From the Department of Exercise Science (K.J.H.), Thomas Jefferson University; Department of Neurology (C.A.L., A.E.W., A.L.S.), University of Pennsylvania Perelman School of Medicine; Department of Neurology (H.E.), Hospital of the University of Pennsylvania; Memory Impairment and Neurodegenerative Dementia (MIND) Center (B.G.W.), University of Mississippi Medical Center; Department of Neurology (P.P.), University of North Carolina Chapel Hill; Department of Medicine (S.P.J.), Beth Israel Deaconess Medical Center; Department of Surgery (C.W.H.), Johns Hopkins University School of Medicine; National Institute of Neurological Disorders and Stroke (R.F.G.); Department of Biostatistics (A.L.S.), Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine; and Penn Injury Science Center (A.L.S.), University of Pennsylvania.
Neurology. 2023 Nov 27;101(22):e2234-e2242. doi: 10.1212/WNL.0000000000207949.
Falls are a leading cause of head injury among older adults, but the risk of fall occurring after a head injury is less well-characterized. We sought to examine the association between head injury and subsequent risk of falls requiring hospital care among community-dwelling older adults.
This analysis included 13,081 participants in the Atherosclerosis Risk in Communities Study enrolled in 1987-1989 and followed through 2019. The association of head injury (time-varying exposure, self-reported and/or ICD-9/10 code identified) with the risk of subsequent (occurring >1-month after head injury) falls requiring hospital care (ICD-9/10 code defined) was modeled using Cox proportional hazards regression. Secondary analyses included Fine and Gray proportional hazards regression to account for the competing risk of death, analysis of head injury frequency and severity, and formal testing for interaction by age, sex, and race. Models were adjusted for age, sex, race/center, education, military service, alcohol consumption, smoking, diabetes, hypertension, and psychotropic medication use.
The mean age of participants at baseline was 54 years, 58% were female, 28% were Black, and 14% had at least one head injury occurring over the study period. Over a median 23 years of follow-up, 29% of participants had a fall requiring medical care. In adjusted Cox proportional hazards models, individuals with head injury had 2.01 (95% CI 1.85-2.18) times the risk of falls compared with individuals without head injury. Accounting for the competing risk of mortality, individuals with head injury had 1.69 (95% CI 1.57-1.82) times the risk of falls compared with individuals without head injury. We observed stronger associations among men compared with women (men: hazard ratio [HR] = 2.60, 95% CI 2.25-3.00; women: HR = 1.80, 95% CI 1.63-1.99, -interaction <0.001). We observed evidence of a dose-response association for head injury number and severity with fall risk (1 injury: HR = 1.68, 95% CI 1.53-1.84; 2+ injuries: HR = 2.37, 95% CI 1.92-2.94 and mild: HR = 1.97, 95% CI 1.78-2.18; moderate/severe/penetrating: HR = 2.50, 95% CI 2.06-3.02).
Among community-dwelling older adults followed over 30 years, head injury was associated with subsequent falls requiring medical care. We observed stronger associations among men and with increasing number and severity of head injuries. Whether older individuals with head injury might benefit from fall prevention measures should be a focus of future research.
跌倒已成为老年人头部损伤的主要原因，但头部损伤后跌倒的风险特征尚不明确。我们旨在研究社区居住的老年人头部损伤与随后需要住院治疗的跌倒风险之间的关联。
本分析纳入了 1987 年至 1989 年参加社区动脉粥样硬化风险研究（Atherosclerosis Risk in Communities Study）的 13081 名参与者，并随访至 2019 年。采用 Cox 比例风险回归模型分析头部损伤（时间变化的暴露，自我报告和/或 ICD-9/10 代码识别）与随后（头部损伤后>1 个月发生）需要住院治疗的跌倒（ICD-9/10 代码定义）之间的关联。次要分析包括 Fine 和 Gray 比例风险回归以考虑死亡的竞争风险，分析头部损伤的频率和严重程度，并通过年龄、性别和种族进行正式的交互作用检验。模型根据年龄、性别、种族/中心、教育程度、兵役、饮酒、吸烟、糖尿病、高血压和精神药物使用情况进行了调整。
参与者在基线时的平均年龄为 54 岁，58%为女性，28%为黑人，14%在研究期间至少发生过一次头部损伤。在中位数为 23 年的随访期间，29%的参与者发生了需要医疗护理的跌倒。在调整后的 Cox 比例风险模型中，头部损伤患者的跌倒风险是无头部损伤患者的 2.01 倍（95%CI 1.85-2.18）。考虑到死亡的竞争风险，头部损伤患者的跌倒风险是无头部损伤患者的 1.69 倍（95%CI 1.57-1.82）。与女性相比，我们在男性中观察到更强的关联（男性：风险比[HR] = 2.60，95%CI 2.25-3.00；女性：HR = 1.80，95%CI 1.63-1.99，-交互<0.001）。我们观察到头部损伤次数和严重程度与跌倒风险之间存在剂量-反应关系（1 次损伤：HR = 1.68，95%CI 1.53-1.84；2 次及以上损伤：HR = 2.37，95%CI 1.92-2.94；轻度损伤：HR = 1.97，95%CI 1.78-2.18；中度/重度/穿透性损伤：HR = 2.50，95%CI 2.06-3.02）。
在随访 30 多年的社区居住的老年人中，头部损伤与随后需要住院治疗的跌倒有关。我们在男性和头部损伤次数和严重程度增加的情况下观察到更强的关联。头部损伤的老年患者是否可能受益于预防跌倒的措施，应成为未来研究的重点。
