1. Falls: what does the evidence tell us? ,
Shropshire Public Health
Falls: what does the evidence tell us? ,
Miranda Ashwell
Public Health Programme Lead
Whole System Approach to Falls Prevention Workshop
2nd Sept 2014
Intro my role

2. Falls in the UK
A third of people 65+, and half of people over 80, fall at least once a year.
Falls are the most common cause of death from injury for 65+s
Cost the NHS over £2bn a year and over 4 million bed days.
1 in 3 people with a hip fracture dies within a year
300,000 fragility fractures every year and leads to 1,150 needless deaths each month (NOS 2013
Nearly 11 million, or 1 in 6 people is 65 or over (1 in 4 by 2030)
Incidence of falls is rising at about 2% per annum.
1 hip fracture every 10 minutes
1 wrist fracture every 9 minutes
(most of the deaths are not caused by the fracture itself but rather by underlying ill-health, of which the fall may be a sign).
Hip fractures: 20% die within four months and 30% within a year. Approximately half of those who were previously independent become partly dependent following a hip fracture, while one-third become totally dependent.

3. For a typical 300K CCG How many people fall in Shropshire in a year?
> 15,000 will fall each year, >6000 twice or more.
Most will not call for help
>70/week will attend A&E or MIU
A similar number will call the ambulance service
350 hip fractures/year
~1000 other fragility fractures
Average CCG & council costs on falls are £50m per annum
Ageing demography means this will increase 50% by 2020
Shropshire has 63,400 people aged 65 years and over (2011 Census).
ONS predict that Shropshire age group will increase by 70.2% by 2031 and 85yr + increase by 194.6%.
How many people fall in Shropshire in a year?
75-80% of fallers do not tell a health professional
60% go on to fall again
1st fall is a predictor of further falls
Shropshire has higher than national average of older people so can expect these figures to be higher for Shropshire.

4. When do we become “fallers”?
When intrinsic abilities to remain upright cannot cope with extrinsic risk factors
Nervous system, reaction times and gait speed slows
Balance and strength deteriorates
Fracture site changes with age, wrist fractures more common in younger people, hip fractures more common in older people
“Hip fracture is all too often the final destination in a thirty year journey fuelled by decreasing bone strength and increasing falls risk”
Who has never fallen?
Difference between a trip and a fall
Physical function/mobilty key –how active should we be?

5. How active?
Older adults should aim to be active daily. Over a week, activity should add up to at least 150 minutes of moderate intensity activity in bouts of 10 minutes or more.
Older adults should also undertake physical activity to improve muscle strength on at least two days a week.
Older adults at risk of falls should incorporate physical activity to improve balance and co-ordination on at least two days a week.
All older adults should minimise the amount of time spent being sedentary (sitting) for extended periods.
CMO guidance

6. HUMAN FRAILTY (Spirduso, 1995)
“Sedentariness appears a far more dangerous condition than physical activity in the very old.” American College of Sports Medicine 1998
Sedentary behaviour = active bone and strength loss.
No standing activity leads to active loss of bone and muscle..
1 week bed rest  leg strength by ~ 20%.
1 week bed rest  spine BMD by ~1%.
Sedentary behaviour = worse balance.
40% of people aged 50 are sedentary.
Nursing home residents spend 80-90% of their time seated or lying down.
50 % over 50s and 75% over 70’s believe they are active enough to keep fit.
TIME
HUMAN FRAILTY
(Spirduso, 1995)
DISEASE
DISUSE
30% of women, 10% of men aged yrs do not have aerobic capacity to comfortably walk at a 20 minute mile pace
25% of women yrs do not have enough leg strength to be confident to get out of a chair without using their arms

7. The human cost A downward spiral? Further loss of function
Loss of , independence, dignity and confidence
Increased isolation and loneliness
Frequent fallers have poor outcomes:
Fear of falling and lack of confidence predicts:
Decrease in physical activity (indoors and out)
Deteriorating physical function
Increase in fractures
Admission to institutional care
Fear of falling: loss of confidence and fear of falling again. This can lead to isolation and increased dependency on others
80% of older women surveyed said they would rather be dead than experience the loss of independence and quality of life that results from a bad hip fracture and subsequent admission to a nursing home

8. Understanding falls and fragility fractures as long-term conditions
Genetics and maternal factors
Lifestyle
Events and illnesses and chance
Well woman with first fracture, usually wrist
Age 50-70s
Postural instability and falls
Osteopenia
and osteoporosis
First fracture in frail person
Age 70-80s
Fall, injury, loss of confidence
 strength, balance, vision or judgment
50%
Second fracture, usually more serious,
often hip - average age 82 yrs
Reduced activity
The vicious cycle into dependency

9. Risk factors
History of falls
Effect of commonly prescribed drugs, especially in combination (e.g medications for cardiovascular disease or depression,4 or more)
Physiological changes (poor eyesight, foot health, loss of muscle strength and balance, gait),
Medical conditions (Parkinson’s or dementia, continence),
Environmental hazards (ill-fitting shoes, poor lighting, slippery surfaces)
Lifestyle (alcohol, physical inactivity).
A trip becomes a fall when intrinsic abilities to remain upright e.g gait, strength and balance are unable to cope with extrinsic factors e.g uneven paving
Patients at particularly high risk of falling include people with a history of multiple unexplained falls
DAME Drugs/alcohol, Ageing effects, Medical conditions, Environment/equipment.
fragility fractures
attendance at Accident and Emergency (A&E), or by ambulance following a fall
two or more intrinsic risk factors for a fall (e.g. muscle weakness, poor balance, visual deficit, cognitive impairment, arthritis, syncope).
Also at risk of falls are people who:
take more than three medications
have fallen in hospital
live in a care home
have a fear of falling.

10. Reducing risk The problem is complex, it’s not inevitable.
Falls are not a “normal” part of ageing.
Many can be prevented, using interventions that are evidence-based and effective.
NICE guidance
2011 Systematic Review: best practice recommendations
Cochrane review: 200+ RCTs from
Royal College of Physicians Report 2012

11. What works? Challenge: to motivate older people
150 mins MIPA reduces risk of high blood
pressure, obesity, stroke and diabetes ,improves quality of life
>3 hrs a week targeted exercise
Osteoporosis - 2 x less likely
Hip fracture - 2 x less likely
>3 hrs a week on your feet
Reduced risk of falls and fractures.
Active people are more likely
to have better mood,
be less anxious,
have better memory,
sleep better
have more social contacts
Challenge: to motivate older people
to be as active as possible
Primary prevention/low risk – CMO guidelines
Greatest effect of exercise on falls rates is for interventions that include highly challenging balance training
High does (50+ hours)
No walking programme

12. What works?
Identifying people at risk and organising appropriate treatment
Interventions in the community with the highest quality evidence base include:
multi-factorial interventions
Group and home-based exercise delivered by trained professionals
Trials of exercise programmes have shown 35% to 54% reductions in risk of falls
Home safety interventions (delivered by OT)
Vitamin D supplementation in nursing care facilities.
Feedback from older people (Don’t Mention the F- Word Help the Aged 2005): key messages to maximise impact of lifestyle advice for preventing falls are:
focus on improving strength and balance, not falls
encourage people to personally choose the advice and activities that suit them
don’t focus on avoiding ‘hazards’ or physical restriction such as wearing hip protectors – this is perceived as over-bearing
Early cataract removal reduced falls by 34% (PROFANE)
Home safety assessment , modification and coping strategy delivered by an OT reduced falls by 41% NOS (Profane)
falls are a risk as you get older, but are not inevitable●●staying active and dealing proactively with any long-term condition will reduce frailty and preserve independence ●●if you are getting unsteady, seek advice so underlying factors, such as eyesight, medications, strength and balance, can be addressed.

13. Broader context
“Falls prevention in older people should be high on our agenda. This isn’t just because it’s a major population health problem that’s expected to increase with an ageing demographic. We should prioritise falls prevention because it’s the mark of a society in which older people are valued.”
Professor Kevin Fenton, P.H.E National Director for Health and Wellbeing
July 2014
Interventions to prevent falls are only part of the picture. If we’re going to improve the quality of life of older people, we need to think about what it means to age well and how all of us – as citizens, health professionals, relatives, and friends – help to create opportunities for older people to feel healthy, safe and connected.
Key actions include:
Individuals invest in their long-term health: healthy lifestyles will contribute to healthy ageing
Families contribute to keeping older relatives engaged and healthy
Commissioners consider the benefits and impact of falls prevention interventions and how to integrate these with other commissioning decisions (across acute hospital, community and social care sectors)