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Original Investigation |

The Course of Disability Before and After a Serious Fall Injury

Thomas M. Gill, MD1; Terrence E. Murphy, PhD1; Evelyne A. Gahbauer, MD, MPH1; Heather G. Allore, PhD1
[+] Author Affiliations
1Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
JAMA Intern Med. 2013;173(19):1780-1786. doi:10.1001/jamainternmed.2013.9063.
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Importance  Although a serious fall injury is often a devastating event, little is known about the course of disability (ie, functional trajectories) before a serious fall injury or the relationship between these trajectories and those that follow the fall.

Objectives  To identify distinct sets of functional trajectories in the year immediately before and after a serious fall injury, to evaluate the relationship between the prefall and postfall trajectories, and to determine whether these results differed based on the type of injury.

Design, Setting, and Participants  Prospective cohort study conducted in greater New Haven, Connecticut, from March 16, 1998, to June 30, 2012, in 754 community-living persons aged 70 years or older who were initially nondisabled in their basic activities of daily living. Of the 130 participants who subsequently sustained a serious fall injury, 62 had a hip fracture and 68 had another fall-related injury leading to hospitalization.

Main Outcomes and Measures  Functional trajectories, based on 13 basic, instrumental, and mobility activities assessed during monthly interviews, were identified in the year before and the year after the serious fall injury.

Results  Before the fall, 5 distinct trajectories were identified: no disability in 16 participants (12.3%), mild disability in 34 (26.2%), moderate disability in 34 (26.2%), progressive disability in 23 (17.7%), and severe disability in 23 (17.7%). After the fall, 4 distinct trajectories were identified: rapid recovery in 12 participants (9.2%), gradual recovery in 35 (26.9%), little recovery in 26 (20.0%), and no recovery in 57 (43.8%). For both hip fractures and other serious fall injuries, the probabilities of the postfall trajectories were greatly influenced by the prefall trajectories, such that rapid recovery was observed only among persons who had no disability or mild disability, and a substantive recovery, defined as rapid or gradual, was highly unlikely among those who had progressive or severe disability. The postfall trajectories were consistently worse for hip fractures than for the other serious injuries.

Conclusions and Relevance  The functional trajectories before and after a serious fall injury are quite varied but highly interconnected, suggesting that the likelihood of recovery is greatly constrained by the prefall trajectory.

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Figure 1.
Functional Trajectories During the 12-Month Periods Before (A) and After (B) a Serious Fall Injury in 130 Participants

Number and percentage of participants for each trajectory are shown in parentheses. The percentages may not sum to 100 because of rounding. The number of disabilities ranged from 0 to 13 based on 4 basic activities (bathing, dressing, walking inside the house, and transferring from a chair), 5 instrumental activities (shopping, housework, meal preparation, taking medications, and managing finances), and 4 mobility activities (walking a quarter mile, climbing a flight of stairs, lifting or carrying 10 lb, and driving). Dashed lines indicate identified trajectories; solid lines, predicted trajectories. The error bars represent 95% CIs for the predicted severity of disability. The average posterior probabilities of class membership for the trajectories before the fall were greater than 0.9, with values ranging from 0.92 for moderate to 0.98 for mild disability. All but 1 of the corresponding probabilities for the postfall trajectories were greater than 0.9, with values ranging from 0.89 for gradual to 0.99 for rapid recovery. The Bayesian information criterion was −6142.8. Among participants with no recovery, little recovery, gradual recovery, or rapid recovery, the number (percentage) of deaths in the year after the fall was 20 (35%), 1 (4%), 4 (11%), and 0, respectively, and the median time to death was 5, 9, 1, and 0 months, respectively.

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Figure 2.
Adjusted Probabilities of Postfall Functional Trajectories Conditional on Prefall Functional Trajectories According to Type of Serious Fall Injury

Multivariable model included age, sex, race, educational level less than high school, number of chronic conditions, cognitive impairment, depressive symptoms, and physical frailty, using data available immediately before the start of the prefall trajectory (eTable in the Supplement). Probabilities may not sum to 1.0 because of rounding.

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