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| <div class="noeditbox">Welcome to "Contemporary and Emerging Issues in Physiotherapy Practice" Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice project. This space was created by and for the students at Queen Margaret University in Edinburgh, UK. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
| | <div class="editorbox"> '''Original Editor '''- [[User:Helene Slettebakk Gjerde|Helene Slettebakk Gjerde]], [[User:Alice Porteous|Alice Porteous]], [[User:Benedicte Aarseth|Benedicte Aarseth]], [[User:Matthew Laird|Matthew Laird]], [[User:Beth Donnelly|Beth Donnelly]] as part of the [http://www.physio-pedia.com/Contemporary_and_Emerging_Issues_in_Physiotherapy_Practice QMU Contemporary and Emerging Issues in Physiotherapy Practice Project] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div> |
| '''Original Editors '''- [[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]] as part of the [http://www.physio-pedia.com/Contemporary_and_Emerging_Issues_in_Physiotherapy_Practice QMU Contemporary and Emerging Issues in Physiotherapy Practice Project] | | == 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> |
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| <br> | | == 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>. |
| = Introduction<br> =
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| This online learning resource has been created by a group of student physiotherapists and is tailored towards final year students and newly qualified physiotherapists. This has been designed as an individual Wiki and should take 10 hours to complete.
| | * 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]].<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: |
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| The management of older adults is not a new concept however, as the average age of the population increases it is suggested that the prevalence of frailty will multiply<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>. Subsequently this causes further demand on the NHS an already overstretched service. In response to this there has been an increased drive to improve the efficiency of the management of frailty. There has been a shift of care from reactive to preventative strategies and a focus on providing early interventions to reduce costly unplanned admissions to hospital<ref>Edwards N. Community services - how they can transform care. London: The King's Fund, 2014.</ref>.<br>
| | * [[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>. 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. |
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| <br> | | * [[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> |
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| From our experience on clinical placements and following discussion with expert clinicians, it became apparent to us that final year students may lack knowledge and awareness around frailty and the role of the physiotherapist in providing holistic care.
| | == Benefits of Physical Activity in Frail Older Adults == |
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| <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> |
| | === Physiotherapists Role in Promoting Physical Activity in Frail Older Adults === |
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| === Navigation === | | 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>: |
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| As mentioned above this a 10-hour interactive learning resource. This means you will be working through various learning material, including multimedia resources, learning tasks and a case study. <br>These are developed and adapted in order to facilitate optimal learning whilst considering different learning styles. <br>In order for you to make the most out of this resource please read the guidance below.<br>
| | *Identify fears and barriers to being physically active and provide solutions to overcome these |
| | *Provide ongoing support and encouragement |
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| '''How much time to spend on each section:'''
| | ==== 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> |
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| 1. Introduction: 1 hour<br>2. Frailty: 1 hour <br>3. Guidelines & Policies: 1 hour <br>4. Introduction to the physiotherapist’s role: 30 minutes <br>5. The Comprehensive Geriatric Assessment: 2 ½ hours <br>6. Physiotherapy Treatment: 3 hours <br>7. Conclusion: 1 hour <br><br>
| | Suggested activities: |
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| '''Learning tasks you will encounter and what they involve:'''
| | *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" /> |
| <br> | | *Adhering to a physiotherapist recommended home exercise program |
| | | *Breaking up time spent sitting with short regular periods of standing or walking<ref name="BHF2012" /> |
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| | == Conclusion == |
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| In this section we will ask you to reflect upon your knowledge and skills<br>as well as previous experiences and new learning. <br>Consider using a reflecting model of your choice when doing this. <br>If you are unsure please access: ... For more information on reflection. <br>
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| In order to facilitate learning we have created learning activities <br>which will include reviewing the presented material, answering questions<br> and making mind maps.
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| All information related to the case study will be presented here.<br>
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| In order to stay within the 10-hour timeframe to present a concise <br>and manageable learning resource for you we have only presented <br>what we believe is the most essential evidence in relation to our topic. <br>However, throughout this learning resource you will find sections called <br>“Resources” with additional reading you can access in relation to the topic <br>being discussed. This reading is optional and is out with the <br>10-hours you should allocate for this wiki. <br>
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| The sections below will outline the aims of this learning resource and present 3 learning outcomes you should aim to achieve by completing this resource. The learning outcomes have been created using the appropriate levels of the Bloom’s Taxonomy for final year students and/or newly qualified physiotherapists in order facilitate a high level of thinking and learning. <br>
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| === Aims ===
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| • 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> </span>
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| === Learning outcome ===
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| • Analyse the emerging issue of frailty in relation to the current context of health and social care in the UK. • Critically evaluate the physiotherapists’ role in the holistic assessment and treatment of frail individuals to prevent hospital admission. • Evaluate the skills and knowledge gained from this resource; identify and apply appropriately in clinical practice.
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| = Frailty =
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| Before commencing with this learning resource take 20 minutes to reflect upon<br> your current knowledge in relation to frailty. <br>Please write this down as we will revisit this at the end of the learning resource.
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| You might want to consider these questions:
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| *What is frailty? | |
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| *Why is it important to know about frailty?
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| *What do you think a physiotherapist’s role is?
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| *How do you assess and treat a frail patient? | |
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| === Definition ===
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| According to Fried et al (2001), frailty is defined as a “biological syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiological systems and causing vulnerability to adverse outcomes.” However it is also to be noted that despite the large proportion of the elderly population who are diagnosed as Frail, there is no standardised definition.<br>Fried et al. also provides a Phenotype for identifying those who are frail. It designates that to be considered frail the person must match three of five categories. <br>
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| | A drop in bodyweight of ≥10lbs/4.5kg in the past year or a drop in bodyweight of ≥5% in the past year.
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| | Measured using grip strength. A result within the lowest 20 percentile according to gender and BMI indicates a weakness.
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| | The lowest 20 percentile of the population according to gender and standing height, 15ft walking time.
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| <br>This can be a good way of describing the multiple physiological declines described in frail persons.<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>. 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>. Several guidelines are available, but none specifically detail the physiotherapist's role. |
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| Frailty can sometimes be missed in persons with multiple pathologies as the focus is very much disease based. As professionals we must try to maintain an awareness of frailty and the impact that it will have for each individual despite their diagnosis. It is also noted that the label of frail can have negative connotations for patients and everyone will react differently. 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 may be the causation of disability. Again this will be very unique to each individual. BGS 2014
| | == References == |
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| Frailty is associated with: <br>• Increased risk of falls<br>• Hospitalisation<br>• Loss of mobility and independence<br>• Increasing disability and death (Fried et al. 2001)
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| [[Image:Risk Factors Mindmap .png|center|500x300px]]<br><br>
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| Assessment: <br>The Fried Frailty Index (FFI) as described above is commonly used to diagnose frail persons, those with 3 or more categories out of 5. It can also be used to designate persons as Intermediate frail or Pre-frail. Fried et al. suggests that those who score in 1 or 2 of the categories but not 3 are “Pre-frail”.
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| <br>Another commonly used assessment tool is the [http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist%27s_Role_in_Preventing_Hospital_Admission#The_comprehensive_geriatric_assessment Comprehensive Geriatric Assessment (CGA). This is a multidimensional assessment tool which is implemented by the multidisciplinary team (Martin 2015). This will be looked at in more depth in the assessment section of this Wiki. ]<br>
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| === Demographics ===
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| <u>Prevalence</u>
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| • Frailty prevalence increases with age. In those aged 65-75 in the United States, 7-12% will be classified as frail. This number increases to 25% in those over 85. <br>• The general trend is for greater incidence in females than males. (Chen et al. 2014)<br>• The average prevalence within Europe is 17% in those over 65 years. (Santos-Eggimann et al. 2009)
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| According to the Scottish Government, the number of persons over 75 years is going to rocket by 28% over a ten year period from 2012 to 2022. To compare, for those of working age there will be a 5% increase (National Records of Scotland, 2013). This suggests that there will be a much larger proportion of the population regarded as elderly and therefore an increase in the number of frail persons within Scotland. This will push the number of dependants within the population to almost 70 per 100 persons in the working population by 2037 as demonstrated by the graph below from the National Records for Scotland, 2013.
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| A graphic produced by the Office of National Statistics shows the population change from 1971 with predicted changes through until 2085. This graphic shows the significant change to a top heavy population in the coming 10-15 years.
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| === Costs ===
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| '''The next section will outline the length of stay and cost implications of frailty on the NHS.'''
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| <br> [[Image:Total NHS Expenditure 2013.png|right]]
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| The latest published UK 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 <ref name="DOH B" />.
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| [[Image:Hospital admissions in the NHS.png|left]]<br>
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| 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>.<br>
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| ! colspan="3" scope="col" | A table to show the cost of average stays in hospital<ref name="DOH 2013B" /><br>
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| | '''Type of stay<br>'''
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| | '''Cost'''<br>
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| | £1489<br>
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| Most emergency admissions to hospital happen through accident and emergency<ref name="DOH B" />. On average a person over 85 spends 11 days in hospital<ref name="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<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> . This means that even more money is spent.
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| {| width="400" cellspacing="1" cellpadding="1" border="1" align="right"
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| ! scope="col" colspan="2" | <br>A table to show the cost of health care input needed from falls <ref>AGE UK. Later in life United Kingdom. http://www.ageuk.org.uk/Documents/EN-GB/Factsheets (accessed 19 dec 2015).</ref><br>
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| | '''Type of fall'''<br>
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| | '''Cost to NHS in millions'''<br>
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| | falls on stairs<br>
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| | £16<br>
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| 410,377 elderly persons were admitted to hospital due to a fall in 2013. Appropriate strategies could prevent this by up to 30%<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> .
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| The length of time frail people stay in hospital differs thorughout the world. The UK is 16th in the world when it comes to average length of stay in hospital<ref>OECD. Health at a Glance, 2013. http://www.oecdilibrary.org/docserver/download/8113161e.pdf?expires=1444911042&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;id=id&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;accname=guest&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;checksum=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="AHIW">AHIW. 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>
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| The above statistics show that elderly people spend a lot of time in hospital, some of which may not be necessary and is very costly for the NHS.<br>
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| {| width="800" cellspacing="1" cellpadding="1" border="1" align="center"
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| | [[Image:Additional reading heading.png]]
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| *Australia's hospital at a glance, explains about the length of stay and hospital admissions in the frail population in Australia<ref name="AHIW 2013">AHIW. Australia’s hospitals 2013-14: at a glance http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551482 (accessed 20 Dec 2015).</ref> :<br>
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| [http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551482 http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129551482] <br>
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| *This article looks at an overview of hospital stays in the USA<ref name="Weiss and Elixhauser 2014" />:
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| [http://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-Hospitalizations-United-States-2012.jsp http://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-Hospitalizations-United-States-2012.jsp]
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| |}
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| <br>
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| === Relevance ===
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| Based upon the statistics and projections of The Scottish Government (ref), over the next decade we will face an ageing population. As shown by literature on the topic of prevelance and cost the already limited NHS budgets will have to stretch further as with more elderly dependants will come greater expenditure on care.
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| This indicates a need for change avoiding costly hospital addmissions unless absolutely neccessary. Throughout this online Wiki module we shall discuss these possible options to help you implement change.
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| === Health and Social Care Integration ===
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| One aim of the Health and Social Care Integration of the NHS is to help tackle the rising costs of the ageing population, whilst improving service delivery and effectiveness of care.
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| The Department of Health<ref name="DOH B" /> 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.
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| <br>The planning, resources and delivery of care will be now carried out together by the local authority or health board<ref>The Scottish Government. National health and wellbeing outcomes. http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration/Outcomes (accessed 16 Oct 2015).</ref>. This will mean that health and social care can run smoothly as one entity and users will experience a continuity of care.
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| <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<ref name="Cornwall et al. 2012" />
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| <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<ref name="DOH B" />.<br><br>
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| = Policies and Guidelines =
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| This section will present the most relevant guidelines and policies in relation to frailty and highlight the most useful points.<br><br>The policies and guidelines included in this learning resource are:<br>
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| {| width="400" align="left" border="1" cellspacing="1" cellpadding="1"
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| | [[Image:HIS.jpg|left]]
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| | [[Image:THINK FRAILTY.png|225x200px]]
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| | [[Image:BGS logo.png]]
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| | [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>]
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| | [http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/frailty_report.aspx Think Frailty<ref name="Think Frailty">Healthcare Improvement Scotland. Improving the identification and management of frailty. fckLRhttp://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/frailty_report.aspx (accessed 19 Nov 2015)</ref>]
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| | [http://www.bgs.org.uk/index.php/fit-for-frailty Fit for Frailty<ref name="FF1" />]
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| 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>
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| === Older People's Acute Care Improvement Programme (OPAC) ===
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| 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)”<ref name="OPAC" /> was commissioned by the Scottish Government.
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| The programme focuses on 2 key areas
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| *Frailty
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| *Delirium
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| 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. <ref name="OPAC" /> <br>The document “Think Frailty” explored the strategies implemented in practice in more depth and will be discussed in Section 3.2. <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> reported the impact of the programme and found that:
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| *Frailty screening in 3 surgical wards at the Royal Infirmary of Edinburgh decreased the length of stay, number of falls and number of complaints
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| *A reduced length of stay in NHS Grampian
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| *50% decrease in the number of falls per month in 2 wards in NHS Greater Glasgow and Clyde<br>
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| 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" /> .
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| === Think Frailty ===
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| As mentioned above the Scottish Government provided funding for Healthcare Improvement Scotland's policy to improve health care for older people due to the rising numbers of unplanned admissions in older people. 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" />
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| This case study report focuses on the work to identify frailty and ensure rapid CGA in four NHS boards in Scotland: NHS Ayrshire & Arran, NHS Grampian, NHS Lanarkshire and NHS Lothian.<br>
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| Common themes underpinning the success in the NHS boards mention in the report included<ref name="Think Frailty" />:
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| '''Easy to use screening tool <br>'''
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| The use of these should be at first point contact with older people; at the front door or at home
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| *Important to enable rapid identification and referral to CGA
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| *Valid screening tools reduces variability and increases the number of appropriate referrals to frailty services
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| <br>'''Early intervention & Senior decision makers'''
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| *Senior decision makers were valued in particularly in NHS Ayrshire & Arran and NHS Grampian. As senior clinicians were more likely to use a wider range of care management options other than admission
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| *Early intervention focusing on discharge planning
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| <br>'''Multidisciplinary team working'''
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| *Having a strong, integrated team was valued by all sites
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| *Good communication between the members of the MDT was important
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| *Common aim for all sites: Expanding the team. In particular physiotherapy and OT services so that a 7 day a week around the clock service is available
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| The sites involved in this project were able to show significant improvements in outcomes for 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 [http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/frailty_report.aspx Think Frailty: Improving the identification and management of frailty]<br>
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| === Fit for Frailty ===
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| '''Part 1: Recognition and management of frailty in individuals in community and outpatient settings'''<ref name="FF1">British Geriatrics Society. Fit For Frailty: Part 1: Recognition and management of frailty in individuals in community and outpatient settings. http://www.bgs.org.uk/index.php/fit-for-frailty (accessed 12 Oct 2015)</ref>
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| This part of the Fit for Frailty guidelines by the British Geriatric Society (BGS) intend to support health and social care professionals working with frail older people in the community.
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| <br>In order to recognise and identify frailty BGS recommends<ref name="FF1" />:
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| *During all encounters with health and social care professionals older people should be assessed for frailty
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| *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
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| *Gait speed, timed up and go test and the PRISMA questionnaire are recommended outcome measures to assess for frailty<br>
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| For managing frailty in an individual BGS recommends<ref name="FF1" />:
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| *A Comprehensive Geriatric Assessment (CGA), which involves a holistic, multidimensional and multidisciplinary assessment of an individual
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| *The result of the CGA should be an individualised care and support plan (CSP).
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| *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<br>
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| <br>
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| === Gap in literature ===
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| Clinical guidelines provide evidence based recommendations in relation to the management of a specific condition or a syndrome. They are aiming to assists health and social care professionals in their decision making and help reduce undesirable variations in practice (Broughton and Rathbone 2001).<br>The guidelines on frailty discussed above are aimed to all health and social care professionals and it has been found that these rarely go in depth in their explanation of specific healthcare professional's role. As physiotherapists it can be difficult to identify what recommendations are most applicable to our practice in relation to the management of frailty. <br>The guidelines do not state the main role of physiotherapy in the management of frailty. However, exact guidance is challenging to provide as the assessment and treatment of frailty will vary depending on the individual, the setting and the situation.
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| The following sections of this wiki learning resource aims to critically synthesise evidence on the physiotherapy management of frailty in relation to preventing hospital admissions. <br>This aims to help “fill the gap” in the national clinical guidelines and make you as a final year physiotherapy student or recent graduate more aware of the physiotherapy role and practice in relation to frailty. <br>
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| <br>
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| === Resources ===
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| {| width="500" align="center" border="1" cellspacing="1" cellpadding="1"
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| *[http://www.bgs.org.uk/index.php/fitforfrailty-2m Fit for Frailty Part 2] - Developing, commissioning and managing services for people <br>living with frailty in community settings. <br>This is a resource for all GPs, geriatricians, Health Service managers, <br>Social Service managers and Commissioners of Services<ref name="FF2">British Geriatrics Society. Fit for Frailty Part 2.fckLRhttp://www.bgs.org.uk/index.php/fitforfrailty-2m (accessed 12 Oct 2015)</ref>.<br><br>
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| *[http://www.bgs.org.uk/index.php/bgscampaigns-715/silverbook Silver book] - Quality Care For Older People with Urgent and Emergency Care Needs. <br>Click on "Complete Silverbook" in the toolbar to access this document on managing <br>frailty in acute settings<ref name="Silver book">British Geriatrics Society. Silver Book. http://www.bgs.org.uk/index.php/bgscampaigns-715/silverbook (accessed 13 Jan 2016)</ref>.
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| <br>
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| = Introduction to the physiotherapist's role.<br> =
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| === Delivery of care ===
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| Physiotherapists work within multiple teams that help with preventing hospital admissions. Day hospital and community are two very common areas that work with the frail elderly.
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| For patients who are unable to travel, physiotherapy treatments are offered at home. At times home can be the most appropriate environment to have treatments. When aiming for living independently or increasing mobility it can be beneficial for physiotherapists to work within the environment patients live in, to get a better understanding and to adapt any treatments<ref>Brekshire Healthcare NHS: Physiotherapy at homefckLRhttp://www.berkshirehealthcare.nhs.uk/ServiceCatInfo.asp?id=60 (accessed 11 Jan 2016)</ref>. Physiotherapy at home offers treatment for a lot of different conditions such as: respiratory, muscular and skeletal problems, nervous system and if any issues with mobility and balance<ref>NHS. PhysiotherapyfckLRhttp://www.nhs.uk/Conditions/Physiotherapy/Pages/Introduction.aspx (accessed 9 Jan 2016).</ref>.
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| The video below is one example of an initiative in England, which was set up to reduce hospital admissions and length of hospital stay in the frail elderly.<br> {{#ev:youtube|u4hgX7EzgNA}}
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| Recently, physiotherapists have started working within A&E as part of the multi-disciplinary teams, by helping to reduce delays and inefficiencies, and also preventing unnecessary hospital admissions. In the UK 18.3 million people attended A&E units in 2012-2013, 24% of those who attended were aged 60 or above, almost 21% was due to ligament, joint, muscle, and soft tissue injuries and 21% were then admitted to hospital<ref>Chartered Society Of Physiotherapy. Physiotherapy Works: accident and emergency. http://www.csp.org.uk/professional-union/practice/your-business/evidence-base/physiotherapy-works/accident-emergency (accessed 9 Jan 2016)</ref>. Physiotherapists main task in A&E is assessing and managing people with MSK injuries, loss of function and falls in elderly. Occupational therapists and physiotherapists works together with discharge planning, assessing elderly patient’s management of activity of daily living, avoiding unnecessary hospital admission and enable patients to return safely to home.
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| In 2015 there was a conference held in Liverpool discussing the effectiveness of musculoskeletal emergency physiotherapy practitioner. As A&E is a new working environment for physiotherapists continuous research is needed, and due to this there is a lack of evidence within this area<ref>Physiotherapy UK. Effectiveness of musculoskeletal emergency physiotherapy practitionershttp://www.physiotherapyuk.org.uk/presentation/effectiveness-musculoskeletal-emergency-physiotherapy-practitioners (accessed 4 Jan 2016).</ref>.
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| In 2015 there was a six-week trial where a physiotherapists and a paramedic joined forces for non life- threatening emergency calls, aiming to prevent unnecessary A&E attendances and reducing hospital admissions. Conditions that were commonly seen was falls, chronic pain, loss of mobility, exacerbations of long- term conditions and frailty. 61 incidents were responded to during this trail, 49 were due to falls in own home. 57 % of the patients seen remained at home. Through this trail £2,850 was saved every time a person was not transferred to hospital. This shows an emerging role in which physiotherapists are helping to prevent unnecessary hospital admissions<ref>Chartered Society of Physiotherapy. Physio and paramedic pool resources in Lakes initiativefckLRhttp://www.csp.org.uk/news/2015/10/12/physio-paramedic-pool-resources-lakes-initiative (accessed 11 Jan 2016).</ref>.<br>
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| {| width="200" align="center" border="1" cellspacing="1" cellpadding="1"
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| | [http://www.csp.org.uk/publications/physiotherapy-works-accident-emergency CSP: Physiotherapy works: Accident and Emergency]
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| = The Comprehensive Geriatric Assessment =
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| All the guidelines outlined above state a need for a CGA to be completed to diagnose patients who may be frail. From this assessment a holistic interdisciplinary treatment program can be devised to suit the problems and needs of the individual. The assessment is usually carried out by a geriatrician or another trained professional<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>. <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.
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| <br> Below is a table adapted from <ref name="Martin 2010" /> which identifies and outlines what should be included in each domain.
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| [[Image:CGA.jpg]]<br>
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| <br> The methods used to achieve this are specific to the region of the UK in which you work. However, the measurement tools should be standardised and reliable. Some measures identify problems while others examine their severity.
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| <br> The assessment will allow health professionals to identify the problems and allow for onward referral now and in the future. Once specific problems have been identified onward referral can be made to appropriate healthcare professionals. This can then allow for a more in depth assessment to be made around these problems. For example a patient may be referred to physiotherapy to help increase mobility<ref name="Martin 2010" />.
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| <br>
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| '''Benefits'''
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| <br> A study examined whether a comprehensive assessment after an emergency admission is more effective when carried out by a team trained in a using a CGA. The paper showed that this approach reduced; costs, length of hospital stay, deterioration, mortality. Routine follow up appointments are an essential part of the CGA and identify effectiveness of treatment. There is no specifc time frame for these, yet follow up sessions usually occur when people are readmitted to hospital.<ref name="Ellis 2004">Ellis G, Langhorne P. Comprehensive geriatric AX for older hospital patients. Bri Med Bull 2004; 71: 45-49.</ref>
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| <br> 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 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; aging 2011; 28(7):509.</ref>. 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 <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 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Gerontology International 2015; 15(1): 80-88.</ref>. It can also reduce hospital stay, increase the likelihood of keeping patients out of 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>.<br>
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| How many of the key points can you recall?<br><br>1. Who carries out a comprehensive geriatric assessment?<br>2. Where can it take place?<br>3. What are its key components?<br>4. What effects can completing a CGA have?
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| Use the reading in this section and your prior knowledge to reflect upon any problems that you <br>think may arise when carrying out this type of assessment.
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| This activity should take 10 minutes to complete.
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| == Functional capacity ==
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| <br><br>
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| Physiotherapists have the knowledge and skill level to carry out the functional aspect of the CGA<ref name="Wyrko 2015">Wyrko Z. Frailty at the front door. Clinical Medicine 2015; 15(4): 377–81.</ref><ref name="King10" />.
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| '''What is a functional assessment?'''
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| <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 <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<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 comprehensive geriatric assessment 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.
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| <br>However, assessing frail elderly patients can be difficult as it takes a long time due to…
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| <br>• A through top to toe assessment needs to be done including all of the elements of the ICF model <ref name="Wagstaff and Coakley 1988">Wagstaff P and Coakley D. Physiotherapy and the elderly patient. Kent: Croom Helm ltd, 1988.</ref> <ref name="Smyth 1990">Smyth L. Practical physiotherapy with older people. Chapman and Hall, 1990.</ref><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><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<ref name="Morala 2006">Morala D. Factors Associated with the Functional Status of Community-dwelling. Elderly Journal of Geriatric Physical Therapy 2006; 29(3).</ref>. It can also impact on how you carry out your assessment and communicate with the patient <ref>Albert SM, Tabert MH, Dienstag A, Pelton G, Devanand D. The impact of mild cognitive impairment on functional abilities in the elderly. Current Psychiatry Reports 2002; 4(1):64-68.</ref><ref name="Deary et al. 2009">Deary IJ, Corley J, Gow AJ, Harris SE. Age-associated cognitive decline. Br Med Bull 2009; 92(1): 135-152.</ref>. <br>• Auditory problems, affecting the patients’ ability to hear you<ref name="Fairhall et al. 2011" /><br>• Visual problems, meaning the patient cannot see you or what you are trying to get them to do clearly<ref name="Fairhall et al. 2011" />. <br>• Easily fatigued, causing patients to have reduced performance in activities which occur at the end of the assessment<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>. This may skew the results of any outcome measures used. <br>• Reduced / slow mobility (i.e. Sit-stand takes longer)<ref name="Theou et al. 2008" />.
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| === Subjective Assessment ===
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| <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.
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| <br>1. Has anything changed recently in terms of the patients’; vision, hearing, mobility status, cognitive ability, medication usgae 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>.
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| <br>2. Questions should be asked regarding 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.
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| <br>3. It is useful to know how often the patient is eating and what foods they consume<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>.
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| <br>4. 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" />.
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| Think about why the above questions are important to ask with this type of patient.
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| This task should take 20 minutes.
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| Answers are below
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| 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?
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| 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<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>.
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| 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<ref name="Needle 2011" />. The physiotherapist can then reinforce good eating habits and if needed refer the patient to a dietician. It is also important to have an idea about how much the patient eats as this could contribute to increased fatigue. A reduced tolerance to activity is present in frail patients <ref name="Theou et al. 2008" /> and so how much you include in your first assignment is crucial.
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| 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<ref name="Edwards 2002">Edwards S. Neurological physiotherapy: a problem-solving approach. 2nd ed. London: Churchill Livingstone,2002</ref> <ref name="Stokes 2004" />.
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| === <br>Objective Assessment ===
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| <br>The objective assessment should begin by observing posture, skin condition and body shape <ref name="Wagstaff and Coakley 1988" />. This can give you clues as to their general health and the extent of their frailty. <br>
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| <u></u>
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| The dependency level of the patient should be established as high dependency can reduce quality of life<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 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Go”: A Test of Basic Functional Mobility for Frail Elderly Persons, Journal of the American Geriatrics Society 1991;39(2):142–148.</ref>. <br>
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| 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 <ref name="Fairhall et al. 2011" />. Keeping track of the patient’s gait speed will enable the physiotherapist to objectively measure patient progress. <br>
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| 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<ref name="HAS 2005" />. The six minute walk test has been shown to be valid and reliable within this population<ref name="Farrell 2004" />. Measuring endurance gives the physiotherapist an indication of how far the patient is likely to be able to walk, which can aid treatment planning and goal setting. <br>
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| 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 have 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 their maximum speed<ref name="Schwenk 2014">Schwenk M, Howe C, Saleh A, Mohler J, Grewal G, Armstrong D and Najafi B. Frailty and Technology: A Systematic Review of Gait Analysis in Those with Frailty. Gerontology 2014; 60(1): 79–89.</ref>. Good indicators of falls risk are the berg balance scale and the Tinneti, as these 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>. Reduced balance is linked with increasing falls (<ref name="Sherrington 2015" />.
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| [[Image:Gait assessment.png|right]]<br>Balance should be assessed comprehensively as this will allow for individualised treatment. 75% of over 70’s have reduced balance, which can increase falls<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>. 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<ref name="Sibley 2013" />. 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<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>.
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| <br>Tibiotarsal range is important to measure as it can impact on posture and may therefore contribute to falls<ref name="HAS 2005" />. 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 <ref name="Chkeir 2013">Chkeir A, Jaber R , Hewson DJ , Duchêne J. Estimation of grip force using the Grip-ball dynamometer. Medical Engineering &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Physics 2013; 35(11):1698-1702.</ref>. This type of dynamometer shows high validity and reliability <ref name="Chkeir 2015">Chkeir A, Jaber R , Hewson DJ , Duchêne J. Reliability and validity of the GripBall dynamometer for grip-strength measurement. Annual international conference of the IEEE Engineering in medicine and biological sciences 2012; Aug; France, Reserach gate, 2015.</ref>. <br>
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| 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 <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>. It is therefore important to establish if your patient has reduced ROM as tailored interventions may help reduce falls.
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| <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 <ref name="Millan-calenti 2010" /><ref name="Martin 2010" />.<br>
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| *Basic ADL’s are self-care tasks, whereas, <br>
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| *instrumental ADL’s 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>
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| IADL’s 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 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 <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>.<br>
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| 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<ref name="Smyth 1990" />. <br>
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| | Ward, 1998 looked at different standardised IADL which can be used in practice.<br>
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| Take a look at the case study, What instrumental activties of daily living do you
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| think need to be measured as part of Mr Smith's assessment?
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| This activity should take 10 minutes
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| <br><br>'''Outcome measures'''<br>Outcome measures may be useful to track the patient’s progress but also to assess the patient’s abilities <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 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.
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| ! scope="col" | Outcome Measures (OM)<br>
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| ! scope="col" | Description of OM<br>
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| ! scope="col" | Psychometric properties<br>
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| | Frail elderly functional assessment (1995)<br>
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| *Examines functional ability in the frail
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| *Nineteen point questionnaire
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| *Valid
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| *Reliable
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| *Sensitive to change <ref name="Gloth et al. 1995">Gloth FM, Walston J, Meyer J &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Pearson J. Frail elderly functional assessment. American Journal of Physical Medicine &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Rehabilitation 1995; 74(1): 45-53.</ref><ref name="Gloth et al. 1999">Gloth FM, Walston J, Meyer J &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; 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>
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| | Ten Meter walk test <br>
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| | [[10 Metre Walk Test]] <br>
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| *Excellent test-retest reliability and high concurrent validity when compared to the shorter 4 meter 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>.
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| *High concurrent validity in the frail population with a 10 meter and 20 meter 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>.
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| | The Edmonton frail scale<br>
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| | 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>
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| *Good inter-rater reliability
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| *Takes less than 5 mins to complete
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| *Good construct validity
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| *Acceptable internal consistency<ref name="Rolfson 2006" />
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| | PRISMA 7<br>
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| | A questionnaire devised of seven yes/no questions that can be used when the patient is unable to carry out a stand up and go or a 10 meter 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>
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| | 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>. Its use is recommended by the BGS and can indicate frailty. <ref name="FF1" /> <br>
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| | The Barthel index<br>
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| | It measures the patients’ 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>
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| | The interrater reliability of this outcome is fair to good depending on which activity is being assessed <ref name="Richards et al. 2000" />. <br>
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| | Tinetti<br>
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| | 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>
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| *70% sensitivity score
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| *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>).
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| *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>.
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| *In community-dwelling older adults the concurrent validity was adequate when compared to the timed-up and go<ref>Lin M R, Hwang H F et al. Psychometric comparisons of the timed up and go, one-leg stand, functional reach, and Tinetti balance measures in community-dwelling older people. Journal of the American Geriatrics Society 2004; 52(8): 1343-1348.</ref>.
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| | Elderly Mobility Scale<br>
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| | Assesses mobility in the frail by answering 20 questions<ref>Smith R. Validation and Reliability of the Elderly Mobility Scale. Physiotherapy1994;80(11):744-747.</ref>.<br>
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| | Good concurrent validity, discriminant validity and inter-rater reliability<ref>Nolan J, Remilton L &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; 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>
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| 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 <ref name="FF1" />.
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| '''Key points to take'''<br>
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| *Assessment of known frail patients is important and should be carried out by physiotherapists at the first contact with every patient.
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| *Outcome measures should be regularly administered to review the physiotherapists’ effectiveness at improving frailty.
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| *There are specific elements which need to be measured with persons who are frail: dependency level and ADL ability, Gait; speed and quality, endurance, balance, strength and falls risk.
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| *Doing these may help prevent hospital admissions. <br>
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| You have reached the end of the Functional assessment section.
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| Reflect on how your learning thorughout this section will change any future assessments
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| you carry out with patients who are frail.
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| This task should take 10 minutes
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| <br>
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| == '''Medical''' ==
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| 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.<ref>NHS. PHYSIOTHERAPY FOR OLDER ADULTS.fckLRhttps://www.cumbriapartnership.nhs.uk/our-services/community-health/our-community-health-services/physiotherapy/elderly-physiotheraphy (accessed 5 Jan 2016).</ref><br>
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| 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>.
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| '''Risk factors for ADR is such as <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>:<br>'''- Age (≥85) <br>- Multiple prescribers <br>- Long duration of use<br>- Multiple chronic disease <br>- History of drug reactions <br>- Regular alcohol intake
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| '''Common medication and their side effects '''
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| ! scope="col" | Medication
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| ! scope="col" | Conditions used to treat
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| ! scope="col" | Common side effects
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| ! scope="col" | Examples
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| | Beta Blockers<ref name="NHS">NHS. Beta- BlockersfckLRhttp://www.nhs.uk/Conditions/Beta-blockers/Pages/Introduction.aspx (Accessed 5 Jan 2016)</ref>
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| | Angina, Heart failure, Atrial fibrillation and Heart attach
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| | Angina, Heart failure, Atrial fibrillation and Heart attach Dizziness, tiredness, Blurred vision, slow heartbeat, diarrhoea and nausea
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| | Atenolol, bisoprolol, acebutolol, metoprolol
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| | Antidepressants<ref>NHS. Antidepressants.fckLRhttp://www.nhs.uk/Conditions/Antidepressant-drugs/Pages/Introduction.aspx (Accessed 2 Jan 2016)</ref>
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| | Depression
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| | Dizziness, insomnia, headaches, loss of appetite, anxious, feeling agitated and blurry vision
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| | Tricyclic antidepressants, Selective serotonin reuptake inhibitors, <br>Serotonin- noradrenaline reuptake inhibitors
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| | Benzodiazepines<ref>NHS. Generalised anxiety disorder in adults - Treatment. http://www.nhs.uk/Conditions/Anxiety/Pages/Treatment.aspx (Accessed 3 Jan 2016).</ref>
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| | Relief of severe anxiety
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| | Drowsiness, difficulty concentrating, headaches and vertigo
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| | Diazepam, lorazepam, Chlordiazepoxide
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| | 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>
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| | Relieve pain, reduce inflammation and a high temperature
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| | Short term use of NSAIDs is unlikely to have any side effects. However long term use causes indigestion and stomach ulcers
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| | Ibuprofen, Aspirin, diclofenac, naproxen
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| |}
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| <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>
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| == Mental health ==
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| Although it is not the prime role of a physiotherapist, in order to provide a holistic service we must be aware of and understand mental health of our patients and the impact that this may have on the individual and their ability to carry out any treatments.
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| Within community dwelling elderly persons 1 in 5 suffer from depression and within care homes this figure doubles to 2 in 5 (Mental health foundation). Older persons are much more susceptible to depression as with age they become much more exposed to death, particularly of loved ones. This can then leave them feeling lonely or isolated leading to depression. Illness and complex health issues may also have an impact on the mood of elderly persons. It is also important to note that depression is different for everyone and some may feel low where others will feel like their entire world is coming to an end (Mental Health Foundation 2).
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| Although it is not a certainty with age, progressive conditions such as dementia present in later life with 5% of over 60 y/o suffering and 20% of over 80 y/o. Around 700000 persons suffer from dementia in the UK at one time which is around 1.2% of the total population (Mental Health Foundation).
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| With this in mind a large proportion of elderly persons suffer mental illness in one form or another and it is vital that we can acknowledge this in order to provide holistic care.
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| {{#ev:youtube|WBZsa3diKMs}}
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| Delirium: The Older People in Acute Care improvement program highlights delirium as being a factor involved in the length of stay in older patients. As previously seen within the [http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist's_Role_in_Preventing_Hospital_Admission#Costs cost section], long hospital stays prove to be costly.
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| Delirium occurs in around 20-30% of patients on medical wards and incidence of up to 50% has been observed following surgery (Healthcare Improvement Scotland). Therefore in a frail elderly population who are already at increased risk of prolonged stays we must be careful and aware of delirium and its’ seriousness.
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| Delirium is a state of medical confusion and can severely affect anyone who is suffering from it, a more specific description can be found here: http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/delirium.aspx
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| Regarding intervention Healthcare Improvement Scotland has published a Delirium toolkit alongside the OPAC improvement program. This can be found in the additional reading section.
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| Cognition: As we get older our cognition can be affected in a number of ways, Emory University have produced a short web article which details the normal processes of cognitive ageing and what may be affected and what will generally not show decline. This can be found here: http://alzheimers.emory.edu/healthy_aging/cognitive-skills-normal-aging.html
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| Another mental health issue for elderly persons is anxiety. Within the community around 5-10% of over 65 year olds suffer from an anxiety disorder and within institutions like care homes this incidence is much higher (Anxiety Canada). Some older persons who present with an anxiety disorder may have previously suffered when they were younger and others develop in later life, this can be due to the loss of a loved one, health changes, independence or a combination of these (Anxiety Canada). Anxiety disorders are usually treated with medication but alternative therapies such as cognative behavioural therapy (CBT) are also known to be used. <br>Further information can be found in the pamphlet linked in the additional reading section below.<br>
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| {| width="500" cellspacing="1" cellpadding="1" border="1" align="center"
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| |+ '''Additional Reading'''
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| | OPAC Delirium Toolkit: http://www.healthcareimprovementscotland.org/our_work/person-centred_care/opac_improvement_programme/delirium_toolkit.aspx
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| | Anxiety Canada Pamphlet:http://www.anxietycanada.ca/english/pdf/ElderlyEn.pdf
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| |}
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| == '''Social and Environmental''' ==
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| <u>Assessment</u>
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| Assessment of the social and environmental aspects of a patient’s life is a fundamental part of the CGA, as laid out on section 4.2
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| Recap of the social and environmental sections of the CGA:
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| [[Image:CGA x2.png]]
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| Taking 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>.<br> It is an occupational therapists (OT’s) role to find out this type of information. Their assessments 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 patients’ ability to carry out activities in the home is dependent on its layout and the persons’ social situation. As physiotherapy interventions try to help improve peoples’ ability to perform ADL’s, it is important for physiotherapists to know how the environment and social situation can impact on their treatment.<br>
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| The international classification of health, functioning and disability (ICF) can be used by physiotherapists to help establish the needs of a patient<ref name="WHO 2001" />. <br>
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| <br>
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| [[Image:ICF.jpg|center|ICF]] <br> The ICF is a model which allows professionals to see the impact a health condition has on a persons’ life, by taking a holistic viewpoint. Participation restrictions and activity limitations are the two areas of the ICF which relates to the influence of the patients social and environmental circumstances. Activity limitations are the execution of a task by the patient. Whereas, participation restrictions relates to how involved with a life situation the patient is due to the societal setup <ref name="WHO 2001">World Health Organization. ICIDH-2: International classification of functioning, disability, and health. Geneva: World Health Organization, 2001.</ref>.
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| <br> The World Health Organization (WHO) has devised a checklist which allows clinicians to identify what activity and participation restrictions the patient has <ref name="WHO 2003">World Health Organisation. ICF Checklist version 2.1a clinicians. http://www.who.int/classifications/icf/icfchecklist.pdf?ua=1 (accessed 04 Jan 2016).</ref>. <br>
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| <u>Activity limitations </u><br> Elderly people who have a high participation level in leisure activities also have better health outcomes. Reduced mobility and activity limitations directly reduce participation in leisure activities. Activity limitations have a bigger impact on social involvement than the severity of the patients’ medical condition. Specific activity limitations which may cause participation restriction are: <br> • Anxiety <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><br> • 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" /><br> • 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><br> • Memory <ref name="Makizako et al. 2015" /> <ref name="Cambois et al. 2005" />
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| <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 prim position to help reduce activity limitations. However, these activity limitations affect a greater number of people who live in institutions than those who live at home <ref name="Cambois et al. 2005" />. <br>
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| 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 &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Blindness 2001; 95(8):453-467.</ref>.
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| <u>Participation restrictions </u><br>
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| Knowing what participation restrictions a patient has is really important as they are linked to the patients’ 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="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><ref name="Fairhall et al. 2011" />. 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 patients’ 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>.
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| <u>Interventions available </u><br> Physiotherapists need to tackle the barriers which cause activity limitations<ref name="Nilsson et al. 2015" />. One way to do this is by using motivational techniques such as CBT and motivational interviewing, which have been shown to reduce activity limitations <ref name="McGrane 2015">McGrane N, Galvin R, Cusack T, Stokes E. Addition of motivational interventions to exercise and traditional Physiotherapy: a review and meta-analysis. Physiotherapy 2015; 101(1): 1–12. http://www.sciencedirect.com/ (accessed 28 Dec 2015).</ref>. However, the above meta-analysis included studies using samples of varying ages and impairments and so these results may not be found in the frail population. <br>
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| Participation restrictions in the elderly population do not change with time, unless targeted interventions are implemented<ref name="Wilkie 2008" />. Adopting a behavioral coping strategy, which swops a high intensity social activity for a lower intensity social activity i.e. football for bird watching, can ensure reduced participation restrictions and increased involvement in daily activities for older adults in the Community. Therefore physiotherapists should educate patients to adopt behavioral coping strategies to maximise social participation and reduce stress where needed <ref name="Demers et al. 2009">Demers L, Robichaud L, Gélinas I, Noreau L et al. Coping strategies and social participation in older adults. Gerontology 2009; 55:233–239. http://www.karger.com/Article/Pdf/181170 (accessed 17 Dec 2015).</ref>.<br>
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| As seen in section 5 physiotherapy interventions can improve mobility and musculoskeletal impairments in the frail population and so they are able to independently carry out more ADL’s. In doing this patients will face less activity limitations and participation restrictions allowing them to have increased social participation <ref name="Makizako et al. 2015" />. <br>
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| 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. <br>
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| === Social circumstances <br> ===
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| <br> Taking a social history allows the physiotherapist to understand the patients 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; activities they do in and outside their home and what formal or informal care/support they receive<ref name="Wagstaff and Coakley 1988" /><ref name="Petty 2011" />. 80% of nonagenarians have carers to help with some of their ADL’s<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 patients’ social circumstances. <br>
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| Physiotherapists can help to increase patients’ social networks by informing the patient about activities or groups which occur in their local area<ref name="Jessep et al. 2009">Jessep SA, Walsh NE, Ratcliffe J, Hurley MV. Long-term clinical benefits and costs of an integrated rehabilitation programme compared with outpatient physiotherapy for chronic knee pain. Physiotherapy 2009; 95(2): 94-102. http://resolver.ebscohost.com/openurl (accessed 8 Jan 2016).</ref>. The therapist can also help the patient plan the best way to get to these. For example, a physiotherapist may provide a four wheeled walker and a map so that a patient can get to and from the shops without carrying heavy bags. The map may show benches along the route where the patient can rest, if needed. This may further reduce participation restrictions and aid an increased mood<ref name="Aranadottir 2011" />. It is important that treatment plans are devised around ways to help patients become more socially active<ref name="Wagstaff and Coakley 1988" />. For example, exercises which increase cardiopulmonary function will also increase walking distance and time and so may allow the patient to spend the day in their garden. <br>
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|
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| === Environment <u><br></u> ===
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| <u></u>
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| {| width="600" cellspacing="1" cellpadding="1" border="1" align="center"
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| | [[Image:Test yourself heading.png|center]]
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| | Create a mind map around the different hazards that can be found in someones house. This should include the bathroom, the kitchen and the stairs. Once completed compare to the one below. This should take 20 minutes
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| |}
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| <u></u>
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| [[Image:Enviromental considerations in the house.png]]
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| The mind map above shows the different things which should be checked in the patients house on assessment, before a treatment plan is devised or goals are set. Sometimes these assessments are performed jointly with an OT<ref name="Wagstaff and Coakley 1988" />. <br>
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| 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> <br>
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| Being aware of the environment in which the patient lives will allow the physiotherapist to tailor treatments effectively and safely to their surroundings. <br>
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| {| width="800" cellspacing="1" cellpadding="1" border="1" align="center"
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| | [[Image:Test yourself heading.png|center]]
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| End of section Quiz. This activity should take 20 minutes
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| #What are activity limitationa nd participation restrictions?
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| #What are the four most common activity limitations in the frail/eldelry?
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| #What is the link between participation restrictions and the frailty phenotypes?
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| #Why should physiotherapists take a socail history from their patients?
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|
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| |}
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| = Physiotherapy treatment =
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| As previously mentioned, there are several clinical guidelines available for healthcare professionals to assist them in preventing hospital admissions providing quality care for patients. However, whilst they recommend physiotherapy intervention, these guidelines lack rigorous information and evidence surrounding treatment. This section will summarise and synthesis available evidence on physiotherapy treatment options for preventing hospital admissions in the frail elderly.
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| 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 in to 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>. For the purpose of condensing this learning resource and delivering the information you are more likely to need, we will consider the more common admission causes that the physiotherapist can play a part in preventing. However, some of the information provided here could be transferable to other cases.
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| <br>
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| === Injury ===
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| 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>.
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| 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">Gowing R, Jain MK. Injury patterns and outcomes associated with elderly trauma victims in Kingston, Ontario. Can J Surg 2007; 50; 437-44</ref> found that a fall is the most common mechanism of injury and accounts for approximately 64% of 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>
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| [[Image:Graph.PNG|center]]<br>
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| A fall is an incident which results in a person coming to rest unintentionally on the floor or ground or other lower level<ref>World Health Organisation. WHO global report on falls prevention in older age. Geneva, Switzerland: World Health Organisation, 2007.</ref> and can result in fracture, dislocation, traumatic brain injury and even death<ref name="Tinetti 1995">Tinetti ME, Doucette J, Claus E, et al. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc 1995; 43; 1214-1221</ref>. Anyone can have a fall, however, the natural ageing process means that older people are at higher risk. Over 400 risk factors leading to falls have been highlighted including muscle weakness, impaired balance, delayed reaction time, poor vision, polypharmacy and co-morbidities such as dementia, cardiovascular disease and hypotension<ref name="Skelton 1995">Skelton DA, Dinan SM. Exercise for falls management: rationale for an exercise programme aimed at reducing postural instability. Physiotherapy Theory and Practice 1999; 15; 105-20</ref>. Additionally, several extrinsic factors that could lead to falls have been suggested, including poor lighting, cluttered environment and ill-fitting footwear. The risk of falls and related complications increase gradually with age and can be an indication of increasing frailty<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>. Falls represent the main cause of disability and are the leading cause of morbidity and mortality among people over 75 in the UK. Not all falls will result in injury, however in some cases a fall could be fatal and it is thought that the repercussions of even a minor fall could have catastrophic effects on physical and mental health<ref name="Age UK 2010" />.
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| Despite these statistics, falls are not an inevitable consequence of old age. A multifaceted interaction of several risk factors relating to the ageing process, lifestyle choices, environmental factors and the presence of long term conditions determines an individual’s risk of falling<ref name="Age UK 2010" />. As risk increases with age and it is important for the physiotherapist identify those at risk early, recognise and modify risk factors and provide timely intervention to prevent falls and subsequent injury<ref>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>.
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| A summary of some potential treatment options follows. This list is not exhaustive. <br>
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| ==== Resistance training ====
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|
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| [[Image:Weights.png|thumb|right|350x350px]]
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| A significant component of age-related weakness and frailty is sarcopenia. Sarcopenia is the gradual loss of muscle tissue, resulting in diminished strength<ref name="Janssen 2002">Janssen I, Heymsfield SB, Ross R, et al. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. J Am Geriatr Soc 2002; 50; 889-96.</ref> and it is thought that 2% of skeletal muscle mass is lost each year past the age of 50<ref name="Hughes 2002">Hughes VA, Frontera WR, Roubenoff R, et al. Longitudinal changes in body composition in older men and women: role of body weight change and physical activity. Am J Clin Nutr 2002; 76; 473-81</ref>. 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>. 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>Seynnes et al 2004), however, it is questionable whether this transfers to reducing the risk of falling.
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| 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. This study solely involved home-based, progressive, seated quadriceps strength exercises using 60-80% of the individuals 1RM with ankle weights. It was found to have no effect on falls rate or risk of falling and an increased chance of musculoskeletal injury. As a result, seated resistance training or high intensity resistance are not recommended.
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| 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 course of 50-minute resistance training sessions, twice weekly for 25 weeks on number of falls and risk of falls in a female population aged 75-85. Exercises included targeted upper limb, trunk and lower limb muscles and again, resistance training alone was found to have no significant effect on number of falls or risk of falls. However, when combined with agility training, participants did develop a decreased risk of falling.
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| 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 wiki. <br>
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| ==== Balance re-education ====
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| Balance disorders are very common in older adults and are a key cause of falls in this population. They are associated with reduced level of function, as well as an increased risk of disease and death. Most balance disorders comprise of several contributing factors including long-term conditions and medication side effects<ref>Rubenstein, LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 2006; 35.</ref>.
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| 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, there were 397 injurious falls in the control group compared with 305 in the intervention group, the injurious fall rate was 19% lower in the intervention group than in the control group highlighting the benefit of a balance training programme.
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| Exergaming is a relatively new treatment concept and is thought to increase motivation and enjoyment for users. 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. 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 reduce their risk and incidence of falls, the intervention group showed a more significant improvement. 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.
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| Exercise aimed at improving balance control has been proven to be a key component in falls prevention. It will be explored further in the multi-component falls prevention programme section of this wiki.<br>
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| ==== Tai Chi ====
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| 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 although some may require assistance in locating a suitable local group for them to join.
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| <br> Below is a useful video clip highlighting the benefits of tai chi through interview.<br>
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| Watch this and then take 5 minutes to reflect upon the opinion of the participants.
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| What did they enjoy? What health benefits did they see?
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| ==== Backward Chaining ====
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| 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>
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| 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.
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| The movement is broken into several stages depending on the patient’s ability. The patient will complete one stage, then return to a stand. Then they will add on the next stage and return to a stand. This is repeated until the patient is able to stand from a lying on the floor.
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| |+ Backward Chaining <ref>NHS Sutton and Merton Community Services. Getting on and off the floor safely. London: Staying Steady Falls Prevention Service, 2012</ref>
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| The effect of backward chaining on an individual’s ability to rise unassisted from the ground has been proven to be beneficial. In the only study to compare backward chaining with a control of conventional therapy, it was found that backward-chaining method significantly enhances ability in rising after an incidental fall (20-40%)<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.
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| <br> If you are unfamiliar with backward chaining, take 20 minutes to practice a routine yourself.
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| As you are completing a chain, think about giving clear and concise instructions;
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| the concept of backward chaining can sometimes be confusing.
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| This should make it easier to teach to a patient.
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| Make sure you have plenty of space around you. The only equipment required is a chair.
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| ==== Fear of falling ====
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| The prevalence of 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 ADL’s due to fear avoidance 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>
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| 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 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>
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| [[Image:Fear avoidance model (Falls).PNG|thumb|right|618x257px]]<br>
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| 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>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>. 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.
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| ==== Multi-component falls prevention programmes ====
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| Finally, we will consider the effect of a multi-component falls prevention programme. As most falls are multifactorial in origin, they usually require several interventions<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 optimization and education, environmental modification and exercise. This type of programme would be delivered by a multidisciplinary team in which the physiotherapist would be a key member. A Cochrane systematic review suggests that the physiotherapy treatment should combine all elements mentioned above; that is strengthening, balance, backward chaining, tai chi and confidence building with education, tailored to each individual. Clinic-based group exercise or individual exercise in the home setting is suitable. However, further research is needed into the effectiveness of medication management in preventing falls<ref name="Gillespie 2012" />.
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| 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 the also the general community and it should be performed for at least two hours per week on an ongoing basis.
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| ==== Key points ====
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| <br>Write down the key points you have learned from section 6.1.<br>Expand the table below and compare your answers.
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| ==== <br> ====
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| *[http://agile.csp.org.uk/documents/guidelines-physiotherapy-management-older-people-risk-falling?networkid=338430 AGILE guidelines for physiotherapy management of older people at risk of falling]
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| AGILE is the CSP’s professional network for members working with older people.
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| Their guidance can be downloaded from here.
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| *[http://www.westlothian.gov.uk/localgroups West Lothian Council database for local groups.]
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| Here you can search for activites in the area.<br> This website is also a useful resource you can direct patients to.
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| *[http://www.bridgewater.nhs.uk/wp-content/uploads/2012/11/Bridgewater-backward-chaining.pdf NHS Bridgewater falls leaflet.]
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| Here is a useful patient falls leaflet from NHS Bridgewater.<br> Does your trust have something similar?
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| <br> | | <br> |
| | | [[Category:Older People/Geriatrics]] |
| <br>
| | [[Category:Interventions]] |
| | | [[Category:Primary Contact]] |
| === Illness<br> ===
| | [[Category:Older People/Geriatrics - Interventions]] |
| | | [[Category:Queen Margaret University Project]] |
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| ==== Self-management ====
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| <br>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 at high risk of being admitted to the hospital<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>.
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| 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>.<br>The Scottish Government<ref>The Scottish Government. Long Term Conditions.fckLRhttp://www.gov.scot/Topics/Health/Services/Long-Term-Conditions (accessed 20 Nov 2015)</ref> reports that people with LTCs are twice as likely to be admitted to the hospital. The aging population and the increase prevalence of long term conditions requires healthcare professionals to move their focus towards preventative strategies and empowering self-management<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>.<br>
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| Disease related self management abilities such as taking medication and exercise are often promoted by health care professionals. <br>However, there may also be a need for interventions aimed at self-management of overall health and well-being to contribute to healthy aging<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>. Older peoples’ abilities to self-manage the aging 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.fckLR 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 aging as evidence shows that interventions to promote health aging can be used to the delay the onset of frailty and reduce its adverse outcomes among older people<ref name="Cramm2014" />.
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| As older people often have co-morbidities leading to a mixture of physical and psychosocial issues, self-management interventions should focus on providing them with general behavioral and cognitive skills for dealing with range of problems rather than focusing on on health-related problems only<ref name="Cramm2013" />.
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| <br>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. - <br>Treatment plan will depend on circumstances. However, as physiotherapists we believe our main role within self-management can be to promote physical activity to contribute to the healthy aging process. Therefore, this will be discussed in more detail in [http://www.physio-pedia.com/Frail_Elderly:_The_Physiotherapist%27s_Role_in_Preventing_Hospital_Admission#Physical_activity Section 6.2 – Physical activity].<br><br>Please see additional reading to access useful resources in relation to promoting self-management.<br>
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| ===== Resources =====
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| <br>
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| The King’s Fund have published evidence based information on self-management <br>in response to a growing interest amongst policy-makers, healthcare professionals<br>and patients<ref name="Self management LTC">The King’s Fund. Self-management for Long-Term Conditions: Patients’ perspectives on the way ahead. http://www.kingsfund.org.uk/publications/self-management-long-term-conditions (accessed 7 Jan 2016)</ref><span style="line-height: 1.5em; font-size: 13.28px;">.</span>
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| *[http://www.kingsfund.org.uk/publications/articles/transforming-our-health-care-system-ten-priorities-commissioners Transforming our health care system]<br>This publication provides information on how to shift the emphasis on <br>acute care towards prevention and self-management in order to cope <br>with the aging population and the increased prevalence of long term conditions<ref name="Transforming">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 7 Jan 2016)</ref>.<br><br>
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| *[http://www.kingsfund.org.uk/publications/self-management-long-term-conditions Self-management for Long-Term Conditions (Patients’ perspectives) ]<br>This paper reviews patients' perceptions about self-managing their <br>conditions and identifies how healthcare professionals can support them to do so<ref name="Self management LTC" />.<br><br>
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| *Browse the website [http://www.myconditionmylife.org/professional-resources/about-self-management/ my condition, my terms, my life for information] on<br>self-management and how you as a healthcare professional can help facilitate this<ref name="My CTL">My condition, my terms, my life. Professional Resources: About self management. fckLRhttp://www.myconditionmylife.org/professional-resources/about-self-management/ (accessed 14 Jan 2016)</ref>.
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| '''Resources for patients'''
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| *[http://www.nhs24.com/ NHS 24] is an online and telephone-based service. <br>Call for free (111) and they can answer questions about your health and offer advice. Visit their website to access self-help guides and find local services in Scotland<ref name="NHS 24">NHS 24. NHS 24 Explained. http://www.nhs24.com/explained/services/ (accessed 14 Jan 2016)</ref>.
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| *[http://www.lothianrespiratorymcn.scot.nhs.uk/for-public/ NHS Lothian’s self-management plans for COPD, bronchiectasis and asthma]<ref name="RCN">NHS Lothian Respiratory Managed Clinical Network. Public Resources. http://www.lothianrespiratorymcn.scot.nhs.uk/for-public/ (accessed 14 Jan 2016)</ref>.
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| *[http://shop.blf.org.uk/collections/self-management The British Lung Foundation have developed tools and self-management plans for people living with COPD. ]<br>Exercise handbooks, symptoms diary and flare up action plans amongst other useful information can be found on their website<ref name="TBLF">The British Lung Foundation. COPD self-help tools. http://shop.blf.org.uk/collections/self-management (accessed 14 Jan 2016)</ref>.
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| *[http://www.chss.org.uk/chest-information-and-support/resources-to-help/order-download-publications/ Chest, Heart & Stroke Scotland’s factsheets and booklets]<ref name="CHSS">Chest, Heart &amp;amp;amp;amp;amp;amp;amp;amp; Stroke Scotland. Chest factsheets &amp;amp;amp;amp;amp;amp;amp;amp; booklets. http://www.chss.org.uk/chest-information-and-support/resources-to-help/order-download-publications/ accessed 14 Jan 2016)</ref>.
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| *[http://www.arthritisresearchuk.org/arthritis-information.aspx Arthritis Research UK’s information]<ref name="Arthritis Research UK">Arthritis Research UK. Arthritis information. http://www.arthritisresearchuk.org/arthritis-information.aspx (accessed 14 Jan 2016)</ref>.
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| *[https://www.alzheimers.org.uk/site/scripts/documents.php?categoryID=200342 Alzheimers Scotland’s resources on living with dementia]<ref name="Alzheimers Scotland">Alzheimers Scotland. Living with Dementia. https://www.alzheimers.org.uk/site/scripts/documents.php?categoryID=200342 (accessed 14 Jan 2016)</ref>.
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| *[http://www.ageuk.org.uk/publications/age-uk-information-guides-and-factsheets/#Infoguides Age UK’s] information and advice guides in relation to health and wellbeing & home and care<ref name="Age UK GF">Age UK. Age UK information guides and factsheets. http://www.ageuk.org.uk/publications/age-uk-information-guides-and-factsheets/#Infoguides (accessed 14 Jan 2016</ref>.<br>
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| <br>
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| ==== Physical activity ====
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| Functional capacity declines with age and this is further accelerated by low levels of physical activity.<br><br>The recommendations for physical activity for older adults (65+)<ref name="DOH">Department of Health. Start active, stay active: report on physical activity in the UK. https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officersfckLR (accessed 28 Oct 2015)</ref>:
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| *Older adults should aim to be active daily
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| *At least 150 minutes a week of moderate intensity activity
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| *Muscle strength training twice a week in addition to the 150 minutes of activity
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| *Balance training and co-ordination should be incorporated into activities to manage risk of falls
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| *Minimise sedentary time
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| <br>
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| 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>.
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| [[Image:PA levels Scotland.png|center|500px]]
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| <br> '''Benefits of physical activity in frail older adults'''
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| Strength, endurance, balance and bone density is lost about 10% per decade, while muscle power reduces with 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>. The loss of muscle mass and strength is called sarcopenia, which 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>.<br>Being physically active slows down these physiological changes associated with aging. Physical activity can also reduce the risk of falls, promote cognitive health and self-management of chronic diseases. As well as slowing down the deterioration in ability to perform ADLs and maintain quality of life in older adults<ref name="Chou">Chou CH, Hwang CL, Wu YT. Effect of Exercise on Physical Function, Daily Living Activities,and Quality of Life in the Frail Older Adults: A Meta Analysis. Arch Phys Med Rehabil 2012;93:237-44.fckLRhttp://www.sciencedirect.com/science/article/pii/S0003999311008173 (accessed 16 Oct 2015)</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>.
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| 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 adults.
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| '''<br>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>.<br>Recently there has been a shift in the general public health agenda towards the prevention of chronic conditions and enabling the aging population to stay active and manage conditions in the community. This have required a change in the role of physiotherapists 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>.<br>
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| <br>'''Factors influencing participation in physical activity in older adults'''<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>'''<br>'''<br>Older peoples’ participation in physical activity can be effected by biological, demographic, physiological and social factors<br>These factors are important to be aware of when attempting to motivate older people to increase their activity levels.
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| *Men are more active then women
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| *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
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| *Older people might be less able due to pain, reduced mobility and the need of assistance to mobilise<ref name="Weeks" />
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| *Physical activity can be influenced by trusted others such as health care professionals, care givers, family and friends
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| *Lack of transport often affects older peoples abilities to part take in activity<br>
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| Psychological factors that can positively affect participation
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| *Beliefs and confidence in abilities to active
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| *General values, beliefs and attitudes
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| <br>Psychological factors that can negatively affect participation
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| *Fear of falling and over exertion
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| *Safety concerns<br><br>
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| '''Exercises for frail older adults<br>'''<br>These are the recommended activities and intensity for frail older adults to increase physical activity in order to improve general health and well being as well as reduce the risk of falls and manage chronic lifestyle conditions:
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| *Sessions as short as 10 minutes can provide health benefits<ref name="BHF11" />
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| *Frail older adults should aim to accumulate numerous of 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>
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| <br>Suggested activities:
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| *Take the stairs<ref name="DOH" />
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| *Walking<ref name="DOH" />
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| *Do housework or gardening<ref name="DOH" />
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| *Tai Chi<ref name="BHF2012" />
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| *Dance<ref name="BHF2012" />
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| *Swimming<ref name="DOH" />
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| *Home-based or group exercise classes<ref name="BHF11" />
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| *Breaking up time spent sitting with short regular periods of standing or walking<ref name="BHF2012" />
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| *Encourage to move for longer. E.g. Going from moving 5 minutes to 10 minutes may increase the intensity<ref name="BHF2012" />
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| <br>
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| When encouraging physcial 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.fckLRhttp://www.bhfactive.org.uk/older-adults-resources-and-publications-item/18/405/index.html (accessed 13 Jan 2016)</ref>:
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| :
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| *Identify fears and barriers to being physically active and provide solutions to overcome these
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| *Provide ongoing support and encouragement<br>
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| <br>
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| <br> '''Did you know?<br>'''<br>There is a National Physical Activity Pathway for Secondary Care established to support all healthcare professionals to raise the issue of physical activity, offer simple advice and suggested appropriate activities <ref>NHS Health Scotland. Physical Activity. :http://www.healthscotland.com/physical-activity.aspx (accessed 13 Jan 2016)</ref>.<br>
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| <br>
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| {| width="550" border="1" cellspacing="1" cellpadding="1"
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| | The National Physical Activity Pathway<ref name="TKN" />
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| | Providing brief advice<ref name="TKN" />
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| | {{#ev:youtube|nmmGmFmbpmY|400}}
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| | {{#ev:youtube|c9Oj234kGaM|400}}
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| |}
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| If you prefer reading about The National Physical Activity Pathway please access the document [http://www.healthscotland.com/documents/21759.aspx Physical Activty Pathway in Secondary Care]<ref>NHS Health Scotland. Publication: Physical Activity Pathway For Secondary Care. http://www.healthscotland.com/documents/21759.aspx (accessed 13 Jan 2016)</ref>.<br><br>
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| ===== Resources =====
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| {| width="500" align="center" border="1" cellspacing="1" cellpadding="1"
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| | [[Image:Additional reading heading.png|center|500px]]
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| *[https://www.gov.uk/government/publications/uk-physical-activity-guidelines UK Physical Activity Guidelines]<ref name="DOH" /> presents recommendations <br>on how much physical activity people should be doing in relation to their age. <br>
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| *[https://www.youtube.com/playlist?list=PLdtTilZi8S7-8perBH8buYgW2GGTPZXpL Watch the full “Every step counts” video series from NHS Scotland]<ref name="TKN">The Knowledge Network. NHS Physical Activity Promotion. http://www.knowledge.scot.nhs.uk/home/portals-and-topics/health-improvement/hphs/nhs-physical-activity-promotion.aspx (accessed 13 Jan 2016)</ref>
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| <br>
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| {| width="450" align="center" border="1" cellspacing="1" cellpadding="1"
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| '''Resources for patients'''
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| *[http://www.activescotland.org.uk/ Active Scotland can assist with finding places to go to be active ]<br>near you sports centres, community halls, parks, gyms, climbing walls, woodlands, swimming beaches, national cycle routes,<br> and lots more<ref name="Active Scotland">Active Scotland. Lets get active. http://www.activescotland.org.uk/ (accessed 13 Jan 2016)</ref>.<br>
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| *[http://www.healthscotland.com/documents/20649.aspx Get active your way every day. This guide is aimed at young adults, adults and older people and provides information about being active. It is designed for healthcare professionals to give to their patients]<ref name="Get active">NHS Health Scotland. Publication: Get Active Your way. http://www.healthscotland.com/documents/21759.aspx (accessed 13 Jan 2016)</ref>.<br>
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| *[http://www.ageuk.org.uk/health-wellbeing/keeping-fit/ Age UKs] advice on how to keep fit<ref name="Keeping fit">Age UK. Keeping fit. http://www.ageuk.org.uk/health-wellbeing/keeping-fit/ (accessed 13 Jan 2016)</ref>.
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| |}
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| <br>
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| ==== Motivation in Elderly Persons ====
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| For the purposes of narrowing down this section I have chosen to look at the motivation of the elderly population in relation to exercise as this is a commonly used and effective physiotherapy intervention for many ailments.
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| Improved activity levels in the elderly population has been shown to improve mobility and fitness whilst also reducing the risk of falls and a decreased cardiorespiratory fitness level indicated more chance of becoming dependant (Weeks et al. 2008). Weeks et al. which is a qualitative study looked at groups of both community-dwelling and cared for elderly persons and asked a series of questions regarding their participation in Physical Activity.
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| The results of the study highlight many of the reasons why an elderly person may become less physically active: <br>• Less able due to health<br> o Pain<br> o Mobility <br> o Assistance required<br>• Providing care to family members
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| However the study also showed a great deal of impact from historical interaction with physical activity: <br>• Growing up with active parents generally meant that the person would be more physically active themselves <br>• Those with active partners would be more active and in turn those with inactive partners would suffer<br>• Many reported reduced time for physical activity in their mid-life while caring for family<br> o Children <br> o Parents<br>• Work commitments
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| Some persons increased activity with age: <br>• To improve/maintain mobility<br>• Preventing falls <br>• Friends suffering poor health due
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| The study also highlights the need for more trained professionals to work in care settings as this population require extra assistance with physical activity but don’t get enough of it. On average the community dwelling elderly persons in this study were found to complete vigorous exercise on 4 days per week where as in the care setting they did not complete vigorous exercise at all and spent more time undertaking sedentary activities.
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| Guo & Phillips 2010 also suggests that decreased Physical activity leads to negative health factors such as reduced function and mobility. This study looks at the self-imposed activity limitations (SIALs) of the elderly population; it expresses the natural limitations that come with age such as poor health, dependency and inactive lifestyle but also notes that SIAL is present within the generally healthy elderly populations also. It is also shown here that many older persons tend to favour sedentary activities such as reading and watching TV to exercise in their leisure time.
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| Guo & Phillips goes on to show the implications for health care staff in the management of persons with SIALs. There is a model that outlines the process of SIAL (see below), which has not currently been tested however helps to highlight the importance of both intrinsic and extrinsic factors in SIALs. There is also an emphasis on the impact of a Trigger event, a significant health event in which mind-set may be altered triggering changes in behaviours and habits. The role of the healthcare staff is to make options of assistance available to the elderly persons and also to be aware of any SIALs as they occur to help reduce their impact and their effect on the persons’ overall health. <br> <br>[[Image:SIAL.png|center|500x300px|SIAL Model: Guo & Phillips 2010]]
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| Muse 2005 takes a look at goal setting within the elderly population. Without goals adherence to exercise is limited. The literature covers the general principles of goal setting: <br>• Person centred goals <br>• Based upon persons objectives <br>• Small goals to large goals e.g. short term and long term <br>• SMART
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| However there is further discussion suggesting that with this population it is extremely important to show attentive listening and not patronise these persons. When communicating it is important to avoid slang terms and to be clear but again avoiding patronisation.
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| Thomas & Storey, 2000 also looks at motivating factors in getting elderly persons to perform self-treatments within long term care. One stand out feature of this article is that we must not rush to label persons as unmotivated; instead we should appreciate why they feel how they feel and help them to make a change. Again the importance of patient led goals is highlighted, stating that this will make the patients feel more in control and motivated. On top of this there is a large focus on making the patients feel respected and listened to as well as working to build up a trusting bond. This article also mentions the rewards may help motivate patients, such as getting home sooner if they work on their exercises. However other sources refute the benefit of using reward in the long term as it does not promote a long term change in behaviour (Pink 2011). <br>
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| Maslow’s Hierarchy provides professionals with an insight into how successful their efforts of motivation may be with individuals. Maslow’s Hierarchy is made up of five levels of need and can be represented as a pyramid with the most basic needs at the bottom working up to the more complex needs. A visual representation of Maslow's Theory can be found below.
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| [[Image:Maslow.png|center|500x300px|Maslow's Hierarchy: Simons, Irwin & Drinnien 2016]]
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| Physiological needs are you basic requirements for survival e.g. food, water, warmth. <br>Once the Physiological needs have been met the individual will be able to work towards fulfilling their Safety needs.<br>This continues through each level, only being able to move on to the next once the previous level has been satisfied adequately. For professionals this means if we can gauge where our patient is according to Maslow’s Hierarchy then we have a better idea of what their requirements from us as professionals may be. (Simons et al)<br>For example; a patient who is currently not motivated to eat and drink would not be likely to respond well to a physiotherapist trying to get them up and on their feet following an operation. It is then our job as health professionals to try and assist the patient in fulfilling their needs in order to move onto the next level of Maslow’s Hierarchy and progressing their treatment.
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| A short informative video outlining the Maslow's Hierarchy can be found below: <br> {{#ev:youtube|Ugp3hm2JIqM}}
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| In summary, in order to motivate the elderly population you must take time to listen and respect each individual. Create holistic patient led goals and be appreciative of how each patient is feeling and why their motivation may be diminished. <br>
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| = Conclusion<br> =
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| You should now be able to... <br>
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| • Analyse the emerging issue of frailty in relation to the current context of health and social care in the UK. <br>
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| • Critically evaluate the physiotherapists’ role in the holistic assessment and treatment of frail individuals to prevent hospital admission.<br>
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| • Evaluate the skills and knowledge gained from this resource; identify and apply appropriately in clinical practice.
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| {| width="200" border="1" cellpadding="1" cellspacing="1"
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| | [[Image:Reflection_heading.png]]
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| Reflect on your knowledge gained from this learning resource
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| and compare this to your reflection prior to starting.
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| You can use these prompt questions to guide you:<br>• Are there any similarities/differences between
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| your first thoughts and your final reflection?<br>• How can you best apply the knowledge gained?<br>• How will this impact your practice?<br>• Is there anything you would now do differently?<br>• Is there any additional reading you need to carry out?<br>
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| |}
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| Well done for completing this learning resource.
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| = References =
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| <references /><br>
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