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Falls

A fall is defined as an unintentional/unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level. (NICE Evidence 2014).

Across the UK, every year 280,000 people end up in A&E after a fall, costing the NHS £1.5 billion. If everyone 65+ at risk of falling were referred to physiotherapy, 160,000 falls would be prevented, saving the NHS £250 million every year. (Chartered Society of Physiotherapy 2015). In fact, injury due to falls is the leading cause of mortality in people aged over 75. Recurrent falls are also associated with higher rates of requiring long term care (Chartered Society of Physiotherapy (CSP), 2014).

A third of people over 65 and half of those over 80, fall at least once a year. Falls are the most common cause of death from injury in the over 65s and cost the NHS over £2bn a year and over 4 million bed days.

Nearly 9 million, or one in six people in the population in England was 65 or over at the time of the last census, and the figure is forecast to rise by another 2 million by 2021. (Public Health 2014).

Females aged over 65 have a higher rate of admission due to falling (HSCIC, 2013). Falling is actually very complicated as it links to a range of risks that often co-exist in older people such as:

  • Dementia.
  • Effects of combined prescribed medicines.
  • Poor eyesight.
  • Loss of muscle strength and balance.
  • Lifestyle (excessive alcohol, physical inactivity).

(National Institute for Health and Care Excellence (NICE) 2016).

It is recommended that older people should be routinely asked if they have fallen in the past year, and should be offered a multifactorial falls risk assessment (NICE, 2013). Since July 2017, the GP contract requires this question be asked of all severely frail people at their annual review.

Osteoporosis significantly increases the risk of sustaining a fracture through falling. Fractured hips in older people are associated with long hospital stays, and a third of older people who fracture their hip will die within a year (Royal College of Physicians, 2017).

Half of those who fracture their hip can no longer live independently (NICE, 2017). Screening for and treating osteoporosis in primary care, and screening those who present to hospital with other fractures to hip fractures, can save costs and promote healthy ageing (National Osteoporosis Society (2014).

Those who fall and fracture their hip should receive rehabilitation whilst in hospital. This should be continued once they are discharged home, with individuals waiting no more than 1 week for rehabilitation. (Royal College of Physicians, 2018). The rehabilitation should also incorporate addressing falls risks.

The local picture

Calderdale Clinical Commissioning Group (CCG) report that in 2016/17, 1,479 Calderdale registered patients (all ages) were admitted to a ward in Calderdale and Huddersfield NHS Foundation Trust with injuries associated with falling. This included 108 fractured necks of femurs.

During 2016/2017 there were 785 emergency hospital admissions for falls among those aged 65+ in Calderdale (PHE, 2018). This equates to 2,154 per 100,000 population aged 65 and above. The rate is similar to the national (2,114) and regional (2,059) averages.

The following table shows the rate of hospital admissions for a hip fracture at ward level. Hip fractures are the most common injury relating to falls in older people; therefore it gives a good estimate into the occurrence of falls within an area. The rates are for admissions between 2011/12 and 2015/16 (data has been aggregated due to small numbers). It illustrates that rates are higher among the wards of Park and Todmorden and lowest in Warley.

Emergency hospital admissions for hip fracture in 65+, 2008/9 to 2012/3

Wards Standardised Admission Ratio Lower Confidence Interval Upper Confidence Interval
Park 206.4 167 251.8
Todmorden 146.3 118.6 177
Ovenden 137.3 102.2 178.9
Rastrick 126.7 100.3 156.3
Northowram and Shelf 104.5 82 130.5
Town 100.8 77.1 128.1
Illingworth and Mixenden 100.4 75 130.7
Skircoat 95.5 75.4 118.8
Luddendenfoot 83.7 60.8 111.5
Ryburn 83.6 58.3 113.6
Elland 82.9 61.6 107.3
Sowerby Bridge 80.9 60.2 106
Greetland and Stainland 79.5 56.3 108.2
Calder 73.1 52.7 98.5
Hipperholme and Lightcliffe 73 54 95.9
Brighouse 72.1 53.7 93.5
Warley 64.4 46.2 86.7

Source: PHE, 2018.

Inequalities

There is a clear link between falls and deprivation. The rate of falls for the most deprived decile being greater than that of the least deprived. The chart below shows the rates for England in 2012/13.

Image
Fall rates by deprivation in England 2012/13

Source: Health & Social Care Information Centre, Hospital Episode Statistics

Current provision

Community Services, Calderdale and Huddersfield NHS Trust

The Support and Independence Team provide pathways of care for individuals who have fallen or who are at risk of falling. Individuals will receive an individualised assessment and intervention plan dependent on their needs. This may include:

  • A multifactorial falls risk assessment.
  • Environmental assessment.
  • Advice.
  • Referrals onto other services.
  • And/or strength and balance exercise.

Strength and balance exercises may be prescribed to be done at home, in a clinic or in a group setting. Nurses, Physiotherapist's, Occupational Therapists or Falls Prevention Workers dependent on need may complete assessment and intervention.

Finding Your Feet strength and balance classes are run from Todmorden Health Centre, Beechwood Health Centre or Brighouse Health Centre. Individuals who are safely able to participate can attend for up to 13 weeks. They will then be encouraged to attend exercise groups run by other providers. These groups may not always challenge strength and balance.

Other community services providers are encouraged to screen for falls risks and to refer to the Support and Independence Team as required.

People living within care homes are also able to access these services.

Referrals can be made to these services via the local Gateway to Care (01422 383000).

The Falls Clinic

The Falls Clinic is provided by Calderdale and Huddersfield Foundation Trust. It offers outpatient, geriatrician-led multi-disciplinary team assessment for patients who have fallen, when complex medical problems have contributed to the falls. Healthcare professionals can refer directly to this service by completing a referral form.

The Quest for Quality in Care Homes Service

There are 34 Calderdale care homes using the 'Quest' service. As part of the service, care home residents have access to telecare equipment such as falls detectors, bed occupancy sensors and chair occupancy sensors. These help to prevent falls and enables staff to respond quicker when residents have fallen. This provides reassurance to residents and their families and supports care homes staff.

GPs

From July 2017, the GP contract requires practices to use an appropriate tool (usually the electronic frailty index) to identify patients aged 65 and over who are living with moderate or severe frailty. For those people identified with severe frailty, practices are required to review them annually and as part of this review. This is to ask if the patient has fallen in the last 2 months and provide any relevant interventions, for example referral to a falls clinic.

Fire and Rescue Service

The Fire and rescue service visit vulnerable individuals in their own homes to complete Safe and Well checks. This assessment includes questions about falls risks. They have received training to allow them to provide basic advice about environmental falls risks, footwear and can provide advice leaflets. They will refer to Gateway to Care if individuals need more specialist intervention.

Other health and social care services

A number of local services have accessed training or awareness raising sessions from the Support and Independence Team, including:

  • Out-Patient Physiotherapy Services.
  • Learning Disability Services.
  • Housing Associations.
  • Home Care providers.

The sessions included education about falls risks, advice to provide to clients and guidance about referring on for specialist input.

User views

Attenders at the recent 13 week long “Finding Your Feet” classes, provided by the Support and Independence Team in locations across Calderdale gave the following feedback:

  • "The 13 week course had improved my mobility enormously and given me back my confidence."
  • "I have used a walking stick for the last 2 years. This course has reduced my need to only use a stick when walking over rough ground."
  • "The team are very helpful, friendly and caring and helped improve my confidence."
  • "I am now able to do things that I have not been able too for a long time."

90% of attendees said they wished the classes could be extended.

Unmet needs

  • Older people need to be able to travel to “Finding your Feet” classes. Difficulties in accessing or funding suitable transport may exclude a number of potential participants.
  • There are good links between health and social care. The Staying Well service, ran by the local authority, attends Finding Your Feet classes. They link participants into other exercise and activity groups at the end of the 13 week class. However, these groups may not target strength and balance effectively.
  • There is currently no Fracture Liaison service within Calderdale, to identify risk of osteoporosis in individuals presenting to the emergency department. Fracture liaison is key for initiating bone health treatment and referring individuals to other services to address long-term needs.
  • There can be waits, on average, of 4 weeks for rehabilitation once an individual is discharged home from hospital following surgery to repair a hip fracture. However, individuals will receive ongoing rehabilitation immediately if discharged into Intermediate Care beds or discharged home with the support of the Reablement service. Work is ongoing to improve pathways of care and timely access to services.

Projected future need

There are currently 209,800 people in Calderdale according to the ONS 2016 Mid-Year population estimates. This is an increase of approximately 5,900 people since the 2011 Census. There have been large increases in the proportion and the numbers of residents aged 45 to 54 and 55 to 64 since 1991. This may have implications for the residents aged 65 and over within the next ten years. The population aged 85 and over has increased steadily from 3,200 in 1991 to over 4,700 in 2016.

According to the Office for National Statistics (2014) and mid-year population estimates in 2016 the largest growth is expected to occur in the older age groups. A 29% increase in those aged 85 and over by 2014, a 11% increase in those aged 65 to 74 and a 42% increase in those 75 to 84.

Current estimates suggest 17% of the population in Calderdale is aged 65 or over. By 2037 the Office for National Statistics estimate 25% of Calderdale's population will be over 65. This will equate to, approximately, 21,000 additional people over 65. Such a large rise, in a little over 20 years, will undoubtedly increase demand on services. It is likely that the number of falls within this age group will also increase.

Key considerations linked to the known evidence base (what works?)

  • Exercise classes targeting strength and balance have been shown to be highly effective in reducing falls when attended for over 36 weeks (Skelton et al, 2005). Home-based exercise can reduce falls when completed over 1 year (Campbell et al, 1997). There is a lack of resourcing in Calderdale to provide the long-term exercise interventions required.
  • Tai Chi is only effective for those who have not fallen yet or who have mild strength and balance deficits (Wolfe et al, 2003). yet it is one of the only options for older people who wish to participate in on-going exercise for balance after completing the “Finding your Feet” class.
  • A multifactorial falls risk assessment should be performed by a healthcare professional with appropriate skills and experience, in the setting of a specialist falls service (NICE, 2013). This is offered by the Falls Prevention Team. NICE (2013) also suggest that all older people who present for medical attention because of a fall, who report recurrent falls or who demonstrate abnormalities of gait and balance should be offered a multifactorial falls risk assessment. Due to limited resources available for promotion and publicity, there may be older people and health/social care professionals who are not aware of the Falls Prevention Service and potential referrals may be missed.

There are a number of high quality evidence reviews and guidelines published regarding the effectiveness of falls prevention interventions. References below provide further details:

References and further information

References

Further information

There are several guides on helping to prevent falls, including:

Authors

Clinical Lead Physiotherapist, Falls Prevention Service, CHFT and Information and Evaluation Officer, Calderdale Council (Nov 2015).

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