Outdoor Falls Among Middle-Aged and Older Adults: A Neglected Public Health Problem

Wenjun Li, PhD; Theresa H.M. Keegan, PhD; Barbara Sternfeld, PhD; Stephen Sidney, MD, MPH; Charles P. Quesenberry Jr, PhD; Jennifer L. Kelsey, PhD


Am J Public Health. 2006;96(7):1192-1200. 

In This Article


The study population for our analyses comprised 2193 people: 78% of study participants were women, 47% were aged 65 years and older, 60% were college graduates, 50% were White, 18% were Black, 10% were Hispanic, 20% were Asian/Pacific Islander, and 2% were of other race/ethnicity. Five hundred twelve participants (23%) reported at least 1 fall during the previous year: 297 (58%) reported an outdoor fall as their most recent fall, and 215 (42%) reported an indoor fall. Outdoor falls accounted for 72% of the most recent falls among middle-aged men, 57% of the falls among older men, 58% of the falls among middle-aged women, and 51% of the falls among older women. Among men and women aged 80 years and older, outdoor falls accounted for 48% of their most recent falls.

Outdoor falls occurred most often on sidewalks, curbs, and streets ( Table 1 ). Gardens, patios, yards, decks or porches, parks and recreational areas, parking garages and parking lots, and outdoor stairs also were frequently cited. Among all groups except middle-aged men, the highest percentage of outdoor falls occurred when participants were walking ( Table 1 ). Among middle-aged men, an outdoor fall was most likely to have occurred while engaging in a vigorous activity. Study participants reported that approximately three quarters of outdoor falls were precipitated by 1 or more (not mutually exclusive) environmental causes, including an uneven surface, a wet surface, and tripping and/or slipping on an object ( Table 1 ). Among those who fell outdoors, more than 70% landed on a hard surface (concrete, asphalt, tile, marble, stone, or a wood floor), and almost half fell forward. Falls on sidewalks, curbs, or streets were often attributed to 1 or more environmental causes, particularly uneven surfaces and tripping on something.

Table 2 compares characteristics of outdoor and indoor fallers. Outdoor fallers were more likely to be men, younger, White, and more educated compared with both indoor fallers and nonfallers. On average, outdoor fallers had a higher level of leisure-time physical activity during the past year compared with indoor fallers and nonfallers. Additionally, outdoor fallers had better health and a higher level of physical functioning. Outdoor fallers were less likely to be obese and more likely to smoke cigarettes and drink alcohol than nonfallers. Outdoor falls were more likely to have been precipitated by environmental causes compared with indoor falls. Higher proportions of outdoor fallers landed on a hard surface and fell in a forward direction.

Table 3 shows adjusted odds ratios for several factors associated with falling outdoors or indoors compared with having not fallen. After adjusting for gender, age, race/ethnicity, education, and mode of interview, odds for outdoor falls—but not indoor falls—were strongly associated with more leisure-time physical activity. Cigarette smoking was associated with both outdoor and indoor falls, but the odds were lower and not statistically significant for indoor falls. Foot problems, lower-extremity neuromuscular symptoms, use of a walking aid, and alcohol consumption were associated with increased odds for both outdoor and indoor falls. Attributes associated with increased odds for an indoor fall—but only slightly or not at all associated with an outdoor fall—included various indicators of poor health, underweight (BMI < 18.5) or obesity (BMI > 30), and current use of sleep-inducing medications. Number of medications was somewhat associated with increased odds for both types of falls.

Table 4 shows multivariate adjusted odds ratios for falling both outdoors and indoors, with each variable adjusted for all other variables in the table. Differential risk factor profiles between those who fell outdoors and those who fell indoors remained evident. Higher level of leisure-time physical activity was still an independent predictor of outdoor but not indoor falls, whereas more health problems and more physical difficulties were independent predictors of indoor but not outdoor falls. Independent risk factors for both outdoor and indoor falls included lower-extremity neuromuscular symptoms, use of walking aids, cigarette smoking, and alcohol consumption during the past year.


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