Principal FindingsIn this study, we used DALYs, YLDs, and YLLs to evaluate the overall, disability, and mortality burden of falls among individuals aged 65 years and above. APCs and average APCs of ASRs were calculated to provide insights into trends in burden from 1990 to 2021. Our findings demonstrate that the burden of falls exhibited distinct patterns according to development status. Specifically, YLDs (disability burden) were more prevalent in high-SDI regions, whereas YLLs (mortality burden) were more concentrated in low- and low-middle–SDI regions, reflecting a heavier mortality burden. Consequently, the overall burden (DALYs) followed a U-shaped distribution, with burdens being comparatively more severe at both development extremes.
The observed variations in fall-related burden across geographical regions appear to mirror the broader patterns observed across different levels of socioeconomic development. In high-SDI regions such as Australia, Europe, and North America, the high burdens are primarily driven by older population structures [26,27]. However, beyond demographics, environmental and lifestyle factors play a significant role. Higher rates of urbanization and sedentary lifestyles in these regions may contribute to age-related sarcopenia and impaired balance [28-30]. While infrastructure in high-income settings is generally superior, the urban built environment introduces unique hazards; complex public transportation systems, high-speed escalators, and dense pedestrian traffic can pose challenges for older adults with diminished reaction times [31-33]. Additionally, seasonal climatic factors significantly modulate this burden in high-latitude regions, where winter ice and snow create hazardous conditions that drive seasonal surges in fall-related fractures [34-36]. Furthermore, while health systems in these regions often demonstrate high proficiency in acute trauma surgery, potentially reducing short-term mortality, the elevated YLDs potentially point toward a relative gap in specialized geriatric rehabilitation [37-40]. This indicates that, although life-saving interventions are effective, the current infrastructure for long-term fall prevention and functional recovery might not yet fully keep pace with the needs of an increasing aging population [41-43].
In contrast, the burden observed in countries such as India and parts of the African region appears to reflect a dual pattern of persistent mortality alongside rising disability, potentially shaped by an interplay of systemic, environmental, and cultural factors [44-47]. Structurally, health system capacity may represent a significant challenge; limited emergency medical services and a scarcity of geriatric specialists are potentially associated with suboptimal clinical outcomes and higher case fatality rates following fall injuries [48]. Environmentally, natural topography and infrastructure limitations appear to play a notable role, particularly in rural settings. Older adults often navigate uneven, unpaved terrain and steep slopes, frequently without the aid of stabilized walkways or safety railings [49,50]. These risks may be further compounded by insufficient lighting in both communal and domestic spaces, which can hinder navigation for individuals with age-related visual impairments [51,52]. Additionally, domestic environments in these regions may not always feature age-friendly modifications such as grab bars or standardized step heights [53]. Culturally, while the traditional reliance on informal family caregiving is significant, access to the specialized medical and physiotherapeutic knowledge required for effective postfall rehabilitation may be limited [54-56]. Without professional guidance on secondary prevention, these informal care structures, despite their supportive intent, might correlate with challenges in preventing recurrent falls and managing long-term disability [57,58].
The observed epidemiological transition in fall-related burdens is further elucidated by the health inequality analysis, which reveals distinct patterns between absolute gaps (country-level rates) and relative distributions (population-level volume). Regarding absolute inequality, the positive SII for DALYs and YLDs indicates that higher-SDI countries bear a greater absolute burden per 100,000 population, particularly in terms of disability. This is likely attributable to the fact that higher-income countries possess more advanced medical and nursing resources, ensuring timely intervention and survival after a fall. While these resources successfully reduce the mortality burden (YLLs), the combination of survival following injury and a higher proportion of older individuals leads to a more pronounced disability burden. Conversely, the negative SII for YLLs confirms that mortality rates remain higher in lower-income regions, where limited medical infrastructure often results in higher fatality rates following falls. From a temporal perspective, the period from 1990 to 2021 witnessed a narrowing of the absolute gaps in both disability (YLDs) and mortality (YLLs) between the most advantaged and least advantaged countries. It was observed that the absolute gap in the overall burden (DALYs) expanded during this time frame; however, this divergence should be interpreted with caution. It appears to be linked to the reduction in age-standardized DALY rates in lower-SDI countries, suggesting that the gap may be widening due to unequal rates of improvement rather than worsening outcomes [59,60].
While absolute gaps indicate disparities in rates between the highest- and lowest-income countries, the analysis of relative inequality (concentration index) provides a complementary perspective by examining how the total burden (absolute number) is distributed across the global population ranked by SDI. Notably, a near-zero concentration index for YLDs suggests a relatively even distribution of disability, and the negative concentration indexes for DALYs and YLLs underscore a persistent health inequity. This implies that, despite higher disability rates in the highest-income countries, the global volume of mortality and overall burden remains predominantly concentrated among populations in lower-income regions. This concentration of burden appears to be driven by 2 primary factors: first, lower-SDI countries often have significantly larger population sizes, meaning that even a moderate incidence rate translates into a much larger absolute number of affected individuals, and second, the dominant contribution of mortality (YLLs) in disadvantaged regions is often exacerbated by inadequate emergency response and a lack of specialized geriatric rehabilitation. Therefore, while high-SDI countries are increasingly challenged by the long-term care of survivors, the most disadvantaged populations continue to carry the heaviest cumulative weight of the burden due to high fatality rates and large population volumes.
However, this global landscape has evolved favorably over the past 3 decades, as indicated by the narrowing concentration indexes for DALYs and YLLs between 1990 and 2021, suggesting a more balanced global distribution of the fall burden. This shift may be partly attributable to the socioeconomic advancements in populous emerging economies, most notably China and India. As these countries experienced steady increases in their SDI, their massive populations gradually shifted toward higher-SDI quintiles. This demographic-economic transition has played a pivotal role in reducing relative inequality. In summary, while absolute metrics (SII) highlight an increasing disability rate in high-SDI countries as a byproduct of aging and survival, relative indexes (concentration index) emphasize that global health efforts must remain focused on the persistent inequities in lower-income areas. Thus, addressing the fall-related burden requires a dual strategy: managing the rising disability in aging, high-income societies while simultaneously tackling the high mortality burden in disadvantaged populations.
The frontier analysis identified the ideal levels of burden that countries could achieve given their stage of development. Thus, countries positioned farther from the frontier have greater potential to enhance fall prevention among older adults. The analysis also highlights which countries excel in controlling the burden of falls and which fail to meet these ideal levels. Although one might expect higher-SDI countries to more effectively manage the burden of falls in older populations, the relatively flat frontier curve for YLDs against SDI suggests little difference in ideal burden of disability between lower- and higher-SDI countries.
Projections of the fall-related burden among older adults highlight potential public health challenges in the coming decades. Although the age-standardized overall burden (DALYs) is expected to decline, the ASR of YLDs is projected to increase, suggesting that the disability burden may pose an increasingly significant future challenge. To mitigate this anticipated shift toward a disability-predominant burden, forward-looking strategies must simultaneously address 3 critical dimensions: preserving intrinsic capacity, minimizing extrinsic hazards, and generalizing system capacity.
Specifically, prevention efforts may benefit from prioritizing the preservation and enhancement of intrinsic capacity, defined as the composite of an individual’s physical and mental reserves [61]. The integration of systematic screening approaches such as the World Health Organization’s integrated care for older people framework into primary health care systems could facilitate the early identification of deficits in functional ability [62,63]. Crucially, screening must be coupled with targeted interventions; identifying risk is only the first step. Comprehensive management should extend to personalized lifestyle guidance, encompassing nutritional optimization to combat sarcopenia, sleep hygiene to maintain cognitive alertness, and psychological support to alleviate the fear of falling [64-66]. Subsequent individualized exercise prescriptions, such as the Otago Exercise Program or tai chi, should be implemented to improve muscle strength and balance [67,68]. This proactive continuum aims to reverse physical frailty, thereby fortifying the individual’s intrinsic resilience against falls.
Complementing these active measures, policy efforts may benefit from prioritizing the reduction in extrinsic hazards through environmental modifications. Implementing universal design principles in urban planning, including barrier-free walkways and adequate street lighting, alongside subsidizing home modifications such as grab bars and nonslip flooring, is critical for supporting “aging-in-place” [69-71]. By systematically mitigating external environmental stressors, such measures can provide a passive safety buffer that operates independently of an individual’s fluctuating physical condition, thereby lowering the probability of injury in daily life.
Finally, the adoption of emerging technologies offers a potential solution to generalize and extend system capacity, bridging the workforce gap in geriatric care [72,73]. Wearable fall detection sensors and tele-rehabilitation platforms could provide continuous, unobtrusive monitoring and accessible home-based training [74-77]. These technologies hold the potential to democratize access to specialized resources, supporting the delivery of fall prevention and rehabilitation services and ensuring they are available even in resource-constrained or remote settings.