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

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<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>
<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>
 
== Introduction ==
<div class="noeditbox"> ==Page Under Review== This article is currently under review and may not be up to date. Please come back soon to see the finished work! ({{REVISIONDAY}}/{{REVISIONMONTH}}/{{REVISIONYEAR}}) </div>
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>
== Frailty ==
Frailty is defined as:&nbsp;<br>
 
{| width="500" border="1" cellpadding="1" cellspacing="1" align="center"
|-
| “a biological syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiological systems and causing vulnerability to adverse outcomes"<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</ref>.
|}
 
<br>The British Geriatrics Society (BGS) support that frailty is an age-related health state affecting multiple body systems<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>.&nbsp;They describe Fried's<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 (Table 1). 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<ref name="Fried 2001" />.
 
{| width="500" align="center" border="1" cellspacing="1" cellpadding="1"
|+ Table 1<ref name="Fried 2001" />
|-
! scope="col" | Phenotype
! scope="col" | Description
|-
| Weight loss
| A drop in bodyweight of ≥10lbs/4.5kg in the past year or a drop in bodyweight of ≥5% in the past year.
|-
| Weakness
| Measured using [[Grip Strength|grip strength]]. A result within the lowest 20 percentiles according to gender and BMI indicates a weakness.
|-
| Reduced energy/endurance
| Self-reported, can also be a predictor of cardiovascular disease.
|-
| Slowness
| The lowest 20 percentile of the population according to gender and standing height, 15ft walking time.
|-
| Low physical activity
| Based on reported activity levels translated into a kilocalories score. Again with a cut-off at the lowest 20th percentile for each gender.
|}
 
The phenotype model can also be used as a quick screening assessment tool for frailty<ref name="Fried 2001" />. However, the [[Comprehensive Geriatric Assessment|Comprehensive Geriatric Assessment (CGA)]] is often preferred due to the multi-dimensional and holistic nature<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<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 [http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist's_Role_in_Preventing_Hospital_Admission#THE_COMPREHENSIVE_GERIATRIC_ASSESSMENT assessment section].<font color="#002bb8"><u></u></font> 
 
The physiotherapist should be aware of the risk factors for frailty. If frailty is suspected, referral to other professionals may be required.&nbsp;
 
{| width="200" border="1" cellpadding="1" cellspacing="1"
|+ Risk Factors<ref>Espinoza SE, Fried LP. Risk Factors for Frailty in the Older Adult. Clinical Geriatrics 2007; 15: 37-44</ref>
|-
| [[Image:Risk factors.png]]
|}
 
Frailty is associated with poorer outcomes including disability 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<ref name="FF1" />.&nbsp;
 
{| width="200" border="1" cellpadding="1" cellspacing="1"
|+ Frailty associations<ref name="Fried 2001" />
|-
| [[Image:FRAILTY IS.png]]
|}
 
It is important to note that although frailty is age-related, it is not an inevitability<ref name="Xue 2011">Xue QL. The Frailty Syndrome: Definition and Natural History. Clin Geriatr Med 2011; 27: 1-15</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<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.</ref><span style="line-height: 1.5em; font-size: 13.28px;">.</span>
== <u></u>Ageing Population<u></u>  ==
 
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%<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)</ref>.&nbsp;People are living longer, and as result, healthcare services are required to transform to better meet the population’s needs<ref name="The Kings Fund 2016">The King’s Fund. Making our health and care systems fit for an ageing population. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-health-care-systems-fit-ageing-population-oliver-foot-humphries-mar14.pdf (accessed 28 Jan 2016)</ref>.
 
{| width="500" border="1" align="center" cellpadding="1" cellspacing="1"
|-
| Estimated and projected age structure of the UK population 2012-2037<ref name="ONS18">Office for National Statistics. National Population Projections, 2012-based Statistical Bulletin. http://www.ons.gov.uk/ons/dcp171778_334975.pdf (accessed 28 Jan 2016)</ref>
|-
| [[Image:AgeingPopulation.PNG|center|500px]]
|}
 
As seen from the above graph, the percentage of the population aged over 65 is set to dramatically increase<ref name="ONS18" />. 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<ref name="The Kings Fund 2016" /> resulting in a surge of pressure on the NHS; an already strained service.&nbsp;
=== Costs  ===
[[Image:Total NHS Expenditure 2013.png|right|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)]]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 <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).</ref>.&nbsp;
 
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<ref name="RCP 2012">Royal College of Physicians. Hospitals on the edge: the time for action. London: RCP, 2012.</ref>. 
 
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 the average length of stay in hospital<ref>Organisation for Economic Co-operation and Development. Health at a Glance, 2013. http://www.oecdilibrary.org/docserver/download/8113161e.pdf?expires=1444911042checksum=AAD68253A0B959E184ACCEE3FFE37481 (accessed 16 Oct 2015).</ref>. However, admittance to hospital and the cost implications of long term hospital stays are similar worldwide to the UK<ref name="AIHW 2013">Australia Institute of Health and Welfare. Australia’s hospitals 2013-14: at a glance http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551482 (accessed 20 Dec 2015).</ref><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).</ref>.<br> 
{| width="200" border="1" align="center" cellpadding="1" cellspacing="1"
|+Table 3<ref name="AGE UK">Age UK. Later in life United Kingdom. http://www.ageuk.org.uk/Documents/EN-GB/Factsheets (accessed 16 Oct 2015).</ref>
|-
|[[Image:Table3Costfromfalls.PNG]]
|}
== Relevance  ==
 
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. Research suggests health care providers must address frailty proactively to salvage the benefit for patients undergoing a procedure like transcatheter aortic valve implantation as total costs are driven by department-level charges associated with longer in-hospital length of stay room, physical therapy, pharmacy, laboratory, supply, and imaging services<ref>[https://www.ncbi.nlm.nih.gov/pubmed/31806209 Relation of Frailty to Cost for Patients Undergoing Transcatheter Aortic Valve Implantation]. Am J Cardiol. 2020 Feb 1;125(3):469-474. doi: 10.1016/j.amjcard.2019.10.021. Epub 2019 Nov 11.
</ref>. Providers must address frailty proactively to salvage the benefit associated with TAVI.  There are three ways the NHS can help reduce costs<ref name="DOH B" />
 
*Health and social care integration
*Preventative medicine
*Increased provision in the community.
 
Health and social care integration aim to increase the effectiveness of care while keeping associated costs low. The Department of Health reports that at least one-third of emergency admissions could be dealt with in the community<ref name="DOH B" /> Providing a free movement of information between hospitals and the community will allow increased communication and will reduce hospital admissions <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).</ref>.
 
Preventative healthcare strategies include<ref name="Nice DDF">National Institute for Health and Care Excellence. Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset. London: National Institute for Health and Care Excellence, 2015</ref>  
 
*Promoting healthy behaviours like physical activity
*Reducing tobacco and alcohol use
*Improving community facilities to promote physical activities.
*Raising awareness of frailty<br>
 
== Older People's Acute Care Improvement Programme (OPAC)  ==
 
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)”<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)</ref> was commissioned by the Scottish Government.
 
The programme focuses on 2 key areas:  
 
*[[Frailty: Theoretical Frameworks|Frailty]]
*Delirium
 
In relation to frailty, the programme focused on the identification and the 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. <ref name="OPAC" /> <br><br>Healthcare Improvement Scotland<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)</ref>&nbsp;reported the impact of the programme and found that:
 
*Frailty screening in three surgical wards at the Royal Infirmary of Edinburgh decreased the length of stay, number of falls and number of complaints
*A reduced length of stay in NHS Grampian
*50% decrease in the number of falls per month in 2 wards in NHS Greater Glasgow and Clyde<br>
 
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 <ref name="OPAC report" />.&nbsp;
 
=== Think Frailty  ===
 
Think Frailty was an initiative funded by the  Scottish Government and was part of the 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<ref name="Think Frailty">Healthcare Improvement Scotland. Improving the identification and management of frailty. http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/frailty_report.aspx (accessed 19 Nov 2015)</ref>. 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.  Common themes underpinning the success in the NHS boards mentioned in the report included<ref name="Think Frailty" />:
 
==== Easy to Use Screening Tool  ====
The use of these should be at first point of contact with older people; at the front door or at home
 
*Important to enable rapid identification and referral to [[Comprehensive Geriatric Assessment|CGA]]
*Valid screening tools reduce variability and increases the number of appropriate referrals to frailty services.
 
==== Early Intervention and Senior Decision Makers ====
*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
*Early intervention focusing on discharge planning
 
==== Multidisciplinary Team Working ====
* Having a strong, integrated team was valued by all sites
* Good communication between the members of the MDT was important
*Common aim for all sites: expanding the team. In particular physiotherapy and OT services so that a seven day a week, around the clock service is available.
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<ref name="Think Frailty" />.<br><br>To read more about each NHS board strategies to improve frailty identification and management access:&nbsp;[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]&nbsp;&nbsp;
 
=== Fit for Frailty  ===
 
==== Recognition and Management of Frailty in Individuals in Community and Outpatient Settings ====
This part of the Fit for Frailty<ref name="FF1" /> guidelines by the British Geriatric Society (BGS) is intended to support health and social care professionals working with frail older people in the community.<br>In order to recognise and identify frailty, BGS recommends<ref name="FF1" />:
 
*During all encounters with health and social care professionals, older people should be assessed for frailty
*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.
*Gait speed, timed up and go test and the PRISMA questionnaire are recommended outcome measures to assess for frailty.<br>
 
For managing frailty in an individual, BGS recommends<ref name="FF1" />:
 
*A CGA, which involves a holistic, multidimensional and multidisciplinary assessment of an individual
*The result of the CGA should be an individualised care and support plan (CSP).
*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.
 
=== Gap in Literature  ===
 
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<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)</ref>.
 
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;
 
In the Fit for Frailty<ref name="FF1" /> guidelines, it is suggested that physiotherapists should play a role in assessing and treating frailty.  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. 
 
In the Think Frailty<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<ref name="Think Frailty" />.&nbsp;&nbsp;


== Introduction to the Physiotherapist's Role ==
== Introduction to the Physiotherapist's Role ==
The nature of the physiotherapy profession is to help restore movement and function in someone affected by illness or injury<ref>NHS Choices. Physiotherapy. http://www.nhs.uk/conditions/Physiotherapy/Pages/Introduction.aspx (accessed 20 Jan 2016).</ref>.&nbsp;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 out with standard inpatient care and moving to several different settings; for example, within day hospitals, in the patient’s home and in community clinics.
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;  
 
There is an emerging body of evidence supporting physiotherapy in emergency departments to assess and treat trauma and soft tissue injuries<ref name="Crane and Delany 2013">Crane J, Delany C. Physiotherapists in emergency departments: responsibilities, accountability and education. Physiotherapy 2013; 99; 2: 95-100</ref>. 
 
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<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).</ref>.&nbsp;
 
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<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>. However, little high quality research has been conducted and at present evidence is inconclusive, suggesting the need for further study in this area. A randomized control trial<ref>Hsieh TJ, Su SC, Chen CW, Kang YW, Hu MH, Hsu LL, Wu SY, Chen L, Chang HY, Chuang SY, Pan WH. [https://www.ncbi.nlm.nih.gov/pubmed/31791364 Individualized home-based exercise and nutrition interventions improve frailty in older adults: a randomized controlled trial.] International Journal of Behavioral Nutrition and Physical Activity. 2019 Dec 1;16(1):119.</ref> suggests home-based exercise and nutrition strategies have a positive outcome on the frailty score and physical performance in the pre-frail or frail older adults.
 
Whilst having an awareness of the different settings is important, the physiotherapy assessment and treatment is likely to be similar from place to place.
 
== The Comprehensive Geriatric Assessment (CGA) ==
 
Many of the guidelines available state a need for a [[Comprehensive Geriatric Assessment|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<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).</ref>. 
 
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<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).</ref>. There are five domains in which assessment takes place.  Below is a table adapted from Martin<ref name="Martin 2010" />, which identifies and outlines what should be included in each domain.
 
[[Image:CGA.jpg]]<br>
 
The assessment will allow health professionals to identify the problems and allow for onward referral now and in the future. For example, a patient may be referred to physiotherapy to help increase mobility<ref name="Martin 2010" />.
 
=== Benefits ===
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 specific time frame for these, yet follow up sessions usually occur when people are readmitted to hospital<ref name="Ellis 2004">Ellis G, Langhorne P. Comprehensive geriatric AX for older hospital patients. Bri Med Bull 2004; 71: 45-49.</ref>.


In hospitalised patients, it has been shown to improve the accuracy of diagnosis and enhances management in both the long and short term<ref name="Ellis 2004" /><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.</ref>. 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<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.</ref>. It can also reduce hospital stay, decrease the likelihood of readmission to hospital<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.</ref><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.</ref> and reduce mortality<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.</ref>.
* 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>.
== What is a Functional Assessment? ==
* The [[Comprehensive Geriatric Assessment|comprehensive geriatric assessment]] also is a valuable tool for risk of frailty screening.
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<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.</ref>. More specifically, functional assessments should be done on every patient over 75 years old<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.</ref>. 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<ref name="Martin 2010" />. All these areas should be assessed by the attending physiotherapist.&nbsp;
* 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>.
* '''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]].
'''Examples of Physiotherapy Interventions''' below:


=== Subjective Assessment ===
* [[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.


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.
* [[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.]]
* [[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]]
* [[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.
* [[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.
* 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>


#Has anything changed recently in terms of the patient's: vision, hearing, mobility status, cognitive ability, medication usage or activity levels<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).</ref>?
#Falls risk assessment tool (FRAT) questions should be asked which regard falls history and mobility status<ref name="Stokes 2004">Stokes M. Physical management in neurological rehabilitation. 2nd ed. London: Elsevier mosby,2004.</ref><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<ref name="BHPS" />.
#It is useful to know about the patient's dietary intake<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.</ref>.
#Do they have help or support with activities of daily living from anyone? Do they give help or support to anyone?<ref name="Stokes 2004" />.
<br>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?  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<ref name="BHPS" />.We can then tailor treatment where it is needed<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.</ref><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.</ref>.  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<ref name="Edwards 2002">Edwards S. Neurological physiotherapy: a problem-solving approach. 2nd ed. London: Churchill Livingstone,2002</ref><ref name="Stokes 2004" />.
===  Objective Assessment  ===
The objective assessment should begin by observing posture, skin condition and body shape<ref name="Wagstaff and Coakley 1988">Wagstaff P and Coakley D. Physiotherapy and the elderly patient. Kent: Croom Helm ltd, 1988.</ref>. This can give you clues as to their general health and the extent of their frailty.
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<ref name="Smyth 1990">Smyth L. Practical physiotherapy with older people. Chapman and Hall, 1990.</ref><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).</ref>. 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<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.</ref> . This type of information can also be gathered through the subjective assessment<ref name="Smyth 1990" />.
==== Gait ====
[[Image:Gait assessment.png|right|ClkerFreeVectorImages. pixabay.com (accessed 21/01/2016).|492x492px]]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<ref name="Fairhall et al. 2011" />. Keeping track of the patient’s gait speed will enable the physiotherapist to objectively measure patient progress.&nbsp; Endurance can be tested by completing multiple sit to stands or by carrying out a [[Six Minute Walk Test / 6 Minute Walk Test|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<ref name="HAS 2005" />. The six minute walk test has been shown to be valid and reliable within this population<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.</ref>. 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. 
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.
==== Balance ====
Balance should be assessed comprehensively as this will allow for individualised treatment. 75% of people over 70 have reduced balance, which can increase falls risk<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.</ref>. 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 Test (TUG)|Timed Up and Go]] were seen by physiotherapists as useful tools to measure functional ability<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<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.</ref>. Reduced balance is linked with increasing falls risk and hospitalisation<ref name="Sherrington 2015" />.  Good indicators of falls risk are the Berg Balance Scale and the [[Tinetti Test|Tinetti Balance]] and Gait Assessment as these both look at functional balance<ref name="Farrell 2004" /><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.</ref>.&nbsp;A home assessment can identify if modifications need to occur to allow for increased safety<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).</ref>. [http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist%27s_Role_in_Preventing_Hospital_Admission#Environment See the Environment section.]
==== Range of Motion and Strength ====
As previously mentioned, reduced grip strength is an indicator of frailty<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<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.</ref>.  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<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.</ref>.&nbsp;Tibiotarsal range is also important to measure as it can impact on posture<ref name="HAS 2005" />.&nbsp;It is therefore important to establish if your patient has reduced ROM as tailored intervention may help reduce falls.
====  Activities of Daily Living (ADLs) ====
ADLs can help establish the functional ROM and strength of frail patients. Two main types of ADLs should be assessed: instrumental (IADLs) and basic<ref name="Millan-calenti 2010" /><ref name="Martin 2010" />.
*Basic ADLs are self-care tasks, whereas,
*instrumental ADLs are activities which are needed for a person to live independently in the community<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.</ref>.<br>
ADLs are important to measure as an inability to do these is a better indicator of dysfunction than ability to self-care<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<ref name="Ward 1998" />. Functional dependence should be assessed, as there are correlations between dependence and increased length of stay in hospital<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.</ref>.
== Outcome Measures ==
Outcome measures may be useful to assess the patient's ability, but also to track the patient’s progress<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.</ref><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).</ref>. 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.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
{| width="600" border="1" cellspacing="1" cellpadding="1"
|-
! scope="col" | Outcome Measures (OM)<br>
! scope="col" | Description of OM<br>
! scope="col" | Psychometric properties<br>
|-
| Frail elderly functional assessment<br>
|
*Examines functional ability in the frail
*Nineteen point questionnaire
<br>
|
*Valid
*Reliable
*Sensitive to change <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.</ref><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.</ref>
|-
| 10 Metre Walk Test <br>
| [[10 Metre Walk Test]] <br>
|
*Excellent test-retest reliability and high concurrent validity when compared to the shorter 4 metre walking test<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).</ref>.
*High concurrent validity in the frail population with a 10 metre and 20 metre walk test <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.</ref>.
<br>
|-
| The Edmonton Frail Scale<br>
| 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<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.</ref>.<br>
|
*Good inter-rater reliability
*Takes less than 5 mins to complete
*Good construct validity
*Acceptable internal consistency<ref name="Rolfson 2006" />
<br><br>
|-
| PRISMA 7<br>
| 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<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).</ref>. It was developed with a service in Canadian healthcare, to integrate frailty assessment and management and allow for increase patient-centred care<ref name="Hebert 2003" />.<br>
|
*Using this approach can reduce hospitalisation and is an encouraged approach across systems<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.</ref>.
*Recommended by the BGS and can indicate frailty<ref name="FF1" /> <br>
|-
| [[Barthel Index|The Barthel Index]]<br>
| 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>
|
*The interrater reliability of this outcome is fair to good depending on which activity is being assessed<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.</ref>. <br>
|-
| [http://ptclinic.com/websites/991/files/TinettiBalanceAndGaitAssessment.pdf Tinetti Balance and Gait Assessment]<br>
| The Tinetti is a 17 item OM used to assess gait and balance<ref>Tinetti ME.Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986; 34(2): 119-126.</ref>.<br>
|
*70% sensitivity score
*52% sensitivity (good predictor of falls risk<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.</ref>).
*Excellent test-retest and intrarater reliability<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.</ref><ref>Faber MJ, Bosscher RJ et al. Clinimetric properties of the performance-oriented mobility assessment. Phys Ther  2006;86(7): 944-954.</ref><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.</ref>.
*In community-dwelling older adults, the concurrent validity was adequate when compared to the Timed Up and Go<ref name="Lin et al. 2004" />.
|-
| [[Elderly Mobility Scale]]<br>
| Assesses mobility in the frail by completing 20 components<ref>Smith R. Validation and Reliability of the Elderly Mobility Scale. Physiotherapy1994;80(11):744-747.</ref>.<br>
|
*Good concurrent validity
*Good discriminant validity
*Good inter-rater reliability<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).</ref>. <br>
|}
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<ref name="FF1" />.
== Medical Management ==
Frail adults are highly likely to be prescribed medication to treat their symptoms and co-morbidities. Below you will find a list of common medications, the conditions they are used to treat, some common side effects and some named examples<ref>NHS. Arthritis Research UK: Painkillers (analgesics).<nowiki>http://www.nhs.uk/ipgmedia/national/Arthritis%20Research%20UK/Assets/Painkillers-analgesics.pdf</nowiki> (accessed 9 Jan 2016)</ref>.&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
{| width="500" border="1" cellspacing="1" cellpadding="1"
|-
! scope="col" | '''Medication'''
! scope="col" | '''Conditions used to treat'''
! scope="col" | '''Common side effects'''
! scope="col" | '''Examples'''
|-
| Non- opioid analgesics<br>(Non-steroidal anti- inflammatory drugs, NSAIDs)
| Mild to moderate pain
| Minimal side effects, however dizziness and headache may occur
| paracetamol, aspirin, ibuprofen
|-
| Compound Analgesics
| Mild to moderate pain, often as an addition to NSAIDs
| Nausea, loss of concentration, constipation, confusion
| co-codamol, co-codaprin, co-dydramol
|-
| Opioid analgesics
| Moderate to severe pain.
| Impaired balance, confusion nausea and vomiting, constipation, drowsiness and dizziness
| codeine, tramadol morphine
|}
{| width="500" border="1" cellspacing="1" cellpadding="1"
|-
! scope="col" | Medication
! scope="col" | Conditions used to treat
! scope="col" | Common side effects
! scope="col" | Examples
|-
| Beta Blockers<ref name="NHS">NHS. Beta- Blockers. http://www.nhs.uk/Conditions/Beta-blockers/Pages/Introduction.aspx (Accessed 5 Jan 2016)</ref>
| Angina, Heart failure, Atrial fibrillation and Heart attach
| Dizziness, tiredness, blurred vision, slow heartbeat, impaired balance
| atenolol, bisoprolol, acebutolol, metoprolol
|-
| Antidepressants<ref>NHS. Antidepressants. http://www.nhs.uk/Conditions/Antidepressant-drugs/Pages/Introduction.aspx (Accessed 2 Jan 2016)</ref>
| Depression
| Dizziness, impaired balance, slow reaction, headaches, loss of appetite, anxious, feeling agitated, blurry vision<br>
| duloxetine, venlafaxine, mirtazapine, amitriptyline, imipramine, lithium.<br>
|-
| Benzodiazepines<ref>NHS. Generalised anxiety disorder in adults - Treatment. http://www.nhs.uk/Conditions/Anxiety/Pages/Treatment.aspx (Accessed 3 Jan 2016).</ref>
| Relief of severe anxiety
| Drowsiness, difficulty concentrating, headaches and vertigo
| diazepam, lorazepam, chlordiazepoxide
|-
| Angiotensin receptor blockers<ref>Mayo Clinic, Diseases and Conditions:High blood pressure (hypertension). http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/angiotensin-ii-receptor-blockers/art-20045009 (accessed 9 Jan 2016).</ref>
| Hypertension
| Dizziness, confusion, muscle cramps and/or weakness, faintness
| azilsartan, candesertan, eprosartan, losartan
|-
|
Diuretics<ref>Mayo Clinic, Diseases and Conditions: Diuretics. http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/diuretics/art-20048129 (Accessed 4 Jan 2016).</ref>
|
Water retention, high blood pressure and heart failure
|
Nausea, dizziness, muscle cramps,&nbsp;increased frequency and urgency&nbsp;of urination
|
furosemide, torsemide, chlorthalidone, amiloride<br>
|-
| Anticoagulants<ref>NHS Choice, Anticoagulant medicines. http://www.nhs.uk/conditions/Anticoagulant-medicines/pages/side-effects.aspx (accessed 19 Jan 2016)</ref>
| Hypotension
| Haemorrhage, dizziness, headaches.
| heparin, warfarin and aspirin,
|}
<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 and the associated side effects so they can modify treatments. <br>
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)<ref>The King’s Fund. Polypharmacy and medicines optimization – making it safe and sound. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf (accessed 20 Jan 2016)</ref>.
ADRs can become a vicious cycle where more drugs are prescribed in order to treat side effects. This can result in increased numbers of unnecessary and potentially harmful medications. The physiotherapist can help prevent polypharmacy and the vicious cycle by recognising changes in the patient's response to their drug therapy and highlighting need for medication review<ref>Sullivan G and Lansbury G. Physiotherapists’ knowledge of their clients’ medications: A survey of practicing physiotherapists in New South Wales, Australia. 2009;15: 191-198. http://www.tandfonline.com/doi/pdf/10.1080/095939899307748 (accessed 18 Jan 2016).</ref>. It is fundamental for physiotherapists to have knowledge and understanding of common medicine and their adverse side effects.
== Nutritional Status ==
Nutrition is important for this population and it should be part of the physiotherapist's subjective assessment to check dietary&nbsp;intake<ref name="Needle 2011" />.  A 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<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).</ref>&nbsp;and the&nbsp;physiotherapist should be mindful of this when assessing and treating.&nbsp;&nbsp;
== Mental Health  ==
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. Mental health disorders can be classified as organic or functional<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).</ref>
=== Organic ===
Age-related cognitive decline is inevitable<ref>Salthouse TA. When does age-related cognitive decline begin? Neurobiol Aging 2009; 30: 507-14</ref>, however, some conditions common amongst frail adults can have dramatic effects on cognition<ref>Barberger-Gateau P, Fabrigoule C. Disability and cognitive impairment in the elderly. Disabil Rehabil 1997; 19: 5 :175-93.</ref>. Organic disorders are usually caused by disease affecting the brain, for example, [[dementia]] or delirium. Depression and anxiety can also be seen in these frail adults.
==== Implications for Physiotherapists ====
With any cognitive condition, effective communication may become challenging and prove to be a barrier to successful assessment and treatment. Some tips to tackle this are:
# Keep commands clear and concise with one request at a time – “Stand up please”
# Allow plenty of time for a response before repeating your question. If the patient is still struggling, try rephrasing.
# Remove distractions – this could include talking, background noise, eye-catching pictures.
# Use names and explanations where possible – “Your daughter, Ann”
# Use other forms of communication:
# Visual – show tasks rather than explaining instructions.
# 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”.
# Tactile – can be used to aid the movement. For example, offering a hand when walking, stroking up the spine when standing.
Lack of motivation is common amongst most frail adults, including those with a functional mental health disorder and treatment to tackle this can feature heavily in the physiotherapy treatment plan<ref>Kaur J, Masaun M, Bhatia MS. Role of physiotherapy in mental health disorders. Delhi Psychiatry Journal 2013; 16: 2: 404-8</ref>. 
==Social and Environmental Factors  ==
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<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).</ref>.  It is primarily an occupational therapists (OT’s) role to devise interventions and amend any problems with these. Their assessment and the subsequent home modifications and adaptions can help increase the functional abilities of people who are frail<ref name="Horowitz 2002">Horowitz B P. Supporting community living through client-centered care. Occupational therapy in mental health; 2002 : 18(1).</ref>. However, a patient's ability to carry out activities in the home is dependent on its layout and their social situation. As physiotherapy interventions try to help improve people's ability to perform ADLs, it is important for physiotherapists to know how the environment and social situation can impact on their treatment.  The international classification of health, functioning and disability ([[International Classification of Functioning, Disability and Health (ICF)|ICF]])<ref name="WHO 2001">World Health Organization. ICIDH-2: International classification of functioning, disability, and health. Geneva: World Health Organization, 2001.</ref> can be used by physiotherapists to help establish the needs of the patient.
=== Social Circumstances    ===
====Activity Limitations ====
Frail 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 can have a bigger impact on social involvement than the severity of the patient's medical condition. Specific activity limitations which may cause participation restriction are:
* Anxiety<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.</ref><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).</ref>
* Needing help with personal care<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.</ref><ref name="Nilsson et al. 2015" />
* Mobility aid use and walking speed<ref name="Nilsson et al. 2015" /><ref name="Cambois et al. 2005" /><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).</ref>
* Memory<ref name="Makizako et al. 2015" /><ref name="Cambois et al. 2005" />
<br>Musculoskeletal impairments cause the majority of activity limitations in elderly community-dwelling adults<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.</ref> . Physiotherapists are therefore in a prime position to help reduce activity limitations.&nbsp;A study by Mast and Azar<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.</ref> 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.
==== Taking a Social History ====
Taking a social history allows the physiotherapist to understand the patient's current level of functioning and their desired functional goals<ref name="Petty 2011">Petty, NJ. Neuromusculoskeletal examination and assessment: a handbook for therapists. Edinburgh : Churchill Livingstone, 2011.</ref><ref name="Cott 1995">Cott, CA. Goal setting.  In: Pickles B et al, editor. Physiotherapy with older people. London: WB Saunders company ltd, 1995.</ref>. This should include assessment of activities they do in and outside their home and what formal or informal care or support they receive<ref name="Wagstaff and Coakley 1988" /><ref name="Petty 2011" />. 80% of nonagenarians have carers to help with some of their ADLs<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<ref name="Wagstaff and Coakley 1988" />. This shows the importance of knowing the patient's social circumstances.
=== Environment <u></u>  ===
==== Participation Restrictions ====
Elderly people who experience activity limitations sometimes also have participation restrictions<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.</ref><ref name="Cambois et al. 2005" /><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.</ref>.  Knowing what participation restrictions a patient has is important as they are linked to the patient's quality of life. Participation frequency should also be noted<ref name="Aranadottir 2011" />. It is common for people with frailty who live in the community to report having participation restrictions<ref name="Fairhall et al. 2011" /><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.</ref>. This is due to reduced community mobility and a reduced ability to carry out work both at home and in the community<ref name="Fairhall et al. 2011" />. Increased participation restrictions are also linked with increasing age<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</ref>. The symptoms of frailty most closely linked to participation restrictions are grip strength, mobility and the number of co-morbidities a patient has<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 patient's condition may decline<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.</ref>.  The mind map below 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<ref name="Wagstaff and Coakley 1988" />.
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<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).</ref>  Being aware of the environment in which the patient lives will allow the physiotherapist to tailor treatments effectively and safely to their surroundings. &nbsp; &nbsp;
== Physiotherapy Treatment  ==
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. As two thirds of NHS clients are aged 65 or over<ref name="Philp 2007">Philp I. A recipe for care – not a single ingredient. London: Department of Health, 2007.</ref>, there is a plethora of different occasions in which an older person may be admitted to hospital, however, it can be loosely split into two categories: injury and illness <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</ref>.&nbsp;
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<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>.  [[Falls]] represent the most frequent and serious type of accident in people aged 65 and over in the UK <ref name="Age UK 2010">Age UK. Stop Falling: Start Saving Lives and Money. London: Age UK, 2010.</ref>. Gowing and Jain<ref name="Gowing and Jain 2007" /> found that a fall is the most common mechanism of injury in elderly trauma patients presenting to accident and emergency units and falls cases are the most common presentation to the Scottish Ambulance Service in the older adult population<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.</ref>.
{| width="200" align="center" border="1" cellspacing="1" cellpadding="1"
|+ Most common mechanism of injury in elderly trauma&nbsp;<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</ref>&nbsp;
|-
! scope="col" | [[Image:Pie chart hospital admissions.PNG]]
|}
The natural ageing process means that older people are at higher risk of [[falls]]. Over 400 risk factors leading to falls have been highlighted (Table&nbsp;9).<br>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<ref name="Age UK 2010" />. As risk increases with age, it is important for the physiotherapist to identify those at risk early, recognise and modify risk factors 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>. 
== Treating falls and fall related injuries: ==
Below are examples of treatment options follows, although this list is not exhaustive. 
=== Resistance Training  ===
[[Image:Weights.png|right|200x200px]]
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.
Latham and colleagues<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</ref> have conducted the only trial which has studied the effect of seated resistance training on risk of falls in an older adult population. 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.  Furthermore, Liu-Ambrose and colleagues<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</ref> examined the effect of a twice weekly course of 50-minute resistance training sessions 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.  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<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>. We will discuss this in further detail later on in the learning resource.&nbsp;
=== 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>.  Recent research conducted examined the effectiveness of two-year progressive balance retraining in reducing injurious falls among community-dwelling women aged 75-85<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.</ref>. 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, the injurious fall rate was 19% lower in the intervention group than in the control group highlighting the benefit of a balance training programme.<br> [[Image:Enjoying the wii.png|390x250px|right]]
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. There is evidence that a Wii based balance exercise programme could improve balance ability in the frail elderly population<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</ref>, so as a result, Fu and colleagues<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.</ref> 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.  The results showed that while both groups reduced their risk and incidence of falls, the intervention group showed a more significant improvement.<br> 
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.
=== Tai Chi  ===
[[Tai Chi and the Older Person|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<ref>NHS Choices. A guide to tai chi. http://www.nhs.uk/Livewell/fitness/Pages/taichi.aspx (accessed 8 Jan 2016)</ref>. 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<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</ref>, reducing stress<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</ref> and controlling osteoarthritis pain<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.</ref>. 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<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>. 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.
=== Otago Exercise Programme ===
The [[Otago Exercise Programme]] (OEP) is an evidenced-based, "home-based, individually tailored strength and [[balance]] retraining programme”<ref>Campbell AJ, Robertson MC for the New Zealand Accident Compensation Corporation. [https://www.acc.co.nz/assets/injury-prevention/acc1162-otago-exercise-manual.pdf Otago Exercise Programme to prevent falls in older adults]. 2003. Accessed 2 October 2018.</ref>. The OEP is carried out by physiotherapists (and/or trained providers such as community nurses). It is designed to be carried out over 12 months (or more recently, six months). The physiotherapist makes approximately five home visits within that period and also makes monthly phone calls to the participant to encourage adherence<ref>Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR. [http://www.publish.csiro.au/nb/pdf/NB10056 Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations]. NSW Public Health Bulletin. 2001,22;3–4: 78-83. Accessed 13 October 2018.</ref>.
=== Backward-chaining  ===
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 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<ref>Reece A, Simpson JM. Teaching elderly people how to cope after a fall. Physiotherapy 1996; 82; 27-35</ref>.
[[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.  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 lying on the floor.
{| width="200" align="center" border="1" cellspacing="1" cellpadding="1"
|+ Backward Chaining, adapted from NHS Sutton and Merton Community Services&nbsp;<ref>NHS Sutton and Merton Community Services. Getting on and off the floor safely. London: Staying Steady Falls Prevention Service, 2012</ref>
|-
| [[Image:BackwardChaining.png|center]]
|}
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 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>. 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.
=== Fear of Falling  ===
The prevalence of [[Fear of Falling|fear of falling]] in community-dwelling older adults ranges between 12% and 65%<ref>Legters K. Fear of falling. Phys Ther 2002; 82; 264-272</ref>. Whilst it frequently occurs after falls<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</ref>, it is also established in those without a fall history<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</ref>. It can lead to a loss of independence, activity restriction and ultimately a poorer quality of life<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</ref>. Not all will avoid ADLs due to fear but for those who do, it can have debilitating and devastating effects<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</ref>.  Lethem et al<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</ref> introduced the psychiatric concept of a [[Fear Avoidance Model|fear avoidance model]] and is it is commonly utilised in the prevention of acute musculoskeletal pain becoming chronic<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.</ref>. 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<ref name="Lethem" />.<br>
{| width="200" align="center" border="1" cellspacing="1" cellpadding="1"
|+ Adapted fear avoidance model<ref name="Lethem" />
|-
| [[Image:Fear avoidance model (Falls).PNG|center]]
|}
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.<br>
=== Multi-Component Falls Prevention Programmes  ===
[[Image:Falls class.png|center|850x300px]]<br>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. 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<ref name="Gillespie 2012" />.
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<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 also the general community and it should be performed for at least two hours per week on an ongoing basis.
== Self-Management  ==
[[Image:Selfmanagement NHS.jpg|right]]For many people, older age is associated with long term conditions such as heart failure, dementia, chronic obstructive pulmonary disease (COPD) and diabetes. As we know, an element of frailty is 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<ref name="Think Frailty" />.  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 higher risk of hospital admittance<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)</ref>. 
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<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)</ref>.  The Scottish Government<ref>The Scottish Government. Long Term Conditions. http://www.gov.scot/Topics/Health/Services/Long-Term-Conditions (accessed 20 Nov 2015)</ref>&nbsp;reports that people with LTCs are twice as likely to be admitted to hospital.&nbsp;The ageing population and the increased prevalence of LTCs requires healthcare professionals to move their focus towards preventative strategies and empowering self-management<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)</ref>.
Physiotherapist's have a role in promoting self-management of long term conditions and physical activity. Disease-related self-management abilities such as taking medication and exercise are often promoted by health care professionals. However, there may also be a need for interventions aimed at self-management of overall health and well-being to contribute to healthy ageing<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)</ref>.&nbsp;Older peoples’ abilities to self-manage the effects of the ageing process depends on physical, psychological and social aspects of their life<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>.  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" />.
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 behavioural and cognitive skills for dealing with range of problems, rather than focusing on health-related problems only<ref name="Cramm2013" />.  It is outwith 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 ageing process.
=== Physical Activity  ===
Functional capacity declines with age and this is further accelerated by low levels of physical activity.<br>The recommendations for physical activity for older adults (65+)<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>:
*Older adults should aim to be active daily
*At least 150 minutes a week of moderate intensity activity
*Muscle strength training twice a week in addition to the 150 minutes of activity
*Balance training and co-ordination should be incorporated into activities to manage risk of falls
*Minimise sedentary time&nbsp;
Physical activity significantly decreases with age. The graph below shows the percentage of men and women meeting the physical activity recommendations in Scotland<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)</ref>.
==  Benefits of Physical Activity in Frail Older Adults  ==
==  Benefits of Physical Activity in Frail Older Adults  ==


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" />&nbsp;found that exercise is beneficial to improve balance, gait speed and abilities to carry out ADLs in the frail older adult population.&nbsp;
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>
 
=== Factors Influencing Participation in Physical Activity in Older Adults ===
 
Older peoples’ participation in physical activity can be effected by biological, demographic, physiological and social factors.  These factors are important to be aware of when attempting to motivate older people to increase their activity levels.<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)</ref>
 
*Men are more active than women
*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
*Older people might be less able due to pain, reduced mobility and the need of assistance to mobilise<ref name="Weeks" />  
*Physical activity can be influenced by trusted others such as health care professionals, care givers, family and friends
*Lack of transport often affects older people's abilities to part take in activity
 
=== Physiotherapists Role in Promoting Physical Activity in Frail Older Adults ===
=== Physiotherapists Role in Promoting Physical Activity in Frail Older Adults ===


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==== Exercises for Frail Older Adults ====
==== Exercises for Frail Older Adults ====
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:
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>
 
*Sessions as short as 10 minutes can provide health benefits<ref name="BHF11" />  
*Frail older adults should aim to accumulate numerous 10 minute 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><br>


Suggested activities:  
Suggested activities:  


*Take the stairs<ref name="DOH" />
*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>
*Walking<ref name="DOH" />
*Group exercise classes<ref name="BHF11" />
*Do housework or gardening<ref name="DOH" />
*Adhering to a physiotherapist recommended home exercise program
*Tai Chi<ref name="BHF2012" />
*Dance<ref name="BHF2012" />
*Swimming<ref name="DOH" />  
*Home-based or group exercise classes<ref name="BHF11" />  
*Breaking up time spent sitting with short regular periods of standing or walking<ref name="BHF2012" />  
*Breaking up time spent sitting with short regular periods of standing or walking<ref name="BHF2012" />  
*Encourage to move for longer. E.g. Going from moving 5 minutes to 10 minutes may increase the intensity<ref name="BHF2012" />
A Systematic Review of Randomized Controlled Trials<ref>Stares A, Bains M. [https://www.ncbi.nlm.nih.gov/pubmed/30762623 The Additive Effects of Creatine Supplementation and Exercise Training in an Aging Population: A Systematic Review of Randomized Controlled Trials.] Journal of geriatric physical therapy (2001). 2019 Feb.</ref> suggested that a low dose of creatine monohydrate along with resisted exercises may improve upper and lower extremities strength in healthy older adults.
== Motivation  ==
[[Image:Maslow.png|300x280px|right]]Motivation can be defined as the processes that explain 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<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)</ref>.  In 1943, Maslow developed a theory of human motivation aiming to explain and rank all types of human needs<ref name="Maslow54">Maslow AH. Motivation and personality. London: Methuen, 1954.</ref>.  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>
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.{{#ev:youtube|O-4ithG_07Q|400}}<ref>Maslow's Hierarchy of Needs. https://www.youtube.com/watch?v=O-4ithG_07Q (accessed 9 June 2019)</ref>&nbsp;
There are many factors that motivate the elderly to participate in exercise programs, see below<ref name="Weeks" />.
[[Image:Motivating Factors.PNG|center]]It is important to note that studies have found a correlation between those with a previously active lifestyle and those who were more likely to perform exercise programs<ref name="Weeks" /> 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: 
* [[Goal Setting in Rehabilitation|Patient-centred goals]]
* Small goals incrementally increasing to large goals e.g. short term and long term
* Should adhere to SMART principles
Despite the need to motivate it is also important to listen to the patient and their needs. One of the ways we can encourage motivation is by arranging a group exercise class, as this not only promotes the physical benefits of exercise, but allows participation in a social gathering<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.</ref>. Furthermore, research suggests that people are more likely to exercise if they have a companion<ref>Rosenfeld M. Motivational Strategies in Geriatric Rehabilitation. Bethseda, MD: American Occupational Therapy Association; 1997.</ref>.
== Conclusion  ==
== Conclusion  ==


The average age of the population is increasing and it is suggested that 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, 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<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.  
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.  


== References ==
== References ==

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, Admin and Jane Hislop

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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