/or a fracture of a vertebra and/or positive for two of the three following factors:
● Mother suffered hip fracture
● Low body weight (men <67 kg, women < 60 kg)
● Severe immobility
The data were analysed using SPSS-PC software version 18.0 (SPSS inc. Chicago, Illinois). The baseline data are summarized using standard descriptive statistics: as percentages for categorical data, as means and standard deviations (SD) for normally distributed numerical data, and as medians and ranges for non-normally distributed numerical data, based on visual inspection of the histogram. Differences in the scores of normally distributed continuous variables were tested with Student’s t-test, and differences in the scores of non-normally distributed continuous variables were tested with a Mann–Whitney U test. The Chi-square test was used to analyse the differences in dichotomous variables between the two study groups. A risk factor was defined as missing for a participant if more than 50% of the CTI items constituting that risk factor were not completed . The total number of risk factors for each patient was calculated by the sum score of the individual modifiable risk factors. To identify modifiable risk factors independently associated with visiting the A&E Department after a fall, we performed a logistic regression analysis. We started with a univariate logistic regression analysis. Modifiable risk factors known to be associated with falling, as described above, were included in the regression analysis. All variables with a p-value of ≤ 0.05 in the univariate logistic regression analysis were included in the multivariate analysis. A backward selection procedure was used, and a p-value of ≤0.05 was considered statistically significant.
General characteristics of participants and p-values for the differences between the groups
Accident & emergency department cohort
Not visiting the A&E department cohort
Age in years, mean (sd)
Social status (%)
Living arrangements (%)
Living independently without help
Living independently with help
Physical activity (%)
Several times a week
Once a week
Once a month
Once a week
Once a month
Self-reported health-related issues (%)
Number of medications, median (quartiles)
Sleep medication (%)
Sedative and psychoactive (%)
Use of alcohol (%)
Falls and mobility (%)
More than one fall in the last 12 months
Use of walking aid
VAS-Fear of Falling, median (quartiles)
Prevalence of modifiable risk factors in the A&E department group and in the non-A&E group
Modifiable risk factor (%)
Balance and mobility
Fear of falling
High risk of osteoporosis
Number of modifiable risk factors, mean (sd)
Univariate and multivariate analyses for modifiable risk factors associated with visits to the A&E department
Risk factors (%)
0.49 to 0.84
0.18 to 0.39
Balance and mobility
0.89 to 1.49
1.42 to 2.36
High risk of osteoporosis
1.92 to 3.16
1.41 to 2.79
1.84 to 3.34
1.53 to 3.70
1.88 to 3.37
1.26 to 2.93
Fear of Falling
2.45 to 4.28
2.31 to 5.24
3.67 to 6.44
2.77 to 5.77
This study shows that although the number of modifiable risk factors present in patients who visited the A&E Department was significantly higher, the non-A&E group still had a mean of 2.9 modifiable risk factors. Additionally, five of eight modifiable risk factors were present in more than 40% of the individuals who did not visit the A&E Department.
All modifiable risk factors, except disturbances in balance and mobility and complaints of orthostatic hypotension, were more prevalent in older persons visiting the A&E Department after sustaining a fall than in those with a fall history who did not visit the A&E Department.
There were fewer recurrent fallers in the mobile fall prevention group than in the A&E group. Despite this, 45.3% of the individuals in the non-A&E group had fallen more than once in the last 12 months, compared to 57.3% in the A&E Department group. Our findings regarding the risk factors associated with presenting to the A&E Department are similar to those obtained in previous studies [17, 18, 20, 21], which demonstrated that balance and gait abnormalities, visual impairment, peripheral neuropathy, polypharmacy, depression and advanced age are more prevalent in older patients from the A&E group than participants from the non-A&E group. Stel et al.  studied treatable risk factors in community-dwelling older persons and found an association between balance and mobility parameters, which could easily be measured and modified, and recurrent falling.
In our study, however, we focused on modifiable risk factors for falling, and therefore, our results should be useful for developing intervention studies targeted at reducing these risk factors among at-risk individuals. Because modifiable risk factors can be improved or removed by intervention , efforts aimed at primary prevention of fall injuries and secondary prevention of recurrent falls should focus on modifiable risk factors.
We found a higher prevalence of the modifiable risk factor ‘orthostatic hypotension’ in the non-A&E group than in the A&E group. This result may be explained by the observation participants from the non-A&E group were more active and experienced orthostatic hypotension more often than individuals in the A&E group . Although the complaints of orthostatic hypotension may have been provoked by an active lifestyle, there is precedence for such cases. A study by Gangavati et al. (2011) demonstrated that systolic orthostatic hypotension, in combination with uncontrolled hypertension, increases the risk of falling in community-dwelling persons . Another study has shown that the prevalence of orthostatic hypotension in adults with controlled hypertension is lower than that in adults with uncontrolled hypertension . Although information regarding the effectiveness of hypertension treatment is lacking, we found a higher prevalence of hypertension in the individuals from the non-A&E group compared to participants who did visit the A&E Department. This might exemplify a higher prevalence of complaints of orthostatic hypotension in this study group. Participants from the A&E group fell did fall more at home than participants from the mobile non-A&E group. The latter reported more frequent physical activity and went outside more often than participants from the A&E group. In our study, we made a distinction between falls that occurred at home and those that occurred elsewhere. However, it was still unclear if these falls occurred indoors or outdoors. For example, a fall that occurred outside the home could mean a fall in the streets or a fall inside another house. Although the distinction between indoor and outdoor falls in our study is less clear than in earlier studies, our findings are consistent with those of previous reports in that indoor falls tend to occur more often in vulnerable people with compromised health, who presumably also have a higher rate of visiting the A&E Department after a fall, while outdoor falls tend to occur more frequently in active people [26–29]. The fact that the participants in the A&E group used an average of three medications may be an indication of compromised health.
The current study has some limitations. Information regarding falls and the circumstances of falls was based on a self-administered questionnaire completed by the participants and/or their caregivers. Therefore, some inaccuracy is undoubtedly present. This, in combination with the fact that the questionnaire was completed some time after the episode, could have led to recollection bias of the fall and its circumstances, especially in the age group studied . Another limitation is the lack of information concerning the cognitive functioning of the included participants. Cognitively impaired persons may be at particular risk of falling and of serious sequelae when they fall . Patients with severe cognitive decline were excluded from the A&E group. However, these individuals were only excluded when information on the A&E chart indicated that the patient had severe cognitive impairment. As patients from the group that did not visit the A&E Department were all living independently and had to volunteer actively to participate, it was assumed that the presence of cognitive impairment was not high. Another potential limitation was the exclusion of patients who were admitted to the ICU or the Department of Neurology from the A&E Department Group. This could have led to an inclusion of fewer persons with a high number of modifiable risk factors in this study group and therefore an underestimation of the difference in the number of modifiable risk factors between the two study groups.
The results of this study have implications for both public health and clinical practice. Community-dwelling elderly persons with a fall history who did not visit the A&E Department exhibited several modifiable risk factors for falling. Although this number of risk factors was lower than that of patients visiting the A&E Department, it was still high, and here we counted only the modifiable risk factors. Therefore, secondary prevention of falls should also be conducted for these individuals, as they are still at high risk for recurrent falls with major injury. The early identification of members of this group and further preventative actions, including providing more information for these persons to reduce fall risk and concomitant injury, are essential.
The identification of several risk factors supports the multifactorial nature of falls and suggests that a multidimensional, rather than a single, intervention strategy may result in the greatest risk reduction in elderly individuals . Many studies and guidelines have focused on multifactorial fall-risk assessment to provide interventions, often aimed at older persons with the highest risk of recurrent falling, but the use of incorrect selection criteria could negatively impact the efficacy of such interventions . The effect of multiple interventions to prevent new falls is still the focus of international discussion. Falls in community-dwelling older people could be prevented through a reduction in the number of modifiable risk factors and by creating awareness of the increased fall risk associated with the use of sedatives and benzodiazepines. New studies may further clarify if early intervention can reduce the occurrence of injury and visits to the A&E Department in this group of individuals.
Although all modifiable risk factors for falling were shared between community-dwelling elderly individuals with a fall history who did not visit the A&E Department after a fall and those who did visit the A&E Department after a fall, there was a slightly lower prevalence of these risk factors in the former group. Preventive strategies aimed at both individuals presenting to the A&E Department after a fall and individuals not presenting to the Department after a fall could potentially reduce the incidence of recurrent falls, the occurrence of injury and the number of visits to the A&E Department.
Accident & emergency
Carefall triage instrument
Fear of falling
Intensive care unit.
Funding provided by the Dutch health insurance company OHRA, who also provided the mobile fall prevention van. We also thank American Journal Experts for editing the manuscript.
- Campbell AJ, Borrie MJ, Spears GF, Jackson SL, Brown JS, Fitzgerald JL: Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. Age Ageing. 1990, 19: 136-141. 10.1093/ageing/19.2.136.View ArticlePubMedGoogle Scholar
- Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, et al: Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ. 2004, 328: 680-10.1136/bmj.328.7441.680.View ArticlePubMedPubMed CentralGoogle Scholar
- Kiel DP, O’Sullivan P, Teno JM, Mor V: Health care utilization and functional status in the aged following a fall. Med Care. 1991, 29: 221-228. 10.1097/00005650-199103000-00004.View ArticlePubMedGoogle Scholar
- Kosorok MR, Omenn GS, Diehr P, Koepsell TD, Patrick DL: Restricted activity days among older adults. Am J Public Health. 1992, 82: 1263-1267. 10.2105/AJPH.82.9.1263.View ArticlePubMedPubMed CentralGoogle Scholar
- O’Loughlin JL, Robitaille Y, Boivin JF, Suissa S: Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. Am J Epidemiol. 1993, 137: 342-354.PubMedGoogle Scholar
- Tinetti ME, Speechley M, Ginter SF: Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988, 319: 1701-1707. 10.1056/NEJM198812293192604.View ArticlePubMedGoogle Scholar
- Tromp AM, Smit JH, Deeg DJ, Bouter LM, Lips P: Predictors for falls and fractures in the Longitudinal Aging Study Amsterdam. J Bone Miner Res. 1998, 13: 1932-1939. 10.1359/jbmr.19188.8.131.522.View ArticlePubMedGoogle Scholar
- CBS: Statline database: population. 2011, Netherlands: CBS, Retrieved on 4 June 2011, staline.cbs.nl., StatisticsGoogle Scholar
- Consumer Safety Institute: Incidents; numbers and costs: fall-incidents (> 55 years). 2007, Amsterdam, the Netherlands: Consumer Safety InstitueGoogle Scholar
- Tinetti ME, Williams CS: Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997, 337: 1279-1284. 10.1056/NEJM199710303371806.View ArticlePubMedGoogle Scholar
- Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ: Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997, 26: 189-193. 10.1093/ageing/26.3.189.View ArticlePubMedGoogle Scholar
- Murray C, Lopez A: Global and regional descriptive epidemilogy of disability: Incidence, prevalence, health expectancies and years lived with disabilty. The Global Burden of Disease. Edited by: Murray CJL, Lopez AD. 1996, Boston, MA: Harvard University Press, 201-246.Google Scholar
- Scheffer AC, Schuurmans MJ, van Dijk N, van der Hooft T, de Rooij SE: Fear of falling: measurement strategy, prevalence, risk factors and consequences among older persons. Age Ageing. 2008, 37: 19-24.View ArticlePubMedGoogle Scholar
- Tinetti ME, Doucette J, Claus E, Marottoli R: Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc. 1995, 43: 1214-1221.View ArticlePubMedGoogle Scholar
- Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, et al: Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009, 9: CD007146Google Scholar
- Boele van Hensbroek P, van Dijk N, van Breda GF, Scheffer AC, van der Cammen TJ, Lips P, et al: The CAREFALL Triage instrument identifying risk factors for recurrent falls in elderly patients. Am J Emerg Med. 2009, 27: 23-36. 10.1016/j.ajem.2008.01.029.View ArticlePubMedGoogle Scholar
- Davison J, Bond J, Dawson P, Steen IN, Kenny RA: Patients with recurrent falls attending Accident & Emergency benefit from multifactorial intervention–a randomised controlled trial. Age Ageing. 2005, 34: 162-168. 10.1093/ageing/afi053.View ArticlePubMedGoogle Scholar
- Van Nieuwenhuizen RC, Van Dijk N, Van Breda FG, Scheffer AC, Korevaar JC, Van Der Cammen TJ, et al: Assessing the prevalence of modifiable risk factors in older patients visiting an ED due to a fall using the CAREFALL Triage Instrument. Am J Emerg Med. 2010, 28: 994-1001. 10.1016/j.ajem.2009.06.003.View ArticlePubMedGoogle Scholar
- Vandenbroucke JP, Von EE, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, et al: Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Ann Intern Med. 2007, 147: W163-W194.View ArticlePubMedGoogle Scholar
- Davies AJ, Kenny RA: Falls presenting to the accident and emergency department: types of presentation and risk factor profile. Age Ageing. 1996, 25: 362-366. 10.1093/ageing/25.5.362.View ArticlePubMedGoogle Scholar
- Paniagua MA, Malphurs JE, Phelan EA: Older patients presenting to a county hospital ED after a fall: missed opportunities for prevention. Am J Emerg Med. 2006, 24: 413-417. 10.1016/j.ajem.2005.12.005.View ArticlePubMedGoogle Scholar
- Stel VS: Balance and mobility performance as treatable risk factors for recurrent falling in older persons. J Clin Epidem. 2003, 56: 659-668. 10.1016/S0895-4356(03)00082-9.View ArticleGoogle Scholar
- Gupta V: Orthostatic hypotension in the elderly: diagnosis and treatment. Am J Med. 2007, 120: 841-847. 10.1016/j.amjmed.2007.02.023.View ArticlePubMedGoogle Scholar
- Gangavati A, Hajjar I, Quach L, Jones RN, Kiely DK, Gagnon P, et al: Hypertension, orthostatic hypotension, and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc. 2011, 59: 383-389. 10.1111/j.1532-5415.2011.03317.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Harris T, Lipsitz LA, Kleinman JC, Cornoni-Huntley J: Postural change in blood pressure associated with age and systolic blood pressure. The National Health and Nutrition Examination Survey II. J Gerontol. 1991, 46: M159-M163. 10.1093/geronj/46.5.M159.View ArticlePubMedGoogle Scholar
- Bath PA, Morgan K: Differential risk factor profiles for indoor and outdoor falls in older people living at home in Nottingham, UK. Eur J Epidemiol. 1999, 15: 65-73. 10.1023/A:1007531101765.View ArticlePubMedGoogle Scholar
- Bergland A, Jarnlo GB, Laake K: Predictors of falls in the elderly by location. Aging Clin Exp Res. 2003, 15: 43-50. 10.1007/BF03324479.View ArticlePubMedGoogle Scholar
- Kelsey JL, Berry SD, Procter-Gray E, Quach L, Nguyen US, Li W, et al: Indoor and outdoor falls in older adults are different: the maintenance of balance, independent living, intellect, and Zest in the Elderly of Boston Study. J Am Geriatr Soc. 2010, 58: 2135-2141. 10.1111/j.1532-5415.2010.03062.x.View ArticlePubMedPubMed CentralGoogle Scholar
- O’Loughlin JL, Boivin JF, Robitaille Y, Suissa S: Falls among the elderly: distinguishing indoor and outdoor risk factors in Canada. J Epidemiol Community Health. 1994, 48: 488-489. 10.1136/jech.48.5.488.View ArticlePubMedPubMed CentralGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/13/286/prepub
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