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

== Introduction to the Physiotherapist's Role ==
Physiotherapists working with frail older people could play a role in promoting healthy ageing. Evidence shows that interventions to promote healthy ageing can be used to the delay the onset of frailty and reduce its adverse outcomes among older people<ref name="Cramm2014">Cramm JM, Twisk J, Nieboer AP. Self-management abilities and frailty are important for healthy aging among community-dwelling older people; a cross-sectional study. BMC Geriatrics 2014;14:28.  http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-28 (accessed 11 Jan 2016)</ref>.&nbsp; 

* It has been suggested that physiotherapists could be stationed within hospital A&amp;E departments to undertake frailty and falls risk screening and make rapid decisions on whether the patient can safely return to their pre-admission destination. Frailty can be identified using the [[Clinical Frailty Scale]].<ref>Anaf S, Sheppard LA. Describing physiotherapy interventions in an emergency department setting: an observational pilot study. Accident and emergency nursing 2007; 15:1:34-9</ref><ref>Arendts G, Fitzhardinge S, Pronk K, Donaldson M, Hutton M, Nagree Y. The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study. BMC Geriatrics 2012; 12:8</ref>.
* The [[Comprehensive Geriatric Assessment|comprehensive geriatric assessment]] also is a valuable tool for risk of frailty screening.
* Falls prevention: Critical injuries leading to hospitalisation are more common in people over 65 and often preventable, with [[falls]] representing the most frequent and serious type of accident<ref name="Rothschild et al. 2000">Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Archives of Internal Medicine 2000; 160; 2717-28</ref> <ref name="Age UK 2010">Age UK. Stop Falling: Start Saving Lives and Money. London: Age UK, 2010.</ref>.  Falls risk increases with age and physiotherapists need to identify those at risk and provide timely intervention to prevent falls and subsequent injury<ref name="CSP Falls 2016">CSP. Physiotherapy works: Falls and frailty. http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/falls-and-frailty (accessed 8 Jan 2016)</ref><ref>Perracini MR, Kristensen MT, Cunningham C, Sherrington C. Physiotherapy following fragility fractures. Injury. 2018 Aug 1;49(8):1413-7.</ref>.
* '''Falls Reduction,''' in the frail''':''' exercise strength and balance has been shown to have the most effective outcomes in reduction of falls rates. As the majority of people who attend balance programmes relapse into old ways by six months, the physiotherapist should attempt to reinforce and encourage [[Adherence to Home Exercise Programs|adherence to their home exercise program]].
'''Examples of Physiotherapy Interventions''' below:

* [[Strength Training|Resistance training]] : A significant component of age-related weakness and frailty is [[sarcopenia]].  Sarcopenia increases the risk of frailty and falls and in turn, hospitalization in the older adult population<ref>Sousa AS, Guerra RS, Fonseca I, et al. Sarcopenia and length of hospital stay. Eur J Clin Nutr 2015.</ref>. Resistance training has been suggested as a potential treatment for sarcopenia and its prevention. Resistance training is designed to improve muscular fitness by exercising a muscle or a muscle group against resistance<ref>Azeem K, Al Almeer A. Effect of weight training programme on body composition, muscular endurance, and muscular strength of males. Annals of Biological Research 2013; 4; 154-6</ref>.&nbsp;This could lead to improved function, increased quality of life and reduced likelihood for falls<ref>Burton LA, Sumakadas D. Optimal management of sarcopenia. Clin Interv Aging 2010; 5; 217-28</ref>. Resistance training programmes have consistently shown to improve muscle strength and mass in older adults<ref>Liu CJ, Latham NK. Progressive resistance training for improving physical function in older adults (Cochrane review). Cochrane Database Syst Rev 2009; (3); CD002759</ref><ref>Seynnes O, Fiatarone Singh MA, Hue O. Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. J Gerontol Ser A-Biol Sci Med Sci 2004; 59A; 503-9</ref>, however, it is questionable whether this transfers to reducing the risk of falling.

* [[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>