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Topic on a Page - Falls

Data Sources:

Public Health England (PHE):

Older People's Health and Wellbeing

Injury Observatory Britain and Ireland

Falls Workstream:

National Audit of Inpatient Falls

Royal College of Physicians:

National Hip Fracture Database website

Fracture Liaison Service Database (FLS-DB)

Chartered Society of Physiotherapy:

Calculate the cost of falls

Supporting Information:

NHS Evidence:

Falls

Falls and the Elderly

Falls and Diabetes

Falls and Parkinson's Disease

Falls and Dementia

Prevention of Falls

NICE:

NICE: Impact: Falls and Fragility Fractures

Delirum: prevention, diagnosis and management [CG103]

Pathway: Preventing falls in older people overview

Clinical Knowledge Summaries Falls - risk assessment Revised: January 2014

Public Health England:

Falls and fracture prevention pack Published: January 2017

Falls prevention: cost-effective commissioning - GOV.UK Published: February 2018

NHS England:

NHS England: Falls and Fragility Fractures Pathway

Right Care Frailty Toolkit

NHS Scotland:

Falls Information

ProFaNE Prevention of Falls Network Earth:

ProFane Community Online

Age UK:

Falls Prevention Exercise: Following the evidence (Age UK and Age Concern)

Staying Steady

Chartered Society of Physiotherapy:

Get up and go: a guide to staying steady

Physiotherapy works: Falls and frailty

College of Occupational Therapists:

Helping people to live not exist

Linked Topics

Topic last reviewed: Aug-18

JSNA Topic: Falls

Background

Falls can happen to anyone, anywhere and at any time. Falls and fall-related injuries are a common and serious problem for older people. Three in 10 people over the age of 75 in England (about 2.5 million) will have at least 1 fall each year. Half of those aged 80 or above will have a fall (Source: NICE).

Falls destroy confidence, increase isolation and reduce independence and can hasten a move into residential care. After a hip fracture, 50 per cent of people can no longer live independently, and the incident may lead to death. Falling can also affect family members and carers. Falls are estimated to cost the NHS more than £2.3 billion per year. Therefore falling has an impact on quality of life, health and healthcare costs (Source: NICE Guideline Falls in older people: assessing risk and prevention [CG161]).

Falls are commonly associated with frailty, but it is not only frail people who can be affected. Falls are not an inevitable consequence of old age and can be prevented by well organised services and organisations working in partnership with the person and their carers.

Effective falls prevention and management requires co-ordination and collaboration across health and social care, as well as housing providers and the third and independent sectors. The integration of health and social care, and closer working with housing providers, presents an opportunity to strengthen the planning and delivery of an integrated multiagency pathway.

The most common places for people to fall are in their home, in hospitals, in care homes or on roads. The risk of falls at home can be mitigated by reducing clutter, mopping up spillages, using non-slip rugs and mats, adequate lighting, wearing well-fitted footwear and avoiding loose-fitting or trailing clothes which can cause trips. The risk of falls can also be reduced by regular strength and balance training, medication review, sight tests, and reducing alcohol consumption (Source: NHS Choices – falls prevention).

With an increasing ageing population, preventing people from falling is a key challenge for all organisations in Lincolnshire.

Context

National Strategies, Policies & Guidance

The NICE Guideline Falls in older people: assessing risk and prevention [CG161] (reviewed 2016) provides guidance on how to carry out a falls assessment and interventions to prevent falls for people aged 65 and over. It aims to reduce the risk and incidence of falls and the associated distress, pain, injury, loss of confidence, loss of independence and mortality. This guideline has been produced to support the following people and organisations:

  • Healthcare and other professionals and staff who care for older people who are at risk of falling
  • People aged 65 or older who fall or are at risk of falling in the community, and their families and carers
  • All hospital inpatients aged 65 or older
  • Hospital inpatients aged 50 to 64 who have been identified as being at higher risk of falling.

The NICE Quality Standard document Medicines management in care homes [QS85] March 2015 covers prescribing, handling and administering of medicines for people of all ages living in care homes, and the provision of care or services relating to medicines to those people. This is particularly important in preventing people from falling, as certain medication can increase the risk of falls.

The NICE Quality Standard document Falls in Older People [QS86] March 2015 outlines a set of specific, concise and measurable statements to improve the quality of falls services. This document covers assessment after a fall and preventing further falls (secondary prevention) in older people living in the community and during a hospital stay. Secondary prevention focuses on interventions targeted at older people with a history of falls. Older people are those aged 65 years and over.

The Medtech innovation briefings for Quantitative Timed Up and Go (QTUG) for assessing falls risk and fragility [MIB73] July 2016 describes technology used to carry out assessment of falls and frailty risk using average values for age and gender and statistical models. The technologies applied are body-worn sensors and a mobile software app to assess mobility, falls risk and frailty which are used during the TUG test.

NHS England promotes the Frailty Fulcrum model (January 2016), which provides the opportunity to take the concept of frailty as a long-term condition and adopt a much more proactive, person-centred, community- based approach to care.

The Quality Care for Older People with Urgent & Emergency Care Needs (June 2012), published by the British Geriatrics Society and known as the "Silver Book", identifies the complexity and interconnections of the six frailty syndromes: falls, dementia/delirium, continence, polypharmacy, immobility and end of life care; which all contribute to increased admissions to acute trusts, institutionalisation and patient harm.

The British Geriatrics Society produce best practice guidance on falls.

The Chartered Society of Physiotherapy has developed a Falls Prevention Economic Model to demonstrate how preventative physiotherapy saves money when planning care for older people and preventing falls.

The College of Occupational Therapists have produced the guidance, Occupational Therapy in the prevention and management of falls in adults. This is an evidence- based resource to support occupational therapists working with adults in the prevention and management of falls. The guideline, which is NICE accredited, can be used to inform service users and carers, together with other health professionals, managers and commissioners working in adult services, about the roles and responsibilities of the occupational therapist in clinical area.

In 2012 Age UK and the National Osteoporosis Society established the Falls and Fractures Alliance. The Falls and Fractures Declaration contains a series of commitments for achieving the common goals of preventing falls and fractures and, specifically, reducing the rate of hospital admissions for hip fractures and for falls-related injuries among older people.

Age UK have produced Falls Prevention Exercise – following the evidence (June 2013) which explains the evidence base for falls prevention exercise, how it can be applied in practice, and the benefits which can be expected, for older people and for health and care services. It includes case studies which are delivering a reduction in falls.

The Royal College of Physicians have developed FallSafe Resources which provides resources for good practice on care and equipment for reducing falls.

Local Strategies & Plans

The Lincolnshire Sustainability and Transformation Plan (STP) aims to help people take care of themselves through support from accessible, proactive care and neighbourhood teams.

What is the picture in Lincolnshire?

What the data is telling us

In 2016/17, the direct standardised rate of emergency hospital admissions for injuries due to falls in Lincolnshire among those aged 65 years and over was 1,874 per 100,000 population compared to 2,114 per 100,000 population in England. The rate for those aged 80+ years in Lincolnshire was 4,890 per 100,000 population compared to 5,363 per 100,000 in England in the same year (Source: Public Health Outcomes Framework (PHOF)

Hospital episodes (HES) data is used as an indication of falls as it is quantifiable. It accounts for falls which are serious enough to require hospital attention, and is fairly immune to policy and recording changes. It is a complete data set available from record level upwards providing a robust basis for analysis and interpretation, both to understand the underlying demographics of those affected and some of the potential factors which may have influenced the fall. It also enables monitoring of trends and the impacts of local interventions. Falls which may not have required hospital attention are not captured by HES data, for example those which take place and may be treated locally in care homes and those where the patient presents at the GP and do not require more specialist treatment. These datasets are not readily available and do not have the same qualities in terms of complete and consistent recording for the population.

Key information from HES shows that:

  • In the financial year 2014/15 in Lincolnshire, falls were the cause of 8.67% of emergency hospital admissions for people aged 65+, and 11.5% among people aged 80+.
  • In 2016/17 there were 3,075 emergency hospital admissions of Lincolnshire residents aged 65 + as a result of falls.
  • Based on those figures, falls affected 1% of population aged 65-79 and 4% of the population aged 80+ in one year in Lincolnshire.
  • Falls consistently affect more females than males. PHOF data shows that injuries due to falls are more common among women than men. The rate of emergency hospital admissions for injuries due to falls among women aged 65-79 years in 2016/17 in Lincolnshire was 1,081 per 100,000 population compared to 570 per 100,000 population among men in the same age group. This follows a national trend (rate of injuries due to falls in England, in the same year, and same age group was 1,152 women per 100,000 population compared to 814 men per 100,000 population). Gender inequality can partly be explained because of differences in life expectancy (women live longer than men and the risk of falls increases with age).
  • Latest figures show that hospital admissions due to falls are at a significantly lower level in Lincolnshire compared to the national average. There were no significant differences between Lincolnshire CCG areas; however Lincolnshire East CCG recorded the highest rate.

Trend

The rates of emergency hospital admissions due to falls in people aged 65 and over were significantly above national levels in 2011/12. Since then rates have been steadily falling. This is not consistent with the national trend. Further work needs to be undertaken to determine the reasons behind this positive change to ensure that progress is maintained.

The impact of falls is projected to increase in the future as the population ages. The number of hospital admissions are projected to increase by 43% for people aged 65+ by 2030 (Source: Projecting Older People Population Information System (POPPI)).

It is estimated that in 2015, in Lincolnshire over 44,000 people aged 65+ experienced at least one fall; this number is projected to increase to over 63,000 by 2030 as the population increases and ages (these figures are based on rates from Health Survey for England (2005) applied to ONS population estimates and projections).

Public Health England estimate that 30% of people aged 65+ living at home, and 50% of people in residential care will experience a fall during their lifetime.

Key Inequalities

According to NHS England the following factors or combination of factors can put a person at risk of falling:

  • Slippery surfaces; the floor is wet or recently polished, such as in the bathroom
  • Inadequate room lighting
  • Unsecured rugs or carpets
  • The person is reaching into storage areas, such as a cupboard, or is going down stairs
  • The person is rushing to get to the toilet
  • Slips and trips due to clutter
  • Ill-fitting footwear
  • Side effects of medication, particularly where multiple prescriptions are taken
  • Alcohol consumption, particularly whilst taking medication.

Older people are more likely to have a fall because they may have:

  • Balance problems and muscle weakness
  • Poor vision, even with glasses
  • A long-term health condition, such as heart disease, dementia or low blood pressure (hypotension) which can lead to dizziness and a brief loss of consciousness.

According to the British Geriatrics Society, those that have two or more of the following six syndromes (falls, dementia/delirium, continence, polypharmacy, immobility and end of life care) can be classified as frail. The other five syndromes can add to the risk of having a fall.

Current Activity & Services

The JSNA Falls Expert Panel in November 2016 identified the following falls activities and services. These are categorised as either reactive or proactive:

Reactive

  • Lincolnshire Community Health Services use a falls screening risk assessment based on the Edmonton Frailty Scale which can be used in Secondary as well as Primary Prevention.
  • Patients can be referred for medical assessment at United Lincolnshire Hospital Trust (ULHT) or Lincolnshire Partnership Foundation Trust (LPFT).
  • The Joint Ambulance Conveyance Project (JACP) builds on the Lincolnshire Fire and Rescue (LFR) existing co-responder scheme, run in partnership with East Midlands Ambulance Service (EMAS) and Lincolnshire Integrated Voluntary Emergency Service (LIVES). The JACP involves some co-responders being mobilised to medical incidents in an ambulance vehicle. The LFR staff have the capability to convey a patient to hospital rather than having to wait at the scene until an EMAS ambulance arrives.
  • Since April 2015, low level prevention of falls has formed part of the county's Wellbeing Service. The Wellbeing Service provides a range of interventions and community based support to promote confidence in living independently. This includes providing small aids for daily living and minor adaptations. A Wellbeing Response service, linked to provision of Telecare, sends a responder to service users who have had non-injury falls, assisting them to mobilise after a fall. Fees apply to some service elements. The Wellbeing Service looks at vulnerability around falls and captures this data.
  • Both Lincolnshire Community Health Services (LCHS) and LPFT have Rapid Response Teams which provide a service to people who experience a serious exacerbation of a health need which requires urgent clinical attention, but not hospital admission. This team is an important part of helping people stay safely in their own home, and provides peace of mind for many families. The team is a multidisciplinary health team, led by community nurses and community psychiatric nurses specialising in both physical and mental health needs, and referrals are usually through a GP or East Midlands Ambulance Service (EMAS).

Proactive

  • LPFT have developed the Recovery College, which uses an educational based approach to help people recognise and develop their personal resourcefulness and awareness in order to become experts in their self-care, to make informed choices and do the things they want to in life. Programmes such as the Lifestyle Matters course can help people that have had falls or are at risks of falling.
  • Within LPFT each older adult in contact with the service is routinely screened for falls risk as part of the initial assessment and proactive steps taken where risks are apparent, for example a referral made to Occupational Therapy or Physiotherapy assessment. LPFT will then review this risk on a regular basis as part of the person care and treatment.
  • LCHS have a Pulmonary Rehabilitation Service, which provides programmes of education and exercise for patients with Chronic Obstructive Pulmonary Disease (COPD) across the county with specialist nurses. The focus is on improving core strength, medication reviews, exercise tolerance, breathlessness management, quality of life and mood state. This will help people that have had falls or are at risks of falling.
  • LCHS have 22 locations that offer their Podiatry Service around the county. Podiatry is the diagnosis and treatment, by podiatrists, of diseases and other disorders of the feet. Podiatrists are trained to prevent, diagnose, treat and rehabilitate abnormal conditions of the feet and lower limbs to keep people mobile and active, relieve pain and treat infections. This will help people that have had falls or are at risks of falls.
  • EMAS are currently conducting ongoing research into early intervention for falls patients.
  • Lincolnshire County Council (LCC) has commissioned a Sensory Impairment Service run in partnership with Action on Hearing Loss, Lincoln and Lindsey Blind Society and South Lincolnshire Blind Society. The Lincolnshire Sensory Service provides assessment and support for Visually Impaired, Deaf, Hard of Hearing and Deafblind adults, children and young people across the county. Part of the service is to provide rehabilitation support to assist in daily living skills and mobility training for safe independent travel.
  • LCC Adult Care commission Care Homes, Homecare Services and Reablement Services who are required to monitor and respond to falls and the risk through their contract monitoring meetings.
  • LCC Adult Care have commissioned Lincolnshire Care Association (LinCA) to provide training and support to the external social care workforce, which will cover work around Frailty and Falls.

Reactive and Proactive
The Cardiac Rehabilitation Service: this is both a proactive and reactive service and it aims to avoid hospital admissions.

Falls Prevention Steering Group
Following the JSNA Falls Expert Panel in November 2016, the countywide Falls Prevention Steering Group was re-established to take stock of the work being carried out by different organisations around falls prevention, to discuss possible collaboration on future work and to avoid duplication.

There is recognition amongst partner agencies that falls prevention does not 'stand-alone' and is integral to service delivery, service quality and has financial repercussions throughout the whole health and care system. The group agreed that falls are part of the syndrome of frailty and cause the most serious injuries to people who are frail. Individuals need to be assessed with the six syndromes of frailty in mind, which are dementia/delirium, falls, incontinence, polypharmacy, immobility and end of life care.

The group is integral in providing further evidence of need, action planning and setting targets, alongside the Frailty Expert Group, who are creating a frailty pathway for the whole system to use.

Frailty Expert Group
Following the JSNA Falls Expert Panel in November 2016, the Frailty Expert Group was established, led by the STP, to develop the ideal Frailty Pathway, with an agreed assessment tool based on evidence and best practice, which will require a system-wide change that will simplify the process, and be consistent across health and care sector. All partners will ensure professional ownership and mutual trust to reduce duplication and ensure the individual remains at the centre.

The national Acute Frailty Network recommends the Edmonton Frailty Assessment Tool as its preferred assessment tool, and the PRISMA questions for lower level use, which Lincolnshire has agreed to follow. The group reports to the STP Boards.

An interactive, web-based Frailty Pathway has been developed. This holds useful tools and links to information and can be used as an education tool, for example, developing podcasts by relevant experts. This dynamic webpage will be constantly updated and appraised to ensure best practise for the local population.

Unmet Needs & Gaps

There is a need for a central hub where information around falls services and groups are available in Lincolnshire and this should be part of proactive care.

The JSNA Falls Expert Panel identified further data sources that could be collated. This data could be used to understand the needs of those affected by falls further and to help create a list of people vulnerable to falls. This data could be collected from groups and services such as LIVES, telecare, EMAS, alcohol services, Blue Badge, Care Home settings and falls in the community subject to its availability and data sharing agreements.

Local Views & Insights

Since the JSNA Falls Expert Panel took place in November 2016, no local views have been captured. Further work is needed to capture the views and needs of partners and people who use services and their carers/families. A re-establishment of the multi-agency falls prevention steering group would help with this.

Risks of not doing something

Preventing people from falling is a key challenge for the NHS and local authorities in Lincolnshire. The consequences of falls can have huge implications for an individual as well as being an issue which cuts across all agencies working with older people. Costs due to falls run into billions of pounds per year. Further information can be found in NICE guidelines.

Although the rate of hospital admissions has fallen, there is a risk, given Lincolnshire's demographic that without action, avoidable hospital admissions would continue to increase, adding to pressures for United Lincolnshire Hospitals NHS Trust. The effects of a fall are felt in Adult Social Care, Housing and cause stress and anxiety to patients and their families. Doing nothing would result in a lost opportunity to develop a valuable tool for supporting and encouraging self-management, independence and all the benefits that brings for the individual and healthcare organisations. The impact of an increasing older population; rising costs and reduced funding will be felt all the more if no action is taken proactively on a joint commissioning basis in this area.

The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falls also affect family members and carers. NICE estimate that falls are estimated to cost the NHS more than £2.3 billion per year.

What is coming on the horizon?

The following could impact on the subject area of falls:

  • The Lincolnshire Sustainability and Transformation Plan (STP) is a partnership approach to transforming health and care in Lincolnshire through developing proposals for a high quality, safe and sustainable health and care system which better meets the needs of current and future residents. STPs are a national requirement and sets out how health and wellbeing, quality and care and the finances of Lincolnshire's systems will improve by 2021. The STP will have an impact on how services are commissioned and delivered in the future. By 2021, people will be supported close to their homes and only need to go to hospital for specialist treatment or emergencies. This could have an impact on hospital admissions when a person has a fall.
  • Lincolnshire County Council is developing a commissioned falls programme across Lincolnshire. Part of this work includes a pilot postural stability instruction programme (strength and balance training) for falls prevention in high risk groups to avoid falls, avoidable hospital admissions and social care costs.

What should we be doing next?

Key activities that will be carried out next to contribute to the falls agenda are:

  • To map all the services and groups in Lincolnshire that offer support around falls to determine any unmet needs and services.
  • To obtain data from all services to gain a clearer picture of falls in Lincolnshire.
  • Engage with people who use services and their carers/families to obtain their views around falls to determine any unmet needs and services that would support people.

 

If you need to contact us about this topic, please email JSNA@lincolnshire.gov.uk

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