MMWR - Deaths from Fall-Related Traumatic Brain Injury

Morbidity and Mortality Weekly Report

Weekly / Vol. 69 / No. 9 March 6, 2020

Brain Injury Awareness Month —

March 2020

Brain Injury Awareness Month, recognized each

March, provides an important opportunity to bring

attention to the prevention of traumatic brain injury

(TBI) and to promote strategies to improve the quality

of life for persons living with TBI and their families.

TBIs, caused by an impact or force to the head or body

or a penetrating injury to the head, affect millions of

U.S. persons each year (1). Falls are a leading mechanism

of TBI, and older adults are at increased risk for sus-

taining a TBI and experiencing TBI-associated adverse

outcomes (1,2). A report in this issue of MMWR found

a nationwide 17% increase in the rate of fall-related

TBI deaths during 2008–2017, with increases in most

states (3). The largest increases in fall-related TBI deaths

occurred among persons aged ≥75 years.

Evidence-based prevention efforts to decrease falls are

important to reducing the incidence and prevalence of

TBI among older adults. CDC’s STEADI (Stopping

Elderly Accidents, Deaths & Injuries; https://www.cdc.

gov/steadi/index.html) initiative includes resources and

tools for health care providers to improve identification

of patients at risk for a fall, as well as effective strategies

to reduce the risk for fall-related injuries, including TBI.

References

1. CDC. Surveillance report of traumatic brain injury-related

emergency department visits, hospitalizations, and deaths—

United States, 2014. Atlanta, GA: U.S. Department of Health

and Human Services, CDC; 2019.

2. Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-

related emergency department visits, hospitalizations, and

deaths—United States, 2007 and 2013. MMWR Surveill Summ

2017;66(No. SS-9). https://doi.org/10.15585/mmwr.ss6609a1

3. Peterson AB, Kegler SR. Deaths from fall-related traumatic brain

injury—United States, 2008–2017. MMWR Morb Mortal Wkly

Rep 2020;69:225–30.

Deaths from Fall-Related Traumatic

Brain Injury — United States,

2008–2017

Alexis B. Peterson, PhD

; Scott R. Kegler, PhD

One in 10 U.S. residents aged ≥18 years reports falling each

year (1). Among all age groups, falls can cause serious injury

and are the second leading cause of traumatic brain injury

(TBI)–related deaths (2). TBI is a head injury caused by a

bump, blow, or jolt to the head or body or a penetrating head

injury that results in disruption of normal brain function.*

CDC estimated national and state-specific rates and trends

for TBI-related deaths (TBI deaths) caused by unintentional

falls (fall-related TBI deaths) among U.S. residents during

2008–2017, by selected decedent characteristics. The national

age-adjusted rate of fall-related TBI deaths increased by 17%

INSIDE

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Continuing Education examination available at

https://www.cdc.gov/mmwr/mmwr_continuingEducation.html

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

* https://www.cdc.gov/traumaticbraininjury/index.html.

Morbidity and Mortality Weekly Report

226 MMWR / March 6, 2020 / Vol. 69 / No. 9 US Department of Health and Human Services/Centers for Disease Control and Prevention

The MMWR series of publications is published by the Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),

U.S. Department of Health and Human Services, Atlanta, GA 30329-4027.

Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2020;69:[inclusive page numbers].

Centers for Disease Control and Prevention

Robert R. Redfield, MD, Director

Anne Schuchat, MD, Principal Deputy Director

Chesley L. Richards, MD, MPH, Deputy Director for Public Health Science and Surveillance

Rebecca Bunnell, PhD, MEd, Director, Office of Science

Arlene Greenspan, PhD, Acting Director, Office of Science Quality, Office of Science

Michael F. Iademarco, MD, MPH, Director, Center for Surveillance, Epidemiology, and Laboratory Services

MMWR Editorial and Production Staff (Weekly)

Charlotte K. Kent, PhD, MPH, Editor in Chief

Jacqueline Gindler, MD, Editor

Mary Dott, MD, MPH, Online Editor

Terisa F. Rutledge, Managing Editor

Douglas W. Weatherwax, Lead Technical Writer-Editor

Glenn Damon, Soumya Dunworth, PhD, Teresa M. Hood, MS,

Technical Writer-Editors

Martha F. Boyd, Lead Visual Information Specialist

Maureen A. Leahy, Julia C. Martinroe,

Stephen R. Spriggs, Tong Yang,

Visual Information Specialists

Quang M. Doan, MBA, Phyllis H. King,

Terraye M. Starr, Moua Yang,

Information Technology Specialists

MMWR Editorial Board

Timothy F. Jones, MD, Chairman

Michelle E. Bonds, MBA

Matthew L. Boulton, MD, MPH

Carolyn Brooks, ScD, MA

Jay C. Butler, MD

Virginia A. Caine, MD

Katherine Lyon Daniel, PhD

Jonathan E. Fielding, MD, MPH, MBA

David W. Fleming, MD

William E. Halperin, MD, DrPH, MPH

Jewel Mullen, MD, MPH, MPA

Jeff Niederdeppe, PhD

Patricia Quinlisk, MD, MPH

Patrick L. Remington, MD, MPH

Carlos Roig, MS, MA

William Schaffner, MD

Morgan Bobb Swanson, BS

from 2008 to 2017. Rate trends at the national level increased

significantly for nearly all decedent characteristics, with the

most notable increases observed among persons living in

noncore (i.e., most rural), nonmetropolitan counties and those

aged ≥75 years. Analysis of state-specific rate trends determined

that rates of fall-related TBI deaths increased significantly in

29 states over the 10-year study period. A fall can happen to

anyone of any age, but falls are preventable. Health care provid-

ers and the public need to be aware of evidence-based strate-

gies to prevent falls, given that rates of fall-related TBI deaths

are increasing. Health care providers can educate patients on

fall and TBI prevention, assess their risk for falls, and when

needed, encourage participation in appropriate evidence-based

fall prevention programs.

†

National Vital Statistics System multiple-cause-of-death

database on death certificates filed in 50 states and the

District of Columbia (DC) were analyzed to determine the

incidence of fall-related TBI deaths among U.S residents by

year, decedent characteristics (sex, age group, race/ethnicity,

and urban/rural residence classification status

), and state of

residence. To identify cases, an initial screen for International

Classification of Diseases, Tenth Revision (ICD-10) underlying-

cause-of-death codes in the range W00–W19 was performed,

indicating an unintentional fall as the underlying cause of

†

https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/cdc_falls_

compendium-2015-a.pdf.

https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf.

death. A fall-related death was further identified as a TBI

death when any of the ICD-10 multiple-cause-of-death codes

indicated a TBI-related diagnosis (2).

Study years 2008–2017

were selected to support estimation of 10-year national and

state-specific trends.

Annual death rates and accompanying 95% confidence

intervals (CIs) were calculated per 100,000 population by

integrating the National Vital Statistics System data with U.S.

bridged-race population estimates.** With the exception of

age-group rates, death rates were age-adjusted to the U.S. year

2000 standard age distribution. National and state-specific rate

trends of fall-related TBI deaths were modeled using Joinpoint

regression software (version 4.6.0.0; National Cancer Institute)

to estimate average annual percent changes (AAPCs) for the

10-year study period. AAPCs were considered statistically

significant at

α=0.05.

During 2008–2017, the national age-adjusted rate of fall-

related TBI deaths increased by 17%, from 3.86 per 100,000

persons to 4.52 (Table 1), representing 17,408 fall-related

TBI deaths in 2017. State-specific age-adjusted rates ranged

from 2.25 (Alabama) to 9.09 (South Dakota) during 2017

(Figure). Considering only the study endpoint years (2008

and 2017), the number of fall-related TBI deaths increased

TBI injury-related diagnosis codes identified by ICD-10 include S01.0–S01.5,

S01.7–S01.9, S02.0–S02.1, S02.3, S02.7–S02.9, S04.0, S06.0–S06.9, S07.0–

S07.1, S07.8–S07.9, S09.7–S09.9, T90.1–T90.2, T90.4–T90.5,

T90.8–T90.9.

** https://www.cdc.gov/nchs/nvss/bridged_race.htm.

Morbidity and Mortality Weekly Report

MMWR / March 6, 2020 / Vol. 69 / No. 9 227

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 1. Number* and rate

†

of traumatic brain injury–related deaths caused

by unintentional falls — United States, 2008–2017

Year No. of deaths Rate (95% CI)

2008 12,311 3.86 (3.80–3.93)

2009 12,804 3.94 (3.87–4.01)

2010 13,386 4.05 (3.98–4.12)

2011 13,632 4.02 (3.95–4.09)

2012 14,272 4.12 (4.05–4.19)

2013 15,064 4.26 (4.19–4.33)

2014 15,918 4.40 (4.33–4.47)

2015 16,258 4.42 (4.35–4.49)

2016 16,694 4.44 (4.37–4.51)

2017 17,408 4.52 (4.45–4.59)

Abbreviation: CI=confidence interval.

* Numbers exclude decedents with unknown age.

†

Deaths per 100,000 population, age-adjusted to the 2000 U.S. standard

population; decedents with unknown age were excluded.

Based on multiple-cause-of-death data from the National Center for Health

Statistics (NCHS) Vital Statistics System (https://www.cdc.gov/nchs/nvss/

deaths.htm) and NCHS Bridged-Race Population data (https://www.cdc.gov/

nchs/nvss/bridged_race.htm).

in 49 of 51 jurisdictions (50 states and DC), and correspond-

ing age-adjusted rates increased in 45 of these 49 jurisdic-

tions (Supplementary Table, https://stacks.cdc.gov/view/

cdc/85245). The largest AAPCs in rates of fall-related TBI

deaths occurred in Maine (6.5%), South Dakota (6.1%), and

Oklahoma (5.2%). A significant increase in rates occurred

in 29 states (Arkansas, California, Colorado, Connecticut,

Florida, Indiana, Iowa, Kansas, Louisiana, Maine, Maryland,

Massachusetts, Minnesota, Missouri, Nebraska, Nevada,

New Hampshire, North Carolina, Ohio, Oklahoma, Oregon,

Pennsylvania, Rhode Island, South Carolina, South Dakota,

Tennessee, Texas, Virginia, and Wisconsin). The remaining

21 states and DC experienced no significant change in rates.

During 2017, national rates of fall-related TBI death were

highest among persons aged ≥75 years (54.08 per 100,000)

and males (6.31) (Table 2). Notably, the rate among persons

aged ≥75 years was approximately eight times higher than that

among those aged 55–74 years (6.24), and the rate among

males was nearly double that of females (3.17). For the period

2008 to 2017, significantly increasing rate trends in fall-related

TBI deaths were identified for both males and females, persons

aged ≥55 years, non-Hispanic whites, non-Hispanic blacks,

and Hispanics, and across all levels of urbanization. The

largest modeled rate increases occurred among persons living

in noncore nonmetropolitan counties (AAPC=2.9%) and

those aged ≥75 years (AAPC=2.6%). The only significantly

decreasing national rate trend identified was for persons aged

0–17 years (AAPC=−4.3%).

Discussion

Nationally, nearly 17,500 fall-related TBI deaths occurred

during 2017, and state-specific age-adjusted rates ranged from

Summary

What is already known about this topic?

Falls can cause serious injuries, including a traumatic brain

injury (TBI). Unintentional falls represent the second leading

cause of TBI-related death.

What is added by this report?

The national age-adjusted rate of fall-related TBI deaths

increased by 17% from 2008 to 2017; rates increased signifi-

cantly in 29 states and among nearly all groups, most notably

persons living in noncore nonmetropolitan counties and those

aged ≥75 years.

What are the implications for public health practice?

Health care providers can educate patients about falls and TBIs,

assess fall risk, and encourage participation in evidence-based

fall prevention programs. Annual wellness visits might serve as

a time to review previously assessed fall risk factors and update

personalized prevention plans.

2.25 (Alabama) to 9.09 (South Dakota). The rate of this health

event significantly increased during 2008–2017 in 29 states,

and the national rate increased by 17%. This increase in the

national rate of fall-related TBI deaths is consistent with find-

ings from a recent CDC surveillance report that estimated a

22% increase in this health event during 2006–2014.

††

Variations in the rate of fall-related TBI deaths among states

might have partially resulted from urban and rural differences

in the risk of traumatic injury mortality (3). U.S. rural regions

experience a higher rate of TBI-related mortality (4), and het-

erogeneity in the availability and accessibility of resources (e.g.,

access to high-level trauma centers and rehabilitative services)

can result in disparities in post-injury outcomes (5). Over

the 10-year study period, noncore, nonmetropolitan counties

experienced the most rapidly increasing rates. These results are

consistent with previous findings of higher TBI-related mor-

tality rates among nonmetropolitan counties compared with

those in metropolitan counties across the United States (4).

During 2017, the rate of fall-related TBI deaths was higher

among males; this finding might result from circumstances

of the falls, such as a higher proportion of men falling from

heights (e.g., ladders) (6) leading to moderate or severe injuries,

including a TBI. The highest rate of fall-related TBI deaths

in 2017 was among adults aged ≥75 years, and over the study

period, this group experienced the largest increase in rates

among all age groups, consistent with older age being a major

risk factor for falls (7). CDC’s Stopping Elderly Accidents,

Deaths, & Injuries (STEADI)

§§

initiative can aid health care

providers in screening older patients for risk for falls, assessing

††

https://www.cdc.gov/traumaticbraininjury/data/tbi-deaths.html.

§§

https://www.cdc.gov/steadi/.

Morbidity and Mortality Weekly Report

228 MMWR / March 6, 2020 / Vol. 69 / No. 9 US Department of Health and Human Services/Centers for Disease Control and Prevention

FIGURE. Age-adjusted* rate of traumatic brain injury–related deaths caused by unintentional falls, by state

†

— United States, 2008 and 2017

Wyoming

North Dakota

Colorado

South Dakota

Washington

Wisconsin

Vermont

Utah

Arizona

Montana

Nebraska

New Mexico

Hawaii

Rhode Island

Maryland

Ohio

Pennsylvania

Minnesota

Mississippi

West Virginia

Missouri

Georgia

Virginia

Kansas

Michigan

Oregon

Illinois

Massachusetts

Iowa

Maine

North Carolina

Oklahoma

Idaho

Tennessee

Connecticut

Texas

New Hampshire

Florida

evada

California

South Carolina

Arkansas

New York

Delaware

Kentucky

Louisiana

Indiana

New Jersey

Alabama

0 1 2 3 4 5 6 7 8 9 10

Deaths per 100,000 population

2008

2017

* Age-adjusted to the 2000 U.S. standard population.

†

Forty-nine states; Alaska and the District of Columbia not shown because total case count was <20.

Morbidity and Mortality Weekly Report

MMWR / March 6, 2020 / Vol. 69 / No. 9 229

US Department of Health and Human Services/Centers for Disease Control and Prevention

TABLE 2. Numbers* and rates

†

of traumatic brain injury–related deaths caused by unintentional falls, by decedent characteristics — United

States, 2008 and 2017

Characteristic

2008 2017

2008–2017 rate trend

AAPC (95% CI)No. of deaths Rate (95% CI) No. of deaths Rate (95% CI)

Total 12,311 3.86 (3.80 to 3.93) 17,408 4.52 (4.45 to 4.59) 1.8

(1.5 to 2.1)

Sex

Male 7,129 5.49 (5.36 to 5.62) 10,180 6.31 (6.19 to 6.44) 1.6

(1.3 to 2.0)

Female 5,182 2.69 (2.61 to 2.76) 7,228 3.17 (3.09 to 3.24) 1.9

(1.5 to 2.4)

Age group (yrs)**

0–17 75 0.10 (0.08 to 0.12) 54 0.07 (0.05 to 0.09) −4.3

(−7.6 to −0.9)

18–34 304 0.43 (0.38 to 0.48) 295 0.39 (0.34 to 0.43) −1.1 (−3.0 to 0.8)

35–54 1,241 1.43 (1.35 to 1.51) 1,137 1.37 (1.29 to 1.45) −0.3 (−1.2 to 0.5)

55–74 2,855 5.22 (5.03 to 5.41) 4,470 6.24 (6.05 to 6.42) 1.8

(1.4 to 2.3)

≥75 7,836 42.89 (41.94 to 43.83) 11,452 54.08 (53.09 to 55.07) 2.6

(2.0 to 3.2)

Race/Ethnicity

††

White 10,501 4.09 (4.01 to 4.17) 14,472 4.90 (4.82 to 4.98) 2.1

(1.7 to 2.4)

Black 581 1.99 (1.82 to 2.16) 844 2.29 (2.13 to 2.45) 1.6

(0.2 to 3.1)

AI/AN 68 4.13 (3.08 to 5.18) 121 5.16 (4.20 to 6.11) 1.0 (−1.9 to 4.1)

A/PI 361 3.61 (3.22 to 3.99) 645 3.68 (3.39 to 3.97) 0.3 (−0.7 to 1.3)

Hispanic 777 3.23 (2.98 to 3.48) 1,282 3.51 (3.31 to 3.71) 1.2

(0.3 to 2.0)

Not stated 23 NA

§§

44 NA

§§

Level of urbanization

Large central metro 3,320 3.77 (3.64 to 3.90) 4,604 4.31 (4.18 to 4.44) 1.4

(1.2 to 1.6)

Large fringe metro 2,946 3.90 (3.76 to 4.05) 4,051 4.31 (4.17 to 4.44) 1.4

(0.5 to 2.3)

Medium metro 2,673 3.96 (3.81 to 4.11) 3,889 4.72 (4.57 to 4.87) 2.1

(1.5 to 2.7)

Small metro 1,181 3.76 (3.54 to 3.97) 1,791 4.76 (4.54 to 4.98) 2.2

(1.4 to 3.1)

Micropolitan (nonmetro) 1,292 4.10 (3.87 to 4.33) 1,793 4.98 (4.75 to 5.22) 2.1

(1.5 to 2.8)

Noncore (nonmetro) 899 3.65 (3.41 to 3.89) 1,280 4.60 (4.34 to 4.86) 2.9

(2.5 to 3.4)

Abbreviations: AAPC=average annual percent change; AI/AN=American Indian/Alaska Native; A/PI=Asian or other Pacific Islander; CI=confidence interval;

NA = not available.

* Numbers exclude decedents with unknown age.

†

Per 100,000 population, age-adjusted to the 2000 U.S. standard population; rates exclude decedents with unknown age.

Based on multiple-cause-of-death data from the National Center for Health Statistics (NCHS) Vital Statistics System (https://www.cdc.gov/nchs/nvss/deaths.htm)

and NCHS Bridged-Race Population data (https://www.cdc.gov/nchs/nvss/bridged_race.htm).

Statistically significant at α=0.05.

** Age group rates are not age-adjusted.

††

Whites, blacks, AI/ANs, and A/PIs were non-Hispanic; Hispanics could be of any race.

§§

Accompanying rates are not available because of lack of corresponding population denominator data.

modifiable risk factors, and intervening to reduce risk using

effective interventions. Health care providers might consider

prescribing exercises that incorporate balance, strength and

gait activities, such as tai chi, and reviewing and managing

medications linked to falls (8). Actions the public can take to

prevent falls include talking to their health care provider about

their or their parents’ risk for falls, performing strength and

balance exercises, having an annual eye exam, and making the

home safer (e.g., removing tripping hazards).

The findings in this report are subject to at least three limita-

tions. First, estimated annual rates and trends in rates of fall-

related TBI deaths might be affected by misclassification or

incomplete reporting of the cause of death on death certificates,

which could lead to overestimation or underestimation of this

health event (9). Second, misclassification of race and ethnicity

on death certificates is a common occurrence, particularly for

American Indian/Alaska Native, Asian/Pacific Islander, and

Hispanic populations and could lead to an underestimation

of deaths among these populations (10). Finally, in cases of

multiple trauma, non-TBI diagnoses might have also contrib-

uted to deaths included in the analysis.

A fall can happen to anyone of any age and can cause serious

injuries, including a TBI. Although falls are preventable, the

public should be aware that fall-related TBI deaths are increas-

ing in many states as well as nationally. Nationally, this increase

might be explained by longer survival following the onset of

common diseases such as stroke, cancer, and heart disease

¶¶

be attributable to the increasing population of older adults***

in the United States. In older adults, evidence-based fall pre-

vention strategies can prevent falls and avert costly medical

expenditures (8). Additional research is needed to determine

the magnitude of medically treated falls that could be prevented

¶¶

https://www.sciencedirect.com/science/article/pii/

S002243750600051X?via%3Dihub.

*** https://www.census.gov/prod/2014pubs/p25-1140.pdf.

Morbidity and Mortality Weekly Report

230 MMWR / March 6, 2020 / Vol. 69 / No. 9 US Department of Health and Human Services/Centers for Disease Control and Prevention

and direct medical costs that could be averted by employing

evidence-based fall prevention strategies in other age groups.

Nonetheless, annual wellness visits might serve as a time to

focus on previously assessed risk factors for falls and to update

personalized prevention plans.

Corresponding author: Alexis Peterson, AP[email protected], 770-488-0767.

Division of Injury Prevention; National Center for Injury Prevention and

Control; CDC.

All authors have completed and submitted the International

Committee of Medical Journal Editors form for disclosure of potential

conflicts of interest. No potential conflicts of interest were disclosed.

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