Falls

A fall is defined as an event which results in a person coming to rest inadvertently on the floor or another level. Falls are a global and national public health problem (World Health Organisation (WHO), 2012).

In the United Kingdom, falls are estimated to cost the NHS more than 2.3 billion per year. In 2012-13, there were 410,377 admissions due to falls. From these admissions, 3.7 % died in hospital (Health and Social Care Information Centre (HSCIC), 2013).

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).

People aged 65 and older have the highest risk of falling, with 30% of people aged older than 65 and 50% of people aged older than 80 falling at least once a year (National Institute for Health and Care Excellence (NICE), 2013). Females aged over 65 have a higher rate of admission due to falling (HSCIC, 2013). As well as age, other risk factors for falling include drug and alcohol misuse; occupations at hazardous heights; side effects from medication;  poor mobility, cognition and vision; underlying health conditions; reduced balance and physical activity; continence problems; and environmental hazards (WHO, 2012; NICE, 2013).

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).

The local picture

Using data from 2013/2014 - Public Health England (PHE) estimated the rate of injuries due to falls in people aged 65+ in Calderdale  was 2,167 per 100,000 (directly standardised rate (DSR)). This is statistically similar to both Yorkshire and Humber and the national average (PHE, 2015).

Falls are costly to the local healthcare economy; between 2014–2015 there were 1,097 emergency hospital admissions for falls among those aged 65+ in Calderdale. The total cost associated with these admissions was in the region of £3,000,000 (or £2,648 per admission) (Yorkshire and Humber Commissioning Support Unit (CSU)).

The following recent statistics demonstrate the demand falls place on the Calderdale and Huddersfield NHS Foundation Trust (CHFT):

  • In this financial year to date (April 2015-October 2015), there have been 3,273 people aged over 65 presenting to the Accident and Emergency Departments at Calderdale Royal Hospital and Huddersfield Royal Infirmary with injuries associated with falling;
    (Note: this figure includes residents of Calderdale, Kirklees and surrounding areas);
  • 537 of these older people seen in Accident and Emergency, due to falling, have been recorded as being discharged home, without any onwards referrals to services;
  • Calderdale Clinical Commissioning Group (CCG) report that between April 2015 and August 2015, 409 Calderdale residents were admitted to a ward in CHFT with injuries associated with falling. This included 49 fractured necks of femurs;
  • CHFT capture data about patients seen by clinicians on the 1st Wednesday morning of each month, and have reported that over the past year, 29 patients being cared for by Community Services on those dates have experienced a fall.

When trying to determine need at a sub-regional level, the hospital admission ratio for fractured neck of femur is a good proxy measure of the incidence of falls in older people (as hip fracture is the most common injury related to falls in older people). Therefore, using multiple years data - indirectly age standardised emergency hospital admission ratios can indicate areas of Calderdale where there are more or less emergency admissions for falls than would be expected (compared  the national average and taking into account the age structure of the population):

Wards Emergency hospital admissions for hip fracture in 65+, 2008/9 to 2012/3 (Standardised Admission Ratio) Lower Confidence Interval Upper Confidence Interval
Park 157.5 125.2 194.8
Todmorden 128.2 103.4 156.6
Ovenden 123.4 93.5 159.6
Rastrick 121.9 97.9 149.3
Greetland and Stainland 100.0 74.7 130.4
Illingworth and Mixenden 100.0 76.1 128.9
Skircoat 99.3 79.5 121.4
Elland 97.5 75.4 122.5
Northowram and Shelf 95.5 74.4 119.3
Town 92.2 70.9 116.4
Ryburn 91.3 66.7 121.5
Sowerby Bridge 84.6 64.7 108.8
Hipperholme and Lightcliffe 81.2 62.0 104.3
Luddendenfoot 81.0 59.2 106.9
Warley 79.2 59.6 102.4
Calder 77.6 56.9 102.0
Brighouse 76.6 58.7 97.7

Source: PHE, 2013.

  • The data should be interpreted as: between 2008 and 2013 Park Ward and Todmorden had statistically significantly more hospital admissions for hip fracture in over 65s than would be expected (compared to the national average and taking into account the age structure of the population);
  • The number of hospital admissions for all other wards (except Brighouse) was similar to that which would be expected;
  • Brighouse has less hospital admissions for hip fracture in the over 65s than expected.

These statistics could be used to help inform equitable provision of falls prevention services across the borough.

Current provision

The Falls Prevention Service

The Falls Prevention Service will see adults in Calderdale in their own homes (including care homes) for multifactorial assessment of their falls risk, and offer individualised advice and management. Strength and balance exercises may be prescribed to be done at home or in a group setting. The team comprises of Physiotherapists and Falls Prevention Workers (qualified Postural Stability Instructors). Between October 2012 and October 2015, 1,671 older people in Calderdale were referred to the Falls Prevention service, and 60 people were referred to the “Finding Your Feet” class provided by the team - the class lasts for 12 weeks. The Falls Prevention Service is part of the Support and Independence Team (SIT). SIT will assess the risk of falling in relation to a long-term condition, and also provide goal-orientated rehabilitation to improve strength and balance.

The Falls Clinic

The Falls Clinic is provided by Calderdale and Huddersfield Foundation Trust, and offers out-patient multi-disciplinary team assessment for patients who have fallen, when complex medical problems have contributed to the falls. Between October 2012 and October 2015, 42 people were seen in Falls Clinic.

Telecare

Telecare provide equipment that allows people at risk of falling to live safely in their own homes, and provides reassurance to families and carers. Equipment such as Falls Detectors, Bed Occupancy Sensors and Chair Occupancy Sensors can be used in conjunction with a Care Line, and can send an alert to a 24 hour response centre.

The Quest for Quality Team, Tele-health, the Falls Prevention Service and the Support and Independence Team all support older people living in 24 hour care environments, who are at risk of falling. However, staff report there can be duplication of assessments between the services.

User views

Attenders at recent 12 week long “Finding Your Feet” classes, provided by the Falls Prevention Service in locations across Calderdale provided the following feedback:

  • “I enjoyed these classes and would like them to continue.”
  • “Very useful in helping improve balance.”
  • “The course is valuable.”
  • “Could there be as much publicity as possible so more people could benefit?”
  • “I would like to continue with the class.”

When the participants were asked if there was anything they would change about the class, they stated:

  • “Would have liked it to carry on a little longer.”
  • “Extend the course.”
  • “More weeks.”
  • “A bigger room.”

Unmet needs

  • Older people need to be able to travel to “Finding your Feet” classes, and difficulties in accessing or funding suitable transport may exclude a number of potential participants;
  • There is a lack of suitably-sized rooms available for use for the “Finding your Feet” classes across Calderdale;
  • The Falls Prevention Team are only able to run their “Finding your Feet” classes for 12 weeks;
  • The Falls Prevention Workers report that options are limited for older people wanting to continue with strength and balance exercises after completing the “Finding your Feet” classes.  Tai Chi is one of only a few options, but is not always suitable or appropriate;
  • The Falls Prevention Service would like to carry out more education, health promotion and early prevention work, but lacks the staffing resources to complete this in addition to managing referrals/waiting lists and providing classes;
  • Improved coordination of services visiting care homes could improve timely and appropriate access to the correct team or professional, and reduce duplication;
  • There is a need to establish up to date information about services, groups, and exercise classes for older people held across Calderdale, provided by CHFT, Calderdale Council, the voluntary sector and the private sector, to allow for improved and individualised sign-posting for older people;
  • There may still be a lack of awareness of community services by staff in local A&E departments, and lack of knowledge of NICE guidelines in relation to falls, accounting for the large number of patients discharged without any onwards referrals. Education from the community services may help.

Projected future need

Current estimates suggest 18% 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 and 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 haven’t yet fallen, 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), and 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

More information on older people can be found in the Further resources .

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

Authors

Claire Folan, Clinical Lead Physiotherapist, Falls Prevention Service, CHFT;
John Lomas, Information and Evaluation Officer, Calderdale Council.

November 2015.