Falls and Frailty

This topic area covers statistics and information relating to falls and frailty including hip fractures in Hull including local strategic need and service provision.

This page contains information from the Office for Health Improvement & Disparities’ Fingertips. Information is taken ‘live’ from the site so uses the latest available data from Fingertips and displays it on this page. As a result, some comments on this page may relate to an earlier period of time until this page is next updated (see review dates at the end of this page).

In July 2022, Clinical Commissioning Groups (CCGs) ceased to exist and were replaced by the Integrated Care System. Data will still be available at CCG level for some time after July 2022 so this page continues to refer to CCGs and Hull CCG, and continues to present data at the CCG geographical level. Six local CCGs were also combined to form the Humber, Coast and Vale geographical area, which has also ceased to exist. It has been replaced by the Humber and North Yorkshire ICS. However, data will still be available at Humber, Coast and Vale geographical level, and will be presented within our JSNA.

Headlines

• It is important to know which patients are frail so that additional support can be tailored to those who are most vulnerable to reduce falls and other accidents and injuries resulting from their frailty as well as other support that might be needed in relation to their wellbeing.
• Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. For 2019/20, 525 (0.5%) patients aged 50+ who were registered with Hull GPs had a diagnosis of osteoporosis which was considerably lower than England (0.9%).
• Anyone can have a fall, but older people are more vulnerable than others. This is mainly because long-term health conditions increase the chances of a fall. Falls can also have an adverse psychological impact on elderly people and can also result in hip fractures which can be very serious with about 10% dying within one month, and about one third dying within 12 months.
• During 2019/20, there were 815 emergency hospital admissions for injuries related to falls among those aged 65+ years (300 for those 65-79 years and 515 for those aged 80+ years). The rates have been consistently higher than England, but have fallen in Hull recently, and for 2019/20 emergency admission rates due to falls were similar in Hull compared to England.
• The situation is different for emergency hospital admissions for hip fractures, where the emergency admission rate are 13% higher in Hull compared to England and second highest when compared with the local authorities across the Yorkshire and Humber region. However, the rate in Hull has fallen in the last couple of years (rates were 38% higher than England in 2017/18). In 2019/20, there were 245 admissions in total among those aged 65+ years for hip fractures (75 for people aged 65-79s and 165 for people aged 80+ years).

The Population Affected – Why Is It Important?

Frailty can develop as a consequence of a range of long-term conditions throughout an individual’s life but is more often associated with age-related decline in multiple body systems, which results in vulnerability to sudden health status changes triggered by minor stress or events such as an infection or a fall at home (British Geriatrics Society and the Royal College of Nursing, 2015).

Polypharmacy (being on multiple medications), having long-term conditions such as respiratory or circulatory disease, and having had a previous fall or falls all increase the risk of frailty. There is also a link to deprivation. From the Marmot Review, people living in more deprived areas experience more ill health, worse access to health and social care services, and earlier death than the rest of the population. A survey published in the Journal of Public Health concluded that there was overall, greater area-level deprivation associated with higher levels of frailty, but people who survived to at least 75 years of age had similar one-year frailty trajectories, regardless or area-level deprivation. From this they suggested that interventions to reduce frailty should target younger age groups, especially those living in the most deprived areas.

It is important to know which patients are frail so that additional support can be tailored to those who are most vulnerable to reduce falls and other accidents and injuries resulting from their frailty as well as other support that might be needed in relation to their wellbeing. There may be other changes that could be made to reduce frailty such as changes to medication.

In mid-2018, people aged 65 years and over accounted for 18.2% of the population of England with those over 85 years of age making up 2.4% of England’s population. By mid-2043 the population over 65 years of age in England is projected to increase by 44.7% with this age cohort expected to account for 23.9% of the overall population of England. As the percentage of older people living in England increases so too will the number of people living with frailty and the demand for services to support.

Nationally there are policy drivers to keep people living independently at home, to avoid admissions to hospital and reduce length of stay in hospital; this is particularly relevant for frail older people. Not everything can or should be done outside hospitals, but much can be.

There are national challenges associated with frailty as noted in the NHS RightCare Frailty Toolkit and the British Geriatrics Society in June 2019:

• Increasing numbers of people are at risk of developing frailty. A person living with mild frailty has twice the mortality risk of a fit (non-frail) older person.
• More people living with frailty are attending emergency departments, with over 4,000 admissions daily for people living with frailty.
• Older people living with frailty are more likely to have delayed transfers of care. Almost a half (45%) of people experiencing delayed transfers of care are aged over 85 years with approximately 50% of people aged 85+ years will encounter frailty.
• People living with frailty could often have their needs met best in settings outside of acute hospital care. Severe frailty care often brings over four times the costs of non-frailty care.

Falls are associated with frailty due to loss of muscle mass (sarcopenia ), as well as associations with long term conditions and certain medicines, cognitive deficit and delirium. However, there are also environmental associations with falls, including physical hazards in the home and outside, and adverse weather conditions such as snow and ice.

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. It’s a fairly common condition that affects around three million people in the UK. There are an estimated 500,000 frailty fractures in the UK every year according to the National Institute for Health and Care Excellence. Osteoporosis can also be made worse by smoking. Treatment for osteoporosis is based on treating and preventing fractures and using medication to strengthen bones. Taking regular exercise, healthy eating including foods rich in calcium and vitamin D, giving up smoking and reducing alcohol intake can help reduce the risk of developing osteoporosis. Anyone can have a fall, but older people are more vulnerable than others. This is mainly because long-term health conditions increase the chances of a fall. Falls are a common but often overlooked cause of injury, and sometimes death. The World Health Organisation state approximately 30% of people over 65 fall each year, and for those over 75 the rates are higher. Between 20% and 30% of those who fall suffer injuries that reduce mobility and independence and increase the risk of premature death. Fall rates among institution residents are much higher than among community-dwellers. Most falls do not result in serious injury, but there is a risk of problems such as broken bones. Falls can also have an adverse psychological impact on elderly people (losing confidence, becoming withdrawn, losing independence, etc). With the ageing population, it is predicted that the number of people in England aged 65+ years admitted to hospital as a result of a fall will increase. Hip fractures can be very serious in older people. Mortality is high and cost of care can be high. The National Institute for Health and Care Excellence state that about 10% of people with a hip fracture die within one month, and about one third within 12 months. However, fewer than half of deaths are attributable to the fracture. Over 70,000 hip fractures occur in the UK each year. The annual cost for all hip fractures in the UK, including medical and social care, is about £2 billion.

The diagnosed prevalence of osteoporosis can be examined from data collected as part of the Quality and Outcomes Framework within primary care. Quality of care indicators are also included, and it means that high percentage of the patients diagnosed with osteoporosis have annual reviews which gives medical staff the opportunity to provide information and encourage their patients to improve their lifestyle behaviours to improve their health, and lower their risk of morbidity and mortality from their condition. Local analysis of the QOF data has been completed with prevalence calculated for each GP practice and Primary Care Network group.

The Hull Picture

Ageing Population

From the Office for National Statistics, by 2043, it is projected that around one in every five Hull residents will be aged 65 or over (18.6%). This equates to 9,746 additional older people in the 25 years between 2018 and 2043.

The population aged 65+ years in Hull, from 2018, is projected to increase by:

• 14.2% to 2028 (from 38,997 in 2018 to 44,535 in 2028)
• 25.0% to 2043 (from 38,997 in 2018 to 48,743 in 2043)

For Hull, the number of people aged over 75 years is projected to increase 54.9%, by 2043. A similar increase is also expected in the number of people over the age of 85 years of age, projected to increase 52.3% by 2043.

This 25.0% increase in the percentage of people aged 65+ years, whilst the highest age banding increase within Hull, still falls behind that of the expected England increase (44.7%).

Further information can be found within Population Projections within Population.

Frailty

The electronic frailty index (eFI) uses routine health data to automatically calculate a score which can identify whether a person is likely to be fit or living with mild, moderate or severe frailty.

In 2018, GP practices in Hull ran the eFI which showed there was over 12,000 registered patients with moderate or severe frailty who were also at risk of admission (3,142 at risk of severe frailty and 9,672 at risk of moderate frailty).

Diagnosed Prevalence of Osteoporosis

The Office for Health Improvement & Disparities’ Fingertips presents the prevalence of patients aged 50+ years registered with Hull GPs who have been diagnosed with osteoporosis. There are 442 such patients for 2020/21 which represents 0.4% of the patient population aged 50+ years and this is among the lowest prevalence of the Clinical Commissioning Groups (CCGs) within Humber, Coast and Vale, and half the rate of England.

In 2014/15, the prevalence in Hull was the same as for England and the Humber, Coast and Vale, but whilst Hull’s rate has increased since then except between 2019/20 and 2020/21, the rate across both England and the Humber, Coast and Vale has increased at a much faster rate.

The rates fell between 2019/20 and 2020/21, and it is possible that slightly more people who were particularly frail and who had osteoporosis died of COVID-19 than would be expected a in single year. The reduction in the number of people diagnosed with osteoporosis fell by 83 people between 2019/20 and 2020/21 in Hull. Decreases also occurred for England and across the Humber, Coast and Vale.

Emergency Admissions Due to Falls Among Those Aged 65+ Years

Fingertips also presents information on the emergency admission rate due to falls and for hip fractures among people aged 65+ years. The rates are directly age standardised admission rates and are presented as the number of admissions per 100,000 population in the standard population which is the European Standard Population.

In 2020/21, the emergency hospital admission rates due to falls was lower than England and the majority of local authorities across the Yorkshire and Humber region.

However, the generally been considerably higher than England but have fallen to levels similar to or lower than England only in last three years to 2020/21. At the peak in 2013/14, there were 1,082 emergency admissions due to falls in Hull among people aged 65+ years giving a rate of 2,916 per 100,000 population. Since then the rate in Hull has consistently fallen and in 2019/20 there were 815 such admissions giving a rate of 2,176 admissions per 100,000 population (a fall of 25%). There was also a further decrease between 2019/20 and 2020/21, but part of this decrease could be associated with the COVID-19 pandemic due to changes in the behaviour and the changes to the overall number of admissions to hospital.

Among those aged 65-79 years, Hull had a relatively consistent admission rate of around 1,300 admissions per 100,000 population between 2010/11 and 2017/18, but the rate fell significantly in 2018/19 and remained at a similar level in 2019/20 with just over 1,000 emergency admissions per 100,000 population. The rate has further fallen in 2020/21 to a new low of 879 admissions per 100,000 population, but part of this decrease might be attributable to the COVID-19 pandemic.

Among those aged 80+ years, the rates were consistently higher than England between 2010/11 and 2016/17 at its peak in 2013/14 being 37% higher (7,523 versus 5,479 admissions per 100,000 population), but since 2013/14 the admission rates have fallen and for the first time in 2019/20, the rate in Hull is lower than England. In Hull, there were 725 admissions in 2013/14 among those aged 80+ years, but 515 in 2019/20. The rates have further fallen to a low of 4,617 admissions per 100,000 population with 435 admissions during 2020/21.

Of the 685 emergency admissions for falls among those aged 65+ years during 2020/21, 435 occurred to people aged 80+ years representing just under two-thirds of admissions among those aged 65+ years.

Emergency Admissions For Hip Fractures Among Those Aged 65+ Years

Whilst there is a lower rate of emergency admissions due to falls in Hull, the rate of emergency admission rate for hip fractures among people aged 65+ years in Hull is high being the second highest across Yorkshire and Humber after North East Lincolnshire. The rates are again age-standardised to the European Standard Population and represents the number of admissions per 100,000 population in this standard population.

In 2020/21, the emergency admission rate for hip fractures was 19% higher than England among all people aged 65+ years, and 16% and 21% higher for people aged 65-79 years and 80+ years respectively.

In 2020/21, there were 240 emergency admission rate for hip fractures in Hull with 75 occurring to people aged 65-79 years and 165 to people aged 80+ years.

For all those aged 65+ years, the rates have fallen markedly in the last two years. Between 2010/11 and 2019/20, at its peak in 2017/18 there were 294 admissions (797 per 100,000 population) but the rate has fallen by 19% to 240 admissions in 2020/21 to 632 admissions per 100,000 population.

The rate has been consistently higher than England and the region.

Rates among those aged 65-79 years in Hull have been relatively constant between 2014/15 and 2018/19, but fell quite sharply by 17% between 2018/19 and 2019/20. The rate fell further between 2019/20 and 2020/21 to a new low rate of 253 admissions per 100,000 population with 75 admissions in total. The rate has been consistently higher than England and the region.

A similar recent fall has also occurred among those aged 80+ years between 2017/18 and 2019/20 although the rate remained relatively unchanged between 2019/20 and 2020/21. The rate has been consistently higher than England and the region.

The Projecting Older People Population Information Service (POPPI) provide current estimates and future projections at local authority level of the number of people aged 65+ years who are predicted to have a fall (within a one year period).

They use estimates for the percentages predicted to have a fall for different age groups for men and women separately from the Health Survey for England 2015, and apply those percentages to Hull’s population. POPPI states that more recent research from the English Longitudinal Study of Ageing had similar age gender specific estimates for the percentages predicted to have a fall. Their estimates do not take into account other factors such as deprivation.

It is estimated in 2020, that more than 10,000 people in Hull aged 65+ year will have a fall (over a one year period), and with the ageing population this is anticipated to increase to over 13,000 by 2040.

Age	2020	2025	2030	2035	2040
65-69	2,401	2,616	2,898	2,734	2,506
70-74	2,572	2,431	2,653	3,002	2,834
75-79	1,634	2,140	2,021	2,259	2,535
80-84	1,764	1,730	2,315	2,216	2,513
85+	1,978	2,021	2,064	2,623	2,838
All 65+	10,349	10,938	11,951	12,834	13,226

POPPI also give the modelled estimated number of people who are predicted to have be admitted to hospital as a result of a fall. The estimates are derived from hospital data for 2016/17.

It is estimated in 2020, that more than 1,200 people in Hull aged 65+ year will be admitted to hospital as a result of having had a fall, and with the ageing population this is anticipated to increase to over 1,600 by 2040.

In the year 2020/21, there were 685 emergency hospital admissions due to falls among those aged 65+ years considerably lower than the 1,200 estimated for 2020. The reason for the difference is not clear. There could be a difference in the definition in relation to falls or the emergency status, although it is not clear how the definition could differ as falls are clearly coded under the International Classification of Diseases used to code the reason for hospital admissions. It is relatively unlikely that a person will be admitted through non-emergency route from a fall. It is possible though that the estimate from POPPI takes into account admissions due to falls that occurred because of a fall but that it was not coded within the hospital admission as a fall.

Age	2020	2025	2030	2035	2040
65-69	95	104	116	109	100
70-74	148	140	153	171	163
75-79	173	227	215	239	269
80+	787	779	927	1,005	1,106
All 65+	1,203	1,250	1,411	1,524	1,638

Strategic Need and Service Provision

It is important that people who are frail or at risk of becoming frail have their medications reviewed and support is given to reduce the risk of becoming frail or reducing the severity of the frailty. When designing service, this ideally means shifting the focus of delivery to early help and prevention, delivering responsive integrated out of hospital care, and preventing or reducing the demand for acute and social care services.

Exercise and physical activity can improve strength and balance, and reduce the likelihood of falls. Among those at risk of a fall, risk can be reduced by removing hazards from the home, and having regular sight tests and hearing tests. Steps could include using walking sticks and other walking aids, using non-slip mats in the bathroom, mopping up spills to avoid wet floors, getting help lifting and moving items, removing clutter from the home, ensuring the home is properly lit, etc. People at risk of a fall can request a home hazard assessment. Age UK and the Royal Voluntary Service also offer advice about adapting the home so older people can remain independent and safe in their own home. The National Institute for Health and Care Excellence recommend a co-ordinated programme of care for people who have fractured a hip.

Day-to-day behaviour changed for virtually everyone during the COVID-19 pandemic, and it is possible that changes in behaviour could have affected the number of falls. It is likely that older people did not go out of their houses as much, and whilst one might anticipate that falls could have reduced, falls in the home are more common than falls outside the home probably because more time is spend within the home and people at risk of falling are probably more cautious about the risk of falling when they are outside the home. The number of referrals have increased in the local Falls Service and the complexity of patients having falls has amplified possibly as they have not had as many face-to-face GP reviews or hospital appointments due to the pandemic.

The Hull Falls Intervention Response Safety Team (Hull FIRST) are involved in safe and well checks after a fall. They work together with local public sector partners and have created a NHS Alliance to introduced a pioneering scheme in Hull which provides a rapid 24/7 response to elderly or vulnerable patients in Hull who have fallen and need non-emergency medical support. Calls to NHS 111 or 999 are triaged by trained staff at Yorkshire Ambulance Service, where clinically appropriate, the patient is referred to the Hull FIRST Service. The service is made up of professionals with a range of skills and includes officers from Humberside Fire and Rescue Service to help move or offer physical support to the patient, and ambulance staff and City Health Care Partnership (CHCP) emergency care practitioners to provide non-emergency medical care. The team aims to reach the patient within one hour. The Humber Foundation Trust Falls Prevention Team follow up the initial response with one to one support to resolve any instant problems which may have caused the fall. The team also offer fragility fracture risk assessments in the home, occupational therapy, physiotherapy and fracture liaison nurses. Any required safety equipment is provided through the joint Hull City Council and Hull CCG (and its successor) Better Care in Hull programme.

Resources

Office for National Statistics. Population projections for local authorities, 2018. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/localauthoritiesinenglandtable2

NHS England Frailty what it means and how to keep well over the winter months. https://www.england.nhs.uk/blog/frailty/

Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6):392 7.

British Geriatrics Society. NHS RightCare: Frailty toolkit, 2019. https://www.bgs.org.uk/resources/nhs-rightcare-frailty-toolkit?msclkid=555abcb4d04a11ec8765e0d9d4285987

Stow D, Hanratty B, Matthews FE. The relationship between deprivation and frailty trajectories over one year and at end of life: a case-control study. Journal of Public Health, 2021: fdab 230. https://doi.org/10.1093/pubmed/fdab320

Institute of Health Equity. Fair Society Healthy Lives: Marmot Review.

NHS Falls – overview. https://www.nhs.uk/conditions/falls/

Benyon C et al. The cost of emergency hospital admissions for falls on snow and ice in England during winter 2009/10: a cross sectio na l analysis. Environ
Health. 2011; 10: 60.

National Institute for Health and Care Excellence. Impact of falls and fragility: https://www.nice.org.uk/Media/Default/About/what-we-do/Into-practice/measuring-uptake/NICE-Impact-falls-and-fragility-fractures.pdf

World Heath Organisation. What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? http://www.euro.who.int/__data/assets/pdf_file/0018/74700/E82552.pdf

National Institute for Health and Care Excellence. Hip fracture – the management of hip fracture in adults: https://www.nice.org.uk/guidance/cg124/documents/hip-fracture-final-scope2

NHS Digital. Quality and Outcomes Framework. https://qof.digital.nhs.uk/

The Office for Health Improvement & Disparities’ Fingertips: https://fingertips.phe.org.uk/

Age UK. Avoiding a fall: https://www.ageuk.org.uk/information-advice/health-wellbeing/exercise/falls-prevention/

Royal Voluntary Service. Preventing falls: https://www.royalvoluntaryservice.org.uk/

Updates

This page was last updated on 11 July 2022.

This page is due to be updated / checked in March 2023.