implementing programmes to encourage active healthy lifestyles in older people - the role of the ot

Dr Dawn Skelton PhDDr Dawn Skelton PhDReader in Ageing and Health, HealthQWest, Glasgow Reader in Ageing and Health, HealthQWest, Glasgow Caledonian UniversityCaledonian University

Co-ordinator of Prevention of Falls Network EuropeCo-ordinator of Prevention of Falls Network Europe

Chair, Organising Committee, World Congress on Chair, Organising Committee, World Congress on Active Ageing 2012Active Ageing 2012

Implementing programmes to encourage active healthy lifestyles in older people - the role of the OT

Why active ageing?Why active ageing?

Many older people are dissatisfied, depressed and socially isolated

40% of older people attending GP surgeries, and 60% of those living in residential institutions have ‘poor mental health’.

Five key factors: – discrimination (for example, by age or culture)

– participation in meaningful activity

– relationships

– physical health (including physical capability to undertake everyday tasks) and

– poverty

Nice 16: 2008; Allen 2008; UK Inquiry into Mental Health and Well-being in Later Life

2006

3 Dimensions of Human 3 Dimensions of Human FrailtyFrailty

TIME

DISEASE DISUSE

HUMAN FRAILTY

Spirduso, 1995

1-2% in functional ability p.a.1-2% in functional ability p.a.– StrengthStrength

– Power Power

– Bone densityBone density

– FlexibilityFlexibility

– EnduranceEndurance

– Balance and co-ordinationBalance and co-ordination

– Mobility and transfer skillsMobility and transfer skills

Ageing affects us all, and Ageing affects us all, and earlier than you think!earlier than you think!

Sedentary behaviour accelerates the loss of Sedentary behaviour accelerates the loss of performance...performance...

A Vicious cycle of A Vicious cycle of InactivityInactivity

Physical deterioration - Heart disease- High blood pressure- Aches and pains- Osteoporosis

Further decrease in physical activity

Social / psychological ageing- Feeling ‘old’- ‘Acting’ one’s age- Increased stress- Anxiety, depression- Low self-esteem- Fear of falling

Increasing age

Less exercise

Decreased physical abilities- Increased body fat- Sagging muscles - Decreased energy

Sedentary Behaviour = Active Sedentary Behaviour = Active bone and strength lossbone and strength loss

No standing activity leads to active No standing activity leads to active

loss of bone and muscleloss of bone and muscle

– 1 wk bed rest 1 wk bed rest leg strength by ~ 20% leg strength by ~ 20%

– 1 wk bed rest 1 wk bed rest spine BMD by ~1% spine BMD by ~1%

Sedentary behaviour = worse balanceSedentary behaviour = worse balance

Nursing home residents spend 80-90% Nursing home residents spend 80-90%

of their time seated or lying downof their time seated or lying down

(Krolner 1983; Tinetti 1988; Skelton 2001; Beyer 2002)

70 yr old woman, active, strength-

trained

70 yr old woman, sedentary

(Adapted from Sipilä & SuominenMuscle Nerve 1993;16:294)

Size difference is equivalent to a 30 year old (L) and an 70 year old (R)

Ageing and Energy

Ageing and Posture/Falls

National Service Framework National Service Framework For Older People 2001For Older People 2001

Role of Exercise explicit in Role of Exercise explicit in

5/8 Standards5/8 Standards

33 Intermediate CareIntermediate Care

55 StrokeStroke

66 Falls Falls

77 Mental HealthMental Health

88 Promotion of Health Promotion of Health

and and active life in old ageactive life in old age

Active LifestylesActive Lifestyles

>3 hrs per week targeted exercise>3 hrs per week targeted exercise– Heart Attack - 3 x less likely Heart Attack - 3 x less likely – Osteoporosis - 2 x less likelyOsteoporosis - 2 x less likely– Fall-related injuries - 2 x less likelyFall-related injuries - 2 x less likely– Hip fracture - 2 x less likelyHip fracture - 2 x less likely

regular moderate physical activity– reduces the risk of cardiac death by 20 - 25%

among people with established heart disease.– Reduces risk of high blood pressure, obesity,

stroke and diabetes– Maintains function even in the presence of

disease

ACSM 2007; CDC 1996,2002; Sesso et al 2000; Nicholl 1994, WHO 1997, NIA 1998.

Benefits of Benefits of ExerciseExercise

PsychologicalPsychological– Anxiety, depression, sleep, fear of fallingAnxiety, depression, sleep, fear of falling

PhysiologicalPhysiological– Maintain bone density, ability to perform everyday Maintain bone density, ability to perform everyday

activities, reduce breathlessness, reduce stiffness and activities, reduce breathlessness, reduce stiffness and chance of injurychance of injury

PsychosocialPsychosocial– Isolation, social contacts, peer support, playing with Isolation, social contacts, peer support, playing with

grandchildren, using the bathgrandchildren, using the bath Even the very frailEven the very frail

– DVT, constipation, transfer skills DVT, constipation, transfer skills

It’s never too lateIt’s never too late

The lower the baseline The lower the baseline level of physical activity, level of physical activity, the greater the health the greater the health benefit associated with an benefit associated with an increase in physical increase in physical activityactivity

(Haskell 1994)(Haskell 1994)

A 12 week high Intensity A 12 week high Intensity Strength Training Strength Training programme in 90+ year programme in 90+ year old nursing home residents old nursing home residents doubled their leg strengthdoubled their leg strength

(Fiatarone, 1990) (Fiatarone, 1990)

What’s the difference?What’s the difference?

Physical ActivityPhysical Activity– any bodily movement produced any bodily movement produced

by skeletal muscles that results in by skeletal muscles that results in energy expenditureenergy expenditure..

ExerciseExercise– planned, structured and repetitive planned, structured and repetitive

bodily movement undertaken to bodily movement undertaken to improve or maintain one or more improve or maintain one or more components of physical fitness.components of physical fitness.

Bouchard 1990Bouchard 1990

Gardening

DIY

Housework

Bowling

Walking

Cycling

Exercise class

Sports

How much is enough?How much is enough?

Adult population Adult population - physical activity of a - physical activity of a moderate moderate

intensityintensity for for half an hourhalf an hour, on at least , on at least fivefive days of the week. days of the week.

(Department of Health 1999)(Department of Health 1999)

New guidelines for older people….2010New guidelines for older people….2010– Addition of strength and balance Addition of strength and balance

guidelinesguidelines(BHF NC PAH 2010)(BHF NC PAH 2010)

Maintenance of Independence – Maintenance of Independence – twice/threetwice/three a week a week minimum – specific, progressive exerciseminimum – specific, progressive exercise

(Consensus)(Consensus)

But for falls prevention….Don’t forget STRENGTH AND BALANCE…

Wide range of abilities Wide range of abilities and needsand needs

Training Standards in Training Standards in provisionprovision

Physiotherapist

Postural Stability Instructor

Seniors Exercise Instructor

Chair Based Exercise Leader

Physical Activity Leader

Senior Peer Activity Motivator

Self Led Activity / Exercise

Otago Exercise Instructor

Chair Based ExerciseChair Based Exercise

Improvements Improvements

– Strength and Power Strength and Power (Fiatarone 1990, (Fiatarone 1990,

1994; Skelton 1995, 1996)1994; Skelton 1995, 1996)

– Flexibility and Functional Ability Flexibility and Functional Ability

(McMurdo 1993; Skelton 1995, 1996)(McMurdo 1993; Skelton 1995, 1996)

– Arthritic Pain Arthritic Pain (Hochberg, 1995) (Hochberg, 1995)

– Postural Hypotension Postural Hypotension (Millar, 1999)(Millar, 1999)

– Depression Depression (McMurdo, 1993)(McMurdo, 1993)

– Rehabilitation following hip fracture Rehabilitation following hip fracture

(Nicholson, 1997)(Nicholson, 1997)

Reducing Falls (or injurious falls) Reducing Falls (or injurious falls) Reducing known Risk Factors for Reducing known Risk Factors for

Falls Falls Reducing Fractures ? (or changing Reducing Fractures ? (or changing

the site of fracture) the site of fracture)

Increasing Quality of Life & Social Increasing Quality of Life & Social ActivitiesActivities

Improving bone densityImproving bone density Reducing FearReducing Fear Reducing InstitutionalisationReducing Institutionalisation

Gardner 2000; Skelton & Dinan 1999; Skelton & Todd, 2005; NICE 2004

Exercise could help fallers Exercise could help fallers in a number of waysin a number of ways

Sherrington et al., JAGS 2008

Effective ExerciseEffective Exercise

– Community Dwellers (11)Community Dwellers (11)– Sheltered Housing (1)Sheltered Housing (1)

– Group Based (8)Group Based (8)– Home Based + walking (3)Home Based + walking (3)

Ineffective Ineffective ExerciseExercise

– Community Dwellers (6) Community Dwellers (6) – Sheltered Housing (2)Sheltered Housing (2)– Nursing Care (1)Nursing Care (1)– Visually impaired (1)Visually impaired (1)

– Group Based (7)Group Based (7)– Home Based (5)Home Based (5)

– Walking Programmes Walking Programmes (2)(2)

But not all exercise helps reduce falls

Lessons that last a Lessons that last a lifetimelifetime

Highly challenging Balance Highly challenging Balance TrainingTraining

Exercise in standing involving:Exercise in standing involving:– movement of the centre of movement of the centre of

massmass– narrowing of the base of narrowing of the base of

supportsupport– minimising upper limb minimising upper limb

supportsupport

24%

RR 0.76 (95%CI =0.62 to 0.93)


High DoseHigh Dose

50+ hours 50+ hours – At least 2 hours a week of At least 2 hours a week of

exercise for at least 6 monthsexercise for at least 6 months– Home or group-based or a Home or group-based or a

combination of bothcombination of both

20%

RR 0.80 (95%CI =0.65 to 0.99)


No reduction: RR 0.95 (0.78 to 1.16)



Increased risk: RR 1.20 (1.00 to 1.44)

High balanceLow doseWalking

Low balanceLow doseWalking

Low balanceLow doseNo walking

Low balanceHigh doseWalking


Greatest effects of exercise on fall rates from Greatest effects of exercise on fall rates from

interventions including:interventions including:

– Highly challenging balance trainingHighly challenging balance training

– High doseHigh dose

– No walking programNo walking program

These 3 factorsThese 3 factors explained 68% of varianceexplained 68% of variance


So what do we need to know?

Commonly found in the UK

Otago Home Exercise Programme (OEP)Otago Home Exercise Programme (OEP)

– 1 yr; 3 x p/w; standing strength and balance; 1 yr; 3 x p/w; standing strength and balance;

graded walking programme; 6 home visits graded walking programme; 6 home visits

(physiotherapist, nurse) to progress and tailor (physiotherapist, nurse) to progress and tailor

exercise but otherwise unsupervisedexercise but otherwise unsupervised

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

exercise instructor exercise instructor

Falls Management Exercise Programme (FaME)Falls Management Exercise Programme (FaME)

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

strength and balance plus floorwork; specialist strength and balance plus floorwork; specialist

exercise instructor to progress and tailor exercise instructor to progress and tailor

exerciseexercise

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

FallsFallsInjuriesInjuries

Cost effective >80sCost effective >80sCost neutral >65sCost neutral >65s

Cognitive FunctionCognitive Function

Falls Falls Quality of LifeQuality of Life

Bone Mineral DensityBone Mineral DensityChange of residenceChange of residence

Coping strategiesCoping strategiesLong liesLong lies

OEP Strengthening OEP Strengthening ExercisesExercises

5 exercises5 exercises

OEP Balance Exercises OEP Balance Exercises

12 exercises12 exercises

Teaching transfer skills

Regaining Floor Coping Skills

FaME – Postural Stability Instructor:

Avoid long-lies - Crawling, rolling, getting to help,

keep moving to avoid complications….

Get back up again….play with grandchildren

Motivators BarriersMotivators Barriers

Social activitiesSocial activities CostCost Playing with grandchildrenPlaying with grandchildren AccessAccess Getting out and aboutGetting out and about Overprotective carersOverprotective carers Keeping healthyKeeping healthy HealthHealth Family contactFamily contact Attitudes/beliefsAttitudes/beliefs Approval from othersApproval from others Caring committmentsCaring committments Self confidenceSelf confidence Pain / discomfortPain / discomfort Remaining independentRemaining independent DiscriminationDiscrimination WeatherWeather WeatherWeather ExtrovertExtrovert IntrovertIntrovert Ability to adaptAbility to adapt Safety Concerns / VisionSafety Concerns / Vision

Reducing barriersReducing barriers

Walk from Home Walk from Home Mary Moffat - 93Mary Moffat - 93

– Referred to a class but unable to Referred to a class but unable to

travel to the class and unwilling travel to the class and unwilling

to leave the hometo leave the home

– Loss of confidence and fear of Loss of confidence and fear of

fallingfalling

– Isolated and lonely and Isolated and lonely and

dependent upon others to get dependent upon others to get

outout

– Mentoring with peers / Mentoring with peers /

volunteers / rehabilitation volunteers / rehabilitation

assistantsassistants

Recommendations for Promoting the Recommendations for Promoting the Engagement of Older People in Falls Engagement of Older People in Falls Prevention ExercisePrevention Exercise Yardley L, 2007 Yardley L, 2007

1.1. Raise awarenessRaise awareness in the general population that undertaking in the general population that undertaking specific physical activities has the potential to improve balance specific physical activities has the potential to improve balance and prevent fallsand prevent falls

2.2. When offering or publicising interventions, When offering or publicising interventions, promote benefits promote benefits which fit with a positive self-identitywhich fit with a positive self-identity

3.3. Utilise a variety of forms of Utilise a variety of forms of social encouragementsocial encouragement to engage to engage older people in interventionsolder people in interventions

4.4. Ensure the intervention is Ensure the intervention is designed to meet the needs, designed to meet the needs, preferences and capabilitiespreferences and capabilities of the individual of the individual

5.5. Encourage self-managementEncourage self-management rather than dependence on rather than dependence on professionals by giving older people an active role professionals by giving older people an active role

6.6. Draw on Draw on validated methodsvalidated methods for promoting and assessing the for promoting and assessing the processes that maintain adherence, especially in the longer-processes that maintain adherence, especially in the longer-termterm

What can the OT do?What can the OT do?….with thanks to….….with thanks to…. Gayle Kinniburgh 2010: MSc OT Gayle Kinniburgh 2010: MSc OT

student, GCU dissertationstudent, GCU dissertation– Systematic review of the role of the Systematic review of the role of the

OT in engaging older people in OT in engaging older people in leisure activities (community and leisure activities (community and nursing home)nursing home)

NICE 16 Guideline: Oct 2008NICE 16 Guideline: Oct 2008 COT & NAPA 2008: Activity COT & NAPA 2008: Activity

Provision: benchmarking good Provision: benchmarking good practice in care homespractice in care homes

Hurtley et al 2005: The successful Hurtley et al 2005: The successful activity co-ordinator. Age Concernactivity co-ordinator. Age Concern

BHF Active – BHF Active – www.bhfactive.orgwww.bhfactive.org

NICE 16: OT & PA NICE 16: OT & PA interventions to promote interventions to promote mental wellbeingmental wellbeing Guidance for OT’s working with Guidance for OT’s working with

older people in primary care older people in primary care and residential careand residential care

Mental WellbeingMental Wellbeing– life satisfaction, optimism, self-

esteem, mastery and feeling in control, having a purpose in life, and a sense of belonging and support

Recommendations– Occupational Therapy Occupational Therapy

InterventionsInterventions– Physical Activity InterventionsPhysical Activity Interventions– Walking SchemesWalking Schemes– TrainingTraining

What actions should What actions should OT’s take?OT’s take?1.1. Offer regular group and/or individual sessions to encourage Offer regular group and/or individual sessions to encourage

older people to identify, construct, rehearse and carry out older people to identify, construct, rehearse and carry out daily routines and activities to improve their health and daily routines and activities to improve their health and wellbeingwellbeing

– involve older people as experts and partners – pay particular attention to communication, physical access (and provision

of aids), length of session and informality to encourage the exchange of ideas and foster peer support

– take place in a setting and style that best meet the needs of the older person or group

– provide practical solutions to problem areas – Work particularly with those from ethnic minorities, those in rural Work particularly with those from ethnic minorities, those in rural

areas and those aged over 75 who may be widowed or living areas and those aged over 75 who may be widowed or living alonealone

Nice 16: 2008

OT interventionsOT interventions

Well elderly intervention (Clarke et al. 1997)Well elderly intervention (Clarke et al. 1997)– RCT (USA) evaluated the efficacy of preventative RCT (USA) evaluated the efficacy of preventative

occupational therapy to reduce health-related decline among occupational therapy to reduce health-related decline among urban, multi-ethnic independent-living older adults.urban, multi-ethnic independent-living older adults.

– Health through occupation (regularly performed activities Health through occupation (regularly performed activities such as grooming, exercising and shopping)such as grooming, exercising and shopping)

– Cost effectiveCost effective

Lifestyle matters intervention (Mountain et al. 2006)Lifestyle matters intervention (Mountain et al. 2006)– Adapted version of the ‘Well elderly’ intervention to Adapted version of the ‘Well elderly’ intervention to

determine its feasibility in a UK setting.determine its feasibility in a UK setting.

– 8 month intervention delivered through a combination of 8 month intervention delivered through a combination of group sessions, individual sessions and visits or outings, group sessions, individual sessions and visits or outings, giving participants the opportunity to put their ideas into giving participants the opportunity to put their ideas into practice.practice.

2. Increase older people’s knowledge and awareness of where to get reliable information and advice on a broad range of topics & arranging trips and social activities. Topics covered should include:

– meeting or maintaining healthcare needs (for example, eye, hearing and foot care)

– nutrition (for example, healthy eating on a budget)

– personal care (for example, shopping, laundry, keeping warm)

– staying active and increasing daily mobility

– getting information on accessing services and benefits

– home and community safety

– using local transport schemes. Nice 16: 2008

What actions should What actions should OT’s take?OT’s take?

……Physiotherapists, registered exercise Physiotherapists, registered exercise professionals….other health, social care…staff who have professionals….other health, social care…staff who have the qualifications, skills and experience to the qualifications, skills and experience to deliverdeliver exercise programmes appropriate for older people.exercise programmes appropriate for older people.– Focus on a range of mixed exercise programmes of Focus on a range of mixed exercise programmes of

moderate intensitymoderate intensity– Strength and resistance exercise Strength and resistance exercise – Toning and stretching exerciseToning and stretching exercise– Reflect preferences of older peopleReflect preferences of older people

Encourage attendance at sessions at least once or twice Encourage attendance at sessions at least once or twice a weeka week

Unfortunately, did not take into account evidence for Unfortunately, did not take into account evidence for balance activities balance activities

Nice 16: 2008

Physical Activity Physical Activity RecommendationsRecommendations

Walking SchemesWalking Schemes

……anyone working with older peopleanyone working with older people

Offer a range of walking schemes of Offer a range of walking schemes of

low to moderate intensity with a low to moderate intensity with a

choice of local routes to suit choice of local routes to suit

different abilitiesdifferent abilities

Promote walking as a way to Promote walking as a way to

improve mental wellbeing improve mental wellbeing (but (but

beware fallers!)beware fallers!)

Encourage and support older people Encourage and support older people

to participate fully according to to participate fully according to

health and mobility needs and health and mobility needs and

personal preferencepersonal preference

Nice 16: 2008

TrainingTraining

Professional bodies, Skills Councils, NHS training Professional bodies, Skills Councils, NHS training

providers…providers…– Involve OT in the design and development of locally Involve OT in the design and development of locally

relevant training schemes for those working with older relevant training schemes for those working with older

peoplepeople

– Essential knowledge (and application) of principles and Essential knowledge (and application) of principles and

methods of OT and health and wellbeing promotionmethods of OT and health and wellbeing promotion

– Effective communication (including group facilitation and Effective communication (including group facilitation and

person-centred approach)person-centred approach)

– Foster peer supportFoster peer support

– Promotion of activity within daily routinesPromotion of activity within daily routinesNice 16: 2008

Confounding factors?Confounding factors?

Fear of falling, over-exertion or “doing harm” e.g. (Finch et al 1997)

Ageism amongst health professionals

Roles / Professional boundaries??

Concerns re workforce, liability and safety

Concept of “gentle exercise” !!

Transport for the frailest who need “specialist instruction”…. why ignore if no transport?

A little support goes a long way

Active Ageing Weeks…Active Ageing Weeks…

- To provide a national and local profile to celebrate and

promote the concept of Active Ageing.

- To provide support for local Active Ageing programmes.

- To stimulate debate and policy on Active Ageing.

- To provide a national and local programme of Active

Ageing events and promotions.

- To ensure that older people are included in activities

designed to leave a health and physical activity legacy.

WANT TO GET INVOLVED?: email

[email protected]

Ideas for AA WeeksIdeas for AA Weeks

Mass participation eventsMass participation events

– How many people How many people all together all together

or at the same time ?or at the same time ?

Walking your local area, be a Walking your local area, be a

guide or share your knowledgeguide or share your knowledge

Open days to gyms, Open days to gyms,

community centres with community centres with

sessions etc…..sessions etc…..

Mobile library buses bringing Mobile library buses bringing

people into librariespeople into libraries

Issues in activity Issues in activity provision in Nursing provision in Nursing homes…homes…

Family tend to try previous favoured activities Family tend to try previous favoured activities

(problem if unable)(problem if unable)

Access to opportunities (rare)Access to opportunities (rare)

Involving spouses and family importantInvolving spouses and family important

Staff time to support (rare)Staff time to support (rare)

Staff interest and knowledge (poor)Staff interest and knowledge (poor)

Appropriate space and environmentAppropriate space and environment

Structured inflexible routinesStructured inflexible routines

Olympage Games – Olympage Games – Sheffield 2009Sheffield 2009

20 Teams competing20 Teams competing 6 events6 events Teams of 6 – 8 Teams of 6 – 8

(participants + carers)(participants + carers) Unruly supporters in Unruly supporters in

team kit !team kit ! Medals, certificates Medals, certificates

and prizesand prizes Lots of cheating as Lots of cheating as

well !well ! Average age 87!Average age 87!

Key MessagesKey Messages

Active Ageing is Active Ageing is important and vital for important and vital for quality of life, physical quality of life, physical and mental healthand mental health

OT’s can help support OT’s can help support and encourage and encourage maintenance in an active maintenance in an active lifestylelifestyle

OT’s can deliver exercise OT’s can deliver exercise – if appropriately trained– if appropriately trained

“Man does not cease to play because he grows old.

Man grows old because he ceases to play” George Bernard Shaw

[email protected] Questions?

Come and join the fun Come and join the fun – – Glasgow SECC Glasgow SECC Aug 13-17Aug 13-17thth 2012 2012

www.wcaa2012.comwww.wcaa2012.com

Other useful sitesOther useful sites

www.www.bhfactivebhfactive.org..org.ukuk/older-adults/index.html/older-adults/index.html for useful for useful resources to download including Active Ageing weeksresources to download including Active Ageing weeks

www.ucl.ac.uk/dementia/bookreview/act.htmwww.ucl.ac.uk/dementia/bookreview/act.htm for Activity for Activity Provision: benchmarking good practice in care homesProvision: benchmarking good practice in care homes

Training Organisations:– www.exerciseregister.org for trained exercise professionals directory

and training providers

– www.www.laterlifetraininglaterlifetraining.co..co.ukuk - Otago, FaME and Chair based exercise - Otago, FaME and Chair based exercise trainingtraining

– www.pfe.co.ukwww.pfe.co.uk - Chair Based exercise training - Chair Based exercise training

– www.extend.org.ukwww.extend.org.uk - exercise to music - exercise to music

– www.vitalyz.co.ukwww.vitalyz.co.uk - one day motivation courses on chair exercise in - one day motivation courses on chair exercise in nursing homesnursing homes