Unintentional injuries among elderly people: Incidence, causes, severity, and costs

4ccid. Anal. & Prev. Vol. 21. No. 3, pp. 233-242, 1989 ?rimed in Great Britain.

0001-4575/89 $3.00+.00 © 1989PergamonPress plc

UNINTENTIONAL INJURIES AMONG ELDERLY PEOPLE: INCIDENCE, CAUSES, SEVERITY, AND COSTS H A R M E E T S J O G R E N a n d U L F BJORNSTIG The Umeh Accident Analysis Group, Department of Surgery, University of Ume~, S-901 85 Umeh, Sweden (Received 20 May 1988)

Abstract~People aged 60 years or older (1,313 injured) treated for unintentional injuries at the emergency department of the Regional Hospital in Umeh, Sweden, over a period of one year were included in the material. The injury, fracture, and mortality rates per 1,000 persons aged 60 years or over were 57, 31, and 0.6, respectively. The causes of injuries were falls (70%), vehicle accidents (10%), and other (20%). Injury incidence, severity of injuries, proportion of injuries that were fractures, femur neck fracture frequency, duration of hospitalization, and mean costs of medical care increased with age of patients. Women had a higher injury rate, more severe injuries, longer duration in hospital, and higher cost of medical care than men. The cost of medical care of this group of elderly, making up 15% of all injured in the primary admission area, was SEK* 14 million; this being almost half the cost for all injured. Since the elderly population, especially the very old, is expected to increase in the future, prevention of falls (taking up 80% of total treatment costs) and vehicle accidents (causing the most critical injuries) is of utmost importance.

INTRODUCTION

Injury is one of the foremost causes of death and ill health in the western world (Baker, O'Neill, and Karpf 1984). In Sweden, about 5% of deaths are due to injuries (Official Statistics of Sweden 1987). More than half (55%) of the people, who die due to unintentional injuries, are aged 60 years and over (Official Statistics of Sweden 1987). The iraportance of injuries as a cause of mortality and morbidity in the elderly is further reflected by the number hospitalized as a result of injuries: in Stockholm, almost one ir every seven inpatients aged 65 years or older is being treated for injuries (Ahlbom and Engblom 1977). In Sweden, the number of people over the age of 65 is expected to increase by 10% and make up about 20% of the population after the turn of the century; this group accounts for 17% of the population today. It is mostly the number of very old people, above 80 years of age, who are expected to account for this increase: this group increasing by 30% by the end of the century (Swedish Official Report 1987). In view of this, studies oft injuries in the elderly are important in elucidating underlying causes, to prevent injuries in the elderly and thereby restrict the expected increase in economic demands ort the health care system. The main objectives of the present study were to analyse the incidence, causes, se verity, and costs of injuries in elderly people treated at the Regional Hospital in Ume~, as little is known about the total injury panorama in the elderly, especially in this region of northern Sweden, which has a winter climate lasting nearly half the year. MATERIAL

AND METHODS

The present material consisted of 1,313 injured aged 60 years and over (14.6% of all injured), treated for unintentional injuries, during a period of one year (April 1, 1985-March 31, 1986). In this number of injured, the same patient was counted more thorn once if he or she had been injured twice (18 men, 21 women) or three times (3 men). Thus, 1,268 injured had a total of 1,313 injury events. The patients were inter*1 US$ = 6 SEK (February 1988).

234

H. SJOGREN and U. BJORNSTIG

viewed when receiving their primary treatment at the Regional Hospital in Ume~. This is the only hospital serving an area of 60 km around Ume~. This area has a population of about 115,000 inhabitants. The age distribution of the elderly population in this area is presented in Table 1. These are official figures for 1985, obtained from the local health authority. It is possible that there may be some overlap with the neighbouring catchment area especially at the borderline regions; but this is probably negligible as the rural population is so low. Most of the patients (82%) came directly to the hospital, and 15% had been referred by a general practitioner. Forensic medical reports were also examined for the same area to determine the number of people who, as a result of fatal unintentional injuries, had died outside the hospital and thereby had not been treated at the hospital. They are described separately and not included in the analysis of the hospital-based material. Patients included in the hospital-based material who may have died after their discharge from the hospital or after transfer to Geriatrics or another institution were not included in the mortality figures. Medical records and social security records for each patient were studied for up to one year after the patient had been injured. The calculation of the cost of medical care, which included both inpatient and outpatient treatment, was based on the hospital accounts on mean operational costs for different departments for 1985. The severity of the injuries was graded according to the Abbreviated Injury Scale (AIS); where MAIS designates the maximum injury. A minor injury is AIS -- 1 and a critical injury where the survival is uncertain is AIS = 5 (Committee on Injury Scaling 1980). The causes of injuries were classified into three groups: falls, vehicle accidents caused by at least one vehicle in motion, and "other" types of event. RESULTS

Distribution of patients by age and sex Of a total of 1,313 injured, 761 (58%) were females and 552 (42%) were males. Almost half of the patients (45%) were aged between 60-69 years (Fig. 1). The number injured decreased with increasing age (Table 1). After the age of 70 years, more women than men were injured in each age group (Fig. 1). Both the injury rate and the fracture rate per 1,000 old people in population, however, increased with advancing age after the age of 74 years (Table 1). Time of injury event The highest proportion of people (9% per month) were injured in October and November and the least number in the midwinter months (December and January) (7% per month). It was also noted that in the "other" injury events, people were largely injured during the summer months. During weekdays, there was an even distribution of the number injured (mean Table 1. Number injured, population in study area, and injury and fracture rate/1,000 persons in each age group Injured (n)

Population

Injury rate / 1,000 persons

Fracture rate / 1,000 persons

Age

Men

Women

Men

Women

Men

Women

Total

Men

Women

Total

60-64 65-69 70-74 75-79 80-84 85-89 ~90

173 134 91 73 41 28 12

159 134 142 145 113 45 23

2 925 2 641 2 144 1 520 783 319 109

3 135 2 840 2 438 2 010 1 312 588 202

59 51 42 48 52 88 110

51 47 58 72 86 77 114

55 49 51 62 74 81 113

18 23 15 28 29 66 73

26 30 37 48 60 51 79

22 26 27 39 48 56 77

Total

552

761

10 441

12 525

53

61

57

23

38

31

Unintentional injuries amongelderlypeople

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10

l

60-6~

65-69

70-7k

75-79

80-84

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Fig. 1. Distributionof injured by age and sex and causes of injury related to age.

15%), with a decrease at weekends (mean 12%). The ratio of falls to vehicle accidents on the different days of the week remained largely unchanged. When the number injured was related to the time of the day, it was found that aearly half the patients were injured between 09.00 and 17.00 (46%), and 6% between 123.00 and 07.00. Most (93%) were injured during leisure time and 7% during working 1:ime. It was mostly men (67 men, 12% of men; 20 women, 3% of women) who injured l:hemselves during working time. Delay in arrival at hospital and means of transport Half the patients arrived at the hospital within six hours of being injured; most (17%) arriving within the first hour of being injured. Ambulance was used by 18% of the cases and taxi by 16%; the rest used other means of transport. The use of ambulance increased with advancing age of patient: 9% of 60- to 64-year-olds compared to 37% of 85- to 89-year-olds. Site of occurrence Nearly half (48%; 247 men, 377 women) were injured in residential areas (Fig. 2). In these areas, most were injured in falls (77%), and 22% were injured in "other" types of event (Fig. 2). In the residential areas, the garden together with the grounds, driveway, ~arage, and shed were the most common sites (27%), followed by the living room (21%), the kitchen (16%), and the stairs (12%) (Fig. 3). It was noted that more than half of the men were injured outside the residential building and women were most commonly ilajured in the living room (27%) followed by the kitchen (21%) (Fig. 3). It was also noted that a much higher percentage of women (14%) than men (8%) were injured on tae stairs (Fig. 3). In traffic areas, 23% (118 men, 180 women) of patients were injured; most of them being injured on public roads (Fig. 2). In these areas, more were injured by falling (.52%) than in an accident with a vehicle (44%) (Fig. 2). Nearly 12% (43 men, 108 women) were injured in institutions including schools and public administration (Fig. 2), and, as would be expected, old people's homes were the most common places. For this group of elderly in institutions, falling was the most common cause of injury. A~P

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H. SJOGRENand U. BJORNSTIG

236

% Total injured

0

10

20

SO

40

30

Area : residentiat traffic

institution production open air

falls

shopping

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sports

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Fig. 2. Causes of injury at different sites. Sixty-nine (5%) patients, mostly men aged between 60 and 70 years, were injured at production areas; farms and forests being the most common sites. It was noted that those who got injured in open air and recreation areas (4%) had been out picking wild berries in forests or uneven terrain (Fig. 2).

Causes and mechanisms of injury Falling was the most common cause of injury. Almost 70% (904 injured) of the total injured had fallen (Fig. 1). Women (80% of women) fell more frequently than men (50% of men). With advancing age, the frequency of falling increased: almost 45% of 60- to 64-year-old patients compared to 85% of 80- to 84-year-old patients (Fig. 1). Just over half of the injured (54%) fell on the same level; women (66% of women) falling more often than men (40% of men) (Fig. 4). However, in falls from another level, which constituted 18% of the total injured, an almost equal proportion of men and women were involved (Fig. 4). When these falls from another level (100 men, 148 women) were classified further into falls from stairs (78 injured, 31%), falls from less than one meter (138 injured, 56%), and from a level more than one meter (32 injured, 30 [ ] % of men ~ % of women E~1%of tofol injured

.=_ 2O

10

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drive

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shed

unspecified

Unintentional injuries among elderly people

237

70

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20

10

foil on some level

foil from another level

crash into resistance

crushed, foreign stabbed body,fluid in eye

acute overloading

heat, unspecified electricity, chemical

Mechanisms of injury Fig. 4. Mechanisms of injury.

[3%), it was noted that men (28 men, 28%) were more likely than women (4 women, 3%) to fall from levels more than one meter, whilst women (60 women, 40%) fell more often from stairs than men did (18 men, 18%). Just over 10% (73 men, 13%; 68 women, 9%) of the total injured were victims of ,,ehicle accidents (Fig. 1): 46% were cyclists, 32% car occupants, 8% skeleton sledge riders, 4% snowmobile riders, and 4% pedestrians; the rest being motorcyclists, mopedists and other vehicle occupants. The percentage injured in each age group in vehicle ~tccidents tended to decrease with increasing age of patients: 12% of 60- to 64-year-olds compared to 7% of 85- to 89-year-olds (Fig. 1). Over 20% (189 men, 35% of men; 78 women, 10% of women) of the total number were injured in other types of injury-producing events (Fig. 1). The number injured in these events decreased with advancing age (Fig. 1). One in every four injured (66 persons) by "other" causes was preparing firewood or doing woodwork. Other main activities in this group included repair or building work (42 injured, 16%), farming, forestery, garcening and hunting (36 injured, 14%) , walking, getting caught in a door (27 injured, 10%), household chores including cooking and eating (21 injured, 8%), and sports (17 injured, 6%).

Severity of injuries More than half of the patients (56%) had major injuries (MAIS ->->2). Two female patients had severe injuries (MAIS = 4) and five patients critical injuries (MAIS = 5). Four of the patients with critical injuries (MAIS = 5) died within 14 days of being injured. Women (21% of women) on the whole received more serious injuries (MAIS -> 3) than men (15% of men). With increasing age, the severity of injuries also increased (Fig. 5). Seven percent of 60- to 64-year-old patients compared to 40% of 85- to 89-year-old patients had serious injuries (MAIS - 3). Between the ages of 60 and 84 years, a higher proportion of women (19% of 60- to 85-year-old women) than men (14% of 60- to 84-year-old men) received serious injuries (MAIS - 3). After the age of 85 years, however, a higher percentage

238

H. SJOGREN and U. BJORNST1G

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of men (53% of ->85-years-old men) than women (32% of ->85-year-old women) had serious injuries (MAIS >- 3) (Fig. 5). Falls gave rise to a much higher proportion (22%) of serious injuries (MAIS - 3) than vehicle accidents (14%) and "other" types of injury-producing events (2%). However, only patients injured in vehicle accidents received severe (MAIS -- 4) and critical injuries (MAIS = 5). On the other hand, patients injured by "other" causes suffered mostly (78%) minor injuries (MAIS = 1); the corresponding figure for falls being only 35%. Although most of the people were injured in residential areas, it was on public roads that all severe and life-threatening (MAIS - 4) injuries occurred. Another interesting observation was that nearly 40% of those injured in institutions, which included old people's homes, received serious injuries (MAIS --- 3); the corresponding figures for residential areas and public roads being 18% and 14%, respectively.

Distribution of injuries Each patient had an average 1.14 injuries; total number of injuries being 1,508. The injury and fracture rate increased with increasing age after the age of 74 years (Table 1). Half of the injuries were fractures; upper extremities (40%) being the most common location, followed by the lower extremities (37%) (Table 2). The upper (33%) and lower (34%) extremities were the two most commonly injured regions of the body (Table 2). The proportion of injuries that were fractures increased with age of patient in both males and females. In 60- to 64-year-old patients, about 35% of the injuries were fractures, whilst in 85- to 89-year-old patients the corresponding number was 59%. As far as the difference in sexes was concerned, in the younger age group (60-69 years), women were more likely than men to get a fracture (45% of injuries in the women and 26% of injuries in the men in this age group). In the very old group (85-89 years), however, the injuries in men were in fact just as likely as in women to be fractures (58% of injuries in the women and 60% of injuries in the men in this age group). The most common fractures were those of the femur neck (169 injured), radiusulna (165 injured), rib-sternum (65 injured), humerus (63 injured), malleolus (43 injured), and vertebral column (42 injured). The frequency of femur neck fractures increased with increasing age of patient. In the age group 60-84 years, fractures of the femur neck were more common in women (23% of fractures in 60- to 84-year-old women) than in men (16% of fractures in 60- to 84-year-old men). However, in patients aged 85

Unintentional injuries among elderly people

239

Table 2. Type and location of injuries Type of injury

Head/face

Back/neck

Trunk

Upper extremity

Lower extremity

Total

Fracture/dislocation Wound/contusion Sprain Cerebral concussion or contusion Intrathorax, intraabdomen, and pelvis Others

17 159 0 51

46 0 11 0

107 54 0 0

299 178 37 0

276 141 96 0

745 (49%) 526 (35%) 144 (10%) 51 (3%)

0

0

7

0

0

7 (1%)

18

0

0

8

3

29 (2%)

245 (16%)

57 (4%)

Total

168 (11%) 522 (35%) 516 (34%) 1,508(100%)

years and over, 69% of the fractures in men in this age group were those of the femur neck, compared to 37% of the fractures in women. Most of the injuries resulting from falls were fractures and dislocations (60%) and only 27% of the injuries were wounds and contusions. However, in case of " o t h e r " injury-producing events, over 70% of the injuries were wounds and contusions; fractures and dislocations accounting for only 12% of the injuries. It was noted that cerebral zoncussions or contusions were more common injuries in vehicle accidents (11%) than in falls (3%).

Treatment and cost of medical care All patients had a total of 2,603 outpatient consultations at the departments of the hospital. Patients also visited the district nurse (111 patients), the district general prac~.itioner (43 patients), local medical centre (14 patients), and physiotherapy (17 patients). Of the 1,313 injured, 435 (33%) patients (169 men, 266 women) were hospitalized !or a total of 5,807 days; average duration being 13 days (range 1-90 days). Women, on :he whole, stayed in the hospital one day longer than men. With increasing age, the ~:otal number of days in the hospital increased and reached a peak in the age group 75'79 years. The mean number of days in the hospital for each patient also increased with advancing age of the patient; for those aged above 80, this being 15 days compared to patients aged between 60-64 years who stayed for 9 days. The total cost of inpatient and outpatient treatment was calculated to be SEK* 14 million; women (SEK 8.7 million) costing more than men (SEK 5.3 million). The total cost of medical care increased with increasing age, reaching a peak in age group 75-79, after which it declined (Fig. 6). This decline is accounted for by the rapid decrease in l he number of patients above the age of 80 years. However, the mean cost per person (SEK 10,700) increased with advancing age, rising from SEK 5,300 for age group 60~i4 years to SEK 23,000 for patients over 95 years of age (Fig. 6). The highest costs of medical treatment were for injuries acquired from falls; this being SEK 11.1 million compared to SEK 1.8 million for vehicle accidents. The mean cost per accident was highest for vehicle accidents (SEK 12,700); cost for falls being SEK 12,400. Treatment of injuries produced by " o t h e r " causes had the lowest medical costs, both total (SEK 0.9 million) and mean (SEK 3,900). Duration of sick leave and sickness benefit Since the retirement age in Sweden is 65 years, it was mostly the patients aged t,etween 60 and 65 years (97 patients) who were on sick leave. In total, 102 patients (52 raen and 50 women) had a total of 5,396 days of leave, i.e. a mean of 52 days (men 55 c ays, women 50 days) per entitled person. These 102 patients received SEK 939,000 in sickness benefit; on average SEK 9,200 per person. Mortality A total of 13 persons were fatally injured: six in vehicle crashes, six in fails, and one in " o t h e r " injury event. Nine of these injured died in the hospital. The other four *1 US$ = 6 SEK (February 1988).

240

H. SJOGREN and U. BJORNSTIG

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died outside the hospital and thus were taken directly to the State Institute of Forensic Medicine and were not included in the hospital material. Of the nine w h o died in hospital, four died on the same day as their accident and the other five within 21 days. Five of these were injured in traffic: three in cycle-car crashes, one in a car crash, and one was a pedestrian who got k n o c k e d down by a car. It was noted that in almost all these cases the elderly person injured appeared to be at fault. One example illustrating this point was the case of the fatally injured car driver, a 75-year-old w o m a n , w h o drove into the back of another car that was standing still at a crossing. The other four patients who died in hospital received injuries in association with falling. These included a 92-year-old w o m a n who fell indoors and an 87-year-old man w h o slipped on a wet patch on a varnished floor. There was also one man (65 years old) w h o fell of a roof while shovelling snow. The four persons w h o were taken directly to the State Institute of Forensic Medicine included one man w h o fell on the same level when in an inebriated state, one man w h o suffocated when snow fell on him from a barn roof. another one choked over his food,

Unintentional injuries among elderlypeople

241

and a 67-year-old woman who was knocked down by a car when she was crossing the road after getting off a bus. DISCUSSION The present study showed that in one year 57 per 1,000 elderly aged 60 years and over were treated at the hospital because of injuries, while the mortality rate in the area was 0.6 per 1,000 elderly. Since patients treated by general practitioners outside the hospital (estimated to be about one tenth; treated for mostly minor injuries), were not included in the present material, it is of interest to consider the fracture rate as a more reliable figure, as almost all patients with fractures are treated at the hospital. Since, to our knowledge, there is not much work done on elderly injured in all types of accidents, and in all environments, our fracture rate of 31 per 1,000 elderly can only be compared to the rate found for selected groups of people. In a study on residents living in an old people's home, Margulec, Librach, and Schradel (1970) found a fracture rate of 34 per 1,000 residents. Our results are also comparable with the fracture rate of 10.6 per 1,000 persons found by Waller (1978) in a study on patients treated at an emergency department for injuries resulting solely from falls. The incidence of injuries increased with advancing age of the patients after the age of 74 years; this being double in the oldest age group compared to the 60- to 74-yearc)ld group. A similar injury incidence trend has also been described by Lucht (1971) in a study on falls in the home. Women, in the present material, on all causes of injuries, were found to have a higher injury incidence than men. This is consistent with reports on elderly in institutions (Margulec et al. 1970; Gryfe, Amies, and Ashley 1977), in the home (Lucht 1971), and in the community (Prudham and Evans 1981). In the present study, the highest incidence of injuries was found during periods in which the elderly would be expected to be most active. Conversely, the lowest incidence :oincided with the mid-winter months, December and January, when outdoor activities ~re restricted due to the low temperature [mean temperature for December 1985 and Ianuary 1986 was -14.2°C (10 ° lower than normal)]. A daily variation in the number njured was also observed; most being injured in the daytime hours, with 6% being :njured between 11 P.M. and 7 A.M. Similar findings have been reported by Rodstein ,11964), on falls in the home by Lucht (1971), and in institutions by Haga, Shibata, Shichita, et al. (1986). However, in a group of very old people living in an institution, no such daily or seasonal variations in falls was observed, which was thought to reflect ~:he greatly protective environment and low activity among these individuals compared with the variety of hazards which the aged in a general community are exposed to (Ashley, Gryfe, and Amies 1977). Half of the patients were injured in residential areas. This is to be expected as this is where old people are likely to spend most of their time. This is in line with findings from southern Sweden (Schelp and Svanstr6m 1986). In the present study, the garden, logether with the drive, and garage had the highest injury incidence, followed by the living room and kitchen. Men were mostly injured outside the residential building whilst women were most frequently injured in the living room and kitchen. This probably 1effects differences in activities between the sexes. It was noted that preparing firewood was a particularly risky activity for men. The severity of injuries, the proportion of injuries that were fractures, the duration of hospitalization, and the mean cost of medical care was found to increase with advancing age. An increase in severity with age has also been reported by Margulec et al. (1970) and Gryfe et al. (1977). Women, in the present study, had more severe injuries, a longer duration in hospital, and higher costs of medical care than men. However, as regards the severity of injuries, the contrast between the sexes was more distinct between 60 to ;9 years of age. Above this age, men were just as likely as women to be severely injured. Furthermore, as expected (Melton and Riggs 1985), even in the present study, the frequency of femur neck fractures increased with age. It was interesting that this type c,f fracture was more common among women up to the age of 85; above this age it was

242

H. SJOGREN and U. BJORNSTIG

more common among men. These findings are particularly important in light of the expected 30% increase in the population of very old people aged above 80 years in the next 15 years in Sweden (Swedish Official Report 1987). Thus, it would be reasonable to assume that the demands on hospital resources would also increase for these age groups. The demand on treatment resources for unintentional injuries among the elderly was SEK 14 million, which is 45% of the cost for treating injuries in patients of all ages during one year at the hospital. Sickness benefits cost a further million. Since other costs, after the discharge from the hospital, have not been taken into account, our figures show minimum costs indicating the importance of this age group compared to other groups. Falls caused the highest demands on hospital resources (80%), followed by vehicle accidents (13%); the mean cost per injured for these two causes, however, being similar. Vehicle accidents caused the same number of fatalities as falls, indicating that attention must also be directed towards the problems faced by the elderly in modern traffic, especially regarding the unprotected road users (cf. Organisation for Economic Co-operation and Development 1986). The injury-reducing potential must be high concerning unintentional injuries among the elderly. In view of the expected increase of 30% of the especially vulnerable very old population, it must be of utmost importance to intensify the injury-prevention effort. Further analysis of the most important injury mechanisms, which have been pointed out in the present report, must be undertaken to identify the most effective injury-reducing approach. The most effective measures are often those that will protect the person automatically without any action on his or her part (Haddon and Baker 1981). To reduce the demands on hospital resources in the future, authorities and public health workers must accept the challenge to continue and intensify the injury preventive work for the elderly.

Acknowledgements--The authors

thank Anders Eriksson for providing the forensic medical material and Lolomai Ornehult for typing the manuscript. REFERENCES

Ahlbom, A.; Engblom, S. Konsumtion av sluten sjukvhrd i Stockholms l~ins landsting f6r 1974. H~ilso- och Sjukv~rdsnamnden: Socialmedicinska institutionen, Huddinge sjukhus och sjukvfirdsplaneringsavdelningen; 1977. (In Swedish.) Ashley, M. J.; Gryfe, C. I.; Amies, A. A longitudinal study of falls in an elderly population. II. Some circumstances of falling. Age Ageing. 6:211-220; 1977. Baker, S.; O'Neill, B.; Karpf, R. S. The injury fact book. Lexington, MA: Lexington Books, D.C. Heath and Co; 1984. Committee on Injury Scaling, The abbreviated injury scale. Morton Grove, IL: Am. Assoc. Automot. Med.; 1980. Gryfe, C. I.; Amies, A.; Ashley, M. I. A longitudinal study of fails in an elderly population. 1. Incidence and morbitity. Age Ageing. 6:201-210; 1977. Haddon, W.; Baker, S. P. Injury control. In: Clark, D; MacMahon, B., editors. Preventive and community medicine. Boston: Little Brown Co; 1981: 109-140. Haga, H.; Shibata, H.; Shichita, K.; Matsuzaki, T.; Hatano, S. Fails in the institutionalized elderly in Japan. Arch. Gerontol. Geriatr. 5:1-9; 1986. Lucht, U. A prospective study of accidental fails and resulting injuries in the home and among elderly people. Acta Socio-Med. Scand. 2:105-120, 1971. Margulec, I.; Librach, G.; Schradel, M. Epidemiological study of accidents among residents of homes for the aged. J. Gerontol. 24:342-346; 1970. Melton, L. J.; Riggs, B. L. Risk factors for injury after a fall. Clin. Geriatr. Med. 1:525-539; 1985. Official Statistics of Sweden. Causes of death for 1985. Liber, Stockholm; Statistics Sweden; 1987. Organisation for Economic Co-operation and Development. Road safety research: A synthesis. Paris; OECD; 1986. Prudham, D.; Evans, J. G. Factors associated with falls in the elderly. A community study. Age Ageing. 10:141-146; 1981. Rodstein, M. Accidents among the aged: Incidence, causes and prevention. J. Chron. Dis. 17:515-526; 1964. Schelp, L.; SvanstrOm, L. One-year incidence of home accidents in a rural Swedish municipality. Scand. J. Soc. Med. 14:75-82; 1986. Swedish Official Report. Bet~inkande av aldreberedningen. A.ldreomsorg i utveckling. SOU: 1987:21. (In Swedish.) Waller, J. A. Falls among the elderly: Human and environmental factors. Accid. Anal. Prev. 10:21-33; 1978.