Fall-related mortality in older persons during the COVID-19 pandemic| JOURNAL OF GERONTOLOGY AND GERIATRICS

Abstract

Backgrounds and purpose. The indirect effects of the coronavirus disease 2019 (COVID-19) pandemic on human health have gone beyond direct biological injury. We have hence investigated whether the fall-related mortality rate among older people may have been amplified during the early phase of the pandemic.
Methods. We conducted an electronic search of the US CDC Wonder online database to determine the fall-related mortality of older persons in the US during the COVID-19 pandemic, using the specific ICD-10 codes W01, W03, W05, W06, W07, W08 and W10.
Results. A consistent trend toward an increase in fall-related mortality was found for the three age groups we examined (65-74; 75-84; ≥ 85 years) between 2018 and 2021, with the largest increase observed in persons aged 85 years or older.
Conclusions. The increased risk of dying from falls recorded after the first year of the pandemic requires social and health interventions aimed at halting or even reversing physical and mental decline in the elderly.

INTRODUCTION

The indirect effects of the coronavirus disease 2019 (COVID-19) pandemic on human health have been multifaceted and far-reaching, going beyond the direct biological effects of the virus itself, thus also including disruption of healthcare, the emergence of mental health problems and impairment of chronic disease management, which exacerbated or worsened physical and mental impairments, especially in older adults and those with pre-existing pathological conditions ¹. All these aspects have contributed to increasing vulnerability to severe illness and accelerated decline in physical functioning, mental health, and well-being, which have also been exacerbated by the disruption of care and support services, particularly in the early stages of the pandemic when social isolation measures (e.g., quarantine, lockdowns, and even curfews) were introduced ². An increased risk of becoming frail was one of the worst consequences of all these major social and health changes, leading some authors to coin the term post-COVID “wave of frailty” ³.

It is now clear that frailty may be associated with a significantly higher risk of falling in older adults. A recent meta-analysis published by Yang et al. ⁴ concluded that the risk of falling is almost 50% higher in older adults with frailty than in those without (relative risk: 1.48; 95% confidence interval (95%CI): 1.27-1.73). It is, therefore, unsurprising that recent reports, such as those published by Thomas et al. ⁵, demonstrate an increased risk of falls and fractures in frail people during and after COVID-19-related closures in the UK. To this end, we investigated whether the fall-related mortality rate among older people in the US may have been amplified during the early phase of the COVID-19 pandemic.

MATERIALS AND METHODS

An electronic search was conducted in the latest version of the US CDC Wonder (Wide-Ranging, Online Data for Epidemiologic Research), a specific database designed for epidemiological research which records the underlying cause of death at the national level between the years 2018-2021 ⁶. The data in the database are derived from death certificates for US residents that report a single underlying cause of death and demographics. Our search was defined as follows: year (between 2018-2021) was set as the first variable, ten-year age group (65-74 years; 75-84 years; and ≥ 85 years) was set as the second variable, while the following ICD-10 codes were used grouped as the third variable: W01 (fall on same level from slipping, tripping and stumbling); W03 (other fall on same level due to collision with, or pushing by, another person); W05 (fall involving wheelchair); W06 (fall involving bed); W07 (fall involving chair); W08 (fall involving other furniture); W10 (fall on and from stairs and steps). The final output of our search was reported as crude death rate ×100,000 and the relative 95% interval. Statistical significance of the variation in crude death rate during the observation period was estimated with one-way analysis of variance (ANOVA) and Tukey post-hoc test, using the total number of deaths, the mean crude death rate, and the standard error of the mean (SEM) using StatPages (Interactive Statistical Calculation), and setting statistical significance at p < 0.05. This study was designed following the Declaration of Helsinki and the Guidelines for Good Clinical Practice, and did not need ethical committee approval, since the data were derived from a freely searchable anonymized database.

RESULTS

The results of our analysis are summarized in Table I and graphically represented in Figure 1, where values are shown as percentage variation from the baseline value in 2018. In the 65-74 years range, the crude death ratio due to falls increased throughout the observation period, from 2.807 × 100,000 in 2018 to 3.056 × 100,000 in 2021, but this variation was not statistically significant (f = 1.42; p = 0.235). In the 75-84 age range, the crude death ratio for falls increased throughout the observation period, from 8.685 × 100,000 in 2018 to 9.570 × 100,000 in 2021, and even in such cases, this variation was not statistically significant (f = 2.24; p = 0.085). Tukey Post-hoc Test analysis showed a significant difference between 2021 and 2018 (p = 0.048). In the ≥85 years age class, the crude death ratio for falls increased from 32.699 × 100,000 in 2018 to 36.330 × 100,000 in 2021, and this variation was found to be statistically significant (f = 8.93; p < 0.001). In Tukey Post-hoc Test analysis, statistically significant variations were found between the years 2021 and the years 2018 (p = 0.002), 2019 (p < 0.001), and 2020 (p < 0.001). Although in 2021, the crude death ratio due to falls increased for all three age ranges, the pattern was considerably different. In fact, in both the 65-74 and 75-84 years classes, the increase followed a continuous trend; for very older people (i.e., aged 85 or older), we found a decreasing trend in 2019 and 2020, which was completely reversed by a considerable increase in 2021.

DISCUSSION

It is now widely recognized that the adverse consequences of the COVID-19 pandemic are not only attributable to the direct biological injuries caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) but also include numerous “indirect” effects that may have contributed to a reduction in health and fitness in the general population, especially among the older persons. Social isolation measures, which have been widely applied in many countries worldwide, have led to many mobility and social restrictions, which in turn have promoted or accelerated physical and mental decline ⁷. It is, therefore, not surprising that the crude death rate from falls that we estimated from the CDC Wonder database in the US population aged 65 years and older has steadily increased in 2021, especially in the ancient population. As can be clearly seen in Figure 1, the trend in this population segment has seen a gradual decline in 2019 and an exponential increase in the following two years, with variation achieving statistical significance over the previous three years. Although a direct relationship between increased levels of frailty in the older population and enhanced risk of falls cannot be unequivocally defined, this association has been reported as being highly likely ⁸, and is also supported by the suggestive evidence of lower risk of falls in older people with frailty remission compared with those who instead remain frail ⁹.

In conclusion, the results of our analysis suggest that the risk of dying from a fall has increased during the COVID-19 pandemic, especially among very old people. This finding would, therefore, call for the adoption of social and health interventions aimed at halting or even reversing physical and mental decline in the elderly, such as the promotion of physical activities to improve strength, balance, and flexibility, a balanced diet with essential nutrients such as calcium and vitamin D that could help maintain bone health and reduce the risk of fractures, and increased education of older people and caregivers on the adoption of fall prevention strategies.

Conflict of interest statement

The authors declare no conflict of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

CM, GL: acquisition of data; FSG, GL: data analysis. All authors contributed to the study concept and design, interpretation of the data, and preparation of the manuscript.

Ethical consideration

This study was designed following the Declaration of Helsinki and the Guidelines for Good Clinical Practice, and did not need ethical committee approval, since the data were derived from a freely searchable anonymized database.

The datasets analysed during the current study but are available from the corresponding author on reasonable request. The CDC WONDER portal can be accessed at

History

Received: June 14, 2024

Accepted: January 12, 2025

Figures and tables

Figure 1.Relative increase (%) of fall-related mortality in older US persons between 2018 and 2021.

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