Frail Elderly: The Physiotherapist's Role in Preventing Hospital Admission: Difference between revisions

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<div class="noeditbox">Welcome to "Contemporary and Emerging Issues in Physiotherapy Practice" Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice project. This space was created by and for the students at Queen Margaret University in Edinburgh, UK. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
<div class="editorbox"> '''Original Editor '''- [[User:Helene Slettebakk Gjerde|Helene Slettebakk Gjerde]], [[User:Alice Porteous|Alice Porteous]], [[User:Benedicte Aarseth|Benedicte Aarseth]], [[User:Matthew Laird|Matthew Laird]], [[User:Beth Donnelly|Beth Donnelly]]&nbsp;as part of the [http://www.physio-pedia.com/Contemporary_and_Emerging_Issues_in_Physiotherapy_Practice QMU&nbsp;Contemporary and Emerging Issues in Physiotherapy Practice&nbsp;Project]  '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
<p><b>Original Editors </b>- <a href="User:Helene Slettebakk Gjerde">Helene Slettebakk Gjerde</a>, <a href="User:Alice Porteous">Alice Porteous</a>, <a href="User:Benedicte Aarseth">Benedicte Aarseth</a>, <a href="User:Matthew Laird">Matthew Laird</a>, <a href="User:Beth Donnelly">Beth Donnelly</a>&nbsp;as part of the <a href="http://www.physio-pedia.com/Contemporary_and_Emerging_Issues_in_Physiotherapy_Practice">QMU&nbsp;Contemporary and Emerging Issues in Physiotherapy Practice&nbsp;Project</a>
== Introduction ==
</p><p><br />
A frail older person is in a condition that is associated with an increased risk of [[falls]], harm events, institutionalisation, care needs and disability/death<ref>GAjOS M, PERkOwSki R, KUjAwSkA A, ANdROSiUk JO, WydRA JO, FiliPSkA K. Physiotherapy methods in prevention of falls in elderly people. Journal of Education Culture and Society. 2016 Jun 28;7(1):92-102.</ref> [[Introduction to Frailty]]. Today, with life expectancy continuing to rise globally, there is an increasing number of frail elderly. The physiotherapist is well placed to screen for frailty and should be aware of the risk factors for frailty. If frailty is suspected referral to other professionals may be required. Frailty can be identified using the [[Clinical Frailty Scale]]. Identifying interventions that improve physical outcomes in pre-frail and frail older adults is of vital importance. <ref>Kidd T, Mold F, Jones C, Ream E, Grosvenor W, Sund-Levander M, Tingström P, Carey N. What are the most effective interventions to improve physical performance in pre-frail and frail adults? A systematic review of randomised control trials. BMC geriatrics. 2019 Dec;19(1):1-1.Available:https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1196-x (accessed 13.11.2022)</ref><ref name="FF1">British Geriatrics Society. Fit For Frailty: Part 1: Recognition and management of frailty in individuals in community and outpatient settings. http://www.bgs.org.uk/index.php/fit-for-frailty (accessed 12 Oct 2015)</ref>
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<h1> INTRODUCTION<br />  </h1>
<p>The physiotherapy management of older adults is not a new concept however, as healthcare advances, the average age of the population increases and it is suggested that the prevalence of frailty will multiply<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Karunananthan et al. 2009">Karunananthan S, Wolfson C, Bergman H, Beland F, Hogan DB. A multidisciplinary systematic literature review on frailty: overview of the methodology used by the Canadian Initiative on Frailty and Aging. BMC Med Res Methodol 2009;9:68.</span>. Subsequently, this causes further demand on the NHS; an already overstretched service. In response to this, there has been an increased drive to improve the efficiency of the management of frailty. There has been a shift of care from reactive to preventative strategies and a focus on providing early interventions to reduce costly unplanned admissions to hospital<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Edwards N. Community services - how they can transform care. London: The King's Fund, 2014.</span>. Furthermore, from our experience on clinical placements and following discussion with expert clinicians, it became apparent to us that final year students may lack knowledge and awareness around the holistic management of frailty. <br />  
</p><p>Consequently, this online learning resource has been created by a group of student physiotherapists and is tailored towards final year students and newly registered physiotherapists. This has been designed as an individual resource and should take 10 hours to complete.
</p>
<h3> Navigation  </h3>
<p>As mentioned above, this a 10-hour interactive learning resource. This means you will be working through various learning materials,&nbsp;including multimedia resources, learning tasks and a case study. <br />These have been tailored for you in order to facilitate optimal deep learning<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Biggs J. Teaching for quality learning at university. Buckingham: Society for Research into Higher Education and Open University Press, 1999.</span> whilst considering different learning styles<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Drago">Drago WA, Wagner RJ. VARK Preferred Learning Styles and Online Education. Management Research News 2004;27:1-13. http://www.emeraldinsight.com/doi/abs/10.1108/01409170410784211 (accessed 15 Jan 2016)</span>.<br /><br /><b>How much time to spend on each section:</b>
</p><p>1. Introduction: 30 minutes<br />2. Frailty: 1 hour <br />3. Policies &amp;&nbsp;Guidelines: 30 minutes<br />4. Introduction to the Physiotherapist’s Role: 30 minutes <br />5. The Comprehensive Geriatric Assessment: 3 hours <br />6. Physiotherapy Treatment: 3 ½ hours <br />7. Conclusion: 1 hour
</p><p>These time frames are intended as a guide and you should take adequate rest as required. Furthermore, this wiki has been designed to allow you to work through it in your own time and you are not required to complete it in one sitting.<br /><br />
</p><p><b>Learning tasks you will encounter and what they involve:</b>
</p><p><br />
</p>
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== Introduction to the Physiotherapist's Role ==
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Physiotherapists working with frail older people could play a role in promoting healthy ageing. Evidence shows that interventions to promote healthy ageing can be used to the delay the onset of frailty and reduce its adverse outcomes among older people<ref name="Cramm2014">Cramm JM, Twisk J, Nieboer AP. Self-management abilities and frailty are important for healthy aging among community-dwelling older people; a cross-sectional study. BMC Geriatrics 2014;14:28. http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-28 (accessed 11 Jan 2016)</ref>.&nbsp;  
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<p>In this section we will ask you to reflect upon your knowledge and skills<br />as well as previous experiences and new learning.&nbsp;<br />Consider using a reflective model of your choice when doing this. <br /><br />If you are unsure on how to structure your reflections, please access:
</p>
<ul><li>Melanie Jaspers’ book “Beginning Reflective Practice”<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Jasper">Jasper M. Beginning Reflective Practice. 2nd ed. Hampshire: Cengage Learning, 2013</span> or
</li><li>&nbsp;<a href="http://www.qmu.ac.uk/els/docs/Reflection%202014.pdf">“Reflection”</a>&nbsp;by Queen Margaret University's&nbsp;Effective Learning Service<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="QMU REF">Queen Margaret University. Reflection. http://www.qmu.ac.uk/els/docs/Reflection%202014.pdf (accessed 15 Jan 2016)</span><br /><br />
</li></ul>
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<td> <img src="/images/thumb/e/e5/Test_yourself_heading.png/500px-Test_yourself_heading.png" _fck_mw_filename="Test yourself heading.png" _fck_mw_location="center" _fck_mw_width="500" alt="" class="fck_mw_center" />
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<p>In order to facilitate learning, in this section we have created learning activities <br />which will include reviewing the presented material, answering questions<br /> and making mind maps.  
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<p><img src="/images/thumb/2/2c/Casestudy_heading.png/500px-Casestudy_heading.png" _fck_mw_filename="Casestudy heading.png" _fck_mw_location="center" _fck_mw_width="500" alt="" class="fck_mw_center" />
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<p>All information related to the case study will be presented here.<br />
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<p>In order to stay within the 10-hour timeframe and present a concise and <br />manageable learning resource for you, we have only presented what we <br />believe is the most essential evidence in relation to our topic.<br /><br />However, throughout this learning resource you will find sections called&nbsp;<br />“Resources”&nbsp;with additional reading you can access in relation to the topic <br />being&nbsp;discussed. <br />This reading is optional and is outwith the 10 hours you should allocate for<br />completing this learning resource. <br />
</p>
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<p><br />
</p><p><br />
</p><p><img src="/images/thumb/0/0e/Bloom_taxonomy_Wikimedia.jpg/190px-Bloom_taxonomy_Wikimedia.jpg" _fck_mw_filename="Bloom taxonomy Wikimedia.jpg" _fck_mw_location="left" _fck_mw_width="190" alt="" class="fck_mw_left" /><br /><br /><br />The sections below will outline the aims and learning outcomes of this resource.<br />These have been created using the appropriate levels of Bloom’s Taxonomy<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Krat">Krathwohl DR. A Revision of Bloom's Taxonomy: An Overview. http://www.unco.edu/cetl/sir/stating_outcome/documents/Krathwohl.pdf (accessed 15 Jan 2016)</span>&nbsp;for final year students and newly registered physiotherapists in order facilitate a high level of thinking and learning.<br />
</p><p>&nbsp;&nbsp;<br /><br /><br /> <br />
</p>
<h3> Aims  </h3>
<p><br />This learning resource aims to...
</p>
<ul><li>Provide you with an introduction to contemporary and&nbsp;emerging issues in the field of reducing hospital admissions in the frail elderly population and current management strategies.<br />
</li><li>Provide you with an evidence-based overview of the physiotherapists’ role in the prevention of hospital admissions in the frail elderly population by using a holistic, patient centred approach<br /><span>&nbsp;</span>&nbsp;
</li></ul>
<h3> Learning outcomes  </h3>
<p><br />By the end of this learning resource you should be able to...
</p>
<ul><li>Analyse the emerging issue of frailty in relation to the current context of health and social care in the UK.
</li><li>Critically evaluate the physiotherapist's role in the holistic assessment and treatment of frail individuals to prevent hospital admission.
</li><li>Evaluate the skills and knowledge gained from this resource, identifying appropriate application in clinical practice.
</li></ul>
<p><br />
</p><p>&nbsp;&nbsp;
</p>
<h1> FRAILTY  </h1>
<p>In this section we will define and contextualise the contemporary and emerging issue that is frailty, providing demographics and the current climate of health and social care.&nbsp;This section is in relation to learning outcome 1.
</p><p><br />
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* It has been suggested that physiotherapists could be stationed within hospital A&amp;E departments to undertake frailty and falls risk screening and make rapid decisions on whether the patient can safely return to their pre-admission destination. Frailty can be identified using the [[Clinical Frailty Scale]].<ref>Anaf S, Sheppard LA. Describing physiotherapy interventions in an emergency department setting: an observational pilot study. Accident and emergency nursing 2007; 15:1:34-9</ref><ref>Arendts G, Fitzhardinge S, Pronk K, Donaldson M, Hutton M, Nagree Y. The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study. BMC Geriatrics 2012; 12:8</ref>.
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* The [[Comprehensive Geriatric Assessment|comprehensive geriatric assessment]] also is a valuable tool for risk of frailty screening.
<p><img src="/images/thumb/4/46/Reflection_heading.png/500px-Reflection_heading.png" _fck_mw_filename="Reflection heading.png" _fck_mw_location="center" _fck_mw_width="500" alt="" class="fck_mw_center" />
* Falls prevention: Critical injuries leading to hospitalisation are more common in people over 65 and often preventable, with [[falls]] representing the most frequent and serious type of accident<ref name="Rothschild et al. 2000">Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Archives of Internal Medicine 2000; 160; 2717-28</ref> <ref name="Age UK 2010">Age UK. Stop Falling: Start Saving Lives and Money. London: Age UK, 2010.</ref>.  Falls risk increases with age and physiotherapists need to identify those at risk and provide timely intervention to prevent falls and subsequent injury<ref name="CSP Falls 2016">CSP. Physiotherapy works: Falls and frailty. http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/falls-and-frailty (accessed 8 Jan 2016)</ref><ref>Perracini MR, Kristensen MT, Cunningham C, Sherrington C. Physiotherapy following fragility fractures. Injury. 2018 Aug 1;49(8):1413-7.</ref>.
</p>
* '''Falls Reduction,''' in the frail''':''' exercise strength and balance has been shown to have the most effective outcomes in reduction of falls rates. As the majority of people who attend balance programmes relapse into old ways by six months, the physiotherapist should attempt to reinforce and encourage [[Adherence to Home Exercise Programs|adherence to their home exercise program]].
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'''Examples of Physiotherapy Interventions''' below:
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<td>
<p>Before commencing with this learning resource, take 20 minutes to reflect upon<br /> your current knowledge in relation to frailty. <br />Please write this down as we will revisit this at the end of the learning resource.  
</p><p>You might want to consider these questions:  
</p>
<ul><li>What is frailty?
</li></ul>
<ul><li>Why is it important to know about frailty?
</li></ul>
<ul><li>What do you think a physiotherapist’s role is in relation to frailty?
</li></ul>
<ul><li>How do you assess and treat a frail patient?
</li></ul>
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<p><br />
</p><p><br />
</p>
<h3> Definition  </h3>
<p>Frailty is defined as:&nbsp;<br />  
</p>
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* [[Strength Training|Resistance training]] : A significant component of age-related weakness and frailty is [[sarcopenia]]. Sarcopenia increases the risk of frailty and falls and in turn, hospitalization in the older adult population<ref>Sousa AS, Guerra RS, Fonseca I, et al. Sarcopenia and length of hospital stay. Eur J Clin Nutr 2015.</ref>. Resistance training has been suggested as a potential treatment for sarcopenia and its prevention. Resistance training is designed to improve muscular fitness by exercising a muscle or a muscle group against resistance<ref>Azeem K, Al Almeer A. Effect of weight training programme on body composition, muscular endurance, and muscular strength of males. Annals of Biological Research 2013; 4; 154-6</ref>.&nbsp;This could lead to improved function, increased quality of life and reduced likelihood for falls<ref>Burton LA, Sumakadas D. Optimal management of sarcopenia. Clin Interv Aging 2010; 5; 217-28</ref>. Resistance training programmes have consistently shown to improve muscle strength and mass in older adults<ref>Liu CJ, Latham NK. Progressive resistance training for improving physical function in older adults (Cochrane review). Cochrane Database Syst Rev 2009; (3); CD002759</ref><ref>Seynnes O, Fiatarone Singh MA, Hue O. Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. J Gerontol Ser A-Biol Sci Med Sci 2004; 59A; 503-9</ref>, however, it is questionable whether this transfers to reducing the risk of falling.
<td> “a biological syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiological systems and causing vulnerability to adverse outcomes"<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fried">1. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA. Frailty in Older Adults. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001 Mar 1 [cited 2015 Oct 11];56(3):M146. Available from: http://biomedgerontology.oxfordjournals.org/content/56/3/M146.full doi: 10.1093/gerona/56.3.M146.</span>.
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<p><br />The British Geriatrics Society (BGS) support that frailty is an age-related health state affecting multiple body systems<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BGS 2014">1. British Geriatric Society. British Geriatric Society. Fit for Frailty; 2014 [cited 2015 Sep 25]. Available from: http://www.bgs.org.uk/index.php/fit-for-frailty.</span> They describe Fried's <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fried 2001" /> phenotype model which concisely highlights the signs and symptoms of frailty. If an individual satisfies three out of the five criteria, they are diagnosed as being frail. However, if one or two criteria are met, they may be deemed as being pre-frail. This can act as an early warning sign for frailty <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fried 2001" />
</p>
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<caption> Table 1<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fried 2001" />
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<th scope="col"> Phenotype
</th><th scope="col"> Description
</th></tr>
<tr>
<td> Weight loss
</td><td> A drop in bodyweight of ≥10lbs/4.5kg in the past year or a drop in bodyweight of ≥5% in the past year.
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<td> Weakness
</td><td> Measured using grip strength. A result within the lowest 20 percentiles according to gender and BMI indicates a weakness.
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<td> Reduced energy/endurance
</td><td> Self-reported, can also be a predictor of cardiovascular disease.
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<td> Slowness
</td><td> The lowest 20 percentile of the population according to gender and standing height, 15ft walking time.
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<td> Low physical activity
</td><td> Based on reported activity levels translated into a kilocalories score. Again with a cut-off at the lowest 20 percentile for each gender.
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<p>The phenotype model can also be used as a quick screening assessment tool for frailty<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fried 2001" />. However, the Comprehensive Geriatric Assessment (CGA) is often preferred due to the multi-dimensional and holistic nature<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Martin 2010" />. Furthermore, in an international systematic review, it was concluded that prevalence of frailty increased when a psychosocial model of assessment was used as opposed to the biomedical phenotype<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Nice DDF" />. Therefore, it would appear the CGA is a more robust measure of assessment and as a result we have decided to use it to illustrate physiotherapy assessment. This will be described in further detail in the <a href="http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist's_Role_in_Preventing_Hospital_Admission#THE_COMPREHENSIVE_GERIATRIC_ASSESSMENT">assessment section</a>.<font color="#002bb8"><u></u></font>
</p><p><br />
</p><p>The physiotherapist should be aware of the risk factors for frailty. If frailty is suspected, referral to other professionals may be required.&nbsp;  
</p>
<table width="200" border="1" cellpadding="1" cellspacing="1">
<caption> Risk Factors<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Espinoza SE, Fried LP. Risk Factors for Frailty in the Older Adult. Clinical Geriatrics 2007; 15: 37-44</span>
</caption>
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<td> <img src="/images/b/bf/Risk_factors.png" _fck_mw_filename="Risk factors.png" alt="" />
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<p><br />
</p><p><br />
</p><p>Frailty is associated with poorer outcomes including disabilty and even death.&nbsp;Frailty and disability do not always co-exist, however they can be linked. In some cases, frailty may be a consequence of disability and in others, the causation of disability<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BGS 2014" />.&nbsp;  
</p>
<table width="200" border="1" cellpadding="1" cellspacing="1">
<caption> Frailty associations<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fried 2001" />
</caption>
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<td> <img src="/images/0/06/FRAILTY_IS.png" _fck_mw_filename="FRAILTY IS.png" alt="" />
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<p><br />
</p><p><br />
</p><p>It is important to note that although frailty is age-related, it is not an inevitability REF. In those aged 65 to 85, there is thought to be a 10% incidence of frailty. However, this figure increases to 25 to 50% in those aged 85 and over<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cleg et al 2013">Clegg A, Young J, Iliffe S, Rikkert M, Rockwood K. Frailty in elderly people. Lancet (London, England). 2013 Feb 12 [cited 2016 Jan 27];9868(381). Available from: http://www.ncbi.nlm.nih.gov/pubmed/23395245.</span><span style="line-height: 1.5em; font-size: 13.28px;">.</span>  
</p><p><br />
</p>
<h3> <u></u>Ageing Population<u></u>  </h3>
<p>The success of modern medicine has resulted in an increase in average life expectancy. When the NHS was founded in 1948, 48% of the population died before reaching the age of 65; that figure has now decreased significantly to 14%<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Office for National Statistics. Interim Life Tables, 2008–2010. http://www.ons.gov.uk/ons/rel/lifetables/interim-life-tables/2008-2010/index.html?format=hi-vis (accessed 28 Jan 2012)</span>. People are living longer, and as result, healthcare needs are required to transform.  
</p>
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* [[Balance Training|Balance Re-education]]: Balance disorders are very common in frail older adults and are a key cause of falls in this population. They are associated with [[Fear Avoidance Model|reduced level of function]], as well as an increased risk of disease and death. Most balance disorders comprise of several contributing factors including long-term conditions and medication side effects<ref>Rubenstein, LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 2006; 35.</ref>. See [[Balance Training]], [[Otago Exercise Programme]] ,[[Inoculation Against Falls: Balance Intervention Strategies]] , [[Reactive Balance Training|Reactive Balance Training.]]
<td> Estimated and projected age structure of the UK population 2012-2037<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Office for National Statistics. National Population Projections, 2012-based Statistical Bulletin. http://www.ons.gov.uk/ons/dcp171778_334975.pdf (accessed 28 Jan 2016)</span>
* [[Tai Chi and the Older Person|Tai Chi]]: Tai chi is a newly emerging exercise incorporating breathing, relaxation and slow and gentle movements with strengthening and balance exercises.<ref>NHS Choices. A guide to tai chi. http://www.nhs.uk/Livewell/fitness/Pages/taichi.aspx (accessed 8 Jan 2016)</ref>. See [[Tai Chi and the Older Person]]
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* [[Backward-chaining|Backward-chaining (see link)]]: Declining muscle function in older adults reduces their ability to rise from the floor following a fall and up to a half of all non-injured fallers are unable to get up<ref>Skelton D, Dinan SM, Campbell M, et al. Tailored group exercise (Falls Management Exercise – FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34; 636-639</ref>. When someone is unable to get up off the floor unassisted, the associated risks are far greater due to the complications that can occur from lying on the floor for an extended period of time – for example, dehydration, hypothermia, pneumonia, pressure sores, unavoidable incontinence and even death<ref name="Tinetti 1993">Tinetti ME, Liu WL, Claus EB, et al. Predictors and prognosis of inability to get up after falls among elderly persons. JAMA 1993; 269; 65-70</ref>. This inability to get up has a poor prognosis in terms of hospitalisation and mortality<ref name="Tinetti 1993" />, thus, a [[Long Lie|long lie]] is one of the most serious consequences of a fall. It was found that the backward-chaining method significantly enhances ability in rising after an incidental fall (20-40%)<ref>Zak M, Skalska A, Szczerbinska K. Instructional programmes on how to rise unassisted effectively after sustaining an incidental fall, designed specifically for the elderly: a randomized, controlled trial. Ortop Traumatol Rehabil 2008; 10; 496-507</ref>. This training falls within the physiotherapists domain.
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* [[Fear of Falling|Fear of falling]] (FOF): The prevalence of '''FOF''' in community-dwelling older adults ranges between 12% and 65%<ref>Legters K. Fear of falling. Phys Ther 2002; 82; 264-272</ref>. The physiotherapist is in an ideal position to steer the individual towards the route of confrontation and recovery as opposed to activity avoidance and disability<ref name="CSP Falls 2016" />. There is high quality evidence from two systematic reviews highlighting the benefits of treatment to improve confidence and reduce fear of falling<ref>Zijlstra GAR, van Haastregt JCM, van Rossum E. Interventions to reduce fear of falling in community-living older people: a systematic review.  J Am Geriatr Soc 2007; 55; 603-15</ref><ref>Rand D, Miller WC, Yiu J, et al. Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis. Age Ageing 2011; 40; 297-206</ref>. Recommended interventions include: exercise, including tai chi, and multi-component falls prevention programmes.
<td> <img src="/images/thumb/b/b9/AgeingPopulation.PNG/500px-AgeingPopulation.PNG" _fck_mw_filename="AgeingPopulation.PNG" _fck_mw_location="center" _fck_mw_width="500" alt="" class="fck_mw_center" />
* Multi-Component Falls Prevention Programmes: As most falls are multifactorial in origin, they usually require several interventions<ref>Hausdorff JM, Nelson ME, Kaliton D, et al. Etiology and modification of gait instability in older adults: a randomised controlled trial of exercise. J Appl Phys 2001; 90; 2117-29</ref>. Such interventions typically involve a combination of medication review and optimisation and education, environmental modification and exercise. This type of programme would be delivered by a multidisciplinary team in which the physiotherapist would be a key member.Physiotherapy treatments should combine strengthening, balance, backward chaining, tai chi and confidence building with education, tailored to each individual. Clinic-based group exercise or individual exercise in the home setting is suitable. <ref name="Gillespie 2012">Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community (Cochrane review). Cochrane Database Syst Rev 2012; (2): CD007146</ref>. For the greatest effect, exercise programmes should include a high level challenge to balance, alongside strength and walking training.  Programmes should be performed for at least two hours per week on an ongoing basis.<ref name="Sherrington 2011">Sherrington C, Tiedemann A, Fairhall N, et al. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 2011; 22; 78-83</ref>
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<p>As seen from the above graph, the percentage of the population aged over 65 is set to dramatically increase. As a result, it is thought that there could also be rise in the number of frail older adults in Scotland. Older adults and indeed frail adults are more likely to require healthcare resulting in a surge of pressure on the NHS; an already strained resource.
</p><p><br />If you would like to view an animated version of the projected population growth, watch the video below.<br />  
</p>
<table width="500" border="1" align="center" cellpadding="1" cellspacing="1">


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==  Benefits of Physical Activity in Frail Older Adults  ==
<td> UK population pyramid<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Rob Gamesby. UK population pyramid. fckLRhttps://www.youtube.com/watch?v=YILD506m9KU (accessed 28 Jan 2016)</span>
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<p>&nbsp;
</p>
<h3> Costs </h3>
<p>The next section will outline the length of stay and cost implications of frailty on the NHS.
</p><p><br /> <img src="/images/5/56/Total_NHS_Expenditure_2013.png" _fck_mw_filename="Total NHS Expenditure 2013.png" _fck_mw_location="right" alt="Department Of Health. Emergency admissions to hospital: merging the demand. http://www.nao.org.uk/wp-content/uploads/2013/10/10288-001-Emergency-admissions.pdf (accessed 16 Oct 2015)" class="fck_mw_right" />
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</p><p><br />
</p><p><br />
</p><p>The latest UK statistics regarding hospital admissions and costs, which have been published relating to the years 2012-2013. Within this time frame 2,211,228 people over 60 were admitted to hospital in an emergency <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH B">Department Of Health. Emergency admissions to hospital: merging the demand. http://www.nao.org.uk/wp-content/uploads/2013/10/10288-001-Emergency-admissions.pdf (accessed 16 Oct 2015).</span>.&nbsp;
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</p><p><img src="/images/4/46/Hospital_admissions_in_the_NHS.png" _fck_mw_filename="Hospital admissions in the NHS.png" _fck_mw_location="left" alt="Royal College of Physicians. Hospitals on the edge: the time for action. London: RCP, 2012." class="fck_mw_left" /><br />
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</p><p>70% of day beds are occupied by people over 65; this is more than 51,000 beds at any one time. 85 year olds on average stay in hospital eight days longer than their younger counterparts<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="RCP 2012">Royal College of Physicians. Hospitals on the edge: the time for action. London: RCP, 2012.</span>.<br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p><br />
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</p>
<table width="200" border="1" cellpadding="1" cellspacing="1" align="center">
<caption> Table 2<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH B" />
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<td>
<p><img src="/images/4/48/Table2Hospitalstay.PNG" _fck_mw_filename="Table2Hospitalstay.PNG" alt="" />
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<p>Most emergency admissions to hospital happen through accident &nbsp;and emergency departments<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH B" />.&nbsp;On average, a person over 85 spends 11 days in hospital<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="RCP 2012" />. If they pass through accident and emergency the total spent is approximately <b>£3241</b> per patient, per visit (Table 2).&nbsp;However, More than a 25% of over 85 year olds stay for 2 weeks and 10% stay longer than a month, when admitted as an emergency<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cornwall et al. 2012">Cornwall J, Levenson R, Sonola L, Poteliakhoff E. Continuity of care for older hospital patients: a call for action. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/continuity-of-care-for-older-hospital-patients-mar-2012.pdf (accessed 16 Oct 2015).</span> . This means that even more money is spent.
</p><p><br />
</p>
<table width="200" border="1" align="center" cellpadding="1" cellspacing="1">
<caption> Table 3<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="AGE UK" />
</caption>
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<td> <img src="/images/1/11/Table3Costfromfalls.PNG" _fck_mw_filename="Table3Costfromfalls.PNG" alt="" />
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<p><br />410,377 elderly persons were admitted to hospital due to a fall in 2013. Appropriate strategies could prevent this by up to 30%.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="AGE UK">Age UK. Later in life United Kingdom. http://www.ageuk.org.uk/Documents/EN-GB/Factsheets (accessed 16 Oct 2015).</span>
</p><p><br />
</p><p>The length of time frail people stay in hospital differs throughout the world. The UK is 16th shortest in the world when it comes to average length of stay in hospital<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">OECD. Health at a Glance, 2013. http://www.oecdilibrary.org/docserver/download/8113161e.pdf?expires=1444911042checksum=AAD68253A0B959E184ACCEE3FFE37481 (accessed 16 Oct 2015).</span><span style="line-height: 1.5em; font-size: 13.28px;">. However, admittance to hospital and the cost implications of long term hospital stays are similar worldwide to the UK</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="AHIW 2013" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Weiss and Elixhauser 2014">Weiss, A. J., And Elixhauser, A., 2014. Overview of Hospital Stays in the United States, 2012. Online from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-Hospitalizations-United-States-2012.jsp (accessed 4 Jan 2016).</span><span style="font-size: 13.28px; line-height: 1.5em;">.</span>
</p><p>The above statistics show that elderly people can spend a prolonged time in hospital, some of which may&nbsp;<span style="line-height: 1.5em; font-size: 13.28px;">not be necessary and is very costly for the NHS.</span>
</p>
<table width="200" border="1" align="center" cellpadding="1" cellspacing="1">


<tr>
Strength, endurance, balance and bone density is lost at a rate of 10% per decade, while muscle power reduces at around 30% per decade<ref name="BHF11">The British Heart Foundation National Centre for Physical Activity and Health. Interpreting the UK physical activity guidelines for older adults in transition. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/39/429/index.html (accessed 17 Oct 2015)</ref>. Sarcopenia is highly prevalent among older adults and has been identified as a risk factor for frailty<ref name="Jansen">Jansen FM, Prins RG, Etman A, van der Ploeg HP, de Vries SI, van Lenthe FJ, Pierik, FH. Physical Activity in Non-Frail and Frail Older Adults. PLoS One 2015;10:1-15. http://www.ncbi.nlm.nih.gov/pubmed/25910249 (accessed 27 Oct 2015)</ref>. [[Physical Activity in Older Adults|Being physically active]] slows down these physiological changes associated with ageing. Physical activity can also reduce the risk of falls, promote cognitive health and self-management of chronic diseases. It can also slow down the deterioration in ability to perform ADLs and maintain quality of life in older adults<ref name="Chou">Chou CH, Hwang CL, Wu YT. Effect of Exercise on Physical Function, Daily Living Activities and Quality of Life in the Frail Older Adults: A Meta Analysis. Arch Phys Med Rehabil 2012;93:237-44.http://www.sciencedirect.com/science/article/pii/S0003999311008173 (accessed 16 Oct 2015)</ref><ref name="Weeks">Weeks LE, Profit S, Campbell B, Graham H, Chircop A, Sheppard-LeMoine D. Participation in Physical Activity: Influences Reported by Seniors in the Community and in Long-Term Care Facilities. Journal of Gerontological Nursing 2008;34:36–43. http://www.healio.com/nursing/journals/jgn/2008-7-34-7/%7Bf65345f8-58ac-4381-a607-f663b5d57d53%7D/participation-in-physical-activity-influences-reported-by-seniors-in-the-community-and-in-long-term-care-facilities (accessed 7 Jan 2016)</ref>.  A meta-analysis<ref name="Chou" /> found that exercise is beneficial to improve balance, gait speed and abilities to carry out ADLs in the frail older adult population [[Physical Activity in Older Adults|,Physical Activity in Older Adults]].<ref>Yau L, Soutter K, Ekegren C, Hill KD, Ashe M, Soh SE. Adherence to Exercise Programs in Community-Dwelling Older Adults Postdischarge for Hip Fracture: A Systematic Review and Meta-analysis. Archives of Physical Medicine and Rehabilitation. 2022 Sep 1;103(9):1827-38.</ref>
<td> <img src="/images/a/a4/Additional_reading_heading.png" _fck_mw_filename="Additional reading heading.png" alt="" />
=== Physiotherapists Role in Promoting Physical Activity in Frail Older Adults ===
</td></tr>
<tr>
<td> <br />
<ul><li><a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551482">Australia's hospital at a glance</a>. This document explains about the length of stay&nbsp;<span style="font-size: 13.28px; line-height: 1.5em;">and </span><br /><span style="font-size: 13.28px; line-height: 1.5em;">hospital admissions in the frail population in Australia</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="AHIW 2013">AHIW. Australia’s hospitals 2013-14: at a glance http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551482 (accessed 20 Dec 2015).</span>. <br />
</li></ul>
<ul><li><a href="http://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-Hospitalizations-United-States-2012.jsp">An overview of hospital stays in the USA</a><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Weiss and Elixhauser 2014" />.
</li></ul>
<p><br />
</p>
</td></tr></table>
<p><br />
</p>
<h3> Relevance  </h3>
<p>Based upon the statistics and projections from the Scottish Government, over the next decade we will be faced with an ageing population with more elderly dependants. This means that there will be more of a financial strain on the NHS due to the prolonged hospital stays associated with age. This indicates a need for change avoiding costly hospital admissions unless absolutely necessary.<br />
</p><p>There are three ways the NHS can help reduce costs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH B" /><span style="line-height: 1.5em; font-size: 13.28px;">:</span>
</p>
<ul><li>Health and social care integration
</li><li>Preventative medicine
</li><li>Increased provision in the community. <br />
</li></ul>
<p>Health and social care integration aims to increase the effectiveness of care while keeping associated costs low. The Department of Health report that at least one third of emergency admissions could be dealt with in the community<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH B" /><span style="line-height: 1.5em; font-size: 13.28px;">.&nbsp;</span>Providing a free movement of information between hospitals and the community will allow increased communication and will reduce hospital admissions <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cornwall et al. 2012" />. <br /> <br />
</p><p>Preventative healthcare strategies include<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Nice DDF">Nice. Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset. https://www.nice.org.uk/guidance/NG16/chapter/1-Recommendations (accessed 22 Jan 2016).</span><span style="line-height: 1.5em; font-size: 13.28px;">:</span>  
</p>
<ul><li>Promoting healthy behaviours like physical activity<br />
</li><li>Reducing tobacco and alcohol use<br />
</li><li>Improving community facilities to promote physical activities.
</li><li>Raising awareness of frailty
</li></ul>
<p><br />
</p><p>The physiotherapy service is included in all three strategies to improve the efficieny of care. We shall now discuss some of the current guidance from a variety of sources to help you work towards reducing hospital admissions in the frail elderly population with the view to reducing the strain on the NHS budget.  
</p><p><br />  
</p>
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Due to their training and experience, physiotherapists are in a good position to promote health and well-being of individuals and the community through education on physical activity and exercise prescription<ref name="Verhagen">Verhagen E, Engbers L. The physical therapist’s role in physical activity promotion. Br J Sports Med 2009;43:99–101. http://bjsm.bmj.com/content/43/2/99.abstract (accessed 28 Oct 2015)</ref>.  Recently there has been a shift in the general public's health agenda towards the prevention of chronic conditions and enabling the ageing population to stay active and manage conditions in the community. This has required a change in the role of the physiotherapist towards addressing these issues through promotion of physical activity and other lifestyle changes<ref name="SM">Spijker J, MacInnes J. Population ageing: the timebomb that isn’t? BMJ 2013;347:1-5. http://www.bmj.com/content/347/bmj.f6598.full.pdf+html (accessed 11 Jan 2016)</ref>. When encouraging physical activity, physiotherapists should also aim to<ref name="BHFAW">The British Heart Foundation National Centre for Physical Activity and Health. Physical activity interventions for older adults. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/18/405/index.html (accessed 13 Jan 2016)</ref>:  
<td> <img src="/images/a/a4/Additional_reading_heading.png" _fck_mw_filename="Additional reading heading.png" alt="" /><br />
</td></tr>
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<td>
<ul><li><a href="http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/About-the-Bill">The Public Bodies (Joint Working) (Scotland) Act<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">The Scottish Government. About the act. http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/About-the-Bill (accessed 26 Jan 2016)</span></a>. This is the Act of Parliament that <br />has introduced health and social care intergration in Scotland
</li></ul>
<ul><li><a href="http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Outcomes">The National Health and Wellbeing Outcomes</a>. These are&nbsp;high-level statements of what <br />health and social care partners are attempting to achieve through the integration<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">The Scottish Government. National Health and Wellbeing Outcomes. http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Outcomes (accessed 26 Jan 2016)</span>.<br />
</li><li><a href="https://www.nice.org.uk/guidance/ng16">Dementia, disability and frailty in later life: mid-life approaches to delay or prevent onset</a><br />This NICE guideline covers mid-life approaches to delay or prevent the onset of<br /> dementia, disability and frailty in later life<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="nice DDF" />.<br />
</li></ul>
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<p><br />
</p><p><br />
</p>
<h1> POLICIES AND GUIDELINES  </h1>
<p>This section will present the most relevant guidelines and policies in relation to frailty and highlight the most useful points. <br />It will discuss the current context of frailty in healthcare, aiming to enhance your understanding in relation to learning outcome 1.
</p><p>&nbsp;<br />The policies and guidelines included in this learning resource are:<br />
</p>
<table width="400" cellspacing="1" cellpadding="1" border="1" align="left">


<tr>
*Identify fears and barriers to being physically active and provide solutions to overcome these  
<td> <img src="/images/8/8b/HIS.jpg" _fck_mw_filename="HIS.jpg" _fck_mw_location="left" alt="" class="fck_mw_left" />
*Provide ongoing support and encouragement
</td><td> <img src="/images/thumb/9/9d/THINK_FRAILTY.png/224px-THINK_FRAILTY.png" _fck_mw_filename="THINK FRAILTY.png" _fck_mw_width="225" _fck_mw_height="200" alt="" />
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<td> <a href="http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme.aspx">Healthcare Improvement Scotland<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="OPAC">Healthcare Improvement Scotland. Older People in Acute Care improvement programme. http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme.aspx (accessed 10 Nov 2015)</span></a>
</td><td> <a href="http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/frailty_report.aspx">Think Frailty<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Think Frailty">Healthcare Improvement Scotland. Improving the identification and management of frailty. fckLRhttp://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/frailty_report.aspx (accessed 19 Nov 2015)</span></a>
</td><td> <a href="http://www.bgs.org.uk/index.php/fit-for-frailty">Fit for Frailty<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="FF1" /></a>
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<p><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p>&nbsp;<br /><br />These policies and guidelines were chosen as they are the most current Scottish and British documents focusing on frailty in relation to managing frailty in the community and preventing hospital admissions. <br />If you intend to work, or are currently working outwith the NHS, you might be required to familiarise yourself with policies in relation to your workplace.<br /><br />
</p><p>&nbsp;
</p>
<h3> Older People's Acute Care Improvement Programme (OPAC)  </h3>
<p>As the number of older people is increasing, there is an increased need to ensure appropriate care for them. Improving older people's acute care is a priority for the Scottish Government and in 2012 “The Older People’s Acute Care improvement programme (OPAC)”<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="OPAC" /> was commissioned by the Scottish Government.
</p><p>The programme focuses on 2 key areas:
</p>
<ul><li>Frailty
</li><li>Delirium
</li></ul>
<p>In relation to frailty, the programme focused on identification and immediate management of frailty. This included screening for frailty and ensuring that older people who were identified as frail received a CGA within 24 hours of admission. <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="OPAC" /> <br />The document “Think Frailty” explored the strategies implemented in practice in more depth and will be discussed in <a href="http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist's_Role_in_Preventing_Hospital_Admission#Think_Frailty">Section 3.2</a>.&nbsp;<br /><br />Healthcare Improvement Scotland<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="OPAC report">Healthcare Improvement Scotland. Improving older people’s acute care: Impact report.http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/opac_impact_report.aspx (accessed 10 Oct 2015)</span>&nbsp;reported the impact of the programme and found that:
</p>
<ul><li>Frailty screening in 3 surgical wards at the Royal Infirmary of Edinburgh decreased the length of stay, number of falls and number of complaints
</li><li>A reduced length of stay in NHS Grampian
</li><li>50% decrease in the number of falls per month in 2 wards in NHS Greater Glasgow and Clyde<br />
</li></ul>
<p>The report emphasises the importance to continue building on this work and Healthcare Improvement Scotland is committed to continue working with NHS Boards and staff to support learning and improvement of skills in relation to the management of frailty and delirium <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="OPAC report" />.<br /> &nbsp; &nbsp;<br />&nbsp;
</p>
<h3> Think Frailty  </h3>
<p>As mentioned above, the Scottish Government provided funding for Healthcare Improvement Scotland's policy to improve health care for older people due to the rising numbers of unplanned admissions of this population.&nbsp;There is strong evidence for the benefits of CGA for frail patients. The programme is aiming to ensure that 95% of frail patients have a CGA and are admitted or referred to a specialist unit within 24 hours of admission<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Think Frailty" />.
</p><p>This case study report focuses on the work to identify frailty and ensure rapid CGA in four NHS boards in Scotland: NHS Ayrshire &amp; Arran, NHS Grampian, NHS Lanarkshire and NHS Lothian.<br />
</p><p>Common themes underpinning the success in the NHS boards mentioned in the report included<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Think Frailty" />:
</p><p><b>Easy to use screening tool <br /></b>
</p><p>The use of these should be at first point of contact with older people; at the front door or at home
</p>
<ul><li>Important to enable rapid identification and referral to CGA
</li><li>Valid screening tools reduce variability and increases the number of appropriate referrals to frailty services.
</li></ul>
<p><br /><b>Early intervention &amp; Senior decision makers</b>
</p>
<ul><li>Senior decision makers were valued, particularly in NHS Ayrshire &amp; Arran and NHS Grampian. As senior clinicians were more likely to use a wider range of care management options other than admission
</li><li>Early intervention focusing on discharge planning
</li></ul>
<p><br /><b>Multidisciplinary team working</b>
</p>
<ul><li>Having a strong, integrated team was valued by all sites
</li><li>Good communication between the members of the MDT was important
</li><li>Common aim for all sites: expanding the team. In particular physiotherapy and OT services so that a 7 day a week, around the clock service is available.
</li></ul>
<p>The sites involved in this project were able to show significant improvements in outcomes for the frail elderly presenting at the hospital. <br />These outcomes included a reduction in the number of admissions and re-admissions to hospital<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Think Frailty" />.<br /><br />To read more about each NHS board strategies to improve frailty identification and management access:&nbsp;<a href="http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/frailty_report.aspx">Think Frailty:&nbsp;Improving the identification and management of frailty</a><br />
</p><p>&nbsp;&nbsp;
</p>
<h3> Fit for Frailty  </h3>
<p><b>Part 1: Recognition and management of frailty in individuals in community and outpatient settings</b><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="FF1">British Geriatrics Society. Fit For Frailty: Part 1: Recognition and management of frailty in individuals in community and outpatient settings. http://www.bgs.org.uk/index.php/fit-for-frailty (accessed 12 Oct 2015)</span>
</p><p>This part of the Fit for Frailty guidelines by the British Geriatric Society (BGS) are intended to support health and social care professionals working with frail older people in the community.
</p><p><br />In order to recognise and identify frailty, BGS recommends<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="FF1" />:
</p>
<ul><li>During all encounters with health and social care professionals older people should be assessed for frailty
</li><li>There are 5 main syndromes of frailty; Falls, change in mobility, delirium, change in continence and susceptibility to side effects of medication. Encountering one of these should raise suspicion of frailty.
</li><li>Gait speed, timed up and go test and the PRISMA questionnaire are recommended outcome measures to assess for frailty.<br />
</li></ul>
<p>For managing frailty in an individual, BGS recommends<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="FF1" />:
</p>
<ul><li>A CGA, which involves a holistic, multidimensional and multidisciplinary assessment of an individual
</li><li>The result of the CGA should be an individualised care and support plan (CSP).
</li><li>The CSP includes a named health or social care professional coordinating the person’s care. A plan for maintaining and optimising the person’s care as well as urgent, escalation and end of life care plans should be in place.<br />
</li></ul>
<p><br />
</p>
<h3> Gap in literature  </h3>
<p>Clinical guidelines provide evidence-based recommendations in relation to the management of a specific condition or syndrome. They are aiming to assist health and social care professionals in their decision making and help reduce undesirable variations in practice<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BR">Broughton R,  Rathbone B. What makes a good clinical guideline? http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/whatareclinguide.pdf (accessed 14 Oct 2015)</span>.<br />The guidelines on frailty discussed above are aimed to all health and social care professionals and it has been found that these rarely go in depth in their explanation of specific healthcare professional's roles. As physiotherapists, it can be difficult to identify what recommendations are most applicable to our practice in relation to the management of frailty.&nbsp;
</p><p>In the Fit for Frailty<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="FF1" /> guidelines, it is suggested that physiotherapists should play a role in assessing and treating frailty. <br />It is reported that during every encounter with healthcare professionals, older people should be assessed for frailty. In addition to this, they also suggest that frail older adults would benefit from multidisciplinary assessment and intervention. Are physiotherapists routinely involved in this?
</p><p><br />
</p><p>In the Think Frailty<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Think Frailty" /> document, NHS Grampian reports physiotherapists are involved in the rapid MDT assessment team, seeing those who meet the frailty criteria. NHS Lanarkshire states that physiotherapists work in an early discharge team to see frail patients at the front door. Whilst NHS Lothian’s frailty screening tool suggests a referral to physiotherapy if the patient meets the appropriate criteria<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Think Frailty" />. <br />&nbsp;<br />As argued above, the guidelines simply state that physiotherapists should be involved in the management of frailty,<br />but what is our main role?<br />&nbsp;<br />The following sections of this learning resource aim to critically synthesise current evidence in order to present evidence-based information on the physiotherapists role in assessing and treating frailty.
</p><p><br />
</p>
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==== Exercises for Frail Older Adults ====
<td> <img src="/images/a/a4/Additional_reading_heading.png" _fck_mw_filename="Additional reading heading.png" _fck_mw_location="center" _fck_mw_width="1000" alt="" class="fck_mw_center" />
These are the recommended activities and intensity for frail older adults to increase physical activity. These aim to improve general health and well being, as well as reduce the risk of falls and manage chronic lifestyle conditions<ref name="BHF11" />. Frail older adults should aim to accumulate numerous 5 - 10 minute exercise sessions to achieve the recommended activity guides<ref name="BHF2012">The British Heart Foundation National Centre for Physical Activity and Health. Interpreting the UK physical activity guidelines for frailer older adults. http://www.bhfactive.org.uk/resources-and-publications-item/39/430/index.html (accessed 17 Oct 2015)</ref>
</td></tr>
<tr>
<td>
<p><br />
</p>
<ul><li><a href="http://www.bgs.org.uk/index.php/fitforfrailty-2m">Fit for Frailty&nbsp;Part 2</a> - Developing, commissioning and managing services for people <br />living&nbsp;with frailty in community settings.&nbsp;<br />This is a resource for&nbsp;all GPs, geriatricians, Health Service managers, <br />Social Service managers and Commissioners of Services<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="FF2">British Geriatrics Society. Fit for Frailty Part 2.fckLRhttp://www.bgs.org.uk/index.php/fitforfrailty-2m (accessed 12 Oct 2015)</span>.<br /><br />
</li><li><a href="http://www.bgs.org.uk/index.php/bgscampaigns-715/silverbook">Silver book</a> -&nbsp;Quality Care For Older People with Urgent and Emergency Care Needs. <br />Click on "Complete Silverbook" in the toolbar to access this document on managing <br />frailty in acute settings<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Silver book">British Geriatrics Society. Silver Book. http://www.bgs.org.uk/index.php/bgscampaigns-715/silverbook (accessed 13 Jan 2016)</span>.
</li></ul>
<p><br />
</p>
</td></tr></table>
<p><br />
</p><p><br />
</p><p>&nbsp; &nbsp;&nbsp;
</p>
<h1> INTRODUCTION TO THE PHYSIOTHERAPIST'S ROLE  </h1>
<p>This section will introduce you learning outcome 2 and we will begin to explore the role of the physiotherapist in preventing hospital admissions in a frail elderly population.
</p><p><br />
</p><p>The nature of the physiotherapy profession is to help restore movement and function in someone affected by illness or injury<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS Choices. Physiotherapy. http://www.nhs.uk/conditions/Physiotherapy/Pages/Introduction.aspx (accessed 20 Jan 2016).</span>.&nbsp;Physiotherapy input in the treatment for frailty is not a new concept. However, as previously discussed, the delivery of care is evolving in order to better meet the needs of this population. Physiotherapist’s are expanding their service to deliver intervention outwith standard inpatient care and moving to several different settings; for example, within day hospitals, in the patient’s home and in community clinics.
</p><p><br />
</p><p>There is an emerging body of evidence supporting physiotherapy in emergency departments to assess and treat trauma and soft tissue injuries<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Crane and Delany 2013">Crane J, Delany C. Physiotherapists in emergency departments: responsibilities, accountability and education. Physiotherapy 2013; 99; 2: 95-100</span>. However, could physiotherapists be included in emergency services to assist in preventing admissions of frail patients?
</p><p><br />
</p><p>In 2015, a physiotherapist joined forces with paramedics to treat non-life threatening emergency calls, with the aim of preventing unnecessary A&amp;E attendances and reducing hospital admissions. Commonly seen conditions included falls, chronic pain, decreased mobility, exacerbations of long-term conditions and frailty. 57% of patients remained at home and it is thought that £2850 was saved every time a patient was not transferred to hospital<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Chartered Society of Physiotherapy. Physio and paramedic pool resources in Lakes initiative. http://www.csp.org.uk/news/2015/10/12/physio-paramedic-pool-resources-lakes-initiative (accessed 20 Jan 2016).</span>.&nbsp;
</p><p><br />
</p><p>Furthermore, it has been suggested that physiotherapists could be stationed within hospital A&amp;E departments to undertake frailty and falls risk screening and make rapid decisions on whether the patient can safely return to their pre-admission destination<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Anaf S, Sheppard LA. Describing physiotherapy interventions in an emergency department setting: an observational pilot study. Accident and emergency nursing 2007; 15:1:34-9</span> <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Arendts G, Fitzhardinge S, Pronk K, Donaldson M, Hutton M, Nagree Y. The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study. BMC Geriatrics 2012; 12:8</span>. However, little high quality research has been conducted and at present evidence is inconclusive, suggesting the need for further study in this area.
</p><p><img src="/images/thumb/6/6a/Accident_and_emergency.jpg/400px-Accident_and_emergency.jpg" _fck_mw_filename="Accident and emergency.jpg" _fck_mw_location="center" _fck_mw_width="500" _fck_mw_height="300" alt="" class="fck_mw_center" />
</p><p><br />
</p><p>Whilst having an awareness of the different settings is important, the physiotherapy assessment and treatment is likely to be similar from place to place.<br />
</p><p>&nbsp;&nbsp;
</p>
<h1> THE COMPREHENSIVE GERIATRIC ASSESSMENT  </h1>
<p>The next section will cover the assessment of a frail individual. This relates to learning outcome two and three.
</p><p>All the guidelines outlined above state a need for a CGA to be completed to diagnose patients who may be frail. From this assessment, a holistic interdisciplinary treatment program can be devised to suit the problems and needs of the individual. The assessment is usually carried out by a geriatrician or another trained professional, such as a physiotherapist<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Martin 2010">Martin F.  Comprehensive Assessment of the Frail Older Patient. http://www.bgs.org.uk/index.php/topresources/publicationfind/goodpractice/195-gpgcgassessment (accessed 16 Sept 2015).</span>. <br /> This assessment usually takes place when a patient is identified as possibly being frail; during acute illness, prior to surgery or when returning to a community environment. It is a multi-dimensional program, which looks at the patient's health (physical and mental), mobility and social status. This approach was introduced in 2001 by the Department of Health<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Department of health. Common Assessment Framework for Adults: a consultation on proposals to improve information sharing around multi-disciplinary assessment and care planning. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_093438 (accessed 4 Jan 2016).</span>. There are five domains in which assessment takes place.
</p><p><br /> Below is a table adapted from Martin<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Martin 2010" />, which identifies and outlines what should be included in each domain.
</p><p><img src="/images/e/ed/CGA.jpg" _fck_mw_filename="CGA.jpg" alt="" /><br />
</p><p><br /> The methods used to achieve this are specific to the region of the UK in which you work. However, the measurement tools should be standardised and reliable. Some measures identify problems while others examine their severity.
</p><p><br /> The assessment will allow health professionals to identify the problems and allow for onward referral now and in the future. Once specific problems have been identified, onward referral can be made to appropriate healthcare professionals. This can then allow for a thorough assessment to be made around these problems. For example, a patient may be referred to physiotherapy to help increase mobility<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Martin 2010" />.
</p><p><br />
</p><p><b>Benefits</b><br /> A study examined whether a comprehensive assessment after an emergency admission is more effective when carried out by a team trained in a using a CGA. The paper showed that this approach reduced costs, length of hospital stay, deterioration and mortality. Routine follow up appointments are an essential part of the CGA and identify effectiveness of treatment. There is no specifc time frame for these, yet follow up sessions usually occur when people are readmitted to hospital<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ellis 2004">Ellis G, Langhorne P. Comprehensive geriatric AX for older hospital patients. Bri Med Bull 2004; 71: 45-49.</span>.
</p><p><br /> In hospitalised patients, it has been shown to improve the accuracy of diagnosis and enhances management in both the long and short term<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ellis 2004" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Sergi 2011">Sergi G, De Rui M, Sarti S, Manzato E. Polypharmacy in the elderly: can comprehensive geriatric assessment reduce inappropriate medication use? Drugs and aging 2011; 28(7):509.</span>. Completing a CGA in the community can prevent reductions in mobility and problems which arise from poor mobility by implementing treatment programmes tailored to all the patients’ needs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Tikkanen et al. 2015">Tikkanen P, Lönnroos E, Sipilä S, Nykänen I, Sulkava R, Hartikainen S. Effects of comprehensive geriatric assessment-based individually targeted interventions on mobility of pre-frail and frail community-dwelling older people. Geriatrics Gerontology International 2015; 15(1): 80-88.</span>. It can also reduce hospital stay, decrease the likelihood of readmission to hospital<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Nikolaus et al. 1999">Nikolaus T, Specht-Leible N, Bach M, Oster P and Schlierf G . A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients . Age Ageing 1999;28(6): 543-550.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Barer 2011">Barer D. Inpatient comprehensive geriatric assessment improves the likelihood of living at home at 12 months. ACP Journal Club; 2011; 155(6): 1.</span> and reduce mortality<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Frese et al. 2012">Frese T , Deutsch T, Keyser M, Sandholzer H. In-home preventive comprehensive geriatric assessment (CGA) reduces mortality—A randomized controlled trial. Archives of Gerontology and Geriatrics 2012;55(3): 639–644.</span>.<br />
</p><p><br /> <b>Why is this relevant to physiotherapy?</b>
</p><p>Below we have split the physiotherapy assessment into the CGA sections to show that physiotherapists can use its structure to help them carry out a comprehensive, holistic assessment. <br />
</p><p><br />
</p>
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<tr>
Suggested activities:
<td> <img src="/images/e/e5/Test_yourself_heading.png" _fck_mw_filename="Test yourself heading.png" alt="" /><br />
</td></tr>
<tr>
<td>
<p>How many of the key points can you recall?<br /><br />1. Who carries out a comprehensive geriatric assessment?<br />2. Where can it take place?<br />3. What are its key components?<br />4. What effects can completing a CGA have?
</p>
</td></tr></table>
<p><br />
</p>
<table width="800" cellspacing="1" cellpadding="1" border="1" align="center">


<tr>
*Walking<ref name="DOH">Department of Health. Start active, stay active: report on physical activity in the UK. https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officers (accessed 28 Oct 2015)</ref>
<td> <img src="/images/4/46/Reflection_heading.png" _fck_mw_filename="Reflection heading.png" _fck_mw_width="800" alt="" />
*Group exercise classes<ref name="BHF11" />
</td></tr>
*Adhering to a physiotherapist recommended home exercise program
<tr>
*Breaking up time spent sitting with short regular periods of standing or walking<ref name="BHF2012" />  
<td>
== Conclusion  ==
<p>Use the reading in this section and your prior knowledge to reflect upon any problems that you <br />think may arise when carrying out this type of assessment.
</p><p>This activity should take 10 minutes to complete.
</p>
</td></tr></table>
<p><br />
</p><p><br />
</p><p><br />
</p>
<h2> Functional capacity  </h2>
<p>Physiotherapists have the knowledge and skill level to carry out the functional aspect of the CGA<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wyrko 2015">Wyrko Z. Frailty at the front door. Clinical Medicine 2015; 15(4): 377–81.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="King10" />.
</p><p>Here is a recap of the Functional Capacity section of the CGA:<br />
</p><p><img src="/images/f/fd/Functional_Capacity_table.png" _fck_mw_filename="Functional Capacity table.png" alt="" />
</p><p><br /> There is a lack of evidence supporting the use of specific assessment techniques for physiotherapists to adopt to complete a comprehensive functional assessment of a frail elderly person. However, there is a lot of evidence supporting the use of specific outcome measures within this population. These will be covered later in this section. <br />
</p><p>Due to the above gap, only assessment techniques which have been reported in the literature will be included in this learning resource. There may be some common areas of assessment not covered; this does not mean they are not valid or useful to review when working with frail patients.  
</p><p><br /> <br /><b>What is a functional assessment?</b><br />Functional assessments are a way of determining health needs now and in the future. Assessments of patients with frailty should occur after every illness or injury to establish the effect the episode had on the patient’s functional ability<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fairhall et al. 2011">Fairhall N, Sherrington C, Kurrle  S E, Lord S R and Cameron I D. ICF participation restriction is common in frail, community-dwelling older people: an observational cross-sectional study. Physiotherapy [serial online]. 2011 [cited 2016 Jan 11]; 97(1):26-32. Available from:  Wiley online library.</span>. More specifically, functional assessments should be done on every patient over 75 years old<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mohile et al. 2015">Mohile SG,  Velarde C, Hurria A, Magnuson A, Lowenstein L, Pandya C, O'Donovan A,  Gorawara-Bhat R,  Dale W. Geriatric assessment-guided care processes for older adults: A Delphi consensus of geriatric oncology experts.  Journal of the National Comprehensive Cancer Network 2015; 13(9):1120-1130.</span>. The functional assessment element of the CGA compromises of: gait, balance, abilities to carry out activities of daily living (both fundamental and basic) and activity/exercise status<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Martin 2010" />. All these areas should be assessed by the attending physiotherapist.<br />&nbsp;<br />
</p>
<h3> Subjective Assessment </h3>
<p><br />The subjective assessment will be very similar to that of any other patient. Yet, some specific questions related to age and frailty must be asked.
</p><p><br />1. Has anything changed recently in terms of the patient's: vision, hearing, mobility status, cognitive ability, medication usage or activity levels<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Baker 2015">Baker L. 2015. Physiotherapy guidelines for management of people at risk of falling version 6. http://www.torbaycaretrust.nhs.uk/publications/TSDHC/Physio%20Guidelines%20for%20the%20Management%20of%20People%20at%20Risk%20of%20Falling.pdf (accessed 20 Dec 2015).</span>?
</p><p><br />2. Falls risk assessment tool (FRAT) questions should be asked which regard falls history and mobility status <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Stokes 2004">Stokes M. Physical management in neurological rehabilitation. 2nd ed. London: Elsevier mosby,2004.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Baker 2015" />. When did they last fall and why? How often do they fall? The context around circumstances of the fall should also be asked, like mechanism of fall, home set up and medication use<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHPS" />.
</p><p><br />3. It is useful to know about the patient's dietary intake<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Needle 2011">Needle JJ, Petchey RP, Benson J, Scriven A, Lawrenson J, Hilari K. The allied health professions and health promotion: a systematic literature review and narrative synthesis. Final report. NIHR Service Delivery and Organisation programme;2011.</span>.
</p><p><br />4. Do they have help or support with activities of daily living from anyone? Do they give help or support to anyone? <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Stokes 2004" />.
</p><p><br />
</p>
<table width="800" cellspacing="1" cellpadding="1" border="1" align="center">


<tr>
With the ageing of the global population the prevalence of frailty will multiply<ref name="Karunananthan et al. 2009">Karunananthan S, Wolfson C, Bergman H, Beland F, Hogan DB. A multidisciplinary systematic literature review on frailty: overview of the methodology used by the Canadian Initiative on Frailty and Aging. BMC Med Res Methodol 2009;9:68.</ref>.&nbsp;Subsequently, we need a shift of care from reactive to preventative strategies, focusing on providing early interventions to reduce costly unplanned admissions to hospital<ref name="Edwards">Edwards N. Community services - how they can transform care. London: The King's Fund, 2014.</ref>.&nbsp;Several guidelines are available, but none specifically detail the physiotherapist's role.  
<td> <img src="/images/e/e5/Test_yourself_heading.png" _fck_mw_filename="Test yourself heading.png" alt="" /><br />
</td></tr>
<tr>
<td>
<p>Think about why the above questions are important to ask with this type of patient.
</p><p>This task should take 20 minutes.
</p><p>Answers are below
</p>
</td></tr></table>
<p><br />
</p><p>1. It is important to know any changes which could affect the rest of your assessment and treatment plan. How could these changes have impacted on the patient's life? Can we help to change any issue or problem?
</p><p>2. We need to know about any previous falls. This will help determine their mobility status and how well they are coping. The FRAT tool is helpful to determine future falls risk<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHPS" />.We can then tailor treatment where it is needed<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Stubbs et al. 2015">Stubbs B, Brefka S, Denkinger MD. What Works to Prevent Falls in Community-Dwelling Older Adults? Umbrella Review of Meta-analyses of Randomized Controlled Trials. Physical therapy 2015; 95(8):1095-110.</span> <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Sherrington 2015">Sherrington C, Tiedemann A. Physiotherapy in the prevention of falls in older people. Journal of Physiotherapy 2015; 61(2): 54–60.</span>.
</p><p>3.<a href="http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist%27s_Role_in_Preventing_Hospital_Admission#Medical">refer to medical section for answer.</a>
</p><p>4. You can get an idea of what ADL’s they are able to do, how they are coping with these demands and how busy they are throughout the day<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Edwards 2002">Edwards S. Neurological physiotherapy: a problem-solving approach. 2nd ed. London: Churchill Livingstone,2002</span> <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Stokes 2004" />.
</p>
<h3> <br />Objective Assessment  </h3>
<p><br />The objective assessment should begin by observing posture, skin condition and body shape <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wagstaff and Coakley 1988" />. This can give you clues as to their general health and the extent of their frailty. <br />
</p><p><br />
</p><p>The therapist should have an idea as to what level of independence the patient has and how much physical activity they carry out on a daily basis<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Smyth 1990" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="HAS 2005">HAS. Physiotherapy-Preserving motor function in frail elderly people living at home. http://www.has-sante.fr/portail/upload/docs/application/pdf/physiotherapy_guidelines.pdf (accessed 11 Oct 2015).</span>. This can be achieved by using outcome measures such as the timed up and go, which has been shown to have good reliability and validity as a tool for measuring the mobility status of patients who are frail<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Podsiadlo 1991">Podsiadlo D and Richardson S. The Timed “Up and Go”: A Test of Basic Functional Mobility for Frail Elderly Persons, Journal of the American Geriatrics Society 1991;39(2):142–148.</span> . This type of information can also be gathered through the subjective assessment<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Smyth 1990" />. <br />
</p><p><br />
</p><p><b>Gait</b><br />
</p><p>As gait speed is a key measure of frailty, it is important for physiotherapists to measure it. A speed of less than 0.8 m/sec indicates frailty&nbsp;<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fairhall et al. 2011" />. Keeping track of the patient’s gait speed will enable the physiotherapist to objectively measure patient progress.&nbsp; <br />
</p><p>Endurance can be tested by completing multiple sit to stands or by carrying out a six-minute walk test. Monitoring the patient's heart rate during this will give an indication of their bodies ability to respond to increased effort<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="HAS 2005" />. The six minute walk test has been shown to be valid and reliable within this population<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Farrell 2004" />. Measuring endurance gives the physiotherapist an indication of how far the patient is likely to be able to walk, which can aid treatment planning and goal setting. <br />
</p><p>Analysing the individuals gait is also important. However, the difference in gait in people who are frail has not been widely researched. As well as frail individuals having reduced gait speed, they also have reduced stride length and cadence. Reductions in stride length are linked with the severity of frailty and come about due to sarcopenia and associated lower limb weakness. It is advised that in order to truly assess gait, the person should be asked to walk at their maximum speed<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Schwenk 2014">Schwenk M, Howe C,  Saleh A, Mohler J, Grewal G, Armstrong D and  Najafi B. Frailty and Technology: A Systematic Review of Gait Analysis in Those with Frailty. Gerontology 2014; 60(1): 79–89.</span>.
</p><p><img src="/images/5/55/Gait_assessment.png" _fck_mw_filename="Gait assessment.png" _fck_mw_location="right" alt="ClkerFreeVectorImages. pixabay.com (accessed 21/01/2016)." class="fck_mw_right" /><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p><b>Balance</b><br />
</p><p>Balance should be assessed comprehensively as this will allow for individualised treatment. 75% of over 70’s have reduced balance, which can increase falls risk<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Sibley 2013">Sibley KM, Straus SE, Inness EL, Salbach NM, Jaglal SB. Clinical balance assessment: perceptions of commonly-used standardized measures and current practices among physiotherapists in Ontario, Canada. Implement Sci 2013; 8: 33.</span>. Whilst some physiotherapists prefer using their own observations to assess balance, others favour the use of standardised outcome measures.&nbsp;The Berg Balance Scale, Single Leg Stance Test and Timed Up and Go were seen by physiotherapists as useful tools to measure functional ability<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Sibley 2013" />. Furthermore, balance outcome measures were assessed in a systematic review for their psychometric properties. There are many which the physiotherapist can use, however, very few measure all aspects of balance. Testing a patient's reactive balance was one area which was rarely examined. It is therefore important to know what aspects of balance and postural awareness are being tested by the outcome measure so that treatment will be tailored to problems<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Sibley 2015">Sibley KM, Beauchamp MK, Van Ooteghem K, Straus SE, Jaglal SB. Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review. Arch Phys Med Rehabil 2015;96(1):122-132.</span>.
</p><p><br />
</p><p>Reduced balance is linked with increasing falls risk and hospitalisation<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Sherrington 2015" />.  
</p><p>Good indicators of falls risk are the Berg Balance Scale and the Tinneti Balance and Gait Assessment as these both look at functional balance<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Farrell 2004" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Lin et al. 2004">Lin MR, Hwang HF, Hu MH, Wu HD, Wang YW, Huang FC. Psychometric comparisons of the timed up and go, one-leg stand, functional reach, and Tinetti balance measures in community-dwelling older people. J Am Geriatr Soc 2004;52(8):1343-8.</span>.&nbsp;A home assessment can identify if modifications need to occur to allow for increased safety<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHPS">BHPS. Assessment of falls risk in older people: Falls Risk Assessment Tool-FRAT. http://www.bhps.org.uk/falls/documents/FRATtool.pdf (accessed 16 Jan 2016).</span>. <a href="http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist%27s_Role_in_Preventing_Hospital_Admission#Environment">See the Environment section.</a> <br />
</p><p><br />
</p><p><b>Range of Motion</b> <b>(ROM) and Strength</b><br />As previously mentioned, reduced grip strength is an indicator of frailty<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fried 2001" />. Grip strength can be tested by using a grip ball dynamometer and which has been shown to be accurate and comfortable for people with frailty to use. It is important to measure grip strength, as weakness can limit the patient's ability to carry out activities of daily living<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Chkeir 2013">Chkeir A, Jaber R , Hewson DJ , Duchêne J. Estimation of grip force using the Grip-ball dynamometer. Medical Engineering Physics 2013; 35(11):1698-1702.</span>.<br />
</p><p>Determining ROM is important with this population as a link between reduced lower limb mobility and fall prevalence has been found. Ankle plantarflexion and hip extension, internal rotation and abduction were found to be reduced<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Chiacchiero 2010">Chiacchiero M, Dresely B, Silva U, DeLosReyes R, Vorik B. The relationship between range of movement, flexibility, and balance in the elderly. Topics in Geriatric Rehabilitation 2010; 26(2): 148-155.</span>.&nbsp;Tibiotarsal range is also important to measure as it can impact on posture<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="HAS 2005" />.&nbsp;It is therefore important to establish if your patient has reduced ROM as tailored intervention may help reduce falls.
</p><p><br /> <b>Activities of Daily Living (ADLs)</b>
</p><p>ADLs can help establish the functional ROM and strength of frail patients. Two main types of ADLs should be assessed: instrumental (IADLs) and basic<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Millan-calenti 2010" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Martin 2010" />.<br />
</p>
<ul><li>Basic ADLs are self-care tasks, whereas, <br />
</li><li>instrumental ADLs are activities which are needed for a person to live independently in the community<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ward 1998">Ward G, Jagger C and Harper W. A review of instrumental ADL assessments for use with elderly people. Reviews in Clinical Gerontology 1998; 8: 65-71.</span>.
</li></ul>
<table width="200" border="1" cellpadding="1" cellspacing="1">
<caption>
ADLs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Millan-calenti 2010" />


</caption>
== References ==
<tr>
<td> <img src="/images/6/6e/Basic_and_Instrumental_ADL%27s.png" _fck_mw_filename="Basic and Instrumental ADL's.png" alt="Millan-calenti 2010" />
</td></tr></table>
<p><br />
</p><p>IADLs are important to measure as an inability to do these is a better indicator of dysfunction than ability to self-care<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ward 1998" />. The percentage of elderly people reported as being independent increased to 65.4% from 46.5% when looking at basic ADLs, when compared to IADLs. There are standardised outcome measures in which to assess IADLs, yet the specific activities needed to enable independence vary depending on the environment and social aspects of the patient's life. It is therefore important to have a grasp of what the patient needs to be able to do to remain independent and then review these activities<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ward 1998" />. Functional dependence should be assessed, as there are correlations between dependence and increased length of stay in hospital<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Millan-calenti 2010">Millán-Calenti JC, Tubío J, Pita-Fernández S, González-Abraldes I, Lorenzo T,  Fernández-Arruty T, Maseda A. Prevalence of functional disability in activities of daily living (ADL), instrumental activities of daily living (IADL) and associated factors, as predictors of morbidity and mortality. Archives of Gerontology and Geriatrics 2010; 50(3): 306–310.</span>.<br />
</p><p><br /><b>Outcome measures</b>
</p><p>Outcome measures may be useful to assess the patient's ability, but also to track the patient’s progress<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Jette 2009">Jette DU et al.Use of Standardized Outcome Measures in Physical Therapist Practice: Perceptions and Applications. Physical therapy 2009; 89(2):125-35.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Kyte and Calvert 2015">Kyte DG, Calvert M. An introduction to patient-reported outcome measures (PROMs) in physiotherapy. Physiotherapy 2015; 101(2):119-25. http://www.ncbi.nlm.nih.gov/pubmed/25620440 (accessed 5 Jan 2016).</span>. There are many different outcome measures to choose from in this population. Some were specifically designed for frailty, while others were developed for other conditions but have been shown to have good psychometric properties within this population. The next section will review some commonly used outcome measures. However, this is not an exhortative list and will not necessarily be the best to use with each patient. It is up to the clinician to select the most appropriate measure for their practice.
</p><p><br />
</p>
<table width="600" cellspacing="1" cellpadding="1" border="1">


<tr>
<references /><br>  
<th scope="col"> Outcome Measures (OM)<br />
</th><th scope="col"> Description of OM<br />
</th><th scope="col"> Psychometric properties<br />
</th></tr>
<tr>
<td> Frail elderly functional assessment<br />
</td><td>
<ul><li>Examines functional ability in the frail
</li><li>Nineteen point questionnaire
</li></ul>
<p><br />
</p>
</td><td>
<ul><li>Valid
</li><li>Reliable
</li><li>Sensitive to change <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Gloth et al. 1995">Gloth FM, Walston J, Meyer J and Pearson J. Frail elderly functional assessment. American Journal of Physical Medicine and Rehabilitation 1995; 74(1): 45-53.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Gloth et al. 1999">Gloth FM, Walston J, Meyer J and Pearson J. The frail elderly functional assessment questionnaire: Its responsiveness and validity in alternative settings. Archives of Physical Medicine and Rehabilitation 1999; 80(12):1572–1576.</span>
</li></ul>
</td></tr>
<tr>
<td> 10 Metre Walk Test <br />
</td><td> <a _fcknotitle="true" href="10 Metre Walk Test">10 Metre Walk Test</a> <br />
</td><td>
<ul><li>Excellent test-retest reliability and high concurrent validity when compared to the shorter 4 metre walking test<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Peters et al. 2001">Peters DM, Fritz SL, Krotish D. Assessing the Reliability and Validity of a Shorter Walk Test Compared With the 10-Meter Walk Test for Measurements of Gait Speed in Healthy, Older Adults. Journal of geriatric physical therapy 2001; 36(1).</span>.
</li><li>High concurrent validity in the frail population with a 10 metre and 20 metre walk test <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Leerar and Miller 2002">Leerar P J, Miller EW. Concurrent Validity of Distance-Walks and Timed-Walks in the Well-Elderly. Journal of Geriatric Physical Therapy 2002; 25(2): 3-7.</span>.
</li></ul>
<p><br />
</p>
</td></tr>
<tr>
<td> The Edmonton Frail Scale<br />
</td><td> 12 questions related to cognition, general health status, mobility, social status, medication use, nutrition, mood, continence and functional performance. It has a total score of 17 which depicts severe frailty. It is a very brief way of assessing for frailty and can be used to see whether a CGA should take place<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rolfson 2006">Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A and Rockwood K . Validity and reliability of the Edmonton Frail Scale. Age and aging 2006; 35(5):526-29.</span>.<br />
</td><td>
<ul><li>Good inter-rater reliability
</li><li>Takes less than 5 mins to complete
</li><li>Good construct validity
</li><li>Acceptable internal consistency<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rolfson 2006" />
</li></ul>
<p><br /><br />
</p>
</td></tr>
<tr>
<td> PRISMA 7<br />
</td><td> A questionnaire devised of seven yes or no questions that can be used when the patient is unable to carry out a Stand Up and Go or a 10 Metre Walk Test <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="NHS 2015">NHS. Prisma 7 questionnaire. https://www.england.nhs.uk/wp-content/uploads/2015/01/frlty-spec-tools-prisma.pdf (accessed 15 Nov 2015).</span>. It was developed with a service in Canadian healthcare, to integrate frailty assessment and management and allow for increase patient-centred care<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Hebert 2003" />.<br />
</td><td>
<ul><li>Using this approach can reduce hospitalisation and is an encouraged approach across systems<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Hebert 2003">Hebert R, Durand PJ, Dubuc N, Tourigny A. Frail elderly patients: new model for integrated service delivery.  Can Fam Physician 2003; 49: 992-997.</span>.
</li><li>Recommended by the BGS and can indicate frailty. <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="FF1" /> <br />
</li></ul>
</td></tr>
<tr>
<td> The Barthel Index<br />
</td><td> It measures the patient's ability to look after themselves by asking 10 questions and answers that are graded on the amount of assistance needed to carry out the activity.<br />
</td><td>
<ul><li>The interrater reliability of this outcome is fair to good depending on which activity is being assessed <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Richards et al. 2000">Richards, S. H., Peters, T. J., et al. Inter-rater reliability of the Barthel ADL index: how does a researcher compare to a nurse? Clinical Rehabilitation 2000; 14(1): 72-78.</span>. <br />
</li></ul>
</td></tr>
<tr>
<td> Tinetti Balance and Gait Assessment<br />
</td><td> The Tinetti is a 17 item OM used to assess gait and balance<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Tinetti ME.Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986; 34(2): 119-126.</span>.<br />
</td><td>
<ul><li>70% sensitivity score
</li><li>52% sensitivity (good predictor of falls risk<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Raiche M, Rejean H, Francois P, Corriveau H. Screening older adults at risk of falling with the Tinetti balance scale. The Lancet 2000; 356(9234):1001-1002.</span>).
</li><li>Excellent test-retest and intrarater reliability<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Thomas JI and Lane JV. A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients. Archives of Physical Medicine and Rehabilitation 2005; 86(8): 1636-1640.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Faber MJ, Bosscher RJ et al. Clinimetric properties of the performance-oriented mobility assessment. Phys Ther  2006;86(7): 944-954.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Vaniersel M, Benraad CM et al.Validity and reliability of quantitative gait analysis in geriatric patients with and without dementia. Journal of the American Geriatrics Society 2007; 55(4): 632-633.</span>.
</li><li>In community-dwelling older adults, the concurrent validity was adequate when compared to the Timed Up and Go<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Lin et al. 2004" />.
</li></ul>
</td></tr>
<tr>
<td> Elderly Mobility Scale<br />
</td><td> Assesses mobility in the frail by completing 20 components<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Smith R. Validation and Reliability of the Elderly Mobility Scale. Physiotherapy1994;80(11):744-747.</span>.<br />
</td><td>
<ul><li>Good concurrent validity
</li><li>Good discriminant validity
</li><li>Good inter-rater reliability<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Nolan J, Remilton L and Green M.The reliability and validity of the Elderly Mobility Scale in the acute hospital setting. Internet J Allied Health Sci Pract 2008;6(4).</span>. <br />
</li></ul>
</td></tr></table>
<p><br />
</p><p><br />
</p><p>Both the Edmonton frail scale and the PRISMA 7 can be used by physiotherapists to determine whether a patient who displays symptoms of frailty is frail or not. If a positive result is found, they could refer a patient back to their GP for further assessment and intervention&nbsp;<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="FF1" />.
</p><p><br />
</p><p><br />
</p><p><b>Barriers to assessment:</b><i><br /></i>
</p>
<table width="800" cellspacing="1" cellpadding="1" border="1" align="center">


<tr>
<br>  
<td> <img src="/images/e/e5/Test_yourself_heading.png" _fck_mw_filename="Test yourself heading.png" alt="" />
</td></tr>
<tr>
<td>
<p>Assessing frail elderly patients can be challenging as a thorough assessment can take a long time.
</p><p>List a few reasons why this may be the case.<br />
</p><p>This should take 5 minutes. Answers are below.
</p>
</td></tr></table>
<p><br /><b>Answers:</b><br />
</p>
<ul><li>A thorough top to toe assessment needs to be done including all elements of the ICF model<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wagstaff and Coakley 1988">Wagstaff P and Coakley D. Physiotherapy and the elderly patient. Kent: Croom Helm ltd, 1988.</span> <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Smyth 1990">Smyth L. Practical physiotherapy with older people. Chapman and Hall, 1990.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Farrell 2004">Farrell MK. Using functional assessment and screening tools with frail older adults. Topics in geriatric rehabilitation 2004;20(1):14-20.</span>. <br />
</li></ul>
<ul><li>Are there any cognitive issues present? These include dementia and long-term or short-term memory problems. Cognitive function in the elderly has been shown to have a strong association with reduced functional performance<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Morala 2006">Morala D. Factors Associated with the Functional Status of Community-dwelling. Elderly Journal of Geriatric Physical Therapy 2006; 29(3).</span>. It can also impact on how you carry out your assessment and communicate with the patient<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Deary et al. 2009">Deary IJ, Corley J, Gow AJ, Harris SE. Age-associated cognitive decline. Br Med Bull 2009; 92(1): 135-152.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Albert SM, Tabert MH, Dienstag A, Pelton G, Devanand D. The impact of mild cognitive impairment on functional abilities in the elderly. Current Psychiatry Reports 2002; 4(1):64-68.</span>.<br />
</li></ul>
<ul><li>Auditory problems affecting the patients’ ability to hear you<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fairhall et al. 2011" /><br />
</li></ul>
<ul><li>Visual problems - the patient may not be able to see you or what you are trying to get them to do clearly<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fairhall et al. 2011" />.<br />
</li></ul>
<ul><li>Easily fatigued - causing patients to have reduced performance in activities which occur at the end of the assessment. This may skew the results of any outcome measures used<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Theou et al. 2008">Theou O, Jones GR, Overend TJ, Kloseck M, and Vandervoort AA. An exploration of the association between frailty and muscle fatigue. Appl. Physiol. Nutr. Metab. 2008; 33: 651–665. http://www.researchgate.net/publication/51415786_An_exploration_of_the_association_between_frailty_and_muscle_fatigue (accessed 4 Jan 2016).</span>.<br />
</li></ul>
<ul><li>Reduced or slow mobility (i.e. Sit-stand takes longer)<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Theou et al. 2008" />.
</li></ul>
<p><br />
</p><p><br />
</p>
<table width="500" cellspacing="1" cellpadding="1" border="1">


<tr>
<br>  
<th scope="col"> Key points to take <br />
</th></tr>
<tr>
<td>
<ul><li>Assessment of known frail patients is important and should be carried out by physiotherapists at the first contact with every patient. <br />
</li></ul>
</td></tr>
<tr>
<td>
<ul><li>Outcome measures should be regularly administered to review the physiotherapists’ effectiveness at improving frailty. <br />
</li></ul>
</td></tr>
<tr>
<td>
<ul><li>There are specific elements which need to be measured with people who are frail: ADL ability, Gait; speed and quality, endurance, balance, strength and falls risk. <br />
</li></ul>
</td></tr>
<tr>
<td>
<ul><li>Doing these may help prevent hospital admissions. <br />
</li></ul>
</td></tr></table>
<p><br />
</p>
<table width="800" cellspacing="1" cellpadding="1" border="1" align="center">


<tr>
<br>  
<td> <img src="/images/4/46/Reflection_heading.png" _fck_mw_filename="Reflection heading.png" alt="" />
</td></tr>
<tr>
<td>
<p>You have reached the end of the functional assessment section.
</p><p>Reflect on how your learning thorughout this section will change any future assessments<br />you carry out with patients who are frail.
</p><p><br />This task should take 10 minutes<br />
</p>
</td></tr></table>
<p>&nbsp;
</p><p>&nbsp;
</p>
<h2> Medical  </h2>
<p>Here is a recap of the Medical section of the CGA:
</p><p><img src="/images/2/2d/Medical_CGAtable.png" _fck_mw_filename="Medical CGAtable.png" alt="" /><br />
</p><p><br />
</p><p><b>Health Conditions</b>
</p><p>Aging process&nbsp;
</p><p>Cardiovascular<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">MedlinePlus. Aging changes in body shape.fckLRhttps://www.nlm.nih.gov/medlineplus/ency/article/003998.htm (accessed 18 Jan 2016).</span>:
</p>
<ul><li>Decreases in heart, blood vessels and arteries stiffen.
</li><li>Meaning that the heart is needing to work harder to maintain oxygen levels in the body.
</li><li>Increase risk of cardiovascular disease
</li></ul>
<p>Bone<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Boskey AL, Coleman R. Aging and Bone. 2010; 89: 1333-1348.fckLR http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2991386/ (accessed 18 Jan 2016).</span>:
</p>
<ul><li>Minerals decrease, reducing their density and becoming more fragile.
</li><li>Gradual loss of bone mass resulting in osteoporosis and fractures.
</li><li>Ligaments become less elastic and reduced flexibility
</li></ul>
<p>Muscle<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Nair KS. Aging muscle 1-5. 2005;81:953-63. fckLRhttp://ajcn.nutrition.org/content/81/5/953.long (accessed 19 Jan 2016).</span>:
</p>
<ul><li>Sarcopenia; Decrease of skeletal muscle mass and strength resulting in age.
</li><li>Some of the muscle – wasting is due to reduced growth in hormone production.
</li><li>Sarcopenia is associated with increased fatigue and higher risk of falling.
</li><li>Also affecting respiratory muscles, resulting in decreased efficiency of breathing and gastrointestinal tract leading to constipation.
</li></ul>
<p>Cognitive changes<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Glisky EL. Changes in Cognitive function in Human Aging. 2007. fckLRhttps://www.researchgate.net/publication/49727031_Changes_in_Cognitive_Function_in_Human_Aging (accessed 20 Jan 2016).</span>:
</p>
<ul><li>10% loss of brain volume after aged 80
</li><li>Reduction in blood flow and levels of chemical neurotransmitters
</li><li>Attention and memory are the most affected of the basic cognitive function.
</li></ul>
<p>It is out of the scope of this learning resource to go into depth about different health conditions that are prevalent in the frail population. However, we have provided additional reading if you wish to know more.<br />
</p><p><br />
</p><p><b>Medication</b><br /> <u>Common medication and their side effects</u>
</p><p>Analgesia<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS. Arthritis Research UK: Painkillers (analgesics).fckLRhttp://www.nhs.uk/ipgmedia/national/Arthritis%20Research%20UK/Assets/Painkillers-analgesics.pdf (accessed 9 Jan 2016)</span>:
</p>
<table width="500" cellspacing="1" cellpadding="1" border="1">


<tr>
<br>  
<th scope="col"> <b>Medication</b>
</th><th scope="col"> <b>Conditions used to treat</b>
</th><th scope="col"> <b>Common side effects</b>
</th><th scope="col"> <b>Examples</b>
</th></tr>
<tr>
<td> Non- opoid analgesics<br />(Non-steroidal anti- inflammatory drugs, NSAIDs)
</td><td> Mild to moderate pain
</td><td> Minimal side effects, however dizziness and headache may occur
</td><td> paracetamol, aspirin, ibuprofen
</td></tr>
<tr>
<td> Compound Analgesics
</td><td> Mild to moderate pain, often as an addition to NSAIDs
</td><td> Nausea, loss of concentration, constipation, confusion
</td><td> co-codamol, co- codaprin, co-dydramol
</td></tr>
<tr>
<td> Opioid analgesics
</td><td> Moderate to severe pain.
</td><td> Impaired balance, confusion nausea and vomiting, constipation, drowsiness and dizziness
</td><td> codeine, tramadol morphine
</td></tr></table>
<p>Other Medication:
</p>
<table width="500" cellspacing="1" cellpadding="1" border="1">


<tr>
<br>  
<th scope="col"> Medication
</th><th scope="col"> Conditions used to treat
</th><th scope="col"> Common side effects
</th><th scope="col"> Examples
</th></tr>
<tr>
<td> Beta Blockers<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="NHS">NHS. Beta- BlockersfckLRhttp://www.nhs.uk/Conditions/Beta-blockers/Pages/Introduction.aspx (Accessed 5 Jan 2016)</span>
</td><td> Angina, Heart failure, Atrial fibrillation and Heart attach
</td><td> Dizziness, tiredness, blurred vision, slow heartbeat, impaired balance
</td><td> atenolol, bisoprolol, acebutolol, metoprolol
</td></tr>
<tr>
<td> Antidepressants<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS. Antidepressants.fckLRhttp://www.nhs.uk/Conditions/Antidepressant-drugs/Pages/Introduction.aspx (Accessed 2 Jan 2016)</span>
</td><td> Depression
</td><td> Dizziness, Impaired balance, slow reaction, headaches, loss of appetite, anxious, feeling agitated, blurry vision<br />
</td><td> duloxetine, venlafaxine, mirtazapine, amitriptyline, imipramine, lithium.<br />
</td></tr>
<tr>
<td> Benzodiazepines<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS. Generalised anxiety disorder in adults - Treatment. http://www.nhs.uk/Conditions/Anxiety/Pages/Treatment.aspx (Accessed 3 Jan 2016).</span>
</td><td> Relief of severe anxiety
</td><td> Drowsiness, difficulty concentrating, headaches and vertigo
</td><td> diazepam, lorazepam, chlordiazepoxide
</td></tr>
<tr>
<td> Angiotensin receptor blockers<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Mayo Clinic, Diseases and Conditions:fckLRHigh blood pressure (hypertension)fckLRhttp://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/angiotensin-ii-receptor-blockers/art-20045009 (accessed 9 Jan 2016).</span>
</td><td> Hypertension
</td><td> Dizziness, Confusion, muscle cramps and/or weakness, faintness
</td><td> azilsartan, candesertan, eprosartan, losartan
</td></tr>
<tr>
<td>
<p>Diuretics<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Mayo Clinic, Diseases and Conditions: DiureticsfckLRhttp://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/diuretics/art-20048129 (Accessed 4 Jan 2016).</span>
</p>
</td><td>
<p>Water retention, high blood pressure and heart failure
</p>
</td><td>
<p>Nausea, dizziness, muscle cramps,&nbsp;increased frequency and urgency&nbsp;of urination
</p>
</td><td>
<p>furosemide, torsemide, chlorthalidone, amiloride<br />
</p>
</td></tr>
<tr>
<td> Anticoagulants<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS Choice, Anticoagulant medicines. http://www.nhs.uk/conditions/Anticoagulant-medicines/pages/side-effects.aspx (accessed 19 Jan 2016)</span>
</td><td> Hypotension
</td><td> Haemorrhage, Dizziness, headaches.
</td><td> heparin, warfarin and aspirin,
</td></tr></table>
<p><br />Side effects of medication such as drowsiness, blurred vision and insomnia can interfere with the treatment session and also delay any recovery, it is therefore important for physiotherapists to know if the patient is on any medication to modify treatments. <br />
</p><p>Polypharmacy is the use of multiple medications and is often unavoidable as the elderly population are more likely to have several co-morbidities. Polypharmacy introduces drug interaction, this can be harmful, as when combined some medications increase the risk of adverse drug reactions (ADRs).
</p><p><br /> ADRs can become a vicious cycle where more drugs are needed to treat the ADRs for new drugs. Which can result in increased numbers of unnecessary and potentially harmful medications. The physiotherapist can help preventing polypharmacy and the vicious cycle by recognising changes in the patients respond to their drug therapy. It is therefor highly important for physiotherapists to have knowledge and understanding on common medicine and their adverse side effects.
</p><p><br /> <b>Nutritional status</b> <br />
</p><p>Nutrition is important for these patients and it should be part of the physiotherapist subjective assessment to check what and how often the patient is eating<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Needle 2011" />. The physiotherapist can then reinforce good eating habits and if needed refer the patient to a dietician. It is also important to have an idea about how much the patient eats as this could contribute to increased fatigue. A reduced tolerance to activity is present in frail patients <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Theou et al. 2008" /> and so how much you include in your first assignment is crucial.
</p>
<table width="200" border="1" cellpadding="1" cellspacing="1">


<tr>
<br>
<td> <img src="/images/a/a4/Additional_reading_heading.png" _fck_mw_filename="Additional reading heading.png" alt="" />
[[Category:Older People/Geriatrics]]
</td></tr>
[[Category:Interventions]]
<tr>
[[Category:Primary Contact]]
<td>
[[Category:Older People/Geriatrics - Interventions]]
<p><a href="http://www.ageuk.org.uk/health-wellbeing/conditions-illnesses/">Age UK-</a> A list of common health conditions within the elderly population.
[[Category:Queen Margaret University Project]]
</p><p>Identifying what condition it is, the cause and the symptoms<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Age UK. Health and wellbeing: conditions and illnesses.fckLRhttp://www.ageuk.org.uk/health-wellbeing/conditions-illnesses/ (accessed 18 Jan 2016).</span>.
</p><p><br /><a href="http://www.agingsociety.org/agingsociety/pdf/chronic.pdf">Aging Society </a>– Identify the meaning of chronic conditions,
</p><p>listing the most common chronic conditions by age, gender and race<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Aging Society. Chronic Conditions – A challenge for the 21st century. http://www.agingsociety.org/agingsociety/pdf/chronic.pdf (accessed 21 Jan 2016).</span>.
</p><p><br /><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125318/">Drug- related falls in older patients –</a> Going through the implicated drugs,
</p><p>the consequences and possible prevention strategies<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Jong MR, Elst MV and Hartholt KA. Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. 2013; 4(4): 147–154. Full version: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125318/ (accessed 19 Jan 2016).</span>.
</p><p><br /><a href="http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-40">Fall risk- increasing drugs and falls </a>– A cross sectional study on drugs
</p><p>and falls with elderly patient in primary care<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">BioMedCentral. Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-40 (Accessed 20 Jan 2016).</span>.
</p>
</td></tr></table>
<p><br />
</p>
<h2> Mental health  </h2>
<p>Here is a recap of the Mental health section of the CGA:
</p><p><img src="/images/a/a6/Mental_Health_table.png" _fck_mw_filename="Mental Health table.png" alt="" />
</p><p><br />
</p><p>Although it is not the prime role of a physiotherapist, in order to provide a holistic service, we must be aware of and understand the mental health of our patients and the impact that this may have on the individual and their ability to carry out any treatments.&nbsp;
</p><p>Mental health disorders can be classified as functional or organic<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS Southern Health. Inpatient services - older people's mental health. http://www.southernhealth.nhs.uk/services/mental-health/older/inpatient/ (accessed 20 Jan 2016).</span>
</p><p><u>Organic</u><br />Age-related cognitive decline is inevitable<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Salthouse TA. When does age-related cognitive decline begin? Neurobiol Aging 2009; 30: 507-14</span>, however, some conditions common amongst older adults can have dramatic effects on cognition<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Barberger-Gateau P, Fabrigoule C. Disability and cognitive impairment in the elderly. Disabil Rehabil 1997; 19: 5 :175-93.</span>. Organic disorders are usually caused by disease affecting the brain, for example, dementia or delirium. Table 1 compares age-related cognitive decline with the early signs of dementia.<br />
</p>
<table width="200" border="1" cellpadding="1" cellspacing="1">
<caption> Table 1<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Whalley LJ. Brain ageing and dementia: what makes the difference? The British Journal of Psychiatry 2002; 181: 369-71</span>
</caption>
<tr>
<td> <b>Early signs of dementia</b>
</td><td> <b>Normal ageing</b>
</td></tr>
<tr>
<td> Forgetting things more often than previously, forgetting names of people close to them
</td><td> Briefly forgetting parts of an experience, forgetting the names of people they rarely see
</td></tr>
<tr>
<td> Repeating phrases or conversations
</td><td> Putting things away incorrectly
</td></tr>
<tr>
<td> Unpredictable mood swings
</td><td> Mood changes appropriately
</td></tr>
<tr>
<td> Lack of interest in activities, difficulty making decisions
</td><td> Changes in their interests
</td></tr></table>
<p><br />
</p><p><u>Dementia</u><br />The word dementia describes a set of symptoms that could include memory disorders, personality changes and impaired reasoning. There are various types of dementia, the most common types are Alzheimer’s disease, vascular dementia and dementia with Lewy bodies<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS Choices. About dementia. http://www.nhs.uk/conditions/dementia-guide/pages/about-dementia.aspx (accessed 18 Jan 2016)</span>. The likelihood of developing dementia increases drastically with age and it is thought that 1 in 14 people over 65 suffer from this condition<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Alzheimer’s Society. About dementia. https://www.alzheimers.org.uk/site/scripts/documents.php?categoryID=200120 (accessed 20 Jan 2016)</span><span style="line-height: 1.5em; font-size: 13.28px;">. Due to the progressive nature of the disease, communication will gradually worsen over time.</span>
</p><p><br />
</p><p><u>Delirium</u>
</p><p><u></u>Delirium is a common clinical syndrome categorised by fluctuating cognitive function and disturbed consciousness. It usually develops over 1–2 days, however, it is associated with poor outcomes<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Inouye SK, Rushing JT, Foreman MD, Palmer RM, Pompei P. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998; 13: 234-42</span>. Delirium can be hypoactive or hyperactive, occasionally people will display signs of a mixed picture. Hyperactive delirium usually manifests itself as restlessness, agitation and aggression, whereas people with hypoactive delirium present as withdrawn and quiet<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">O’Keefe ST, Lavan JN. Clinical significance of delirium subtypes in older people. Age and Ageing 1999; 28: 115-9</span>. It is thought that the prevalence of delirium on medical wards is 20 to 30%, but reporting in the UK is poor and it is expected this figure is underestimated<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management. London: National Institute for Health and Care Excellence, 2010.</span>. People who develop delirium are more likely to stay longer in hospital and have more hospital-acquired complications, such as falls<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">McCusker J, Cole MG, Dendukuri N, Belzile E. Does delirium increase hospital stay? J Am Geriatr Soc 2003; 51: 1539-46</span>. The physiotherapist may be the patient’s first contact with healthcare and they be required to screen for frailty. OPAC have created a delirium toolkit (see additional reading) and recommend the use of the 4AT to do so and any abnormal results should be discussed with the relevant healthcare professionals<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Healthcare Improvement Scotland. Older People in Acute Care improvement programme – Delirium Toolkit. http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/delirium_toolkit.aspx (accessed 14 Jan 2016)</span>.
</p><p><br />
</p><p><u>What does this mean for physiotherapists?</u><br />With any cognitive condition, effective communication may become challenging and prove as a barrier to successful assessment and treatment. Table 2 highlights some tips to tackle this.
</p><p><br />
</p>
<table width="200" border="1" cellpadding="1" cellspacing="1">
<caption> Table 2<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Kempanaar L. The Role of Physiotherapy in Dementia Rehabilitation. In: Marshall, M editor. Perspectives on Rehabilitation and Dementia. London: Jessica Kingsley Publishers, 2004. P91-8.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Chartered Society of Physiotherapy. Physiotherapy works: Dementia care. http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/dementia-care (accessed 20 Jan 2016)</span>
</caption>
<tr>
<td> 1. Keep commands clear and concise with one request at a time – “Stand up please”<br /><br />2. Allow plenty of time for a response before repeating your question. If the patient is still struggling, try rephrasing. <br /><br />3. Remove distractions – this could include talking, background noise, eye-catching pictures. <br /><br />4. Use names and explanations where possible – “Your daughter, Ann” <br /><br />5. Use other forms of communication:<br />
<ul><li>Visual – show tasks rather than explain instructions.
</li><li>Sound – cueing can encourage normal movement. For example, counting or using music can provide a rhythm and trigger a response. It may also help provide an auditory clue when the patient cannot understand the verbal instruction – patting the chair to signify “sit down”.
</li><li>Tactile – can be used to aid the movement. For example, offering a hand when walking, stroking up the spine when standing.
</li></ul>
</td></tr></table>
<p><br />
</p><p>Now watch this video which describes effective communication specifically for people with dementia, however, some of this could be applied to anyone with cognitive decline.
</p>
<table width="200" border="1" cellpadding="1" cellspacing="1">
<caption> <br />
</caption>
<tr>
<td> Effective communication and dementia<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Emeritus Senior Living. Communicating with someone with dementia. https://www.youtube.com/watch?v=xDEYH518cKU (accessed 20 Jan 2016)</span>
</td></tr>
<tr>
<td> <span class="fck_mw_template">{{#ev:youtube|xDEYH518cKU}}</span>
</td></tr></table>
<p><br />
</p><p><u>Functional:</u><br />Functional disorders have a predominately psychological cause and may include conditions such as depression or anxiety<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Tucker S, Wilberforce M, Brand C, Abendstern M, Crook A, Jasper R, et al. Community mental health teams for older people: variations in case mix and service receipt. International Journal of Geriatric Psychiatry 2015; 30: 595-604</span>
</p><p><br /><u>Depression&nbsp;</u><br />1 in 5 community-dwelling older adults are thought to suffer from depression<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Mental Health Foundation. Mental health statistics: older people. https://www.mentalhealth.org.uk/statistics/mental-health-statistics-older-people (accessed 20 Jan 2016).</span>. Whilst this statistic is alarming, it has been suggested that older adults are more susceptible to depression as with age they become more exposed to chronic conditions, health concerns and death, particularly of loved ones<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Fiske A, Wetherell JL, Gatz M. Depression in Older Adults. Annu Rev Clin Psychol 2009; 5: 363–89.</span>. Depression comes with a whole range of symptoms and these vary from person to person.
</p><p>Now watch this video which explores the cause of depression in ageing.
</p>
<table width="200" border="1" cellpadding="1" cellspacing="1">
 
<tr>
<td> Depression in ageing<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Morton K. Aging &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Depression? What should we know and look for? https://www.youtube.com/watch?v=WBZsa3diKMs (accessed 20 Jan 2016)</span>
</td></tr>
<tr>
<td> <span class="fck_mw_template">{{#ev:youtube|WBZsa3diKMs}}</span>
</td></tr></table>
<p>&nbsp;
</p><p><u>Anxiety</u><br />The most recently published statistics suggest that 17% of older adults suffer from an anxiety disorder<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Kirmizioglu Y, Dogan O, Kugu N, Akyuz G. Prevalence of anxiety disorders among elderly people. Int J Geriatr Psychiatry 2009;24:9:1026-33.</span>. Anxiety has a wide range of physical and psychological symptoms that can have a debilitating effect on an individual’s life; they may be able to complete tasks physically, however, are limited by their mental health. Anxiety disorders are usually treated with medication but alternative therapies such as cognitive behavioural therapy and hypnotherapy are also known to be used<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Mind. Anxiety Treatments. http://www.mind.org.uk/information-support/types-of-mental-health-problems/anxiety-and-panic-attacks/anxiety-treatments/#.VqksFvmLTIU (accessed 12 Jan 2016)</span>.
</p><p><br /> <u>What does this mean for physiotherapists?</u><br />Lack of motivation is common amongst most older adults, including those with a functional mental health disorder and treatment to tackle this can feature heavily in your physiotherapy treatment plan<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Kaur J, Masaun M, Bhatia MS. Role of physiotherapy in mental health disorders. Delhi Psychiatry Journal 2013; 16: 2: 404-8</span>. This will be discussed in further detail in the motivation section.
</p><p><br />
</p><p><br />
</p>
<table width="500" cellspacing="1" cellpadding="1" border="1" align="center">
 
<tr>
<td> <img src="/images/thumb/a/a4/Additional_reading_heading.png/500px-Additional_reading_heading.png" _fck_mw_filename="Additional reading heading.png" _fck_mw_location="center" _fck_mw_width="500" alt="" class="fck_mw_center" />
</td></tr>
<tr>
<td> <br />
<ul><li><a href="https://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=1754">Alzheimer's Society</a> - a comprehensive guide to dementia
</li></ul>
<p>Read this for more information on dementia.
</p><p><br />
</p>
<ul><li><a href="https://www.nice.org.uk/guidance/cg103">National Institute for Health and Care Excellence</a> -
</li></ul>
<p>NICE guidelines for prevention, diagnosis and treatment of delirium.
</p><p>Read this for evidence-based information on delirium.
</p><p><br />
</p>
<ul><li><a href="http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/delirium_toolkit.aspx">OPAC Delirium Toolkit</a>
</li></ul>
<p>Resources developed for clinicians to improve identification and
</p><p>management of delirium - this includes a copy of the 4AT
</p><p><br />
</p>
</td></tr></table>
<p><br />
</p>
<h2> <b>Social and Environmental</b><br />  </h2>
<p>Assessment of the social and environmental aspects of a patient’s life is a fundamental part of the CGA, as laid out on section 4.2
</p><p>Recap of the social and environmental sections of the CGA:
</p><p><img src="/images/c/c5/CGA_x2.png" _fck_mw_filename="CGA x2.png" alt="" />
</p><p>Assessing this type of information is also a key component of the common assessment framework for adults, which was published by the Department of Health <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH 2009">Department of health. Common Assessment Framework for Adults: a consultation on proposals to improve information sharing around multi-disciplinary assessment and care planning. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_093438 (accessed 4 Jan 2016).</span>.
</p><p><br /> It is an occupational therapists (OT’s) role to devise interventions amend any problems with these. Their assessments and the subsequent home modifications and adaptions can help increase the functional abilities of people who are frail <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Horowitz 2002">Horowitz B P. Supporting community living through client-centered care. Occupational therapy in mental health; 2002 : 18(1).</span>. However, a patients’ ability to carry out activities in the home is dependent on its layout and the persons’ social situation. As physiotherapy interventions try to help improve peoples’ ability to perform ADL’s, it is important for physiotherapists to know how the environment and social situation can impact on their treatment.<br />
</p><p><br />
</p><p>The international classification of health, functioning and disability (ICF) can be used by physiotherapists to help establish the needs of the patient<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="WHO 2001" />. <br />
</p><p><br />
</p><p><img src="/images/5/57/ICF.jpg" _fck_mw_filename="ICF.jpg" _fck_mw_location="center" alt="ICF" class="fck_mw_center" /> <br /> The ICF is a model which allows professionals to see the impact a health condition has on a persons’ life, by taking a holistic viewpoint. Participation restrictions and activity limitations are the two areas of the ICF which relates to the influence of the patients social and environmental circumstances. Activity limitations are the execution of a task by the patient. Whereas, participation restrictions relates to how involved with a life situation the patient is due to the societal setup <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="WHO 2001">World Health Organization. ICIDH-2: International classification of functioning, disability, and health. Geneva: World Health Organization, 2001.</span>.
</p><p><br /> The World Health Organization (WHO) has devised a checklist which allows clinicians to identify what activity and participation restrictions the patient has <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="WHO 2003">World Health Organisation. ICF Checklist version 2.1a clinicians. http://www.who.int/classifications/icf/icfchecklist.pdf?ua=1 (accessed 04 Jan 2016).</span>. <br />
</p><p><br />
</p>
<h3> Social circumstances <br />  </h3>
<p><b><br />Activity limitations</b>
</p><p>Elderly people who have a high participation level in leisure activities also have better health outcomes. Reduced mobility and activity limitations directly reduce participation in leisure activities. Activity limitations have a bigger impact on social involvement than the severity of the patients’ medical condition. Specific activity limitations which may cause participation restriction are:<br />• Anxiety <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Norton et al. 2012">Norton J, Ancelin ML, Stewart R, Berr C, Ritchie K, Carrière I. Anxiety symptoms and disorder predict activity limitations in the elderly. Journal of Affective Disorders 2012; 141(2/3): 276-285.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Nilsson et al. 2015">Nilsson I, Nyqvist F, Gustafson Y and Nygård M. Leisure Engagement: Medical Conditions, Mobility Difficulties, and Activity Limitations—A Later Life Perspective. Journal of Aging Research; 2015. http://dx.doi.org/10.1155/2015/610154 (accessed 04 Jan 2016).</span><br />• Needing help with personal care<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cambois et al. 2005">Cambois E, Robine J-M, Romieu I. The influence of functional limitations and various demographic factors on self-reported activity restriction at older ages. Disability and Rehabilitation 2005; 27(15): 871 – 883.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Nilsson et al. 2015" /><br />• Mobility aid use and walking speed<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Nilsson et al. 2015" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cambois et al. 2005" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Makizako et al. 2015">Makizako H, Shimada H, Doi T, Tsutsumimoto K, Lee S, Hotta R, et al. Cognitive Functioning and Walking Speed in Older Adults as Predictors of Limitations in Self-Reported Instrumental Activity of Daily Living: Prospective Findings from the Obu Study of Health Promotion for the Elderly. Int. J. Environ. Res. Public Health 2015; 12: 3002-3013. www.mdpi.com/1660-4601/12/3/3002/pdf (accessed 20 Dec 2015).</span><br />• Memory <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Makizako et al. 2015" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cambois et al. 2005" />
</p><p><br />Musculoskeletal impairments cause the majority of activity limitations in elderly community-dwelling adults<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Qu et al. 2011">Qu W, Stineman, MG, Streim J E, Dawei Xie D. Understanding Linkages between Perceived Causative Impairment and Activity Limitations among Older People Living In the Community. A Population-Based Assessment. Am J Phys Med Rehabil. 2011; 90(6): 466–476.</span> . Physiotherapists are therefore in a prim position to help reduce activity limitations.&nbsp;A study by Mast and Azar<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mat and Azar 2004">Mast BT, Azar AR, MacNeill SE, Lichtenberg PA. Depression and activities of daily living predict rehospitalization within 6 months of discharge from geriatric rehabilitation. Rehabilitation Psychology 2004; 49(3): 219-223.</span> found a correlation between ADL limitations and readmission to hospital in the geriatric population. This shows that physiotherapy targeted at reducing activity limitations could reduce hospital stay as well as improving social network and participation. <br />
</p><p><br />
</p><p><b>Taking a social history</b>
</p><p>Taking a social history allows the physiotherapist to understand the patient's current level of functioning and their desired functional goals <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Petty 2011">Petty, NJ. Neuromusculoskeletal examination and assessment: a handbook for therapists. Edinburgh : Churchill Livingstone, 2011.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cott 1995">Cott, CA. Goal setting.  In: Pickles B et al, editor. Physiotherapy with older people. London: WB Saunders company ltd, 1995.</span>. This should include assessment of activities they do in and outside their home and what formal or informal care/support they receive<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wagstaff and Coakley 1988" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Petty 2011" />. 80% of nonagenarians have carers to help with some of their ADL’s<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cambois et al. 2005" />. Having a small amount of regular help with ADL’s may prevent an acute episode turning into an emergency where the patient is no longer safe to stay at home<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wagstaff and Coakley 1988" />. This shows the importance of knowing the patient's social circumstances.<br />
</p><p><br />
</p>
<h3> Environment <u><br /></u>  </h3>
<p><u></u>
</p><p><br /> <b>Participation restrictions</b>
</p><p>Elderly people who experience activity limitations sometimes also have participation restrictions<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Aranadottir 2011">Arnadottir  S A, Gunnarsdottir  E D, Stenlund H and Lundin-olsson L. Participation frequency and perceived participation restrictions at older age: applying the International Classification of Functioning, Disability and Health (ICF) framework. Disability and rehabilitation 2011; 33(22-23): 2208-2216.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cambois et al. 2005" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Crews 2001">Crews JE and Campbell VA. Health Conditions, Activity Limitations, and Participation Restrictions Among Older People with Visual Impairments. Journal of Visual Impairment and Blindness 2001; 95(8):453-467.</span> . <br />
</p><p>Knowing what participation restrictions a patient has is important as they are linked to the patients’ quality of life. Participation frequency should also be noted<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Aranadottir 2011" />. It is common for people with frailty who live in the community to report having participation restrictions<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fairhall et al. 2011" /><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wilkie 2006">Wilkie R, Peat G, Thomas E, Croft P. The prevalence of person-perceived participation restriction in community-dwelling older adults. Qual Life Res. 2006;15: 1471–1479.</span>. This is due to reduced community mobility and a reduced ability to carry out work both at home and in the community<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fairhall et al. 2011" />. Increased participation restrictions are also linked with increasing age<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wilkie 2008">Wilkie R, Thomas E, Mottram S, Peat G, Croft P. Onset and persistence of person-perceived participation restriction in older adults: a 3-year follow-up study in the general population. Health Qual Life Outcomes [serial online]. 2008 [cited 2016 Jan 11];6(92). Available from: www.biomedcentral.com</span>. The symptoms of frailty most closely linked to participation restrictions are grip strength, mobility and the number of co-morbidities a patient has<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fairhall et al. 2011" />. Participation is also linked to environmental factors such as, access to public transport. It has been shown that mobility levels can remain constant even though the patients’ condition may decline<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wilkie 2007">Wilkie R, Peat G, Thomas E, Croft P. Factors associated with restricted mobility outside the home in community-dwelling adults ages fifty years and older with knee pain: An example of use of the international classification of functioning to investigate participation restriction. Arthritis Care and Research. 2007; 57 (8): 1381-1389.</span> .<br />
</p><p><br />
</p><p><u></u>
</p>
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<ul><li>Create a mind map around the different hazards that can be found in someones house.<br />This should include the bathroom, the kitchen and the stairs.<br />&nbsp;&nbsp;
</li><li>Once completed please click the picture below to expand the mind map.<br />Compare this to yours<br />&nbsp;<br />This activity should take 20 minutes.
</li></ul>
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<p><u></u>
</p>
<pre class="_fck_mw_lspace"><img src="/images/thumb/a/af/Enviromental_considerations_in_the_house.png/180px-Enviromental_considerations_in_the_house.png" _fck_mw_filename="Enviromental considerations in the house.png" _fck_mw_location="center" _fck_mw_type="thumb" alt="" class="fck_mw_frame fck_mw_center" />
 
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<p>The mind map above shows the different things which should be checked in the patients' house on assessment, before a treatment plan is devised or goals are set. Sometimes these assessments are performed jointly with an OT<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wagstaff and Coakley 1988" />. <br />
</p><p>It is important to know if any intervention is being put in place to help rectify these. Finding out if an OT is involved, what their findings were and what their plan is, is important as then interdisciplinary goals can be devised which are safe and suited to the patient<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Mears 2015">Mearns N, Duguid I. Physiotherapy and Occupational Therapy in the Acute Medical Unit: Guidelines for Practice. http://www.acutemedicine.org.uk/wp-content/uploads/2015/05/10.2-PTOT-AMU-Guidance-Document-2015.pdf (accessed 13 Jan 2016).</span> <br />
</p><p>Being aware of the environment in which the patient lives will allow the physiotherapist to tailor treatments effectively and safely to their surroundings. <br />
</p><p><br />&nbsp;&nbsp;
</p><p><b>Learning activities&nbsp;&nbsp;</b><br />&nbsp;&nbsp;<br />
</p>
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<p>Answer these questions to&nbsp;test your knowledge in relation to the information presented<br /> in the sections above. <br />
</p>
<ul><li>What are activity limitation and participation restrictions?
</li><li>What are the four most common activity limitations in the frail elderly?
</li><li>What is the link between participation restrictions and the frailty phenotypes?
</li><li>Why should physiotherapists take a social history from their patients?<br />&nbsp;<br />This activity should take 20 minutes.
</li></ul>
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<p>&nbsp; &nbsp;<br />
</p>
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<p>Mr Smith is an 84 year old man who was referred for physiotherapy by<br />the&nbsp;community occupational therapist.
</p><p>Mr Smith had reported “feeling like he cannot walk very far anymore and <br />his balance&nbsp;is just dreadful”. He stated “I’m scared to leave the house, <br />I just do not want to fall&nbsp;and end up in hospital”
</p><p>He was happy for the referral to a community physiotherapist to be made.<br />
</p><p><br />
</p><p>Based on this information and what you learned in the section above:&nbsp;
</p>
<ul><li>Plan your subjective assessment - Make sure you cover all sections <br />of the CGA<br />
</li><li>Plan your objective assessment<br />&nbsp;
</li></ul>
<p>You will be able to read the full case study with the subjective and <br />objective assessment after the treatment section.&nbsp;
</p>
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<p><br />
</p><p><br />
</p><p>&nbsp; &nbsp;
</p>
<h1> PHYSIOTHERAPY TREATMENT  </h1>
<p>Having considered the assessment, we will now move on to explore potential physiotherapy interventions in relation to learning outcomes 2 and 3.
</p><p><br />
</p><p>As previously mentioned, there are several clinical guidelines available for healthcare professionals to assist them in preventing hospital admissions providing quality care for patients. However, whilst they recommend physiotherapy intervention, these guidelines lack rigorous information and evidence surrounding treatment. This section will summarise and synthesis available evidence on physiotherapy treatment options for preventing hospital admissions in the frail elderly. As there is a lack of evidence available on the effect of physiotherapy in reducing hospital admissions in frail adults, some of the evidence here has been extrapolated from an older adult population and using outcome measures that are thought to reduce likelihood of admission, for example, falls risk.
</p><p><br />
</p><p>As two thirds of NHS clients are aged 65 or over<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Philp 2007">Philp I. A recipe for care – not a single ingredient. London: Department of Health, 2007.</span>, there is a plethora of different occasions in which an older person may be admitted to hospital, however it can be loosely split in to two categories: injury and illness <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Albert et al 2013">Albert M, McCaig LF, Ashman JJ. Emergency department visits by person aged 65 and over: United States, 2009-2010. Hyattsville, MD: National Center for Health Statistics, 2013</span>.&nbsp;For the purpose of condensing this learning resource and delivering the information you are more likely to need, we will consider the more common admission causes that the physiotherapist can play a part in preventing. However, some of the information provided here could be transferable to other cases.&nbsp;<br />
</p>
<h3> Injury<br />  </h3>
<p>Injuries leading to hospitalisation are more common in people over 65 and they can be more critical and more often preventable. The increasing age of the population heightens the significance of this problem<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Rothschild et al. 2000">Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Archives of Internal Medicine 2000; 160; 2717-28</span>.
</p><p><br />
</p><p>Falls represent the most frequent and serious type of accident in people aged 65 and over in the UK <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Age UK 2010">Age UK. Stop Falling: Start Saving Lives and Money. London: Age UK, 2010.</span>. Gowing and Jain<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Gowing and Jain 2007">Gowing R, Jain MK. Injury patterns and outcomes associated with elderly trauma victims in Kingston, Ontario. Can J Surg 2007; 50; 437-44</span> found that a fall is the most common mechanism of injury in elderly trauma patients presenting to accident and emergency units (figure 1) and falls cases are the most common presentation to the Scottish Ambulance Service in the older adult population<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Scottish Government. Up and About or Falling Short? – A Report of the Findings of a Mapping of Services for Falls Prevention in Older People. Edinburgh: Scottish Government, 2012.</span>
</p>
<table width="200" cellspacing="1" cellpadding="1" border="1" align="center">
<caption> Figure 1 <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Gowing and Jain 2007">Gowing R, Jain MK. Injury patterns and outcomes associated with elderly trauma victims in Kingston, Ontario. Can J Surg 2007; 50; 437-44</span>&nbsp;
</caption>
<tr>
<th scope="col"> <img src="/images/6/64/Pie_chart_hospital_admissions.PNG" _fck_mw_filename="Pie chart hospital admissions.PNG" alt="" />
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<p><br />
</p><p><br />
</p><p>A fall is an incident which results in a person coming to rest unintentionally on the floor or ground or other lower level<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">World Health Organisation. WHO global report on falls prevention in older age. Geneva, Switzerland: World Health Organisation, 2007.</span> and can result in fracture, dislocation, traumatic brain injury and even death<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Tinetti 1995">Tinetti ME, Doucette J, Claus E, et al. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995; 43; 1214-1221</span>. Anyone can have a fall, however, the natural ageing process means that older people are at higher risk. Over 400 risk factors leading to falls have been highlighted including muscle weakness, impaired balance, delayed reaction time, poor vision, polypharmacy and co-morbidities such as dementia, cardiovascular disease and hypotension (table 3)<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Skelton 1995">Skelton DA, Dinan SM. Exercise for falls management: rationale for an exercise programme aimed at reducing postural instability. Physiotherapy Theory and Practice 1999; 15; 105-20</span>. Additionally, several extrinsic factors that could lead to falls have been suggested, including poor lighting, cluttered environment and ill-fitting footwear. The risk of falls and related complications increase gradually with age and can be an indication of increasing frailty<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Fried 2001">Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol Ser A-Biol Sci Med Sci 2001; 56; 146-56</span>. Falls represent the main cause of disability and are the leading cause of morbidity and mortality among people over 75 in the UK. Not all falls will result in injury, however in some cases a fall could be fatal and it is thought that the repercussions of even a minor fall could have catastrophic effects on physical and mental health<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Age UK 2010" />.
</p><p><br />
</p>
<table width="200" cellspacing="1" cellpadding="1" border="1" align="center">
<caption> Table 3&nbsp;<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Skelton 1995">Skelton DA, Dinan SM. Exercise for falls management: rationale for an exercise programme aimed at reducing postural instability. Physiotherapy Theory and Practice 1999; 15; 105-20</span>
</caption>
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<td> <img src="/images/6/6a/Risk_factors_falls.PNG" _fck_mw_filename="Risk factors falls.PNG" alt="" />
</td></tr></table>
<p><br />
</p><p><br />
</p><p>Despite these statistics, falls are not an inevitable consequence of old age. A multifaceted interaction of several risk factors relating to the ageing process, lifestyle choices, environmental factors and the presence of long term conditions determines an individual’s risk of falling<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Age UK 2010" />. As risk increases with age and it is important for the physiotherapist identify those at risk early, recognise and modify risk factors and provide timely intervention to prevent falls and subsequent injury<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="CSP Falls 2016">CSP. Physiotherapy works: Falls and frailty. http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/falls-and-frailty (accessed 8 Jan 2016)</span>.
</p><p><br />
</p><p>A summary of some potential treatment options follows. This list is not exhaustive. <br />
</p><p><br />
</p>
<h4> Resistance training  </h4>
<p><img src="/images/thumb/e/e8/Weights.png/200px-Weights.png" _fck_mw_filename="Weights.png" _fck_mw_location="right" _fck_mw_width="200" _fck_mw_height="200" alt="" class="fck_mw_right" />
</p><p>A significant component of age-related weakness and frailty is sarcopenia. Sarcopenia is the gradual loss of muscle tissue, resulting in diminished strength<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Janssen 2002">Janssen I, Heymsfield SB, Ross R, et al. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. J Am Geriatr Soc 2002; 50; 889-96.</span> and it is thought that 2% of skeletal muscle mass is lost each year past the age of 50<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Hughes 2002">Hughes VA, Frontera WR, Roubenoff R, et al. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am J Clin Nutr 2002; 76; 473-81</span>. Sarcopenia increases the risk of frailty and falls and in turn, hospitalization in the older adult population<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Sousa AS, Guerra RS, Fonseca I, et al. Sarcopenia and length of hospital stay. Eur J Clin Nutr 2015.</span>. Resistance training has been suggested as a potential treatment for sarcopenia and its prevention. Resistance training is designed to improve muscular fitness by exercising a muscle or a muscle group against resistance<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Azeem K, Al Almeer A. Effect of weight training programme on body composition, muscular endurance, and muscular strength of males. Annals of Biological Research 2013; 4; 154-6</span>.&nbsp;This could lead to improved function, increased quality of life and reduced likelihood for falls<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Burton LA, Sumakadas D. Optimal management of sarcopenia. Clin Interv Aging 2010; 5; 217-28</span>. Resistance training programmes have consistently shown to improve muscle strength and mass in older adults<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Liu CJ, Latham NK. Progressive resistance training for improving physical function in older adults (Cochrane review). Cochrane Database Syst Rev 2009; (3); CD002759</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Seynnes O, Fiatarone Singh MA, Hue O. Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. J Gerontol Ser A-Biol Sci Med Sci 2004; 59A; 503-9</span><b>Seynnes et al 2004)</b>, however, it is questionable whether this transfers to reducing the risk of falling.
</p><p><br />
</p><p><br />
</p><p>Latham and colleagues<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Latham NK, Anderson CS, Lee A, et al. A randomized, controlled trial of quadriceps resistance exercise and vitamin D in frail older people: The frailty interventions trail in elderly subjects (FITNESS). J Am Geriatr Soc 2003; 51; 291-99</span> have conducted the only trial which has studied the effect of seated resistance training on risk of falls in an older adult population. This study solely involved home-based, progressive, seated quadriceps strength exercises using 60-80% of the individuals 1RM with ankle weights. It was found to have no effect on falls rate or risk of falling and an increased chance of musculoskeletal injury. As a result, seated resistance training or high intensity resistance are not recommended.
</p><p>Furthermore, Liu-Ambrose and colleagues<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Liu-Ambrose T, Khan KM, Eng JJ, et al. Both resistance and agility training reduce fall risk in 75-85 year old women with low bone mass: a six-month randomized controlled trial. J Am Geriatr Soc 2004; 52; 657-65</span> examined the effect of a course of 50-minute resistance training sessions, twice weekly for 25 weeks on number of falls and risk of falls in a female population aged 75-85. Exercises included targeted upper limb, trunk and lower limb muscles and again, resistance training alone was found to have no significant effect on number of falls or risk of falls. However, when combined with agility training, participants did develop a decreased risk of falling.
</p><p>It has been proposed that strength training alone is not enough to fully manage falls risk, however, it should be part of a multi-component falls prevention exercise programme<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Sherrington 2011">Sherrington C, Tiedemann A, Fairhall N, et al. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 2011; 22; 78-83</span>. We will discuss this in further detail later on in the wiki. <br />
</p><p><br />
</p><p>&nbsp;
</p>
<h4> Balance re-education  </h4>
<p>Balance disorders are very common in older adults and are a key cause of falls in this population. They are associated with reduced level of function, as well as an increased risk of disease and death. Most balance disorders comprise of several contributing factors including long-term conditions and medication side effects<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Rubenstein, LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 2006; 35.</span>.
</p><p>Recent research conducted examined the effectiveness of two-year progressive balance retraining in reducing injurious falls among community-dwelling women aged 75-85<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">El-Khoury F, Cassou B, Latouche A, et al. Effectiveness of two-year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: Ossebo randomised controlled trial. BMJ 2015; 22.</span>. The study took place over 20 centres and recruited 706 participants who were randomised in to the intervention group, who received weekly dynamic balance exercise supplemented by prescribed home exercise, or the control group, who did not take part in the exercise. Over the two-year intervention period, there were 397 injurious falls in the control group compared with 305 in the intervention group, the injurious fall rate was 19% lower in the intervention group than in the control group highlighting the benefit of a balance training programme.
</p><p><br />
</p><p><img src="/images/thumb/c/c1/Enjoying_the_wii.png/371px-Enjoying_the_wii.png" _fck_mw_filename="Enjoying the wii.png" _fck_mw_location="left" _fck_mw_width="390" _fck_mw_height="250" alt="" class="fck_mw_left" />
</p><p>Exergaming is a relatively new treatment concept and is thought to increase motivation and enjoyment for users. <br />The Nintendo Wii has a built in pressure sensor that allows for feedback to be delivered to the user on their performance. <br />There is evidence that a Wii based balance exercise programme could improve balance ability in the frail elderly population<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Laufer Y, Dar G, Kodesh E. Does a Wii-based exercise program enhance balance control of independently functioning older adults? A systematic review. Clin Interv Aging 2014; 9; 1803-13</span>, so as a result, Fu and colleagues<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Fu AS, Gao KL, Tung AK, et al. Effectiveness of exergaming training reducing risk and incidence of falls in frail older adults with a history of falls. Phys Med Rehabil 2015; 96; 2096-102.</span> conducted research into whether this would transfer to reducing fall risk and incidence. <br />Sixty participants aged 65 or over received balance training three times per week for six weeks. They were randomly allocated into the intervention group who undertook balance activity on the Wii, or the control group who received conventional exercise. <br />The results showed that while both groups reduce their risk and incidence of falls, the intervention group showed a more significant improvement.<br />
</p><p>The Wii balance training has shown to reduce falls by 69% compared with conventional training. Additionally, the intervention group had a 35% improvement in the fall risk score, considerably greater than that of the conventional balance training at 11%. As a result, the use of the Nintendo Wii for balance re-education is highly recommended and perhaps this suggests the need for further research on various other computer games available.
</p><p><br />
</p><p>Exercise aimed at improving balance control has been proven to be a key component in falls prevention. It will be explored further in the multi-component falls prevention programme section of this wiki.<br />&nbsp;&nbsp;<br />
</p>
<h4> Tai Chi  </h4>
<p>Tai chi is a newly emerging exercise incorporating breathing, relaxation and slow and gentle movements with strengthening and balance exercises. Whilst originally an ancient 13th century Chinese martial art, it has recently become more prevalent around the world as a health-promoting exercise<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS Choices. A guide to tai chi. http://www.nhs.uk/Livewell/fitness/Pages/taichi.aspx (accessed 8 Jan 2016)</span>. Whilst there is room for more rigorous research on the health benefits of tai chi, it is thought that it could help adults aged 65 and over in improving balance<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Song R, Ahn S, So H, et al. Effects of t’ai chi on balance: a population-based meta-analysis. J Altern Complement Med 2015; 21; 141-51</span>, reducing stress<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Li F, Duncan TE, Duncan SC, et al. Enhancing the psychological well-being of elderly individuals through tai chi exercise: A latent growth curve analysis. Structural Equation Modelling: A Multidisciplinary Journal 2001; 8; 53-83</span> and controlling osteoarthritis pain<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Kang JW, Lee MS, Posadzki P, et al. T’ai chi for the treatment of osteoarthritis: a systematic review and meta-analysis. BMJ Open 2009; 1.</span>. Additionally, in a high quality systematic review, tai chi was not only found to significantly reduce rate of falls, but also lessen risk of falls<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Gillespie 2012">Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community (Cochrane review). Cochrane Database Syst Rev 2012; (2): CD007146</span>. As tai chi is considered a low impact exercise, it is suitable for most to participate in and should be considered as a treatment option although some may require assistance in locating a suitable local group for them to join.&nbsp;
</p><p><br />
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<p><br />Watch this useful video clip<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Tufts Health Plan Foundation. The Benefits of Tai Chi for Older Adults. https://www.youtube.com/watch?v=D-GFreeZTow (accessed 20 Jan 2016).</span> highlighting&nbsp;the benefits of tai chi&nbsp;through several interviews.<br />Take 5 minutes to&nbsp;reflect upon the opinion of the participants.
</p><p>Consider these questions:  
</p>
<ul><li>What did they enjoy?
</li></ul>
<ul><li>What health benefits did they see?<br />
</li></ul>
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<td> <span class="fck_mw_template">{{#ev:youtube|D-GFreeZTow|575}}</span>
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<p><br />
</p><p><br />
</p>
<h4> Backward Chaining  </h4>
<p>Declining muscle function in older adults reduces their ability to rise from the floor following a fall and up to a half of all non-injured fallers are unable to get up<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Skelton D, Dinan SM, Campbell M, et al. Tailored group exercise (Falls Management Exercise – FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34; 636-639</span>. When someone is unable to get up off the floor unassisted, the associated risks are far greater due to the complications that can occur from lying on the floor for an extended period of time – for example, dehydration, hypothermia, pneumonia, pressure sores, unavoidable incontinence and even death<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Tinetti 1993">Tinetti ME, Liu WL, Claus EB, et al. Predictors and prognosis of inability to get up after falls among elderly persons. JAMA 1993; 269; 65-70</span>. This inability to get up has a poor prognosis in terms of hospitalisation and mortality<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Tinetti 1993" />, thus, a long lie is one of the most serious consequences of a fall. The responsibility of the physiotherapist is to ensure the patient has a plan should they fall and are unable to rise and educate them about available strategies to combat this<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Reece A, Simpson JM. Teaching elderly people how to cope after a fall. Physiotherapy 1996; 82; 27-35</span>
</p><p><br />
</p><p>Backward chaining is a method utilised to re-educate patients in rising from the floor unassisted. It consists of a sequence of movements combined together to help teach someone to be able to get down to the floor safely. Once learnt, the sequence is reversed and is applied to teach a safe and effective way to get up from the floor.
</p><p><br />
</p><p>The movement is broken into several stages depending on the patient’s ability. The patient will complete one stage, then return to a stand. Then they will add on the next stage and return to a stand. This is repeated until the patient is able to stand from a lying on the floor.
</p>
<table width="200" cellspacing="1" cellpadding="1" border="1" align="center">
<caption> Backward Chaining, adapted from NHS Sutton and Merton Community Services&nbsp;<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS Sutton and Merton Community Services. Getting on and off the floor safely. London: Staying Steady Falls Prevention Service, 2012</span>
</caption>
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<td> <img src="/images/7/7e/BackwardChaining.png" _fck_mw_filename="BackwardChaining.png" _fck_mw_location="center" alt="" class="fck_mw_center" />
</td></tr></table>
<p><br />
</p><p>The effect of backward chaining on an individual’s ability to rise unassisted from the ground has been proven to be beneficial. In the only study to compare backward chaining with a control of conventional therapy, it was found that backward-chaining method significantly enhances ability in rising after an incidental fall (20-40%)<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Zak M, Skalska A, Szczerbinska K. Instructional programmes on how to rise unassisted effectively after sustaining an incidental fall, designed specifically for the elderly: a randomized, controlled trial. Ortop Traumatol Rehabil 2008; 10; 496-507</span>. The control group showed no improvement. The study took part over 12 weeks and included 120 participants aged 80-99. Additionally, Timed Up and Go and Tinetti measurements were also compared before and after the intervention and control and a notable improvement was only observed from the intervention group. This highlights the benefits for improving functional capabilities in addition to rising abilities.
</p><p><br />
</p>
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<p><br /> If you are unfamiliar with backward chaining, take 20 minutes to practice a routine yourself.
</p><p>As you are completing a chain, think about giving clear and concise instructions;
</p><p>the concept of backward chaining can sometimes be confusing.
</p><p>This should make it easier to teach to a patient.
</p><p>Make sure you have plenty of space around you. The only equipment required is a chair.
</p><p><br />
</p>
</td></tr></table>
<p><br />
</p>
<h4> Fear of falling  </h4>
<p>The prevalence of fear of falling in community-dwelling older adults ranges between 12% and 65%<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Legters K. Fear of falling. Phys Ther 2002; 82; 264-272</span>. Whilst it frequently occurs after falls<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Tinetti 1994">Tinetti ME, Medes de Leon CF, Doucette JT, et al. Fear of falling and fall-related efficacy in relationship to functioning among community-living elders. Journal of Gerontology Medical Sciences 1994; 49; 140-7</span>, it is also established in those without a fall history<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Vellas BJ, Wayne SJ, Pomero LI, et al. Fear of falling and restriction of mobility in elderly fallers. Age Ageing 1997; 26; 189-93</span>. It can lead to a loss of independence, activity restriction and ultimately a poorer quality of life<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Donoghue OA, Cronin H, Savva GM, et al. Effects of fear and falling and activity restriction on normal and dual task walking in community dwelling older adults. Gait and Posture 2013; 38; 120-4</span>. Not all will avoid ADL’s due to fear avoidance but for those who do, it can have debilitating and devastating effects<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Delbaere K, Crombez G, Vanderstraeten G, et al. Fear-related avoidance of activities, falls and physical frailty. A prospective community-based cohort study. Age and Ageing 2004; 33; 368-73</span>
</p><p><br />
</p><p>Lethem et al<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Lethem">Lethem J, Slade PD, Troup JD, et al. Outline of a fear-avoidance model of exaggerated pain perception – I. Behaviour Research and Therapy 1983; 21; 401-8</span> introduced the psychiatric concept of a fear avoidance model and is it is commonly utilised in the prevention of acute musculoskeletal pain becoming chronic<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Leeuw M, Goossens MEJB, Linton SJ, et al. The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence. Journal of Behavioural Evidence 2007; 30; 77-94.</span>. However, the hypothesis behind the model can be adapted to explain fear of falling and avoidance of activity. Extreme avoidance can lead to a decline in physical function, and ultimately an increased risk of falls, further fuelling fear and avoidance of activities. This is illustrated in the below fear avoidance model, adapted from Lethem et al<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Lethem" />.<br />
</p><p><br />
</p>
<table width="200" cellspacing="1" cellpadding="1" border="1" align="center">
<caption> Adapted fear avoidance model<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Lethem" />
</caption>
<tr>
<td> <img src="/images/3/38/Fear_avoidance_model_%28Falls%29.PNG" _fck_mw_filename="Fear avoidance model (Falls).PNG" _fck_mw_location="center" alt="" class="fck_mw_center" />
</td></tr></table>
<p><br />
</p><p><br />
</p><p>The physiotherapist is in an ideal position to steer the individual towards the route of confrontation and recovery as opposed to activity avoidance and disability<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="CSP Falls 2016" />. There is high quality evidence from two systematic reviews highlighting the benefits of treatment to improve confidence and reduce fear of falling<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Zijlstra GAR, van Haastregt JCM, van Rossum E. Interventions to reduce fear of falling in community-living older people: a systematic review.  J Am Geriatr Soc 2007; 55; 603-15</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Rand D, Miller WC, Yiu J, et al. Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis. Age Ageing 2011; 40; 297-206</span>. Recommended interventions include: exercise, including tai chi, and multi-component falls prevention programmes.
</p><p><br />
</p>
<h4> Multi-component falls prevention programmes  </h4>
<p><img src="/images/thumb/9/98/Falls_class.png/594px-Falls_class.png" _fck_mw_filename="Falls class.png" _fck_mw_location="center" _fck_mw_width="850" _fck_mw_height="300" alt="" class="fck_mw_center" /><br />
</p><p>Finally, we will consider the effect of a multi-component falls prevention programme. As most falls are multifactorial in origin, they usually require several interventions<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Hausdorff JM, Nelson ME, Kaliton D, et al. Etiology and modification of gait instability in older adults: a randomised controlled trial of exercise. J Appl Phys 2001; 90; 2117-29</span>. Such interventions typically involve a combination of medication review and optimization and education, environmental modification and exercise. This type of programme would be delivered by a multidisciplinary team in which the physiotherapist would be a key member. A Cochrane systematic review suggests that the physiotherapy treatment should combine all elements mentioned above; that is strengthening, balance, backward chaining, tai chi and confidence building with education, tailored to each individual. Clinic-based group exercise or individual exercise in the home setting is suitable. However, further research is needed into the effectiveness of medication management in preventing falls<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Gillespie 2012" />.
</p><p>Additionally, in a systematic review, it was reported that for the greatest effect, exercise programmes should include a high level challenge to balance, alongside strength and walking training<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Sherrington 2011" />. However, brisk walking training should not be prescribed to those at a high risk of falls. Furthermore, it was found that exercise should not only target those at high risk but the also the general community and it should be performed for at least two hours per week on an ongoing basis.
</p><p><br />
</p><p><b>Learning activity</b>
</p>
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<p><br />
</p>
<ul><li>Write down the key points you have learned from Section 6.1 Injury.
</li><li>Expand the picture below and compare your answers.<br />&nbsp;<br />This activity should take 15 minutes.
</li></ul>
</td></tr></table>
<p><br />
</p><p><img src="/images/thumb/d/d8/Key_points_treatment.PNG/180px-Key_points_treatment.PNG" _fck_mw_filename="Key points treatment.PNG" _fck_mw_location="center" _fck_mw_type="thumb" alt="" class="fck_mw_frame fck_mw_center" />
</p><p><br />
</p>
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<ul><li><a href="http://agile.csp.org.uk/documents/guidelines-physiotherapy-management-older-people-risk-falling?networkid=338430">AGILE guidelines for physiotherapy management of older people at risk of falling</a>.&nbsp;<br />AGILE is the CSP’s professional network for members working with older people.<br />
</li></ul>
<ul><li><a href="http://www.westlothian.gov.uk/localgroups">West Lothian Council database for local groups.</a>&nbsp;Search for activites available in <br />the area.This website is also a useful resource you can direct patients to.<br /> &nbsp;
</li></ul>
<ul><li><a href="http://www.bridgewater.nhs.uk/wp-content/uploads/2012/11/Bridgewater-backward-chaining.pdf">NHS Bridgewater Falls Leaflet</a>. Does your trust have something similar?
</li></ul>
<p><br />
</p>
</td></tr></table>
<p><br />
</p>
<h3> Illness<br />  </h3>
<p>For many people, older age is associated with long term conditions such as heart failure, dementia, chronic obstructive pulmonary disease (COPD) and diabetes. <br />As we know frailty is known as the decreased ability to withstand illness. Exacerbation of chronic conditions, an acute illness or a combination of both can trigger acute disability in frail older people and cause hospitalisation or institutionalisation<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Think Frailty" /> .<br /><br />Therefore, this next section will discuss the physiotherapists’ role in promoting self-management of long term conditions and physical activity. Information on how to motivate people for behavior change will also be presented.
</p><p><br />
</p>
<h4> Self-management  </h4>
<p>Emergency hospital admissions is a major concern for the NHS. There are a number of factors associated with increased rates of admission including area of residency, ethnicity, socio-economic deprivation and environmental factors. Older people are also identified as being at a&nbsp; higher risk of hospital admittance<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="King10">The King's Fund. Avoiding hospital admissions: What does the research evidence say?. http://www.kingsfund.org.uk/publications/avoiding-hospital-admissions (accessed 11 Jan 2016)</span>.<br />
</p><p>In Scotland, 40% of the population have at least one long term condition (LTC). People with LTCs and co-morbidities are known to have poorer clinical outcomes, poorer quality of life and longer hospital stays<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="KingGoodwin">The King's Fund. Managing people with long-term conditions. http://www.kingsfund.org.uk/sites/files/kf/field/field_document/managing-people-long-term-conditions-gp-inquiry-research-paper-mar11.pdf (accessed 17 Nov 2015)</span>.<br /><br />The Scottish Government<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">The Scottish Government. Long Term Conditions.fckLRhttp://www.gov.scot/Topics/Health/Services/Long-Term-Conditions (accessed 20 Nov 2015)</span>&nbsp;reports that people with LTCs are twice as likely to be admitted to hospital.&nbsp;The aging population and the increase prevalence of long term conditions requires healthcare professionals to move their focus towards preventative strategies and empowering self-management<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="King15">The King's Fund. Transforming our health care system. http://www.kingsfund.org.uk/publications/articles/transforming-our-health-care-system-ten-priorities-commissioners (accessed 11 Jan 2016)</span>.<br />
</p><p><br />
</p><p><img src="/images/2/29/Selfmanagement_NHS.jpg" _fck_mw_filename="Selfmanagement NHS.jpg" _fck_mw_location="center" _fck_mw_width="400" alt="" class="fck_mw_center" />
</p><p>Disease-related self-management abilities such as taking medication and exercise are often promoted by health care professionals. <br />However, there may also be a need for interventions aimed at self-management of overall health and well-being to contribute to healthy aging<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cramm2013">Cramm JM, Hartgerink JM, Steyerberg EW, Bakker TJ, Mackenbach JP, Nieboer AP. Understanding older patients’ self-management abilities: Functional loss, self-management, and well-being. Qual Life Res, 2013;22:85–92. http://www.ncbi.nlm.nih.gov/pubmed/22350532 (accessed 11 Jan 2016)</span>.&nbsp;Older peoples’ abilities to self-manage the aging process depends on physical, psychological and social aspects of their life<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cramm2014">Cramm JM, Twisk J, Nieboer AP. Self-management abilities and frailty are important for healthy aging among community-dwelling older people; a cross-sectional study. BMC Geriatrics 2014;14:28.fckLR http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-28 (accessed 11 Jan 2016)</span>. <br /><br />Physiotherapists working with frail older people could play a role in promoting healthy aging as evidence shows that interventions to promote healthy aging can be used to the delay the onset of frailty and reduce its adverse outcomes among older people<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cramm2014" />.
</p><p>As older people often have co-morbidities leading to a mixture of physical and psychosocial issues, self-management interventions should focus on providing them with general behavioral and cognitive skills for dealing with range of problems rather than focusing on on health-related problems only<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cramm2013" />.
</p><p><br />It is out with the scope of this learning resource to go into detail about how to promote self-management strategies as you are likely to see a range of diverse patients presenting with multiple conditions and challenging psychosocial issues. Your treatment plan will depend on the patient's presenting condition. However, as physiotherapists we believe our main role within self-management can be to promote physical activity to contribute to the healthy aging process. Therefore, this will be discussed in more detail in <a href="http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist%27s_Role_in_Preventing_Hospital_Admission#Physical_activity">Section 6.2.2 – Physical activity</a>.<br /><br />Please see additional reading to access useful resources in relation to promoting self-management.<br />&nbsp;&nbsp;<br />&nbsp;<br />
</p><p><b>Resources</b>
</p>
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<p><img src="/images/a/a4/Additional_reading_heading.png" _fck_mw_filename="Additional reading heading.png" _fck_mw_location="center" _fck_mw_width="600" alt="" class="fck_mw_center" />
</p>
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<p>The King’s Fund have published evidence based information on&nbsp;self-management <br />in response&nbsp;to a growing interest amongst policy-makers, healthcare professionals<br />and patients<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Self management LTC">The King’s Fund. Self-management for Long-Term Conditions: Patients’ perspectives on the way ahead. http://www.kingsfund.org.uk/publications/self-management-long-term-conditions (accessed 7 Jan 2016)</span><span style="line-height: 1.5em; font-size: 13.28px;">.</span>
</p>
<ul><li><a href="http://www.kingsfund.org.uk/publications/articles/transforming-our-health-care-system-ten-priorities-commissioners">Transforming our health care system</a><br />This publication provides information on how to shift the emphasis on <br />acute care towards prevention and self-management in order to cope <br />with the aging&nbsp;population and the increased prevalence of long term conditions<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="KingGoodwin" />.<br /><br />
</li><li><a href="http://www.kingsfund.org.uk/publications/self-management-long-term-conditions">Self-management for Long-Term Conditions (Patients’ perspectives)</a><br />This paper reviews patients' perceptions about self-managing their <br />conditions and identifies how healthcare professionals can support them to do so<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Self management LTC" />.<br /><br />
</li><li>Browse the website <a href="http://www.myconditionmylife.org/professional-resources/about-self-management/">my condition, my terms, my life for information</a>&nbsp;on<br />self-management and how you as a healthcare professional can help facilitate this<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="My CTL">My condition, my terms, my life. Professional Resources: About self management. fckLRhttp://www.myconditionmylife.org/professional-resources/about-self-management/ (accessed 14 Jan 2016)</span>.
</li></ul>
</td></tr></table>
<p><br />
</p>
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<p><b>Resources for patients</b>
</p>
<ul><li><a href="http://www.nhs24.com/">NHS 24</a> is an online and telephone-based service. <br />Call for free (111) and they can answer questions about your&nbsp;health and offer advice. Visit their website to access self-help guides and find local services in Scotland<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="NHS 24">NHS 24. NHS 24 Explained. http://www.nhs24.com/explained/services/ (accessed 14 Jan 2016)</span>.
</li></ul>
<ul><li><a href="http://www.lothianrespiratorymcn.scot.nhs.uk/for-public/">NHS Lothian’s self-management plans for COPD, bronchiectasis and asthma</a><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="RCN">NHS Lothian Respiratory Managed Clinical Network. Public Resources. http://www.lothianrespiratorymcn.scot.nhs.uk/for-public/ (accessed 14 Jan 2016)</span>.
</li></ul>
<ul><li><a href="http://shop.blf.org.uk/collections/self-management">The British Lung Foundation</a>&nbsp;have developed tools and self-management plans for people living with COPD.<br />Exercise handbooks, symptoms diary and flare up action plans&nbsp;amongst other useful information can be found on their website<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="TBLF">The British Lung Foundation. COPD self-help tools. http://shop.blf.org.uk/collections/self-management (accessed 14 Jan 2016)</span>.
</li></ul>
<ul><li><a href="http://www.chss.org.uk/chest-information-and-support/resources-to-help/order-download-publications/">Chest, Heart &amp; Stroke Scotland’s factsheets and booklets</a><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="CHSS">Chest, Heart and Stroke Scotland. Chest factsheets and booklets. http://www.chss.org.uk/chest-information-and-support/resources-to-help/order-download-publications/  accessed 14 Jan 2016)</span>.
</li></ul>
<ul><li><a href="http://www.arthritisresearchuk.org/arthritis-information.aspx">Arthritis Research UK’s information</a><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Arthritis Research UK">Arthritis Research UK. Arthritis information. http://www.arthritisresearchuk.org/arthritis-information.aspx (accessed 14 Jan 2016)</span>.
</li></ul>
<ul><li><a href="https://www.alzheimers.org.uk/site/scripts/documents.php?categoryID=200342">Alzheimers Scotland’s resources on living with dementia</a><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Alzheimers Scotland">Alzheimers Scotland. Living with Dementia. https://www.alzheimers.org.uk/site/scripts/documents.php?categoryID=200342 (accessed 14 Jan 2016)</span>.
</li></ul>
<ul><li><a href="http://www.ageuk.org.uk/publications/age-uk-information-guides-and-factsheets/#Infoguides">Age UK’s</a> information and advice guides in relation to health and wellbeing &amp; home and care<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Age UK GF">Age UK. Age UK information guides and factsheets. http://www.ageuk.org.uk/publications/age-uk-information-guides-and-factsheets/#Infoguides (accessed 14 Jan 2016</span>.<br />&nbsp;<br /><br />This list is not exhaustive but gives an idea of some resources patients can be directed to.<br />
</li></ul>
</td></tr></table>
<p>&nbsp;
</p><p>&nbsp; &nbsp;
</p>
<h4> Physical activity  </h4>
<p>Functional capacity declines with age and this is further accelerated by low levels of physical activity.<br /><br />The recommendations for physical activity for older adults (65+)<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH">Department of Health. Start active, stay active: report on physical activity in the UK. https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officersfckLR (accessed 28 Oct 2015)</span>:
</p>
<ul><li>Older adults should aim to be active daily
</li><li>At least 150 minutes a week of moderate intensity activity
</li><li>Muscle strength training twice a week in addition to the 150 minutes of activity
</li><li>Balance training and co-ordination should be incorporated into activities to manage risk of falls
</li><li>Minimise sedentary time&nbsp;
</li></ul>
<p><br />
</p><p>Physical activity significantly decreases with age. The graph below shows the percentage of men and women meeting the physical activity recommendations in Scotland<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">The Scottish Government. The Scottish Health Survey 2012. Volume 1 – Main report. http://www.gov.scot/Publications/2013/09/3684 (accessed 28 Oct 2015)</span>.
</p><p><img src="/images/thumb/c/c7/PA_levels_Scotland.png/500px-PA_levels_Scotland.png" _fck_mw_filename="PA levels Scotland.png" _fck_mw_location="center" _fck_mw_width="500" alt="" class="fck_mw_center" />
</p><p><br />&nbsp;<br /><br />
</p><p><b>Benefits of physical activity in frail older adults</b>
</p><p>Strength, endurance, balance and bone density is lost about 10% per decade, while muscle power reduces with around 30% per decade<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHF11">The British Heart Foundation National Centre for Physical Activity and Health. Interpreting the UK physical activity guidelines for older adults in transition. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/39/429/index.html (accessed 17 Oct 2015)</span>. Sarcopenia is highly prevalent among older adults and has been identified as a risk factor for frailty<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Jansen">Jansen FM, Prins RG, Etman A, van der Ploeg HP, de Vries SI, van Lenthe FJ, Pierik, FH. Physical Activity in Non-Frail and Frail Older Adults. PLoS One 2015;10:1-15. http://www.ncbi.nlm.nih.gov/pubmed/25910249 (accessed 27 Oct 2015)</span>.<br />Being physically active slows down these physiological changes associated with aging. Physical activity can also reduce the risk of falls, promote cognitive health and self-management of chronic diseases. As well as slowing down the deterioration in ability to perform ADLs and maintain quality of life in older adults<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Chou">Chou CH, Hwang CL, Wu YT. Effect of Exercise on Physical Function, Daily Living Activities,and Quality of Life in the Frail Older Adults: A Meta Analysis. Arch Phys Med Rehabil 2012;93:237-44.fckLRhttp://www.sciencedirect.com/science/article/pii/S0003999311008173 (accessed 16 Oct 2015)</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Weeks">Weeks LE, Profit S, Campbell B, Graham H, Chircop A, Sheppard-LeMoine D. Participation in Physical Activity: Influences Reported by Seniors in the Community and in Long-Term Care Facilities. Journal of Gerontological Nursing 2008;34:36–43. http://www.healio.com/nursing/journals/jgn/2008-7-34-7/%7Bf65345f8-58ac-4381-a607-f663b5d57d53%7D/participation-in-physical-activity-influences-reported-by-seniors-in-the-community-and-in-long-term-care-facilities (accessed 7 Jan 2016)</span>.
</p><p>A meta-analysis<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Chou" />&nbsp;found that exercise is beneficial to improve balance, gait speed and abilities to carry out ADLs in the frail older adults.
</p><p><br />&nbsp;<br /><b>Factors influencing participation in physical activity in older adults</b><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Factors">The British Heart Foundation National Centre for Physical Activity and Health. Factors influencing physical activity in older adults. http://www.bhfactive.org.uk/resources-and-publications-item/18/404/index.html (accessed 11 Jan 2016)</span><b><br /></b><br />Older peoples’ participation in physical activity can be effected by biological, demographic, physiological and social factors<br />These factors are important to be aware of when attempting to motivate older people to increase their activity levels.
</p>
<ul><li>Men are more active then women
</li><li>A decline in physical activity with age is higher among: minority ethnic groups, those from lower socio-economic backgrounds, those with lower education and those living alone
</li><li>Older people might be less able due to pain, reduced mobility and the need of assistance to mobilise<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Weeks" />
</li><li>Physical activity can be influenced by trusted others such as health care professionals, care givers, family and friends
</li><li>Lack of transport often affects older peoples abilities to part take in activity<br />
</li></ul>
<p>Psychological factors that can positively affect participation
</p>
<ul><li>Beliefs and confidence in abilities to active
</li><li>General values, beliefs and attitudes
</li></ul>
<p><br />Psychological factors that can negatively affect participation
</p>
<ul><li>Fear of falling and over exertion
</li><li>Safety concerns<br /><br />&nbsp;
</li></ul>
<p><b>Physiotherapists role in promoting physical activity in frail older adults<br /></b><br />Due to their training and experience, physiotherapists are in a good position to promote health and wellbeing of individuals and the community through education on physical activity and exercise prescription<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Verhagen">Verhagen E, Engbers L. The physical therapist’s role in physical activity promotion. Br J Sports Med 2009;43:99–101. http://bjsm.bmj.com/content/43/2/99.abstract (accessed 28 Oct 2015)</span>.<br />Recently there has been a shift in the general public's health agenda towards the prevention of chronic conditions and enabling the aging population to stay active and manage conditions in the community. This has required a change in the role of physiotherapist towards addressing these issues through promotion of physical activity and other lifestyle changes<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="SM">Spijker J, MacInnes J. Population ageing: the timebomb that isn’t? BMJ 2013;347:1-5. http://www.bmj.com/content/347/bmj.f6598.full.pdf+html (accessed 11 Jan 2016)</span>.<br />
</p><p><br />When encouraging physical activity, physiotherapists should also aim to<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHFAW">The British Heart Foundation National Centre for Physical Activity and Health. Physical activity interventions for older adults. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/18/405/index.html (accessed 13 Jan 2016)</span>:
</p>
<ul><li>Identify fears and barriers to being physically active and provide solutions to overcome these
</li><li>Provide ongoing support and encouragement<br />
</li></ul>
<p><br />&nbsp;&nbsp;<br /> <b>Exercises for frail older adults<br /></b><br />These are the recommended activities and intensity for frail older adults to increase physical activity in order to improve general health and well being as well as reduce the risk of falls and manage chronic lifestyle conditions:
</p>
<ul><li>Sessions as short as 10 minutes can provide health benefits<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHF11" />
</li><li>Frail older adults should aim to accumulate numerous of 10 minute sessions to achieve the recommended activity guides<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHF2012">The British Heart Foundation National Centre for Physical Activity and Health. Interpreting the UK physical activity guidelines for frailer older adults. http://www.bhfactive.org.uk/resources-and-publications-item/39/430/index.html (accessed 17 Oct 2015)</span><br />
</li></ul>
<p><br />Suggested activities:
</p>
<ul><li>Take the stairs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH" />
</li><li>Walking<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH" />
</li><li>Do housework or gardening<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH" />
</li><li>Tai Chi<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHF2012" />
</li><li>Dance<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHF2012" />
</li><li>Swimming<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH" />
</li><li>Home-based or group exercise classes<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHF11" />
</li><li>Breaking up time spent sitting with short regular periods of standing or walking<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHF2012" />
</li><li>Encourage to move for longer. E.g. Going from moving 5 minutes to 10 minutes may increase the intensity<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="BHF2012" /><br /> <br />
</li></ul>
<p><br /> <b>Did you know?<br /></b><br />There is a National Physical Activity Pathway for Secondary Care established to support all healthcare professionals to raise the issue of physical activity, offer simple advice and suggest appropriate activities<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS Health Scotland. Physical Activity. :http://www.healthscotland.com/physical-activity.aspx (accessed 13 Jan 2016)</span>.<br />
</p><p><br />
</p>
<table width="550" cellspacing="1" cellpadding="1" border="1">
 
<tr>
<td> The National Physical Activity Pathway<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="TKN" />
</td><td> &nbsp; Providing brief advice<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="TKN" />
</td></tr>
<tr>
<td> <span class="fck_mw_template">{{#ev:youtube|nmmGmFmbpmY|400}}</span>
</td><td> <span class="fck_mw_template">{{#ev:youtube|c9Oj234kGaM|400}}</span>
</td></tr></table>
<p>If you prefer reading about The National Physical Activity Pathway please access the document <a href="http://www.healthscotland.com/documents/21759.aspx">Physical Activty Pathway in Secondary Care</a><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">NHS Health Scotland. Publication: Physical Activity Pathway For Secondary Care. http://www.healthscotland.com/documents/21759.aspx (accessed 13 Jan 2016)</span>.<br />&nbsp; &nbsp;
</p><p><b>Resources</b>
</p>
<table width="500" cellspacing="1" cellpadding="1" border="1" align="center">
 
<tr>
<td> <img src="/images/thumb/a/a4/Additional_reading_heading.png/500px-Additional_reading_heading.png" _fck_mw_filename="Additional reading heading.png" _fck_mw_location="center" _fck_mw_width="500" alt="" class="fck_mw_center" />
</td></tr>
<tr>
<td>
<ul><li><a href="https://www.gov.uk/government/publications/uk-physical-activity-guidelines">UK Physical Activity Guidelines</a><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="DOH" />&nbsp;presents recommendations&nbsp;<br />on how much physical activity people should be doing in relation to their age. <br />
</li></ul>
<ul><li><a href="https://www.youtube.com/playlist?list=PLdtTilZi8S7-8perBH8buYgW2GGTPZXpL">Watch the full “Every step counts” video series from NHS Scotland</a><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="TKN">The Knowledge Network. NHS Physical Activity Promotion. http://www.knowledge.scot.nhs.uk/home/portals-and-topics/health-improvement/hphs/nhs-physical-activity-promotion.aspx (accessed 13 Jan 2016)</span>
</li></ul>
</td></tr></table>
<p><br />
</p>
<table width="450" cellspacing="1" cellpadding="1" border="1" align="center">
 
<tr>
<td>
<p><b>Resources for patients</b>
</p>
<ul><li><a href="http://www.activescotland.org.uk/">Active Scotland</a>&nbsp;can assist with finding places to go to be active near you&nbsp;sports centres, community halls, parks, gyms, climbing walls,&nbsp;woodlands, swimming beaches, national cycle routes,<br /> and lots more<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Active Scotland">Active Scotland. Lets get active. http://www.activescotland.org.uk/ (accessed 13 Jan 2016)</span>.<br /><br />
</li><li><a href="http://www.edinburghleisure.co.uk/activities/older-adult-activities/older-adult-sportexercise-activities">Edinburgh Leisure’s website</a> can assist with finding activities in Lothian for older adults<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="EL">Edinburgh Leisure. Older Adult Sport/Exercise Activities. http://www.edinburghleisure.co.uk/activities/older-adult-activities/older-adult-sportexercise-activities (accessed 26 Jan 2016)</span>.<br />&nbsp; &nbsp;
</li><li><a href="http://www.edinburghleisure.co.uk/activities/older-adult-activities/older-adult-sportexercise-activities/steady-steps">Steady steps</a> is one of the group based activities run by Edinburgh Leisure in partnership with NHS Lothian. <br />This programme delivers group exercise classes for older people <br />who have had a fall or are at risk of falling<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Steady steps">Edinburgh Leisure. Steady steps. http://www.edinburghleisure.co.uk/activities/older-adult-activities/older-adult-sportexercise-activities/steady-steps (accessed 26 Jan 2016)</span>.<br /><br />
</li></ul>
<ul><li><a href="http://www.healthscotland.com/documents/20649.aspx">Get active your way every day</a>.&nbsp;This guide is aimed at young adults, adults and older people and provides information about being active. It is designed for healthcare professionals to give to their patients<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Get active">NHS Health Scotland. Publication: Get Active Your way. http://www.healthscotland.com/documents/21759.aspx (accessed 13 Jan 2016)</span>.<br />
</li></ul>
<ul><li><a href="http://www.ageuk.org.uk/health-wellbeing/keeping-fit/">Age UKs</a>&nbsp;advice on how to keep fit<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Keeping fit">Age UK. Keeping fit. http://www.ageuk.org.uk/health-wellbeing/keeping-fit/ (accessed 13 Jan 2016)</span>.<br /><br />This list is not exhaustive but gives an idea of some resources patients can be directed to<br />
</li></ul>
</td></tr></table>
<p><br />
</p>
<h4> Motivation  </h4>
<p>What is Motivation?
</p><p>Motivation can be defined as the processes that explains an individual’s intensity, direction and persistence of effort towards <br />achieving a goal.&nbsp;Motivation often stems from a need we must fulfil and this leads to a specific behaviour<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Lambro">Lambro P, Kontodimopoulos N, Niakas D. Motivation and job satisfaction among medical and nursing staff in a Cyprus public general hospital. Human Resources for Health 2010; 8:1-9. http://www.human-resources-health.com/content/pdf/1478-4491-8-26.pdf (accessed 21 Jan 2016)</span>.<br />
</p><p><img src="/images/thumb/2/2b/Maslow.png/300px-Maslow.png" _fck_mw_filename="Maslow.png" _fck_mw_location="left" _fck_mw_width="300" _fck_mw_height="280" alt="" class="fck_mw_left" />
</p><p><br />
</p><p><br />
</p><p>In 1943, Maslow developed a theory of human motivation aiming to explain and rank all types of human needs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Jarvis">Jarvis M. Sport Psychology. http://basijcssc.ir/sites/default/files/0415206413.pdf (accessed 21 Jan 2016)</span><span style="line-height: 1.5em; font-size: 13.28px;">.</span>
</p><p>Maslow’s Hierarchy model is made up of five levels ranked in importance with the most basic needs at the bottom. In order to progress up the hierarchy the lower needs must be fulfilled. <br /><br />
</p><p><br />
</p><p><br />
</p><p><br />
</p><p>Depending on your preferred ways of learning, choose if you want to read or watch the video below to learn more about the Maslow’s Hierarchy.
</p><p>&nbsp;
</p>
<table width="800" align="center" border="1" cellspacing="1" cellpadding="1">
 
<tr>
<td> Read
</td><td> Watch Video - &nbsp;Maslow's Hierarchy of Needs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Maslow's Hierarchy of Needs. https://www.youtube.com/watch?v=Ugp3hm2JIqM (accessed 21 Jan 2016)</span>
</td></tr>
<tr>
<td>
<p>Maslow’s hierarchy model is made up of five levels represented in a pyramid with the most basic&nbsp;needs at the bottom working up to the more complex needs. <br />Physiological needs are your basic requirements for survival e.g. food, water, warmth. <br />Once the Physiological needs have been met the individual will be able to work towards fulfilling their Safety needs.<br />This continues through each level, only being able to move on to the next once the previous level has been satisfied adequately. <br /><br />Maslow’s Hierarchy provides professionals with an insight into how successful their efforts of motivation may be with individuals.&nbsp;<br />If we as healthcare professionals can gauge where our patient is according to <br />Maslow’s Hierarchy then we have a better idea of what their requirements from us may be (Simons et al).<br />For example; a patient who is currently not motivated to eat and drink would not be likely to respond well to a physiotherapist trying to get them up and on their feet. <br />It is then our job as health professionals to try and assist the patient in fulfilling their needs<br /> in order to move onto the next level of Maslow’s Hierarchy and progressing their treatment.&nbsp;<br />
</p>
</td><td> <span class="fck_mw_template">{{#ev:youtube|Ugp3hm2JIqM|400}}</span>
</td></tr></table>
<p>What motivates the elderly to exercise? <br />
</p><p>Shown in the bubbles are some factors that motivate the elderly to participate in exercise programs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Weeks 2008">Weeks LE, Profit S, Campbell B, Graham H, Chircop A, Sheppard-Lemoine D. Participation in Physical Activity. Journal of Gerontological Nursing. 2008 Jul 1;34(7):36–43.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Motivating">Resnick B, Spellbring AM. Understanding what MOTIVATES older adults to exercise. Journal of Gerontological Nursing. 2000 Mar 1;26(3):34–42.</span>.
</p><p><img src="/images/d/d6/Motivating_Factors.PNG" _fck_mw_filename="Motivating Factors.PNG" _fck_mw_location="center" alt="" class="fck_mw_center" />It is also important to note that within the study conducted by Weeks et al. there was found to be a correlation between those with a previously active lifestyle and those who were more likely to perform exercise programs<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Weeks 2008" />.
</p><p>How do we motivate?
</p><p>An article from the Journal of Gerontological Nursing<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Motivating" /> reported that education plays a large role in the motivation, highlighting the benefits of exercise in later years as many older persons will have pre conceived ideas from their younger years. It is also important to allow self-efficacy as this was also found to be motivating to the participant group. This can be achieved through patient centered goal setting.
</p><p>Muse<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Muse 2005">Muse T. Motivation and Adherence to Exercise for Older Adults. Topics in Geriatric Rehabilitation. 2005;21(2):107–115.</span> supports this idea of goal setting within the elderly population. Without goals adherence to exercise is limited. The literature again reinforces the fundamentals of effective goal setting: <br />• Person centred goals <br />• Based upon persons objectives <br />• Small goals to large goals e.g. short term and long term <br />• SMART
</p><p>Further to this it is suggested that we must show a willingness to listen to the patient and their needs and that as therapists we can draw upon the benefits of a group exercise class to help motivate the elderly as this gives them not only the physical benefits of exercise but allows them to participate in a social gathering<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Thomas B, Storey E. [place unknown: publisher unknown]. Motivating the elderly client in long-term care; 2015 Dec 28 [cited 2016 Jan 8]. Available from: http://physical-therapy.advanceweb.com/Article/Motivating-the-Elderly-Client-in-Long-Term-Care.aspx.</span>.
</p><p>&nbsp;&nbsp;<br /> <b>Resources</b>
</p>
<table width="500" align="center" border="1" cellspacing="1" cellpadding="1">
 
<tr>
<td> <img src="/images/thumb/2/2c/Casestudy_heading.png/500px-Casestudy_heading.png" _fck_mw_filename="Casestudy heading.png" _fck_mw_location="center" _fck_mw_width="500" alt="" class="fck_mw_center" />
</td></tr>
<tr>
<td>
<p><a href="https://drive.google.com/file/d/0BwUrb9dSyDFLVXNoVUZLUnhtNjQ/view?usp=sharing"><br />Read the full case study on Mr Smith</a>
</p><p>Use the table in the document to formulate Mr Smith’s:
</p>
<ul><li>Problem list
</li><li>Treatment Plan
</li><li>Short &amp; Long Term goals
</li></ul>
</td></tr></table>
<p><br /><br />
</p>
<h1> CONCLUSION<br />  </h1>
<p>You should now be able to... <br /> • Analyse the emerging issue of frailty in relation to the current context of health and social care in the UK. <br /> • Critically evaluate the physiotherapists’ role in the holistic assessment and treatment of frail individuals to prevent hospital admission.<br /> • Evaluate the skills and knowledge gained from this resource; identify appropriate application in clinical practice.
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<td> <img src="/images/4/46/Reflection_heading.png" _fck_mw_filename="Reflection heading.png" alt="" />
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<p>Reflect on your knowledge gained from this learning resource
</p><p>and compare this to your reflection prior to starting.
</p><p>You can use these prompt questions to guide you:<br />• Are there any similarities/differences between
</p><p>your first thoughts and your final reflection?<br />• How can you best apply the knowledge gained?<br />• How will this impact your practice?<br />• Is there anything you would now do differently?<br />• Is there any additional reading you need to carry out?<br />
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<p>As previously discussed ‘the management of older adults is not a new concept however, as the average age of the population increases it is suggested that the prevalence of frailty will multiply[1]. Subsequently this causes further demand on the NHS an already overstretched service. In response to this there has been an increased drive to improve the efficiency of the management of frailty. There has been a shift of care from reactive to preventative strategies and a focus on providing early interventions to reduce costly unplanned admissions to hospital[2].’<br /> Several guidelines are available, but none specifically detail the physiotherapists’ role. <br /> Therefore, we have developed the above learning package aimed to increase final year/ newly registered physiotherapists knowledge and awareness of their role in the assessment and treatment of frail elderly patients to prevent hospital admissions.<br /> Now you have completed this learning resource and associated learning activities, you should be able to… <br /> • Analyse the emerging issue of frailty in relation to the current context of health and social care in the UK. <br /> • Critically evaluate the physiotherapists’ role in the holistic assessment and treatment of frail individuals to prevent hospital admission.<br /> • Evaluate the skills and knowledge gained from this resource; identify appropriate application in clinical practice. <br /> You have now completed this 10 hour learning package, well done!!
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<h1> REFERENCES  </h1>
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Latest revision as of 12:36, 14 July 2023

Original Editor - Helene Slettebakk Gjerde, Alice Porteous, Benedicte Aarseth, Matthew Laird, Beth Donnelly as part of the QMU Contemporary and Emerging Issues in Physiotherapy Practice Project Top Contributors - Helene Slettebakk Gjerde, Alice Porteous, Beth Donnelly, Benedicte Aarseth, Matthew Laird, Lucinda hampton, Scott Buxton, Kim Jackson, Shaimaa Eldib, Lauren Lopez, Vidya Acharya, Rucha Gadgil, Kalyani Yajnanarayan, 127.0.0.1, Jane Hislop and Admin

Introduction[edit | edit source]

A frail older person is in a condition that is associated with an increased risk of falls, harm events, institutionalisation, care needs and disability/death[1] Introduction to Frailty. Today, with life expectancy continuing to rise globally, there is an increasing number of frail elderly. The physiotherapist is well placed to screen for frailty and should be aware of the risk factors for frailty. If frailty is suspected referral to other professionals may be required. Frailty can be identified using the Clinical Frailty Scale. Identifying interventions that improve physical outcomes in pre-frail and frail older adults is of vital importance. [2][3]

Introduction to the Physiotherapist's Role[edit | edit source]

Physiotherapists working with frail older people could play a role in promoting healthy ageing. Evidence shows that interventions to promote healthy ageing can be used to the delay the onset of frailty and reduce its adverse outcomes among older people[4]. 

  • It has been suggested that physiotherapists could be stationed within hospital A&E departments to undertake frailty and falls risk screening and make rapid decisions on whether the patient can safely return to their pre-admission destination. Frailty can be identified using the Clinical Frailty Scale.[5][6].
  • The comprehensive geriatric assessment also is a valuable tool for risk of frailty screening.
  • Falls prevention: Critical injuries leading to hospitalisation are more common in people over 65 and often preventable, with falls representing the most frequent and serious type of accident[7] [8]. Falls risk increases with age and physiotherapists need to identify those at risk and provide timely intervention to prevent falls and subsequent injury[9][10].
  • Falls Reduction, in the frail: exercise strength and balance has been shown to have the most effective outcomes in reduction of falls rates. As the majority of people who attend balance programmes relapse into old ways by six months, the physiotherapist should attempt to reinforce and encourage adherence to their home exercise program.

Examples of Physiotherapy Interventions below:

  • Resistance training : A significant component of age-related weakness and frailty is sarcopenia. Sarcopenia increases the risk of frailty and falls and in turn, hospitalization in the older adult population[11]. Resistance training has been suggested as a potential treatment for sarcopenia and its prevention. Resistance training is designed to improve muscular fitness by exercising a muscle or a muscle group against resistance[12]. This could lead to improved function, increased quality of life and reduced likelihood for falls[13]. Resistance training programmes have consistently shown to improve muscle strength and mass in older adults[14][15], however, it is questionable whether this transfers to reducing the risk of falling.
  • Balance Re-education: Balance disorders are very common in frail older adults and are a key cause of falls in this population. They are associated with reduced level of function, as well as an increased risk of disease and death. Most balance disorders comprise of several contributing factors including long-term conditions and medication side effects[16]. See Balance Training, Otago Exercise Programme ,Inoculation Against Falls: Balance Intervention Strategies , Reactive Balance Training.
  • Tai Chi: Tai chi is a newly emerging exercise incorporating breathing, relaxation and slow and gentle movements with strengthening and balance exercises.[17]. See Tai Chi and the Older Person
  • Backward-chaining (see link): Declining muscle function in older adults reduces their ability to rise from the floor following a fall and up to a half of all non-injured fallers are unable to get up[18]. When someone is unable to get up off the floor unassisted, the associated risks are far greater due to the complications that can occur from lying on the floor for an extended period of time – for example, dehydration, hypothermia, pneumonia, pressure sores, unavoidable incontinence and even death[19]. This inability to get up has a poor prognosis in terms of hospitalisation and mortality[19], thus, a long lie is one of the most serious consequences of a fall. It was found that the backward-chaining method significantly enhances ability in rising after an incidental fall (20-40%)[20]. This training falls within the physiotherapists domain.
  • Fear of falling (FOF): The prevalence of FOF in community-dwelling older adults ranges between 12% and 65%[21]. The physiotherapist is in an ideal position to steer the individual towards the route of confrontation and recovery as opposed to activity avoidance and disability[9]. There is high quality evidence from two systematic reviews highlighting the benefits of treatment to improve confidence and reduce fear of falling[22][23]. Recommended interventions include: exercise, including tai chi, and multi-component falls prevention programmes.
  • Multi-Component Falls Prevention Programmes: As most falls are multifactorial in origin, they usually require several interventions[24]. Such interventions typically involve a combination of medication review and optimisation and education, environmental modification and exercise. This type of programme would be delivered by a multidisciplinary team in which the physiotherapist would be a key member.Physiotherapy treatments should combine strengthening, balance, backward chaining, tai chi and confidence building with education, tailored to each individual. Clinic-based group exercise or individual exercise in the home setting is suitable. [25]. For the greatest effect, exercise programmes should include a high level challenge to balance, alongside strength and walking training. Programmes should be performed for at least two hours per week on an ongoing basis.[26]

Benefits of Physical Activity in Frail Older Adults[edit | edit source]

Strength, endurance, balance and bone density is lost at a rate of 10% per decade, while muscle power reduces at around 30% per decade[27]. Sarcopenia is highly prevalent among older adults and has been identified as a risk factor for frailty[28]. Being physically active slows down these physiological changes associated with ageing. Physical activity can also reduce the risk of falls, promote cognitive health and self-management of chronic diseases. It can also slow down the deterioration in ability to perform ADLs and maintain quality of life in older adults[29][30]. A meta-analysis[29] found that exercise is beneficial to improve balance, gait speed and abilities to carry out ADLs in the frail older adult population ,Physical Activity in Older Adults.[31]

Physiotherapists Role in Promoting Physical Activity in Frail Older Adults[edit | edit source]

Due to their training and experience, physiotherapists are in a good position to promote health and well-being of individuals and the community through education on physical activity and exercise prescription[32]. Recently there has been a shift in the general public's health agenda towards the prevention of chronic conditions and enabling the ageing population to stay active and manage conditions in the community. This has required a change in the role of the physiotherapist towards addressing these issues through promotion of physical activity and other lifestyle changes[33]. When encouraging physical activity, physiotherapists should also aim to[34]:

  • Identify fears and barriers to being physically active and provide solutions to overcome these
  • Provide ongoing support and encouragement

Exercises for Frail Older Adults[edit | edit source]

These are the recommended activities and intensity for frail older adults to increase physical activity. These aim to improve general health and well being, as well as reduce the risk of falls and manage chronic lifestyle conditions[27]. Frail older adults should aim to accumulate numerous 5 - 10 minute exercise sessions to achieve the recommended activity guides[35]

Suggested activities:

  • Walking[36]
  • Group exercise classes[27]
  • Adhering to a physiotherapist recommended home exercise program
  • Breaking up time spent sitting with short regular periods of standing or walking[35]

Conclusion[edit | edit source]

With the ageing of the global population the prevalence of frailty will multiply[37]. Subsequently, we need a shift of care from reactive to preventative strategies, focusing on providing early interventions to reduce costly unplanned admissions to hospital[38]. Several guidelines are available, but none specifically detail the physiotherapist's role.

References[edit | edit source]

  1. ↑ GAjOS M, PERkOwSki R, KUjAwSkA A, ANdROSiUk JO, WydRA JO, FiliPSkA K. Physiotherapy methods in prevention of falls in elderly people. Journal of Education Culture and Society. 2016 Jun 28;7(1):92-102.
  2. ↑ Kidd T, Mold F, Jones C, Ream E, Grosvenor W, Sund-Levander M, Tingström P, Carey N. What are the most effective interventions to improve physical performance in pre-frail and frail adults? A systematic review of randomised control trials. BMC geriatrics. 2019 Dec;19(1):1-1.Available:https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1196-x (accessed 13.11.2022)
  3. ↑ British Geriatrics Society. Fit For Frailty: Part 1: Recognition and management of frailty in individuals in community and outpatient settings. http://www.bgs.org.uk/index.php/fit-for-frailty (accessed 12 Oct 2015)
  4. ↑ Cramm JM, Twisk J, Nieboer AP. Self-management abilities and frailty are important for healthy aging among community-dwelling older people; a cross-sectional study. BMC Geriatrics 2014;14:28. http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-28 (accessed 11 Jan 2016)
  5. ↑ Anaf S, Sheppard LA. Describing physiotherapy interventions in an emergency department setting: an observational pilot study. Accident and emergency nursing 2007; 15:1:34-9
  6. ↑ Arendts G, Fitzhardinge S, Pronk K, Donaldson M, Hutton M, Nagree Y. The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study. BMC Geriatrics 2012; 12:8
  7. ↑ Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Archives of Internal Medicine 2000; 160; 2717-28
  8. ↑ Age UK. Stop Falling: Start Saving Lives and Money. London: Age UK, 2010.
  9. ↑ 9.0 9.1 CSP. Physiotherapy works: Falls and frailty. http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/falls-and-frailty (accessed 8 Jan 2016)
  10. ↑ Perracini MR, Kristensen MT, Cunningham C, Sherrington C. Physiotherapy following fragility fractures. Injury. 2018 Aug 1;49(8):1413-7.
  11. ↑ Sousa AS, Guerra RS, Fonseca I, et al. Sarcopenia and length of hospital stay. Eur J Clin Nutr 2015.
  12. ↑ Azeem K, Al Almeer A. Effect of weight training programme on body composition, muscular endurance, and muscular strength of males. Annals of Biological Research 2013; 4; 154-6
  13. ↑ Burton LA, Sumakadas D. Optimal management of sarcopenia. Clin Interv Aging 2010; 5; 217-28
  14. ↑ Liu CJ, Latham NK. Progressive resistance training for improving physical function in older adults (Cochrane review). Cochrane Database Syst Rev 2009; (3); CD002759
  15. ↑ Seynnes O, Fiatarone Singh MA, Hue O. Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. J Gerontol Ser A-Biol Sci Med Sci 2004; 59A; 503-9
  16. ↑ Rubenstein, LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 2006; 35.
  17. ↑ NHS Choices. A guide to tai chi. http://www.nhs.uk/Livewell/fitness/Pages/taichi.aspx (accessed 8 Jan 2016)
  18. ↑ Skelton D, Dinan SM, Campbell M, et al. Tailored group exercise (Falls Management Exercise – FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34; 636-639
  19. ↑ 19.0 19.1 Tinetti ME, Liu WL, Claus EB, et al. Predictors and prognosis of inability to get up after falls among elderly persons. JAMA 1993; 269; 65-70
  20. ↑ Zak M, Skalska A, Szczerbinska K. Instructional programmes on how to rise unassisted effectively after sustaining an incidental fall, designed specifically for the elderly: a randomized, controlled trial. Ortop Traumatol Rehabil 2008; 10; 496-507
  21. ↑ Legters K. Fear of falling. Phys Ther 2002; 82; 264-272
  22. ↑ Zijlstra GAR, van Haastregt JCM, van Rossum E. Interventions to reduce fear of falling in community-living older people: a systematic review. J Am Geriatr Soc 2007; 55; 603-15
  23. ↑ Rand D, Miller WC, Yiu J, et al. Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis. Age Ageing 2011; 40; 297-206
  24. ↑ Hausdorff JM, Nelson ME, Kaliton D, et al. Etiology and modification of gait instability in older adults: a randomised controlled trial of exercise. J Appl Phys 2001; 90; 2117-29
  25. ↑ Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community (Cochrane review). Cochrane Database Syst Rev 2012; (2): CD007146
  26. ↑ Sherrington C, Tiedemann A, Fairhall N, et al. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 2011; 22; 78-83
  27. ↑ 27.0 27.1 27.2 The British Heart Foundation National Centre for Physical Activity and Health. Interpreting the UK physical activity guidelines for older adults in transition. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/39/429/index.html (accessed 17 Oct 2015)
  28. ↑ Jansen FM, Prins RG, Etman A, van der Ploeg HP, de Vries SI, van Lenthe FJ, Pierik, FH. Physical Activity in Non-Frail and Frail Older Adults. PLoS One 2015;10:1-15. http://www.ncbi.nlm.nih.gov/pubmed/25910249 (accessed 27 Oct 2015)
  29. ↑ 29.0 29.1 Chou CH, Hwang CL, Wu YT. Effect of Exercise on Physical Function, Daily Living Activities and Quality of Life in the Frail Older Adults: A Meta Analysis. Arch Phys Med Rehabil 2012;93:237-44.http://www.sciencedirect.com/science/article/pii/S0003999311008173 (accessed 16 Oct 2015)
  30. ↑ Weeks LE, Profit S, Campbell B, Graham H, Chircop A, Sheppard-LeMoine D. Participation in Physical Activity: Influences Reported by Seniors in the Community and in Long-Term Care Facilities. Journal of Gerontological Nursing 2008;34:36–43. http://www.healio.com/nursing/journals/jgn/2008-7-34-7/%7Bf65345f8-58ac-4381-a607-f663b5d57d53%7D/participation-in-physical-activity-influences-reported-by-seniors-in-the-community-and-in-long-term-care-facilities (accessed 7 Jan 2016)
  31. ↑ Yau L, Soutter K, Ekegren C, Hill KD, Ashe M, Soh SE. Adherence to Exercise Programs in Community-Dwelling Older Adults Postdischarge for Hip Fracture: A Systematic Review and Meta-analysis. Archives of Physical Medicine and Rehabilitation. 2022 Sep 1;103(9):1827-38.
  32. ↑ Verhagen E, Engbers L. The physical therapist’s role in physical activity promotion. Br J Sports Med 2009;43:99–101. http://bjsm.bmj.com/content/43/2/99.abstract (accessed 28 Oct 2015)
  33. ↑ Spijker J, MacInnes J. Population ageing: the timebomb that isn’t? BMJ 2013;347:1-5. http://www.bmj.com/content/347/bmj.f6598.full.pdf+html (accessed 11 Jan 2016)
  34. ↑ The British Heart Foundation National Centre for Physical Activity and Health. Physical activity interventions for older adults. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/18/405/index.html (accessed 13 Jan 2016)
  35. ↑ 35.0 35.1 The British Heart Foundation National Centre for Physical Activity and Health. Interpreting the UK physical activity guidelines for frailer older adults. http://www.bhfactive.org.uk/resources-and-publications-item/39/430/index.html (accessed 17 Oct 2015)
  36. ↑ Department of Health. Start active, stay active: report on physical activity in the UK. https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officers (accessed 28 Oct 2015)
  37. ↑ Karunananthan S, Wolfson C, Bergman H, Beland F, Hogan DB. A multidisciplinary systematic literature review on frailty: overview of the methodology used by the Canadian Initiative on Frailty and Aging. BMC Med Res Methodol 2009;9:68.
  38. ↑ Edwards N. Community services - how they can transform care. London: The King's Fund, 2014.








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