Falls Prevention Slideset

1. Injurious falls in Cambridgeshire
Falls Prevention Slideset
March 2016
Public Health, Cambridgeshire County Council

2. 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

3. Contents
1. Background and definitions of falls
2. Quick facts
3. Risk factors
4. Consequences of falls including fear of falling
5. 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 interventions
9. Local falls prevention integrated framework
10. Measuring the effectiveness of falls prevention
approaches

4. 1. Background & Definitions
Falls 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.

5. 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.

7. 3. Risk factors for falls
Intrinsic risk factors Extrinsic risk factors
A 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

8. 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 impacts
Loss 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

9. 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

10. Overarching indicators: injuries due to falls
http://www.phoutcomes.info/Public Health Outcomes Framework
By Region
By District

11. Overarching indicators: hip fractures
http://www.phoutcomes.info/Public Health Outcomes Framework
By Region
By District

12. 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

13. • 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

14. 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.

15. 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

16. 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

17. 0
50
100
150
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Cambridge
0
50
100
150
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
East Cambridgeshire
0
50
100
150
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Fenland
0
50
100
150
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Huntingdon
0
50
100
150
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
South Cambridgeshire
65+ Emergency
admissions for injury due
to falls in people aged
65+
Number of admissions
2012/13 and 2013/14
pooled
0
100
200
300
400
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Cambridgeshire
Time of year of falls: seasonality
There is little evidence
of a seasonal pattern to
falls

18. 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.

19. 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 attendances
8,700 ambulance call outs
6,300 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

20. 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

21. NICE: Falls in older people pathway

22. 8. Evidence for the effectiveness of key
interventions
Cochrane Review: preventing falls in older people living in the community
Effectiveness
• 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 evidence
Three 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.

23. 9. Local integrated framework
Primary prevention in the
community (untargeted
interventions) 65+
Identification
& Assessment
Targeted interventions
At 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

24. 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.