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Falls and fractures in older people are a costly and often preventable health issue. Reducing falls and fractures is important for maintaining health, wellbeing and independence amongst older people.
A fall is defined as an event which causes a person to, unintentionally, rest on the ground or lower level, and is not result of a major intrinsic event (such as a stroke) or overwhelming hazard. Having a fall can happen to anyone; it is an unfortunate but normal result of human anatomy. However, as people get older, they are more likely to fall over. Falls can become recurrent and result in injuries including head injuries and hip fractures.
The causes of having a fall are multifactorial – a fall is the result of the interplay of multiple risk factors. These include:
- having a history of falls
- muscle weakness
- poor balance
- visual impairment
- polypharmacy and the use of certain medicines
- environmental hazards and a number of specific conditions.
Falls are an event resulting from the presence of risk factors. The likelihood and severity of injury resulting from this event is related to bone health. People with low bone mineral density are more likely to experience a fracture following a fall. One of the main reasons why people have low bone mineral density is osteoporosis.
Over 3 million people in the UK have osteoporosis and they are at much greater risk of fragility fractures. Hip fractures alone account for 1.8 million hospital bed days and £1.9 billion in hospital costs every year, excluding the high cost of social care.
Facts about falls
Falls and fractures are a common and serious health issue faced by older people in England. People aged 65 and older have the highest risk of falling; around a third of people aged 65 and over, and around half of people aged 80 and over, fall at least once a year. Falling is a cause of distress, pain, injury, loss of confidence, loss of independence and mortality.
The human cost can include distress, pain, injury, loss of confidence, loss of independence and mortality. For health services, they are both high volume and costly.
In terms of annual activity and cost:
- the Public Health Outcomes Framework (PHOF) 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 leading cause of injury
- unaddressed fall hazards in the home are estimated to cost the NHS in England £435 million
- the total cost of fragility fractures to the UK has been estimated at £4.4 billion which includes £1.1 billion for social care; hip fractures account for around £2 billion of this sum
- short and long-term outlooks for patients are generally poor following a hip fracture, with an increased one-year mortality 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
- falls in hospitals are the most commonly reported patient safety incident with more than 240,000 reported in acute hospitals and mental health trusts in England and Wales
Core principles for healthcare professionals
Healthcare professionals should:
- know the needs of individuals, communities and population and the services available
- think about the resources available in health and wellbeing systems
- understand specific activities which can prevent, protect, and promote
The National Falls Prevention Coordination Group’s ‘Falls and fracture consensus statement’ advocates a whole system approach to prevention which takes in: risk factor reduction across the life-course; case finding and risk assessment; strength and balance exercise programmes; healthy homes; high-risk care environments; fracture liaison services; collaborative care for severe injury.
Interventions can take place at population, community and individual levels.
Healthcare professionals should be aware of the interventions at population level, which include:
- understanding the local population; consider the proportion of older people and the number of falls in the population and review access to falls prevention services
- influencing relevant parties to increase service provision if falls prevention is a local health priority, using tools from the Chartered Society of Physiotherapy (CSP)
- considering training needs of workforce and action needed to give all healthcare professionals the knowledge and skills to identify and assess older people’s falls risk, referring when necessary
- ensuring that promotion of physical activity is prominent within commissioned services
Community health professionals and providers of specialist services can have an impact by:
- considering role in primary falls prevention and the messages given out about healthy lifestyles
- ensuring that inpatient care is in line with falls and fracture clinical guidelines and quality standards
- encouraging people to stay active, connected, eat well and reduce alcohol, to reduce the risk of falling and improve outcomes if a fall happens
- promoting physical activity to everyone, including the NHS workforce as well as patients and their families
- making it easier for people to stay active and connected
- developing links with local community providers
- displaying information in workplaces promoting physical activity benefits for adults and older adults
Family and individual level
Healthcare professionals can have an impact on an individual level by:
- routinely asking older people about falls
- knowing how to recognise the signs and assess risk
- understanding the referral pathway to local services that reduce falls risks
- reassuring individuals and their carers or families that help is available
- helping individuals to improve their health, making every contact count and signposting eligible patients to NHS health checks
- providing up to date patient information on falls such as Get up and go: a guide to staying steady from the CSP
The PHOF includes indicators on injuries due to falls in people aged 65 and over:
- 2.24i - aged 65 and over
- 2.24ii - aged 65 to 79
- 2.24iii - aged 80 and over
- 4.14i - aged 65 and over
- 4.14ii - aged 65 to 79
- 4.14ii - aged 80 and over
Mortality rates from accidental falls can be found in the Health and Social Care Information Centre Indicator Portal.
The Everyday Interactions measuring public health impact toolkit provides a quick, straightforward and easy way for healthcare professionals to record and measure their public health impact in a uniform and comparable way.
The falls impact pathway is recommended for healthcare professionals to record and measure actions undertaken as part of routine care which impact on adult obesity.
Examples of good practice
The CSP’s Get up and go - a guide to staying steady is a 32-page guide for the public and patients on how to prevent falls, produced by Saga in partnership with the CSP and PHE.
PHE’s Everybody active, every day: an evidence-based approach to physical activity (2014) is a physical activity strategy co-produced with over 1,000 partners including health professionals, local authorities, research specialists, educationalists, charities and fitness experts.
The Royal College of Physicians’ National audit of inpatient falls: audit report (2015) contains key recommendations aimed at reducing inpatient falls.
PHE and the National Falls Prevention Coordination Group member organisations have produced a ‘Falls and fracture consensus statement’ detailing key interventions, approaches to commissioning and the commitment to national support. It is accompanied by a resource pack which details resources relating to the key interventions and contains an additional section on frailty.
Specific guidance includes:
- Prevention of falls in older people American Geriatrics Society/British Geriatrics Society clinical practice guideline 2010
- Occupational therapy in the prevention and management of falls in adults: practice guidelines College of Occupational Therapists 2015
- Clinical guideline for the prevention and treatment of osteoporosis National Osteoporosis Guideline Group 2017
- The management of hip fracture in adults NICE CG124 2014
- Osteoporosis: assessing the risk of fragility fracture NICE CG146 2017
- Falls in older people: assessing risk and prevention NICE CG161 2013
- Midlife approaches to preventing the onset of disability, dementia and frailty NICE NG16 2016
- Multimorbidity: clinical assessment and management NICE NG56 2016