Accidents involving older people: a review of the literature - Special Review

Age and Ageing, July, 1995 by J.M. Lilley, T. Arie, C.E.D. Chilvers

Introduction

People aged 65 years and over comprise less than on fifth of the population of England and Wales, yet the account for more than a third of deaths due to injury and poisoning [1]. In 1990 more than 6000 people aged over 65 were killed and around 300 000 were injured in accidents [2]. For older individuals, accidents have consequences that are more severe than for'younger victims. More than one-fifth (21%) of people over 75 who visit an Accident and Emergency department are admitted to hospital, compared with 9% of people aged 6 5 - 74, and only 4% of children aged under 1 5 [2, Table 7]. Studies of road traffic accidents [3, 4] and bums [5] make it clear that for injuries of the same severity old people _areynore likely than are younger adults to be hospitalized and to have longer inpatient stays. They also experience greater disability and extended periods of rehabilitation and have a higher risk of dying. A common consequence for those elderly people who survive an accident is increased dependency [6, 7]. Six months after sustaining their injuries, only 50% of proximal femoral fracture patients are able to return to their usual place of residence and 10% are still in hospital [8]. Analysing population-based surveillance data in the USA, Sattin and colleagues in 1990 [9] found that around half of the falls which occurred at home and required hospital admission resulted in the person being discharged to a nursing home. Indeed, falls are mentioned as a contributing factor in 40% of admissions to nursing homes [10, 11].

In addition to causing physical problems, accidents often have significant psychological consequences for their elderly victims. They may change their lives completely, leading to loss of independence and of confidence and to low self-esteem [12]. Fear of recurrence can curtail activities such as house cleaning and shopping [13] and may cause a reduction in social activities leading to isolation and loneliness [14]. Fear of falling has been found to be critical in the decision by elderly people to move into a more sheltered environment [15]. In financial terms, it is difficult precisely to determine the costs associated with accidents because of the wide range of injuries and treatmentitinvolved; however estimates suggest that the costs are considerable. Hip fractures alone cost the UK health service an estimated 160 million[pounds] each year [16]. This is in addition to the direct costs of providing social services, residential care and domiciliary support and the indirect costs associated with informal care. In spite of this, accidental injuries in old age have not received the attention in the research literature accorded to other causes of morbidity and mortality.

Few reviews of accidents have focused on all types of injury, concentrating rather on isolated subdivisions within the larger overall category of accidental injury. The term 'accident' is often used to describe a multitude of disparate events from falls and road accidents to suicides and violence. The use of this term implies that these events have several common aspects and these will be explored here. In this review, studies of accidents are considered under the headings: falls, road accidents and burns. These accident categories have been chosen because they are the accidents which lead to the highest rates of mortality among elderly people. Accidents considered under one category are not included in any other. Within each of these categories, the review will: (a) summarize the main UK sources of routinely

collected accident data; (b) report incidence and prevalence rates for these

types of accidental injuries in old age; (c) describe the nature and causes of these injuries

among older people living at home; (d) examine age and sex patterns in these accidental

injuries and the reasons why elderly people may be at greater risk of having an accident than younger adults; (e) outline the existing state of knowledge of the

consequences and outcomes of accidents for elderly people; (f) consider ways of preventing accidents to older

people; (g) explore methodological issues relating to the

existing accident literature; (h) identify problems, weaknesses and gaps in the

literature and focus on areas for further study.

Method

Most of the papers cited in this review have been identified by an English-language literature search of the MEDLINE database using the keywords: accidents, home accidents, accidental injuries, falls, bums, scalds and road traffic accidents. Reference sections of individual publications were also used to identify relevant studies. Useful sources of information on accidents, especially those involving the older road user, include the ergonomics and engineering literature as well as the medical literature. Both cross-sectional and longitudinal studies are considered and incidence and prevalence data are reported. Retrospective and prospective studies of injuries published between 1960 and March 1994 are included regardless of the severity of the injury, whether medical treatment was sought or-whether the victim survived. The majority of papers cited were published during the 1980s and 1990s. Two unpublished manuscripts are also cited. Also included are published UK government statistics on accidents, reviews, letters and case reports.