Joint strategic needs assessment

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Falls and bone health (2015)

Topic titleFalls and Bone Health
Topic ownerMary Corcoran
Topic author(s)Gill Oliver/Sally Garlick/Marie Ward
Topic quality reviewedLindsay Price
Topic endorsed byLong Term Conditions Strategic Group (City)
Topic approved byLong Term Conditions Strategic Group (City)
Current version19.08.2015
Replaces version2010
Linked JSNA topicsPopulation & Demography, Dementia
Insight Document ID130947

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Executive summary

Introduction

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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. Therefore falling has an impact on quality of life, health and healthcare costs. Guidance on the assessment and prevention of falls in older people was updated in 2013 (NICE CG161) [i].

The key issue of concern is not simply the high incidence of falls in older people, but the combination of a high incidence and a high susceptibility to injury. Bone health is therefore considered alongside falls in this JSNA because osteoporosis increases bone fragility and susceptibility to fracture, particularly as a result of a fall (NICE).

Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Osteoporosis leads to over 300,000 patients presenting with fragility fractures to hospitals in the UK each year. Because of increased bone loss after the menopause in women, and age-related bone loss in both women and men, the prevalence of osteoporosis increases markedly with age, from 2% at 50 years to more than 25% at 80 years in women. If people at risk can be identified, treatments and therapies are available. Guidance on assessing people at risk was updated in 2012 [ii].



[i] CG161 Falls: Assessment and prevention of falls in older people, June 2013

[ii] CG 146 Osteoporosis: Assessing the risk of fragility fracture, August 2012

 

 

Unmet needs and gaps

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Addressing falls and bone health enables older people in Nottingham to increase healthy life expectancy. However a number of factors will widen unmet need and service gaps:

  • increasing population over 65
  • growth in numbers of people with osteoporosis
  • co-morbidities such as dementia

Current unmet needs and service gaps include:

  • access to postural stability classes (Otago/FaME)
  • slight increase in admissions to care homes following a fall (and subsequent management of falls in care homes)

Audit by the Royal College of Physicians, published in 2011, made 4 recommendations covering the Falls and Bone Health pathway[i].

  • Improve outcomes and efficiency of care after hip fractures
  • Access to Fracture Liaison Services in acute and primary care
  • Early intervention to restore independence - through falls care pathway linking to acute and urgent care services to secondary preventionPrevent frailty, preserve bone health, reduce accidents through preserving physical activity, healthy lifestyles and reducing environmental hazards

[i] Falling standards, broken promises Report of the national audit of falls and bone health in older people 2010. Royal College of Physicians 2011

 

Recommendations for consideration by commissioners

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Falls and bone health assessments and interventions are multifactorial and may be provided by a range of health and social care providers. Commissioners will need to ensure that services and pathways are consistent with NICE guidance (CG161 and CG146), the recommendations in the Royal College of Physicians audit report and the forthcoming NICE Quality Standard.

Key priorities for implementation brought forward from CG161 (2004) are:

  • 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 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.
  • New priorities include patients at risk of falling in hospital.  A multifactorial assessment and multifactorial intervention should also be performed.

Osteoporosis guidance (CG146) recommends targeting risk assessment in all women aged over 65 and men aged over 75, and in women and men aged over 50 in the presence of risk factors e.g. history of falls.

In order to achieve this the main recommendations are:

  • Local Falls and Bone Health co-ordinators in line with guidanceIntegration of the pathway across primary and secondary care to include bone health and clear referral to falls services
  • Exercise programmes
    • Exercise promotion e.g. using home care providers to encourage exercise
    • Falls prevention focusing on strength & balance training e.g. could also provide in day services
  • Medication reviews, especially following hospital discharge
  • Learning & development
  • Reduce admissions to hospital and care homes as a result of falls
  • Reduce falls in care homes and nursing homes
  • Reduce falls in hospital

What do we know?

1. Who is at risk and why?

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A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level. (WHO)[i] An injurious fall is a fall resulting in a fracture or soft tissue damage that needs treatment (NICE CG161). Injurious falls include fragility fractures - fractures that result from a fall mechanical forces that would not ordinarily result in fracture, known as low-level (or ‘low energy’) trauma (NICE CG146)

The key issue of concern is therefore not simply the high incidence of falls in older people – since children and athletes have a very high incidence of falls – but rather the combination of a high incidence and a high susceptibility to injury.

Bone health is considered alongside falls in this JSNA because osteoporosis increases bone fragility and susceptibility to fracture, particularly as a result of a fall (NICE CG161).

1) Who is at risk and why?

Age

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.

Gender

Because of increased bone loss after the menopause in women the prevalence of osteoporosis increases markedly with in older women, from 2% at 50 years to more than 25% at 80 years. This increases the risk of injury due to a fall. (NICE CG146)

Other risk factors  (WHO)

  • underlying medical conditions, such as neurological, cardiac or other disabling conditions;
  • side effects of medication, physical inactivity and loss of balance, particularly among older people;
  • unsafe environments, particularly for those with poor balance and limited vision.
  • poor mobility, cognition, and vision, particularly among those living in an institution, such as a nursing home. 

What is the impact?

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 and fragility fractures are estimated to cost the NHS more than £2.3 billion per year. Therefore falling has an impact on quality of life, health and healthcare costs (NICE CG161). Having one fall requiring health care has also been shown to be a key factor leading to admission to a care home (alongside dementia, depression and incontinence)[ii].

300,000 people present with fragility fractures to hospitals in the UK each year and this will increase as the population ages. Direct medical costs from fragility fractures to the UK were estimated at £1.8 billion in 2000, with the potential to increase to £2.2 billion by 2025, and with most of these costs relating to hip fracture care. Up to 14,000 people also die annually in the UK as a result of an osteoporotic hip fracture (NICE CG146).



[i] World Health Organisation, Falls Factsheet 344, October 2012

[ii] Taylor et al, Oxfordshire County Council’s research into preventing care home admissions and subsequent service redesign, Research, Policy and Planning (2010) 28(2), 91-102 Oxford Brookes University, Institute of Public Care (IPC)

 

 

2. Size of the issue locally

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The number of people in Nottingham City aged over 65 is expected to rise from 37,258 in 2015 to 49,244 in 2030, an increase of 32%. This is associated with a corresponding increase in numbers of falls, particularly in those aged over 80. For Nottingham approximately 30% of older people will fall each year (11,986), some more than once, of these:

  • approx. 5% suffer fractures and
  • 2% suffer hip fractures (based on population/actual number of hip fractures 2012-13)

The graphic below applies these rates to the population of Nottingham, assuming a mid-point where there is a range

Figure 1: Infographic showing numbers of people experiencing a fall in Nottingham in 2015 and 2030.

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The main change in need since the last JSNA (2010) is the increasing number of older people living with frailty and dementia, both of which are risk factors for falls.

Earlier detection and management of both frailty and dementia help to address falls.

 

 

 

3. Targets and performance

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Figure 2: Public Health Outcomes Framework measures related to falls and bone health

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There were more admissions to hospital due to injuries from falls in 2012/13 than in 2011/12, particularly for men and people aged 65-79. To address this, Nottingham has developed a Falls Rapid Response Team in conjunction with EMAS. This is a crisis service which assesses people at home and puts measures in place to maintain the person at home rather than transporting to hospital. There is more information about this service in Section 4 below.

Nottingham’s hip fracture rate has improved significantly compared with 2010/11, both in comparison to England and the East Midlands. The graph below shows the improvement in rate. The actual number of admissions for hip fracture has also reduced from 319 in 2010/11 to 220 in 2012/13.

Figure 3: Healthcare and premature mortality - hip fractures in people aged 65 and over; age/sex standardised rate per 100,000 population 2012/13

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Adult Social Care Outcomes Framework

As noted above, falls are a key factor in admission to residential care. The relevant ASCOF measure included is the number of permanent admissions to residential care (care homes and nursing homes).

 

Permanent admission to care homes: people aged 65 and over  2013-14

England

East Midlands

Nottingham

Standardised rate per 100,000 population

697.2

759.1

719.4

Note: Figures do not include self-funders

HSCIC accessed 20 January 2015

http://ascof.hscic.gov.uk/Outcome/511/

Nottingham is ranked 102 of 151

Nottingham has a higher admission rate than the England average, 650.6 per 100,000, however a lower rate when compared with similar authorities.

NHS Outcomes Framework 2014/15

Domain 3 - Helping people recover from ill-health or following injury

Domain 3.5 Proportion of patients with a fragility fracture recovering to their previous levels of mobility at i. 30 days and ii. 120 days

In year data will be available after December 2015 from National Hip Fracture Database

http://www.nhfd.co.uk/20/hipfractureR.nsf/welcome?readform

CCG Outcomes Indicator Set 2014/15

Improving recovery from fragility fractures

  • Proportion of patients recovering to their previous level of mobility or walking ability (NHS OF 3.5 i and ii) (as above)
  • Hip fracture: formal hip fracture programme, timely surgery, and multifactorial risk assessment. Hip fracture care is audited annually against the fragility fracture hip fracture Best Practice Tariff (BPT) criteria. The tariff is applied for individual patients where all the criteria are met. The criteria have been amended and expanded to include an AMT (Abbreviated Mental Test) to determine whether a dementia risk assessment is needed. The complete list is:

a) time to surgery within 36 hours from arrival in an emergency department, or time of diagnosis if an admitted patient, to the start of anaesthesia

(b) admitted under the joint care of a consultant geriatrician and a consultant orthopaedic surgeon

(c) admitted using an assessment protocol agreed by geriatric medicine, orthopaedic surgery and anaesthesia

(d) assessed by a geriatrician in the perioperative period (within 72 hours of admission)

(e) postoperative geriatrician-directed multi-professional rehabilitation team

(f) fracture prevention assessments (falls and bone health)

(g) two Abbreviated Mental Tests (AMT) performed and all the scores recorded in NHFD with the first test carried out prior to surgery and the second post-surgery but within the same spell.

Nottingham University Hospitals (71.8%) met the criteria for the BPT for over 70% of their patients. This is better than the overall England rate of 60.6%. Further information is available at http://www.nhfd.co.uk/2014report

General Practice Quality Outcomes Framework (QOF)

The QOF for Osteoporosis - secondary prevention of fragility fractures is a register of patients aged over 50 with a record of a fragility fracture since April 2012, where osteoporosis has been confirmed with a bone mineral density (BMD) scan and treated with a bone-sparing agent. . Achievement is available at practice, CCG and Area Team level. 92% of Nottingham City practices have a register. This has improved between 2012/13 and 2013/14 with the number on the register increasing from 210 to 402 (Public Health Information Team).

 

4. Current activity, service provision and assets

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Falls mainly affect older people, especially people aged over 80. Therefore many people who fall may have other medical conditions and require an integrated approach wherever possible. The Falls and Bone Health Service is provided by Nottingham CityCare Partnership who link with secondary care, social care and the third sector.

Local Guidelines

The Nottingham Falls Pathway may be found at Appendix 1

Nottingham and Nottinghamshire have also developed a Guide to Action for Falls Prevention tool (GtAT) and the Guide to Action for Care Homes (GtACH) to help anyone working with older people to recognise and mitigate falls risks. The tool has been designed to raise awareness of falls and fractures and offers advice on reducing risk, advice on further management and referral to the Falls and Bone Health or Rehabilitation Service. Appendix 2

Nottingham and Nottinghamshire’s Osteoporosis Guidelines have been reviewed and are available at: http://www.nottsapc.nhs.uk/index.php/clinical-guidelines

The section below is an overall summary of the services available

  • Primary Prevention

Primary prevention aims to prevent the first fall in a person who is vulnerable to falling because of, for example, unsteady gait, but who has not yet fallen. The Guide to Action tool helps to identify those at risk of falling in order to target effective intervention(s).

People aged over 65 may be at risk of vitamin D deficiency and Public Health England has published new guidance about protecting bone health by ensuring people have sufficient Vitamin D. https://www.gov.uk/government/publications/vitamin-d-for-healthcare-professionals-and-the-public

The local Vitamin D guideline is currently under review (2015) and can be found at: http://www.nottsapc.nhs.uk/attachments/article/3/vitamin%20d%20guideline.pdf

The Public Health England Report Everybody Active, Everyday (September 2014) finds that older adults who remain active, are more engaged in the community, contribute more to society, and protect themselves from falls and circulatory problems. The Report further recommends that older adults at risk of falls should incorporate physical activity to improve balance and co-ordination on at least two days a week.

  • Secondary Interventions/Rehabilitation

Secondary interventions are targeted at a person who has already fallen or who has a history of falls.

Primary Care (GPs and Medicines Management)

GPs may undertake a multi-factorial clinical assessment to exclude medical causes of falls and injuries from falls e.g. Parkinson’s, dizziness, medication, osteoporosis. For patients in hospital, this may be carried out by a hospital doctor.

Medicines management pharmacists (and others) may undertake medication reviews with a particular focus on falls and bone health in older people.

Community Rehabilitation Teams

Rehabilitation Teams assess and provide treatment to patients who have fallen but without injury. Referrals can be made by GPs, health and social care, the voluntary sector or by self-referral.

The Falls and Bone Health Service (FBHS).

The Falls & Bone Health Service is a specialist team, provided by Nottingham CityCare and offering a service to people aged over 65 with complex conditions associated with falls.  The service receives the majority of referrals from the NUH Emergency Department, where people have been seen as a result of an injury caused by a fall.  2000-2500 referrals are screened each year and of these, approximately 1500 will be seen by the FBHS. For people experiencing falls, or with a fear of falling, the service provided offers:

  • Full nursing assessment
  • Medication reviews
  • Bone health checks
  • Physiotherapy
  • Occupational Therapy
  • Exercise programmes
  • Balance training
  • Equipment & aids
  • Home safety assessments
  • Postural stability classes

The service can be accessed by anyone over the age of 65 who has a City GP, and the referral can be made by anyone. Patients are seen in their own home. Further information is available at: http://www.nottinghamcitycare.nhs.uk/

Nurse-led Falls and Bone Health Clinics

Nurse-led clinics have been commissioned in Nottingham City following the ‘Better Balance, Better Bones’ project in 2012. The project involved case-finding from GP databases to generate lists of patients requiring assessment for falls and fractures risk. Patients are seen in clinic, at home or in a care home, for assessment and treatment, lifestyle changes or referral on to other services. Where appropriate, patients are added to the osteoporosis QOF register.

Outcomes from the Falls and Bone Health Service

The service conducts an annual audit which measures outcomes from national and local standards and guidelines. These include:

  • Improved support, advice and information available to older people who fall and their carers
  • The promotion of effective medicines management
  • A reduction in the pressure on the Emergency Care Pathway by a reduction in:
    • unplanned hospital admissions and emergency bed days due to falls
    • attendances at the Emergency Department due to falls
  • A reduction in hospital admissions from care homes precipitated by falls
  • A reduction in hip fractures resulting from falls

The 2013/14 audit showed a reduction in the average number of falls, in patients seen by the service, from an average of 4.9 each, to only 7% of patients reporting a further fall at 6 months following intervention.

Social Care Services and Voluntary Sector Support

Nottingham CityCare Partnership and Nottingham City Council work in partnership to offer a single point of access to community health and adult social care services for local people. Nottingham City Council’s Adult Social Care department provides a range of services that enable people to live at home independently. These include:

Social Worker and Occupational Therapy Assessment, Home Care, Day Care, Meals at Home, Care Homes for Older People, Carer Support Assistive Technology, Preventive Adaptations service (PAD), Telecare support

General information about the services  above is available at: http://www.nottinghamcitycare.nhs.uk/

The Preventive Adaptations service (PAD) installs aids and adaptations such as grab rails, stair rails, half steps for both tenants and people who own their own home. The team prioritises people being discharged from hospital.

http://www.housingcare.org/service/ser-info-4615-the-adaptations.aspx

Telecare is the community alarm service provided by Nottingham City Homes which monitors and responds to approximately 13,000 alarms and other monitoring systems across the City. The service works closely with the FBHS. Further information about Nottingham on Call is available at: http://www.nottinghamcityhomes.org.uk/supported_housing/nottingham_on_call.aspx

The Sixty Plus Nottingham City Signposting service enables older people and frontline staff to access services provided by a range of organisations which help to promote and maintain people at home. Further information is available at:

https://www.metropolitan.org.uk/support-services/sixty-plus/

  • Urgent and Acute Care

East Midlands Ambulance Service (EMAS)/ Falls & Bone Health Service (Nottingham CityCare) Falls Rapid Response Team (FRRT)

The integrated team is one of the first in the country and specialises in providing an emergency, health and social care response to non-life threatening falls for patients coming through 999 and 111 referrals. The service commenced in April 2013 and has been commissioned by Nottingham City for 3 more years from August 2014. Rushcliffe, Nottingham West and Nottingham North and East have so far also commissioned year one.

During 2013/14, the FRRT saw 864 patients in the City CCG area alone (and over 1,600 in total).  68% of patients were treated at home and not taken to hospital compared with a baseline of 50%. This means out of 864, 588 patient were not conveyed, that is an additional 156 patients were treated at home and avoided the Emergency Department and associated acute admission.

Acute Hospital Care

Falls, with or without an injury, are a major cause of admission to hospital for people over 65. Reducing demand on hospitals in the form of Emergency Department attendances, acute admissions and potential loss of independence following a hospital stay, is an important priority across health and social care. (see also Section 3 for NUH’s performance in relation to the Best Practice Tariff for hip fractures.)

In Nottingham City, the Emergency Department Falls pathway is directly linked to the community Falls and Bone Health service and patients are directly referred into this service without the need for the GP to refer. A letter is sent to the GP notifying them of the referral (see pathway attached) Appendix 1.

An important addition to the NICE guidelines CG161 June 2013 is the identification and inclusion of inpatients at risk of falling in hospital. The guideline includes:

  • all patients aged 65 years or older
  • patients aged 50 to 64 years who are judged by a clinician to be at higher risk of falling because of an underlying condition

NUH has set targets to reduce the number of falls and the number of harmful falls for inpatients.

Care Homes & Nursing Homes

Research has shown that people being admitted to a care home have a number of predominant characteristics and that a fall requiring a healthcare intervention is one of these. People in a care home or nursing home continue to have a higher risk of falling [i]

The Health Promotion Specialist within the Falls and Bone Health Service works with Social Care to provide training for staff across Care Homes (including Learning Disability Homes), Day Centres and Home Care Teams (independent sector and Social Services). The Falls and Bone Health Service also support care homes in the City using the GtACH tool to develop care plans and strategies to reduce the risk of falls.

A Guide to Action Tool has been developed specifically for care homes to use. Where a risk is identified, homes are expected to refer to the GP and Falls services for assessment.

Activity

Falls and Bone Health service

2000-2500 referrals are screened each year and of these, approximately 1500 will be seen by the FBHS. This service impacts on hospital admissions and hip fracture rates in the City (see above).

Hospital admissions

The graphs below show total number of admissions for a fall with or without injury and admissions for a fall where there was no injury. These graphs relate to the performance measures in Section 3 above and additionally show:

  • Trends in admission rates caused by a fall 65+ per 1000 population since 2004 
  • Trends in admission rates by District

The data are only up to December 2012 and are not currently available to update. This may be revisited in the future however, it does show a useful picture of trends over the last decade.

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Discussion

Nottingham has a higher rate of admissions compared with Nottinghamshire County, however this rate reflects the level of relative socio-economic deprivation in the City. There is a strong relationship between the rate of emergency admissions generally (including falls) and deprivation. In areas where the most deprived 10% of the population live, the rate of admissions can be more than twice that seen in the most affluent areas. (NHS England, Reducing Emergency Admissions at http://www.england.nhs.uk/wp-content/uploads/2014/03/red-acsc-em-admissions.pdf

The overall trend in injury admissions caused by a fall (first graph) shows an increase in all areas including Nottingham City. This increase may be partly explained by the growth in the number of people aged over 65. However admissions for hip fractures have reduced from 319 in 2010/11 to 220 in 2012/13.

All admissions caused by a fall, the second graph, shows a decrease in the majority of areas, including Nottingham City, for 2010-12.

The two graphs taken together show that the number of people admitted, who have not suffered an injury, has reduced as a proportion of all admissions caused by a fall. This suggests that people are being admitted to hospital more appropriately.


[i] Oxford Brookes University, Institute of Public Care (IPC) Nottinghamshire County Council, Research for Preventative Approaches to Reducing Older People’s Need for Care, July 2013

 

 

5. Evidence of what works (what we should be doing)

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Preventing falls and fractures needs a combined approach that encompasses both[i]:

  • Falls prevention intervention and
  • Identification and treatment of osteoporosis where indicated

Evidence based interventions include population-wide strategies to promote appropriate weight-bearing and strength enhancing physical activity and healthy eating, through to maintenance of pavements [ii] and providing general information such as  the ROSPA website Facing up to Falls at www.rospa.com

5.1. Assessment and Prevention of falls

The full NICE guideline CG161, June 2013, summarises the evidence for:

  • Risk factors
  • Assessment tools including balance and gait, home hazards and fear of falling
  • Interventions for preventing falls i.e. evidence of what works including compliance and cost effectiveness

The latest NICE guideline for ‘Assessment and prevention of falls in older people’ recommends the following:

Research supports and shows that the most effective intervention for falls prevention is a multifactorial assessment and management programme http://www.bmj.com/content/328/7441/680, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007146.pub3/abstract, http://www.cph.org.uk/wp-content/uploads/2012/08/falls-in-older-people-a-review-of-evidence-for-prevention.pdf, http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=12009105464

5.2. Osteoporosis

NICE recommends: using GP lists to identify people at high risk of osteoporosis. Guidance on the use of bisphosphonates to treat and prevent osteoporosis is set out in TA161.

http://www.nice.org.uk/guidance/TA161

The British Orthopaedic Society ‘Blue Book’ (2007) set out the evidence base for the

care of patients with fragility fractures and in particular informed the development of the National Hip Fracture database.

http://www.bgs.org.uk/pdf_cms/pubs/Blue%20Book%20on%20fragility%20fracture%20care.pdf

http://www.nhfd.co.uk

Nottinghamshire Osteoporosis guidelines for men and postmenopausal women can be accessed using the following link:

http://www.nottsapc.nhs.uk/index.php/clinical-guidelines

5.3. Vitamin D

There is evidence to support that Vitamin D supplementation and combined Vitamin D and calcium in older people with deficiencies may reduce the risk of falling however there is varying evidence to support whether also contributes towards reduced fractures in this population.

http://www.bmj.com/content/339/bmj.b3692,

http://qjmed.oxfordjournals.org/content/99/6/355.full

NICE has issued new guidance on promoting Vitamin D supplements in at risk groups including older people and this is available at:

https://www.nice.org.uk/guidance/PH56

The local Vitamin D guideline is currently under review (2015) and can be found at: http://www.nottsapc.nhs.uk/attachments/article/3/vitamin%20d%20guideline.pdf


[i] Masud T., Current Evidence on Falls presentation, Falls & Bone Health Stakeholder event , Nottingham, 15 May 2014

[ii] National Service Framework for Older People, Standard 6, Falls, 2001

 

 

6. What is on the horizon?

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Projected service use and outcomes in 3-5 years and 5-10 years

  • The number of people in Nottingham City aged over 65 is expected to rise from 37,258 in 2015 to 49,244 in 2030, an increase of 32%. This is likely to be associated with a corresponding increase in numbers of falls and fragility fractures, especially in people aged over 80.
  • More complex co-morbidities e.g. dementia
  • Publication of Falls Quality Standard expected in February 2015

NICE guidance on Falls and Secondary Prevention in Older People May 2015

7. Local views

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Clinical views were collected via a stakeholder event on 15 May 2014

  • Falls are ‘everybody’s business’
  • Specialist falls teams were recommended by the NSF for older people[i] and many staff consider they are still required and should also address bone health
  • However some concern about lack of communication between different teams
  • Support for falls’ lead clinicians
  • More people fall than the specialist teams are able to manage
  • Falls are a particular issue in care homes
  • Access to postural stability classes is variable
  • Integrate falls and bone health

Patient and Public views are available from the national Falls & Fractures Alliance members event report

 Working Towards an Integrated Care Pathway for Falls and Fractures

http://www.nos.org.uk/document.doc?id=1518

Comments from Nottingham City Long Term Conditions Strategic Group (July 2015)

  • Ongoing support – need for refresh of postural stability training for people who continue to fall
  • Links to falls team – ensure links between different elements of the service are robust e.g. A&E to falls team; fracture clinic and referral for DEXA scan


[i] National Service Framework for Older People, Standard 6, Falls, 2001

 

 

 

What does this tell us?

8. Unmet needs and service gaps

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Addressing falls and bone health enables older people in Nottingham to increase healthy life expectancy. Nottingham City offers good access to Falls and Bone Health Services including:

  • access to postural stability classes (Otago/FaME)
  • access to Fracture Liaison Services
  • early intervention to restore independence - through falls care pathway linking to acute and urgent care services to secondary prevention
  • access to Falls and Bone Health Clinics in GP practices
  • Falls and Rapid Response Team

However a number of factors will challenge the capacity of local services

  • increasing population over 65
  • growth in numbers of people with osteoporosis

co-morbidities such as dementia

9. Knowledge gaps

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Auditing the falls pathway will provide information about its effectiveness

Information from hospital

  • number of people aged over 65 identified within 2 days of an emergency admission who then
    • admitted following a fall receiving a CGA/multifactorial falls assessment
    • are discharged to GP with request for a multifactorial assessment (including bone health)
    • are readmitted due to a further fall

What should we do next?

10. Recommendations for consideration by commissioners

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Falls and bone health assessments and interventions are multifactorial and may be provided by a range of health and social care providers. Commissioners will need to ensure that services and pathways are consistent with NICE guidance (CG161 and CG146), the recommendations in the Royal College of Physicians audit report and the forthcoming NICE Quality Standard.

Key priorities for implementation brought forward from CG161 (2004) are:

  • 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 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.
  • New priorities include patients at risk of falling in hospital.  A multifactorial assessment and multifactorial intervention should also be performed.

Osteoporosis guidance (CG146) recommends targeting risk assessment in all women aged over 65 and men aged over 75, and in women and men aged over 50 in the presence of risk factors e.g. history of falls.

In order to achieve this the main recommendations are continued access to:

  • strength and balance training
  • aids and adaptations
  • use of Guide to Action tools
  • medication reviews (additional capacity may be required)
  • completion of FRAX risk assessment for osteoporosis

Key contacts

References

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CG161 Falls: Assessment and prevention of falls in older people, June 2013

CG 146 Osteoporosis: Assessing the risk of fragility fracture, August 2012

Falling standards, broken promises Report of the national audit of falls and bone health in older people 2010. Royal College of Physicians 2011

World Health Organisation, Falls Factsheet 344, October 2012

Taylor et al, Oxfordshire County Council’s research into preventing care home admissions and subsequent service redesign, Research, Policy and Planning (2010) 28(2), 91-102

Oxford Brookes University, Institute of Public Care (IPC)

Oxford Brookes University, Institute of Public Care (IPC) Nottinghamshire County Council, Research for Preventative Approaches to Reducing Older People’s Need for Care, July 2013

Masud T., Current Evidence on Falls presentation, Falls & Bone Health Stakeholder event , Nottingham, 15 May 2014

National Service Framework for Older People, Standard 6, Falls, 2001

 

[1] National Service Framework for Older People, Standard 6, Falls, 2001

Glossary