We are consulting on a draft national prevention strategy for falls and fractures 2019 to 2024.
The outcomes we want to see
6. More people proactively recognising their risk of falls and/or fractures and taking action to reduce risk.
7. More people taking preventive action after a first fall or fracture to prevent another.
Outcome 6
More people proactively recognising their risk of falls and/or fractures and taking action to reduce risk.
What we know and where we are now
People don't always recognise in themselves, or others, age-related functional decline, the onset of frailty or increased risk of falls or fractures. Even when there is realization and acceptance, the person, carers and families may not have the knowledge or the means to take action to slow or reverse the decline.
From the age of 30, muscle strength and balance can slowly decline without us noticing. Our muscles can lose up to 8% of their strength each decade – especially if we're not physically active. This means a simple trip, slip or loss of balance can become a fall.
A range of approaches can enable people to recognise age-related decline and an increasing falls risk, many of which are linked with support to take steps to slow down, or reverse, changes. They include use of the compression of functional decline framework (the LifeCurve), the Functional Fitness MOT [26] and the Falls Assistant tool. [27]
In 2017–2018, our Active and Independent Living Programme introduced the 'Take the Balance Challenge', [28] which adopts a self-assessment approach. The Challenge raises awareness of age-related loss of muscle strength and balance. It invites people to check their balance, provides six simple exercises to improve strength and balance, and signposts to a range of resources providing information about keeping active and well, improving bone health and preventing falls. We work with national partners, including Age Scotland and the Care Inspectorate, and over 400 partners locally to deliver the Challenge across Scotland. There has been a tenfold increase in traffic to NHS Inform's falls information pages since it was launched.
Good practice
The Take the Balance Challenge targets people over the age of 50 who may be beginning to experience changes in their muscle strength and balance. It invites people to check how good (or otherwise!) their balance is. For anyone who finds it's maybe not quite as good as they thought, there are six simple strength and balance activities – the super six – to help them start improving their strength and balance right away.
Strength and balance activities can help you to stay steady, whatever your age. Falls are not an inevitable part of getting older – simple steps can reduce your risk.
Technology and technology-enabled care are providing new and exciting opportunities to identify people at risk before they have experienced harm. They combine pioneering 'predictive analytics' with innovative wearable technology to identify risk of falling. We should encourage widespread use of commercially available technology as part of self-management messages – supported by our commitments to digital inclusion.
Good practice
Scotland's world-leading Technology Enabled Care Programme [29] continues to support greater independent living and healthy ageing by delivering a step-change in how technology is used as a cost-effective support. Telecare is already seen as a key support for people to live longer, healthier lives at home or in community settings, but the switch to digital telecare offers the chance to use data from consumer devices, wearables and health monitoring solutions in a more integrated and preventative way. Every £39 million spent by local authorities on telecare is estimated to bring around £99 million worth of savings to the public sector. Scope now exists to increase the number of people using telecare nationally from around 20% of over-75s to 33%.
Another emerging practice is the use of the Electronic Frailty Index. This uses GP records to identify levels of frailty in people over 65 years, providing an opportunity to give timely support to prevent the progression of frailty. Healthcare Improvement Scotland is working with Integration Authorities across Scotland to embed the use of the Electronic Frailty Index to target preventive support, such as falls management, polypharmacy reviews and anticipatory care planning, to individuals living in the community before they have a crisis (such as a fall) that results in unplanned hospital admissions.
Recognising increasing fracture risk before a fracture is sustained is equally important. Osteoporosis can develop slowly over several years and is often only diagnosed when a minor fall or sudden impact causes a bone fracture. There needs to be greater awareness of preventative actions, such as the right physical activity and sufficient calcium and vitamin D, and of risk factors for osteoporosis, including certain drug therapies and medical conditions. Use among practitioners of assessment tools such as Qfracture, [30] which has been recommended for use in Scotland by the Scottish Intercollegiate Guidelines Network, could result in earlier detection.
Outcome 7
More people taking preventive action after a first fall or fracture to prevent another.
What we know and where we are now
Falls
Older people who fall once are 2–3 times more likely to fall again within a year. Even if there is no injury, a fall can trigger loss of confidence and independence and increase isolation. Taking action after a first fall can prevent this downward spiral.
The Prevention and Management of Falls in the Community: a framework for action for Scotland 2014/2015, [31] stresses the importance of routinely having a conversation about falls whenever a person reports a fall or an injury, loss of function or increased care needs due to a fall. The structured conversation identifies the need for information or support to enable full recovery, maintain independence and prevent further falls. This was identified as a priority in the Framework as opportunities to prevent further falls and associated harm were frequently being missed at that time.
Since then, a growing number of professions, services and organisations across the system have been engaging in 'falls conversations' and providing or signposting people to further assessment and support. We need to build on this and start routinely having 'falls conversations' – and not just after someone has reported a fall. People often experience numerous falls before an injury causes them to contact a health professional. But many older people would be happy to be asked by a professional, such as a GP , practice nurse, physiotherapist, pharmacist, optician or social care practitioner, if they had fallen recently or were concerned about falls.
Commitment 12
We will work with NHS Education for Scotland to create national guidance on the 'falls conversation' for our workforce. The resource will help people to gain the knowledge and skills to initiate a meaningful conversation that leads to potentially beneficial actions.
A national improvement collaborative between 2016 and 2018, led by the Active and Independent Living Programme in partnership with the Scottish Ambulance Service and Healthcare Improvement Scotland, focused on improving experience and outcomes for the around 40,000 older people each year who fall and trigger an ambulance response. New ways of working enable ambulance crews to refer people directly to local assessment, rehabilitation and care services. In some situations, this prevents an unnecessary attendance at emergency departments. Economic modelling suggests this approach also has potential to prevent spend across the system. These 'see and refer' pathways are now operating across Scotland, with the Scottish Ambulance Service supporting ongoing work to ensure more people benefit in the future.
Fragility fractures
After a first fracture, the risk of fracturing again is increased 2–3 fold. Approximately half of all hip fractures follow a previous fragility fracture. Taking action after a first fragility fracture is key to preventing further fractures.
A Fracture Liaison Service identifies people who have sustained a fragility fracture and ensures that fracture risk assessment (and treatment where appropriate) is delivered to reduce the risk of further fractures. A fracture risk assessment may include bone-density scanning. Thirteen of the 14 NHS boards in Scotland have a Fracture Liaison Service, or equivalent, in operation.
Although a range of opportunities present to identify a person with increasing risk, success depends on the action taken as a result; risk identification needs to be linked with an outcomes-focused conversation and/or access to the right information and level of support.
Outcome 8
People receiving a proportionate response at the time of a fall that minimises harm and enables the best possible recovery.
What we know and where we are now
Older people and carers need better information about what to do at the time of a fall, in terms of how to get up from the floor, how to assist another person safely from the floor, and who to call for assistance. The prospect of getting stuck on the floor is a source of considerable anxiety for many older people. We need to ensure this information is readily available.
The Scottish Ambulance Service is the main responder if a person is injured or needs urgent clinical care. Responsibility for responding if someone is uninjured but needs assistance to get up varies across the country. This is important because a long lie on the floor can lead to serious complications for a person with frailty.
Technology enabled care provides a means of summoning help for many, with 20% of people aged 75 and older in Scotland using a telecare service. Uptake, however, varies widely across the country. Some local authorities use mobile responders who can provide practical help in an emergency on a 24/7 basis, but no response or only a limited response (such as out-of-hours only) is provided in around half of local authority areas due to staffing and geographical limitations. Service users in these areas depend on volunteers (friends and family) acting as nominated keyholders to provide a response, which can be problematic for some people.
Commitment 13
Our Technology Enabled Care Programme will work with the Scottish Ambulance Service, NHS 24 and other local and national partners to develop and test guidance for implementing sustainable response services.