Falls (health and wellbeing needs in South Tyneside)

"Falls and fall-related injuries are a common and serious problem for older people. People aged 65 and older have the highest risk of falling, with 30% of people older than 65 and 50% of people older than 80 falling at least once a year.

The human cost of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falling also affects the family members and carers of people who fall. Falls are estimated to cost the NHS more than £2.3 billion per year (College of Optometrists/British Geriatrics Society, 2011). Therefore falling has an impact on quality of life, health and healthcare costs. "(NICE, 2013)

1. The local population is ageing and the proportion of those aged 65 and over continues to increase.
2. Injury and debility due to falls will demand even greater resources from the Health Service, the local authority, and third party providers. All of whom are already struggling to meet the current demands.
3. The current approach to this issue is generally reactive rather than proactive. Without an investment in prevention, services will not be able to cope with the demand in the very near future.
4. There are evidence proven interventions and guidance that can reduce one's risk of falling.
5. Evidence has also shown a positive economic return on investment in fall prevention interventions. (Gillespie, 2009)An audit of Sunderland's Community Falls Service in 2012 found a potential savings of £640,000 (Metz, 2014)
6. This issue cannot be addressed by one agency or service in isolation but rather requires the coordinated efforts and engagement of the health services, local authority, and third party providers.

1. A shift in focus towards the prevention of falls, as well as the recovery afterwards, must happen among providers of all services that come into contact with older adults and their families and / or carers.
2. A campaign to educate people on the risks of falls and ways to reduce that risk must be available to the general public.
3. Education on fall prevention needs to be available in formats accessible and familiar to older adults.
4. General practitioners and other primary care providers, such as Integrated Community Teams, need to be supported with appropriate education, information, and innovative ways to educate their patients and their families on the prevention of falls.
5. The Community Falls Service must continue to be supported and developed.
6. Links between the local authority, third party providers and the Health Services must continue to be supported and developed further.
7. Leisure centres are ideally positioned to provide appropriate exercise interventions to older adults. More of these types of classes need to be available on a regular basis.

Falls and fall-related injuries are a common and serious problem for older people.

• According to the latest Cochrane Review on falls, "About a third of community-dwelling people over 65 years old fall each year (Campbell 1990; Tinetti 1988), and the rate of all related injuries increases with age (Peel 2002).
• Falls can have serious consequences, e.g. fractures and head injuries (Peel 2002). Around 10% of falls result in a fracture (Campbell 1990; Tinetti 1988); fall-associated fractures in older people are a significant source of morbidity and mortality (Keene 1993).
• About 15%of falls result from an external event that would cause most people to fall, a similar proportion have a single identifiable cause such as syncope, and the remainder result from multiple interacting factors (Campbell 2006).
• Since many risk factors appear to interact in those who suffer fall related fractures (Cummings 1995), it is not clear to what extent interventions designed to prevent falls will also prevent hip or other fall-associated fractures.
• Falls can also have psychological consequences: fear of falling and loss of confidence that can result in self restricted activity levels leading to a reduction in physical function and social interactions (Yardley 2002). Falling puts a strain on the family and is an independent predictor of admission to a nursing home (Tinetti 1997)."

Public Health England's guidance on falls gives information specific to the nation:

• The Public Health Outcomes Framework reported that in 2013 to 2014 there were around 255,000 emergency hospital admissions related to falls among patients aged 65 and over, with around 173,000 (68%) of these patients aged 80 and over.
• Falls were the ninth highest cause of disability adjusted life years (DALYs) in England in 2013 and the highest cause of injury.

Short and long-term outlooks for patients are generally poor following a hip fracture, with an increased risk of dying in the following 12 months of between 18% and 33% and negative effects on daily living activities such as shopping and walking. A review of long-term disability found that around 20% of hip fracture patients entered long-term care in the first year after fracture.

The economic burden of incident and previous fragility fractures, those that result from mechanical forces that would not ordinarily result in fracture (equivalent to a fall from a standing height or less) in the UK is estimated as being £3.5 billion in 2010. 74% of these costs relate to incident fractures (ie health care), 24% relate to long-term (social) care and 2% to pharmacological prevention. (PHE, 2015)

For the latest data and trends related to falls in South Tyneside, see:

Fingertips: Public health profiles: Falls

South Tyneside currently has 29,300 people or 19.6% of its population that is over age 65.

• If one in three people over the age of 65 will fall in one year, that is 9,669 people who will fall this year.
• Nearly 1,000 of those will require medical attention.

The Community Falls Service is a shared service with Sunderland. One full-time Band 7 and one part-time Band 3 employees are dedicated to South Tyneside. The Band 7 also provides one day a week at the Galleries in Washington. Services provided in fiscal year 2015 - 2016 included:

• Screening 3084 referrals and A&E visitors.
• Providing assessments to 502 individuals in the outpatient clinic and in their place of residence.
• There has been a 5 to 10 week wait for assessment throughout the year.
• Providing 73 follow up visits in the community.
• Providing monthly fall prevention training to care home employees and managers.
• Starting a vestibular assessment and rehabilitation weekly clinic due to previously unrecognised need. There is currently an 8 week wait for assessment.
• This does not take into account unreported falls by people who may not seek help, who are treated by other providers and not referred, or who decline a referral.

The South Tyneside District Hospital has audited their rate of inpatient falls and participated in the National Audit of Inpatient Falls.

• The national average rate of falls for inpatients is 6.63 per 1000 bed days.
• The Northeast average rate of falls for inpatients is 8.09 per 1000 bed days.
• The South Tyneside District Hospital's average rate of falls is 10.66 per 1000 bed days. This places the hospital at fourth highest rate of falls in the nation.

1. There are insufficient opportunities for older adults to become or remain active in the region. A review of available classes in the local authority leisure centres reveals three different activities aimed at older adults; Knit and natter groups, isolated rambling dates, and high intensity interval training (HIIT). None of these are appropriate for older adults looking to become or remain active.
2. There is insufficient capacity of occupational therapy services to provide home safety assessments, equipment recommendations, and environmental changes to address fall prevention. The current waiting time is approximately 4 months for an OT visit from the Health Services.
3. Pressures on GPs prevent them from effective education and investigation of falls and fall risk of older adults. They are also unable to prescribe walking aids to patients directly thus requiring a further wait for referral to a physiotherapist or occupational therapist. This puts patients at unnecessary risk.
4. The Community Falls Service and the hospital based Falls and Syncope Service are struggling to meet current demands with patients waiting from 5 to 10 weeks for an assessment. This waiting time puts patients at risk for fall and fracture in the interim.
5. Due to a restructuring process that is not yet complete, the level of support that Age UK in South Tyneside can continue to provide is in question.
6. Leisure centres fail to offer a range of activities for a variety of age groups focusing primarily on children and adults under the age of 65.

The number of people aged 65 and over is expected to increase to 35,300 people or 23.1% of its population by the year 2025 (POPPI, 2016).

• That would be a 17% increase in the most at risk population for falling.

It is estimated that 9,420 older adults will fall annually by 2025 and 757 of those will require hospitalisation (POPPI, 2016).

• These numbers are likely underestimated as the models utilized do not account for socio-economic disparities between regions. South Tyneside is the 23^rd most deprived local authority in the nation according to The English Indices of Deprivation 2015.
• It is well accepted that areas of deprivation tend to have overall poorer health outcomes.

NHS Provision:

• Community Falls Service: A multi-disciplinary team of allied health professionals including nursing and physiotherapists covering both South Tyneside and Sunderland with outpatient falls clinics, public education, and rehabilitation including vestibular assessment and rehabilitation. Care home residents and homebound patients can be seen in their own home as needed.
• Falls and Syncope Service: Care of the Elderly consultant physicians who provide medical and tilt-table clinics on an outpatient basis at South Tyneside District Hospital. They also provide a clinical resource to the Community Falls Service.
• Integrated Community Teams: Multi-disciplinary teams of allied health professionals, including nurses, occupational therapists, and physiotherapists providing acute nursing and rehabilitation to community dwelling patients.
• South Tyneside District Hospital: Provides acute care to people who have fallen and through the fracture liaison nurse, signposts to appropriate services and providers upon discharge. The physiotherapy department, based at Moorlands Day Unit, provides rehabilitation and exercise classes.
• General Practitioners: Provide the bulk of primary care, screening and prevention education to local residents.

Local Authority Provision:

• Telecare Services: Monitoring of vulnerable adults in their homes and assisting if they have fallen.
• Transport: Bus passes and cost sharing for taxi services help to keep older adults connected socially and active in the community
• Equipment: The STAR Centre and local authority occupational therapists can assess needs and provide equipment to residents that improve function and safety.
• House Clearances: Removal of waste and objects from both within and outside of properties, which reduces fall risks.
• Warm up North: A programme to assist residents to maintain a warm home in the winter months. Below optimal ambient temperatures is a risk factor for falling.
• Change4life: Education, information, and coaching on how to make healthy changes and improve one's activity levels.
• Haven Court: An intermediate care facility that provides sub-acute care and services to adults.
• Sheltered Accommodation and Extended Care Facilities: Provides safe home environments to older adults with varying levels of supervision and / or assistance.
• Leisure Centres: The authority operates numerous facilities that could provide space for more activities geared toward the at risk population.

Charitable and Third Party Provision:

• Tyne and Wear Care Alliance: Provides training to care homes and extended care facilities on fall prevention.
• Age Concern Tyneside South: Provides a variety of interventions including:
  • An onsite gym specifically geared to the needs of older adults
  • Exercise classes that focus on strength building and balance.
  • Classes and groups that increase social engagement.
  • Handyperson services to address maintenance issues of the homes of older adults.

Multi-Agency Fall Prevention and Fuel Poverty Strategy Group

A joint effort between South Tyneside Foundation Trust, the South Tyneside Office of Public Health, and Age UK which quarterly brings together numerous and varied stakeholders to address the needs and issues relating to fall prevention

The Northeast Regional Falls Group

This is a group of health professionals from across the Northeast of England who meets quarterly to share information, research findings, guidance, and innovation. The Community Falls Service is represented and has a seat as deputy chair of the quarterly meetings.

NICE Clinical Guideline 161 "Falls in Older People" clearly states recommended interventions as follows:

Case / risk identification

Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s.

Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance.

Multifactorial falls risk assessment

Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention, which may include the following: falls history, gait, balance and mobility, and muscle weakness, osteoporosis risk, perceived functional ability and fear relating to falling, visual impairment, cognitive impairment and neurological examination, urinary incontinence, home hazards, cardiovascular examination, and medication review.

Multifactorial interventions

All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention In successful programmes the following specific components are common: strength and balance training, home hazard assessment and intervention, vision assessment and referral, medication review with modification/withdrawal.

Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function.

Strength and balance training

Those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficit. A muscle-strengthening and balance programme should be offered. This should be individually prescribed and monitored by an appropriately trained professional.

Carande-Kulis, et al in 2015 demonstrated significant return on investment for interventions ranging from the Stepping Out programme (64% ROI) to Otago exercise programme (127% ROI) to Tai Chi (509% ROI)

Extended care settings

Multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falling. Vlaeyen et al reviewed numerous studies in 2015 and were able to demonstrate a 21% decrease in recurrent falls from multifactorial interventions in care homes.

Home hazard and safety intervention

Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer, and appropriate members of the health care team. This is shown to be effective only in conjunction with follow-up and intervention, not in isolation.

Psychotropic medications

Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling.

Cardiac pacing

Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls.

Encouraging the participation of older people in falls prevention programmes

To promote the participation of older people in falls prevention programmes the following should be considered; Healthcare professionals involved in the assessment and prevention of falls should discuss what changes a person is willing to make to prevent falls, Information should be relevant and available in languages other than English, Falls prevention programmes should also address potential barriers such as low self-efficacy and fear of falling, and encourage activity change as negotiated with the participant.

Practitioners who are involved in developing falls prevention programmes should ensure that such programmes are flexible enough to accommodate participants' different needs and preferences and should promote the social value of such programmes.

Education and information giving

All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls assessment and prevention.

Individuals at risk of falling, and their carers, should be offered information orally and in writing about: what measures they can take to prevent further falls, how to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components, the preventable nature of some falls, the physical and psychological benefits of modifying falls risk, where they can seek further advice and assistance, how to cope if they have a fall, including how to summon help and how to avoid a long lie.

Public Health England echoes these recommendations in their publication "Falls: applying All Our Health" (PHE, 2015) with further emphasis on:

• Training of service providers on fall prevention
• Promotion of physical activity
• Examining primary care and its role in prevention of falls
• Making it easier for older adults to be active and connected socially
• Public education on fall prevention
• Ensuring inpatient providers are following established guidance and recommendations.

When the last health needs assessment on falls was completed in 2012, a small survey of people's beliefs and attitudes towards falls was conducted in the Viking Centre shopping facility in Jarrow and in the homes of housebound individuals served by the Intermediate Care Team. The survey showed the following:

• Many people are concerned about falling, but feel it is a natural and possibly unavoidable aspect of getting older.
• Falls may be underreported due to the stigma attached.
• One-third of community active and over one-half of homebound people reported having a fall.
• Only one-third of those who fell sought help afterwards.
• Those able to access the community reported:
  • More regular exercise
  • More options to be active
  • More isolation than those unable to access the community.
• Those unable to access the community reported:
  • Lower knowledge of their own medications
  • Fewer options to be active and less exercise
  • Limitations to activity
  • Less concern about the effects of alcohol
  • More falls, but also that falling need not be part of getting older.

(Metz, 2012)

References from Sections 1 to 11

Age UK & National Osteoporosis Society (2012) Breaking Through: Building Better Falls and Fracture Services in England retrieved 30.08.16

American Geriatrics Society (2010) Summary of the Updated American Geriatrics Society / British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons, "Journal of the American Geriatric Society" 2010

Campbell, A.J., Spears, G.F. and Borrie, M.J., 1990. Examination by logistic regression modelling of the variables which increase the relative risk of elderly women falling compared to elderly men. "Journal of clinical epidemiology, 43(12)", pp.1415 - 1420.

Campbell, A.J., Borrie, M.J., Spears, G.F., Jackson, S.L., Brown, J.S. and Fitzgerald, J.L., 1990. Circumstances and consequences of falls experienced by a community population 70 years and over during a prospective study. "Age and ageing, 19" (2), pp.136-141.

Campbell, A.J. and Robertson, M.C., 2006. Implementation of multifactorial interventions for fall and fracture prevention. "Age and Ageing, 35" (suppl 2), pp.ii60-ii64.

Carande-Kulis, V., Stevens, J.A., Florence, C.S., Beattie, B.L. and Arias, I., 2015. A cost-benefit analysis of three older adult fall prevention interventions. "Journal of safety research, 52", pp.65 - 70.

Cummings, S.R., Nevitt, M.C., Browner, W.S., Stone, K., Fox, K.M., Ensrud, K.E., Cauley, J., Black, D. and Vogt, T.M., 1995. Risk factors for hip fracture in white women. "New England journal of medicine, 332" (12), pp.767 - 774.

Department of Health (2006) A New Ambition for Old Age - Next Steps in Implementing the National Service Framework for Older People retrieved 30.08.16

Department of Health (2007) National Service Framework for Older People Annual Report, Chapter 2, Standard 6, Falls retrieved 30.08.16 from GOV.UK: National Service Framework for Older People

Department of Health (2012, January) Healthy Lives, Healthy People: Improving Outcomes and Supporting Transparency retrieved 30.08.16 from GOV.UK: Improving outcomes and supporting transparency 

Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Lamb, S.E., Gates, S., Cumming, R.G. and Rowe, B.H., 2009. Interventions for preventing falls in older people living in the community. "Cochrane Database Syst Rev, 2"(CD007146).

Institute of Public Care (2016) POPPI: Projecting Older People Population Information System accessed 30.08.16

Keene, G.S., Parker, M.J. and Pryor, G.A., 1993. Mortality and morbidity after hip fractures. Bmj, 307(6914), pp.1248 - 1250.

Metz, D. 2012 Health Needs Assessment "Mind the Gaps" Focus on Fall Prevention, South Tyneside NHS Foundation Trust

Metz, D., Vickers, P., McKinney, K., Coway, S., Hignett, J., 2014. The Clinical and Financial Efficacy of a Falls Prevention and Rehabilitation Unit Over the Course of One Year. South Tyneside NHS Foundation Trust

Tinetti, M.E., Speechley, M. and Ginter, S.F., 1988. Risk factors for falls among elderly persons living in the community. "New England journal of medicine, 319"(26), pp.1701 - 1707.

Tinetti, M.E. and Williams, C.S., 1997. Falls, injuries due to falls, and the risk of admission to a nursing home. "New England journal of medicine, 337" (18), pp.1279 - 1284.

Treml, J., Husk, J., Vasilakis, N., (2011) "Falling standards, broken promises, Report of the national audit of falls and bone health in older people 2010", Royal College of Physicians.

Peel, N.M., Kassulke, D.J. and McClure, R.J., 2002. Population based study of hospitalised fall related injuries in older people. "Injury prevention, 8" (4), pp.280 - 283.

Vlaeyen, E., Coussement, J., Leysens, G., Van der Elst, E., Delbaere, K., Cambier, D., Denhaerynck, K., Goemaere, S., Wertelaers, A., Dobbels, F. and Dejaeger, E., 2015. Characteristics and Effectiveness of Fall Prevention Programs in Nursing Homes: A Systematic Review and Meta‐Analysis of Randomized Controlled Trials. "Journal of the American Geriatrics Society, 63" (2), pp.211 - 221.

Last updated: November 2016