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

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]

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