Injurious falls in Cambridgeshire

Falls Prevention SlidesetMarch 2016

Public Health, Cambridgeshire County Council

Slideset Notes

• This slideset has been developed by Public Health at Cambridgeshire County Council for use in training and awareness raising activities for falls prevention

• Feel free to adapt and tailor appropriately for particular events and audiences

• Please ensure technical notes and references related to the quantitative data provided remain in place

• There are explanatory notes in the notes pane• For further information on any of the content in this slideset

please contact: Jill.Eastment@cambridgeshire.gov.uk or Helen.Johnston2@cambridgeshire.gov.uk

Contents

1. Background and definitions of falls2. Quick facts3. Risk factors4. Consequences of falls including fear of falling5. Data on falls 6. Impact of falls on the health and care system 7. Guidance on measures for falls prevention 8. Evidence for the effectiveness of key interventions9. Local falls prevention integrated framework10. Measuring the effectiveness of falls prevention approaches

1. Background & DefinitionsFalls are a major health problem in older adults• At least 30% of persons aged over 65 years experience one or more

falls each year • This proportion increases to 40% after age of 75 • Both the frequency of falls and the severity of complications

increase with age, level of disability, and extent of functional impairment

Definitions• Falls: A fall is defined as an unplanned descent to the floor with or

without injury to the patient1 • ‘Injurious falls’ and ‘serious falls’ are used variously2 where there is

an injury or the person uses health services due to a fall

1. National Database of Nursing Quality Indicators (2011).2. Differing definitions depending on source, different research study methodologies etc.

2. Quick facts• Falls are a major cause of disability and the leading cause of

mortality due to injury in older people aged over 75 in the UK.

• Falls are the leading cause of injury-related hospitalisation in older people and are a common reason for older people requiring long-term care in their home or a residential facility.

• Up to 90% of older patients who fracture their hip fail to recover their previous level of mobility or independence– Only 46% of older people with a fractured hip return to their usual

residence on discharge from hospital.

3. Risk factors for falls

Intrinsic risk factors Extrinsic risk factorsA history of falls

Environmental hazards (poor lighting, slippery floors, uneven surfaces, etc.)

Age Footwear and clothing Gender Inappropriate walking aids/ assistive devices Medicines including benzodiazepine, psychotropics, class 1a anti-arrhythmic medications, digoxin, diuretics, and sedatives and polypharmacy

Medical conditions including circulatory disease, chronic obstructive pulmonary disease, depression, arthritis, incontinence

Impaired mobility and gait Visual or cognitive impairment Foot problems Malnutrition, vitamin D deficiency Psychological status – fear of falling

Established risk factors for falls

Source: Adapted from 2004 Health Evidence Network Paper for the World Health Organisation

4. Consequences of falls• Injuries due to the fall

1. Fractures• Wrist, spine, and other fractures• Hip fractures

2. Other injuries • cuts and lacerations• pain and distress

• Fear of falling and wider psychological impactsLoss of confidence may result in future activity avoidance, limiting social opportunities, independence, and ability to get out and about

• Reduced independence and increased reliance on formal and informal carers• Anxiety for family and friends and carers• Increased requirement from support by health and social care services

5. Data on falls in Cambridgeshire

• Overarching indicators – hospital admissions due to falls

Injuries due to falls in people aged 65 years and over

Hip fractures in people aged 65 years and over

• Comparison with other areas

• Trends over time

• Where do people fall? - location

• When do people fall? - seasonality

• Limitations of the data

Overarching indicators: injuries due to falls

http://www.phoutcomes.info/Public Health Outcomes Framework

By Region

By District

Overarching indicators: hip fractures

http://www.phoutcomes.info/Public Health Outcomes Framework

By Region

By District

Injury due to falls in people aged 65 and over

Source: Public Health England (PHE). Primary diagnosis code for Injury (ICD 10 S00-T19) with falls code (WOO-W19) anywhere in diagnostic string.

Where the primary diagnosis (main reason for hospital admission) is an Injury code and a falls code has been included in diagnoses 1-12

• Around 2,450 admissions per year in Cambridgeshire • Around 660 admissions per year in Peterborough • 71% in over 80s• 70% in women

Key data on injuries due to falls 2014/15

Rate of hip fractures in people aged 65 and over

Source: Public Health England (PHE) Primary diagnosis ICD 10 S72.0, S72.1, S72.2.

Key data on hip fractures 2014/15

• Around 630 hospital admissions per year in

Cambridgeshire

• Around 190 hospital admissions per year in Peterborough

• 72% in over 80s

• 73% in women

• More than 93% are coded as having experienced a fall

Type of fall and place of fall (ICD 10)How do older people fall?• Slips and trips: 53% in 65-79 and 40% in

over 80s• Falls on same level 13% in 65-79; 22% in

over 80s

Where? Majority of older people fall at home

AprMay Jun Jul

Aug Sep Oct NovDec Jan Feb Mar

020406080

100120140 Cambridge

AprMay Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar-101030507090

110130150 East Cambridgeshire

AprMay Jun Jul

AugSep Oct Nov

Dec Jan Feb Mar-101030507090

110130150 Fenland

AprMayJun Jul Aug Sep Oct Nov Dec Jan Feb Mar0

20

40

60

80

100

120

140Huntingdon

AprMay Jun Jul

Aug Sep Oct NovDec Jan Feb Mar-10

1030507090

110130150 South Cambridgeshire

65+ Emergency admissions for injury due to falls in people aged 65+

Number of admissions 2012/13 and 2013/14 pooled

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar0

50100150200250300350400

Cambridgeshire

Time of year of falls: seasonality

There is little evidence of a seasonal pattern to falls

Limitations of data on falls• Falls: coding is known to be variable between hospital trusts, although

this is thought to have improved. Some artefact of coding is likely nationally.

• Hip fracture: fractures are coded but there is little further detail in the data (such as the place, ‘cause’ of the falls)

• Considered an important proxy metric for serious falls. • Note relatively small numbers when broken down further eg. by

place.

6. Impact of falls on health and care• In 2013, results were published from a Scottish study which aimed to estimate

the costs to health and social care services in managing older people who fall in the community

• The study demonstrated that 34% of people aged 65 years and over living in the community fall at least once a year, of which 20% contacted a medical service for assistance.

• Applying these results to local population figures for Cambridgeshire & Peterborough CCG, it is estimated that falls in in 2016 will result in over:

5,500 GP attendances8,700 ambulance call outs6,300 A&E attendances 3,000 inpatient admissions

• The associated costs are high and estimated to be over £83 million. • Costs at discharge are predominantly associated with social care (but not from

the funder perspective)

Source: Local analysis based on Craig J, Murray A, Mitchell S et al. The high cost to health and social care of managing falls in older adults living in the community in Scotland. Scottish Medical Journal 2013;58(4):198-203

7. Guidance on measures for falls prevention

• NICE 2004 Clinical Guideline (CG 21) replaced by an extended Clinical Guideline in June 2013 (CG161) Falls: assessment and prevention of falls in older people.

• The key recommendations from NICE comprise:

Preventing falls in older people Case or risk identification Multifactorial risk assessment Multifactorial intervention programmes: Information and education: Professional education

Preventing falls in older people during a hospital stay Predicting patients’ risk of falling in hospital Assessment and interventions Information and support

National Institute for Health and Clinical Excellence (NICE): Clinical Guideline (CG161) Falls: assessment and prevention of falls in older people. 2013. Available at: https://www.nice.org.uk/guidance/CG161

NICE: Falls in older people pathway

8. Evidence for the effectiveness of key interventions

Cochrane Review: preventing falls in older people living in the communityEffectiveness• Group and home-based exercise programmes, and home safety interventions reduce

rate of falls and risk of falling.• Multifactorial assessment and intervention programmes reduce rate of falls but not

risk of falling• Tai Chi reduces risk of falling

Economic evidenceThree interventions for preventing falls in community-living older people have indicated cost savings: • home-based strength and balance exercise (the Otago Exercise Programme) in over 80-

year-olds• home safety assessment and modification in those with a previous fall• specific multi-factorial programmes

Gillespie et al. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9.

9. Local integrated frameworkPrimary prevention in the community (untargeted interventions) 65+

Identification& Assessment

Targeted interventionsAt risk/frail or post-fragility fracture/75+

Preventing falls in hospitals & LTCF

Post-discharge (towards independence)

P.1 Exercise Focused on gait, strength,

balance, or functional training

Otago Tai Chi

IA.1 Older people routinely asked whether they have fallen in the past year

TI.1 Multidisciplinary assessment

PS.1 Regard at risk of falling in hospital:• All patients aged 65+• Patients aged 50 to 64 years who are judged by a clinician to be at higher risk

PD.1 Home hazard assessment and safety intervention/ modifications by a suitably trained healthcare professional.

P.2 Vitamin D supplementation (+ Calcium)

IA.2 Older people reporting a fall or at risk of falling observed for balance and gait deficits and considered for interventions to improve strength and balance.

TI.2 Considered for an individualised multifactorial intervention

PS.2 Multifactorial assessment PD.2 Specific exercise programmes (eg Otago)

IA.3 Healthcare professionals’ professional competence in falls assessment and prevention.

TI.3 Strength and balance training is recommended - individually prescribed and monitored.

PS.3 Multifactorial interventions (include individual risk assessment and tailored interventions)

IA.4 Multifactorial falls risk assessment

TI.4 Psychotropic medications reviewed, and discontinued if possible.

PS.4 Multifactorial interventions with an exercise component in extended care settings.

IA.5 Strength and balance training.

TI.5 Cardiac pacing considered for older people with cardioinhibitory carotid sinus hypersensitivity.

PS.5 Vitamin D supplementation

TI.6 Falls prevention programmes (includes behaviour change & addressing barriers)

PS.6 Early anticipation of discharge needs

TI.7 Education & information. PS.7 Information & support PS.8 Ensure that relevant

information is shared across services.PS.9 Medication reviews for residents in LTCFs

Lifecourse approach L.1 Physical activity for bone and muscle strength: children and young people (5-18 years) vigorous intensity activities, at least three days a week; adults (19-64 years) activity to improve muscle strength at least two days a week

10. Measuring the effectiveness of falls prevention approaches

Public Health Outcomes Framework• Injuries due to falls• Hip Fractures

Service indicators:• Incidence of hip and fragility fractures in people aged 65 and over • Percentage of individuals aged 65 and over who have experienced a fall who

experience another fall which results in injury within six months• Measurement of confidence and level of fear for an individual after a fall in people

aged 65 and over

Tools:• Tinnetti confidence index• Patient reported outcome measures • Validated quality of life scales: EQ-5D; SF-6; SF-12; SF-32; WEMWBS etc.