Falls prevention in China: time for action
Authors: Yao Yao, Pengbin Yin, Xiaoyun Liu
Journal: The Lancet Public Health (2021)

Globally, falls are a major public health concern for older people (aged ≥65 years). Approximately a third of older adults and half of those aged 80 years and older have at least one fall a year.1WHOStep safely: strategies for preventing and managing falls across the life-course. World Health Organization, GenevaApril 27 2021https://www.who.int/publications/i/item/978924002191-4Date accessed: November 7, 2021Google Scholar, 2Florence CS Bergen G Atherly A Burns E Stevens J Drake C Medical costs of fatal and nonfatal falls in older adults.J Am Geriatr Soc. 2018; 66: 693-698Crossref PubMed Scopus (431) Google Scholar Falls are not only the leading cause of injury-related mortality but also lead in the causes of traumatic bone fracture and injury-related outpatient visits in older people in China.3Chinese Health CommissionCore messages for health education on fall prevention for older people.https://www.chinacdc.cn/jkzt/mxfcrjbhsh/jcysj/202110/t20211012_250181.htmlDate: Oct 12, 2021Google Scholar In this issue of The Lancet Public Health, Pengpeng Ye and colleagues4Ye P Er Y Wang H et al.Burden of falls among people aged 60 years and older in mainland China, 1990–2019: findings from the Global Burden of Disease Study 2019.Lancet Public Health. 2021; 6: e907-e918Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar report the burden of falls in terms of incidence, mortality, and disability-adjusted life-year (DALY) in people aged 60 years and above in China from 1990 to 2019. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, this Article fills an important gap in the literature because the spatiotemporal trends of fall burden at the national level in China has not previously been reported. We were not surprised to see the high burden of falls in China given the rapid growth in the ageing population. Notably, the incidence rate of falls among Chinese older people increased steadily and substantially during the past three decades, regardless of sex, age group, and geographical location. There are two contrasting views of health trends in ageing populations, the so-named expansion of morbidity and compression of morbidity.5Zeng Y Feng Q Hesketh T Christensen K Vaupel JW Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study.Lancet. 2017; 389: 1619-1629Summary Full Text Full Text PDF PubMed Scopus (228) Google Scholar The increase in the burden of falls identified in this study reflects an expansion of morbidity, which is in line with the findings previously reported by Yi Zeng and colleagues,5Zeng Y Feng Q Hesketh T Christensen K Vaupel JW Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: a cohort study.Lancet. 2017; 389: 1619-1629Summary Full Text Full Text PDF PubMed Scopus (228) Google Scholar that increasing lifespan in people in China could lead to increased physical frailty and disability. We strongly support the conclusion of Ye and colleagues that more efforts and resources are needed for fall prevention in older people. However, we are unconvinced about the representativeness of the study sample and quality of the collected data, especially for GBD in China during the early stage of the study period (ie, 1990–2003). In GBD 2019, the definition of falls was clear. Because data for all the individuals included in Ye and colleagues' study, both inpatients and outpatients, were derived from medical records rather than a carefully designed survey, it might be difficult to extrapolate the findings to the general older population because only a small proportion of people who had a fall would seek aid or care at medical centres, often accompanied by some severe outcomes. The prevalence and burden of falls in community-dwelling older people and inpatients could be different; therefore, to some extent, the study by Ye and colleagues might underestimate the burden of falls in China. Another concern is the data quality. As far as we know, China has developed an Information System for Disease Control and Prevention that has linked hospitals and clinics nationwide since 2003, after the severe acute respiratory syndrome (SARS) epidemic. Therefore, the quality of data between 1990 and 2002 was yet to be validated. These limitations were rightly acknowledged by the authors.4Ye P Er Y Wang H et al.Burden of falls among people aged 60 years and older in mainland China, 1990–2019: findings from the Global Burden of Disease Study 2019.Lancet Public Health. 2021; 6: e907-e918Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Importantly, falls can be prevented. Abundant research shows that exercise, nutrition, and home safety modification are effective in reducing falls.6Lamb SE Lee H Multi-factorial fall prevention strategies: where to next?.in: Lord SR Sherrington C Naganathan V Falls in older people. Cambridge University Press, Nov 4, 2021: 386-395Crossref Google Scholar Although some observational studies have reported on the modifiable factors of falls in older adults in China, few trials have been conducted to assess the cost-effectiveness of those potential intervention strategies in this population. For example, there is no published evidence of the effectiveness of vitamin D supplementation on fall prevention in older people in China, although they have a high prevalence of vitamin D deficiency.7Liu W Hu J Fang Y Wang P Lu Y Shen N Vitamin D status in Mainland of China: a systematic review and meta-analysis.EClinicalMedicine. 2021; 38101017Summary Full Text Full Text PDF Scopus (1) Google Scholar The Chinese National Health Commission released the "Core messages for health education on fall prevention for older people" in October, 2021.3Chinese Health CommissionCore messages for health education on fall prevention for older people.https://www.chinacdc.cn/jkzt/mxfcrjbhsh/jcysj/202110/t20211012_250181.htmlDate: Oct 12, 2021Google Scholar There were 15 recommendations with detailed information relevant to the risks, modifiable factors, prevention, education, and care for older people who have falls. However, who should be responsible for implementing and advancing such ageing-friendly environments, is still being debated. Another concern is that the aforementioned education and prevention strategy, which was primarily disseminated over the internet, might not work in older people because of the substantial digital divide between younger and the older populations.8Yao Y Zhang H Liu X Liu X Chu T Zeng Y Bridging the digital divide between old and young people in China: challenges and opportunities.Lancet Healthy Longev. 2021; 2: e125-e126Summary Full Text Full Text PDF Scopus (5) Google Scholar A robust, sustainable, and scalable falls prevention service should be integrated into policy and the health systems in China.9Ye P Liu Y Zhang J et al.Falls prevention interventions for community-dwelling older people living in mainland China: a narrative systematic review.BMC Health Serv Res. 2020; 20: 808Crossref PubMed Scopus (5) Google Scholar Gagen and Bulzacchelli have designed a pragmatic conceptual model for local delivery of fall prevention programmes for older adults in the community.10Gagen TM Bulzacchelli MT Improving local service delivery to prevent falls in community-dwelling older adults: translating research to practice.Gerontologist. 2021; 61: 819-825Crossref PubMed Scopus (1) Google Scholar We support the idea that interagency collaboration, such as cooperation between health-care providers and local agencies, could benefit older adults through fall prevention services. This conceptual model can also be used as a guide to promote, implement, and assess fall prevention services for community-dwelling older adults in China. Further interagency collaboration between medical services, public health, and social care, especially at the primary care level, should be promoted with the support of new information technologies and multiple financing sources to mitigate the increasing burden of falls among older people in China. We declare no competing interests. We thank Hao Zhang (Weill Cornell Medicine) for advice. We also thank the support from the Healthy Aging Consortium of the China Cohort Consortium Burden of falls among people aged 60 years and older in mainland China, 1990–2019: findings from the Global Burden of Disease Study 2019Between 1990 and 2019, the incidence rate of falls increased substantially in older adults across mainland China, whereas the rates of mortality and DALY of falls among older people remained relatively stable, suggesting improvements in outcomes of falls. Nevertheless, falls remain an ongoing health burden for older people in mainland China, and there is an urgent need to introduce system-wide, integrated, and cost-effective measures to protect and support older people to minimise their risks and combat an increasing absolute burden as the population continues ageing. Full-Text PDF Open Access