On March 17, 2017, the CDC published a report finding that between 2007 and 2013, the number and rate of older adult fall-related traumatic brain injuries (TBIs) have increased substantially. Although considerable public interest has focused on sports-related concussion in youth, the findings in this report suggest that TBIs attributable to older adult falls, many of which result in hospitalization and death, should receive public health attention.
TBI has short- and long-term adverse clinical outcomes, including death and disability. TBI can be caused by a number of principal mechanisms, including motor-vehicle crashes, falls, and assaults. The CDC report described the estimated incidence of TBI-related emergency department (ED) visits, hospitalizations, and deaths during 2013 and makes comparisons to similar estimates from 2007.
The CDC conducts surveillance of TBI to understand the public health burden, to monitor trends, and to identify groups at greatest risk for TBI. TBI is a major cause of mortality in the United States, contributing to approximately 30% of all injury-related deaths. The burden on the health care system is also substantial; in 2010, approximately 2.5 million ED visits, hospitalizations, or deaths were associated with TBI. From 2001 to 2010, the rates of ED visits increased by 70%, and rates of hospitalization and death increased by 11% and 7%, respectively.
State-based administrative health care data were used to calculate estimates of TBI-related ED visits and hospitalizations by principal mechanism of injury, age group, sex, and injury intent. Categories of injury intent included unintentional (motor-vehicle crashes, falls, being struck by or against an object, mechanism unspecified), intentional (self-harm and assault/homicide), and undetermined intent. TBI-related death analyses used CDC multiple-cause-of-death public-use data files, which contain death certificate data from all 50 states and the District of Columbia.
In 2013, a total of approximately 2.8 million TBI-related ED visits, hospitalizations, and deaths (TBI-EDHDs) occurred in the United States. This consisted of approximately 2.5 million TBI-related ED visits, approximately 282,000 TBI-related hospitalizations, and approximately 56,000 TBI-related deaths. TBIs were diagnosed in nearly 2.8 million (1.9%) of the approximately 149 million total injury- and noninjury-related EDHDs that occurred in the United States during 2013. The proportion of TBI-related injuries accounted for approximately one of every 50 ED visits (2.2%). TBI-related deaths accounted for 2.2% of all deaths in the United States.
Rates of TBI-EDHD varied by age, with the highest rates observed among those 75 years old or older (2,232.2 per 100,000 population), 0–4 years (1,591.5), and 15–24 years (1,080.7). With respect to TBI-related ED visits only, the age groups with the highest rates were those 75 years old or older (1,701.7), 0–4 years (1,541.1), and 15–24 years (1,001.9). Rates of TBI-related hospitalizations and deaths were highest among the oldest age groups. For hospitalizations, the age groups with the highest rates were those 75 years old or older (454.4), 65–74 years (139.4), and 55–64 years (86.0). The same pattern was observed for TBI-related deaths with the highest rates found among those 75 years old or older (76.1), 65–74 years (24.3), and 55–64 years (18.8). In terms of overall numbers, persons aged 15–24 years accounted for 17.9% of all TBI-related ED visits, more than any other age group. Those 75 years old or older comprised the largest proportion of both TBI-related hospitalizations (31.4%) and deaths (26.5%).
The age-adjusted rate of ED visits was higher in 2013 (787.1) versus 2007 (534.4), with fall-related TBIs among persons 75 and older accounting for 17.9% of the increase in the number of TBI-related ED visits. The number and rate of TBI-related hospitalizations also increased among persons 75 and older (from 356.9 in 2007 to 454.4 in 2013), primarily because of falls. Whereas motor-vehicle crashes were the leading cause of TBI-related deaths in 2007 in both number and rate, in 2013, intentional self-harm was the leading cause in number and rate. The overall age-adjusted rate of TBI-related deaths for all ages decreased from 17.9 in 2007 to 17.0 in 2013; however, age-adjusted TBI-related death rates attributable to falls increased from 3.8 in 2007 to 4.5 in 2013, primarily among older adults. Although the age-adjusted rate of TBI-related deaths attributable to motor-vehicle crashes decreased from 5.0 in 2007 to 3.4 in 2013, the age-adjusted rate of TBI-related ED visits attributable to motor-vehicle crashes increased from 83.8 in 2007 to 99.5 in 2013. The age-adjusted rate of TBI-related hospitalizations attributable to motor-vehicle crashes decreased from 23.5 in 2007 to 18.8 in 2013. Progress has been made to prevent motor-vehicle crashes, resulting in a decrease in the number of TBI-related hospitalizations and deaths
Rates of TBI-EDHDs varied by principal mechanism of injury, and by age group within principal mechanism of injury. Overall, the most common principal mechanisms of injury were falls (413.2 per 100,000 population, age-adjusted), being struck by or against an object (142.1, age-adjusted), and motor-vehicle crashes (121.7, age-adjusted). These principal mechanisms represented 47.2%, 15.4%, and 13.7% of all TBI-EDHDs, respectively.
Examining each principal mechanism by age group reveals a different pattern. Those 75 years old or older had the highest rate of fall-related TBI-EDHDs (1,859.0), followed by 0–4 years (1,119.3), and 65–74 years (539.8). For TBI-EDHDs attributable to being struck by or against an object, the age groups with the highest rate include those aged 5–14 years (291.9), 0–4 years (262.7), and 15–24 years (243.3). Finally, for TBI-EDHDs attributable to motor-vehicle crashes, those aged 15–24 years (258.3), 25–34 years (182.9), and 35–44 years (126.5) had the highest rates.
Differences in age-adjusted rates were found for each principal mechanism when comparing rates of TBI-EDHDs by sex. Overall, males had higher age-adjusted rates of TBI-EDHDs (959.0 per 100,000 population) compared with females (810.8). Males had higher age-adjusted rates of being struck by or against an object compared with females (167.3 versus 115.6), a higher age-adjusted rate of motor-vehicle crash–related TBI-EDHDs (128.2 versus 115.5), a more than fivefold higher age-adjusted rate of intentional self-harm-related TBI-EDHDs (11.7 versus 2.3), and a higher age-adjusted rate of assault-related TBI-EDHDs (96.0 versus 54.8). Females had a significantly higher age-adjusted rate of fall-related TBI-EDHDs compared to men (417.7 versus 400.7).
Age-adjusted rates of TBI-related ED visits increased from 534.4 per 100,000 in 2007 to 787.1 in 2013. Further, this increase in TBI-related ED visit rates has occurred for nearly all of the major principal mechanism categories: a 65% increase for falls (from 222.6 per 100,000 to 366.5, age-adjusted); a 55% increase in being struck by or against an object (from 90.3 to 139.8, age-adjusted); a 75% increase for TBIs as a result of intentional self-harm (from 0.4 to 0.7, age-adjusted); a 20% increase for assaults (from 56.8 to 68.2, age-adjusted); and a 19% increase for motor-vehicle crashes (from 83.8 to 99.5, age-adjusted).
The number of TBI-related ED visits increased from approximately 1.6 million in 2007 to approximately 2.5 million in 2013, representing an increase of more than 50%, or an increase of more than 850,000 ED visits. The key contributors to the increase are falls (accounting for 57.3% of the increase); being struck by or against an object (accounting for 18.2% of the increase); and motor-vehicle crashes (accounting for 7.0% of the increase). With respect to both principal mechanism and age, the key contributors to the increase are fall-related TBIs among those 75 years old or older (accounting for 17.9% of the increase), aged 65–74 years (accounting for 7.7% of the increase), aged 55–64 years (accounting for 6.7% of the increase), and aged 0–4 years (accounting for 6.1% of the increase), and being struck by or against an object among those aged 5–14 years (accounting for 5.7% of the increase) and 15–24 years (accounting for 4.2% of the increase).
Approximately 75% of TBI-related hospitalizations in 2013 were attributable to two principal mechanisms: falls (50.4%) and motor-vehicle crashes (21.5%). Overall, the total number of TBI-related hospitalizations in 2013 (281,555) was similar to the number of TBI-related hospitalizations in 2007 (267,350) and rates of TBI-related hospitalizations remained nearly the same. The age-adjusted rate of TBI-related hospitalizations attributable to motor-vehicle crashes decreased from 2007 to 2013 (from 23.5 to 18.8 per 100,000). In addition, the age-adjusted rate of TBI-related hospitalizations attributable to falls increased from 33.9 in 2007 to 42.2 in 2013.
Age was an important factor contributing to the TBI-related hospitalization rate change from 2007 to 2013. The overall decrease in rates of TBI-related hospitalizations attributable to motor-vehicle crashes was evidenced most prominently among those aged 15–24 years as the rate decreased from 47.3 in 2007 to 31.8 in 2013. The overall increase in rates of TBI-related hospitalizations attributable to falls was observed most prominently among those 75 years old or older (from 257.3 in 2007 to 354.8 in 2013).
Overall, the number of TBI-related deaths increased from 54,699 in 2007 to 55,920 in 2013. However, age-adjusted rates of TBI-related deaths decreased slightly during that period (from 17.9 to 17.0 per 100,000). This decrease is largely attributable to an overall decrease in the age-adjusted rate of TBI-related deaths attributable to motor-vehicle crashes (5.0 in 2007 to 3.4 in 2013). Despite the overall decrease in rates, there were increases in the age-adjusted rate of TBI-related deaths attributable to falls (from 3.8 in 2007 to 4.5 in 2013) and intentional self-harm (from 4.8 in 2007 to 5.6 in 2013). Whereas motor-vehicle crashes were the leading cause of TBI-related death in 2007, in both number and rate, intentional self-harm was the leading cause, in number and rate, in 2013. Increases between 2007 and 2013 in the number of TBI-related deaths attributable to self-harm were found among all age groups examined (i.e., those 15 years old or older). In 2013, of TBI-related deaths attributable to self-harm, 86.9% were among males; in 96.9% of these cases, a firearm was the principal mechanism. Although leading causes of TBI-related deaths for all other age groups are either falls, motor-vehicle crashes, or unintentional self-harm, the leading cause among those aged 0–4 years in 2007 and 2013 was assault/homicide.
The overall decrease in the rate of TBI-related deaths attributable to motor-vehicle crashes was found among all age groups, with the most pronounced decrease being among those aged 15–24 years (from 10.0 in 2007 to 5.7 in 2013). The increased rate of TBI-related deaths attributable to falls was not evenly spread among all ages as those 75 years old or older had the largest increase (from 39.7 in 2007 to 50.3 in 2013).
Several hypotheses might explain the increase in TBI-EDHDs over time. First, heightened public awareness about sports-related concussions might have translated to greater public concern about the effects of TBI generally, leading people of all ages to more readily seek care. Second, heightened awareness among health care providers, and the broader dissemination of validated assessment tools, might have resulted in more TBI diagnoses. Although increases among youth were found for TBI-related ED visits, there were significant increases in the number of ED visits, hospitalizations, and deaths attributable to TBIs resulting from older adult falls. This across-the-board increase over a relatively short time, suggests the need to address preventing and reducing the number of older adult falls resulting in TBI.
The highest rates of TBI-EDHDs were among the oldest or youngest age groups. TBIs in these age groups are notable for several reasons. In children under the age of seven, TBIs can impair neurologic development and the ability to meet developmental milestones. Impaired development might lead to further challenges as a child ages, such as declines in academic functioning and psychosocial sequelae such as emotional and behavioral disorders (e.g., depression or attention-deficit hyperactivity disorder).
In older adults, TBIs are associated more often with hospitalization and death. Cognitive and physical reserve are diminished at older ages, so TBIs might have a greater impact on daily living. TBIs in older adults are more likely to lead to hospitalization and these hospitalizations can be complicated by the presence of comorbidities. Furthermore, more frequent use of anticoagulants among older adults can result in a greater likelihood of secondary effects because of an increased likelihood of intracranial hemorrhage.
The most common principal mechanisms of injury for TBI-EDHDs were falls, being struck by or against an object, and motor-vehicle crashes. Although these three principal mechanisms accounted for approximately 70% of all TBI-EDHDs, particular age groups were disproportionally affected by specific principal mechanisms. Approximately half of all fall-related TBI-EDHDs occurred among those aged 0–4 years and 75 or older.
Certain prevention strategies have been identified for older adult falls, many of which have been demonstrated in randomized controlled trials to be effective. These include multicomponent physical exercise programs, Tai chi, Vitamin D supplementation (which might be effective among those who are Vitamin D deficient), surgical interventions (e.g., pacemakers and cataract surgery where indicated), and strategies to reduce home hazards (e.g., increased lighting and removal of tripping hazards). The CDC has developed the STEADI initiative (Stopping Elderly Accidents Deaths and Injuries) as a comprehensive strategy to reduce falls in older adults. STEADI incorporates empirically supported clinical guidelines and scientifically tested interventions to help primary care providers address patient fall risk through the identification of modifiable risk factors and implementation of effective interventions (e.g., medication management).
A number of strategies have been suggested for preventing injuries in children in general, including those resulting from falls. These include the use of safety gates at the top and bottom of stairways; ensuring that children under the age of six do not sleep in the top bunk of a bunk bed; seat belt use in a shopping cart; use of an appropriate helmet for activities such as bicycle riding, skateboarding, and horseback riding; and age- and activity-appropriate supervision by adult caregivers.
To prevent TBIs related to motor-vehicle crashes among infants and children, children should sit in the back seat until aged 13 years and be seated in age- and size-appropriate car seats. Unrestrained children aged 4–15 years are three times more likely to sustain a TBI than children who were restrained. The American Academy of Pediatrics (AAP) recommends that infants and toddlers remain in a rear-facing car safety seat until aged 2 years or until they reach the height and weight limit designated by the manufacturer of the car seat, then be restrained in forward-facing car seats (until they reach the height/weight limits on their car seats). The AAP recommends that children sit in a booster seat once they outgrow child safety seats and can fit appropriately into an adult seat belt.
The leading cause of TBI-related death among those aged 0–4 years was assault/homicide, including abusive head trauma by inflicted blunt impact or violent shaking, and other causes, such as firearm-related injuries. A number of strategies have been developed to prevent child abuse and neglect. To help communities make use of the best available evidence for prevention, the CDC has released a technical package that describes a set of strategies and examples of specific approaches that enhance safe, stable, nurturing relationships and environments for children and families to reduce abuse and neglect and promote health.
The highest rates of TBI-EDHDs occurring after being struck by or against objects were among those aged 0–24 years. Sports- and recreation-related activities likely contribute to these types of injuries, especially for those aged 4–24 years.
The most common principal mechanism of TBI-EDHDs among persons aged 15–24 and 25–34 years was motor-vehicle crashes. This corresponds with the age groups that are known to be at higher risk for a motor-vehicle crash. Several factors have contributed to increased motor vehicle-related injuries in teens and young adult drivers compared to older drivers, including a reduced ability to recognize driving hazards and unsafe road conditions, low frequency of seat belt use, and higher levels of alcohol-impaired driving. The motor vehicle mechanism category used in the analysis includes injuries to pedal cyclists and pedestrians by motor vehicles. However, previous research has shown that approximately 70% of the motor-vehicle–related TBIs in persons aged 15–34 years involve occupants of a vehicle, approximately 12% involve motorcycle passengers, and approximately 8% involve pedestrians.
Compared to 2007, in 2013 the overall age-adjusted rate of TBI-related hospitalizations attributable to motor-vehicle crashes decreased, with the largest decreases occurring among those aged 15–24 years. This may be due to the implementation of programs and policies focused on young and inexperienced drivers. Programs such as graduated drivers licensing focus on young drivers as a way to increase safety awareness and reduce driving under high-risk driving conditions when the driver is still relatively inexperienced. All states have instituted zero tolerance for alcohol and driving among young drivers (i.e., those aged under 20). Overall decreases in these motor-vehicle–related hospitalizations were likely the result of both behavioral and vehicle improvements such as the increased use of seatbelts and vehicle safety measures such as airbags and electronic stability control. These advances have helped to reduce the incidence of motor-vehicle crashes but might also contribute to decreased injury severity, resulting in fewer TBIs that require hospitalization.
Although the number of TBI-related deaths increased from 2007 to 2013, the age-adjusted rate of TBI-related deaths decreased. This decrease was largely attributable to a decrease in the rate of fatal TBIs in motor-vehicle crashes. However, to some extent, this decrease has masked increases during the same period in fatal TBIs caused by falls, particularly among older adults, and an increase in fatal TBIs attributable to intentional self-harm. Fatal TBIs attributable to intentional self-harm were found predominantly among males; firearms were the predominant principal mechanism of injury. The increase in fatal TBIs attributable to intentional self-harm is consistent with an overall increase in suicide rates in the United States and underscores the importance of comprehensive and coordinated prevention efforts, including efforts to enhance social support and connectedness, reduce stigma for help-seeking, and provide support for those at greatest risk.
The increase in the overall number of TBI-related hospitalizations and deaths attributable to older adult falls might be in some part attributable to increased life expectancy combined with the increased risk of falls among older adults. However, the increase in life expectancy during the relatively short period of time covered by this analysis (from 78.1 years in 2007 to 78.8 in 2013) cannot explain such a large increase in the rate of TBI-related hospitalizations and deaths attributable to falls among older adult age groups. The reason or reasons for this increase are unknown.
In 2013, approximately 2.8 million TBI-related ED visits, hospitalizations, and deaths occurred in the United States, representing an increase since 2007 that was largely attributed to an increase in the number and rate of TBI-related ED visits. Although much public interest has been devoted to sports-related concussion in youth, the findings in this report indicate that older adult falls account for a much larger proportion of the increase in TBI-related ED visits during this period. In addition, although the modest increases in ED visits that might be attributed to youth sports concussion do not extend to increases in TBI-related hospitalizations and deaths, the same cannot be said for TBIs attributable to older adult falls. From 2007 to 2013, increases in TBI-related hospitalizations and deaths attributable to older adult falls suggest the need for greater attention to preventing older adult falls. Empirically validated prevention measures can help reduce the incidence of older adult falls.
The decrease in TBI-related deaths caused by motor-vehicle crashes from 2007 to 2013 is likely attributable to efforts to prevent motor-vehicle crashes. Nevertheless, more can be done to further reduce motor-vehicle crashes. The United States lags behind other high-income countries in the rate of motor-vehicle crash deaths; in 2013, the rate of motor-vehicle crash deaths in the United States was more than double the average rate of other high-income comparison countries. Redoubling efforts to increase restraint use and reduce alcohol-impaired driving, among other proven interventions, are critical to the continued reduction of motor-vehicle crashes and motor-vehicle crash–related TBIs.
See the CDC Report
See also Medical Law Perspectives, October 2013 Report: Brain Aneurysm and Subarachnoid Hemorrhage: Failure to Diagnose, Delayed Diagnosis, Misdiagnosis
See also Medical Law Perspectives, May 2012 Report: Repeat Brain Trauma That Is More Than a Bump on the Head: Multiple Concussion Injury and Second Impact Syndrome