IAGS 38:1326-1331, 1990
Injuries in an Elderly Inner-City Population Jeane Ann Grisso, MD, MSc,* Donald F. Schwarz, MD, MPH,f Amy R. Wishner, MSN,$ Barbara Weene,* John H. Holmes, MS,* and Rudolph L. Sutton, MPH$
Even though injuries are a leading cause of morbidity and mortality among the elderly in the United States, no comprehensive population-based study of nonfatal and fatal injuries has been carried out in an elderly minority inner-city population. To study injuries in this population, we developed an active surveillance system as part of a large injuy prevention program in a poor urban black community. We report 577 cases of nonfatal and fatal injuries in a community of 12,139 persons 65 years of age and older that resulted in emergency room treatment or death between March 1, 1987, and Februay 29, 1988. Nearly 5% of the elderly population was treated at an emergency room for, or died as a result of, an injuy dur-
ing the study period; the overall injuy rate was 48 injuries per 1,000 persons. Inju y rates for older women exceeded those for older men and increased with advancing age in both sexes. Fall injuries accounted for 312 (54%) of all injuries and 75% of all hospitalizations for injuy. Motor vehicle incidents and violence were the second and third most common injuries, accounting for 13% and 7% of injuries, respectively. Given the predominance of falls relative to other injuries, prevention of falls should receive major emphasis in injuy prevention efforts in inner-city minority populations. J Am Geriatr SOC
I
community and present our findings from the first year of surveillance.
njuries are the sixth leading cause of death among older persons.’ Compared with younger adults, the elderly are at increased risk for death from falls, bums, and motor vehicle incidents.* In addition, nonfatal injuries are a significant problem in the elderly. However, most studies of nonfatal injuries have focused on falls and have usually involved research volunteers or patients in long-term care settings.3-’ Few studies of nonfatal injuries have evaluated the relative importance of falls, motor vehicle incidents, bums, and other injury types. None of these studies have assessed injuries among inner-city minority communities. The Philadelphia Injury Prevention Program has established an active community-based surveillance system of all injuries treated at emergency departments or resulting in death in a geographically defined, indigent minority community in West Philadelphia. In order to learn about the pattern of injuries in elderly inner-city minority people, we report on injuries occurring to the estimated 12,139 persons 65 years and older in the study
From the *Clinical Epidemiology Unit, Section of General Internal Medicine, University of Pennsylvania; the tchildren’s Hospital of Philadelphia;and $Philadelphia Department of Public Health, Philadelphia, Pennsylvania. Supported by a grant for the Division of Injury Epidemiology and Control, Centers for Disease Control. Address correspondence and reprint requests to Jeane Ann Grisso, MD, MSc, Clinical Epidemiology Unit, University of Pennsylvania, 317R Nursing Education Building. Philadelphia, PA 19104-6095.
0 1990 by the American Geriatrics Society
38~1326-1331,1990
METHODS Population The total population residing in the study community in Western Philadelphia is estimated to be 68,103 in 1987. Of these, 27% are under 20 years of age and 18% are 65 years of age or older. Females make up 5590 of the population overall, and 65% of all persons 65 years and older. This population is 97.2% black and poor, with a median family income in 1986 of $11,810. Information regarding the demographic characteristics of the community under study was obtained from intercensal estimates for 1986 and 1987 produced by Donnelley Marketing Information Services (70 Seaview Avenue, P.O. Box 10250, Stamford, CT 06904). The estimates are based on 1980 census data, census bureau projections, and actual updated counts of households at a local level, using postal service, telephone directories, and car registration data (Personal Communication, Mr. Tom Hryniewicz, Donnelley Marketing Information Services). Case Definition A case was defined as any injury involving a resident of one of 17 study census tracts that led to evaluation at a hospital surveillance site or resulted in death between March 1, 1987, and Febm-
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INJURIES IN AN ELDERLY INNER-CITY POPULATION
1327
volved in an event without sustaining physical damage were included under E-code criteria (2.1% of cases). The individual event of an injury, and not each physical Selection of Surveillance Sites A multistage as- injury sustained, was used as the numerator for calcusessment was used to select emergency departments for lating frequencies. Denominator data were obtained surveillance and to evaluate the completeness of case from intercensal estimates for 1987 produced by Donascertainment.This assessmentinvolved: (1)a 20-hospi- nelley MarketingInformation Services(70 Seaview Avetal evaluation of the utilization of inpatient services by nue, P.O.Box 10250, Stamford, CT 06904), aggregated census tract of residence; (2) a population-based door- by 5-year age groups. E-codes were grouped into categoto-door survey of 532 community residents to ascertain ries corresponding to broad definitions given in another which hospitals were and would be used for care of study of emergency room injury frequency.*The definiinjuries; (3) a systematic evaluation of fire department, tions used in this paper are available from the author on school, and emergency medical transport records; and request. (4) a survey of all private practitioners, clinics, and comInjury rates are presented primarily for events occurmunity health centers in West Philadelphia.We thereby ring to persons 65 years and older. However, in some evaluated whether persons with injuries of moderate instances injury rates are also given for younger persons severity were treated in those settings or referred to for comparison. Rates in younger persons were based on emergency rooms. On the basis of these results, the final injuries identified through the surveillance system ocsample of institutions for emergency room surveillance curring to younger residents for the same 17 census included 11 institutions, three regional trauma centers, tracts. three general hospitals, three regional burn centers, one The X2 test was used for subgroup comparisons. children’s hospital, and one eye hospital. Information was also collected on deaths from the vital statistics RESULTS death certificate files and from the Office of the Medical Examiner. From March 1,1987, to February 29,1988,577 injuries occurred in an estimated 12,139 persons 65 years of Data Collection All emergency room charts were age and older in the study community. The overall inscanned by trained medical abstractors, first, to identify jury rate was slightly higher in women compared with individuals living within the targeted census tracts and, men (48.5 per 1,000 versus 45.8 per 1,000) (Table 1). second, to determine if an injury had occurred. Resi- Injury rates rose for both men and women as they indency of injured persons was based on the home ad- creased in age. Ninety-six percent of injured persons dress recorded in the medical records. Data were ab- were black, a proportion similar to that of the study stracted on a standardized form. Inpatient hospital community (97%). records were not reviewed. Fifty-six (9.790)of all injuries in the study group reA quality-control nurse, trained intensively in medi- sulted in hospitalization, and 17 (3.0%) resulted in cal record abstraction, examined all emergency room death. The proportion of injuriesresulting in hospitalizarecords for a 1-week period each month to determine tion among persons 65 and older (9.74b) was more than completenessof case ascertainment, which was 91%. In twice that of those under 65 years of age (4.070). The addition, 1046 of all cases were independently ab- case-fatality rate for older persons (3.070) was three stracted a second time by the quality-control nurse. times that of persons under 65 years of age (1.0%). Agreement on individual items on the abstraction form The most common causes of injuries among the elwas 90%. derly were falls (n = 312) and motor vehicle incidents Data Coding and Analysis Each event and injury (n = 77). Figure 1 shows injury rates by age for major was ICD-9-CM coded by an experienced medical coder, injury types for persons 35 years and older. For each whose performance was assessed through duplicate E- injury type, the rate decreased with age, except for falls, coding of a 10% sample by one of the investigators which increased markedly in those 75 and older. (JHH). For 370 events with more than one E-code, a Falls Falls were the most common injury occurring principal code was assigned independently by two of the authors (BW and JHH)to describebest the event that in older persons, comprising 54.1% of all injuries (Table initiated the sequence leading to the physical injury. The 1). Injuries due to falls increased markedly with age; 20 cases with discrepancies were reviewed with the persons 85 years of age and over had twice the fall rate as those 65 to 69 years of age (Figure 2). Falls were the other investigators and resolved. Injury rates were calculated as injury events per 1,000 most common cause of injury resulting in hospitalizaindividuals per year. Repeat visits for the same injury tion; 42 of the 56 hospitalizations (75.070) for injuries were eliminated in calculating injury frequencieseven if were due to a fall. Fall injuries were also the most comthe visits were to different hospitals. Individuals in- mon cause of injury resulting in fracture (26.070of falls
ary 29,1988. Injury events were defined by the ICD-9CM External Cause of Injury codes (E-codes).
1328 GRISSO ET AL
JAGS-DECEMBER 1990-VOL 38, NO. 12
TABLE 1. INJURY RATES FOR MAJOR INJURY TYPES BY AGE FOR ELDERLY MEN AND WOMEN LIVING IN A POOR URBAN BLACK COMMUNITY IN PHILADELPHIA Age Group (years) Injury
Men n* Falls Motor vehicle incidents Violence Lacerations Bums
Total Women n* Falls Motor vehicle incidents Violence Lacerations Bums Total
65 - 69
70 - 74
75-79
80-84
1417 12.7t 10.6 7.0 5.6 2.8 44.5
1149 16.5 9.6 5.2 3.5 2.6 42.6
862 20.9 3.5 2.3 1.2 1.2 40.6
525 18.6 7.6 1.9 3.8 51.4
2174 20.2 6.0 1.8 3.7 0.4 45.1
1942 22.6 6.2 2.6 3.1 0.5 44.3
1644 31.0 5.5 1.8 0.6 0.6 48.0
1173 45.2 5.1 2.6 1.7 1.7 59.7
-
+
Total
329 42.6 3.0 6.1 3.0 66.9
4282 19.6 7.9 4.9 3.3 2.3 45.8
924 39.0 3.2 2.2 1.1 1.1 51.9
7857 29.0 5.5 2.2 2.3 0.8 48.5
85
-
* Numbers indicate denominator estimates by sex and age categories.
t Numbers indicate rates per 1,000 persons/year. resulted in fracture). Two persons died as a result of a fall. Figure 3 shows the proportion of fall injuries by month for those falls for which we had information indicating whether the falls occurred indoors or outdoors (66.7%).Almost 40% of outdoor falls occurred during December and January, compared with only 18.2% of indoor falls. Overall, the most common site of falls was home (68.0%), followed by the street (18.4%). In the home, the stairs and bedroom were the most common sites of falls (56.0% and 21.3%, respectively). The activity at the time of the fall was noted in 83.6% of cases (Figure 4). Falls occurred most frequently while walking, either on a nonstair surface (51.7%)or on stairs (31.8%).In addition, several cases involved falls from a
FIGURE 1. lnjury rates by age for major injury types.
bed or chair (11.1%). Only 1.9% of falls involved the toilet, bathtub, or shower. Women had higher fall injury rates at each age group until 85 years, after which time men had slightly higher rates than women (Figure 2). A similar proportion of falls in men (81.1%) and women (78.7%) occurred indoors. Women had a higher proportion of falls on stairs than men (33.8% versus 26.1%, P < .05). The fracture rates and hospitalization rates were slightly higher for falls that occurred indoors compared with falls occurring outdoors. The proportion of fall injuries resulting in hospitalization was 17.6%of indoor fall injuries versus 4.7% of outdoor fall injuries. Of the indoor fall injuries, 23.6% resulted in fractures versus 18.6% of outdoor falls. Fracture rates were higher for
Injury R ates Per 1000 Populatlon
35-44'45-54' 55-64'65-74'75-84' 85+ ' Age &OUD
JAGS-DECEMBER 1990-VOL 38, NO. I2
INJURIESIN AN ELDERLY INNER-CITY POPULATION 1329
“” I
1
Fall R O ~ O
31.6% Stairs
5.0% Inlout Chair.,
40 Per 1000 Populatlon
8.1% InlOut B e -d ,
30 20 10
0 65-69 70-74 75-79 80-84
85+
Age Qroup
FIGURE 4. Activity at the time offalling in elderly subjects. Data are based on 261 of 312 falls (83.7%), including both indoor and outdoor falls.
FIGURE 2. Age-specific rates offalls in elderly men (shaded bars) and women (open bars).
falls on stairs (36.9% of staircase fall injuries) compared to nonstaircase fall injuries (21.396).
Motor Vehicle Incidents Motor vehicle incidents (MVI) (n = 77)were the second major cause of injuries and the second most common cause of hospitalization for injury, although they accounted for only 1346 of the 56 hospitalizations. No one died as a result of a motor vehicle incident. Men were most often injured while driving, accounting for 47.10/0of MVIs in men. Women were most often injured as passengers, accounting for 30.00/0of MVIs in women. Pedestrian injuries were uncommon. Only 13.0% of motor vehicle incidents were pedestrian injuries. The pedestrian injury rate among young adults 25 to 34 years of age was more than four times that of the pedestrian injury rate in those 65 and older (3.4 per 1,000 versus 0.8 per 1,000).
20
8
Burns Sixteen burn injuries occurred in the study population, accounting for only 370 of all injuries to older persons. Burns were equally divided into those caused by fire and flames, and those caused by hot liquids. Three persons died as a result of bums.
4
DISCUSSION
16 Percent Of
Fall.
Violence Violence was the third major cause of injuries among older persons, resulting in 38 injuries. The major type of violence for both men and women was assault without reported use of a weapon; this type accounted for 84.24b of violent injuries. Violent injury rates were higher in men than in women (4.9per 1,000 versus 2.2 per 1,000).There was no consistent pattern of change with increasing age; the number of violent injury events in each 5-year age group was too small to ensure accurate estimates of age-specific rates. Although violent injury rates were relatively low among older persons compared with younger persons in this population, violence was the leading cause of death, accounting for 41.246 of the 17 deaths among those 65 years and older. Little informationwas recorded in the medical records about the circumstances of violent injuries. Of the 17 violent injuries occurring in older women, the assailant was mentioned in eight instances; four women were assaulted by a family member, and four women were “mugged’ by an unknown assailant. Of the 21 men who were victims of violence, information about the assailant was recorded in only seven instances; five men were robbed by strangers; one man was assaulted by his son; and one man was assaulted by a neighbor.
12
0
I
I
I
.
1
I
. . .
. .
.
.
Mar Apr May Jun Jul Aug SepOct NovDec Jan Feb Month
FIGURE 3. Proportion of falls indoors (shaded bars) and outdoors (hatched bars) throughout the year in elderly men and women. Data are based on 208 of 312 falls for which information on location of fall was recorded.
Although a large number of injuries were recorded in this study, some injuries may not have been identified by the surveillance system. Physicians may have treated persons with minor injuries in their private offices, and some elderly persons may not have sought medical care. Thus, we are certain to have underestimated total injury rates. Nevertheless, we believe that case ascertainment
1330 GRISSO ET AL
of over 90% of injuries severe enough to result in emergency room evaluation is very good. Because medical records do not function primarily for the use of epidemiologicstudies, it is not surprising that useful epidemiologic information on the circumstances of injury was sometimes lacking. Information was lacking regarding location of the injury for 32.1% of cases and on the perpetrator of violent injuries for 60.5% of cases. To our knowledge, this study is the first communitybased effort to describe injuries occurring in an innercity black elderly population. The pattern of injuries is similar in some respects to that reported by studies of communities that are not inner-city minority populations.9-11 Women generally had higher injury rates than men, and injury rates increased in both sexes with advancing age. For those records with information about the location of the injury, the majority of injuries (for both men and women) occurred indoors, usually at home. Injuries due to falls made up more than half of all injuries, and falls occurring outdoors increased in frequency during the winter months. Fall injury rates increased markedly with age, more than doubling from age 65 to age 85 years. The exponential increase in fall injuries with age occurred at a younger age in women than in men. Although the increase in fall injury rates with advancing age is not as marked as that observed for hip fractures, the patterns of an exponential rise with age and an earlier increase in women than in men is similar to the pattern of hip fracture rates in both white and black persons in the United States.lzJ3 However, the pattern of fall injuries was different in some respects to that reported by other studies.9-11 The proportion of falls that occurred on the stairs was 31.8%,a figure much higher than that reported in recent community studies in Florida and in Sweden.9JoElderly in those communities are perhaps more likely to live in single-level dwellings. The prevalence of hazardous stairs in our study community may also be higher and should be evaluated. Women had a higher proportion of falls on stairs than men, a finding also reported in Sweden. Why older women would have higher fall injury rates on stairs than older men is not apparent and should be studied further. Other locations for falls were much less common than stairs. The low proportion of falls occurring in the bathroom was particularly surprising. Older persons are perhaps more careful when bathing because they realize their risk of falling. Other injuries emphasized in the literature were relatively uncommon in our population. Previous studies report a large number of traffic fatalities among the elder1y;l4-l6 however, motor vehicle incidents comprised only 13.3%of the total number of injuries among the elderly in the population we studied. Concern about pedestrian injuries is prominent in discussions of injuries in the elderly and studies report higher death rates
1AGS-DECEMBER 1990-VOL 38, NO. 12
due to pedestrian injuries among older persons than young adults.17J8However, in our population, young adults were much more likely to be injured as pedestrians than were older persons, and no deaths among the elderly were due to pedestrian injuries. Bums were also uncommon among the elderly population we studied, accounting for only 390 of all injuries. Previous studies place relatively little emphasis on violence as a cause of injury among the elderly. In our population, violence was more common than bums or pedestrian injuries, and was the leading cause of injury death. Few population-based comprehensive studies of injuries in elderly populations have been published. In Northeastern Ohio an active surveillance system of emergency departments was used to estimate age specific injury rates.19 In general, injury rates for men and women 65 years and older were higher than those in our study community. This was true for falls (51.4 per 1,000 versus 25.7 per 1,000) and motor vehicle incidents (1.01 per 1,000 versus 6.3 per 1,000) but not for violence; violence injury rates were greater in Philadelphia than in Northeastern Ohio (3.1 per 1,000 vs. 2.1 per 1,000). In another population-based study limited to falls in a very elderly white population, the overall fall injury rates were also higher than those in Philadelphia, and the increase in fall injury rates with age was much more marked, increasing over four times from age 65 years to 85 years,'9 in contrast to only doubling in Philadelphia. These differences could represent true differences in injury rates or differences in care-seeking behavior. It is interesting to speculate whether the black/white differences observed in hip fracture rates may be in part due to racial differences in fall injury rates. More prospective studies of elderly black populations are needed to evaluate whether fall injury rates differ in elderly black populations compared with elderly white populations. Although the pattern of injuries differed in some important aspects from studies in other elderly populations, the importance of falls as the major cause of injury is similar to reports of other elderly populations. In our population, falls were four times more common than motor vehicle incidents and 20 times more common than bums. The sequelae of falls were clinically significant as well, resulting in 75% of all hospitalizations for injuries. We are presently conducting a follow-up study of those persons who visited an emergency department because of a fall. Although most patients were discharged from the emergency departments with only minor injuries, 59.6%reported disability as a result of a fall two months after the fall occurred. Preliminary follow-up data show that most of those persons (73.4%) were still functionally impaired 6 months later. Thus, given the frequency, impact, and slow recovery of older persons from falls, the prevention of falls in older persons from inner-city minority communities should be given top priority.
IAGS-DECEMBER 1990-VOL 38, NO. 12
INJURIES IN AN ELDERLY INNER-CITY POPULATION
ACKNOWLEDGMENT The authors wish to thank Mane Kaufman for her helpful suggestions and assistance.
10.
11.
REFERENCES 1. National Safety Council, Accident Facts, 1987 Edition 2. Cooper S Accidents and older adults. Geriatr Nurs 287,1981 3. Nevitt MC, Cummings SR, Kidd S, et al: Risk factors for recurrent nonsyncopal falls. a prospective study. JAMA261:2663,1989 4. Tinetti ME:Factors associated with serious injury during falls by ambulatory nursing home residents. J Am Geriatr Soc 35:644, 1987 5. Rubenstein LZ, Robbins AS, Schulman BL, et al: Falls and instability in the elderly. J Am Geriatr Soc 36266,1988 6. Perry BC: Falls among the elderly living in high-rise apartments. J Fam Prac 14:1069,1982 7. Whipple RH, Wolfson LI, Amerman PM The relationship of knee and ankle weakness to falls in nursing home residents. an isokinetic study. J Am Geriatr Soc 35:13,1987 8. Fife D, Barandk JI, Chattejee BF Northeastern Ohio trauma study. 11. Injury rates by age, sex, and cause. Am J Public Health 74:473, 1984 9. DeVitoCA, Lambert DA, Sattin RW, et ak Fall injuries among the
12. 13. 14. 15. 16. 17.
18. 19.
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elderly: community-based surveillance. J Am Geriatr Soc 36: 1029,1988 Sjogren H, Bjomstig U: Unintentional injuries among elderly people: inadence, causes, severity, and costs. Accid Anal Prev 21:233, 1989 Tinetti ME, Speechley M, Ginter SF Risk factors for falls among elderly pe&ns li&g in the community. New Engl J M A 319:1701,1988 Kellie SE, Brody J A Sex-specific and race-specific hip fracture rates. Am J Public Health 80326,1990 Silverman SL, Madison R Decreased inadence of hip fracture in hispanics, asians, and blacks California hospital discharge data. Am J Public Health 78:1482,1988 Williams AF, Carsten 0.Driver age and crash involvement. Am J Public Health 79:326, 1989 McCoy GF, Johnstone RA, Duthie R B Injury to the elderly in road traffic accidents. J Trauma 29:494, 1989 Mortimer RG, Fell JC: Older drivers: their night fatal crash involvement and risk. Accid Anal Prev 21:273,1989 Fatal Accidents Report System, 1986, Chapter 8, Non-Occupants, p. 3 Sklar DP, Demarest GB, McFeeley P Increased pedestrian mortality among the elderly. Am J Emerg Med 7387,1989 Sattin RW, Lambert Huber DA, DeVito CA, et a1 The incidence of fall injury events among the elderly in a defined population. Am J Epidemiol131:1028,1990
Injuries in an Elderly Inner-City Population Jeane Ann Grisso, MD, MSc,* Donald F. Schwarz, MD, MPH,f Amy R. Wishner, MSN,$ Barbara Weene,* John H. Holmes, MS,* and Rudolph L. Sutton, MPH$
Even though injuries are a leading cause of morbidity and mortality among the elderly in the United States, no comprehensive population-based study of nonfatal and fatal injuries has been carried out in an elderly minority inner-city population. To study injuries in this population, we developed an active surveillance system as part of a large injuy prevention program in a poor urban black community. We report 577 cases of nonfatal and fatal injuries in a community of 12,139 persons 65 years of age and older that resulted in emergency room treatment or death between March 1, 1987, and Februay 29, 1988. Nearly 5% of the elderly population was treated at an emergency room for, or died as a result of, an injuy dur-
ing the study period; the overall injuy rate was 48 injuries per 1,000 persons. Inju y rates for older women exceeded those for older men and increased with advancing age in both sexes. Fall injuries accounted for 312 (54%) of all injuries and 75% of all hospitalizations for injuy. Motor vehicle incidents and violence were the second and third most common injuries, accounting for 13% and 7% of injuries, respectively. Given the predominance of falls relative to other injuries, prevention of falls should receive major emphasis in injuy prevention efforts in inner-city minority populations. J Am Geriatr SOC
I
community and present our findings from the first year of surveillance.
njuries are the sixth leading cause of death among older persons.’ Compared with younger adults, the elderly are at increased risk for death from falls, bums, and motor vehicle incidents.* In addition, nonfatal injuries are a significant problem in the elderly. However, most studies of nonfatal injuries have focused on falls and have usually involved research volunteers or patients in long-term care settings.3-’ Few studies of nonfatal injuries have evaluated the relative importance of falls, motor vehicle incidents, bums, and other injury types. None of these studies have assessed injuries among inner-city minority communities. The Philadelphia Injury Prevention Program has established an active community-based surveillance system of all injuries treated at emergency departments or resulting in death in a geographically defined, indigent minority community in West Philadelphia. In order to learn about the pattern of injuries in elderly inner-city minority people, we report on injuries occurring to the estimated 12,139 persons 65 years and older in the study
From the *Clinical Epidemiology Unit, Section of General Internal Medicine, University of Pennsylvania; the tchildren’s Hospital of Philadelphia;and $Philadelphia Department of Public Health, Philadelphia, Pennsylvania. Supported by a grant for the Division of Injury Epidemiology and Control, Centers for Disease Control. Address correspondence and reprint requests to Jeane Ann Grisso, MD, MSc, Clinical Epidemiology Unit, University of Pennsylvania, 317R Nursing Education Building. Philadelphia, PA 19104-6095.
0 1990 by the American Geriatrics Society
38~1326-1331,1990
METHODS Population The total population residing in the study community in Western Philadelphia is estimated to be 68,103 in 1987. Of these, 27% are under 20 years of age and 18% are 65 years of age or older. Females make up 5590 of the population overall, and 65% of all persons 65 years and older. This population is 97.2% black and poor, with a median family income in 1986 of $11,810. Information regarding the demographic characteristics of the community under study was obtained from intercensal estimates for 1986 and 1987 produced by Donnelley Marketing Information Services (70 Seaview Avenue, P.O. Box 10250, Stamford, CT 06904). The estimates are based on 1980 census data, census bureau projections, and actual updated counts of households at a local level, using postal service, telephone directories, and car registration data (Personal Communication, Mr. Tom Hryniewicz, Donnelley Marketing Information Services). Case Definition A case was defined as any injury involving a resident of one of 17 study census tracts that led to evaluation at a hospital surveillance site or resulted in death between March 1, 1987, and Febm-
0002-8614/90/$3.50
JAGS-DECEMBER 1990-VOL 38, NO. 12
INJURIES IN AN ELDERLY INNER-CITY POPULATION
1327
volved in an event without sustaining physical damage were included under E-code criteria (2.1% of cases). The individual event of an injury, and not each physical Selection of Surveillance Sites A multistage as- injury sustained, was used as the numerator for calcusessment was used to select emergency departments for lating frequencies. Denominator data were obtained surveillance and to evaluate the completeness of case from intercensal estimates for 1987 produced by Donascertainment.This assessmentinvolved: (1)a 20-hospi- nelley MarketingInformation Services(70 Seaview Avetal evaluation of the utilization of inpatient services by nue, P.O.Box 10250, Stamford, CT 06904), aggregated census tract of residence; (2) a population-based door- by 5-year age groups. E-codes were grouped into categoto-door survey of 532 community residents to ascertain ries corresponding to broad definitions given in another which hospitals were and would be used for care of study of emergency room injury frequency.*The definiinjuries; (3) a systematic evaluation of fire department, tions used in this paper are available from the author on school, and emergency medical transport records; and request. (4) a survey of all private practitioners, clinics, and comInjury rates are presented primarily for events occurmunity health centers in West Philadelphia.We thereby ring to persons 65 years and older. However, in some evaluated whether persons with injuries of moderate instances injury rates are also given for younger persons severity were treated in those settings or referred to for comparison. Rates in younger persons were based on emergency rooms. On the basis of these results, the final injuries identified through the surveillance system ocsample of institutions for emergency room surveillance curring to younger residents for the same 17 census included 11 institutions, three regional trauma centers, tracts. three general hospitals, three regional burn centers, one The X2 test was used for subgroup comparisons. children’s hospital, and one eye hospital. Information was also collected on deaths from the vital statistics RESULTS death certificate files and from the Office of the Medical Examiner. From March 1,1987, to February 29,1988,577 injuries occurred in an estimated 12,139 persons 65 years of Data Collection All emergency room charts were age and older in the study community. The overall inscanned by trained medical abstractors, first, to identify jury rate was slightly higher in women compared with individuals living within the targeted census tracts and, men (48.5 per 1,000 versus 45.8 per 1,000) (Table 1). second, to determine if an injury had occurred. Resi- Injury rates rose for both men and women as they indency of injured persons was based on the home ad- creased in age. Ninety-six percent of injured persons dress recorded in the medical records. Data were ab- were black, a proportion similar to that of the study stracted on a standardized form. Inpatient hospital community (97%). records were not reviewed. Fifty-six (9.790)of all injuries in the study group reA quality-control nurse, trained intensively in medi- sulted in hospitalization, and 17 (3.0%) resulted in cal record abstraction, examined all emergency room death. The proportion of injuriesresulting in hospitalizarecords for a 1-week period each month to determine tion among persons 65 and older (9.74b) was more than completenessof case ascertainment, which was 91%. In twice that of those under 65 years of age (4.070). The addition, 1046 of all cases were independently ab- case-fatality rate for older persons (3.070) was three stracted a second time by the quality-control nurse. times that of persons under 65 years of age (1.0%). Agreement on individual items on the abstraction form The most common causes of injuries among the elwas 90%. derly were falls (n = 312) and motor vehicle incidents Data Coding and Analysis Each event and injury (n = 77). Figure 1 shows injury rates by age for major was ICD-9-CM coded by an experienced medical coder, injury types for persons 35 years and older. For each whose performance was assessed through duplicate E- injury type, the rate decreased with age, except for falls, coding of a 10% sample by one of the investigators which increased markedly in those 75 and older. (JHH). For 370 events with more than one E-code, a Falls Falls were the most common injury occurring principal code was assigned independently by two of the authors (BW and JHH)to describebest the event that in older persons, comprising 54.1% of all injuries (Table initiated the sequence leading to the physical injury. The 1). Injuries due to falls increased markedly with age; 20 cases with discrepancies were reviewed with the persons 85 years of age and over had twice the fall rate as those 65 to 69 years of age (Figure 2). Falls were the other investigators and resolved. Injury rates were calculated as injury events per 1,000 most common cause of injury resulting in hospitalizaindividuals per year. Repeat visits for the same injury tion; 42 of the 56 hospitalizations (75.070) for injuries were eliminated in calculating injury frequencieseven if were due to a fall. Fall injuries were also the most comthe visits were to different hospitals. Individuals in- mon cause of injury resulting in fracture (26.070of falls
ary 29,1988. Injury events were defined by the ICD-9CM External Cause of Injury codes (E-codes).
1328 GRISSO ET AL
JAGS-DECEMBER 1990-VOL 38, NO. 12
TABLE 1. INJURY RATES FOR MAJOR INJURY TYPES BY AGE FOR ELDERLY MEN AND WOMEN LIVING IN A POOR URBAN BLACK COMMUNITY IN PHILADELPHIA Age Group (years) Injury
Men n* Falls Motor vehicle incidents Violence Lacerations Bums
Total Women n* Falls Motor vehicle incidents Violence Lacerations Bums Total
65 - 69
70 - 74
75-79
80-84
1417 12.7t 10.6 7.0 5.6 2.8 44.5
1149 16.5 9.6 5.2 3.5 2.6 42.6
862 20.9 3.5 2.3 1.2 1.2 40.6
525 18.6 7.6 1.9 3.8 51.4
2174 20.2 6.0 1.8 3.7 0.4 45.1
1942 22.6 6.2 2.6 3.1 0.5 44.3
1644 31.0 5.5 1.8 0.6 0.6 48.0
1173 45.2 5.1 2.6 1.7 1.7 59.7
-
+
Total
329 42.6 3.0 6.1 3.0 66.9
4282 19.6 7.9 4.9 3.3 2.3 45.8
924 39.0 3.2 2.2 1.1 1.1 51.9
7857 29.0 5.5 2.2 2.3 0.8 48.5
85
-
* Numbers indicate denominator estimates by sex and age categories.
t Numbers indicate rates per 1,000 persons/year. resulted in fracture). Two persons died as a result of a fall. Figure 3 shows the proportion of fall injuries by month for those falls for which we had information indicating whether the falls occurred indoors or outdoors (66.7%).Almost 40% of outdoor falls occurred during December and January, compared with only 18.2% of indoor falls. Overall, the most common site of falls was home (68.0%), followed by the street (18.4%). In the home, the stairs and bedroom were the most common sites of falls (56.0% and 21.3%, respectively). The activity at the time of the fall was noted in 83.6% of cases (Figure 4). Falls occurred most frequently while walking, either on a nonstair surface (51.7%)or on stairs (31.8%).In addition, several cases involved falls from a
FIGURE 1. lnjury rates by age for major injury types.
bed or chair (11.1%). Only 1.9% of falls involved the toilet, bathtub, or shower. Women had higher fall injury rates at each age group until 85 years, after which time men had slightly higher rates than women (Figure 2). A similar proportion of falls in men (81.1%) and women (78.7%) occurred indoors. Women had a higher proportion of falls on stairs than men (33.8% versus 26.1%, P < .05). The fracture rates and hospitalization rates were slightly higher for falls that occurred indoors compared with falls occurring outdoors. The proportion of fall injuries resulting in hospitalization was 17.6%of indoor fall injuries versus 4.7% of outdoor fall injuries. Of the indoor fall injuries, 23.6% resulted in fractures versus 18.6% of outdoor falls. Fracture rates were higher for
Injury R ates Per 1000 Populatlon
35-44'45-54' 55-64'65-74'75-84' 85+ ' Age &OUD
JAGS-DECEMBER 1990-VOL 38, NO. I2
INJURIESIN AN ELDERLY INNER-CITY POPULATION 1329
“” I
1
Fall R O ~ O
31.6% Stairs
5.0% Inlout Chair.,
40 Per 1000 Populatlon
8.1% InlOut B e -d ,
30 20 10
0 65-69 70-74 75-79 80-84
85+
Age Qroup
FIGURE 4. Activity at the time offalling in elderly subjects. Data are based on 261 of 312 falls (83.7%), including both indoor and outdoor falls.
FIGURE 2. Age-specific rates offalls in elderly men (shaded bars) and women (open bars).
falls on stairs (36.9% of staircase fall injuries) compared to nonstaircase fall injuries (21.396).
Motor Vehicle Incidents Motor vehicle incidents (MVI) (n = 77)were the second major cause of injuries and the second most common cause of hospitalization for injury, although they accounted for only 1346 of the 56 hospitalizations. No one died as a result of a motor vehicle incident. Men were most often injured while driving, accounting for 47.10/0of MVIs in men. Women were most often injured as passengers, accounting for 30.00/0of MVIs in women. Pedestrian injuries were uncommon. Only 13.0% of motor vehicle incidents were pedestrian injuries. The pedestrian injury rate among young adults 25 to 34 years of age was more than four times that of the pedestrian injury rate in those 65 and older (3.4 per 1,000 versus 0.8 per 1,000).
20
8
Burns Sixteen burn injuries occurred in the study population, accounting for only 370 of all injuries to older persons. Burns were equally divided into those caused by fire and flames, and those caused by hot liquids. Three persons died as a result of bums.
4
DISCUSSION
16 Percent Of
Fall.
Violence Violence was the third major cause of injuries among older persons, resulting in 38 injuries. The major type of violence for both men and women was assault without reported use of a weapon; this type accounted for 84.24b of violent injuries. Violent injury rates were higher in men than in women (4.9per 1,000 versus 2.2 per 1,000).There was no consistent pattern of change with increasing age; the number of violent injury events in each 5-year age group was too small to ensure accurate estimates of age-specific rates. Although violent injury rates were relatively low among older persons compared with younger persons in this population, violence was the leading cause of death, accounting for 41.246 of the 17 deaths among those 65 years and older. Little informationwas recorded in the medical records about the circumstances of violent injuries. Of the 17 violent injuries occurring in older women, the assailant was mentioned in eight instances; four women were assaulted by a family member, and four women were “mugged’ by an unknown assailant. Of the 21 men who were victims of violence, information about the assailant was recorded in only seven instances; five men were robbed by strangers; one man was assaulted by his son; and one man was assaulted by a neighbor.
12
0
I
I
I
.
1
I
. . .
. .
.
.
Mar Apr May Jun Jul Aug SepOct NovDec Jan Feb Month
FIGURE 3. Proportion of falls indoors (shaded bars) and outdoors (hatched bars) throughout the year in elderly men and women. Data are based on 208 of 312 falls for which information on location of fall was recorded.
Although a large number of injuries were recorded in this study, some injuries may not have been identified by the surveillance system. Physicians may have treated persons with minor injuries in their private offices, and some elderly persons may not have sought medical care. Thus, we are certain to have underestimated total injury rates. Nevertheless, we believe that case ascertainment
1330 GRISSO ET AL
of over 90% of injuries severe enough to result in emergency room evaluation is very good. Because medical records do not function primarily for the use of epidemiologicstudies, it is not surprising that useful epidemiologic information on the circumstances of injury was sometimes lacking. Information was lacking regarding location of the injury for 32.1% of cases and on the perpetrator of violent injuries for 60.5% of cases. To our knowledge, this study is the first communitybased effort to describe injuries occurring in an innercity black elderly population. The pattern of injuries is similar in some respects to that reported by studies of communities that are not inner-city minority populations.9-11 Women generally had higher injury rates than men, and injury rates increased in both sexes with advancing age. For those records with information about the location of the injury, the majority of injuries (for both men and women) occurred indoors, usually at home. Injuries due to falls made up more than half of all injuries, and falls occurring outdoors increased in frequency during the winter months. Fall injury rates increased markedly with age, more than doubling from age 65 to age 85 years. The exponential increase in fall injuries with age occurred at a younger age in women than in men. Although the increase in fall injury rates with advancing age is not as marked as that observed for hip fractures, the patterns of an exponential rise with age and an earlier increase in women than in men is similar to the pattern of hip fracture rates in both white and black persons in the United States.lzJ3 However, the pattern of fall injuries was different in some respects to that reported by other studies.9-11 The proportion of falls that occurred on the stairs was 31.8%,a figure much higher than that reported in recent community studies in Florida and in Sweden.9JoElderly in those communities are perhaps more likely to live in single-level dwellings. The prevalence of hazardous stairs in our study community may also be higher and should be evaluated. Women had a higher proportion of falls on stairs than men, a finding also reported in Sweden. Why older women would have higher fall injury rates on stairs than older men is not apparent and should be studied further. Other locations for falls were much less common than stairs. The low proportion of falls occurring in the bathroom was particularly surprising. Older persons are perhaps more careful when bathing because they realize their risk of falling. Other injuries emphasized in the literature were relatively uncommon in our population. Previous studies report a large number of traffic fatalities among the elder1y;l4-l6 however, motor vehicle incidents comprised only 13.3%of the total number of injuries among the elderly in the population we studied. Concern about pedestrian injuries is prominent in discussions of injuries in the elderly and studies report higher death rates
1AGS-DECEMBER 1990-VOL 38, NO. 12
due to pedestrian injuries among older persons than young adults.17J8However, in our population, young adults were much more likely to be injured as pedestrians than were older persons, and no deaths among the elderly were due to pedestrian injuries. Bums were also uncommon among the elderly population we studied, accounting for only 390 of all injuries. Previous studies place relatively little emphasis on violence as a cause of injury among the elderly. In our population, violence was more common than bums or pedestrian injuries, and was the leading cause of injury death. Few population-based comprehensive studies of injuries in elderly populations have been published. In Northeastern Ohio an active surveillance system of emergency departments was used to estimate age specific injury rates.19 In general, injury rates for men and women 65 years and older were higher than those in our study community. This was true for falls (51.4 per 1,000 versus 25.7 per 1,000) and motor vehicle incidents (1.01 per 1,000 versus 6.3 per 1,000) but not for violence; violence injury rates were greater in Philadelphia than in Northeastern Ohio (3.1 per 1,000 vs. 2.1 per 1,000). In another population-based study limited to falls in a very elderly white population, the overall fall injury rates were also higher than those in Philadelphia, and the increase in fall injury rates with age was much more marked, increasing over four times from age 65 years to 85 years,'9 in contrast to only doubling in Philadelphia. These differences could represent true differences in injury rates or differences in care-seeking behavior. It is interesting to speculate whether the black/white differences observed in hip fracture rates may be in part due to racial differences in fall injury rates. More prospective studies of elderly black populations are needed to evaluate whether fall injury rates differ in elderly black populations compared with elderly white populations. Although the pattern of injuries differed in some important aspects from studies in other elderly populations, the importance of falls as the major cause of injury is similar to reports of other elderly populations. In our population, falls were four times more common than motor vehicle incidents and 20 times more common than bums. The sequelae of falls were clinically significant as well, resulting in 75% of all hospitalizations for injuries. We are presently conducting a follow-up study of those persons who visited an emergency department because of a fall. Although most patients were discharged from the emergency departments with only minor injuries, 59.6%reported disability as a result of a fall two months after the fall occurred. Preliminary follow-up data show that most of those persons (73.4%) were still functionally impaired 6 months later. Thus, given the frequency, impact, and slow recovery of older persons from falls, the prevention of falls in older persons from inner-city minority communities should be given top priority.
IAGS-DECEMBER 1990-VOL 38, NO. 12
INJURIES IN AN ELDERLY INNER-CITY POPULATION
ACKNOWLEDGMENT The authors wish to thank Mane Kaufman for her helpful suggestions and assistance.
10.
11.
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