Klaas A. Hartholt

Societal consequences of falls in the older population: injuries, healthcare costs, and long-term reduced quality of life.

BACKGROUND Fall incidents are a major cause of morbidity and mortality in older adults. The aim of this cohort study was to determine the incidence, costs, and quality of life for fall-related injuries in the older Dutch population presenting at the emergency department. METHODS Data on fall-related injuries in persons aged 65 years or older were retrieved from the Dutch Injury Surveillance System, which records injuries treated at the emergency department, and a patient follow-up survey conducted between 2003 and 2007. Injury incidence, discharge rates, healthcare costs, and quality of life measures were calculated. RESULTS Fall-related injuries were to the upper or lower limb in 70% of cases and consisted mainly of fractures (60%), superficial injuries (21%), and open wounds (8%). Falls led to a total healthcare cost of €474.4 million, which represents 21% of total healthcare expenses due to injuries. Both admitted and nonadmitted patients reported a reduced quality of life up to 9 months after the injury. CONCLUSIONS Fall-related injuries in older adults are age and gender related, leading to high healthcare consumption, costs, and long-term reduced quality of life. Further implementation of falls prevention strategies is needed to control the burden of fall-related injuries in the aging population.

Trends in Fall-Related Hospital Admissions in Older Persons in the Netherlands

BACKGROUND Fall-related injuries, hospitalizations, and mortality among older persons represent a major public health problem. Owing to aging societies worldwide, a major impact on fall-related health care demand can be expected. We determined time trends in numbers and incidence of fall-related hospital admissions and in admission duration in older adults. METHODS Secular trend analysis of fall-related hospital admissions in the older Dutch population from 1981 through 2008, using the National Hospital Discharge Registry. All fall-related hospital admissions in persons 65 years or older were extracted from this database. Outcome measures were the numbers, and the age-specific and age-adjusted incidence rates (per 10,000 persons) of fall-related hospital admissions in each year of the study. RESULTS From 1981 through 2008, fall-related hospital admissions increased by 137%. The annual age-adjusted incidence growth was 1.3% for men vs 0.7% for women (P < .001). The overall incidence rate increased from 87.7 to 141.2 per 10,000 persons (an increase of 61%). Age-specific incidence increased in all age groups, in both men and women, especially in the oldest old (>75 years). Although the incidence of fall-related hospital admissions increased, the total number of fall-related hospital days was reduced by 20% owing to a reduction in admission duration. CONCLUSIONS In the Netherlands, numbers of fall-related hospital admissions among older persons increased drastically from 1981 through 2008. The increasing fall-related health care demand has been compensated for by a reduced admission duration. These figures demonstrate the need for implementation of falls prevention programs to control for increases of fall-related health care consumption.

Increase in Fall-Related Hospitalizations in the United States, 2001-2008

BACKGROUND The objective was to determine secular trends in unintentional fall-related hospitalizations in people aged 65 years and older in the United States. MATERIALS Data were obtained from a nationally representative sample of emergency department visits from January 1, 2001, to December 31, 2008, available through the National Electronic Injury Surveillance System-All Injury Program. These data were weighted to estimate the number, incidence rates, and the annual percent change of fall-related hospitalizations. RESULTS From 2001 to 2008, the estimated number of fall-related hospitalizations in older adults increased 50%, from 373,128 to 559,355 cases. During the same time period, the age-adjusted incidence rate, expressed per 100,000 population, increased from 1,046 to 1,368. Rates were higher in women compared with men throughout the study period. The age-adjusted incidence rate showed an average annual increase of 3.3% (95% CI, 1.66-4.95). DISCUSSION Both the number and rate of fall-related hospitalizations in the United States increased significantly over the 8-year study period. Unless preventive action is taken, rising hospitalization rates in combination with the aging US population over the next decades will exacerbate the already stressed healthcare system and may result in poorer health outcomes for older adults in the future. Further research is needed to determine the underlying causes for this rising trend.

The epidemic of hip fractures: are we on the right track?

Background Hip fractures are a public health problem, leading to hospitalization, long-term rehabilitation, reduced quality of life, large healthcare expenses, and a high 1-year mortality. Especially older adults are at greater risk of fractures than the general population, due to the combination of an increased fall risk and osteoporosis. The aim of this study was to determine time trends in numbers and incidence rates of hip fracture-related hospitalizations and admission duration in the older Dutch population. Methods and Findings Secular trend analysis of all hospitalizations in the older Dutch population (≥65 years) from 1981 throughout 2008, using the National Hospital Discharge Registry. Numbers, age-specific and age-adjusted incidence rates (per 10,000 persons) of hospital admissions and hospital days due to a hip fracture were used as outcome measures in each year of the study. Between 1981 and 2008, the absolute number of hip fractures doubled in the older Dutch population. Incidence rates of hip fracture-related hospital admissions increased with age, and were higher in women than in men. The age-adjusted incidence rate increased from 52.0 to 67.6 per 10,000 older persons. However, since 1994 the incidence rate decreased (percentage annual change −0.5%, 95% CI: −0.7; −0.3), compared with the period 1981–1993 (percentage annual change 2.3%, 95% CI: 2.0; 2.7). The total number of hospital days was reduced by a fifth, due to a reduced admission duration in all age groups. A possible limitation was that data were obtained from a linked administrative database, which did not include information on medication use or co-morbidities. Conclusions A trend break in the incidence rates of hip fracture-related hospitalizations was observed in the Netherlands around 1994, possibly as a first result of efforts to prevent falls and fractures. However, the true cause of the observation is unknown.

Rapid increase in hospitalizations resulting from fall-related traumatic head injury in older adults in the Netherlands 1986-2008

Falls occur frequently in older adults. With ageing populations worldwide, an increase in fall-related traumatic head injuries can be expected. The aim of our study was to determine trends in traumatic head-injury-related hospitalizations among older adults. Therefore, a secular trend analysis of fall-related traumatic head injuries in the older Dutch population between 1986 and 2008 was performed, using the National Hospital Discharge Registry. All significant fall-related traumatic head injury hospitalizations in persons aged ≥65 years were extracted from this database. During the study period, traumatic head-injury-related hospitalizations increased by 213% to 3,010 in 2008. The incidence rate increased annually by 1.2% (95% CI: 0.6; 1.9) between 1986 and 2000. Since 2001, the increase has accelerated up to 11.6% (95% CI: 9.5; 13.8) per year. Overall, the age-adjusted incidence rate increased from 53.1 in 1986 to 119.1 per 100,000 older persons in 2008. Age-specific incidence rates increased in all age groups, especially in persons aged ≥85 years. Despite an overall reduction in the length of hospital stay per admission, the total number of hospital-bed-days increased with 31.5% to 20,250 between 1991 and 2008. In conclusion, numbers and incidence rates of significant traumatic head-injury-related hospitalization after a fall are increasing rapidly in the older Dutch population, especially in the oldest old, resulting in an increased health care demand. The recent increase might be explained by the ageing population, but also other factors may have contributed to the increase, such as an increased awareness of traumatic head injuries, the implementation of renewed guidelines for traumatic head injuries, and improved radiographic tools.

Intraosseous Devices: A Randomized Controlled Trial Comparing Three Intraosseous Devices

Abstract Introduction. Access to the circulation is mandatory for adequate treatment in medical emergency situations. Intraosseous (IO) infusion is a safe, fast, and effective alternative for gaining access to the circulation, if intravenous access fails. In the last decade, the IO method gained renewed interest. New devices have been developed, such as the Bone Injection Gun (BIG) 15G/18G and the First Access for Shock and Trauma 1 (FAST1). Objective. To determine which IO needle is preferable for gaining IO access in patients requiring acute administration of fluids or medication in a prehospital setting. Methods. In this single-blind prospective randomized trial, the IO needles were added to the equipment of the helicopter emergency medical services (HEMS) system. The HEMS nurses received training in proper use of all needles. Children (1–13 years) were randomized to the Jamshidi 15G or the BIG 18G, and adults (≥ 14 years) were randomized to the Jamshidi 15G, the BIG 15G, or the FAST1. All patients requiring acute administration of fluids or medication, without successful insertion of an intravenous (IV) catheter, were included. The IO needles were compared in terms of insertion time, success rate, bone marrow aspiration, adverse events during placement, and user satisfaction. Results. Sixty-five adult and 22 pediatric patients were included. The treatment groups were similar with respect to age, gender, mortality, and trauma mechanism (p ≥ 0.05). The median insertion times ranged from 38 seconds for the Jamshidi 15G to 49 seconds for the BIG 15G and 62 seconds for the FAST1 (p = 0.004). The devices did not differ with respect to success rates (adults overall 80% and children overall 86%), complication rates, and user satisfaction. Conclusions. The Jamshidi 15G needle could be placed significantly faster than the FAST1. The devices had similar success rates, complication rates, and user-friendliness. Intraosseous devices provide a safe, simple, and fast method for gaining access to the circulation in emergency situations.

Adverse drug reactions related hospital admissions in persons aged 60 years and over, The Netherlands, 1981-2007: less rapid increase, different drugs.

Background Epidemiologic information on time trends of Adverse Drug Reactions (ADR) and ADR-related hospitalizations is scarce. Over time, pharmacotherapy has become increasingly complex. Because of raised awareness of ADR, a decrease in ADR might be expected. The aim of this study was to determine trends in ADR-related hospitalizations in the older Dutch population. Methodology and Principal Findings Secular trend analysis of ADR-related hospital admissions in patients ≥60 years between 1981 and 2007, using the National Hospital Discharge Registry of the Netherlands. Numbers, age-specific and age-adjusted incidence rates (per 10,000 persons) of ADR-related hospital admissions were used as outcome measures in each year of the study. Between 1981 and 2007, ADR-related hospital admissions in persons ≥60 years increased by 143%. The overall standardized incidence rate increased from 23.3 to 38.3 per 10,000 older persons. The increase was larger in males than in females. Since 1997, the increase in incidence rates of ADR-related hospitalizations flattened (percentage annual change 0.65%), compared to the period 1981–1996 (percentage annual change 2.56%). Conclusion/Significance ADR-related hospital admissions in older persons have shown a rapidly increasing trend in the Netherlands over the last three decades with a temporization since 1997. Although an encouraging flattening in the increasing trend of ADR-related admissions was found around 1997, the incidence is still rising, which warrants sustained attention to this problem.

Costs of falls in an ageing population: a nationwide study from the Netherlands (2007-2009).

BACKGROUND Falls are a common mechanism of injury in the older population, putting an increasing demand on scarce healthcare resources. The objective of this study was to determine healthcare costs due to falls in the older population. METHODS An incidence-based cost model was used to estimate the annual healthcare costs and costs per case spent on fall-related injuries in patients ≥ 65 years, The Netherlands (2007-2009). Costs were subdivided by age, gender, nature of injury, and type of resource use. RESULTS In the period 2007-2009, each year 3% of all persons aged ≥ 65 years visited the Emergency Department due to a fall incident. Related medical costs were estimated at €675.4 million annually. Fractures led to 80% (€540 million) of the fall-related healthcare costs. The mean costs per fall were €9370, and were higher for women (€9990) than men (€7510) and increased with age (from €3900 at ages 65-69 years to €14,600 at ages ≥ 85 year). Persons ≥ 80 years accounted for 47% of all fall-related Emergency Department visits, and 66% of total costs. The costs of long-term care at home and in nursing homes showed the largest age-related increases and accounted together for 54% of the fall-related costs in older people. DISCUSSION Fall-related injuries are leading to a high healthcare consumption and related healthcare costs, which increases with age. Programmes to prevent falls and fractures should be further implemented in order to reduce costs due to falls in the older population and to avoid that healthcare systems become overburdened.

Drug-related falls in older patients: Implicated drugs, consequences, and possible prevention strategies

Falls are the leading cause of injuries among older adults, aged 65 years and older. Furthermore, falls are an increasing public health problem because of ageing populations worldwide due to an increase in the number of older adults, and an increase in life expectancy. Numerous studies have identified risk factors and investigated possible strategies to prevent (recurrent) falls in community-dwelling older people and those living in long-term care facilities. Several types of drugs have been associated with an increased fall risk. Since drugs are a modifiable risk factor, periodic drug review among older adults should be incorporated in a fall prevention programme.

Circumstances leading to injurious falls in older men and women in the Netherlands

BACKGROUND Fall-induced injuries in persons aged 65 years and older are a major public health problem. Data regarding circumstances leading to specific injuries, such as traumatic brain injury (TBI) and hip fractures in older adults are scarce. OBJECTIVE To investigate the activity distributions leading to indoor and outdoor falls requiring an emergency department (ED) visit, and those resulting in TBIs and hip fractures. PARTICIPANTS 5880 older adults who visited the ED due to a fall. METHODS Data is descriptive and stratified by age and gender. RESULTS Two-thirds of all falls occurred indoors. However, there were higher proportions of outdoor falls at ages 65-79 years (48%). Walking up or down stairs (51%) and housekeeping (17%) were the most common indoor activities leading to a TBIs. Walking (42%) and sitting or standing (16%) was the most common indoor activities leading to a hip fracture. The most common outdoor activities were walking (61% for TBIs and 57% for hip fractures) and cycling (10% for TBIs and 24% for hip fractures). CONCLUSION In the present study we found that the indoor activities distribution leading to TBIs and hip fractures differed. Notably, about half of the traumatic brain injuries and hip fractures in men and women aged 65-79 years occurred outdoors. This study provides new insights into patterns leading to injurious falls by age, gender and injury type, and may guide the targeting of falls prevention at specific activities and risk groups, including highly functional older men and women.