Nottinghamshire Insight

Joint strategic needs assessment

Falls and Bone Health (2015)

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Topic title Falls and Bone Health (2015)
Topic owner OPICG
Topic author(s) Gill Oliver
Topic quality reviewed Lindsay Price, 2014
Topic endorsed by OPICG
Topic approved by Approved 17th July 2015 HWIG
Current version 03.03.2015
Replaces version 10.02.2015
Linked JSNA topics

Executive summary


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 CG146).

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

Addressing falls and bone health enables older people in Nottinghamshire to increase healthy life expectancy. Public health outcome measures suggest that Nottinghamshire is performing well overall compared with the East Midlands and England and that fewer people are being admitted to hospital with a non-injurious fall. 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:

  • capacity in specialist falls teams
  • lack of communication and integration between different teams specialising in different conditions
  • ensuring expertise and leadership in areas without a specialist falls team or lead clinician
  • 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)
  • identifying and treating osteoporosis

Recommendations for consideration by commissioners

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 for inpatients at risk of falling.

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:

  • Explore implementation of comprehensive falls prevention programmes to prmote strength and balance
    • 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
  • Reduction of home hazards, use of aids and adaptations
  • Learning & development for health and social care staff to:
  • Improve identification and case finding of people at risk of falling
    • Use of the Guide to Action tools
  • Medication reviews, especially following hospital discharge
  • completion of FRAX assessment for osteoporosis
  • Local Falls and Bone Health co-ordinators in line with guidance
  • Integration of the pathway across primary and secondary care to include bone health and clear referral to falls services
  • Integrated crisis response services, assessing causes of a fall and putting preventative measures in place to reduce chances of further falls, focusing on treatment at home and in the community

Together, these recommendations will::

  • Reduce admissions to hospital and care homes as a result of falls
  • Reduce falls in care homes and nursing homes
  • Reduce falls in hospital

Key contacts

None provided.

This is an online synopsis of the topic which shows the executive summary and key contacts sections. To view the full document, please download it.

Full report »