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The Relationship Between Functional Limitation and Fall Injury Among Older Adults: A 12-Year National Survey Analysis

Submitted:

23 January 2026

Posted:

26 January 2026

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Abstract
Background: One in four US adults aged ≥65 years experiences a fall annually, leading to substantial injury and morbidity. Functional limitations may serve as early markers of vulnerability to fall injury. We aimed to estimate temporal trends and the association between functional limitation and fall injuries among community-dwelling older adults. Methods: For this retrospective cohort analysis, we pooled 2006–2017 National Health Interview Survey data and identified older adult survey respondents. Functional limitation, defined as any reported difficulty performing daily activities, and fall injury, defined as occurring within three months prior to the interview, were measured as binary variables. We controlled for sociodemographic, self-rated health, healthcare access, and physical activity factors. We reported the yearly trend in fall injury and functional limitations and performed survey-weighted univariable and multivariable logistic regression analyses, accounting for the potential confounders. Results: Our sample comprised 79,891 older adults, of whom 66% reported functional limitations and 2.3% reported a fall injury within 3 months of their interview. The prevalence of functional limitation increased from 61.8% in 2007 to 68.4% in 2017 (p<0.001). Also, the fall injury rates ranged from 1.8% to 2.6% during the same period. Older adults with functional limitations were more likely to report fall injuries (3.2% vs. 1.1%, p<0.001). After adjustment, functional limitation was associated with a two-fold higher odds of fall injury (OR = 2.03, 95% CI 1.71–2.40). Conclusion: Functional limitations are highly prevalent and increasing among older U.S. adults, doubling the likelihood of fall injury occurrence.
Keywords: 
functional limitation
;  
fall injury
;  
older adults
;  
national health interview survey
Subject: 
Public Health and Healthcare  -   Public Health and Health Services

1. Introduction

One in four older adults (65 years and older) experiences at least one fall event each year in the United States [1,2]. About a third of these falls result in injuries, including fractures, head trauma, and lacerations (3-5). In the U.S., falls account for nearly 3 million emergency department visits and 1 million hospital admissions annually, and cost approximately $50 billion in direct medical costs (2, 6, 7). Falls are often multifactorial in origin, and there is evidence that underlying functional limitations play a critical role in predisposing older adults to these events (8-10).
Functional limitations refer to difficulties in performing basic physical tasks required for independent daily living, such as walking, climbing stairs, carrying objects, or bathing, as well as the ability to perform daily life activities such as shopping and participating in leisure activities [11,12]. These limitations often stem from chronic health conditions, frailty, degenerative decline, neurological impairments, or a combination of these factors [10]. Among older adults, functional limitations can significantly compromise mobility, increasing reliance on assistive devices, caregivers, or environmental modifications [13,14]. Impaired mobility, in turn, reduces an individual's ability to safely navigate their surroundings, maintain balance, or recover from a loss of footing—all of which are critical for preventing falls [9,15]. While a fall in an older adult is a sentinel event for adverse outcome, functional limitation may be seen as a marker of vulnerability and a manifestation of the physical phenotype of frailty [16,17]. Earlier studies have reported that functional limitation is associated with a two-fold increased likelihood of hospitalization and a two-fold increased likelihood of mortality [9,18,19] Efforts to address functional limitations have included rehabilitation programs, community-based mobility interventions, and multifactorial fall-prevention initiatives that integrate physical therapy, home safety assessments, and assistive technologies [10,20]. However, continued monitoring of the population-level burden of functional limitation remains essential for informing prevention strategies [11,21].
As the older age proportion of the U.S. population increases, accurately identifying functional limitations becomes increasingly important for prioritizing interventions, such as physical and occupational therapy, assistive technologies, or environmental modifications [22,23]. This study aims to estimate the prevalence of fall injury and functional limitation among community-dwelling US older adults, examine their temporal trends, and examine the association between functional limitation and fall injury. While prior studies have reported an association between functional limitations and fall injuries [24,25,26,27], there is a lack of nationally representative data to assess the prevalence and strength of this association. Understanding the prevalence of functional limitations may provide critical insights into population vulnerability, guide resource allocation, and inform targeted strategies to reduce fall-related injuries.

2. Materials and Methods

Study Population

For this retrospective cohort analysis, we pooled data from the National Health Interview Survey (NHIS) between 2006 to 2017. The NHIS is a yearly cross-sectional survey of the non-institutionalized U.S. population that uses a multistage probability sampling method to collect data from households across all U.S. states and the District of Columbia [28]. Each year, more than 86,000 individuals within 35,000 households are surveyed, with intentional oversampling of Blacks, Hispanics, and Asians to ensure adequate subgroup representation [28]. Household data captured include basic family demographics and health characteristics, and one adult and one child per household are sampled. Sampled adults are further asked about specific health conditions, health-related behaviors, functional limitations, and healthcare access and utilization. To account for temporal changes in coding and variable definitions, and to ensure accurate survey data combination across years, we extracted NHIS data from the publicly available Integrated Public Use Microdata Series (IPUMS) platform [29]. The IPUMS NHIS dataset contains harmonized NHIS survey data, and each data extract includes pre-specified sampling weights, strata, and clusters.

Inclusion and Exclusion Criteria

Between 2006 and 2017, 1,109,807 survey respondents participated (Figure 1). We selected individuals aged 65 years and older (n = 146,448) and further restricted the data to sampled adults, excluding household members whose data were captured as part of the household survey (n = 79,891). Our final sample, therefore, was 79,891 older adults.

Outcome Variable

The outcome measure was fall injury, defined as a self-reported injury resulting from a fall in the three months preceding the interview. This variable was extracted from the IPUMS NHIS’s injury module, designed to capture multiple injury events per respondent [30]. We reshaped the fall injury data to person-level, excluded duplicate entries, and linked it to the remaining core demographic and health-related data. For each respondent, we defined fall injury as a binary variable (yes/no).

Predictor Variables

The principal exposure variable was functional limitation, a recoded variable from the NHIS survey responses and defined as any self-reported difficulty or inability to carry out routine activities due to physical, mental, or emotional problems. NHIS survey respondents were asked about the degree of difficulty performing common activities such as walking a quarter mile, climbing ten steps, standing or sitting for two hours, stooping, reaching overhead, grasping small objects, carrying ten pounds, pushing large objects, shopping, or participating in social or leisure activities—without the use of special equipment [31]. Individuals reporting any level of difficulty (“only a little,” “somewhat,” “very,” or “can’t do at all”) on one or more items were classified as having a functional limitation.

Potential Confounders

We controlled for sociodemographic, health care access, self-reported health, and physical activity measures. The sociodemographic variables included age, sex, race/ethnicity, place of birth (US-born—yes/no), educational attainment, marital status, smoking status (never smoked, past smoker, current smoker), and poverty level, defined as either poor or not poor using a family income-to-poverty threshold ratio of 1.0 as the poverty benchmark [32]. Measures of health care access included available, accessible, and affordable care, as well as healthcare insurance. Respondents were asked if they had a usual place for medical care (available care), experienced delayed care because they could not get an appointment soon (accessible care), if they needed but could not afford medical care in the past 12 months (affordable care), and whether they had health insurance (health coverage). All measures of healthcare access were consistent with prior studies and measured as binary variables (33-35). Self-reported health measures included the chronic disease index and self-rated health. We created an index of chronic conditions from ten self-reported diagnoses: Chronic Obstructive Pulmonary Disease, Asthma, Angina, Chronic Arthritis, Cancer, Coronary Heart Disease, Liver Disease, Peptic Ulcer Disease, Diabetes, and Hypertension. We defined the index of chronic disease as 0 (none), 1, 2, or 3 or more. We defined self-rated health using the response to the survey item: “Would you say your health in general is excellent, very good, good, fair, or poor?” We defined self-rated health as a three-level variable: poor, fair, and good to excellent. Physical activity was assessed using self-reported weekly activity intensity, defined using weekly metabolic equivalent of task (MET) minutes. Respondents were asked, "How often do you engage in [1] moderate-intensity and [2] vigorous-intensity leisure-time physical activities” [36]? Following prior studies (37-39), weekly MET-minutes were calculated as: 4 × frequency of moderate activity per week × duration (in minutes) + 8 × frequency of vigorous activity per week × duration (in minutes). We reported activity intensity as none (0 MET-minutes), low (1 – 500 MET-minutes), moderate to high (>500 MET-minutes), similar to prior studies (37-39).

Handling of Missing Data

We encountered missingness in five variables: educational attainment (0.81%), marital status (0.28%), available care (0.14%), healthcare coverage (0.14%), and smoking status (0.78%). We imputed the missing values using the Multiple Imputation by Chained Equations (MICE) approach, generating 100 complete datasets through 100 iterations [40]. Final values were aggregated across imputations consistent with Rubin’s rules [41,42].

Data Analysis

We computed descriptive statistics to characterize the overall sample and reported differences between those with and without fall injuries, as well as between those with and without functional limitations. We reported trends in fall injuries and functional limitations over time and assessed change using a simple linear regression. We computed the unadjusted and adjusted associations between functional limitation and fall injury using univariate and multivariate logistic regression and reported the odds ratios and 95% confidence intervals (CIs). All regression models accounted for the complex NHIS survey design, including stratification, clustering, and weighting. Since we pooled 12 years of data, the original weight was divided by 12, consistent with the NHIS documentation [43,44]. All statistical analyses were performed using STATA version 16 [45].

3. Results

Our study included 79,891 persons, representing 22,642,863 non-institutionalized U.S. older adults. More than half (54%) of the population was between 65 and 74 years old, and the population was predominantly female (60%), non-Hispanic White (80%), US-born (89%), and with high school or less education (52%). Approximately 42% were married, and 39% were current smokers. Approximately 3% did not have a usual place of care, 4% experienced delayed care, 3% could not afford care, and less than one percent did not have healthcare coverage. Although only 87% reported having chronic diseases, 77% described their health as either good, very good, or excellent. Approximately 47% did not engage in any moderate or vigorous activity, and 66% reported having functional limitations.
A total of 1,773 (2.3%) older adults reported sustaining a fall injury within 3 months prior to their interview. The proportion of those having fall injury was higher with increasing age (p<0.001), among females (p<0.001), non-Hispanic White (p<0.001), US-born (p=0.040), with lower education attainment (p<0.001), and among those widowed, divorced, or separated (p<0.001). Additionally, the proportion of fall injury was higher among those who experienced delayed care (p<0.001) and could not afford care (p<0.001). Also, the proportion of fall injuries was higher among those with two or more chronic diseases (p<0.001), who self-reported poor or fair health (p<0.001), and who did not engage in at least moderate activity (p<0.001). Furthermore, 86% of those with functional limitations reported a fall injury, compared with 65% among those without functional limitations (p<0.001).
The proportion of respondents with functional limitations increased with increasing age (p<0.001). Also, the population with functional limitations was disproportionately female (p<0.001), non-Hispanic White and non-Hispanic Black (p<0.001), US-born (p<0.001), with lower educational attainment (p<0.001). Additionally, the proportion of functional limitations was higher among those who were either widowed, divorced, or separated (p<0.001), current and past smokers (p<0.001), without a usual place for care (p<0.001), or who reported that healthcare was unaffordable (p<0.001). Also, the proportion of functional limitations was higher among those with 2 or more chronic diseases (p<0.001), those who reported their health as either poor or fair (p<0.001), and those who did not engage in at least moderate activity (p<0.001)
Between 2006 and 2017, the fall injury rate ranged from 1.8% to 2.6%, with rates consistently higher among females. Also, the proportion of functional limitations significantly increased from 61.8% in 2007 to 68.4% in 2017 (p<0.001), representing a 0.3% increase for each year. Similarly, the rates were significantly and consistently higher among females during the period of study. In the unadjusted model, older adults with functional limitations were 3.2 times (OR: 3.22; 95% CI: 2.78–3.73) more likely to sustain a fall injury. After adjusting for sociodemographic, health, and healthcare access factors, functional limitation was associated with a two-fold increase in the odds of fall injury (OR: 2.03; 95% CI: 1.71 – 2.40).
Table 1. Sociodemographic, injury, healthcare access, and health characteristics among older adults with and without fall injuries.
Table 1. Sociodemographic, injury, healthcare access, and health characteristics among older adults with and without fall injuries.
Variable All Population
(N=79,891)		 Fall Injury
(n=1,773; 2.3%)		 No Fall Injury
(n=78,118; 97.7%)		 p-value
Age Category
65 – 74 years 43,811 (53.6) 723 (39.6) 43,088 (53.9) <0.001
75 – 84 years 25,735 (33.0) 611 (34.9) 25,124 (33.0)
85 years and older 10,345 (13.4) 439 (25.5) 9,906 (13.1)
Sex
Male 32,376 (39.9) 522 (29.2) 31,854 (40.1) <0.001
Female 47,515 (60.1) 1,251 (70.8) 46,264 (59.9)
Race/Ethnicity
Non-Hispanic White 58,413 (79.6) 1,420 (85.1) 56,993 (79.5) <0.001
Non-Hispanic Black 9,944 (9.5) 149 (6.8) 9,795 (9.5)
Hispanic 7,038 (6.8) 121 (5.0) 6,917 (6.8)
Other Races 4,496 (4.1) 83 (3.1) 4,413 (4.2)
Born in the US
No 9,935 (10.9) 180 (9.3) 9,755 (10.9) 0.040
Yes 69,956 (89.1) 1,593 (90.7) 68,363 (89.1)
Education
High school or less 42,000 (51.7) 939 (51.7) 41,061 (51.7) <0.001
Some college or AA 19,640 (24.7) 458 (26.1) 19,182 (24.7)
Bachelor’s degree 10,324 (13.4) 216 (12.7) 10,108 (13.4)
Postgraduate 7,927 (10.3) 160 (9.5) 7,767 (10.3)
Marital Status
Married 33,680 (42.3) 548 (31.3) 33,132 (42.5) <0.001
Single 4,776 (5.8) 96 (5.8) 4,680 (5.8)
WDS 41,435 (51.9) 1,129 (62.9) 40,306 (51.6)
Poverty Level
Not Poor 71,160 (90.3) 1,545 (89.0) 69,615 (90.4) 0.078
Poor 8,731 (9.7) 228 (11.0) 8,503 (9.6)
Smoking Status
Never Smoked 41,975 (52.0) 926 (52.3) 41,049 (52.0) 0.433
Past Smoker 7,531 (9.3) 153 (8.3) 7,378 (9.4)
Current Smoker 30,385 (38.7) 694 (39.4) 29,691 (38.7)
Available Care
No place 2,846 (3.4) 27 (1.5) 2,819 (3.5) <0.001
Has a place 77,045 (96.6) 1,746 (98.5) 75,299 (96.5)
Accessible Care
Delayed 3,249 (4.1) 126 (7.2) 3,123 (4.0) <0.001
Not Delayed 76,642 (95.9) 1,647 (92.8) 74,995 (96.0)
Affordable Care
Cannot Afford 2,487 (3.0) 81 (4.5) 2,406 (2.9) <0.001
Can Afford 77,404 (97.0) 1,692(95.5) 75,712 (97.1)
Health Insurance
No Coverage 605 (0.6) 3 (0.2) 602 (0.6) 0.064
Has Coverage 79,286 (99.4) 1,770 (99.8) 77,516 (99.4)
Chronic Disease Index
None 10,610 (13.4) 112 (6.8) 10,498 (13.6) <0.001
1 41,264 (51.5) 779 (44.3) 40,485 (51.7)
2 23,564 (29.6) 671 (37.3) 22,893 (29.4)
3 or more 4,453 (5.5) 211 (11.7) 4,242 (5.3)
Self-rated health
Poor 4,732 (5.7) 257 (14.3) 4,475 (5.5) <0.001
Fair 14,142 (17.0) 448 (25.4) 13,694 (16.8)
Good/Excellent 61,017 (77.3) 1,068 (60.3) 59,949 (77.7)
Activity Intensity
None 37,356 (46.7) 1,039 (58.0) 36,317 (46.5) <0.001
Low 12,696 (15.8) 264 (15.0) 12,432 (15.8)
Moderate to High 29,839 (37.5) 470 (27.0) 29,369 (37.7)
Functional Limitations
No 27,319 (34.5) 262 (14.3) 27,057 (35.0) <0.001
Yes 52,572 (65.5) 1,511 (85.7) 51,061 (65.0)
WDS: Widowed, Divorced, and Separated.
Table 2. Sociodemographic, injury, healthcare access, and health characteristics among older adults with and without functional limitations.
Table 2. Sociodemographic, injury, healthcare access, and health characteristics among older adults with and without functional limitations.
Variable Functional Limitations
(n=52,572; 65.5%		 No Functional Limitations
(n=27,319; 34.5%)		 p-value
Age Category
65 – 74 years 25,855 (47.6) 17,956 (65.0) <0.001
75 – 84 years 18,088 (35.4) 7,647 (28.5)
85 years and older 8,629 (17.0) 1,716 (6.5)
Sex
Male 19,275 (35.8) 13,101 (47.6) <0.001
Female 33,297 (64.2) 14,218 (52.4)
Race/Ethnicity
Non-Hispanic White 38,832 (80.2) 19,581 (78.6) <0.001
Non-Hispanic Black 6,713 (9.7) 3,231 (9.0)
Hispanic 4,435 (6.5) 2,603 (7.3)
Other Races 2,592 (3.6) 1,904 (5.1)
Born in the US
No 5,882 (9.8) 4,053 (13.0) <0.001
Yes 46,690 (90.2) 23,266 (87.0)
Education
High school or less 29,417 (55.2) 12,583 (45.0) <0.001
Some college or AA 12,884 (24.8) 6,756 (24.5)
Bachelor’s degree 5,997 (11.7) 4,327 (16.5)
Postgraduate 4,274 (8.3) 3,653 (14.0)
Marital Status
Married 20,173 (38.6) 13,507 (49.3) <0.001
Single 3,078 (5.6) 1,698 (6.2)
WDS 29,321 (55.8) 12,114 (44.5)
Poverty Level
Not Poor 45,853 (88.6) 25,307 (93.5) <0.001
Poor 6,719 (11.4) 2,012 (6.5)
Smoking Status
Never Smoked 27,039 (50.8) 14,936 (54.2) <0.001
Past Smoker 5,107 (9.6) 2,424 (8.8)
Current Smoker 20,426 (39.6) 9,959 (37.0)
Available Care
No place 1,412 (2.6) 1,434 (5.0) <0.001
Has a place 51,160 (97.4) 25,885 (95.0)
Accessible Care
Delayed 2,675 (5.2) 574 (2.0) <0.001
Not Delayed 49,897 (94.8) 26,745 (98.0)
Affordable Care
Cannot Afford 2,087 (3.8) 400 (1.4) <0.001
Can Afford 50,485 (96.2) 26,919 (98.6)
Health Insurance
Has Coverage 52,289 (99.5) 26,997 (99.1) <0.001
No Coverage 283 (0.5) 322 (0.9)
Chronic Disease Index
None 3,768 (7.3) 6,842 (25.1) <0.001
1 25,325 (48.1) 15,939 (58.1)
2 19,366 (37.0) 4,198 (15.5)
3 or more 4,113 (7.7) 340 (1.3)
Self-rated health
Poor 4,445 (8.1) 287 (1.0) <0.001
Fair 12,390 (22.8) 1,752 (5.9)
Good/Excellent 35,737 (69.1) 25,280 (93.1)
Activity Intensity
None 27,933 (53.2) 9,423 (34.2)
Low 8,920 (16.9) 3,776 (13.9) <0.001
Moderate-to-high 15,719 (29.9) 14,120 (51.9)
WDS: Widowed, Divorced, and Separated.
Table 3. Unadjusted and adjusted likelihood of fall injury among older adults by functional limitations, sociodemographic, injury, health, and healthcare access factors.
Table 3. Unadjusted and adjusted likelihood of fall injury among older adults by functional limitations, sociodemographic, injury, health, and healthcare access factors.
Variable Unadjusted Odds Ratio (95% CI) Adjusted Odds Ratio
(95% CI)
Functional Limitations
Yes 3.22 (2.78 – 3.73) 2.03 (1.71 – 2.40)
No Ref Ref
Age Category
65 – 74 years Ref Ref
75 – 84 years 1.44 (1.27 – 1.63) 1.25 (1.10 – 1.42)
85 years and older 2.66 (2.32 – 3.04) 2.01 (1.72 – 2.34)
Sex
Male 0.62 (0.54 – 0.70) 0.70 (0.61 – 0.80)
Female Ref Ref
Race/Ethnicity
Non-Hispanic White Ref Ref
Non-Hispanic Black 0.66 (0.54 – 0.81) 0.60 (0.49 – 0.74)
Hispanic 0.69 (0.56 – 0.84) 0.72 (0.57 – 0.91)
Other Races 0.70 (0.55 – 0.90) 0.77 (0.57 – 1.03)
Born in the US
Yes 1.20 (1.01 – 1.43) 1.02 (0.82 – 1.27)
No Ref Ref
Education
High school or less Ref Ref
Some college or AA 1.06 (0.93 – 1.21) 1.22 (1.06 – 1.39)
Bachelor’s degree 0.95 (0.80 – 1.14) 1.30 (1.09 – 1.56)
Postgraduate 0.92 (0.75 -1.14) 1.42 (1.15 – 1.77)
Marital Status
Married Ref Ref
Single 1.35 (1.04 – 1.75) 1.33 (1.02 – 1.72)
WDS 1.65 (1.47 – 1.86) 1.25 (1.09 – 1.43)
Poverty Level
Poor 1.16 (0.98 – 1.37) 0.96 (0.80 – 1.15)
Not Poor Ref Ref
Smoking Status
Never Smoked Ref Ref
Past Smoker 0.88 (0.71 – 1.09) 0.96 (0.77 – 1.19)
Current Smoker 1.01 (0.90 – 1.13) 1.04 (0.93 – 1.17)
Available Care
No place 0.43 (0.27 – 0.67) 0.58 (0.37 – 0.91)
Has a place Ref Ref
Accessible Care
Delayed 1.86 (1.51 – 2.30) 1.50 (1.21 – 1.85)
Not Delayed Re Ref
Affordable Care
Cannot Afford 1.55 (1.20 – 2.01) 1.19 (0.90 – 1.57)
Can Afford Ref Ref
Health Insurance
Has Coverage 0.34 (0.11 – 1.12) 0.57 (0.17 – 1.90)
No Coverage Ref Ref
Chronic disease Index
None Ref Ref
1 1.72 (1.36 – 2.18) 1.27 (0.99 – 1.62)
2 2.55 (2.00 – 3.24) 1.47 (1.14 – 1.89)
3 4.43 (3.38 – 5. 81) 2.04 (1.53 – 2.71)
Self-rated health
Poor 3.38 (2.87 -3.99) 2.43 (2.02 – 2.92)
Fair 1.95 (1.71 – 2.21) 1.54 (1.34 – 1.77)
Good/Excellent Ref Ref
Activity Intensity
None 1.75 (1.54 – 1.99) 1.15 (0.99 – 1.33)
Low 1.32 (1.11 – 1.57) 1.04 (0.87 – 1.23)
Moderate-to-high Ref Ref
WDS: Widowed, Divorced, and Separated.
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Figure 2. Trend in (A.) Proportion of Fall Injuries, and (B.) Functional Limitations among the study population, stratified by sex, between 2006 and 2017.
Figure 2. Trend in (A.) Proportion of Fall Injuries, and (B.) Functional Limitations among the study population, stratified by sex, between 2006 and 2017.
Preprints 195744 g002

4. Discussion

In this nationally representative analysis of older U.S. adults conducted between 2002 and 2017, we observed a slow upward trend in the proportion of persons with functional limitations, affecting two-thirds of the population. While the 3-month incidence of fall injuries ranged between 2–3% among both sexes, females consistently demonstrated higher rates of both functional limitations and fall injuries than males. Also, older adults with functional limitations were two times more likely to sustain a fall-related injury compared with those without functional limitations.
Consistent with earlier studies [46,47], the 3-month incidence of fall injuries among US community-dwelling older adults ranged between 2% and 3%. When extrapolated, our 3-month fall injury rate is closely aligned with national annual fall injury rates of 8% to 10% (46, 48, 49). While intrinsic and extrinsic factors such as age-related physiologic decline, vision, hearing, and other causes of imbalance, polypharmacy and fall risk-inducing drugs, and environmental hazards primarily increase the likelihood of falling [50], the occurrence of injury after a fall depends on additional clinical, biomechanical, and environmental factors [50]. Lower bone mineral density, sarcopenia, slower protective responses, and anticoagulant use increase the risk that a fall will result in fracture rather than a minor event [51]. Injury mechanisms, such as height, speed, and protective responses and reflexes that interrupt the progression of a fall, may affect the occurrence and severity of a fall injury [52,53]. Comorbidities such as osteoporosis, frailty, and cognitive impairment further compound this risk by reducing postural control and the ability to mitigate impact during a fall [50]. Environmental factors, such as hard flooring or a lack of cushioning, also influence the severity of fall injuries (54-56).
Among our study population, functional limitation was associated with a two-fold increased likelihood of fall injury. Several studies have reported that functional limitations predict the risk of fall injuries (57-59). For example, Stevens et al. [57] reported that older adults with functional limitations were three times more likely to sustain fall-related fractures. Yet, other studies have reported that fall injuries predict functional limitations [60,61]. On one hand, functional limitations, such as impaired balance, slowed gait, reduced muscle strength, and poor coordination [62], compromise an individual’s ability to recover from perturbations, navigate environmental hazards, or stabilize after a slip, thereby increasing the risk of sustaining a fall-related injury [58]. On the other hand, prior falls, a strong predictor of future falls [63], can lead to injuries such as fractures and soft-tissue injuries, which can exacerbate or precipitate new functional limitations, manifesting as reduced mobility, deconditioning, and loss of independence [64]. Over time, this cyclical interplay between functional decline and fall injury may contribute to the gradual increase in functional limitation, which may explain the increasing prevalence we report in this study.
Consistent with prior research, our study found that females exhibited higher rates of both functional limitations and fall injuries than males across all study years [65,66]. Several biological, behavioral, and social factors may explain this disparity. Women are more likely to experience musculoskeletal disorders such as osteoporosis and sarcopenia and have lower muscle mass and strength [67,68], all of which contribute to heightened fracture risk and fall injuries [69,70]. The consistently higher rates of functional limitations and fall injuries we report lend credence to this underlying vulnerability.
Our findings have important implications for clinical care and public health. Given the strong association between functional limitations and fall injuries, there should be continued emphasis on screening for functional limitations using instruments such as the Activities of Daily Living and Instrumental Activities of Daily Living scales [71] or as part of the Comprehensive Geriatric Assessment [72]. Fall risk assessment tools such as the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) [73] can further identify individuals whose functional impairments may predispose them to falls [74,75]. Early intervention, such as tailored exercise programs such as Tai Chi, physical and occupational therapy, and environmental assessments, may help reduce falls and extend functional independence [76,77,78]. From a policy perspective, consistent integration of fall prevention and functional assessment into community-based aging programs, such as naturally occurring retirement community social service programs and Medicare wellness visits, could yield significant downstream benefits. Identifying and preventing functional limitations early, such as preclinical mobility limitations [79], may represent one of the most effective strategies for preventing fall-related injuries and promoting healthy aging.
Our study has its limitations. This study’s retrospective cohort design precludes establishing causal relationships between functional limitation and fall injury. Responses to the NHIS questions are self-reported and may be subject to recall and social desirability biases [80,81]. Although we controlled for comorbidity, self-reported health, and physical activity, we did not account for prior functional limitations or the number of prior falls due to the unavailability of such data. Despite these limitations, our large, nationally representative data set enables reliable estimation of population-level trends among U.S. older adults. The 16-year trend enables temporal assessment of changes in both fall injury incidence and functional limitation prevalence. Additionally, our robust control for potential confounders, survey design, clustering, and weights provides reliable estimates for epidemiological assessment, policy recommendations, and intervention design.

Author Contributions

Conceptualization, O.A; Methodology, O.A.; Software, O.A., J.C.; Formal Analysis, O.A.; Data Curation, O.A.; Writing – Original Draft Preparation, O.A.; Writing – Review & Editing, O.A., T.C., G.O., D.B, J.C.; Visualization, O.A.; Supervision, J.C.

Funding

This research received no external funding.

Institutional Review Board Statement

Ethical review and approval were waived for this study. Based on guidance from the New York University Institutional Review Board, secondary data analysis of publicly available dataset does not require IRB approval.

Informed Consent Statement

Not applicable since this study used de-identified publicly available data.

Data Availability Statement

The original data presented in the study are openly available in FigShare at 10.6084/m9.figshare.30739685.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
MET Metabolic Equivalent of Task
IPUMS Integrated Public Use Microdata Series
NHIS National Health Interview Survey
AOR Adjusted Odds Ratio
CI Confidence Interval
US United States
WDS Widowed, Divorced, Separated

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Preprints 195744 g001
Figure 1. Data selection steps.
Figure 1. Data selection steps.
Preprints 195744 g001
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