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


We found that the frequency of outdoor falls was higher compared with indoor falls among middle-aged and older men and women in Northern California. This is consistent with findings from several other studies of middle-aged and older persons in Canada,[14] England,[16] Norway,[15,17] Finland,[30] Israel[31,32] and Japan,[33] suggesting that outdoor falls among older adults occur more frequently than indoor falls across geographic regions. The predominance of outdoor falls is particularly striking because of the small amount of time most middle-aged and older adults spend outdoors compared with time spent indoors. For instance, Robinson and Silvers[34] reported that in a random sample of middle-aged and older men in the United States, the average time spent outdoors was 78 minutes per day,[34] and in the far western part of the country, the average was less than 90 minutes per day.

We also found that the risk profile for outdoor falls differed from indoor falls. Higher leisure-time physical activity was associated with outdoor but not indoor falls, and a greater number of physical difficulties and indicators of poor health were associated with indoor but not outdoor falls. These findings are consistent with results from other studies.[14–17] As noted by Northridge et al.,[8] fall prevention programs should not overlook the active elderly population, whose risk factors for falls may differ from those of the frail elderly population.

Our study adds to the results of the few previous studies on outdoor falls by providing more information about specific outdoor hazards. Sidewalks, curbs, and streets were the most frequent site of outdoor falls. Simple yet effective preventive measures include cleaning sidewalks and streets frequently, installing ramps at intersections, painting/marking curbs, fixing cracks or removing bumps, providing better lighting, and timely removal of construction debris and snow. Public works departments can implement these measures, which should be given high priority in areas where there are high concentrations of older people. A sizable proportion of outdoor falls occurred in parking lots and garages, particularly from tripping over the short curbs often placed at the end of parking spaces (data not shown). Despite the limited time older adults spend in these facilities, the relatively high frequency of falls shows that these settings need to be built and maintained not only for the benefit of motor vehicle drivers but also for pedestrians. Lack of designated walkways in parking lots and garages also may contribute to the increased risk for falls.

As noted in other studies,[15,17,30] the highest proportion of outdoor falls occurred while walking. Walking is the most common type of reported physical activity across all racial/ethnic, income, and age groups[35–39]: 45% of older adults report walking for leisure-time physical activity,[38] and nearly 70% of physically active older adults report walking as their predominant choice of physical activity. Increased walking has been promoted by various health organizations as an important way of lowering risk for chronic diseases,[7] yet little has been done to make walking safe for older adults. Streets, roads, and sidewalks are most often used by older adults for leisure-time physical activity,[40,41] but our results suggest that walking on sidewalks or roads may be dangerous because of uneven surfaces, litter, and other hazards. Elevated risk for falls associated with increasing physical activity may in part offset the lowered risk for chronic diseases, because the consequences of falls may result in older adults becoming homebound or institutionalized. Furthermore, fear of falling can become a significant barrier to physical activity[42,43] and thus lead to decreased independence and mobility.[44] Activity-related risk for falls among older adults is therefore a timely public health concern and should be thoroughly evaluated, because relatively easy environmental modifications can substantially reduce the risk for falls. We recommend that future trials evaluate the effectiveness of such environmental improvements as a means of reducing the occurrence of falls and fractures.

In a 2005 comprehensive review of intervention trials for preventing falls among the elderly, Gillespie et al.[45] reported that none of the 62 intervention trials included modification to or maintenance of the outdoor environment as an intervention component. The only published study on modifications to the outdoor environment for preventing falls among older adults, including lighting in public spaces and the conditions of roads and walkways, was conducted in Motala, Sweden, 20 years ago.[46] The lack of studies on outdoor falls may be the result of a common perception that the elderly spend little time outdoors, and therefore outdoor falls are less important than indoor falls. However, as documented in our study and several other reports,[14,16,17,33,47] outdoor falls are more common than indoor falls in almost all age groups, despite the limited amount of time most people spend outdoors.

Experts on fall-related research have long recognized the lack of studies on outdoor environmental hazards.[1,4,5,48,49] As they have noted, assessing environmental influences is problematic because of a lack of standardized methods for evaluating environmental hazards and because of the difficulty associating falls with specific environmental hazards that are dynamic over space and time. During the past 20 years, several techniques have been developed for studying the health impact of the built environment on falls. Such studies are possible because of the fast growth of spatial statistics, geographic information systems (GIS), and public databases. The knowledge accumulated in this research area should be applied to studies on falls among the elderly. For example, municipal GIS units and public works or transportation departments can develop spatial databases that monitor environmental changes, identify high-risk locales, and prioritize maintenance in neighborhoods where there are high concentrations of older people. Research into the impact of the built environment on falls requires multidisciplinary efforts and a joint framework that connects public health, behavioral research, health economics, transportation, and urban design. Several recent publications provide steppingstones in this emerging field.[50–55]

Our study has strengths and limitations. The data came from a large probability sample that was drawn from a defined community-based population. Data about falls includes place, circumstance, direction, and activity at the time of fall. Many known and potential risk factors for falls and fractures were collected during the study, enabling us to control for many potentially confounding variables. On the other hand, the study was conducted in 1 geographic area, Northern California, where people may spend more time outdoors compared with other geographic areas. Although the sociodemographic characteristics of Kaiser patients were generally similar to those of the general population, except for underrepresentation of the very rich and the very poor,[56] participants in our study tended to be well-educated and relatively active. People who were recovering from previous serious injuries were probably less likely to participate. The focus of the original study was on the etiology of fractures rather than falls and the study was conducted on the basis of self-reported data on falls and potential risk factors for falls. It is likely that the frequency of falls was underreported, because the data were obtained on the basis of past-year recall, and only the most recent fall was queried in detail. Previous studies have shown that past-year falls are likely to be underreported by 13% to 32%.[57] After we accounted for this extent of underreporting, the frequency of falls in our control group was consistent with other studies. However, there are no data to show whether recall error differs between outdoor and indoor falls. Some errors also may have occurred when reporting the circumstance of the fall. Our findings need to be replicated by other investigators.

Outdoor falls are an important but neglected public health problem. Many of the environmental risk factors associated with outdoor falls appear to be preventable through better design and maintenance of sidewalks, curbs, walkways, streets, outdoor parks and recreational places, and parking lots and garages. In this decade of worldwide promotion of Active Living and Active Aging,[19,58] efforts have begun at the national, state, municipal, and community levels to improve the built environment, including making neighborhoods more walkable. Preventing falls among older persons should be included in these efforts.


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