Older adults and falls

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1 TRAUMA & INJURY INTELLIGENCE GROUP CHESHIRE AND MERSEYSIDE THEMED REPORT 1: MARCH 2005 Older adults and falls Introduction Falls amongst older adults have a substantial impact on health and the provision of health care services.the Trauma and Injury Intelligence Group (TIIG) collects data from Accident and Emergency (A&E) Departments and the Ambulance Service in Cheshire and Merseyside and is able to assess any changes in the number of fall related attendances across A&E departments. Combined with mortality, hospital episode and census data, this can provide evidence of at risk groups in Cheshire and Merseyside and of where services should be focused.this report aims to bring these data sources together to provide a more robust picture of older adults and falls. For the purpose of this report, older adults are classified as those in the 60 plus age group. Background The relatively large number of individuals born after the Second World War coupled with a declining birth rate since the mid seventies means the United Kingdom has an ageing population. Sixteen percent of the population are now over the age of 65 years (Office for National Statistics, 2004). With the shift in population structure the future needs of older adults are already the subject of extensive research. The implications of an ageing population on issues such as income, pensions, health and disability, social services, the promotion of sustainable cities and long term care needs are of major concern to government, national and local service providers, as well as older adults themselves (Office of the Deputy Prime Minister, 2004; Evandrou et al, 2001). With increasing age comes a multitude of problems that can affect quality of life. Reducing the impact of these problems often depends on health, social care and community volunteer services being effective in supporting older adults. Moreover, older adults are the main users of health and social care services; at times these services have not adequately met their needs (Department of Health, 2001). To address these issues the Department of Health published the National Service Framework (NSF) for Older People in 2001.This aims to ensure fair, high quality and integrated health and social care services for older adults, to drive up standards and to reduce unacceptable variations in health and social services.the NSF focuses on four main standards: Ending age discrimination Providing person-centred care Promoting older people s health and independence Fitting services around people s needs (Department of Health, 2001). The NSF for Older People also addresses conditions that are a significant issue for older adults that have not been covered in other NSFs such as stroke, falls and mental health problems. One of the aims of the NSF for Older People is to: Reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation of those who have fallen. The rationale for this aim is multi faceted. Falls are a major cause of disability and mortality amongst older adults. They are also avoidable. During 2002 there were 1,874 fall related deaths in the 65 plus age group in England and Wales (Department of Health, 2004). Osteoporosis, a condition associated with fragile bones which are more liable to break, affects one in three women and one in twelve men over the age of 50 in the UK (National Osteoporosis Society, 2004; Department of Health, 2001). Around 14,000 people die each year in the UK as a result of osteoporotic hip fractures (Department of Health, 2001). Furthermore, the detrimental and possibly debilitating effects resulting from falls can lead to admission to long-term care. Research shows that quality of life in women is threatened by falls and hip fractures. Any loss of ability to live independently has a considerable effect on quality of life (Salkeld, et al, 2000). NorthWest Public Health Observatory

2 A benefit of reducing the number of fall related injuries amongst older adults is a reduction in associated Accident and Emergency (A&E) presentations.the NHS has set key target indicators for acute trusts in particular to reduce the time patients spend in A&E.The target requires that 98% of patients spend four hours or less in A&E from arrival to admission, transfer or discharge from January 2005 (HealthCare Commission, 2004). Reducing fall related A&E presentations will reduce pressure on A&E departments and hence help meet this target. Falls and older adults - Data Admissions to Hospital The severity of falls varies widely and the level of treatment required will vary accordingly. Some people may require basic first aid, whereas others require more specialised treatment leading to hospital admission. Hospital Episode Statistics (HES) provide information on all patients admitted to NHS hospitals in England. HES data can provide a picture of those individuals who are deemed as having more serious falls, requiring hospital attendance. HES data for Cheshire and Merseyside illustrated that between April 2003 and March 2004 there were 8,878 hospital attendances for falls admitted via A&E in the 60 plus age group. Table 1 presents the number of falls admitted to hospital by local authority area of residence of patient, along with rates per 1,000 of population (aged 60 plus). Liverpool had higher rates of fall attendees for females and males than other local authorities. For all areas there were more female hospital admissions for falls, via A&E, than male admissions. Table 1: Fall admissions via A&E, Cheshire and Merseyside, age 60 plus,april 2003 to March 2004 Analysis by age shows that the number of female admissions to hospital via A&E for a fall related incident increased with age, until the age of 84 when numbers declined (Figure 1).A similar though less pronounced pattern was seen for males.this may correspond to lower numbers of individuals in the population in these age categories. Figure 1: Fall admissions via A&E, Cheshire and Merseyside, age 60 plus,april 2003 to March Male Female 1200 Total episodes Age group Data from Department of Health, 2004 Mortality Mortality is the most severe outcome of accidental falls. Mortality statistics are based on registrations of deaths using International Classification of Disease codes (ICD) (WHO, 1992). Figure 2 shows standardised mortality ratios (SMRs) for accidental falls in 2001 to 2002 (pooled) for Cheshire and Merseyside by local authority area of residence. Liverpool has the highest SMR for accidental falls (243), two and a half times higher than the average for England and Wales (Confidence Interval: ) (Department of Health, 2004a).The Wirral has the lowest SMR for falls in Cheshire and Merseyside at 66, significantly less than England and Wales.

3 Figure 2: Mortality from accidental falls (ICD 10 W00-W19). Indirectly standardised ratios, 2001/2002 pooled, all ages, Cheshire and Merseyside, by local authority area of residence Table 2 shows death rates from accidental falls by age group and local authority area of residence. The highest death rates are seen amongst the 75+ age group for all areas except Ellesmere Port and Neston. Liverpool and Halton local authority areas had the highest age specific death rates in the 75 plus age group for falls during 2002 (Figure 3). Table 2: Mortality from accidental falls (ICD 10 W00-W19). Age specific death rates per 100,000, all persons, 2002, Cheshire and Merseyside Figure 3:Age specific death rates for falls, per 100,000 population, all persons aged 75 plus, 2002, Cheshire and Merseyside. Quartile shading pattern Data from Department of Health, 2004a

4 Accident and Emergency attendances Accident and Emergency departments provide an excellent opportunity for gathering information on injuries.the following analysis of A&E data provides a breakdown of falls attendees aged 60 plus at Arrowe Park, Aintree and Royal Liverpool A&E departments for the period April to September Falls account for a high percentage of injury related A&E attendance for all three A&E departments (See Table 3), placing a large burden on resources. In particular falls are one of the main reasons for A&E attendance amongst those aged 60 and above, accounting for between 35% and 70% of all attendances. 1 Table 3: Number of fall related trauma attendances at Accident and Emergency, April to September 2004 Demographics of Accident and Emergency fall attendees, aged 60 plus For all three hospitals over two thirds of fall related A&E attendees aged sixty plus were female. admissions to hospital, the number of fall related A&E attendance increased with age group (Figure 4). As with Figure 4: Accident and Emergency fall attendees aged 60 plus, by age group, April to September 2004 Fall attendees aged 60 plus primarily arrived at A&E via ambulance or private transport (Table 4). Further analysis of arrival mode by age showed use of an ambulance increased with age. Table 4: Arrival methods of fall attendees aged 60 plus to Accident and Emergency departments,april to September 2004 Location and time of falls Arrowe Park and Aintree A&E departments collect information on location of falls. Around six in ten falls occurred in the home (Arrowe Park 54%; Aintree 65%). Furthermore, Arrowe Park collects specific location of falls in the home, identifying the living room/dining room and bedroom as the two main locations for falls in the home (28% and 24% respectively). Analysis of fall location by age shows that individuals likelihood of falling in the home increases with age, whereas number falling in public places decreases with age (Figure 5). One reason for this may be that older adults venture outside less frequently. 1 Differences in number of fall attendees at each Accident and Emergency department may be due to different reporting/recording mechanisms within each hospital.

5 Figure 5: Arrowe Park Accident and Emergency fall attendees by incident location and age group, April to September 2004 Time of A&E attendance can be used to inform local authorities and falls prevention groups of the peak times for falls. Through April to September 2004, Aintree, Arrowe Park and Royal Liverpool A&E departments had a consistent number of fall related attendances per month. A similar pattern was seen for attendance by weekday. However, peak hours for fall related A&E attendance for the sixty plus age group were between 10am and 2pm with 35%, 33% and 33% occurring in this period in Arrowe Park, Aintree and Royal Liverpool, respectively. Area of residence of fall attendees Aintree Figure 6 illustrates the spatial distribution of residences of fall attendees aged sixty plus in relation to Aintree A&E department. The map illustrates that the area of Northwood (ward) had the highest rate of fall attendees at Aintree hospital, at 39 per 1,000 population (calculated for population of those aged 60 plus within each ward). Cherryfield,Whitefield, Fazakerley, Linacre and Victoria wards had a rate of between 27 and 33 fall attendees aged sixty plus per 1,000 population. Figure 6:Ward of residence of Aintree Accident and Emergency fall attendees, all persons aged 60 plus, rate per 1,000 population, April to September 2004 Arrowe Park Figure 7 illustrates the spatial ward distribution of residences of fall attendees aged sixty plus at Arrowe Park A&E department. Claughton had the highest rate of fall attendees aged 60 plus at Arrowe Park Accident and Emergency department at 37 per 1,000 population. The wards of Moreton, Upton, Prenton, Oxton, Birkenhead, Tranmere and Egerton all had over 30 fall attendees aged 60 plus per 1,000 population.

6 Figure 7: Ward of residence of Arrowe Park Accident and Emergency fall attendees, all persons aged 60 plus, rate per 1,000 population, April to September 2004 Royal Liverpool Figure 8 illustrates the spatial distribution of residences of fall attendees aged sixty plus at Royal Liverpool A&E department.this map is based on postcode area of residence and is therefore not standardised by population. A postcode map is used here as the data currently received from Royal Liverpool A&E includes first part postcode only, for example L32. Discussions are being held to establish mechanisms to map postcodes to ward area, which would enable the mapping of rates rather than raw numbers. The map illustrates that the postcode area of L8 (Toxteth) had the highest number of individuals attending Royal Liverpool A&E for a fall related injury. Figure 8: Postcode area of residence of Royal Liverpool Accident and Emergency department fall attendees, number of attendees aged 60 plus, April to September 2004 Ambulance call outs Merseyside Regional Ambulance Service (MRAS) respond to ambulance call outs in the Cheshire and Merseyside region. For each call out MRAS responds to, valuable information such as reason for call out, location of incident, age and gender is collected. Such data are used here to build a pattern of fall related ambulance call outs in Cheshire and Merseyside. During April to September 2004 there were 14,683 fall related ambulance call outs in Cheshire and Merseyside. Of these individuals 9,747 (66%) were aged 60 plus. As with fall related A&E attendees, a high percentage of ambulance call outs for falls in the 60 plus age group were female (N=6,520, 67%). The number of fall related call outs in the 60 plus group remained relatively stable throughout the week, with slight peaks in call outs during July (N=1,695) and a slight drop in April (N=1,480). Peak hours for call outs were between 8am and 12noon, with number of call outs dropping after this time period (Figure 9).

7 Figure 9: Fall related ambulance call outs by time of call out, all persons aged 60 plus, Cheshire and Merseyside,April to September 2004 Figure 10 illustrates location of call out by postcode area. Peak areas for fall related call outs in the 60 plus age group included Southport (PR8, PR9), Warrington (WA4) and Macclesfield (SK11). Figure 10: Fall related ambulance call outs, all persons aged 60 plus, by postcode area of incident, April to September 2004 On receipt of a call out an ambulance will attend the scene of the incident and either treat the patient at the scene (if treatment is required) or take the patient to a medical establishment.table 5 shows that of the 9,747 fall related call outs in the 60 plus age group, a third (38%) of patients were treated at the scene.where patients were taken to a medical establishment they were primarily taken to Arrowe Park, Royal Liverpool, Aintree or Whiston A&E departments. Table 5: Fall related ambulance call outs by hospital attended, all persons aged 60 plus, April to September 2004

8 Merseyside Fire Service Older age groups are particularly vulnerable to fire related injury. Older adults make up around 75% of Merseyside fire deaths.this is partly due to their increased likelihood of falling, which exacerbates danger in fires. Issues associated with mobility or hearing difficulties have been linked directly to fire deaths. Anecdotal evidence also indicates that some individuals have caused fires during a fall or have fallen as they have tried to escape from a fire, although it is difficult to draw precise conclusions. Summary Falls are a major cause of disability due to injury in older adults. Hospital Episodes Statistics show that within Cheshire and Merseyside there were 8,878 fall admissions via A&E in the 60 plus age group during April 2003 to March Of fatal falls, during 2002 Liverpool, Halton, Macclesfield, Congleton and Warrington all had higher age specific death rates for falls, for all age groups, compared with England and Wales (Department of Health, 2004). Local data illustrates that falls are one of the main reasons for A&E attendance, particularly in the sixty plus age group. Conditions such as osteoporosis and the fact that females live longer than males, means females are more likely to experience fall related injury. Local A&E data and Ambulance data supports this. Area of residence of A&E fall attendees and location of ambulance call outs for falls can help identify target areas for preventive strategies. The wards of Northwood, Cherryfield, Whitefield, Fazakerley, Linacre, Victoria and Claughton, along with the postcode area of L8 (Toxteth) all had a high number of older adults attending A&E as a result of a fall. Southport (PR8, PR9), Warrington (WA4) and Macclesfield (SK11) had the greatest number of fall related ambulance call outs compared to other postcode areas. Although further analysis is required to calculate rates and establish if there is any relationship with population structure, all these areas may be targeted for prevention strategies. Bringing together a variety of trauma and injury data sources, this report aims to provide an overview of fall injuries in older adults across Cheshire and Merseyside. Other thematic reports will include Children and Inequalities, Fire and Burns, Assaults and Road Traffic Accidents. The Trauma and Injury Intelligence Group would welcome any comments you have regarding this or future thematic reports. Acknowledgements The Trauma and Injury Intelligence Group would like to thank Helen Holme, Paul Langton, Anita Snowdon,Terry Duggan, Barbara Cook, Phil Garrigan and Clare Hiles for their input in the production of this report. We would also like to thank Aintree Hospital, Arrowe Park Hospital, Royal Liverpool Hospital, Merseyside Fire Service, Mersey Regional Ambulance Service and the Department of Health for providing the data used in this report. References: Department of Health (2001). National Service Framework for Older People. Executive Summary. London: Department of Health Department of Health (2004). Hospital Episodes Statistics, Data obtained from the North West Public health Observatory. Department of Health (2004a). Mortality form Accidental Falls (ICD10 W00-W19), pooled, all ages. Data obtained from the North West Public health Observatory. Evandrou, M., Falkingham, J., Johnson, P. and Rake, K. (2001). SAGE: Simulating Social Policy for an Ageing Society, A research agenda (Online). Available at HYPERLINK " Accessed National Osteoporosis Society (2004). What is osteoporosis? (online). Available at HYPERLINK " Accessed Office of the Deputy Prime Minister (2004). New Horizons Project C049 Executive Summary (Online). Available at HYPERLINK " Accessed Office for National Statistics (2004). Population Ageing (online). Available at HYPERLINK " Accessed London: Office of National Statistics. Salkeld, G., Cameron, I, D., Cumming, R, G., Easter, S., Seymour, J., Kurrle, S,E. and Quine, S. (2000). Quality of life related to fear of falling and hip fracture in older women: a time trade off study. British Medical Journal; 230: World Health Organization (1992).The International statistical classification of diseases and related health problems, tenth revision. Geneva: World Health Organization. TIIG Contacts Strategic Queries: Linda Turner linda.turner@southsefton-pct.nhs.uk Author: Zara Anderson,TIIG Analyst Centre for Public Health Faculty of Health and Applied Social Sciences Liverpool John Moores University Castle House North Street L3 2AY Tel z.a.anderson@livjm.ac.uk Website