“Don’t let falls get you down”

1. “Don’t let falls get you down” 19 February 2013 Dr Sarah J Jones, Consultant, Environmental Health Protection, Public Health Wales Insert name of presentation on Master Slide

2. Structure • Epidemiology • Evidence • Conclusions / Recommendations “Don’t let falls get you down...”

3. Background • Lots of work already going on at various levels and through various organisations, e.g. NLIAH • ? Evaluated and effective? • ? Evidence based? • ? Coherent, joined-up? • Much of what we currently do is reactive “Don’t let falls get you down...”

4. Epidemiology of falls • Summary of falls epidemiology, adapted from Rubenstein and Josephson (2002), Cummings and Melton (2002), Peel et al (2002) “Don’t let falls get you down...”

5. Estimated population changes • Based on population of each HB and population projections “Don’t let falls get you down...”

6. Predicting falls incidence • Assumes • Epidemiological data are generaliseable to Wales • All older people are community dwelling • Therefore data are under-estimates • No interventions are in place that reduce incidence • Over-estimate / evidence of effectiveness “Don’t let falls get you down...”

7. Wales Epidemiology 2010 2015 ? “Don’t let falls get you down...”

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12. Summary estimate of epidemiology of falls in Wales in 2009 Produced by Public Health Wales and Swansea University, using EDDS & PEDW (NWIS), ADDE (ONS) “Don’t let falls get you down...”

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17. Local authority areas with the highest and lowest fall related in-patient admission rates per 100,000 population, 2009 Produced by Public Health Wales and Swansea University, using PEDW (NWIS) and MYE (ONS) “Don’t let falls get you down...”

18. Relative burden of fall injuries in Wales, by sex and age, 2009 Produced by Public Health Wales and Swansea University, using PEDW (NWIS), ADDE (ONS) “Don’t let falls get you down...”

19. Epidemiology – part 2 • Mortality estimates • Around 200 deaths pa • Significant underestimate • In-patient burden • ICD-10 codes specified • All Wales data • Welsh residents • Trends in admissions / FCEs by age and sex, also LoS and bed days • Some estimate of costs per bed day • Management of expectations “Don’t let falls get you down...”

20. Effect of preventing falls “Don’t let falls get you down...”

21. Effect of reducing bed days “Don’t let falls get you down...”

22. Epidemiology – limitations • IP data based on external cause codes • 10% of injury discharges lack an external cause code • Avoid ‘paralysis by analysis’ “Don’t let falls get you down...”

23. Evidence - basis • Community strategies • NICE, ProFaNE, AGS / BGS guidance • Vast amount of information available • Not possible to review evidence independently • Structure loosely based on NICE “Don’t let falls get you down...”

24. Evidence... “Don’t let falls get you down...”

25. Evidence 2 • Fraser and Dunstan, BMJ, Dec 2010 • 25k journals, increases 3.5% pa • 1.5M articles published in 2009 • Echocardiography • 5 papers per hour, 8 hours per day, 5 days per week • 11 years, 124 days • By the end... • 40 years, 295 days, 408,049 papers “Don’t let falls get you down...”

26. Evidence – falls • www.safetylit.org • Fall – textword • Limit to 2000 to 2013 • Returns 8531 articles • 5 papers per hour, 8 hours per day, 5 days a week • 200 articles per week Falls Prevention

27. Nature of interventions • Individual multi-factorial • Population based multi-factorial • Population based single factor “Don’t let falls get you down...”

28. Screening / risk assessment • NICE (2004) “Older people in contact with health care professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the falls” “Don’t let falls get you down...”

29. Risk assessment (2) • NICE guideline group supports older people being asked about falls risk on an annual basis. • AGS / BGS - annual screening • A lack of ‘hard evidence’ to support this position • Current approaches require people to suffer injurious falls first • NSC has no position on falls “Don’t let falls get you down...”

30. Need to be ‘picked up’ No further action No / unseen / minor untreated injury Absent GP Not fallen Falls risk factors present Community dwelling older population Home Falls risk factors Gait or balance problems Minor injury A and E Present Fall Major injury Other falls risk factors In-patient Death Care home Falls pathway Key:- Grey boxes indicate areas where interventions have historically been delivered and where work is currently underway. These include work by NLIAH and WAST. Yellow boxes indicate where the evidence base has demonstrated that intervention is effective and available in addition to what is already being done. “Don’t let falls get you down...”

31. Older people living in Wales Primary care Falls case identification process Low risk of falling Faller or at risk of falling Consider general population intervention Falls risk assessment No further action at this time Recall in 1 year? “Don’t let falls get you down...”

32. Screening / risk assessment (4) • Once identification process is resolved a series of algorithms are available to carry out multi-factorial risk assessment • Supported by evidence base “Don’t let falls get you down...”

33. Gait and balance assessment Gait problems increase risk of falling by 2.0 to 2.2 times Balance problems increase risk of falling by 1.8 to 3.9 times Assessment options Do you have any problems with walking or balance? Screening tests No Yes See screening test algorithm Consider general population intervention Gait and / or balance problem identified (consider foot / footwear problems) No gait and / or balance problem Consider general population intervention Reason for problem known Reason for problem not known Referral to specialist for further assessment Check management, make changes if needed Balance / Exercise training programme Referral to specialist for further assessment if necessary “Don’t let falls get you down...”

34. Multi Factorial assessment • No definitive agreement around components • Combined NICE, ProFaNE, AGS / BGS • Full assessment likely to take considerable time • Suggests need for specialist role in primary care • Appropriate referrals needed • High risk referred for more comprehensive assessment, lower risk managed through primary care “Don’t let falls get you down...”

35. Population level approaches • Multi factorial • Include information and education, home hazard reduction, exercise programmes, policy change • 6% to 33% reduction in fall injuries • Not clear what each component contributes • Single factor • Exercise • Reduces falls by 22% (sig) • Education • No clear evidence of effectiveness “Don’t let falls get you down...”

36. Multi v Single factor • Effect on falls similar with both approaches • Conclusion that single interventions most acceptable and more easily targeted • What about tai chi? “Don’t let falls get you down...”

37. Cost effectiveness • Lack of evidence at global level • Would take considerable time and effort to generate such information in Wales • What about tai chi? “Don’t let falls get you down...”

38. Effective interventions “Don’t let falls get you down...”

39. Effective interventions “Don’t let falls get you down...”

40. No effect interventions “Don’t let falls get you down...”

41. Evidence - problems • Difficulties with translating effect sizes seen in research projects into real world “Don’t let falls get you down...”

42. Conclusions • Burden of falls is significant and likely to increase • Coherent, high quality approach • Intervention needed at all levels of prevention • Expectations of what is likely to be possible need to be managed • Without high quality ED data, impact will never be measureable “Don’t let falls get you down...”

43. Recommendations • Stand up against falling down • Population level understanding that falls can be prevented • Stop never fallers from becoming ever fallers • Population level exercise • Take a proactive approach to risk assessment • Primary care ‘screening’ • Take a ‘one day sooner’ approach to fallers admitted to hospital • Ensure that current practice is good practice “Don’t let falls get you down...”

44. Next steps • Identify and evaluate services already in place • Recommendations do not need to all be implemented at once • Develop an approach to implementation that is supportive and collaborative • Population level programmes need to be put in place • Including ED data quality “Don’t let falls get you down...”

45. Final thoughts • Don’t let falls get you down... • “Have a word..” • Empower the public and professionals • Treat the faller, not just the injury • We don’t ignore angina... • There is no “quick fix” • Long, complicated, collaborative process “Don’t let falls get you down...”