NR 503 Week 7 Older Adult Falls Population Analysis Example

Falls Among Older Adults in a Composite Rural County: Local Figures With Their Periods, a Cochrane Rate Ratio of 0.77 Borrowed From Trials Elsewhere, and Whether Those Trial Volunteers Resemble Our Farmers

Student Name

College of Nursing, Chamberlain University

NR 503: Population Health, Epidemiology and Statistical Principles

Instructor Name

Month Day, Year

Falls Among Older Adults in a Composite Rural County: Local Figures With Their Periods, a Cochrane Rate Ratio of 0.77 Borrowed From Trials Elsewhere, and Whether Those Trial Volunteers Resemble Our Farmers

Two Kinds of Number

Pell County is a composite rural county of 21,000 residents, 5,300 of them aged 65 or older, with one critical access hospital and a county health department of six nurses. The figures describing Pell County in this paper are composite; the national figures and the trial evidence are real and cited. The health department is deciding whether to fund a community exercise program to prevent falls in older adults.

The analysis uses two kinds of number and keeps them apart. The first kind describes Pell County: how many older adults fall, are hurt or die, measured locally, each with its source and period. The second kind is an effect estimate from trials run in other places, with other people. The paragraph that matters most sits between them and asks whether the second kind can be applied to the first.

Each Local Figure With Its Period

Each figure is given with the system that produced it and the years it covers, because figures from different periods and sources cannot simply be added together.

Emergency department visits for falls, 2023 and 2024 combined: 612 visits by residents aged 65 and older at the county hospital, from the hospital's discharge data, which is an average of 306 a year, or about 58 per 1,000 older residents per year. This counts visits, not people; one resident may appear several times, and residents who went to the regional trauma center 50 miles away are missing.

Hip fracture hospitalizations, 2020 to 2024 combined: 71, from the state hospital discharge database, or about 14 a year. Five years were pooled because single-year counts are too small to be stable.

Fall deaths, 2019 to 2023 combined: 22 unintentional fall deaths among residents 65 and older, from state vital records, about 83 per 100,000 per year. Nationally, the fall death rate for older adults in 2021 was 78.0 per 100,000 (Kakara et al., 2023). Pell County's figure is similar, but with 22 deaths across five years, the uncertainty around it is wide.

Self-reported falls: no county survey exists. The nearest figure is national: in 2020, 27.6% of U.S. adults aged 65 and older reported falling in the previous year, with state figures ranging from 19.9% to 38.0% (Kakara et al., 2023). Applied to Pell County, that would suggest roughly 1,460 older residents falling each year, but this is a borrowed figure, and it is labeled as such.

The Effect Estimate and Its Design

The best evidence on exercise to prevent falls is a Cochrane systematic review of randomized controlled trials (Sherrington et al., 2019). It included 108 trials with 23,407 participants living in the community in 25 countries. Across 59 trials, exercise reduced the rate of falls by 23% (rate ratio 0.77, 95% CI 0.71 to 0.83), rated as high-certainty evidence. Exercise also reduced the number of people who fell at least once by 15% (risk ratio 0.85). Programs that included balance and functional exercises had the strongest evidence.

The design matters. This is a pooled estimate from randomized trials, which protects against confounding within each trial; the concern is not whether exercise worked for the people studied, but whether those people are like ours. The review also found that effects on fall-related fractures and falls needing medical attention were less certain, rated as low-certainty evidence, because fewer trials measured them.

Are These Populations Alike

This is the paragraph the recommendation depends on. The trial participants were, on average, 76 years old, and 77% were women (Sherrington et al., 2019). They were volunteers, living in the community, able to take part in exercise programs, and most trials were run in cities or suburbs with transport, classes and staff.

Pell County's older population differs in at least three ways. Its sex balance is closer to even, with many older men who farmed or worked outdoors, a group that often does not join group exercise classes. Its residents are spread over a large area, with no public transport and a 30-mile drive to the county seat, so attending a class twice a week is harder than in a trial. And the people most at risk of a fall, those living alone on farms, are probably the least likely to volunteer for a trial or a program.

Two things argue that the effect may still carry over. The review found no difference in effect between trials that selected people at higher risk of falling and those that did not, which suggests that the benefit does not depend on a specific risk level. And the mechanism, strength and balance training, has no obvious reason to work differently in rural older adults once they do the exercises. The main threat to transfer is therefore not whether exercise works in Pell County but whether people there will take part. That makes uptake, not efficacy, the uncertain number.

A Projection, With Its Assumptions Showing

If the department wants a projection, it should show its working. Suppose a home-based balance and strength program reaches 400 older residents at higher risk, and suppose their fall rate, before the program, matches the illustrative control-group rate in the review of 850 falls per 1,000 people per year. A rate ratio of 0.77 would then prevent about 78 falls a year among those 400 people. Every part of that sentence is an assumption: the number reached, their baseline rate and the effect transferring intact. None is a Pell County measurement, and the projection should never be quoted without them.

Recommendations That Carry Their Evidence

1. Fund a home-based exercise program, not only a class. Evidence: high-certainty trial evidence that exercise reduces falls (Sherrington et al., 2019), combined with the local barrier of distance, which a home-based program avoids.

2. Recruit through primary care and emergency visits. Evidence: the local emergency department data identify about 300 older fallers a year, the group at highest risk, and the national screening approach recommends that clinicians screen and act on fall risk (Kakara et al., 2023).

3. Measure uptake and falls from the start. Evidence: the uncertain number is local participation, and the local outcome data (emergency visits, hip fractures) are already collected. Without them, the county will never know whether the trial effect transferred.

4. Do not promise a reduction in deaths or hip fractures. Evidence: the review rated effects on fractures as low certainty, and Pell County's counts are too small to detect a change within a few years.

References

Kakara, R., Bergen, G., Burns, E., & Stevens, M. (2023). Nonfatal and fatal falls among adults aged ≥65 years: United States, 2020-2021. Morbidity and Mortality Weekly Report, 72(35), 938-943. https://doi.org/10.15585/mmwr.mm7235a1

Sherrington, C., Fairhall, N. J., Wallbank, G. K., Tiedemann, A., Michaleff, Z. A., Howard, K., Clemson, L., Hopewell, S., & Lamb, S. E. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2019(1), Article CD012424. https://doi.org/10.1002/14651858.CD012424.pub2