Falls (health and wellbeing needs in South Tyneside)

A. Assets available to respond to an actual fall, or worries about falls:

NHS Primary care

General Practitioners: Provide the bulk of primary care, screening and prevention education to local residents. If someone has a fall or is worried about falling the GP is the gateway to the relevant specialist assessment, treatment or therapy from NHS services following a rigorous consideration of a wide range of possible underlying risk factors as per the Falls Assessment and Prevention pathway on Health Pathways. ^[34]

The NICE Guidance Falls in Older People ^[3] specifies:

"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."

The GP will then determine which of the following services would benefit the person:

Community Falls Service: A multi-disciplinary team of allied health professionals including nursing and physiotherapists working across South Tyneside and Sunderland with outpatient falls clinics, public education and rehabilitation including vestibular assessment (Issues with vestibular system commonly causes symptoms such as vertigo, dizziness, spinning, nausea and vomiting, light-headedness, ringing in the ears (tinnitus), double vision, or impaired balance). People living in care homes or unable to leave their home can be seen in their own home as needed.

Falls and Syncope (fainting) Service: Care of the Elderly Consultant Physicians who provide medical and tilt-table clinics (measuring impact on blood pressure when lying or standing) on an outpatient basis at South Tyneside District Hospital. They also provide a clinical resource to the Community Falls Service.

South Tyneside Community Therapy Team (formerly known as Acute Intermediate Care Therapy Team): A service comprising Occupational Therapists, Physiotherapists, and Therapy Assistants, who work with housebound people who are unable to access community or hospital‑based therapy services. For information or to complete a referral for an assessment, phone the team on 0191 283 1593 or complete a managed referral on EMIS to South Tyneside Community Therapy Team. Services are available 8:30am to 4:30pm, 7 days a week, all year. Phone line is covered 8:30am - 4:30pm Monday to Friday. 

The team:

• Prevents unnecessary admissions to hospital. 
• Maximises independence through rehabilitation in the individuals own home / 24 hour care. 
• Has specialist skills and expertise to assess physical and social needs at home. 
• Assessment of hand contractures in housebound patients and those in 24 hour care.
• Receives referrals from health and social care professionals.
• Provides a comprehensive therapy service into Haven Court Residential Rehabilitation Unit.
• Referrals which are just for equipment (not mobility aids) and do not require any rehabilitation should be sent to Adult Social Care Let's Talk Service on 0191 424 6000 or email LetsTalk@southtyneside.gov.uk.  

Mobility assessments for walking aids: GPs can order walking sticks and walking frames for patients from the Living Better Lives Resource Centre. If GPs feel the person needs an assessment of their mobility, referral should be made to Physiotherapy. If the person is unable to attend outpatient / community-based clinic the referral should be made to Community Therapy Team.

Haven Court: the CCG and Local Authority commission short term rehabilitation support in Haven Court either following a hospital stay or to prevent admission to hospital where the person would benefit form a short-term rehabilitation plan to regain independence and confidence. It provides a safe environment to older adults with varying levels of supervision and / or assistance

Secondary care:

South Tyneside District Hospital:

• Provides acute care to people who have fallen.
• Through the fracture liaison nurse signposts to appropriate services and providers upon discharge.
• The physiotherapy department, based at Moorlands Day Unit, provides rehabilitation and exercise classes.
• Assessment and treatment for osteoporosis delivered by the Osteoporosis Service. Treatment generally consists of prescription of calcium and vitamin D and an activity prescription for weight bearing exercise.

B.  Assets to prevent falls:

NHS Primary Care

Eye care and opticians:

People over 60 receive sight tests on the NHS and are not just about 'getting glasses'. Reduced vision will impact a person's confidence for walking and moving around. Studies have shown that people with glaucoma and Macular degeneration tend to have different gait patterns and raise their feet differently for steps. A study in Australia in 2010 demonstrated that older adults who wear bifocals or varifocals have twice as many trips as people with separate reading and distance lenses. ^[35]

The Local Optical Committee (LOC) provides further education and support on the connection between vision loss and falls through direct links with Vision and Hearing Support and as members of the multi-agency Falls Prevention Steering Group.

Irreversible vision loss is strongly associated with falls risk, highlighting the importance of early diagnosis and treatment of eye disease. Central visual impairment due to age-related macular degeneration, one of the main causes of irreversible visual loss in older adults, increases falls risk, particularly injurious falls ^[36] [37]. Visual field defects also increase falls risk ^{[38] [39] [40] [41]}, likely due to impaired detection and avoidance of obstacles/ hazards in the periphery. Severe binocular field loss was found to be associated with a 1.5x increase in falls in older women ^[38], while another study indicated that visual field loss was the leading visual risk factor for falls. ^[41] Importantly, field loss in the inferior region has been linked to increased falls risk, potentially because it provides important visual information for foot placement and obstacle detection when walking. ^[42] Research is ongoing as to how best to advise patients to cope with visual field loss, but in the meantime eye care interventions that reduce the rates of reversible and irreversible visual impairment could significantly reduce the number of falls occurring in older people.

Primary care - Opticians

Opticians (Optometrists and Dispensing Opticians) have the knowledge and expertise to discuss both health implications, which may increase the risk of eye disease and falls prevention and how methods of correcting visual impairment may impact on falls risk. Their primary care role in public health prevention is often over-looked, due to the unique nature of the relationships they build with their patients they are in a position to identify those at risk of falls or declining frailty. Many of the preventative measures to prevent falling such as healthy diets and exercise also aid to prevent or slow down eye disease.

People over 60 are entitled to NHS funded Sight Tests, these include eye health checks and are advised at least every 2 years.  Eyesight issues often have no symptoms and people find ways to compensate for reduced vision. If the person has been diagnosed with a long-term progressive eye condition they will experience gradual reducing vision even if they are receiving treatment which will slow down the deterioration. Therefore, this will impact their confidence for walking and moving around. Studies have shown that people with glaucoma and Macular degeneration tend to have different gait patterns and raise their feet differently for steps etc.

Domiciliary (at home) sight tests are funded by the NHS for anyone who cannot attend an optician independently. A list of Domiciliary providers can be found at LOC: Domiciliary providers.

The perceived cost of glasses can often be a barrier to people accessing Sight Tests. People claiming Guaranteed Pension Credits are entitled to financial help towards the cost of their glasses funded by the NHS other people on a low income can obtain HC1 forms to claim for help towards the cost. More information can be found at NHS: Free NHS eye tests and optical vouchers.

Northumberland, Tyne and Wear Local Optical Committee (LOC) supports all the optical practices within its footprint and acts as a link between them and the wider NHS. They have provided training to both the optical workforce and wider NHS about the links between vision and falls prevention. Find more information at LOC: Aims of the LOC.

Podiatry: Any foot problems can result in changes to one's gait and / or balance.  Podiatry services can address any of the following issues to improve gait, balance and reduce the risk of falling:

• Swelling, redness, heat to any area of the feet
• Any open wounds, especially if a blister or cut is healing very slowly
• Constant, persistent, pain in the feet-this may be affecting their ability to carry out everyday activities
• Any extremely thick and painful areas of hard skin or corns
• Overgrown, thickened or painful toenails

Referral is generally through one's GP surgery or the Falls Service.

Social prescribers based in GP practices (and in some voluntary organisations) can support people to connect with organisations and activities to enable them to be physically active.

Local Authority Provision

• Adult Social Care provides:
  • Information and advice about remaining independent in your own home including the provision of equipment
  • Carry out an assessment of need (Care Act 2014) to identify any support needs and develop a support plan to meet those needs
  • Occupational Therapy assessment to support with assessment of needs in relation to moving around, access and egress from their home and support with bathing.
  • Age Concern are commissioned to provide Handyperson Services to address install minor works e.g. grab rails 

Assistive Technology Service provides information and advice about a range of assistive technology that can support people to live independently both inside and outside of the home. The equipment available also helps reduce risks as well as prevention of and subsequent detection of a fall. Provide a monitoring service and can assist if the person has a fall (charges for this service may apply).

Equipment: The Living Better Lives Resource Centre and local authority occupational therapists can assess needs and provide equipment to residents that improve function and safety both inside and outside their home. We have an on-site independent living suite where equipment and assistive technology can be demonstrated in a home like environment.

Leisure Centres at Haven Point; Hebburn Central; Temple Park Centre; Jarrow Focus; Monkton Stadium and Jarrow Focus offer a range of programmes and facilities to promote physical activity which include strength and balance activities.

Escape Pain classes are offered in the community via Age Concern Tyneside South, and via leisure facilities at Haven Point and Jarrow Focus, for patients / residents with hip and knee pain/osteoarthritis, however capacity is limited and the back-care pathway is yet to be established / commissioned.

Extra Care Facilities: Provide safe home environments to older adults to meet eligible care and support needs with on-site care team where needs cannot be met in their original / own home.

Substance Misuse Treatment Services (STARS - South Tyneside Adult Recovery Service): provides support and treatment to adults in South Tyneside with drug and alcohol problems to become free from their dependence. There is emerging evidence of the role that alcohol plays in the problem of falls.

Community Provision

Transport: there are a range of Travel passes ^[43] to support people remain independent and access social and leisure activities.

Nexus: Provides public transport throughout the region andprovide free bus travel for older people and people with disabilities. Eligibility criteria applies and is confirmed by the Local Authority.They have various schemes and concessions to improve access and reduce social isolation for residents including the Bridge Card Scheme which alerts operators to passengers requiring additional assistance to ensure safe travel.

They also run the TaxiCard scheme - providing reduced rates for taxi journeys by giving a credit to people.

Age Concern Tyneside South: Provides services and activities which maintain older people's choice and control, improves well-being and enable healthier and happier ageing. Our support includes:

• Handypersons Service (Level 3 Trusted Assessor) supports people to live independently at home, providing Home Assessments to reduce risk of falls, identify hazards and keep homes warm and secure: e.g. loose carpets, lino, rugs or trailing wires, low light levels such as blocked windows and broken lightbulbs, cluttered walkways, especially steps and stairs, tripping points such as raised thresholds and overgrown paths and access routes.
• Recommending and carry out actions to remove or reduce most hazards e.g.: Install small measures such as handrails, banister rails and key safes; identify ways to save energy and money on bills including fitting free measures such as draft excluders and energy saving lightbulbs.
• An onsite gym for anyone age 50+ (offering induction to the equipment before starting)
• Home from Hospital (Level 2 Trusted Assessor) support available 7 days a week from trained Support Workers offering short term support in regaining confidence and independence with practical day to day tasks such as shopping, getting out and about, attending appointments, going for a walk, collecting prescription etc. Supporting people to prevent an admission or readmission into hospital.
• Variety of Exercise and activity classes around the borough that focus on strength building and balance including Escape Pain, Balance and Stability, Line Dancing, Dancercise, Seated Exercise, Walking and Strolling Groups. Transport may be offered to support access where appropriate.
• Classes and groups that increase social engagement e.g., Lunch and Breakfast Clubs, Cuppa and Chat, Hobbies-based groups.
• Information and Advice team offering guidance and support with benefits, debt, form-filling, energy tariffs, housing, care and advocacy, lasting power of attorney and blue badge applications. 
• Individualised holistic assessments are offered across all services
• Support to vulnerable clients in the event of Severe Weather Level 3 alert
• Link Workers (some specifically aligned to Mental Health Services) supporting people to attend and access activities and make social connections
• Digital Inclusion tutoring / tablet loans to enable people access to video link appointments and assessments
• Weekly Wellbeing telephone calls to support isolated older people upon discharge from hospital.

Tyne and Wear Fire Service:Conduct Safe and Well checks within homes to identify any fire and lifestyle associated hazards, in order to reduce the risk of having a fire or an accident at home. They have been trained to identify people at possible risk of falling and are able to provide primary falls prevention advice and refer into the Community Falls Service.

Vision and Hearing Support (formerly Sight Service)delivers interventions for people who are blind, partially sighted, Deafblind, Deaf or hard of hearing. Their support includes:

• Person centred assessments and targeted plans to help individuals achieve their goals.
• Relevant information, advice and guidance to make sure all needs are met, either by the Service or appropriate referrals.
• Home assessments to promote safe and independent living. The assessment is carried out by a qualified Rehabilitation Worker for Vision Impairment and improvements can vary from colour contrast, lighting, layout and independent living skills.
• Mobility and orientation skills including long cane training. Delivered by a qualified rehabilitation worker, this is centred around relevant route planning and promotes confidence in and outside of the home.
• Specialist aids and equipment are provided under the Care Act 2014 to support independent living. This can range from daylight bulbs and liquid level indicators to digital and Artificial Intelligence devices.
• Provide a quality assured Living Well with Sight Loss programme for people - a peer led discussion group focussing on the impact of sight loss and various coping strategies - emotional, mental and practical.
• Provide sighted guide training, deaf aware and a chargeable Vision Impairment training.
• Grant funded activities are subject to external funding but include:
  • a counselling service delivered by a qualified Counsellor with lived experience.
  • a digital support team and equipment library to demonstrate emerging technologies and how they can help access services and keep in touch with people. Staying safe online and cyber security is embedded within this programme.

Community Associations, not for profit and for-profit providers: At the time of writing a number of groups provide ways for older adults to keep active and fit including activities such as Walking Football; Pilates; yoga; gym sessions, dance classes and others. It is beyond the scope of this document to identify and track each of these individual providers however they play a significant role in supporting the population be fit, well, and engaged. 

LEAP Groundwork and The Green Doctors are a Local Energy Advice Partnership (LEAP) partner.

For people who are eligible, LEAP provides a free home visit from a qualified Home Energy Advisor.

They will:

• check cheapest energy tariffs.
• install free simple energy saving measures.
• give energy efficiency hints and tips and ensure heating systems are set keep people warm and save money.
• arrange a free telephone advice service to help with benefits, debt and other money problems.
• refer for further energy efficiency improvements, such as loft insulation or a new boiler.

Housing

There is a range of different kinds of housing which may be suitable when someone's home cannot be adapted to manage or reduce the risk of falls. This ranges from down-sizing to smaller properties or single floor living. Other housing options include sheltered housing with warden support (though South Tyneside Homes) and extra care housing where someone has care and support needs and would benefit from the immediacy of care workers to provide support (accessed through Adult Social Care).

Multi-Agency Fall Prevention Group

A joint effort between South Tyneside and Sunderland Foundation Trust, Public Health, Adult Social Care, the Joint Commissioning Unit, ACTS and a range of other stakeholders meet twice yearly to address the needs and issues relating to fall prevention.

Education and information is provided on various levels from each of the providers named above. The Multi-Agency Falls Group agreed to use Saga's guide to Staying Steady - the Get Up and Go booklet ^[44] universally amongst all providers to ensure consistency of messages. The NHS and Public Health have provided the "Don't Fall For It!" campaign with articles on fall prevention in the South Tyneside Residents' newsletters. Education of Health and Social Care staff is undertaken by the Community Falls Service on an as needed / requested basis.

The Northeast Regional Falls Group

This is a group of health professionals from across the Northeast of England who meets quarterly to share information, research findings, guidance, and innovation. The Community Falls Service is represented and has a seat as deputy chair of the quarterly meetings.

Evidence for interventions

NICE Clinical Guideline 161: Falls in Older People ^[3] has been the UK guidance of falls prevention to date. It is currently in the process of review and update with an update due in 2023. South Tyneside and Sunderland NHS Foundation Trusts are registered stakeholders and will be commenting on any updates made available. The partner to this publication is NICE Quality Standard 86 ^[28] which measures how well a community is meeting the guidance in CG161.

The current guidance clearly states recommended interventions as follows:

Case / risk identification

Older people in contact with health and social care 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 reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance.

Multifactorial falls risk assessment

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, which may include the following: falls history, gait, balance and mobility, and muscle weakness, osteoporosis risk, perceived functional ability and fear relating to falling, visual impairment, cognitive impairment and neurological examination, urinary incontinence, home hazards, cardiovascular examination, and medication review.

Multifactorial interventions

All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention In successful programmes the following specific components are common: strength and balance training, home hazard assessment and intervention, vision assessment and referral, medication review with modification / withdrawal.

Following treatment for an injurious fall, older people should be offered a multidisciplinary assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function.

Strength and balance training

Those most likely to benefit are older people living in the community with a history of recurrent falls and/or balance and gait deficit. A muscle-strengthening and balance programme should be offered. This should be individually prescribed and monitored by an appropriately trained professional.

Carande-Kulis, et al in 2015 ^[45] demonstrated significant return on investment for interventions ranging from the Stepping Out programme (64% ROI) to Otago exercise programme (127% ROI) to Tai Chi (509% ROI).

Extended care settings

Multifactorial interventions with an exercise component are recommended for older people in extended care settings who are at risk of falling. Vlaeyen et al reviewed numerous studies in 2015 ^[46] and were able to demonstrate a 21% decrease in recurrent falls from multifactorial interventions in care homes.

Psychotropic medications

Older people on psychotropic medications should have their medication reviewed, with specialist input if appropriate, and discontinued if possible to reduce their risk of falling.

Cardiac pacing

Cardiac pacing should be considered for older people with cardioinhibitory carotid sinus hypersensitivity who have experienced unexplained falls.

Encouraging the participation of older people in falls prevention programmes

To promote the participation of older people in falls prevention programmes the following should be considered; Healthcare professionals involved in the assessment and prevention of falls should discuss what changes a person is willing to make to prevent falls. Information should be relevant and available in languages other than English. Falls prevention programmes should also address potential barriers such as low self-efficacy and fear of falling, and encourage activity change as negotiated with the participant.

Practitioners who are involved in developing falls prevention programmes should ensure that such programmes are flexible enough to accommodate participants' different needs and preferences and should promote the social value of such programmes.

Education and information giving

All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls assessment and prevention.

Individuals at risk of falling, and their carers, should be offered information orally and in writing about: what measures they can take to prevent further falls, how to stay motivated if referred for falls prevention strategies that include exercise or strength and balancing components, the preventable nature of some falls, the physical and psychological benefits of modifying falls risk, where they can seek further advice and assistance, how to cope if they have a fall, including how to summon help and how to avoid a long lie. The SAGA Falls Prevention Get Up and Go booklet ^[47] could be used for this purpose.

Public Health England echoes these recommendations in their publication, Falls: applying All Our Health (2015) with further emphasis on:

• Training of service providers on fall prevention
• Promotion of physical activity
• Examining primary care and its role in prevention of falls
• Making it easier for older adults to be active and connected socially
• Public education on fall prevention
• Ensuring inpatient providers are following established guidance and recommendations.

Emerging Evidence:

• The bulk of evidence in the literature supports the actions outlined in NICE161 above. There is an updated reference section at the end of this document.
• There is emerging evidence of the role that alcohol plays in the problem of falls. This was not previously addressed but warrants attention moving forward.
• There is now decades of evidence around the presentation of dizziness and the correlation to falls. This presentation is not mentioned at all in the NICE guidance however, like alcohol, we believe we should respond to the peer reviewed literature in addition to published guidelines.
• There is recent debate around the actual effectiveness of multi-factorial interventions with the STRIDE study from the USA and a study from Bournemouth. The British Geriatrics Society has clearly addressed this confounding evidence and states:
  • It is recommended that there should be no changes in clinical practice or policy, or strategic, commissioning or service provision decisions relating to multifactorial falls prevention interventions made on the basis of the July 2018 Cochrane Library systematic review 'Multifactorial and multiple component interventions for preventing falls in older people living in the community' and the September 2018 systematic review 'Interventions for preventing falls in older people in care facilities and hospitals'. These suggest that there is less certainty as to the effectiveness of multifactorial interventions than previously thought, due to the quality of the available evidence largely being rated as low or very low. However, while the emerging evidence base is being reviewed, clinical assessment to identify falls risk factors, including the presence of medical conditions that increase risk and the delivery of interventions that reduce identified risk, should continue.

Alcohol and falls:

The link between alcohol and falls is complex and evidence is mixed, although there is emerging evidence to suggest alcohol may increase the risk of falls, and lead to more severe injury, in some populations.

Older adults who take common medications may be more likely to fall and be injured when they drink alcohol. ^[48] Alcohol-related falls are more often associated with severe craniofacial injury. ^[49]

The volume of alcohol sold and the proportion of adults who drink at harmful levels has also increased nationally as a result of the COVID-19 pandemic. ^[50]

In South Tyneside, alcohol-related admissions in over-65s are significantly higher than the rest of England at 1,375 per 100,00 population (2018 / 19), and slightly higher than the regional average of 1,270 per 100,000. Alcohol-related admissions in women over 65 have increased significantly since 2016 / 17 when the South Tyneside rate was statistically similar to England. The 2018 / 19 rate of 1,030 per 100,000 is the fifth highest in England. ^[51]

Views of the public:

When the last health needs assessment on falls was completed in 2012, a small survey of people's beliefs and attitudes towards falls was conducted in the Viking Centre shopping facility in Jarrow and in the homes of housebound individuals served by the Intermediate Care Team.

The survey showed the following:

• Many people are concerned about falling, but feel it is a natural and possibly unavoidable aspect of getting older.
• Falls may be underreported due to the stigma attached.
• One-third of community active and over one-half of homebound people reported having a fall.
• Only one-third of those who fell sought help afterwards.
• Those able to access the community reported:
  • More regular exercise
  • More options to be active
  • More isolation than those unable to access the community.
• Those unable to access the community reported:
  • Lower knowledge of their own medications
  • Fewer options to be active and less exercise
  • Limitations to activity 
  • Less concern about the effects of alcohol
  • More falls, but also that falling need not be part of getting older.

This survey was repeated with a slightly different audience in 2021, via a series of community consultation events hosted by Age Concern Tyneside South:

In 2012 a survey was taken amongst random people shopping in the Viking Centre in Jarrow and on King Street in South Shields. They were asked the above questions to obtain an idea of their perceptions on the topic of falling. The survey was repeated this year with attendees to events at Age Concern Tyneside South. Although similar in age group, there are some important points to note about the other differences in demographics. The survey in 2012 captured mostly the views of people in postcode NE32 with some others from NE33. The current survey captures opinions from a wider variety of locations in South Tyneside. The 2012 survey also captured people of the general public whereas the current survey captures people willing and able to attend events outside their homes. This could impact upon the results either favourably or unfavourably.

Discussion:

It appears there has been a great deal of positive change in the past decade with nearly all questions having an improved response. There are three areas of concern where knowledge / opinion has deteriorated.

1. More people have stopped doing things because they fear they might fall over. It is worth wondering is this because they are more aware of risks or have they become more afraid? Question one notes that well fewer people are concerned about falling over in 2022. This also makes one wonder is it because of increased ability, decreased fear, decreased knowledge, increased inactivity, or some other cause? The combination of less fear with more inactivity would not be a favourable change.
2. More people feel isolated most times. This has the confounding factor of people having been shielding or isolating during the global pandemic. Isolation was forced upon many older adults in the UK. Would this be a valid comparison to 2012? Most likely it wouldn't be a fair comparison.
3. More people feel that a little alcohol wouldn't affect their walking or balance. This is profoundly troubling, particularly because the change is quite dramatically unfavourable.

Demographics:

In 2012, almost all the respondents were aged 65 or older. A much wider age range is represented in 2022. This is important because the 40 - 54 and 55 - 64 groups are the ones which will be our "older adults" in the decade to come. Their attitudes and how we respond to them will determine how well their needs are met.

The sex ratio is very different from 2012. In 2012 it was 47% male and 53% Female whereas in 2022 it is only 29% male and 71% Female.

As mentioned above, in 2012 47% of respondents were from NE32 whereas in 2022 there is greater heterogeneity of respondents from around South Tyneside.

Lifestyle:

Health Information Source:

In 2012, 70% of respondents said their primary source of health information was their GP surgery. This is vastly different from 2022 where only 38% said their GP was their primary source of information. 23% said they get their information online with 19% getting information from charity events or information. Leaflets, media, and family / friends accounted for 16% combined. This brings up multiple points:

• People appear to be more self-actualized in terms of actively seeking information rather than passively obtaining it from their local practice
• More people are accessing the internet than previously. This could be both positive and negative. Positive in that people are learning to educate themselves on health conditions but negative in that there is no control over the quality of the health information they are absorbing.

Internet Access:

• In 2012 only 9% of respondents accessed the internet regularly. In 2022 60% of respondents access the internet at least weekly. Again, this is a double-edged sword in that this increases the ways people can be reached for education and interventions, which is positive. Unfortunately, once again the control of the quality of information is lost.

Accessing the Community:

• In 2012 45% of respondents either drove or were passengers in their family car. That number has declined to 36% in 2022
• In 2012 25% of respondents used the bus primarily for transport. That had very little change at 23% for 2022
• In 2012 10% of respondents relied on taxis to get around. In 2022 that number had halved to 5%.
• New categories of transport appeared in 2022 as well including walking (20%), motorized chair or scooter (9%), and bicycle (2%).
• It would appear that generally older adults are finding more physical (and greener) ways of getting around.