Epidemiology of falls, fracture and osteoporosis in Bradford and
An estimated 28,411 people in Bradford and Airedale have
osteoporosis. Prevalence is highest in women and increases with
An estimated one in three people aged 65 and over and one in two
people aged 80 and over are likely to experience a fall at least
once a year – this is equivalent to 25,449 people in Bradford and
Only a relatively small proportion of fallers present to health
services: Yorkshire Ambulance Service responds to 3,696 fallers,
6,542 present to A&E and 1,246 are admitted to hospital as a
result of a fall.
Hospital admission rates increase with age;
An estimated 60% of people living in residential and nursing care
homes fall regularly and account for approximately 10% of all
hospital admissions where a fall is indicated;
The majority of falls occur in the home environment and are due
to tripping, slipping or stumbling;
Fragility fractures are one of the most significant consequences
of a fall – there are an estimated 2,559 fragility fractures in
Bradford and Airedale each year. Incidence of fragility again
increases with age;
There are approximately 452 hospital admissions as a result of
hip fracture each year, accounting for 36% of all admissions as a
result of a fall. Incidence of hip fracture again increases with age.
Falls are a major cause of disability and morbidity in Bradford and Airedale
with one in three people aged 65 and over experiencing a fall each year – this
increases to one in two in persons aged 85 and over.
The prevalence of osteoporosis and also general frailty increases with age, as
well as the prevalence of other long term conditions. The result of this is that
not only do the chances of falling increase with age, but the consequences of
falling are also more serious.
Recurrent falls are associated with increased mortality, increased rates of
hospitalisation, inability to carry out daily activities and higher rates of
institutionalisation. All of these consequences are further compounded by the
psychological effects, such as loss of confidence, increased fear of falling and
lower quality of life. Fracture is also a significant consequence of a fall; the
likelihood that a fall will result in a fracture increases with age and also with
decreasing BMD. Accordingly it is important to consider falls, fractures and
bone health at the same time.
This paper provides an overview of the epidemiology of osteoporosis, falls
and fracture in Bradford and Airedale with a view to informing the Falls and
Bone Health Strategy. Specifically the aims of this paper are to:
Describe the risk factors for osteoporosis and identify those persons in
Bradford and Airedale most at risk of developing osteoporosis;
Describe the risk factors for falls and identify those persons in Bradford
and Airedale most at risk of experiencing a fall;
Estimate the prevalence of osteoporosis in Bradford and Airedale;
Estimate the number of falls that occur in Bradford and Airedale each
Estimate the incidence of fracture in Bradford and Airedale.
What is osteoporosis?
Osteoporosis is a progressive, systematic skeletal disorder characterised by
low bone mass and micro-architectural deterioration of bone tissue, with a
consequent increase in bone fragility and susceptibility to fracture.
Bone formation exceeds bone resorption in youth, but by the third decade of
life there is a gradual loss of bone mass. Accordingly, osteoporosis is usually
an age-related disease. It can affect both sexes, but woman are at greater risk
because the decrease in oestrogen production after the menopause
accelerates bone loss to a variable degree.
The World Health Organisation has established diagnostic criteria for
osteoporosis based on the measurement of bone mineral density and defines
osteoporosis as a T-score of -2.5 standard deviations (SD) or below on dual-
energy X-ray absorbtiometry (DXA) scanning.
Table 1: Bone mineral density and osteoporosis
Normal BMD -1 SD or above
Osteopenia -1 to -2.5 SD
Osteoporosis -2.5 or below
Severe osteoporosis -2.5 SD or below with 1 or more
Osteoporosis is an important public health problem because as the disease
progressively reduces BMD, the risk of experiencing a fracture increases.
Risk factors for osteoporosis
A number of risk factors associated with an increased likelihood of developing
osteoporosis have been identified; these are often considered as one of two
types, modifiable and non-modifiable.
Table 2: Risk factors for osteoporosis
Non-modifiable factors Modifiable factors
Female sex Smoking
Caucasian origin Sedentary lifestyle
Family history of osteoporosis Weight loss or low BMI
In addition to the above factors, a number of clinical conditions and some
medications have been found to be associated with osteoporosis in adults1.
Chronic liver disease;
Inflammatory bowel disease;
Long term corticosteroid use;
Vitamin D deficiency.
Epidemiology of osteoporosis
It is difficult to estimate accurately the number of people in Bradford and
Airedale with osteoporosis; this is primarily because osteoporosis is
asymptomatic and is often only recognised when a person falls and sustains a
Published prevalence estimates vary, however, based of estimates from the
Royal College of Physicians2, an estimated 28,411 people aged 50 and over
in Bradford and Airedale have osteoporosis.
Despite discrepancies in the prevalence estimates, the published literature is
clear in that the prevalence of osteoporosis is higher in women than men
(woman are at higher risk than men as they have smaller bones and also
experience the menopause which accelerates the process of bone turnover)
and that the prevalence of osteoporosis increases rapidly with age3.
Table 3: Estimated number of persons with osteoporosis in Bradford
Age Prevalence Estimated number
50-69 15% 10,703
70-79 30% 9,542
80+ 40% 8,166
Source: Royal College of Physicians, 2009
A fall is defined as ‘an unintentional event that results in a person coming to
rest on the ground, or another lower level.’4
Everyone is potentially at risk from falling, however, although not an inevitable
result of ageing, older people are considered to be most at risk, both from
experiencing a fall and suffering from an injury that requires hospitalisation as
a result of a fall5.
Falls are a major cause of disability and a leading cause of mortality in
persons aged 75 and over in the UK6. Not only does the high incidence of falls
amongst older persons cause concern, but the combination of this high
incidence coupled with the high susceptibility to injury and requirement for
hospitalisation associated with falls in older persons, highlights the need to
prevent falls amongst older persons7.
Although most falls do not result in serious injury, the consequences of falling
or not being able to get up from a fall are significant and include:
Psychological problems such as loss of confidence;
Impaired mobility which may lead to social isolation and loneliness;
Increase in dependency and disability;
In some individuals the consequences of falling can result in injury such as
fractures – an estimated 5% of all falls result in fracture8. Hip fractures are
particularly common in older persons; more than 95% of hip fractures in
persons aged 65 and over are the result of a fall.
The National Service Framework for Older People9 included the specific aim
‘to reduce the number of falls which result in serious injury and ensure
effective treatment and rehabilitation for those who have fallen.’
Risk Factors for falls
A number of factors associated with increased risk of experiencing a fall have
been described in the published literature. Commonly such factors are divided
into those that are intrinsic and those that are extrinsic. Intrinsic factors are
those that are patient related; examples include old age, chronic disease,
muscle weakness, gait disorders, mental health problems and medication use.
The interaction of multiple risk factors may also have an additive effect.
The National Institute for Health and Clinical Excellence (NICE)7 has identified
a number of intrinsic factors that are frequently associated with falls – these
are slightly different for older persons living at home and older people residing
in communal establishments.
Table 4: Patient related factors associated with falls
Older people living in the Older people living in residential
Falls history Falls history
Gait deficit Gait deficit
Balance deficit Balance deficit
Mobility impairment Visual impairment
Fear Cognitive impairment
Source: NICE, 2004
In addition to those factors highlighted by NICE, research by Leipzig et al
found medication use to be an important risk factor for falls in both community
and residential establishment settings. In particular, benzodiazapines,
antidepressants, neuroleptics and cardiotonic glycosides were most often
associated with falls.
Extrinsic factors describe non-patient related factors and include
environmental hazards and activities associated with falls. In a review of the
literature, Connell 10 found that environmental hazards such as walking on
slippery or rough surfaces, obstacles, poor lighting or loose carpets can
create conditions likely to cause falls, particularly in older persons who may
already have intrinsic risk factors.
Connell10 also identified a number of risk factors associated with falls in
residents of community establishments; risk factors include use of bedrails,
inappropriate height and stability of seating such as toilets, wheelchair
breaking problems and obstacles created by mobility aids such as
wheelchairs and walking frames.
Epidemiology of falls in Bradford and Airedale
Estimating the number of people in Bradford and Airedale who experience
falls is problematic. Not all falls require hospitalisation; some falls do not even
require treatment (further, even when medical treatment is required, it may not
be sought) and therefore, hospital utilisation data does not provide an
accurate reflection of the true incidence of falls.
In order to better understand the epidemiology of falls in Bradford and
Airedale, hospital utilisation data was interrogated to provide a picture of
those fallers presenting to health services. However, recognising that such
data largely underestimates the incidence of falls, estimates of the incidence
of falls were also gleaned from the published literature and applied to the
Bradford and Airedale population – this provides a relatively crude measure of
the number of falls that occur, but that cannot be identified from health
Table 5: Overview of falls in Bradford and Airedale
Number per year
At risk population: older people aged 65+ 71,220
Estimated number of people experiencing at
least one fall
Estimated number of A&E presentations as a
result of a fall
Ambulance call outs as a result of a fall 3,696
Hospital admissions as a result of a fall 1,246
Recorded GP contacts as a result of a fall 498
Estimated number of falls
Evidence from the published literature can give an indication of the incidence
of falls amongst older persons in Bradford and Airedale. The Royal Society for
the Prevention of Accidents (ROSPA) estimates that one in three people aged
65 and over and one in two people aged 80 and over are likely to experience
a fall at least once a year. Based on these estimates, as many as 25,449
older persons in Bradford and Airedale are likely to fall each year. Given the
geographical distribution of persons aged 65 and over in Bradford and
Airedale, the number of falls is estimated to be highest in South and West,
followed by BANCA.
Table 6: Estimated incidence of falls in Bradford and Airedale, by GP
Alliance Estimated number of persons
experiencing a fall each year
City Care 3,595
South and West 7,943
Falls presenting to general practice
Persons aged 65 and over are the most frequent users of general practice;
accordingly, general practice is ideally placed to identify and respond to fallers.
Analysis of local data shows that in 2009/10, 498 persons aged 65 and over
were recorded as having a fall – this is equivalent to a rate of 699 per 100,000
population. This is low and is most likely a result of the under identification of
fallers in general practice and also under recording of those fallers presenting.
Falls resulting in ambulance call out
Ambulance services are often called as an emergency to assist older people
who have fallen. In 2009/10, there were 3,696 ambulance call outs as a result
of falls in persons aged 65 and over in Bradford and Airedale.
Emergency 999 calls to the ambulance service are prioritised into three
categories to ensure life-threatening cases receive the quickest response.
Category A: immediately life threatening. An emergency response will
reach 75% of calls within eight minutes.
Category B: serious but not immediately life threatening. An ambulance
will arrive within 19 minutes 95% of the time.
Category C: not serious or life-threatening. Performance requirements
are set locally.
In Bradford and Airedale, the majority of call outs as a result of a fall are
category B (48%), followed by C (41%) and A (11%). Of the 3,696 call outs,
three quarters are taken to hospital, with the remainder of patients treated at
Falls presenting to A&E
Because of the way in which A&E data is coded, it is not possible to identify
from records the number of fallers presenting to A&E. However, estimates can
be made from the published literature. In a study of over 800,000 hospital
presentations (admissions and A&E attendances) as a result of a fall, it was
found that on average 19.1% of A&E attendances resulted in hospital
admission; this percentage increased with age11. Applying these findings to
local hospital admission data, suggests that in the region of 6,452 A&E
presentations each year in Bradford and Airedale may be the result of a fall.
Table 7: Estimated numbers of A&E attendances as a result of a fall, by
Age Group Number of presentations to A&E
Source: Scuffham et al
Hospital admissions attributable to falls
The ICD-10 codes W00-W19 identify persons admitted to hospital as a result
of a fall. However, not all persons admitted to hospital as a result of a fall are
coded as such on presentation to hospital. Accordingly, additional ICD-10
codes can be interrogated to identify hospital admissions for falls related
injuries (for example, fracture of the femur) to provide a more complete picture.
Hospital admissions as a result of a fall were defined as those where a fall
was clearly identified (ICD-10 code W00-W19) or for fracture of femur (ICD-10
code S72). Hip fracture was chosen as it is estimated that almost all
admissions as a result of hip fracture are the result of a fall.
Between April 2009 and March 2010 there were 1,246 hospital admissions as
a result of a fall amongst persons aged 65 and over in Bradford and Airedale;
this is equivalent to a rate of 1,749 per 100,000 population aged 65 and over.
Of the 1,246 hospital admissions, 1,181 (95%) were identified as fallers, with
the remaining 65 admissions identified from falls associated injuries.
The hospital admission rate for falls in Bradford and Airedale has changed
little over the last five years, ranging from 1,643 admissions per 100,000
population aged 65 and over in 2005/06, to 1,749 admissions per 100,000
population aged 65 and over in 2009/10.
Table 8: Hospital admission rate, Bradford and Airedale 2005-2010
Hospital admission rate per
The hospital admission rate is significantly higher for women than for men; the
hospital admission rate for women is 2,181 per 100,000 population aged 65
and over, and 1,094 per 100,000 population aged 65 and over for men.
Age specific rates show that the hospital admission rates increase with age.
The rate of hospital admissions amongst persons aged 85 and above is 1.7
times higher than persons aged 80-84 and more than eight times higher than
for persons aged 65-69.
Table 9: Age specific hospital admission rates, Bradford and Airedale
Age Group Number Rate per 100,000
65-69 111 584
70-79 376 1,182
80-84 291 2,735
85+ 468 4,787
Hospital admission rates for falls are similar across Bradford and Airedale;
after adjusting for age there is no significant difference between GP alliances.
Figure 1: Directly age standardised hospital admission rates by alliance,
Bradford and Airedale 2009/10
Directly standardised rate per 100,000
Airedale Alliance South And West CityCare Alliance BANCA
* Data from independent practices has been excluded from the analysis due to the very small
1,158 people were responsible for the 1,246 admissions between April 2009
and March 2010. Of the 1,158 people admitted as a result of a fall on at least
one occasion in 2009/10, 226 (20%) had previously been admitted to hospital
as a result of a fall in the last five years.
The published literature suggests that the risk of falling is particularly high in
persons in communal establishments such as residential and nursing care
homes. NICE7 suggests that the incidence of falls in nursing homes and
hospitals is 2-3 times greater than the incidence in the community.
Furthermore, complication rates as a result of a fall are also significantly
higher. This is unsurprising since those persons requiring residential, nursing
or hospital care are most likely to be those that are frail as a result of physical
health problems or with cognitive impairment.
It is estimated that 60% of people living in residential and nursing care homes
falls regularly. Of the 1,246 hospital admissions as a result of a fall 115 (10%)
were persons residing in residential or nursing care homes in Bradford and
It is likely that this figure is not a true reflection of the actual number of falls
that occur in communal establishments – this is because it is likely that a high
proportion of falls that occur in communal establishment are managed in this
setting and, therefore, do not require hospital care.
As already highlighted, there are a large number of risk factors for falls,
furthermore, there are risk factors for increased morbidity as a result of a fall
(for example, osteoporosis). Of the 1,246 hospital admissions, 12% had a
diagnosis of dementia recorded, 11% a diagnosis of osteoporosis and 2%
visual impairment. Given the prevalence of these conditions in the 65 and
over population, these proportions are lower than expected and most likely
reflect coding practices. However, they may also be indicative of under
identification of risk factors for falls.
Where do falls occur?
Identifying where falls most commonly occur can inform falls prevention
activity. There is some evidence to suggest that persons aged less than 75
years old are more likely to fall outdoors than those aged 75 years and above.
Falls occurring indoors are thought to be associated with frailty, whereas falls
that occur outdoors are thought to be associated with compromised health
status in active persons.
Falls that occur in the community are most common during the day, with a
relatively small proportion of falls occurring at night, most likely reflecting the
time of day when persons are outdoors. Furthermore, evidence suggests that
the incidence of falls increases in the winter months12.
In Bradford and Airedale, an understanding of where falls amongst older
people occur can be gleaned from hospital admission data. The majority of
falls amongst older people in Bradford and Airedale occur at home
(accounting for 66% of hospital admissions as a result of a fall), followed by
residential institutions (14%) and on streets or roads (11%).
Figure 2: Place of occurrence of falls resulting in admission to hospital,
Bradford and Airedale 2009/10
Unknown place of fall = 263
Further analysis of the type of fall shows that in Bradford and Airedale,
tripping, slipping and stumbling are the most common types of fall (40%),
followed by falls from/on steps or stairs (16%) and falls from beds (10%). This
is unsurprising given that most falls that result in hospital admission in
Bradford and Airedale occur in the home or in residential institutions.
Figure 3: Type of falls resulting in admission to hospital, Bradford and
21% Tripping, slipping
Fall involving ice
Fall involing other
Fall from/on stairs
or steps Fall from bed
Unknown type of fall = 184
3. Morbidity associated with falls and osteoporosis
As stated previously, falls in older people are a major cause of morbidity and
mortality. Not only do falls result in admission to hospital but they also have
social, physical and psychological consequences. The consequences of falls
can be significant – life changing, and in many cases life threatening for older
people. Fall can precipitate loss of confidence, the need for regular social care
support at home, or even admission to a care home. Fractures of the hip may
require major surgery and inpatient care in acute and often rehabilitation
Older persons are often traumatised by a fall and as a result of a fall may
develop a fear of falling. It is estimated that around a third of older people
develop some fear after a fall and this in turn can increase the likelihood of
future falls leading to reduced engagement in activities and impacts on a
person’s quality of life12. This fear of falling can itself lead to a progressive
decline in mobility, together with associated complications (such as pressure
sores, incontinence, constipation and infections), depression and social
isolation. Many older fallers are unable to get up again without assistance and
any subsequent ‘long lie’ can lead to hypothermia, dehydration and
Fear of falling is not only a problem amongst fallers but is also an issue
amongst non-fallers. Some non-fallers may have an image of falls as
catastrophic events involving fractures, hospitalisation, and nursing home
admission13. Falls are likely to result in older people losing confidence and a
decrease in independence. Loss of confidence is a huge issue for older
people. In a recent survey, 80% of older people s said they would rather be
dead than experience the loss of independence and quality of life that results
from a bad hip fracture and subsequent admission to a nursing home.
Reduced mobility and functional decline can result from fall injuries, as well as
from loss of confidence in their ability to perform the basic activities of daily
living. Falls have been shown to result in a decline in function as a result both
of physical injury and of a loss of confidence14. It is important to note that not
all falls result in a physical injury, however, as previously discussed the
consequences of falling include social isolation, depression and helplessness.
Longer-term social and emotional support may be required to minimise any
loss of independence that may have arisen by the effects of the fall. This may
include provision of personal or domestic care services or introduction to
social activities to prevent social isolation and depression.
Fragility fractures are one of the most significant consequences of falls in
older people. The majority of fractures in older people occur as a result of a
fall from a standing height (known as a low trauma fracture) and often affect
the pelvis, wrist, upper arm or hip.
Epidemiology of fracture
Using GP data, in 2010/11, the incidence of fracture in persons aged 50 and
over in Bradford and Airedale was 1,508 per 100,000 population (equivalent
to 2,401 fractures). The most commonly recorded type of fracture was
fracture of the wrist, followed by vertebral fracture.
Figure 4: Fractures recorded on GP records by fracture site, Bradford
and Airedale 2010/11
Number of fractures
Incidence of fracture was shown to increase rapidly with age, with the
incidence of fracture in persons aged 85-89 more than double that in persons
Figure 5: Age specific incidence of fractures in Bradford & Airedale,
Incidence per 100,000 population
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99 >100
GP data represents the most complete source of data available on the
incidence of fractures locally (hospital admission data is likely to under
estimate the incidence of fractures as the majority of fractures will not lead to
hospital admission). However, this data should still be interpreted with caution
as it is likely that there will also be under ascertainment of fractures in this
dataset. For example, the number of hip fractures identified from GP records
is approximately 200 per annum, however, hospital admission data indicates
that this figure is closer to 500 – in this instance, hospital admission data is
likely to be a more accurate reflection of the number of hip fractures as hip
fracture always leads to a hospital admission.
In association with the Fracture Liaison Service, data on incident low trauma
fractures are collected comprehensively in Glasgow, enabling annual
incidence fracture rates to be calculated. Furthermore, the Glasgow data
provided an estimate of low trauma fractures, excluding high trauma fractures
from estimates. Age and sex specific rates were applied to the Bradford and
Airedale population to provide an estimate of the number of people
experience a low trauma fracture in a given year.
Based on the Glasgow data, there are an estimated 2,559 low trauma
fractures each year in persons aged 50 and over in Bradford and Airedale.
Incidence was found to be higher in females than males and increased with
Table 10: Number of people experiencing a low trauma fracture in a
given year by age and sex, Bradford and Airedale
Number of people experiencing a low trauma
50-54 108 146
55-59 120 196
60-64 119 234
65-69 77 187
70-74 84 235
75-79 86 231
80-84 68 251
85+ 80 337
Source: Gallagher et al15
Incidence varied by fracture site; for men and women the most common site
of low trauma fracture was the wrist, followed by hip and humerus. Data on
vertebral fractures was not distinguished from ’other’ fractures in the Glasgow
data, however, the authors acknowledged that the figures likely underestimate
the number of vertebral fractures due to the difficulties in identifying them.
Table 11: Number of people experiencing a low trauma fracture in a
given year by site of fracture, Bradford and Airedale
Number of people experiencing a low trauma
Wrist 164 567
Hip 136 368
Humerus 130 262
Hand/foot 97 210
Ankle 91 195
Other 123 215
Source: McLellan et al16
Epidemiology of hip fracture
Fractured neck of femur (hip fracture) is one of the most serious
consequences associated with falls – there is a significant increase in
mortality, with 30% mortality at 12 months. Furthermore, approximately half of
those persons who were previously independent become partly dependent
following a hip fracture, whilst one third become totally dependent.
Data from GP records estimates that there are approximately 200 cases of hip
fracture each year in Bradford and Airedale. However, because hip fracture
almost always leads to hospital admission, hospital admission data can be
used as a proxy for the incidence of hip fracture. Hospital admission data
shows that in 2009/10 there were 452 hospital admissions as a result of hip
fracture, accounting for 36% of all admissions as a result of a fall. This is
equivalent to an incidence of 635 per 100,000 population aged 65 and over.
The incidence of hip fracture increases with age; the incidence of hip fracture
in persons aged 85 and above is almost twice as high as that in persons aged
80-84 and almost five times higher than in persons aged 70-79.
Table 12: Age specific incidence of hip fracture, Bradford and Airedale
Age Group Number Rate per 100,000
65-69 22 115.8
70-79 131 411.8
80-84 109 1,024.4
85+ 190 1,943.5
4. Mortality associated with falls and osteoporosis
The mortality attributable to osteoporosis and falls is largely as a result of
fracture to the hip. Mortality associated with hip fracture is high – it is
estimated that 10% of people with a hip fracture die within the first month and
a third within 12 months. The majority of deaths are thought to be due to
associated co-morbidities and not simply a result of the hip fracture.
Figure 6: Mortality from hip fracture, 2007-2009 (pooled data)
Directly standardised mortality rate per 100,000
Males Females Males Females Males Females
England & Wales Yorkshire Bradford & Airedale
Source: National Compendium of Health Outcomes Database
Mortality from hip fracture is significantly lower in Bradford and Airedale than
in Yorkshire and England. However, whilst in Yorkshire and England mortality
is higher in women than men, the opposite is true in Bradford and Airedale,
with men experiencing a higher rate of mortality as a result of hip fracture than
women, however, the overlapping confidence intervals suggest that this
difference is not statistically significant.
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