Gender differences for non-fatal unintentional fall related
injuries among older adults
J A Stevens, E D Sogolow
See end of article for
Dr J A Stevens, National
Center for Injury
Prevention and Control,
4770 Buford Highway NE,
Mailstop K-63, Atlanta,
GA 30341, USA;
Injury Prevention 2005;11:115–119. doi: 10.1136/ip.2004.005835
Objectives: To quantify gender differences for non-fatal unintentional fall related injuries among US adults
age 65 years and older treated in hospital emergency departments (EDs).
Methods: The authors analyzed data from a nationally representative sample of ED visits for January 2001
through December 2001, available through the National Electronic Injury Surveillance System All Injury
Program (NEISS-AIP). For each initial ED visit, coders record one principal diagnosis (usually the most
severe) and one primary part of the body affected.
Results: Based on 22 560 cases, an estimated 1.64 million older adults were treated in EDs for
unintentional fall injuries. Of these, approximately 1.16 million, or 70.5%, were women. Fractures,
contusions/abrasions, and lacerations accounted for more than three quarters of all injuries. Rates for
injury diagnoses were generally higher among women, most notably for fractures which were 2.2 times
higher than for men. For all parts of the body, women’s injury rates exceeded those of men. Rate ratios
were greatest for injuries of the leg/foot (2.3), arm/hand (2.0), and lower trunk (2.0). The hospitalization
rate for women was 1.8 times that for men.
Conclusions: Among older adults, non-fatal fall related injuries disproportionately affected women. Much
is known about effective fall prevention strategies. We need to refine, promote, and implement these
interventions. Additional research is needed to tailor interventions for different populations and to
determine gender differences in the underlying causes and/or circumstances of falls. This information is
vital for developing and implementing targeted fall prevention strategies.
Center for Health Statistics death certificate data. However,
national statistics for non-fatal falls were not available until
2000 when the National Electronic Injury Surveillance
System All Injury Program (NEISS-AIP) was implemented.
A prospective study in New Zealand,1and retrospective
studies in Finland,2Australia,3and the US4have observed
gender disparities in fall risk and fall related hospitalizations
among different populations. This is the first US study to use
national data to quantify gender differences for non-fatal,
unintentional, fall related injuries among adults age 65 years
and older treated in emergency departments (EDs). This
study goes beyond previous reports and characterizes these
injuries by diagnosis, part of the body affected, and
More than a third of older adults fall each year5 6and 10–
20% of falls cause serious injuries such as fractures or head
traumas.7Fall injury rates increase sharply with age3 8and
these injuries are associated with significant morbidity,
reduced mobility, decreased functioning, and loss of inde-
pendence.9One study found that 12% of older adults who fell
subsequently required long term nursing home care.10
Currently, 34.8 million Americans are 65 years of age and
older; by 2040, this number will more than double.11As the
population ages, the numbers of fall related injuries will
increase. In 1994, the total cost of all fall related injuries
among adults 65 years of age and older was $27.3 billion, and
by 2020 the cost is expected to reach $43.7 billion (in 2002
all related injuries among adults age 65 years and older
are a major health concern. Statistics on fatal falls have
been readily available since 1968 through the National
We analyzed data from NEISS-AIP for non-fatal injuries for
January 2001 through 31 December 2001, the first complete
year of data available, and characterized unintentional fall
related injuries among US older adults (defined as people
aged 65 years and older) by gender and age. NEISS-AIP,
operated by the US Consumer Product Safety Commission,
collects data on initial visits for all types and causes of
injuries treated in US EDs. For each initial ED visit, coders
record one principal diagnosis—usually the most severe—as
determined by the ED physician or healthcare provider and as
recorded in the ED chart, and one primary part of the body
affected. NEISS-AIP data are drawn from a nationally
representative subsample of 66 out of 100 NEISS hospitals,
which were selected as a stratified probability sample of
hospitals. These hospitals have a minimum of six beds,
provide a 24 hour ED, and are located in the United States
and its territories.13NEISS-AIP provides national estimates
based on approximately 500 000 injury and consumer
product related ED cases each year.
The overall estimates for this study were based on
weighted data for 22 560 older adults treated for fall related
injuries at NEISS-AIP hospital EDs during 2001. For the
analyses by gender, three cases were excluded because sex
was unknown. Each case was assigned a sample weight
based on the inverse probability of the hospital being
selected. Confidence intervals (CIs) were calculated by using
a direct variance estimation procedure that accounted for the
sample weights and complex sample design. Rates per
100 000 population were calculated using 2001 US Census
Bureau population estimates.11
Abbreviations: ED, emergency department; NEISS-AIP, National
Electronic Injury Surveillance System All Injury Program; TBI, traumatic
In 2001, based on 22 560 cases, we estimated that 1.64
million older adults (95% CI 1.38 to 1.90 million) were
treated in EDs for unintentional fall related injuries. Of these,
approximately 1.16 million (95% CI 0.96 to 1.35 million), or
70.5%, were women (table 1). Injury rates increased sharply
with age although rates for women were higher in all age
categories. Overall, the rates for adults 85 years and older
were four to five times that of adults aged 65–69 years.
Table 1 shows gender differences for fall related injury
diagnoses. Fractures, contusions/abrasions, and lacerations
resulted in more than three quarters of all injury diagnoses.
Fractures, the most frequent diagnosis, accounted for 37.8%
of women’s and 28.3% of men’s injuries. Except for
lacerations where rates for men and women were similar
(RR=1.1), rates for diagnoses were generally higher among
women, most notably for fractures which were 2.2 times
higher than for men.
For all parts of the body, women’s injury rates exceeded
those of men. Rate ratios were greatest for injuries of the leg/
foot (2.3), arm/hand (2.0), and lower trunk (2.0). Among
men and women, injury rates were highest for head/neck
injuries. Most fall related injuries did not result in hospital
admissions. About three quarters of all patients seen for fall
related injuries were treated and released while only one in
five was hospitalized. However, the hospitalization rate for
women was 1.8 times that for men. Furthermore, women’s
hospitalization rates were 2.3 times higher than men’s for
fractures (878.7 v 387.7) and 2.1 times higher for lower trunk
injuries (614.1 v 288.2) (data not shown).
Rates for all fall related injury diagnoses increased with
advancing age (table 2.) For people aged 85 and older, the
rates were four to five times higher than for those aged 65–
74. Within each age category, rates for all diagnoses except
laceration injuries were higher among women. Both men’s
and women’s rates for all injury diagnoses (except strain/
sprain) doubled with each decade of age. In each age group
and for all parts of the body, women’s injury rates exceeded
men’s. The greatest gender difference in the 65–74 age group
was for leg/foot injuries and in the 85 and older age group, it
was for lower trunk injuries. Within each age group,
hospitalization rates for women were twice that for men.
With each decade of age, hospitalization rates for both men
and women increased about 2.7 times.
Using national data, this study quantified gender differences
in non-fatal, unintentional fall related injuries among adults
aged 65 years and older treated in EDs. The extent of these
differences was striking. Women sustained fall related injury
rates 40–60% higher than men of comparable age. Women’s
hospitalization rates for fall injuries were about 81% higher
then men’s, suggesting that women sustained more severe
injuries. However, hospitalization per se is only a rough proxy
for injury severity. Severity may be more accurately reflected
by the length of hospital stay, type of treatment needed (for
example, surgery), need for rehabilitation services, and
whether, after release, the patient returned home or was
transferred to a long term care facility. However, factors such
as the presence of other medical conditions certainly can
affect these outcomes. Data about such outcomes were not
available through NEISS-AIP. Consequently, we could not
ascertain to what extent patients were functionally impaired
nor could we predict the impact that fall related injuries
might have on future health and wellbeing.
Some of the observed disparity may reflect gender
differences in levels of physical activity. Muscle weakness
and loss of lower body strength, often caused by inactivity, is
a well known risk factor for falling.14Data on older adults
from the1982–84 NationalHealthandNutrition
Non-fatal unintentional fall related injuries among adults aged 65 years and older treated in US emergency
(n=484740) Crude rate* 95% CI
(n=1157230)Crude rate* 95% CI
Part of body affected
Treated & released
Held for observation/
8 669 11673
*Rate per 100 000 population.
?Unstable estimate because of sample size ,20.
Examination Survey (NHANES 1) Follow up Survey estab-
lished that men were more physically active than women,15
and a 1993–95 study of 2025 California residents found that
men had greater lower body strength.16Although non-fatal
fall injury rates were higher among women, fatal fall rates
are known to be higher among men.17Differences in physical
activity levels may influence the circumstances or events
contributing to men’s lower injury rate, as well as help
explain their higher mortality.
The greatest gender difference was in women’s fracture
rate which was twice as high as the rate for men. This
difference has been observed by others.18 19This finding,
along with the gender difference seen for rates of lower trunk
injuries, may be due in large part to differences in hip
fracture rates. Hip fractures, the most serious type of fall
related fracture, is a leading contributor to excess mortality,
disability, and reduced quality of life.20 21Women’s increased
likelihood of hip fracture is frequently attributed to reduced
bone mass.22 23Bone mass for both men and women peaks
around age 30 and then declines about 0.5% per year for men
and 1% per year for women.24Additionally, women suffer a
rapid loss of bone density for about five years following
menopause.A 1992 study
Minnesota, found 59% of 153 women over age 60 (and 84%
of 50 women over age 80) had osteopenia, a reduction in
bone mass two standard deviations below the mean for
normal women under age 40.25Although reduced bone mass
is a significant risk factor, falling sideways onto the hip is
usually necessary to cause a hip fracture.23 26Specialized hip
pads have been developed that reduce the force of impact on
the hip joint when a fall occurs27and can prevent hip
fractures among high risk individuals.28
For the part of the body affected, the highest rates for both
men and women were for head/neck injuries, although the
rate for women was 33% higher than for men. A 1992–94
study of injury related ED visits found that for all ages, falls
were the most common cause of traumatic brain injury
(TBI).29After age 65, the TBI rate for women exceeded that
for men while women age 85 and older had the highest rate.
Our finding differs from a recent report that found fall
of womenin Rochester,
related TBI hospitalization rates in California were higher for
men.30It is possible that men sustain more severe TBI injuries
than women, perhaps due to the underlying causes or
circumstances of their falls.
This study of older adult non-fatal fall related injuries is
subject to a number of limitations. Firstly, it includes only
injuries treated in EDs. ED patients likely suffer more serious
injuries; they may be older, more frail, and/or have more
chronic conditions than older adults who fall and sustain few
or minor injuries. Because NEISS-AIP includes a limited
number of variables, it was not possible to compare these
patients directly with other groups. Secondly, NEISS-AIP
coders record only one injury (generally the most severe) and
one part of the body affected. In the case of multiple injuries,
some underreporting may occur. The system does not include
injuries treated in physicians’ offices or other outpatient
settings and those that did not require medical attention.
Thirdly, we excluded fatal injuries that occurred before or in
the ED because NEISS-AIP does not provide detailed
information about injury deaths. In addition, we did not
include deaths that occurred following treatment because we
did not have information about the patient’s status after
leaving the ED or the hospital. However, deaths represent
fewer than 1% of fall related injuries.31Although NEISS-AIP
does not include information about injury severity, we
probably have captured the majority of significant fall related
injuries because most serious and costly injuries are treated
in EDs. Fourthly, generalizing to the US population may be
limited by selection bias because the people who are treated
in EDs may differ from the general US population. Finally,
the NEISS AIP coding system has a fixed number of
categories for primary part of the body affected and for the
principal diagnosis relevant to consumer product related
injuries. ICD-9-CM diagnosis codes32were not available in
the medical record at the time these data were collected;
therefore, specific types of injuries (for example, hip fracture,
TBI) could not be accurately identified. Currently, NEISS-AIP
has only one complete year of data but it will be possible to
analyze fall related injury trends within a few years as more
data become available.
65 years and older treated in US emergency departments, 2001
Non-fatal, unintentional fall related injury rates* by age among adults aged
Age groupAge group
65–74 75–84 85+
Part of body affected
Treated & released
Held for observation/
*Rate per 100 000 population.
?Unstable estimate because of sample size ,20.
Gender differences for fall related injuries 117
Knowledge about the circumstances surrounding falls is
vital for developing prevention strategies. A number of
researchers have reported on types and mechanisms of fall
injuries. A study of fall related hip fractures in a homo-
geneous elderly urban population found that 75% fell ‘‘while
standing or walking’’.33Another study analyzed the external
cause of injury codes (E codes) for California patients
hospitalized for fall related injuries.4These researchers found
that the largest proportion of falls (41%) occurred on the
same level, and the hospitalization rate for women was twice
the rate for men. However, detailed information about the
location, circumstances, or events preceding the fall was not
available. A follow up study of people treated in EDs for all
fall related injuries could provide such information and help
identify high risk situations and behaviors surrounding fall
Falls and fall related injuries are age related problems and
the world’s population is aging rapidly. Between July 1999
and July 2000, the total size of the world’s older adult
population increased by 9.5 million people.34Although the
industrialized nations of Europe, North America, and Japan
have the highest percentages of older adults, 59% of the
world’s elderly live in developing countries.34Women live
longer than men and typically marry men older than
themselves. Therefore, virtually all countries have higher
numbers of older women than men. It is reasonable to expect
that older women in many countries, like those in the US,
will be disproportionately affected by fall related injuries.
IMPLICATIONS FOR PREVENTION
This is the first US study to quantify gender differences for
non-fatal unintentional fall related injuries among adults
aged 65 years and older treated in EDs. Nationally, an
estimated 1.64 million older adults were treated for fall
related injuries in 2001 and 340 000 of those treated were
hospitalized. And, as our population ages, the number of fall
injuries will increase. This represents an enormous burden to
individuals, society, and to the healthcare system. Non-fatal
fall related injuries disproportionately affect the health and
quality of life of older women, who comprise 58% of the US
population over age 65.11. Because the US population is aging,
this problem will increase unless we take preventive action.
Much is known about effective fall prevention strate-
gies.14 35We now need to refine, promote, and implement
these interventions. We also need to learn how to successfully
disseminate intervention programs and to promote wide-
spread adoption at local level. In addition, further research is
needed to tailor interventions for populations with differing
characteristics and risk factors, and to determine the under-
lying causes and/or circumstances of falls and how these
differ for men and women. Clarifying these differences and
obtaining information about the location and events preced-
ing a fall related injury is vital to identifying high risk
behaviors and situations, and for developing and implement-
ing targeted fall prevention strategies.
The authors thank Ms Patricia Holmgreen for her statistical
J A Stevens, E D Sogolow, National Center for Injury Prevention and
Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
1 Campbell AJ, Spears GFS, Borrie MJ. Examination by logistic regression
modeling of the variables which increase the relative risk of elderly women
falling compared to elderly men. J Clin Epidemiol 1990;43:1415–20.
2 Kannus P, Parkkari J, Koskinen S, et al. Fall-induced injuries and deaths
among older adults. JAMA 1999;281:1895–9.
3 Peel NM, Kassulke DJ, McClure RJ. Population based study of hospitalized fall
related injuries in older people. Inj Prev 2002;8:280–3.
4 Ellis AA, Trent RB. Do the risks and consequences of hospitalized fall injuries
among older adults in California vary by type of fall? J Gerontol: Med Sci
5 Hornbrook MC, Stevens VJ, Wingfield DJ, et al. Preventing falls among
community-dwelling older persons: results from a randomized trial. Gerontol
6 Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in
community-living older adults: a 1-year prospective study. Arch Phys Med &
7 Alexander BH, Rivara FP, Wolf ME. The cost and frequency of
hospitalization for fall-related injuries in older adults. Am J Pub Health
8 Nevitt MC, Cummings SR, Hudes ES. Risk factors for injurious falls: a
prospective study. J Gerontol 1991;46:M164–70.
9 Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high
and disproportionate to mechanism. J Trauma 2001;50:116–19.
10 Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to
a nursing home. N Eng J Med 1997;337:1279–84.
11 Bureau of the Census (US). Population Projections Program, Population
Division, 2002. Available from http://www.census.gov/population/www/
projections/popproj.html (accessed 4 April 2003).
12 Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall
injuries. J Forensic Sci 1996;41:733–46.
13 Schroeder T, Ault K. National Electronic Injury Surveillance System All Injury
Program: Sample Design and Implementation. Bethesda, MD: US Consumer
Product Safety Commission, November, 2001.
14 American Geriatrics Society, British Geriatrics Society, and American
Academy of Othopaedic Surgeons Panel on Falls Prevention 2001. A
guideline for the prevention of falls in older persons. J Amer Geriatr Soc,
15 Davis MA, Neuhaus JM, Moritz DJ, et al. Health behaviors and survival
among middle-aged and older men and women in the NHANES I
Epidemiologic Follow-up Study. Prev Med 1994;23:369–76.
16 Oman D, Reed D, Ferrara A. Do elderly women have more physical disability
than men do? Am J Epidemiol 1999;150:834–42.
17 CDC. Surveillance for injuries and violence among older adults.
In:Surveillance for selected public health indicators affecting older adults,
United States. Morb Mortal Wkly Rep 1999;48:27–50.
18 Griffin MR, Ray WA, Fought RL, et al. Black-white differences in fracture rates.
Am J Epidemiol 1992;136:1378–85.
19 Ytterstad B. The Harstad injury prevention study: the characteristics and
distribution of fractures amongst elders—an eight year study. Int J Circumpolar
20 Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality,
hospitalization, and functional status: a prospective study. Am J Pub Health
21 Hall SE, Williams JA, Senior JA, et al. Hip fracture outcomes: quality of life
and functional status in older adults living in the community. Aust NZ J Med
22 Birge SJ. Osteoporosis and hip fracture 1993. Clin Geriatr Med, 9:69–86.
23 Greenspan SL, Myers ER, Maitland LA, et al. Fall severity and bone mineral
density as risk factors for hip fracture in ambulatory elderly. JAMA
24 Riggs BL, Wahner HW, Dunn WL, et al. Differential changes in bone mineral
density of the appendicular and axial skeleton with aging. J Clin Invest
25 Melton LJ, Chrischilles EA, Cooper C, et al. How many women have
osteoporosis? J Bone Miner Res 1992;7:1005–10.
N This is the first US study to quantify gender differences
for non-fatal unintentional fall related injuries among
adults aged 65 years and older treated in EDs.
N Among older adults, non-fatal fall related injuries
disproportionately affected the health of older women.
N Rates for injury diagnoses were generally higher
among women, most notably for fracture which was
2.2 times higher than the rate among men.
N The hospitalization rate for women was 1.8 times that
N Information about gender differences in locations,
circumstances, and events preceding fall related
injuries is needed to identify high risk situations and
behaviors, and to develop targeted fall prevention
26 Parkkari J, Kannus P, Palvanen M, et al. Majority of hip fractures occur as a
result of a fall and impact on the greater trochanter of the femur: a prospective
controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int
27 Robinovitch SN, Hayes WC, McMahon TA. Energy-shunting hip padding
system attenuates femoral impact force in a simulated fall. J Biomech Eng
28 Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for preventing hip
fractures in the elderly (Cochrane Review). In:The Cochrane Library, Issue 2,
2002. Oxford: Update Software.
29 Jager TE, Weiss WB, Coben JH, et al. Traumatic brain injuries evaluated in
U.S. Emergency Departments, 1992–1994. Acad Emerg Med
30 CDC. Public health and aging: nonfatal fall-related traumatic brain injury
among older adults, California, 1996–1999. Morb Mortal Wkly Rep
31 CDC. Web-based Injury Statistics Query and Reporting System (WISQARS).
National Center for Injury Prevention and Control, Centers for Disease Control
and Prevention (producer). Available at http://www.cdc.gov/ncipc/wisqars
(accessed 12 December 2003).
32 Department of Health and Human Services, National Center for Health
Statistics. The International Classification of Diseases, 9th revision, Clinical
Modification: ICD-9-CM (2003). Available at http://www.cdc.gov/nchs/
icd9.htm#RTF (accessed 21 January 2004).
33 Aharonoff GB, Dennis MG, Elshinawy A, et al. Circumstances of falls causing
hip fractures in the elderly. Clin Orthop 1998;348:10–14.
34 Gillespie LD, Gillespie WJ, Robertson MC, et al. Interventions for preventing
falls in elderly people (Cochrane Review). In:The Cochrane Library, Issue 3,
2004. Chichester, UK: John Wiley & Sons, Ltd.
35 Velkoff K, Velkoff VA. U.S. Census Bureau, Series P95/01-1, An
Aging World, 2001. Washington, DC: US Government Printing Office,
BOARD MEMBER BIOGRAPHY .....................................................................
Publications by Dr Hingson and colleagues in the early and mid-1990s helped stimulate passage
of federal legislation that provided incentives for all states to make it illegal for drivers under 21
to drive after any drinking. Dr Hingson is a researcher whose work has inspired legislative
efforts against drinking and driving.
His more recent studies on the relationship between blood alcohol levels and automobile
accidents has factored into proposals in many states to lower the legal blood alcohol
concentration (BAC) to 0.08%—now passed by all 50 states. He has also evaluated
comprehensive community interventions to reduce alcohol impaired driving.
Dr Hingson serves as a member of the Committee on Alcohol, Drugs, and Traffic Safety for
the National Transportation Research Board of the National Academy of Sciences and the
National Advisory Council of Mothers Against Drunk Driving (MADD). He has served as
National Vice President for Public Policy for MADD and for seven years on their National Board
of Directors. Dr Hingson helped to develop MADD’s Rating the States program which grades
national and state efforts to reduce alcohol and other drug impaired driving.
In recognition of his research contributions, the Robert Wood Johnson Foundation honored
Dr Hingson in 2001 with its Innovators Combating Substance Abuse Award. In 2002, he
received the Widmark Award, the highest award bestowed by the International Council on
Alcohol Drugs and Traffic Safety, of which he is currently President-Elect. In 2003, MADD
instituted the Ralph W Hingson Research in Practice Annual Presidential Award, with Dr
Hingson honored as its first recipient.
In the past year, he has joined the National Institute on Alcohol Abuse and Alcoholism as the
Director of their Division of Epidemiology and Prevention Research.
alph W Hingson, ScD, MPH is a Professor at the Boston University School of Public Health
(BUSPH). Since 2001 he served as Associate Dean for Research and from 1986–2000 he
was Professor and Chair of the BUSPH Social and Behavioral Sciences Department.
Gender differences for fall related injuries 119