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

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<div class="noeditbox">Welcome to &lt;a href="Contemporary and Emerging Issues in Physiotherapy Practice"&gt;Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice project&lt;/a&gt;. This space was created by and for the students at Queen Margaret University in Edinburgh, UK. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
<div class="editorbox"> '''Original Editor '''- [[User:Helene Slettebakk Gjerde|Helene Slettebakk Gjerde]], [[User:Alice Porteous|Alice Porteous]], [[User:Benedicte Aarseth|Benedicte Aarseth]], [[User:Matthew Laird|Matthew Laird]], [[User:Beth Donnelly|Beth Donnelly]]&nbsp;as part of the [http://www.physio-pedia.com/Contemporary_and_Emerging_Issues_in_Physiotherapy_Practice QMU&nbsp;Contemporary and Emerging Issues in Physiotherapy Practice&nbsp;Project]  '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div>
'''Original Editor '''- Your name will be added here if you created the original content for this page.
== Introduction ==
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>


'''Top Contributors''' - &lt;img class="FCK__MWTemplate" src="http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/images/spacer.gif" _fckfakelement="true" _fckrealelement="1" _fck_mw_template="true"&gt; &nbsp;  
== Introduction to the Physiotherapist's Role ==
</div>
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;  
= Introduction<br>  =


This 10 hour online learning resource is tailored towards final year students and newly graduate physiotherapists, aiming to increase your knowledge and understanding of how you can use physiotherapy to prevent hospital admission in the community dwelling, frail elderly population. The module will also hopefully help you in applying this information in practice.  
* 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>.
* The [[Comprehensive Geriatric Assessment|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<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:


=== Aims ===
* [[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.


• To provide a learning resource for final year physiotherapy students or junior physiotherapists with an introduction to contemporary and emerging issues in the field of reducing hospital admissions in the frail elderly population and current management strategies. <br><br>• To provide you with an introduction and overview of the physiotherapists’ role in the prevention of hospital admissions in the frail elderly population by using a holistic, patient centred approach<br><span>&nbsp;</span>&nbsp;
* [[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>


=== Learning outcome ===
==  Benefits of Physical Activity in Frail Older Adults  ==


By the end of this Wiki module you will be able to…<br><br>• Synthesise current evidence and guidelines surrounding frailty and preventative pathways.<br><br>• Evaluate and reflect upon the physiotherapists’ role in the holistic assessment and treatment of frail persons to reduce the risk of hospital admission.<br><br>• Critically evaluate and reflect upon the skills and knowledge gained from this resource and recognise appropriate application in clinical practice. <br>  
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>
<div>
=== Physiotherapists Role in Promoting Physical Activity in Frail Older Adults ===
<br>


<br>  
Due to their training and experience, physiotherapists are in a good position to promote health and well-being of individuals and the community through education on physical activity and exercise prescription<ref name="Verhagen">Verhagen E, Engbers L. The physical therapist’s role in physical activity promotion. Br J Sports Med 2009;43:99–101. http://bjsm.bmj.com/content/43/2/99.abstract (accessed 28 Oct 2015)</ref>.  Recently there has been a shift in the general public's health agenda towards the prevention of chronic conditions and enabling the ageing population to stay active and manage conditions in the community. This has required a change in the role of the physiotherapist towards addressing these issues through promotion of physical activity and other lifestyle changes<ref name="SM">Spijker J, MacInnes J. Population ageing: the timebomb that isn’t? BMJ 2013;347:1-5. http://www.bmj.com/content/347/bmj.f6598.full.pdf+html (accessed 11 Jan 2016)</ref>. When encouraging physical activity, physiotherapists should also aim to<ref name="BHFAW">The British Heart Foundation National Centre for Physical Activity and Health. Physical activity interventions for older adults. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/18/405/index.html (accessed 13 Jan 2016)</ref>:


<br>
*Identify fears and barriers to being physically active and provide solutions to overcome these
*Provide ongoing support and encouragement


<br>  
==== 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<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>


<br>
Suggested activities:


<br>  
*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>
*Group exercise classes<ref name="BHF11" />
*Adhering to a physiotherapist recommended home exercise program
*Breaking up time spent sitting with short regular periods of standing or walking<ref name="BHF2012" />
== Conclusion  ==


<br>  
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.


<br>
== References ==
</div>
= Frailty  =


=== Definition  ===
<references /><br>  
 
=== Current Climate  ===
 
=== Demographics  ===
 
=== Costs  ===
 
<u>Length of stay and cost implications NHS</u>
 
<u></u><br>The latest published statistics which are being used in the literature relate to the years 2012 and 2013. Within this time frame 2,211,228 people over 60 were admitted to hospital in an emergency (DOH 2013b). <br>
 
Graph 1 insert<br>
 
Graph 2 insert<br>
 
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 (RCP 2012).<br>
 
======  ======
 
======  ======
 
{| width="470" cellspacing="1" cellpadding="1" border="1" align="center"
|-
! scope="col" colspan="4" | A table to show the cost of average stays in hospital
|-
| '''Type of stay'''
| Short stay<br>
| Extra bed day<br>
| Visit to A and E<br>
|-
| '''Cost'''<br>
| £1489<br>
| £273<br>
| £114<br>
|-
| <br>
| <br>
| <br>  
| (DOH 2013b)<br>
|}


<br>  
<br>  
Most emergency admissions to hospital happen through accident and emergency (DOH 2013b). On average a person over 85 spends 11 days in hospital (RCP 2012). If they pass through accident and emergency the total spent is approximately '''£3241''' per patient, per visit.<br>However, More than a 25% of over 85 year olds stay for 2 weeks and 10% stay longer than a month, when admitted as an emergency (Cornwall et al. 2012). This means that even more money is spent. <br>
Table 2 insert<br>
410,377 elderly persons were admitted to hospital due to a fall in 2013. Appropriate strategies could prevent this by up to 30% (Age UK, 2015).
<br><u>Length of stay and cost implications worldwide </u>
<u></u><br>Across the world there are varying amounts of elderly people in hospitals, how much time they spend in hospital and how much it costs.<br>
Graph 3 insert<br>
In terms of falls 59,046 males and 113,632 females were admitted to hospital following a fall in Australia in 2013-2014 (AHIW 2015). <br>
Table 3 insert<br>
92% of this care was paid for by insurance companies (Weiss and Elixhauser 2014).
Comparing this to the UK we can see that although most people stay in hospital for fewer days than in the USA, in the UK elderly people remain in hospital for longer. This may have negative health impacts. The UK is 16th in the world when it comes to average length of stay in hospital (health at a glance 2013). <br><br><br><br><br>
=== Health and Social Care Integration  ===
The Department of Health (2013b) report that although there are high numbers of emergency admissions through accident and emergency, which is very costly, at least one fifth could be dealt with in the community. Some ways of doing this are through: telemedicine, risk prediction tools, case management and alternatives to hospitals.<br>The integration of the health and social care systems in the UK was designed to improve service delivery and the effectiveness of care. There are nine outcomes which this incorporation is meant to achieve.
<br>1. To allow people to look after and improve their own health<br>2. To allow as many people as possible to live independent lives<br>3. To ensure users have positive experiences of their health and social care<br>4. To maintain or improve users quality of life<br>5. To reduce health inequalities<br>6. To ensure unpaid carers are supported with their health and wellbeing needs<br>7. To ensure everyone; staff and users, are safe from harm at all times<br>8. To ensure staff employed in health and social care services feel involved in the work they do. They should also feel supported to implement change when needed. <br>9. To ensure that all resources are used effectively
<br>The planning, resources and delivery of care will be now carried out together by the local authority or health board (The Scottish government 2015). This will mean that health and social care can run smoothly as one entity and users will experience a continuity of care. <br>One way this will have an effect is by reducing hospital admissions by allowing patient information to be shared more freely between hospitals and the community. This will allow for more effective multidisciplinary care in the community (Cornwall et al. 2012). <br>It has been said that better communication between health professionals, especially between those in hospitals and the social sector, may help reduce emergency admissions and help people return home sooner. However, there may be some barriers preventing this such as; differing funding levels, contrasting cultures, performance management and no sufficient way to share patient data. (DOH 2013b).<br><br>
= Policies and Guidelines  =
This section will present the most relevant guidelines and policies in relation to frailty and highlight the most useful points.<br>The policies and guidelines included in this wiki resource are:<br>


<br>  
<br>  
{| width="400" border="1" align="center" cellpadding="1" cellspacing="1"
|-
| [[Image:HIS.jpg|left]]
| [[Image:HIS.jpg]]
| [[Image:HIS.jpg]]
|-
| [http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme.aspx Healthcare Improvement Scotland<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>]
| Think Frailty
| Fit for Frailty&nbsp;
|}


<br>  
<br>  
For the purpose of this learning resource the chosen guidelines and policies were Scottish and UK related. If you intend to work or are currently working without the NHS you might be required to be familiar with policies in relation to your workplace.<br>


<br>  
<br>  
=== <span style="font-size: 17.5296px; font-weight: bold; line-height: 1.5em; background-color: initial;">Older People in Acute Care improvement programme (OPAC)</span>  ===
As the number of older people in the population is increasing, there is an increased need to ensure appropriate care for older people. 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)” was commissioned by the Scottish Government.
<br>The programme focuses on 2 key areas
*Frailty
*Delirium<br>
In relation to frailty, the programme focused on identification and immediate management of frailty. This included screening for frailty and ensuring that older people who were identified as frail received a comprehensive geriatric assessment within 24 hours of admission. The document “Think Frailty” explored the strategies implemented in practice in more depth and will be discussed in Section 3.2 – Think Frailty<br>Healthcare Improvement Scotland (2015) reported the impact of the programme and found that:
*Frailty screening in 3 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
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 report)<br>
=== Think Frailty&nbsp;  ===
=== Fit for Frailty  ===
Summary&nbsp;
= Physiotherapy assesment<br>  =
== '''The comprehensive geriatric assessment'''  ==
All the guidelines outlined above 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 (Martin 2010; BGS 2014). <br> This assessment usually takes place when a patient is identified as possibly being frail; during acute illness, prior to surgery or when returning to a community environment. It is a multi-dimensional program, which looks at the patients; health (physical and mental), mobility and social status. This approach was introduced in 2001 by the Department of Health. There are five domains in which assessment takes place. <br> Below is a table adapted from Martin 2010 which identifies and outlines what should be included in each domain.
[[Image:CGA.jpg]]<br>
<br>
<br>
<br> The methods used to achieve this are specific to the region of the UK in which you work. However, the measurement tools should be standardised and reliable. For example, the 6-minute walk test is commonly used to test gait and balance. Some measures identify problems while others examine their severity. <br> The assessment will allow health professionals to identify the associated effects of frailty to the patient, now and in the future. Once specific problems have been identified onward referral can be made to appropriate healthcare professionals. This can then allow for a more in depth assessment to be made around these problems. For example a patient may be referred to physiotherapy to help increase mobility (Martin 2010).
<br> Follow up is part of the CGA and identifies effectiveness of treatment. These sessions usually occur when people are readmitted to hospital. 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, mortality. Yet this approach is not yet taken in the community (Ellis 2011).
<br> In hospitalised patients it has been shown to improve the accuracy of diagnosis and enhances management in both the long and short term (Ellis and Langhorne 2004; Sergi et al 2011). In the community completing a CGA can prevent reductions in mobility and problems which arise from poor mobility by implementing treatment programmes tailored to all the patients’ needs (Tikkanen et al. 2015). It can also reduce hospital stay, increase the likelihood of keeping patients out of hospital (Nikolaus et al. 1999; Barer 2011) and reduce mortality (Frese et al. 2012).
<br> Quiz
– How many of the key points can you recall? Who carries out a comprehensive geriatric assessment? Where can it take place? What are its key components? What effects can completing a CGA have? Reflection- this activity should take 10 minutes to complete. Use the reading in this section and your prior knowledge to reflect upon any problems that you think may arise when carrying out this type of assessment.&nbsp;


<br>  
<br>  


== Functional assessment of frail individuals  ==
<br>
 
[[Category:Older People/Geriatrics]]
<br>Not all of the papers reviewed below look at people diagnosed as being frail. As there is a lack of literature related to this population some literature has been extrapolated and applied to this population of patients.<br>What is it?<br>It is advised that frailty assessments should be carried out by an MDT. Physiotherapists have the knowledge and skill level to carry out the functional aspect. (The kings fund 2012; BGS 2014; Wyrko 2015). <br>Functional assessments are a way of determining health needs now and in the future. Assessments of patients with frailty should occur after every illness or injury to establish the effect the episode had on the patient’s functional ability (Fairhall et al. 2011). More specifically, functional assessments should be done on every patient over 75 (Mohile 2015). The functional assessment element of the comprehensive geriatric assessment compromises of; gait, balance, abilities to carry out activities of daily living (both fundamental and basic)and activity/exercise status (Martin 2010). All these areas should be assessed by the attending physiotherapist. <br>However, assessing frail elderly patients can be difficult as it takes a long time due to…<br>• A through assessment needs to be done (Top to toe including all elements of the ICF) (Wagstaff and Coakley 1988; Smyth 1990; Farrell 2004; BGS 2010). <br>• Are there any cognitive issues present? These include dementia and long-term or short-term memory problems. Cognitive function in the elderly has been shown to have a strong association with reduced functional performance (Morala 2006). It can also impact on how you carry out your assessment and communicate with the patient (Steven et al. 2002; Deary 2009). <br>• Auditory problems, affecting the patients’ ability to hear you (Fairhall et al. 2011)<br>• Visual problems, meaning the patient cannot see you or what you are trying to get them to do clearly. (Fairhall et al. 2011)<br>• Easily fatigued, causing patients to have reduced performance in activities which occur at the end of the assessment (Theou 2008). This may skew the results of any outcome measures used. <br>• Reduced / slow mobility (i.e. Sit-stand takes longer) (Theou 2008).
[[Category:Interventions]]
 
[[Category:Primary Contact]]
<br>'''Subjective assessment'''<br>The subjective assessment will be very similar to that of any other patient. Yet, some specific questions related to age and frailty must be asked. <br>1. Has anything changed recently in terms of the patients’; visual, auditory, mobility, cognitive, medicative or activity levels (Baker 2015). <br>2. Questions should be asked regarding falls history and mobility status (Stokes 2004; Baker 2015).<br>3. It is useful to know how often the patient is eating what foods they consume. (Needle 2011). <br>4. Do they have help or support with activities of daily living from anyone? Do they give help or support to anyone? (Edwards 2002; Stokes 2004).
[[Category:Older People/Geriatrics - Interventions]]
 
[[Category:Queen Margaret University Project]]
'''Activity:''' Think about why these questions are important to ask with this type of patient. This task should take 20 minutes. <br>Answers:<br>1. It’s important to know any changes which could affect the rest of your assessment and treatment plans. How could these changes have impacted on the patients’ life? Can we help to change any issues/problems? <br>2. We need to know about any previous falls. This will help determine their mobility status and how well they are coping. We can then tailor treatment where it is needed (Stubbs 2015; Sherrington and Tiedemann 2015). <br>3. Nutrition is important for these patients and it should be part of the physiotherapist assessment to check what and how often the patient is eating (Needle 2011). The physiotherapist can then reinforce good eating habits and if needed refer the patient to a dietician. It is also important to have an idea about how much the patient eats as this could contribute to increased fatigue. A reduced tolerance to activity is present in frail patients (Theou 2008) and so how much you include in your first assignment is crucial. <br>4. You can get an idea of what ADL’s they are able to do, how they are coping with these demands and how busy they are throughout the day (Edwards 2002; Stokes 2004).
 
<br>'''Objective assessment'''<br>The objective assessment should begin by observing posture, skin condition and body shape (Wagstaff and Coakley 1988). This can give you clues as to their general health and the extent of their frailty. <br>Mobility <br>• The dependency level of the patient should be established as high dependency can reduce quality of life (HAS 2005). 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 (Podsiadlo 1991). <br>• As gait speed is an important measure of frailty, it is important for physiotherapists to measure it. A speed of less than 0.8 m/sec indicates frailty (Fairhall et al. 2011; Woo 2015). Keeping track of the patient’s gait speed will enable the physiotherapist to see how recovery/ treatment are going. <br>• Endurance can be tested by completing multiple sit to stands or by carrying out a six minute walk test. Monitoring the patients’ heart rate during this will give an indication of their bodies ability to respond to increased effort (HAS 2005). The six minute walk test has been shown to be valid and reliable within this population (Farrell 2004). Measuring endurance gives the physiotherapist an indication of how far the patient is likely to be able to walk, which can aid treatment planning and goal setting. <br>• Analysing the persons 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 reduced stride length and cadence. Reductions in stride length are linked with the severity of frailty and come about due to sarcopenia and so lower limb weakness. It is advised that in order to truly assess gait the person should be asked to walk at a maximum speed (Schwenk 2014). <br>• Good indicators of falls risk are the berg balance scale and the Tinneti, as these look at functional balance (Farrell 2004; Lin 2004). Reduced balance is linked with increasing falls (Sherrington and Tiedemann 2015). <br>• Balance should be assessed comprehensively as this will allow for individualised treatment. 75% of over 70’s have reduced, can increase falls (Sibley 2013). Physiotherapists prefer using their own observations to measure balance rather than outcome measures. Some use standardised outcome measures, but clinical decisions were based on observations. The Berg balance scale, single leg stance test and TUG were seen by physiotherapists as useful tools to measure functional ability. (Sibley 2013). <br>• Balance outcome measures were assessed in a systematic review for their psychometric properties. There are many which the physiotherapist can use; very few measure all aspects of balance. Testing a patients’ 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 OM so that treatment will be tailored to problems (Sibley 2014).
 
<br>• The patients’ ROM and strength should be assessed at every joint. Tibiotarsal range is important to measure as it can impact on posture and may therefore contribute to falls (HAS 2005). <br>• Grip strength can be tested by using a grip ball dynamometer and has been shown to be accurate and comfortable to use with people with frailty. It is important to measure grip strength as weakness can limit the patients’ ability to carry out activities of daily living (Chkeir et al. 2013). This type of dynamometer shows high validity and reliability (Chkeir et al. 2015)<br>• Determining ROM is important with these patients as a link between reduced lower limb mobility and fall prevalence has been found. In this population dorsiflexion, plantar flexion, hip extension, internal rotation and abduction were found to be tight (Chiacchiero 2010). It is therefore important to establish if your patient has reduced ROM as tailored interventions may help reduce falls.
 
<br>• Activities of daily living (ADL’s) can help establish the range of motion and strength of frail patients. Two main types of ADL’s should be assessed, instrumental and basic (Martin 2010; Millán-Calenti 2010). Basic ADL’s are self-care tasks, whereas, instrumental ADL’s are activities which are needed for a person to live independently in the community (Ward 1998). IADL’s are important to measure as an inability to do these is a better indicator of dysfunction than ability to self-care (Ward 1998). The percentage of elderly people reported as being independent increased to 65.4% (from 46.5%) when looking at basic ADL’s 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 patients’ life. It is therefore important to have a grasp of what the patients’ needs to be able to do to remain independent and them review these activities (Ward 1998). <br>• Functional dependence should be assessed as there are correlations between dependence and increased length of stay in hospital (Millán-Calenti 2010).<br>• The Barthel index is a way to assess self-care. It was originally designed to use with stroke patients. Yet, research has shown that it is a reliable tool to use with geriatric patients (Richards et al. 1998). However, the Barthel index may be less reliable with individuals who have cognitive impairments (Sainsbury et al. 2005).
 
<br>'''Optional reading''': Ward, 1998 looked at different standardised IADL which can be used in practice. <br>Activity – should take 10 minutes. <br>What instrumental ADL do you think Mrs/Mr X need to be measured? (LINK TO CASESTUDY)<br>Activity levels<br>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. This can be achieved by functional tasks and by asking the patient and their families (Smyth 1990).
 
<br>'''Outcome measures'''<br>Outcome measures may be useful to track the patient’s progress but also to assess the patient’s abilities (Jette et al. 2009; Kyte and Calvert 2015). There are many different outcome measures to choose 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 with 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. <br>• Frail Elderly Functional Assessment was devised in 1995 and examines functional ability in the frail over a 19 point questionnaire. It has been shown to be valid, reliable and sensitive to change (Gloth et al. 1995, Gloth et al. 1999). <br>• 10 meter walk test has excellent test-retest reliability and high concurrent validity when compared to the shorter 4 meter walking test (Peters et al. 2001). There has also been shown that there is high concurrent validity in the frail population with a 10 meter and 20 meter walk test (Leerar and Miller 2002). <br>• The Edmonton frail scale is made up of 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 (Rolfson 2006). Rolfson et al. (2006) found that the Edmonton frail scale had good inter-rater reliability and took less than 5minutes to administer. It was also shown to have good construct validity and acceptable internal consistency. <br>• PRISMA 7 is a questionnaire devised of seven yes no questions and can bu used when the patient is unable to carry out a stand up and go or a 10 meter walk test (NHS 2015). It was developed with a service in Canadian healthcare, to integrate frailty assessment and management and allow for increase patient-centred care. Using this approach can reduce hospitalisation and is an encouraged approach across systems (Hebert 2003). Its use is recommended by the BGS and can indicate frailty. (Fit for frailty reference). <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.<br>• The Barthel index measures the patient’s ability to look after themselves by asking 10 questions and answers are graded on the amount of assistance needed to carry out the activity. The interrater reliability of this outcome is fair to good depending on which activity is being assessed (Richards et al. 1998).
 
'''Key points to take'''<br>• Assessment of known frail patients is important and should be carried out by physiotherapists at the first contact with every patient. <br>• Outcome measures should be regularly administered to review the physiotherapists’ effectiveness at improving frailty. <br>• There are specific elements which need to be measured with persons who are frail: list<br>• Doing these may help prevent hospital admissions. <br>
 
== '''Medical'''  ==
 
As people age the number of medications taken by the elderly increases to help tackle the effects of aging, such as; heart problems, cholesterol, depression and discomfort.<br>
 
Some of the causes of adverse drug reactions (ADRs) can occur with multiple medications or improper drug or dosage selection. Fall, distress, depression, anxiety, confusion and insomnia are a few of the symptoms of ADRs in elderly population<ref name="Vervloet and Durham">Vervloet D, Durham S.Adverse reactions to drugs. BMJ 1998;316:1511-4. Full version: http://www.bmj.com/content/bmj/316/7143/1511.full.pdf (Accessed 12 Dec 2015).</ref>.
 
'''Risk factors for ADR is such as: <br>'''- Age (≥85) <br>- Multiple prescribers <br>- Long duration of use<br>- Multiple chronic disease <br>- History of drug reactions <br>- Regular alcohol intake
 
'''Common medication and their side effects&nbsp;'''
 
{| width="500" border="1" cellpadding="1" cellspacing="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- BlockersfckLRhttp://www.nhs.uk/Conditions/Beta-blockers/Pages/Introduction.aspx (Accessed 5 Jan 2016)</ref>
| Angina, Heart failure, Atrial fibrillation and Heart attach
| Angina, Heart failure, Atrial fibrillation and Heart attach Dizziness, tiredness, Blurred vision, slow heartbeat, diarrhoea and nausea
| Atenolol, bisoprolol, acebutolol, metoprolol
|-
| Antidepressants<ref>NHS. Antidepressants.fckLRhttp://www.nhs.uk/Conditions/Antidepressant-drugs/Pages/Introduction.aspx (Accessed 2 Jan 2016)</ref>
| Depression
| Dizziness, insomnia, headaches, loss of appetite, anxious, feeling agitated and blurry vision
| Tricyclic antidepressants, Selective serotonin reuptake inhibitors, <br>Serotonin- noradrenaline reuptake inhibitors
|-
| 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
|-
| Non-Steroidal Anti- Inflammatory drugs<ref>NHS. Non-steroidal anti-inflammatory drugs (NSAIDS). http://www.nhs.uk/conditions/anti-inflammatories-non-steroidal/Pages/Introduction.aspx (Accessed 3 Jan 2016)</ref>
| Relieve pain, reduce inflammation and a high temperature
| Short term use of NSAIDs is unlikely to have any side effects. However long term use causes indigestion and stomach ulcers
| Ibuprofen, Aspirin, diclofenac, naproxen
|}
 
<br>Side effects of medication such as drowsiness, blurred vision and insomnia can interfere with the treatment session and also delay any recovery, it is therefore important for physiotherapists to know if the patient is on any medication to modify treatments. <br>
 
= Physiotherapy treatment  =
 
= Conclusion  =
 
= Recent Related Research  =
 
= References  =
 
<references /><br>

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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