are we doing harm to our patients? - home | rgpeo ... pa… · strength and balance exercises so...

@GCU_IAHR @ProFouNDEU @LaterLifeTrain

@CaledonianNews

Dawn Skelton Professor of Ageing and Health

Institute of Applied Health Research

School of Health & Life Sciences

Are we doing harm to our

patients? Importance of motivation, support and consistent messages for falls

prevention Part 1


@CaledonianNews

Presentation Aims

• Effective falls prevention

interventions and potential harm if

fidelity not followed

• Importance of falls per unit of

activity

• Sedentary behaviour and

frailty/sarcopenia

• Hospital acquired immobility vs risk

of falls?

• Consistent messages to change

behaviour from the whole team!


@CaledonianNews

”Just like the Olympic athlete,

the elderly person must

perform, frequently and

consistently, at the very limit

of their physical ability. The

85-year-old can therefore

benefit from the study of

athletic training methods...”

(Professor Archie Young, 1997)


@CaledonianNews

Wide range of abilities and needs


@CaledonianNews

Fear of Falling

• Fear and lack of confidence in balance predict – Deterioration in physical functioning – Decreases in physical activity, indoor and

outdoor – Increase in fractures – Admission to Institutional Care

(Arfken 1994, Vellas 1997, Cumming 2000, Horne 2011)

“It’s the fear that restricts me. In my mind I know that I can’t [walk outside]. The fear of falling and not having the strength to go out, that stops me from going out…” (Female, 60yrs)


@CaledonianNews

What makes the difference?

• Greatest effects of exercise on fall rates

(38% reduction) from interventions

including:

– Highly challenging balance training

– High dose (50+ hours)

– Progressive strength training

– No walking program

• These types of exercise also reduce fear of

falling

Sherrington et al., JAGS 2008, NSWPHB 2011

Kendrick Cochrane Review FoF 2014


@CaledonianNews

Secondary falls prevention exercise

• Otago Home Exercise Programme (OEP)

– 1 yr; 3 x p/w; 6 home visits and telephone

support

– 6 mths; 3 x p/w (1 p/w group, 2 p/w home)

exercise instructor

– Effects on strength and balance more pronounced

when run in a group

• Falls Management Exercise Programme

(FaME/PSI)

– 9 mths; 3 x p/w (one group, two home); includes

floorwork;

– Increases habitual physical activity as well

Falls Injuries

Cost effective >80s Cost neutral >65s

Cognitive Function

Falls Quality of Life

Bone Mineral Density Change of residence

Coping strategies Long lies

41% of falls services in

the UK employ a

trained OEP Leader

54% of falls services in

the UK employ a

trained PSI (RCP Audit

2012)

(Campbell 1997; Robertson 2001; Campbell 2005; Liu_Ambrose 2008; Kyrdalen 2014; Skelton 2005, 2008)


@CaledonianNews

Exercise opportunities in UK Falls

Services

0

10

20

30

40

50

60

70

80

90

100

Bone Health Vision Gait & Balance

NICE

Assessment

Intervention

Direct

81% run strength and balance training classes (based on Otago and FaME)

Lamb et al, SDO report, 2008


@CaledonianNews

Lack of fidelity….

• More than half the class seated

• Average duration 8 weeks and frequency once per week! = 8 hours!

• Little strength progression

– Ankle weights often not increased

– Max 2 therabands progression

Highly challenging balance?

Ineffective dose ?

Lack of strength

progression ?

No services record falls as outcomes, only strength and balance – all showed improvements BUT….


@CaledonianNews

Question to you….

• Please all stand up…

• Sit down if you are NOT involved in delivery or referral to exercise to prevent falls….

• Does the exercise intervention really progress strength training and challenge balance (most of session in standing)? Sit down if not….

• Sit down if the exercise intervention is less than 50 hours in length

OH DEAR


@CaledonianNews

Risks if duration too short ?

FaME showed a significant reduction

in falls after 9 months (RR 0.53) in

those with a history of 3 or more

falls in last year (frail)

BUT DURING INTERVENTION

• Exercisers slightly increased risk

of falls compared to controls

(RR 1.19)

• although less likely to have injurious

fall (RR 0.51)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Intervention Follow-up

Re

lati

ve

Ris

k

Increased confidence, strength and balance - but not yet ready to

integrate it all into ability to prevent a trip?


@CaledonianNews

Challenges?


@CaledonianNews

Transitioning onto other exercise

opportunities

• Vital

– to meet effective dose requirements (>50 hours)

• Important

– to encourage an active lifestyle beyond rehabilitation

– to ensure a change in exercise habits and continue to improve social involvement

– to ensure the opportunities continue to improve strength and balance (eg. not seated!)


@CaledonianNews

Fallers Exercise Continuum

CHAIR BASED EXERCISE

GROUP

Referral/Assessment

Community Exercise Sessions

(Otago/FaME/Other)

OTAGO HOME EXERCISE

PROGRAMME

FALLS REHABILITATION

GROUP

‘FaME’ COMMUNITY FALLS EXERCISE

GROUPS

In-Hospital Ward Out-patients groups

and individual training

Group/individual training

Out-patients Community based

Residential Settings

GP /

Exercise

Referral

Tai Chi

Walking

Groups

Falls…Sarcopenia…Frailty...Physical & Psychological Health…Isolation…Inclusion…Social Engagement…Independence…Quality of Life…Health & Social Care costs…

Dance

….


@CaledonianNews

Table Task

List 3 activity/exercise opportunities within a 15 minute walk/30 min drive (from) that includes strength and balance work within the programme and …..

•Has an experienced/qualified/empathetic teacher/instructor/leader

•Is at a sustainable price?

•You are confident to recommend

How do you know?

If you can’t think of any – how are we going to change this?


@CaledonianNews

• Older people who are fearful avoid activity.

• Some reduce activity in order to reduce their exposure to hazards – a behavioural response that some professionals use as well!

• We can stop falls, by not moving at all!

• But what effect does this have on mental health, isolation, loneliness and depression?

• Do some interventions reduce risk by reducing activity/exposure to risk?

The importance of falls per unit of activity


@CaledonianNews

• More falls in home exercise group than in the control group • Performance based mobility improved more in the intervention

group than the control group

• ? More falls just because increased activity (exposure to risk?) • Is this still a bad outcome?


@CaledonianNews


@CaledonianNews

Otago exercises for visually impaired older people

• 6 month study, registered blind older people

• Occupational Therapist gave Otago prescription then visited them at home once, peer mentor visited at home three times plus telephone support

• Activity recorded subjectively with PhoneFITT questionnaire and objectively with ActivPal

• 86.7% of participants reported in their exercise diaries they exercised on average three times a week.

• BUT…

Waterman et al. In press Age

Ageing 2016


@CaledonianNews

Social desirability?

? Compensation, they were doing strength and balance exercises so decided did not need to walk as much?

? They perceived activity was risky unless it was the ‘safe exercises’

Waterman et al. In press Age

Ageing 2016

What will be the long term effect of the Otago intervention in these individuals? Probably an increased risk of falls as they decondition


@CaledonianNews

Is it possible to increase activity and decrease falls ?

Iliffe S et al. Health Technology Assessment 2014

6 months of FaME in low risk older adults? Still effective? FaME increased moderate to vigorous physical activity by 15 mins/day. Up to 12 months post intervention. By 24 months effect discontinued. FaME reduced falls by 26% (IRR 0.74) Up to 12 months post intervention. By 24 months effect discontinued. No increase in falls at beginning of intervention

MVPA increased

by 105 mins per

week


@CaledonianNews

Falls prevention must be more than strength and balance

• If some people compensate by being less physically active because they are doing strength and balance exercise what is the longer term effect?

• We have to have the conversation – these exercises have to be in addition to moving more often…

• Sedentary behaviour leads to poor outcomes


@CaledonianNews


@CaledonianNews

Sedentary Behaviour

Active bone and strength loss

• No standing activity leads to active loss of bone and muscle

• 1 wk bed rest leg strength by ~ 20%

• 1 wk bed rest spine BMD by ~1%

• Sedentary Behaviour linked to low BMD (independent of physical activity).

• Nursing home residents and those in hospital spend 80-90% of their waking day seated or lying down

(Krolner 1983; Tinetti 1988; Skelton 2001; Dallas Bed Rest Studies 1966-present; Chastin et al. 2011; Beyer 2002)


@CaledonianNews

What is sedentary behaviour?

Any waking activity characterized by very low energy expenditure and a sitting or reclining posture.


@CaledonianNews

An Active Day? (meeting guidelines?)

6 hours

30 min

30 min

30 min

4 hours

YES ! But 12 hours

sitting! 60 min

1 hour


@CaledonianNews

0

2

4

6

8

10

12

Self Report:

Sitting

Self Report: TV Self Report:

Screen

Accelerometry

Ho

urs P

er D

ay

Male

Female

How long do older people sit for?

Harvey, Chastin, Skelton (2014) JAPA


@CaledonianNews

Sedentary behaviour health risks

Older adults who meet PA guidelines but are

sedentary rest of their time have a 42%

increased risk of all-cause mortality

Older adults who are sedentary and physically

inactive have a 127% increased risk of all-cause

mortality Martinez-Gomez et al (2013) BMC Med. 22: 47


@CaledonianNews

Sedentary behaviour health risks

In older adults (>60 years old), sedentary behaviour has been found to be significantly associated with:

Sedentary behaviour is also linked to musculoskeletal pain and can affect quality of life, social inclusion and engagement

• Higher plasma glucose • Higher BMI and waist:hip ratio • Higher cholesterol • Reduced muscle strength • Reduced bone density

Gennuso et al (2013) Med Sci Sports Exerc.; Skelton (2001) Age Ageing; Chastin et al (2014) Bone.; WHO (2010) Global Recommendations on Physical Activity for Health


@CaledonianNews

Acute effects of sitting - 45 mins sitting in a hot room (30°C)

• 26 women

• 70+ years

• 30°C vs 20°C

• 45 mins sitting

• Thin clothing

• Higher BP

• Increased postural hypotension

• Shorter distance walked in 6 mins (reduced stamina)

Stotz, Rapp, Skelton et al. Int. J. Environ. Res. Public Health 2014


@CaledonianNews

Acute effects of sitting - 45 mins sitting in a cold room (15°C)

• 88 women

• 70+ years

• 15°C vs 20°C

• 45 mins sitting

• Thin clothing

• 5% lower muscle power

• 10% lower sit to stand velocity

• 3.5% lower walking speed

Lindemann, Skelton et al. Age Ageing, 2014.


@CaledonianNews

Table Task

• Stand up and talk to the person to your right side

• One idea on how to break up long periods of sitting (>1 hour) in your work setting?

• One idea on how to break up long periods of sitting (>1 hour) in the older people you work with?


@CaledonianNews

Sit to Stands – a marker of frailty/sarcopenia

Use of hands to rise from a chair is strongly related to all cause mortality (taking into account age, body mass index and gender)

Reduction in risk:

Unable to rise

Use of two hands to rise

Use of one hand to rise

No hands to rise

de Brito et al (2012) Eur J Prev Cardiol. 21(7):892-898


@CaledonianNews


@CaledonianNews

Frailty is loss of physiological

reserve

FUNCTIONAL ABILITIES

Independent

Dependent

“Minor illness” eg UTI

Frailty syndromes (and falls) present in crisis

Hyper-acute Frailty syndromes:

• Immobility • Falls • Delirium • Fluctuating

disability • Incontinence

(Clegg, Young, Rockwood Lancet 2013)

are we doing harm to our patients? - home | rgpeo ... pa… · strength and balance exercises so...

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