Archives of Gerontology and Geriatrics 91 (2020) 104206

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Archives of Gerontology and Geriatrics

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Midlife falls are associated with increased risk of mortality in women: T

Findings from the National Health and Nutrition Examination Survey III
Carrie A. Karvonen-Gutierreza,*, Kelly R. Ylitalob, Mia Q. Penga
a
Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, United States
b
Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, TX, United States

ARTICLE INFO ABSTRACT

Keywords: Objectives: Falls are a public health concern for older adults but are also common among midlife adults.
Midlife However, the consequences of falls occurring during midlife are not well understood.
Sex differences Methods: This investigation assessed the relationship between falls and mortality among midlife adults using
Recurrent falls survey data from the Third National Health and Nutrition Examination Survey (n = 1,295), linked to the
National Death Index. The relationship between recurrent falls (≥2 falls) in the past year and 10-year death rate
was assessed using survey-weighted Cox regression.
Results: Nearly 20 % of adults who died within 10 years of their interview date were recurrent fallers at the time
of interview. For women only, recurrent fallers had more than 4-fold increased hazard of death within 10 years
compared to non-recurrent fallers (HR = 4.41; 95 % CI:2.24,8.68).
Conclusions: Findings suggest that midlife women are particularly vulnerable to adverse outcomes following
recurrent falls. Fall prevention efforts should include efforts targeted at midlife women.

1. Introduction
Falls are a well-established public health concern, particularly
among older adults and women (Ylitalo & Karvonen-Gutierrez, 2016).
Approximately 30 % of older community-dwelling adults fall once per
year and approximately 15 % fall two or more times per year
(O’Loughlin, Robitaille, Boivin, & Suissa, 1993; Tinetti, Speechley, &
Ginter, 1988). Globally, the age-standardized prevalence rate of falls
was 5186 per 100,000 in 2017 (James et al., 2020). However, at every
age, women fall more often than men (Timsina et al., 2017; Ylitalo &
Karvonen-Gutierrez, 2016) and have worse outcomes (Ylitalo &
Karvonen-Gutierrez, 2016; Xu & Rivera Drew, 2016).
Annually, falls account for $50.0 billion in medical costs in the
United States (Florence et al., 2018), in part because falls are the
leading cause of hospitalization and disability (Chandra et al., 2015;
Gill, Taylor, & Pengelly, 2005; Stewart Williams et al., 2015) and are
associated with adverse health outcomes and early mortality (Rockett
et al., 2012). The burden of adverse, fall-related outcomes increases
with age (Hartholt, Lee, Burns, & van Beeck, 2019; Rockett et al., 2012)
and fall-associated mortality has increased more than 2-fold from 2000
to 2016 (Hartholt et al., 2019). Women are disproportionately affected
by injurious falls (Ylitalo & Karvonen-Gutierrez, 2016) and fall-related
fractures (Stevens & Sogolow, 2005).
Falls are commonly studied among older adults, but there is a
growing body of evidence that the incidence of falls (Caban-Martinez
et al., 2015; Verma et al., 2016; Ylitalo & Karvonen-Gutierrez, 2016)
and fall injuries (Talbot, Musiol, Witham, & Metter, 2005; Ylitalo &
Karvonen-Gutierrez, 2016) among midlife adults is comparable to that
among older adults, particularly among women, and the annual in-
cidence of falls triples during the 25 years spanning the midlife period
(Peeters, van Schoor, Cooper, Tooth, & Kenny, 2018). Understanding
the risk factors and consequences of recurrent falls (i.e., 2 or more falls)
may be more salient than of a single fall, especially for midlife adults.
Recurrent falls are related to intrinsic patient-related factors such as
physical or cognitive decline, whereas single falls may be more related
to extrinsic environmental factors (Cumming, Kelsey, & Nevitt, 1990;
Nevitt, Cummings, Kidd, & Black, 1989; Stalenhoef, Diederiks,
Knottnerus, Kester, & Crebolder, 2002). Contrary to popular belief, the
presence of falls among midlife women do not appear to be merely a
consequence of engaging in a more active lifestyle (Talbot et al., 2005).
The incidence rate for fall-related injuries preceded by vigorous activ-
ities is similar among midlife and older women (Timsina et al., 2017).
However, it is unknown if falls during the midlife are associated with
future adverse health outcomes as has been observed among popula-
tions of older adults. Thus, this study aims to address the gap in the
literature regarding fall sequelae in midlife adults. The purpose of this

⁎
Corresponding author at: University of Michigan, School of Public Health, 1415 Washington Heights, Room 6618, Ann Arbor, MI, 48109, United States.
E-mail address: ckarvone@umich.edu (C.A. Karvonen-Gutierrez).

https://doi.org/10.1016/j.archger.2020.104206
Received 20 April 2020; Received in revised form 20 July 2020; Accepted 22 July 2020
Available online 25 July 2020
0167-4943/ © 2020 Elsevier B.V. All rights reserved.
C.A. Karvonen-Gutierrez, et al.
investigation was to determine the 10-year risk of mortality for midlife
adults who were recurrent fallers as compared to midlife adults were
not recurrent fallers, and to determine if the association differed by sex,
in a nationally representative sample of late middle-aged adults.
2. Methods
2.1. Study population
The study population consisted of late middle-aged adults who
participated in the household interview portion of the Third National
Health and Nutrition Examination Survey (NHANES III). The NHANES
III survey interviewed and examined a nationally-representative sample
of Americans in two phases between 1988 and 1994, and the current
analysis included data from both phases. In NHANES III, questions re-
garding falls were asked only of adults age 60 years and older. Of the
20,050 adults interviewed, 1344 were at least 60 years old but younger
than 65. Of these, 11 were excluded because the number of times they
had fallen in the 12 months preceding the NHANES III interview was
unknown. Additionally, 2 subjects were excluded due to missing mor-
tality information as of 2011 and 14 subjects were further excluded due
to missing body mass index (BMI). We also excluded 22 subjects who
were underweight (BMI ≤ 18.5 kg/m2) because their mortality hazards
were likely different than the others and these hazards were not of
primary interest. The final analytic sample, therefore, included 1295
subjects.
2.2. Measures
2.2.1. Fall information
Participants were asked “About how many times have you fallen in
the past 12 months and landed on the floor or hit an object?” at the
NHANES III household interview. Participants could answer either
“None/never” or report the number of times they had fallen (range:
1–30). For the current analysis, participants’ responses were dichot-
omized into two groups: non-recurrent fallers (had not fallen or fell
only once) and recurrent fallers (fell twice or more), similar to other
work (Stel et al., 2003).
2.2.2. Mortality
The mortality status of participants was obtained from the 2011
Public-use Mortality file linked to NHANES III. The public-use mortality
file was created by the National Center of Health Statistics through
queries to the National Death Index, a national database of death cer-
tificates. The mortality file included information about the participants’
mortality status as of December 31 st, 2011 and the number of months
of follow-up since their NHANES III interview to death. For this ana-
lysis, the outcome event of interest was death occurring within ten
years of the interview in which recurrent fall information was ascer-
tained. Follow-up time for any deaths occurring ≥ 10 years after the
interview were censored at 10 years. We calculated participants’ at-
tained age by summing their age at interview and follow-up time, and
used “attained age” as the time- scale in the survival analysis.
2.2.3. Covariates
Covariates considered in our analysis were sex, race (non-Hispanic
White, non-Hispanic Black, and Other), body mass index (BMI),
smoking status (“never”, “past” and “current”), years of education,
comorbidities (congestive heart failure or heart attack, stroke, diabetes
and cancer), and physical activity. Sex, race/ethnicity, smoking status,
education and comorbidities were obtained by interview. BMI was
calculated from measured weight and height at the NHANES III Mobile
Examination Center (MEC). For participants whose in-person mea-
surements of weight and height were not available (n = 100), their self-
reported weight and height at the household interview was used to
calculate BMI. History of doctor diagnosed congestive heart failure,
2
Archives of Gerontology and Geriatrics 91 (2020) 104206
heart attack, stroke, and cancer were based upon self-report during the
interview. Diabetes was defined as meeting at least two of the fol-
lowing: self-reported doctor diagnosed diabetes, self-reported use of
prescription medications to treat diabetes, or having an HbA1c value
greater than or equal to 6.5 %. Medication use information was ob-
tained from the NHANES III “Prescription Medication file” and HbA1c
was measured in blood samples collected at the MEC. Physical activity
was estimated based on the frequency and intensity of up to 13 activ-
ities reported during the household interview. Participants reported the
number of times they engaged in an activity in the past month and
NHANES III provided the metabolic equivalent (MET) of that activity.
The weekly amount of an activity (in MET hours) was calculated as the
number of times a person engaged in an activity per month multiplied
by 0.5 hours and the activity-specific MET, divided by 4.3 (the number
of weeks per month). Total weekly leisure-time physical activity was
the sum of MET-hours across all activities.
2.3. Statistical analysis
NHANES III is a complex survey and the survey design factors
(cluster, strata and sampling weights) were accounted for in all analyses
per the NHANES III analytic guidelines. Specifically, clusters were
identified with the six-year Primary Sampling Unit (PSU) variable
(SDPPSU6) and strata were identified with the six-year strata variable
(SDPSTRA6). The sampling weights of the six-year household interview
sample were used (WTPFQX6) for all analyses. The analytic dataset was
created in SAS v9.3 (SAS Institute Inc., Cary, NC) and subsequently
analyzed in R 3.2.2 (R Foundation for Statistical Computing, Vienna,
Austria) (using primarily packages “Survey (version 3.30)” and
“Survival (version 2.38)”).
Descriptive statistics of the analytic sample including survey-
weighted means (standard errors), survey-weighted medians (inter-
quartile ranges), and survey-weighted proportions of covariates were
calculated by mortality status. Differences in the distributions of these
covariates by mortality were compared using survey-weighted T-tests,
survey-weighted Wilcoxon rank-sum tests, and Chi-square tests with
Rao & Scott adjustment (Rao & Scott, 1984). Similarly, the distributions
of covariates by fall status were described with survey-weighted means
(standard errors), survey-weighted medians (interquartile ranges), or
proportions by men and women. To assess the relationship between fall
status and mortality hazard, we first fit a survey-weighted Cox regres-
sion model to predict “attained age” with recurrent fall status. We then
added to this model sex, race, BMI, smoking status and years of edu-
cation to account for confounding (9 participants excluded with missing
education data). Next, we added comorbidities (heart failure/heart at-
tack, stroke, diabetes and cancer) and number of prescription medica-
tions to the model to examine potential confounding by health status
(58 participants further excluded due to missing comorbidity or medi-
cation data). Finally, we added physical activity to our final models to
evaluate the potential confounding impact of physical activity on the
association. Baseline hazards were stratified on sex, smoking, and his-
tory of heart failure/heart attack to satisfy the proportional hazard
assumption. To investigate potential differences between men and
women, we repeated the same analyses separately for each sex. As a
sensitivity analysis for our results, we also repeated the analyses after
excluding subjects who had had cancer, because they may have unique
risks for falls and mortality. For all Cox models, the confidence intervals
and p-values of the beta coefficients were calculated based on a T dis-
tribution with 49 degrees of freedom (calculated per NHANES guide-
lines as number of PSUs minus number of strata).
3. Results
Among 60−65 year old adults in the United States, 16.6 % were
deceased within 10 years. Individuals who died within 10-years of
follow-up were less educated, more likely to be current smokers, more
C.A. Karvonen-Gutierrez, et al. Archives of Gerontology and Geriatrics 91 (2020) 104206

Table 1 mortality among recurrent fallers as compared to non-recurrent fallers.

Characteristics of study sample (n = 1295) at National Health and Nutrition In fully adjusted models among women, recurrent fallers had more than
Examination Survey III interview by mortality status after 10 years of follow-up 4-fold increased risk of death within 10 years as compared to non-re-
from date of interview. current fallers (HR = 4.41, 95 % CI 2.24, 8.68).
Characteristic of interest Alive Deceased p-value In the fully adjusted model (Model 4a, Table 2), but excluding pa-
tients with comorbid cancer from the analyses, the association between
n, Weighted proportion (%) 83.4 16.6
recurrent falls and mortality persisted in the overall sample
Weighted Mean (SE)
(HR = 2.01, 95 % CI 1.14, 3.56) and among women (HR = 2.88, 95 %
Age (years) 62.0 (0.06) 62.2 (0.14) 0.204 CI 1.25, 6.67).
Years of education 11.7 (0.16) 10.8 (0.33) 0.013
Body mass index (kg/m2) 27.5 (0.22) 28.5 (0.63) 0.169 4. Discussion
Physical activity (MET hours/week) 12.0 (0.68) 10.5 (1.13) 0.218

Weighted proportion (%) This study evaluated the 10-year risk of death among recurrent and
Recurrent fall status < 0.001 non-recurrent fallers of late middle-age adults. The main finding of this
Had not fallen/fallen once 94.5 80.5 study is that women who were recurrent fallers were more than 4 times
Fallen twice or more 5.5 19.5
as likely to die within 10 years compared to women who were non-
Female 56.1 50.0 0.374
recurrent fallers, but that there was no difference in mortality risk by
fall status among men. The findings of our analysis persisted after ad-
Race 0.341 justment for many known confounders including BMI, comorbid con-
White 82.2 78.3 ditions, and physical activity. Thus, the relationship between recurrent
Black 7.9 11.2
fall status and mortality exists for women only. This sex dimorphism in
Other 9.9 10.5
our findings is notable and suggests that for women, recurrent falls may
Smoking status < 0.001 be an important marker to identify individuals at risk for adverse out-
Never smoker 41.5 26.6 comes, even during the midlife period. One possible reason for this sex
Past smoker 38.4 40.0 dimorphism may be due to sex differences in body composition, par-
Current smoker 20.1 33.4
ticularly those occurring during the midlife, whereby women have
Comorbidities proportionally less lean mass than do age-matched men (Schorr et al.,
Cardiovascular disease 9.1 24.4 < 0.001 2018). Amount of lean mass has been identified as a risk factor for falls
Stroke 2.8 10.6 < 0.001 among both men and women (Xu, Ebeling, & Scott, 2019) and body
Diabetes 16.1 30.7 < 0.001
composition level and change is predictive of adverse health outcomes
Cancer 5.1 13.9 0.002
including cardiometabolic risk (Schorr et al., 2018), and mortality
Median (IQR) (Santanasto et al., 2017). These body composition differences may then
Number of prescription medications 1 (0, 3) 2 (1, 5) < 0.001 confer different risks associated with midlife falls for women as com-
pared to men.
Given the possibility that the observed sex dimorphism may be re-
likely to have comorbid conditions, and had a higher median number of lated to sex differences in body composition, and that low levels of
medications as compared to individuals who remained alive after 10 skeletal muscle may increase risk of falls, we conducted a sensitivity
years of follow-up (Table 1). The sample included 652 men and 643 analysis to consider the impact of including body composition in the
women, and there were no differences in age, sex, race, or BMI by models evaluating the relationship between recurrent falls and mor-
mortality status. Nearly 20 % of individuals who died within 10-years tality. The sensitivity analysis used a subset (91 % of the analytic
of follow-up reported falling twice or more compared to only 5.5 % sample) of NHANES III participants who had measures of body com-
among participants who did not die within 10 years (p < 0.001). position, including waist circumference (cm), waist-to-hip ratio, and
Among both men and women, there were no differences in age, bioelectrical impedance analysis-estimated percent skeletal muscle
education, race, smoking status, or BMI by recurrent fall status mass (kg) (Janssen, Baumgartner, Ross, Rosenberg, & Roubenoff, 2004;
(Table 2). Men and women who were recurrent fallers were more likely Janssen, Heymsfield, & Ross, 2002). The sensitivity analysis demon-
to have cardiovascular disease or stroke as compared to non-recurrent strated that the magnitude of the effect estimate for recurrent falls was
fallers. Among women only, the prevalence of diabetes was greater attenuated by 17 % when additionally including either waist cir-
among women who were recurrent fallers as compared to non-recurrent cumference or waist-to-hip ratio in the multivariable models and by 43
fallers. Also among women only, recurrent fallers used more prescrip- % when including percent skeletal muscle mass (data not shown). For
tion medications as compared to non-recurrent fallers. men, the magnitude of the effect estimate for recurrent falls did not
Being a recurrent faller was associated with more than a 3-fold in- change meaningfully (all < 10 %) with the additional inclusion of the
creased hazard of death in 10 years (HR = 3.44, 95 % CI: 2.05, 5.76) as body composition parameters in the multivariable models.
compared to those who fell once or not at all (Table 3). This association The role of body composition as an important variable in the re-
persisted after adjustment for sex, race, BMI, smoking status and edu- lationship between falls and mortality, particularly among women,
cation (HR = 3.46, 95 % CI: 2.01, 5.97). Given the association between confirms known sex differences in body composition among adults.
chronic comorbidities and falling and chronic comorbidities and mor- Approximately 10 % of adults globally age 60 years and older have age-
tality, models were additionally adjusted for cardiovascular disease, associated loss of muscle mass and muscle strength known as sarco-
stroke, diabetes, cancer and number of prescription medications, and penia (Shafiee et al., 2017). Sarcopenia, with or without obesity, is
the magnitude of the association between falls and mortality was associated with increased risk of physical functioning limitations, dis-
slightly attenuated but remained statistically significant (HR = 3.09, 95 ability, falls, and mortality (Beaudart, Zaaria, Pasleau, Reginster, &
% CI: 1.92, 4.97). Further adjustment for physical activity did not Bruyere, 2017). Increasing recognition of sarcopenia among obese in-
change the estimate. dividuals, termed sarcopenic obesity, suggests that increased fat mass
In fully-adjusted models stratified by sex, the association between and low muscle strength are particularly problematic for health out-
recurrent fall status and mortality within 10 years was not present comes like falls (Scott, Daly, Sanders, & Ebeling, 2015) and may also be
among men in unadjusted or fully adjusted models. Among women, predictive of metabolic disorders and mortality (Zamboni, Mazzali,
however, there was a strong and consistent increased hazard of Fantin, Rossi, & Di Francesco, 2008). In older populations (i.e., ≥75

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C.A. Karvonen-Gutierrez, et al. Archives of Gerontology and Geriatrics 91 (2020) 104206

Table 2
Characteristics of the study sample (n = 1295) at National Health and Nutrition Examination Survey III interview by recurrent fall status and stratified by sex.
Characteristic of interest Men p-value Women p-value
n = 652 n = 643

Non-recurrent faller Recurrent faller Non-recurrent faller Recurrent faller

Weighted Mean Weighted Mean

(Standard Error) (Standard Error)
Age (years) 61.9 (0.089) 62.2 (0.41) 0.424 62.0 (0.086) 62.1 (0.26) 0.928
Years of education 11.7 (0.23) 11.4 (0.96) 0.784 11.4 (0.18) 11.3 (0.45) 0.867
Physical activity (MET hours/week) 13.8 (1.0) 6.1 (1.9) 0.002 10.6 (0.74) 9.2 (2.5) 0.610
Body mass index (kg/m2) 27.5 (0.25) 26.9 (0.83) 0.478 27.8 (0.32) 29.0 (1.33) 0.393

Weighted proportion (%) Weighted proportion (%)

Race 0.332 0.330
White 80.9 87.9 81.1 87.8
Black 7.9 3.7 9.5 3.9
Other 11.1 8.4 9.4 8.2

Smoking status 0.215 0.591

Never smoker 29.4 16.7 47.2 51.6
Past smoker 49.5 67.5 29.6 21.4
Current smoker 21.1 15.8 23.2 27.0

Comorbidities
Cardiovascular disease 15.3 32.0 0.044 6.5 21.4 0.004
Stroke 2.8 23.0 < 0.001 2.9 16.6 0.001
Diabetes 18.9 15.5 0.758 16.8 34.6 0.010
Cancer 3.9 7.2 0.488 7.9 16.6 0.230

Median Median
(Inter-quartile range) (Inter-quartile range)
Number of prescription medications 1 (0,2) 1 (0,2) 0.391 1 (0,3) 3 (2,5) 0.001

years), sarcopenic obesity is more common for men than for women.
However, findings on the sex-specific relationship between sarcopenic
obesity and physical functioning limitations appear to be mixed. Mul-
tiple studies have found that sarcopenia was significantly associated
with self-reported disability in both men and women (Baumgartner
et al., 1998; Janssen et al., 2004; Levine & Crimmins, 2012), but other
work has shown the relationship between sarcopenia and poor func-
tioning appears to be stronger for women than for men (Janssen et al.,
2002). Sarcopenic obesity among late-midlife women, and its adverse
effect on physical functioning, may be explained by accelerated de-
clines in muscle mass and strength during the menopause transition
(Hita-Contreras, Martinez-Amat, Cruz-Diaz, & Perez-Lopez, 2015).
Thus, for women, the accelerated loss of muscle mass and strength
during the menopausal transition and in midlife more broadly may
confer not only increased risk of falls but also an increased risk of other
adverse health outcomes including mortality. We posit that it is possible
that changes in body composition may have a bi-directional
relationship with fall status for midlife women; declines in muscle mass
may increase ones risk for falls, and women who fall may reduce their
physical activity to protect against further falls, thereby leading to
additional declines in skeletal muscle. Because of the cross-sectional
nature of the NHANES III dataset, we cannot evaluate this hypothesis
here, but other studies with longitudinal data on body composition,
physical activity and falls among midlife women are encouraged to
examine this further. If true, this could explain our findings that re-
current falls were associated with an increased rate of mortality among
a sample of overweight women, even in a relatively health, ambulatory
population, and suggests that interventions focused on muscle
strengthening for midlife women may be beneficial not only for phy-
sical functioning, but may even reduce risk of mortality among women
already experiencing falls.
Falls are a commonly studied outcome among populations of older
adults, but this analysis specifically considered recurrent falls among
late-midlife adults. Importantly, we found that recurrent falls were

Table 3
Hazard ratio (HR) of mortality associated with recurrent fall status, overall and stratified by sex, National Health and Nutrition Examination Survey III.
Model Overall Men Women

HR 95 % CI p-value HR 95 % CI p-value HR 95 % CI p-value

a
Model 1 3.44 2.05, 5.76 < 0.001 1.68 0.64, 4.43 0.284 5.53 2.80, 10.94 < 0.001
b
Model 2 3.46 2.01, 5.97 < 0.001 1.82 0.69, 4.80 0.224 5.07 2.38, 10.82 < 0.001
c
Model 3 3.09 1.92, 4.97 < 0.001 1.72 0.66, 4.47 0.260 4.07 2.00, 8.28 < 0.001
d
Model 4 3.09 1.92, 4.97 < 0.001 1.85 0.73, 4.67 0.189 4.41 2.24, 8.68 < 0.001

e
Model 4a 2.01 1.14, 3.56 0.018 1.19 0.46, 3.04 0.718 2.88 1.25, 6.67 0.014

Note. Hazard ratio (HR); Confidence interval (CI).

a
Unadjusted.
b
Adjusted for sex (in overall model), race, BMI, smoking status, and education.
c
Adjusted as Model 2 + cardiovascular disease, stroke, diabetes, cancer, and number of prescription medications.
d
Adjusted as Model 3 + physical activity.
e
Sensitivity analysis with model excluding patients with cancer; adjusted with variables from Model 4.

4
C.A. Karvonen-Gutierrez, et al.
common in this age group of late-midlife adults as has been observed
among a population of midlife Polish adults (Skalska et al., 2013) and
midlife Singaporean adults (Dai et al., 2018). Although older adults
tend to have slightly greater burden of recurrent falls (Huang et al.,
2017; Skalska et al., 2013), accumulating evidence suggests that the
midlife period is a critical window for increased burden of falls, parti-
cularly for women. In the Behavioral Risk Factor Surveillance System,
women age 55–59 years of age had the highest prevalence of injurious
falls in a sample of men and women age 45–79 years of age (Ylitalo &
Karvonen-Gutierrez, 2016). Similarly, in a recent analysis of four po-
pulation-based cohort studies from Australia, Ireland, the Netherlands,
and Great Britain, a sharp increase in fall burden occurred during
midlife for women but not men (Peeters et al., 2018). Thus, there is a
pressing need to consider the consequences of falls among midlife
adults. Our analysis demonstrates that, perhaps for women, falls oc-
curring during midlife may be an indication of at-risk health states, as
evidenced by the higher rate of mortality among women who were
recurrent fallers. There is a commonly held belief that falls among
midlife adults are not of concern because they may merely be the
consequence of engaging in highly active tasks that may actually be
beneficial for health. However, falls may result in injury, and recurrent
falls are may indicate other underlying health conditions warranting
attention (Nevitt et al., 1989). Our analysis is unable to determine
whether the deaths were a direct consequence of the falls or whether
the recurrent falls might be an early indication of individuals at higher
risk of mortality. Our findings were robust to several important health
variables including BMI, cardiovascular disease, stroke, diabetes,
cancer, and prescription medications. Given the high hazard of death
observed among women in this study, it is imperative that this question
be further understood because in either scenario, understanding the
sequelae of falls among midlife adults holds the opportunity for inter-
vention and prevention as individuals are transitioning from midlife to
late life.
Due to constraints with data availability, given that falls were not
queried in NHANES until age 60, our analysis was only able to include
late-midlife adults. However, our findings call for longitudinal studies
of midlife adults with information on fall burden to consider the re-
lationship of falls and future adverse health outcomes. To our knowl-
edge, no studies currently have this information available as the studies
of midlife adults with fall information are either cross-sectional without
follow-up of participants or are longitudinal studies with fall informa-
tion among midlife adults but lacking long enough follow-up to un-
derstand the long-term health outcomes and/or mortality risks. Studies
with data regarding falls among midlife adults are encouraged to con-
sider including post-fall questionnaires in these populations to advance
our understanding of the meaningfulness of these falls. Studies among
older adults can serve as a model for the ways in which to understand
adverse consequences following a fall among midlife adults, particu-
larly for women.
There are several limitations of the present study. First, we used
death status, but not cause of death. Although there are many different
biological pathways by which falls may increase the risk of death, it is
possible that some death events were wholly unrelated to recurrent falls
during the late midlife. Second, while we used a robust set of variables
in our multivariate models, unmeasured confounding is possible. Third,
there may be some recall bias with the self-reporting of falls among
participants as they were recalling falls in the past year. However, we
do not have reason to believe that this would be differential by mor-
tality status. Finally, although we used a large, nationally re-
presentative population of adults in the United States, institutionalized
persons are ineligible for the NHANES study. Recurrent fallers may be
under-represented in the study if they were more likely to be hospita-
lized or institutionalized for fall-related or non-fall-related health con-
cerns. Nevertheless, this study of recurrent falls and 10-year mortality
represents a large, well-characterized sample of late midlife adults. Our
findings, particularly related to sex differences in 10-year mortality risk
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Archives of Gerontology and Geriatrics 91 (2020) 104206
after recurrent falls, are novel and suggest that fall screening and pre-
vention efforts should target midlife women.
5. Conclusion
Women who were recurrent fallers had more than 4 times increased
risk of mortality in the next 10 years as compared to women who were
not recurrent fallers. Recurrent fall status was not associated with
mortality among men. The association of recurrent falls and mortality
among women calls for further research to better understand the short-
and long-term consequences of falls during the midlife. There is a
dearth of data regarding falls among midlife populations, yet this study
indicates that falls during this life stage are prevalent and may serve as
an early indication of future adverse health outcomes, even among
relatively healthy individuals.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
was supported by training grants from the National Institute on Aging
(NIA) [grant number K01AG054615, K01AG058754].
Research ethics
IRB approval not required because analysis includes only publicly
available data sets that do not include information that can identify
individuals.
CRediT authorship contribution statement
Carrie A. Karvonen-Gutierrez: Conceptualization, Methodology,
Validation, Data curation, Writing - original draft, Writing - review &
editing. Kelly R. Ylitalo: Validation, Writing - review & editing. Mia Q.
Peng: Conceptualization, Methodology, Software, Validation, Formal
analysis, Writing - review & editing.
Declaration of Competing Interest
The authors declare that there is no conflict of interest.
Acknowledgements
None.
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