powerpoint presentation...gait and balance, functional assessment vision: acuity, contrast...

Self Management: Inter-professional approaches and challenges

PresenterPresentation NotesKim and Nathalie introduce the sessionExplain to audience case study concept, speakers sent case studies in advance and have prepared a response from different professional perspectives; nursing, clinician, physiotherapist, occupational therapist, exercise instructor, technologist, psychologist and patient perspective.


Session Chair: Kim Delbaere & Nathalie Van der Velde Emma Stanmore, Senior Lecturer Nursing, University of Manchester, UK Clemens Becker, Head of Clinical Gerontology, Robert Bosch Krankenhaus, , Germany Amanda Clifford, Senior Lecturer Physiotherapy, University of Limerick, Ireland Myrthe Pruijn, Occupational Therapist, MC Slotervaart Amsterdam , Netherlands Dawn Skelton, Professor of Ageing & Health, Glasgow Caledonian University, UK Sabato Mellone, Assistant Professor, University of Bologna, Italy Klaus Pfeiffer, Research Coordinator, Robert Bosch Krankenhaus, Germany Anne-Sophie Parent, Secretary General, AGE Platform Europe


Mrs H

PresenterPresentation NotesIntroduce Mrs H explain we will play a short audio clip (play clip) Play twice if you think it’s a good idea?

Mrs H

• Widowed 2 years ago aged 72 • 2 recent falls, one long lie • Atenolol 25mg, Furosemide 40 mg,

Lactulose 10 ml, Nitrazepam 1 mg, Amitryptilin 50 mg

• No regular GP or district nurse • Private home help twice per week

PresenterPresentation NotesKey points from Mrs H’s case study Introduce first speaker EMMA STANMORE, Senior Lecturer Nursing, University of Manchester

Inter-professional approaches & challenges: The nurses’ perspective

Dr Emma Stanmore

psycho

Bio Social

Role of the nurse

Co-ordinator of care (primary, secondary &/or social care, other HCPs, AHPs, voluntary & private sector) & evaluation of care Educator Patient advocate Referral to other agencies

Mrs H – 72 ♀ • Previous & recent fall –

painful back, long lie • Recurrent UTIs, urinary

incontinence, constipation

• Dizziness, type 2 diabetes, hypertension, mild cardiac failure

• Meds-Atenolol, frusemide, lactulose, nitrazepam

• Poor vision (recent bifocals)

Physical

• Recently bereaved • Cognition – mild

confusion, poor memory

• Low mood, ?depression

• Fearful of falling • Feeling isolated • Problems sleeping

Psychological • Family/sig others? • Not known to

GP/DN • Private home-help • Flat small, cramped,

loose rug • Difficulty making

meals • No walking aids • Past employment/

hobbies?

Social/ environmental

Multifactorial, biopsychosocial assessment – based on NICE guidance

PresenterPresentation NotesNurses’ strengths are their in-depth assessments – looking at the biopsychosocial needs of the patient rather than a single medical issue or being task orientated. Also, their ability to build a rapport with a patient and get alongside them as an advocate and they tend to do a lot of co-ordination of care involving many members of the MDT.

Diagnostic priorities

Clinical priorities: Lying/standing BP UTI ? Diabetes, cardio Fall history Gait & balance Vision – single lens Medication review

Patient priorities: Getting up from floor Back pain Social isolation Bereavement Difficulties sleeping

PresenterPresentation NotesImmediate concerns need to be addressed both clinically and for Mrs H – person centredMedication – benzodiazepines (nitrazepam for anxiety and insomnia) one of the worst culprits in falls, when is she taking meds and can the dosage be reviewed, UTI- usually empirically treat UTIs if symptomatic

Further information

Social - Family support & location, next of kin, social contacts,

neighbour & carers, previous employment, hobbies

Medical – When was Mrs H last seen by GP/physician?

Communication – language, hearing and vision, level of

understanding (long term conditions, medication)

Medication - last review, administration issues, any OTC meds?

Continence issues – type (stress, urgency), recurrent UTIs –underlying

reasons ?

Further information

FRAX osteoporosis assessment – previous fracture

Dietary & fluid intake, weight, weekly alcohol consumption

Physical activity – current and previous, level of motivation

Footwear and footcare – circulatory or sensory deficits?

Environment – indoor and outdoor hazards, lighting, use of

glasses at night, how far is toilet, height of bed/chairs, able to

get in/out shower/bath, grab rails, steps/stairs

Treatment

Refer – OT - Home hazard modification, aids required? Telecare – light sensors, falls alarm

Refer - Bereavement counselling

Continence management, Treat UTI? prevention,

Refer - GP – medication review, postural hypotension?, CCF, diabetes, pain (X-ray?), bloods, ECG

Refer - Optician to review eyesight & bifocal prescription

Refer - Podiatrist

Refer - Tailored exercise (Physio/PSI) group or home-based?

Education on hydration, diet, self- management of diabetes, hypertension,

Sleep hygiene

Bone health screen– check vit D & calcium levels

PresenterPresentation NotesSome may only need liaison, others referral and treatment

MDT involvement

1 Co-ordinator - GP (or Elderly Care Consultant) for registration &

full medical review including medication, cardiovascular, neurological, mood/anxiety/cognition/memory

- Community rehab team or falls prevention (OT, Physio, falls co-ordinator, rehab assistants)

Optician, continence advisor Referral to bereavement counsellor May just need to liaise and gain advice rather than

full referrals and assessments Close involvement of patient & family

PresenterPresentation NotesFalls service, community rehab, intermediate care or community matron – needs one key person for patient and family to relate to and

Effective interaction

Gather information – records, any MDT information, PMH –

avoid repetition of assessment

Initial consultation in home then clinic if possible

Elicit patient’s history in context of life circumstances

Involvement of family &/or sig. others

Avoid jargon, use empowering +ve messages

Non-judgmental – values, beliefs, culture, preferences

PresenterPresentation NotesNurses good at gaining a good rapport with patients

Challenges

Time constraints of meeting with other professionals

Availability of services (keeps changing)

IT systems not linked up (social and health records)

Referral processes difficult and time consuming

Time limited support (6 weeks)

Effective solutions for inter-professional collaboration?

• Inter-professional training inter-professional working

• Joined up health informatics

• Joint funding

PresenterPresentation NotesWith finite resources…severe financial pressures – 22bn healthcare deficit – instead of traditional MDTs - virtual clinics - cost savings, improved consultations, more convenient automatic record-keeping, to name but a few. It is widely regarded as the direction all healthcare services are going in the future.Start as we mean to go on with inter-professional training (eg. All disciplines need core skills in communication)

Mrs H post intervention….

PresenterPresentation NotesMrs H today…..it worked!

References • NICE Urinary incontinence in women: management https://www.nice.org.uk/guidance/cg171 • Borrell-Carrio, F., Suchman, A.L., Epstein, RM (2004) The biopsychosocial model 25 years later:

principles, practice, and scientific enquiry. Ann Fam Med 2004;2:576-582 • Kaufman, G. (2008) Patient assessment: effective consultation and history taking. Nursing Standard.

23, 4: 50-56 • ProFouND falls Intervention factsheets http://profound.eu.com/wp-content/uploads/2016/12/Falls-

Intervention-Factsheets-FinalV2.pdf • NICE (2013) Falls in older people: assessing risk and prevention. nice.org.uk/guidance/cg161

https://www.nice.org.uk/guidance/cg161/resources/falls-in-older-people-assessing-risk-and-prevention-pdf-35109686728645

• Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. The Cochrane Database of Systematic Reviews, 9, CD007146. doi:10.1002/14651858.CD007146.pub3

• Turner, S., Arthur, G., Lyons, R. A., Weightman, A. L., Mann, M. K., Jones, S. J., Lannon, S. (2011). Modification of the home environment for the reduction of injuries. The Cochrane Database of Systematic Reviews, (2), CD003600. doi:10.1002/14651858.CD003600.pub3

http://profound.eu.com/wp-content/uploads/2016/12/Falls-Intervention-Factsheets-FinalV2.pdfhttp://profound.eu.com/wp-content/uploads/2016/12/Falls-Intervention-Factsheets-FinalV2.pdfhttps://www.nice.org.uk/guidance/cg161/resources/falls-in-older-people-assessing-risk-and-prevention-pdf-35109686728645https://www.nice.org.uk/guidance/cg161/resources/falls-in-older-people-assessing-risk-and-prevention-pdf-35109686728645

Prof. Dr. Clemens Becker Department of Geriatric Medicine and Clinic of Geriatric Rehabilitation Lehrkrankenhaus Universität Tübingen

Case Studies Session 1 Role of Medics

Role of Medics

• Outpatient setting – GP and Specialist

• Inpatient – short term patients and longer stays

• Accident and Emergency or Falls Clinics

• Listen

• Unsteady walking 2 falls toiletting and associated with sit-to-stand transfer

• Long lie • Poor vision – not specified • Orthostatic hypotension • Wrist fracture • Diab mellitus • CHF • Benzo, ß Blocker, Furosemide, • Depression – medication not mentioned

Role of Medics (GP, Geriatrician) Act

Refer

Recommend

Motivate

Role of Medics (GP, Geriatrician) •Act (diagnose, communicate, review, prescribe, stop … )

•Refer (vision, DXA, environmental assessment, continence counseling, level 3 testing CV, neurology …)

•Recommend (starting exercise, home alarms …)

NICE Guidelines on assessment

Assessment Fall history and medication review Gait and balance, functional assessment Vision: acuity, contrast sensitivity Urinary incontinence Lower limb: pain and ROM Neurological and cardiovascular testing Fear of falling, depression, cognition Bone health assessment

Multifactorial intervention

Periodic case finding in Primary Care: Ask all patients about falls in the past year

Gait & balance problems

Patient presents to medical facility after a

fall

Full Evaluation

Recurrent falls

“By professionals with appropriate skills and

experience”

NICE Guidelines

Assessment Fall history and medication review Gait and balance, functional assessment Vision: acuity, contrast sensitivity Urinary incontinence Lower limb: pain and ROM Neurological and cardiovascular testing Fear of falling, depression, cognition Bone health assessment

Testing to be done Benzodiazepines, discus dosing of medication Perform SPPB including uTUG Refer to ophthalmologist or optometrist Refer community nurse to advise on UTI Check for PNP (Diabetes) Check for orthostatic hypotension Start Mirtazepine instead of Benzodiazepine Refer to DXA measurement




fall

Full Evaluation

Recurrent falls

“By professionals with appropriate skills and

experience”

Checklist via FRAT-up: Fall Risk Assessment Tool

Source: http://ffrat.farseeingresearch.eu/

Cattelani L, et al. Journal of Medical Internet Research. 2015 Feb 18;17(2):e41.

Smartphone Assessment

Would you like to start the test?

Y N

Walking Transfer Turning

340 persons, age 80.1±6.5 yrs Prediction accuracy

AUC=0.74

One test than the other? (Palumbo unpubl.)

Test Sens Spec PPV NPV Acc

TUG > 12 s 52.7% 79.4% 12.6% 96.8% 78.0%

TUG > 15 s 52.7% 80.9% 13.4% 96.8% 79.4%

SPPB < 9 53.4% 80.3% 13.3% 96.8% 78.8%

SPPB < 11 56.0% 75.9% 11.7% 96.8% 74.8%

Gait speed < 0.8 m/s 52.7% 81.1% 13.6% 96.8% 79.6%

Gait speed < 1 m/s 52.7% 79.4% 12.6% 96.8% 78.0%

Aim: safe physical activity

NICE Guidelines

Multifactorial intervention Multifactorial falls due to frailty, depression, urge incontinence, orthostatic hypotension Motivate to participate in an exercise programs Medication modification: stop Benzo, start antidepressant with sedating property Vision counselling: functional vision impairment Postural hypotension treatment: hydration, lower dose of furosemide DXA T-Score of -3: initiate bone health treatment Environmental hazard modification by occupational therapist Add CBT


No falls



fall

Full Evaluation

Single fall Recurrent falls

ProFouND Factsheets

What works What does not work Cautions Who can help Where to find resources Summary of evidence Assessment instruments htt

p://p

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eu.c

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Where to find advice

Cochrane Review expected updates 2017 (!)

Multifactorial intervention individual risk assessment

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Gillespie et al 2012 159 trials 79193 participants

PresenterPresentation NotesWe included 159 trials with 79,193 participants. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Most trials compared a fall-prevention intervention with no intervention or an intervention not expected to reduce falls. Sixty-two percent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment. RaR = Rate Ratios RR= Risk Ratio Multiple-component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80; 7 trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; 6 trials; 714 participants). Multiple-component exercise (balance and strength training) embedded in activities of daily living in people with a history of falls significantly reduced rate of falls (RaR 0.21, 95% CI 0.06 to 0.71; 1 trial; 34 participants) but not risk of falling. For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; 5 trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; 6 trials; 1625 participants). Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants). Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; 7 trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels. Home safety interventions when delivered by an occupational therapist reduced rate of falls (RaR 0.69, 95% CI 0.55 to 0.86; 4 trials; 1446 participants) and risk of falling (RR 0.79, 95% 0.69 to 0.90; 5 trials; 1156 participants). An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54; 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely there was a significant increase in outside falls in intervention group participants who took part in little outside activity. Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; 3 trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; 1 trial; 306 participants), but second eye cataract surgery did not. Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; 1 trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; 1 trial; 659 participants). An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; 1 trial; 109 participants). One trial (305 participants) comparing multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling. There is no evidence that cognitive behavioural interventions reduced the rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; 1 trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; 2 trials; 350 participants).Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; 1 trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; 4 trials; 2555 participants). No conclusions can be drawn from the 37 trials reporting fall-related fractures. There is some evidence that a home-based exercise programme can be cost saving within one year in over 80-year-olds, similarly home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors. Group and home-based exercise programmes, and home safety interventions delivered by an occupational therapist reduce rate of falls and risk of falling.Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling. Interventions for preventing falls in older people living in the communityGillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SEPublished Online: November 14, 2012

Please, cycle with bicycle helmets!

Case Study: Mrs H

Dr Amanda Clifford Senior Lecturer at the University of Limerick Ireland and

Physiotherapist

Mrs H: History of Present Condition

72 year old woman Non-modifiable falls risk factors > 65 years and female

Three recent falls, most recent resulted in *back injury and *long lie Recurrent falls ↑ risk of admission to long-term care x4.5 (Donald and Bulpitt 1999). Resulted in injury and long lie (marker of weakness, illness and social isolation and associated with high mortality rates ) *priority for further ax by Physiotherapist

Feels light headed/ dizzy with sudden position changes *Priority for further investigation medical team to perform cardiovascular assessment and medication review prior to participating in exercise intervention

PresenterPresentation NotesWhat are the key issues to consider for Mrs H?

History of falls is one of best predictors of a future fall and increases risk of another fall x 3. It may result in less physical activity and therefore lead to loss of strength, balance and reflexes.

Why are we concerned about a long lie? Remaining on the ground for more than an hour after the fall is a marker of weakness, illness and social isolation and is associated with high mortality rates Time spent on the floor: correlated with FoF, muscle damage, pneumonia, pressure sores, dehydration and hypothermia50% who lie on the floor > an hour die within 6 mts even when not injuredAlmost 50% of those who fall and are unuinjured are unable to get up from the floor following the fallTeach fall recovery strategies i.e. get up from floor, exercises to maintain temperature if can’t rise

.

Management: Past Medical History

Past Medical History

Previous fractures

Previous falls

Medical condition predisposing to falls

Mrs H: Past Medical History Fell 6 months ago resulting in Colles fracture Bone health, need to ascertain if previous investigations and treatment

Urinary incontinence and UTIs leading to confusion Medical team to investigate and treat underlying infection as appropriate, refer to women’s health PT if appropriate

Hypertensive and mild heart failure Medical team: cardiovascular assessment

Diabetes: Type II diet controlled A major risk factor for falling even after controlling for balance: recommend: medication review, specific balance exercises and cognitive training, PT to liaise with medical team (GP/Geriatrician) OT and Dietician (Mettelinge et al 2013)

Vision poor recently changed to bifocals Refer to optician; use of single lens > multifocal glasses can prevent falls in people who participate in outdoor activities (Haran et al 2010).

PresenterPresentation NotesUrinary Urge Incontinence – urge incontinence is independently associated with risk of falling. Older women with weekly urge incontinence were 26% more likely to fall and 34% more likely to fracture (Brown et al, 2000) Urge incontinence and abnormal daytime sleepiness are independently associated with an increased falls risk (Teo et al, 2006)

Older women with diabetes are 1.6 times more likely to have fallen in the previous year and twice as likely to have had an injurious falls. Rx nutritional management and physical activity

Case Study Mrs H: Drug History

Drug History Atenolol Frusimide Lactulose Nitrazepam Medication review required: polypharmacy ≥ 4 medications Medication can affect metal alertness, judgement and co-ordination, sedation, blurred vision, confusion, balance mechanism/ neuromuscular coordination

PresenterPresentation NotesMedications can affect metal alertness, judgement and co-ordination, sedation, blurred vision, confusion, affect the balance mechanism/ neuromuscular coordinationThose found to increase risk of falling are psychotrophic meds, Class 1a antiarrhythmias, digoxin and diuretics.Some increase the risk of hypotension (antidepressants, antipsychotics diuretics/antihypertensives).70% of those >70 have hypertension and Antihypertensive medications are one of the commonest causes of drug related blackouts and fallsPsychoactive medication: altered balance and quadriceps strength, Benzodiazepines: impairs reaction time and increase postural sway, decreased position sense NSAID’S effects on the CNS: impaired cognition

.

Management: Social History

Social History

Hobbies

House type

Social supports/ family

Functional status

Case Study Mrs H: Social History Social History Lives alone, fairly independent: home help 2/7 Social support /isolation ax by social worker and home visit by OT (environment)

Feels unsteady when walking, furniture walking & reluctant to use walking aid. Difficulty with ADLs’ due to dizziness and unable to stand for long periods cooking: Medical team to assess reasons for dizziness, physiotherapist to assess and treat balance/ function/ gait training and OT to ax ADL’s

Not socialising: low in mood and memory concerns For further assessment: mild cognitive impairment: twice as likely to fall (Delbaere et al. ) and Dementia: 70-80% fall annually (Allan et al. 2009)

Physiotherapist to assess gait and balance and functional ability

PresenterPresentation Notes

She is less active than 6/12 ago. Has she been having falls and restricted activity due to fear? Fear of falling?Fear is present in 50-65% of fallers and up to 40% of non fallersIt predicts decreases in activity, deterioration in physical functioning and higher risk of falling.

Risk Factors for Falls

• Age ≥65 years

• Hx of falls • Female gender • Polypharmacy (≥4 meds) • Dementia / Cognitive

impairment • Visual impairment • Gait impairment

• Diabetes • Balance deficits • Poor proprioception • Slow reaction times • Musculoskeletal problems • Reduced lower limb strength • Environmental factors • Cardiovascular issues

(Ganz et al. 2007; Lord et al. 1994; Lord et al. 1996; van Doorn et al. 2003, Volpato et al 2005)

Plus many more…

The Physiotherapist should assess these modifiable risk factors further to inform the rehabilitation programme for Mrs H

PresenterPresentation NotesLINK CAUSES TO RISK FACTORS e.g. if gait/weakness/balance is a cause, older age is an associated risk factor.

History of falls is one of best predictors of a future fall and increases risk of another fall x 3. It may result in less physical activity and therefore lead to loss of strength, balance and reflexes.

Urinary Urge Incontinence – urge incontinence is independently associated with risk of fallingOlder women with weekly urge incontinence were 26% more likely to fall and 34% more likely to fracture (Brown et al, 2000) Urge incontinence and abnormal daytime sleepiness are independently associated with an increased falls risk (Teo et al, 2006)

Polypharmacy – especially anti-depressants, anti-psychotics, benzodiazepines (sedative, hypnotic, anxiolytic)

Context: Falls Prevention Initiatives in Ireland

Strategy to Prevent Falls and Fractures in Ireland's Ageing Population (2008)

National Clinical Programme for Older People (2012)

AFFINITY – Activating Falls & Fracture Prevention in Ireland Together (2013)

PresenterPresentation NotesFalls and Bone Health Services in IrelandSurvey of Primary Care Local Health Offices (LHO) in Ireland 79% (n = 23) had a falls/bone health programmeAll managed by senior physiotherapists72% = Falls prevention programmes35% = programmes targeted bone healthMost participants 70–80 years Exercise components reflected clinical guidelinesNo follow-up for falls/fracture incidence, health service utilisation Inappropriate venues, lack of patient transport, finance & staffing CONCLUSIONS: Most LHOs provided some form of evidence-based programme, but unlikely that current services meet population needs(Madigan et al. 2014)

Context: Falls & Fracture Prevention Care Pathway for Mrs H

AFFINITY (2013) NICE (2013)

PresenterPresentation NotesSimple, quick, most recommended approach…ASK & OBSERVE!

“Older people in contact with healthcare professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall(s)”

“Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance” (NICE 2013)

Community Falls Prevention Pathway: Mrs H (Level 2)

Adapted from HSE (2008) & NCPOP (2012)

LEVEL 1

LEVEL 2

LEVEL 3

PresenterPresentation NotesStrategy in 2008, AFFINITY now working to implement.

Multifactorial Assessment (Level 2)

• Detailed falls history • Musculoskeletal and

neurological examination • Gait, balance, strength • Mobility • Functional ability • Fear of falling

• Visual impairment • Cognitive impairment • Urinary incontinence • Medications • Osteoporosis risk • Cardiovascular

examination • Depression • Home hazards

(AGS/BGS Guidelines 2010, NICE Guidelines 2013,

APTA CGS 2015)

Primary focus of the role of the Physiotherapist to assess and design a tailored rehabilitation programme for Mrs H based on the findings from this assessment

The Physiotherapist should liaise with the other HCPs as the findings of these assessments will influence and inform the rehab programme for Mrs H

Pharmacist

Public health nurse

Psychologist

GP/Geriatrician

.

Mrs H requires

MDT approach

Occupational Therapist

Physiotherapist

Social worker

Podiatrist

Dietician

Solution to Effective Inter-professional Collaboration

• What are the factors that would enhance quality of care, client satisfaction, functional health and adherence for Mrs H?

• Positive attitude • Common goal and vision of Mrs H’s pathway of care • Mutual respect • Clarity of roles • Clear communication • Effective and efficient collaboration (Baxter and Markle-Reid 2009)

PresenterPresentation NotesAn inter-professional team approach to fall prevention for older home care clients at risk of falling: HCP’s share their experiences Baxter and Markle-Reid 2009, International Journal of Integrated Care Needs to be effective and receive support at individual. Team and organisational level

.

Physiotherapy Management

Detailed Subjective

Assessment Injuries sustained: residual

back pain/ stiffness/#?

Preceding symptoms

How did each fall happen? Pattern, location etc

Loss of consciousness?

Previous Rx following fall resulting in Colles #

PresenterPresentation NotesDetailed subjective assessmentPrevious falls: identify the patterns, location, lighting Two overnight and one in the morning getting out of bed, long lieMost recent fall: hurt her back and was unable to get up off the ground ……residual pain/ stiffness? Previous treatment following previous fall/ fracture? Previous investigations e.g. DEXA Fear of falling

.

Physiotherapy Management

Detailed Objective

Assessment

Upper and lower limb joint ROM

Balance

Posture and gait

Upper and lower limb strength

Specific spinal assessment following recent back injury

Endurance

PresenterPresentation NotesDetailed subjective assessmentPrevious falls: identify the patterns, location, lighting Two overnight and one in the morning getting out of bed, long lieMost recent fall: hurt her back and was unable to get up off the ground ……residual pain/ stiffness? Previous treatment following previous fall/ fracture? Previous investigations e.g. DEXA Fear of falling

Gait & Balance Assessment Tools

• Berg Balance Scale • Tinetti Performance Oriented Mobility Assessment • Mini-BEST Test • BESTest (36 items) • Brief BESTest (6 items) • Fullerton Advanced Balance (FAB) Scale • Dynamic Gait Index (DGI) • Functional Gait Assessment (modified DGI) • Timed walking tests (5m, 10m etc.) • And many, many more…

www.rehabmeasures.org Middleton, A., Fritz, S. L. and Lusardi, M. (2015) 'Walking speed: the functional vital

sign', J Aging Phys Act, 23(2), 314-22.

http://www.rehabmeasures.org/

Technology in Fall-Risk Assessment

• Static balance – computerised posturography

• Instrumented tests e.g. TUG • Daily life gait – activity monitoring • Falls detectors & personal alarms

Other Measures…… • Falls Self Efficacy/ Fear of falling

90%

75%

85%

63%

74%

50%

7%

19%

12%

27%

20%

34%

2%

6%

4%

10%

7%

16%

Men

Women

Men

Women

Men

Women

50-6

465

-74

75+

Fear of Falling among Older Irish Adults (adapted from Barrett et al 2011)

Not Afraid Somewhat Afraid Very Afraid

PresenterPresentation NotesTILDA dataFear of Falling – one of the most common fears of older people. Can motivate some to take preventative action but for others it can result in them limiting what they do, which results in decreased physical activity which itself will further increase the risk of falling

Community Falls Prevention

Consistent high-quality evidence for:

• Exercise – FIRST CHOICE intervention – Falls by 13 - 61%

• Multifactorial interventions

– Falls by 10% - 35%

(Gillespie et al. 2012, Stubbs et al. 2015, Sherrington et al. 2016)

PresenterPresentation NotesExercise: 13/14 pooled analyses from 7 medium-high quality meta-analyses demonstrating a significant reduction.

Rate Ratio provides a summary of the rate of falls between the intervention and control groups. RR compares the number of people who have fallen between the intervention and control groupsOR is the ratio of the odds of a fall happening in each group

Prior to staring exercise need investigations to ensure medically OK to participate:

Unstable angina, heart failure, diabetesResting BP>180/110 or exercise BP>240/110Orthostatic hypotension or >20mmHg drop in BP during or after exerciseUnpredictable ventricular or artrial arrhythmiasFever or illnessSevere muscle sorenessFatigue, dizziness etc.Unstable blood glucose levels

Modifications maybe needed for those withCognitive issuesHearing impairmentsIncreased falls risk or fracture risk

Community Exercise Programmes • Group or home-based exercise • Otago Exercise Programme

– Specific, individual, home-based • Tai Chi • Group exercise interventions

– Circuit-training style classes – E.g. FaME / Later Life Training

• Integration of exercise onto lifestyle – E.g. The LiFE study

• Individualised interventions

(Clemson et 2012, Gillespie et al. 2012, Sherrington et al. 2011, Thomas et al. 2010)

Exercise for Community Falls Prevention

Should include: a. Strength training b. Balance training c. Gait training Grade A: Strong recommendations based on Level I evidence

(Avin et al. 2015 APTA Clinical Guidance Statement)

Individually prescribed, monitored, & adjusted

Have we assessed all of these adequately in

our multifactorial assessment?

PresenterPresentation NotesLevel ‘A’ evidence

Exercise for Community Falls Prevention

(Costello & Edelstein 2008; Power & Clifford 2013; Sherrington et al 2008/2011)

Frequency • ≥3 times per week

Intensity • Moderately-highly challenging yet safe

Type • Balance & gait ± strength training • Flexibility & endurance not effective alone

Time • Exercise a sufficient dose to have an effect • Duration per bout of exercise? • At least 2 hours exercise per week • ≥12 weeks duration • ≥50 hours over course of intervention

PresenterPresentation NotesPrinciples of an exercise programme for Mrs H (+/- Osteoporosis)AssessEducatePrescribe an individualised exercise programmeMaintain bone strengthImprove muscle strength, aerobic capacity (cardiovascular fitness)Improve postureBalance/co-ordinationImprove psychological well-being, increase self-efficacy/ confidenceFalls preventionPrevention of further #Gait re-educationReduce/manage pain

Challenging balance = conducted while standing, decreasing base of support, minimize use of hands to assist, practice controlled movements of the centre of mass

Balance Training: What Works? • Determine Mrs H baseline; prescribe balance exercises that

provide a moderate or high challenge to balance: tailored to Mrs H ability and progress safely

• Aim to safely: – Reduce the base of support – Move the centre of gravity and control body position – Reduce reliance on the upper limbs for support Sherrington et

al 2011)

(Sherrington et al. 2016)

Consider Mrs H’s Muscle Strength and Bone Health

• Include resistance programme: muscle strengthening and bone loading activities using major muscle groups can have significant impact on ADLs & physical function – Overload muscles using weights/ exercise bands (Sherrington et

al 2011) – Individualise to Mrs H ability e.g. progress from 10-13 RPE

(somewhat hard) to 14-15 (hard) – Ensure quality of movement technically correct and through

ROM – Integrate medium* and or low impact activities for a well

designed and safe programme

PresenterPresentation NotesMany benefits from strength training: reduced muscle strength is a risk factor for falls, longer term falls prevention benefits from strength trainingExercise variables: intensity (recommendation defined by the level of difficulty/ fatigue and number of repetitions), quality and speed of movement (contraction velocity) EvidenceForbes et al (2014) – Cochrane Review – 10/11 AMSTARPitkälä et al (2013) – Systematic Review – 8/11 AMSTAR

Pitkälä, K., Savikko, N., Poysti, M., Strandberg, T. and Laakkonen, M. (2013) Efficacy of physical exercise intervention on mobility and physical functioning in older people with dementia: a systematic review, Experimental Gerontology, 48(1):85-93

Forbes, D., Thiessen, E., Blake, C., Forbes, S. and Forbes, S. (2014) Exercise Programs For People With Dementia, Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD006489.

Liaise with medical team (query osteoporosis DEXA scan/ medications)

Exercises prescribed by a physiotherapist can improve general health, muscle strength balance and posture to prevent falls and reduce the risk of further fracturesIf Mrs H is diagnosed with a fracture Physiotherapist needs to take precautions with: High impact exerciseTrunk flexionTrunk rotational torsion movements with any loadingLiftingJoint Mobilisations

Include a combination of weight-bearing exercise with supervised progressive exercise training, balance and mobility exercises 3 per week

Moderate impact activities are only recommended for people with osteoporosis who do not have a previous fracture (s) or lower limb arthritisAvoid forward flexion (bending over holding an object, sit ups with straight legs) twisting of the spine

Should we Include Gait Training?

• Mrs H is furniture walking at home, not socialising, has Diabetes, has expressed memory concerns. Presentation: walk slower, shorter strides and > stride length variability (Roman de Mettelinge et al 2013)

• Walking training can be included in addition to balance training but if high risk

avoid brisk walking programs until safe (Sherrington et al 2011) • Aerobic activity can ↑ metabolic control; ↓ risk of developing cognitive

impairments/ dementia (Erickson et al 2010) and may slow progression of cognitive decline in people with MCI and early stage AD (Barker et al 2011). 30mins of walking 4 days a week maintained cognitive function and improved functional ability over 6 months (Venturelli et al 2011)

PresenterPresentation NotesWalking velocity reflection of overall health, well-being and functional status

Aerobic exercise and cognition Mrs H has expressed memory concerns and is low in mood Exercise ↑ serum levels of Brain Derived Neurotropic Factor (BDNF) (Cotman et al 2002), which promotes neurogenesis, angiogenesis, synaptic and neuronal plasticity (Erickson et al 2012). fMRI: exercise significantly improved cortical connectivity and activation (Ahlskog et al 2011) Exercise had a positive influence on cognitive function, functional mobility & memory function in people with dementia even at low frequency (Cancela et al. 2016 and Groot et al. 2016))

PresenterPresentation NotesCognitive ability –may have impact on treatment

Exercise direct influence on neurodegenerative disease mechanisms & facilitates neuroprotective factors & neuroplasticity

Neurochemical - Exercise increases endorphin and serotonin levels in the brain, increasing the functioning of the CNS and enhancing cognitive performance

Cognitive Reserve - Activating brain plasticity and enhancing synaptogenesis and neurogenesis

Stress - Positive emotional feelings, which reduce stress and lead to lower susceptibility to cognitive impairment

Functional - Facilitates acquisition of spatial learning and memoryKramer, A. and Erickson, K. (2007) Capitalizing On Cortical Plasticity: Influence Of Physical Activity On Cognition And Brain Function, Trends in Cognitive Sciences, 11(8), 342-348.

Erickson, K., Weinstein, A. and Lopez , O. (2012) Physical Activity, Brain Plasticity, and Alzheimer’s Disease Arch Med Res . 43(8): 615–621Improvements in executive function, selected attention, working memory, planning and organisation, multitasking and inhibition (Barker et al 2010)

Improvement in spatial and verbal memory, functional ability and ADLS (Vreugdenhil et al 2011)

Reduction in neuropsychiatric symptoms (Hoffmann et al 2015)

A community-based exercise programme to improve functional ability in people with Alzheimer’s disease: a randomized controlled trial Vreugdenhil et al 2011 40 community-dwelling patients diagnosed with Alzheimer’s disease and their informal carers were randomly allocated This study suggests that participation in a community-based exercise programme can improve cognitive and physical function and independence in ADL in people with Alzheimer’s diseaseEffects of Aerobic Exercise on Mild Cognitive Impairment barker et al 2010 —Thirty-three adults (17 women) with amnestic mild cognitive impairment ranging in age from 55 to 85 years (mean age,70 years). high-intensity aerobic exercise or stretching control group. The aerobic group exercised under the supervision of a fitness trainer at 75% to 85% of heart rate reserve for 45 to 60 min/d, 4 d/wk for 6 months executive function

Dopamine (DA) induces behavioral & physiologic changesDA levels Significantly reduces in the caudate nucleus and putamen of ADExercise Increases Serum calcium levels , it is transported to the brain & stimulates DA synthesis

Moderate-to-High Intensity Physical Exercise in Patients with Alzheimer’s Disease: A Randomized Controlled Trial Hoffman et al 2015 200 patients with mild AD to a supervised exercise group (60-min sessions three times a week for 16 weeks) or to a control group neuropsychiatric symptoms Physical activity improves spatial and verbal memory in older adults with probable mild cognitive impairments nagamatsu et al 2013 86 women random allocation six months aerobic exercise improvements in memory verbal and spatial

Effective interaction with Mrs H and her family “The way that healthcare professionals offer fall advice and prevention programmes often viewed as insulting and dictatorial…..” (Child et al 2012)

• Major barrier to the successful implementation of fall-prevention programmes is the differing perceptions of fall risk amongst the older population, families, and HCPs (Bunn et 2008)

• Listen, educate and advise • Consider the views and experiences of Mrs H and her family to

facilitate uptake of recommendations

• Mrs H should be made aware of their potential risk of falling without causing distress or denial of a problem

Consider: Implementation

PresenterPresentation Notesdiffering perceptionsof fall risk amongst the older population, families, andhealthcare professionals

• Barriers

– Greater age

– Poor health & function

– No history of exercise

– Fear of falling and ↓ self-efficacy

– Poor outcomes expectation

– Denial/Lack of awareness

– Long duration (>20 weeks)

– Within-group variation

– Stigma

Consider: Uptake & Adherence: ongoing exercise is necessary

(Bunn et al 2008; De Groot & Fagerstrom 2011; McPhate et al 2013)

• Facilitators – Accessibility

– Good leadership

– Social support

– Social aspect of intervention

– Individualised programme

– Joint decision-making

– Frequent exercise sessions

– Low intensity exercise

– Good outcomes expectation

PresenterPresentation NotesTeach fall recovery strategies i.e. get up from floor, exercises to maintain temperature if can’t rise

Home situation – she needs to be independent liase with OT

Patient and ? family involvement/education re current deficits and strategies to address them

Consider: Behaviour Change & Self-Management

• Benefits to including self-management component included – Increased confidence and self-efficacy

– Retain independence

– Improved quality of life

– Engagement in new or lapsed activities

– Re-engagement in fun and friendships

Michie et al (2011)

PresenterPresentation NotesSelf-management, where the individual with a long term condition is encouraged to learn to manage their health and identify solutions to meet their specific needs is being promoted as an attractive, workable solution which can enable people to retain independence and quality of life and as such is a significant policy driver.In common with lifestyle matters and lifestyle re-design, the intervention encourages continued participation by people following a dementia diagnosis and is underpinned by social cognitive theory thereby aiming to increase participant self-efficacy.This intervention found to promote physical and mental health and well-being, occupational functioning and life satisfaction in older adults, as well as a retaining approximately 90% therapeutic gain up to 6 months post. Sprange, K., Mountain, G.A., Shortland, K., Craig, C., Blackburn, D., Bowie, P., Harkness, K. and Spencer, M., 2015. Journeying through Dementia, a community-based self-management intervention for people aged 65 years and over: a feasibility study to inform a future trial. Pilot and Feasibility Studies, 1(1), p.1.

Thank you Dr Valerie Power, University of Limerick, Ireland

Dr Amanda Clifford

EU Falls Festival Case study Mrs.H.

Occupational Therapy Perspective

Myrthe Pruijn Ergotherapie Nederland / MC Slotervaart

PresenterPresentation NotesOT at MCS: MC Slotervaart: General hospital where I see many geriatric patients in fall prevention for diagnosis in multidisciplinary setting and treatment.

Involved in:Renewed OT guideline EN: Dutch association of OT 2016.Renewed multidisciplinary guideline: will be released 2017.

In this short presentation I will present the OT’s focus on Mrs.H’s case study.

https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjPl-3_it3SAhVIPBQKHbZmATUQjRwIBw&url=https://www.artsenauto.nl/slotervaart-omzeilt-achmea/&psig=AFQjCNE-ZXB4ZGItft1EGKZJ9d4-nnA_XQ&ust=1489824521953037https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi80La3ld3SAhXCchQKHc8YBd8QjRwIBw&url=https://amsterdam-almere.lhv.nl/actueel/nieuws/16-september-mc-slotervaart&psig=AFQjCNFtR9pA0aBIFDHR-0kLq_iTX-cZRA&ust=1489827323126181

Dutch OT Guideline Fall prevention 2016

PresenterPresentation NotesChoises in this case study are based on the recently renewed OT Guideline fall prevention.Instruments I mention are evidence based.

https://www.google.nl/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwi80La3ld3SAhXCchQKHc8YBd8QjRwIBw&url=https://amsterdam-almere.lhv.nl/actueel/nieuws/16-september-mc-slotervaart&psig=AFQjCNFtR9pA0aBIFDHR-0kLq_iTX-cZRA&ust=1489827323126181

PEO model

(Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L., 1996)

PresenterPresentation NotesOccupational therapy focusses on the complex context of the individual client in where the occupation and activity takes place. The Person-Environment-Occupation (PEO) Model demonstrates the interconnections of a person, their environment and their occupation and focusses in the middle where the circles meet.


Diagnostic choices

Diagnosis OT Instrument

Person Motivation for (OT) diagnosis/ treatment

Canadian Occupation Performance Measure

COPM

Person Identifying risks in awareness and habits

Falls Behavioural Scale FaB

Occupation Observation daily activities

Assessment of Motor and Process Skills OR Perceive Recall Plan Perform

AMPS PRPP

Environment Physical environment

Home Assessment Profile OR Home Falls Accident Screening Tool

HAP HOME FAST

PresenterPresentation NotesPerson:Motivation: Research shows this is essential in results of fall prevention treatment. Focusing on falling (negative) by itself doesn’t seem to motivate older people in making changes in their daily life. Prior to the observation I would use the Falls Behavioural (FaB) Scale to identify Mrs.H’ awareness and habits of risk taking behaviour in her daily activities. For example: is she rushing to the toilet at night or to a ringing phone?

Occupation:The guideline advices 2 instruments to observe daily activities:For mrs.H. I would choose the AMPS Assessment of Motor and Process Skills which measures 36 performance skills (cognition and motor skills) represent how well the client performs ADL tasks, in terms of physical effort, efficiency, safety, and independence. Observation is done in 2 standardized tasks.

Environment:HOME FAST: Home Falls Accident Screening Tool instrument to measure falls risk for older people within their home environment


P, G

P, E

E

Mrs. H. (72y.)

A,G

Neighbour? Private help

Sister?

E

A= advice G= company E= emotional support P= practical support Positive Neutral Tension

Social environment: Ecogram

Expertisecentrummantelzorg.nl

PresenterPresentation NotesThe guideline advices to use the ‘Ecogram’ to clarify who’s involved and which roles (advice, practical/emotional) and connection (positive, neutral, tension). This could be useful in Mrs.H’s case to choose whether to involve or not involve people in her social environment.


Involving other professionals

What Who

Check orthostatic hypotension GP / Geriatrician

Strength, balance and fitness Physiotherapist (basic tests by OT for indication?)

Cognitive testing Geriatrician / GP (MMSE by OT for indication?)

Check on multi pharma on fall risk Geriatrician / GP

PresenterPresentation NotesSince Mrs.H’ falling seems to have a multifactorial cause I would definitely involve other professionals. Preferably in a multidisciplinary setting like the MCS.

Orthostatic hypotension: light headed/dizzy with sudden changes in position. 2 Explained falls are described after changing positions. Strenght, balance, fitness: Unsteady when walking (balance?), ‘unable to get up off the ground’ (strength, praxis cognitive?), ‘struggling to stand for long periods’ (fitness).Cognitive testing: ‘slightly confused’, ‘memory is not so good as it was’Vision has been recently checked, since she changed to wearing bifocals. How is she managing this change?Multi pharma: 5 different types of medication for high BP, 3 different types of sleeping medication, anti-depressant.


Coordination of treatment / care

Multidisciplinary diagnosis at MC Slotervaart coordinated by geriatrician: • OT: home visit week prior to visit in hospital

• 1 day in hospital for multidisciplinary diagnosis

• Multidisciplinary meeting advice to client

PresenterPresentation NotesHome visit to observe Mrs.H’ activities to complete all the areas of the PEO model by observerving her in her own environment in her own daily habits.

Since there seem to be problems in many areas of fall risk (physical, medical, cognition, habits in daily tasks) it would be advisable to do the diagnosis in a multidisciplinary setting where all areas are tested by the geriatrician, the physiotherapist, the OT. If not available and only OT is prescribed by the GP I would do some basic testing and would discuss with the GP to involve other disciplines. Coordination should be done by the GP (or the involved geriatrician).cognitive testing medical checkmultipharma, check vision. Physiotherapist: fitness, balance, strenght


Main intervention priorities OT

- Setting goals

- Training of risk taking in daily activities (involving social environment)

- Client centered advice on physical environment

- Evaluation

PresenterPresentation NotesSetting goals: Focus on rolemanagement, meaningful activities, participation and lifestyle. Motivation of Mrs.H is essential in treatment.

Training: how can this be adapted to improve safety and independency? Depending on outcomes of cognitive testing people in the environment of Mrs.H could be involved and stategy of training should be chosen; lots of repetition, external reminders to change habits etc. Training in meaningful activities in Mrs.H’ environement.

Client centered advice since research shows this gives better outcomes than general advices + advices given by an OT lead to better results than advices given by other professionals.

Evaluation is essential because fall prevention involves changing habits, which takes time and effort and motivation. Research shows proper evaluation is essential for success.


Main intervention priorities multidisciplinary

Multifactorial intervention programmes • ‘Beter in balans’ (‘A matter of balance’) • ‘Vallen verleden tijd’ (‘Falling is the past’)

PresenterPresentation NotesThere are different fall prevention programmes where groups of geriatric client follow a multi week training programme where OT focusses on daily activities, participation and the physical environment. Home visit for client centered advice is recommendable.

Examples: ‘Vallen verleden tijd’ (Falling is the past) is a Dutch group programme where OT, physioth and other disciplines integrate their expertise in an 8 week programme:OT 2 sessions on focussing on daily activities and particpation (home visit is advised for client centered advices)Physio: practising quality of walking, managing obstacles en learning how to fall. This programme is effective on the quantity of falls.Other examples: ‘A matter of balance’ (Beter in balans)


Challenges of liaising with other professionals

Overlap in professions Mobility: physiotherapy - OT Cognition: psychologist – geriatrician - OT

PresenterPresentation NotesThere’s no sharp line on what every discipline should do in fall prevention, some interventions can be done by different professionals. Goal should be to regularly discuss and adapt interventions to each other. Goals should be clear and focussed on the meaningful activities of Mrs.H which motivate her to make changes in her daily life.


PresenterPresentation NotesI hope I have given you a quick impression on how the OT approach would be in Mrs. H case. Are there any questions?


The role of the Exercise Instructor in Self Management of Falls for Mrs H

Dawn A Skelton

Professor of Ageing and Health

Glasgow Caledonian University & Director of Later Life Training Ltd, UK

@GCUEngagement @LaterLifetrain

PresenterPresentation NotesI have 10 minutes to present the perspective of a specialist exercise professional.

Perhaps a question to answer that isn’t on my list here is ‘why do we need exercise professionals?’ – because physio interventions are not long enough, patients will not reach anywhere near their full potential or training gains in 8 weeks.

From the UK perspective this this means I am bound and informed by our training and qualification framework for exercise professionals, you can see the quals I hold here.

The Role of the Exercise Instructor in Self Management – Mrs H

• Exercise is the SINGLE Intervention with the MOST evidence

• Effective exercise is NOT just a selection of exercises • Physiotherapists CANNOT offer adequate dose (>50

hours) within healthcare systems • NOT all Exercise Instructors are the SAME!

– National Occupational Standards in the UK for Exercise Instructors

• More explanation from Bex Townley in 09.45 session tomorrow



• Diagnostic Priorities – Does she need to be seen by a physiotherapist?

• Evidence of postural hypotension and dizziness • Urinary continence

– Current exercise ability – to tailor • 4 point balance scale, TUG, chair rises etc. • Floor rise ability

– Willingness/ability to attend group sessions or home based programme



• Further information to seek? – Back pain

• ? osteoporosis/vertebral fracture • care on types of exercises

– High BP and mild heart failure • ? well managed • exercise tolerance / breathlessness

– Short term and longer term goals • ? Have ability to stand for longer to make own meals again and do

housework • ? Confidence and ability to get out - social engagement • ? Go shopping again independently and confidently – use of

bus/carrying weight



• Other health/social care professions to approach – Orthopedics

• ? Vertebral Fracture leading to back pain – Physiotherapy

• Vestibular assessment and potential rehabilitation (? Benign paroxysmal positional vertigo/Epley/gaze stability rehabilitation)

– Continence Services • Urinary continence management approaches

– Vision Services • ? Change back to single lens glasses (when more active outdoors)



• Intervention Priorities – Strength and balance exercise

• To reduce fear, improve stability, increase confidence to be more active

– Home exercise programme • May need large print booklet or audio version (vision)

– Safe transitions • To avoid postural hypotension and sudden turns of head

– Retraining getting up from the floor • To avoid long lies if no major injury/reduce fear

– Pelvic floor exercises • To help improve continence


Address 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

“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)


PresenterPresentation NotesFear of falling has been documented as 29-55% in the home dwelling elderly and may be as high as 50-65% among people who have previously fallen (Tinetti 1994). This could be understated as many older people will not admit to being fearful, only concerned.

Fear of falling, and loss of confidence in balance capabilities, predict deterioration in physical functioning (Arfken 1994; Vellas 1997), decreases in activity, fractures (Arfken 1994). Fear of personal injury is often cited as a reason for people not taking part in regular indoor and outdoor physical activity (Finch 1997). Up to 40% of admissions to institutional care are as a result of falls, postural stability and concern from the person or their family about falls (Cumming 2000;Vellas 1997).

Think about sitting less

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 and cholesterol • Higher BMI and waist: hip ratio • Reduced muscle strength and bone density • Increased falls and fractures

Gennuso et al (2013); Skelton (2001), Chastin et al. (2014), WHO (2010) Global Recommendations on Physical Activity for Health.

PresenterPresentation NotesPlasma glucose and BMI (Gennuso et al)Muscle strength and bone density (Skelton et al; Chastin et al)Pain (WHO)


• Interactions with her and friends/family? – Be positive – Lives on her own

• Will need prompts and motivation strategies to adhere to exercise • Importance of adherence to programme for maintained independence

– (for her) Importance of: • Being active every day, NOT avoiding activity, breaking up prolonged

sitting • Building strength and balance activities into daily activity

– (for friends/family) Importance of: • Encouraging safe transitions and activity (breaking up prolonged sitting) • Not doing everything for her but facilitating her being more active



• Coordination of treatment/care? – Self management suggests this is all in the hands

of Mrs H but the exercise professional can: • Follow up lapses and relapses (for classes) • Regular motivational prompts (for home based) • Constant check on progress and liaison with other

health/social care professionals • Potential for self-management website support (eg.

fallsassistant.org)


https://fallsassistant.org.uk



• Challenges in liaison with other professionals? – Availability of physiotherapy referral

(cost/availability) • For assessment and also re-referral if condition declines

– Lack of respect of exercise professionals in some countries/areas

• because of lack of robust national training frameworks for exercise professionals in most European countries



• Effective solutions to inter-professional collaboration? – Empower Mrs H (& her friends and family) through

education and encourage them to share successes with other professionals

– Build mutual trust and respect between physiotherapists and exercise professionals

• Eg. through physiotherapy led training of exercise professionals (Otago across Europe)


Conclusion

• Progressive strength and balance exercise is a priority

• Physiotherapists unlikely to be able to support long term effective strength and balance activity

• Trained exercise professionals can provide this support

• Support and motivational strategies are vital for effective behaviour change and falls risk reduction (An effective strength and balance programme is NOT JUST a set of exercises)


SELF-MANAGEMENT: INTER-PROFESSIONAL APPROACHES AND CHALLENGES

TECHNOLOGISTS

Sabato Mellone, PhD University of Bologna

[email protected]

8th and 9th May,2017. Amsterdam, Netherlands

mailto:[email protected]

Nursing

Medics

Physiotherapy Psychologists

Exercise Instructors

Occupational Therapy

Mrs H

Technologists? Technologists Patients/Users

Clinicians/Users specifications

solutions

specifications

solutions

Specifications:Risk Factors? Mrs H is a 72 year old recently widowed lady living on her own. She has been feeling unsteady when walking about her home and has been holding on to the furniture for support. She describes 2 recent falls overnight when rising to go to the toilet and 1 fall first thing in the morning when getting out of bed. She describes feeling light-headed/ dizzy with sudden changes in position. When Mrs H last fell, she hurt her back and was unable to get up off the ground. As a result she lay for several hours until a neighbour was alerted. Mrs H suffers occasional urinary incontinence and urinary tract infections, which can cause her to be slightly confused. Her vision is poor and she wears glasses. She recently changed to wearing bifocals. Mrs H has a history of high BP, and mild heart failure, she has type 2 diabetes which is diet controlled. She fractured her wrist 6 months ago after tripping on a loose mat in her home. Currently Mrs H takes Atenolol for her high BP, Frusemide, Lactulose and Nitrazepam to help her sleep. Her GP also commenced her on a mild anti-depressant following the death of her husband. Mrs H is a fairly independent lady who only recently employed a home help privately for twice weekly assistance with shopping and housework. She is reluctant to accept a walking aid as her flat is small and cramped. She has no difficulty with her transfers but finds she can feel light-headed at times if she rises too quickly or bends to pick objects off the floor. She makes all her own meals, but finds that recently she is struggling to stand for long periods to cook a meal from scratch, so has been using microwave meals instead. Since her husband died she has been feeling low in mood and she is feeling depressed at not being able to get out and about as she used to. She is also concerned that her memory is not as good as it was. She has no regular GP or district nurse input.

Specifications:Risk Factors? • 72 year old • Lady • living on her own • feeling unsteady when

walking • 2 recent falls • unable to get up off the

ground

• urinary incontinence • vision is poor • high BP • type 2 diabetes

• Fractured • Atenolol. Frusemide, Lactulose,

Nitrazepam. anti-depressant • struggling to stand for long

periods

• feeling low in mood, feeling depressed

• memory is not good

Risk Screening

• 72 year old • Lady • living on her own • feeling unsteady

when walking • 2 recent falls • unable to get up

off the ground

• urinary incontinence

• vision is poor • high BP • type 2 diabetes

• Fractured • Atenolol.

Frusemide, Lactulose, Nitrazepam. anti-depressant

• struggling to stand for long periods

• feeling low in mood, feeling depressed


http://ffrat.farseeingresearch.eu/

Medics

http://ffrat.farseeingresearch.eu/

Modifiable? Non-modifiable factors

• 72 year old • Lady • living on her own (?) • 2 recent falls • Fractured • urinary incontinence (?) • vision is poor • high BP (?) • type 2 diabetes • Atenolol. Frusemide, Lactulose,

Nitrazepam. anti-depressant (?)

Modifiable factors

• unable to get up off the ground

• feeling unsteady when walking

• reluctant to accept a walking aid


• feeling low in mood/depressed • memory is not good

Specifications: Context? Mrs H is a 72 year old recently widowed lady living on her own. She has been feeling unsteady when walking about her home and has been holding on to the furniture for support. She describes 2 recent falls overnight when rising to go to the toilet and 1 fall first thing in the morning when getting out of bed. She describes feeling light-headed/ dizzy with sudden changes in position. When Mrs H last fell, she hurt her back and was unable to get up off the ground. As a result she lay for several hours until a neighbour was alerted. Mrs H suffers occasional urinary incontinence and urinary tract infections, which can cause her to be slightly confused. Her vision is poor and she wears glasses. She recently changed to wearing bifocals. Mrs H has a history of high BP, and mild heart failure, she has type 2 diabetes which is diet controlled. She fractured her wrist 6 months ago after tripping on a loose mat in her home. Currently Mrs H takes Atenolol for her high BP, Frusemide, Lactulose and Nitrazepam to help her sleep. Her GP also commenced her on a mild anti-depressant following the death of her husband. Mrs H is a fairly independent lady who only recently employed a home help privately for twice weekly assistance with shopping and housework. She is reluctant to accept a walking aid as her flat is small and cramped. She has no difficulty with her transfers but finds she can feel light-headed at times if she rises too quickly or bends to pick objects off the floor. She makes all her own meals, but finds that recently she is struggling to stand for long periods to cook a meal from scratch, so has been using microwave meals instead. Since her husband died she has been feeling low in mood and she is feeling depressed at not being able to get out and about as she used to. She is also concerned that her memory is not as good as it was. She has no regular GP or district nurse input.

Specifications: Context?

• She has been holding on to the furniture for support

• 1 fall overnight when rising to go to the toilet

• 1 fall in the morning when getting out of bed

• She lay for several hours

• tripping on a loose mat in her home

• her flat is small and cramped • not being able to get out • no regular GP or district nurse

input

Technological Solutions? Context

• holding on to the furniture for support

• 1 fall, overnight, toilet • 1 fall, morning, bedroom • lay for several hours • tripping on a loose mat • flat is small and cramped • not being able to get out • no GP/district nurse input

Modifiable risk factors

• unable to get up off the ground




• feeling low in mood/depressed • memory is not good

Physiotherapy Exercise

Instructors

Technologists Modifiable risk factors • unable to get up off the

ground



specifications solutions

specifications

specifications

Mrs H

Gait Training/Rehabilitation http://www.cupid-project.eu/

Exergames

http://silverfit.com/

Personal Health Systems http://www.preventit.eu/

http://www.cupid-project.eu/http://www.preventit.eu/

Technologists Modifiable risk factors • feeling low in

mood/depressed




specifications

specifications

Nursing Mrs H Psychologists

BaMPer System

Telemedicine/Virtual Coaching

Virtual group exercise

Video Calls/Social Interaction https://www.skype.com

https://www.skype.com/

Technologists Context • 1 fall, overnight, toilet • 1 fall, morning, bedroom • lay for several hours • holding on to the furniture • tripping on a loose mat


specifications

specifications

Nursing

Occupational Therapy Mrs H

Alert Systems https://www.lifeline.philips.com/

Smarthome http://farseeingresearch.eu/

https://www.lifeline.philips.com/https://www.lifeline.philips.com/http://farseeingresearch.eu/http://farseeingresearch.eu/

Take Home Message

• Participatory design

• Multidisciplinary approach

• Preventive approach

• Personal motivation

THANK YOU FOR YOUR ATTENTION

[email protected]

8th and 9th May,2017. Amsterdam, Netherlands

mailto:[email protected]

Self-Management: Inter-professional approaches and challenges

EU Falls Festival, 8th May 2017

Klaus Pfeiffer

Three psychological perspectives

Mrs. H (case report) Death of her husband

→ feeling low in mood, depressed → not being able to get out and about as she

used to → mild anti-depressant

Concerned that her memory is not as good as

it was.

She laid for several hours in her apartment after her last fall until a neighbor was alerted.

Reluctant to accept a walking aid as her flat is small and cramped.

Personality Health behavior change

Psychological flexibility 1 2 3

1. A better understanding of Mrs. H

Hooker & McAdams J Gerontology 2003: Six Foci of Personality, Kloseck et al. JRRD 2008

Duration/severity of depressive symptoms? Depression screening (z.B. PHQ-9) ↔ grief reaction? Memory? Cognitive symptoms of

depression ↔ mild cognitive impairment ? (Cognitive screening) Post traumatic symptoms?

Meaning and importance of mobility, independence, social contacts, physical activity and sports in Mrs. H.’s life?

Current meaningful activities of Mrs. H.? What mobility and physical performance goals are relevant? Being aware of Mrs. H’s resources

(e.g. employed a home help privately) Falls efficacy (FES-I)?

2. Psychological flexibility

Adapt. from Forsyth et al. in Craske et al. (Eds.) 2006

Antecedents (inputs)

Anticipated or actual fall risk situations + corresponding emotional cues

of Mrs. H.

↕

Falls efficacy physical performance

Contextual sensitivity

Inflexible Insensitive

Flexible Sensitive

Evaluation Modulation

CSs USs

UCRs CRs

Consequences (outputs)

Emotional responses (e.g. FoF)

Behavioral (e.g. activity avoidance)

Experiential (e.g. refusal of new routines, devices)

Physiological Cognitive

(e.g. supression, control)

Appraisal is biased on threat dimensions or aversive outcomes (restrictions, personal costs )

Appraisal could also be biased in not being aware of fall risks! Not able to cope with FoF when it occurs

3. Health behavior change process

Schwarzer et al. Rehab Psychology 2011: Health action process approach

Task self-efficacy

Maintenance self-efficacy

Recovery self-efficacy

(Non-) Intervention outcome

expectancies

Fall/fracture risk perception

Intention „goal setting“

Action + coping planning

Action control

↕ Action

Barriers + resources, e.g. social support

Dise

ngag

emen

t

Preintenders Intenders Actors

Motivation phase: Pros and cons of certain

behavioral outcomes Perceived self-efficacy

Moving from deliberation to action

Personal action constructs

Intervention priorities

Improving contextual sensitivity + flexibility when evaluating the own fall risk

Supporting emotion regulation (suppressing, controlling, avoiding and escaping ↓, acceptance ↑)

Successful implementation of fall prevention interventions

Depression? MCI? Relatives? Volunteer visitor program? Other services? Memory ambulance?

Liaising with other professionals (Germany)

GP

Nurse PT

OT

Psychologist

Cognitive assessment, counselling

Psychotherapy

Memory ambulance

Exercise instructor

Technologist

Fall prevention

Social worker

Psychiatrist

Neurologist

In the future: Providing training,

Supervision?

In routine settings psychologists are not involved in fall prevention so far (Germany) Collaboration of psychologists, exercise instructors and physiotherapists in a rehabilitation and

transitional care setting has been successfully evaluated with hip/pelvic fracture patients with FoF (“Step by Step” intervention - Kampe et al. Clin Rehab 2017)

Implementing interventions with components of health psychology, clinical psychology or CBT (e.g. Matter of Balance, Step by Step) are sensible in routine settings (in particular for specific target groups)

Psychologists should be involved in the development of treatment protocols, training and supervision of interventionists.

Thanks for your attention

[email protected]


Anne-Sophie Parent, Secretary General, AGE Platform Europe



Session Chair: Kim Delbaere & Nathalie Van der Velde Emma Stanmore, Senior Lecturer Nursing, University of Manchester, UK Clemens Becker, Head of Clinical Gerontology, Robert Bosch Krankenhaus, , Germany Amanda Clifford, Senior Lecturer Physiotherapy, University of Limerick, Ireland Myrthe Pruijn, Occupational Therapist, MC Slotervaart Amsterdam , Netherlands Dawn Skelton, Professor of Ageing & Health, Glasgow Caledonian University, UK Sabato Mellone, Assistant Professor, University of Bologna, Italy Klaus Pfeiffer, Research Coordinator, Robert Bosch Krankenhaus, Germany Anne-Sophie Parent, Secretary General, AGE Platform Europe


Self Management:�Inter-professional approaches and challengesSelf Management:�Inter-professional approaches and challengesMrs HMrs HInter-professional approaches & challenges: The nurses’ perspectiveRole of the nurseMrs H – 72 ♀ Diagnostic prioritiesFurther informationFurther informationTreatment MDT involvement �Effective interactionChallengesEffective solutions for� inter-professional collaboration?Mrs H post intervention….ReferencesSlide Number 18Role of Medics Slide Number 20Role of Medics (GP, Geriatrician)Role of Medics (GP, Geriatrician)Slide Number 23Slide Number 24Checklist via FRAT-up: Fall Risk Assessment ToolSmartphone AssessmentOne test than the other? (Palumbo unpubl.)Aim: safe physical activity Slide Number 29Slide Number 30Cochrane Review expected updates 2017 (!)Slide Number 32Case Study: Mrs HMrs H: History of Present Condition Management: Past Medical HistoryMrs H: Past Medical HistoryCase Study Mrs H: Drug HistoryManagement: Social HistoryCase Study Mrs H: Social HistoryRisk Factors for FallsContext: Falls Prevention Initiatives in IrelandContext: Falls & Fracture Prevention Care Pathway for Mrs HCommunity Falls Prevention Pathway: Mrs H (Level 2) Multifactorial Assessment (Level 2)Slide Number 45Solution to Effective Inter-professional CollaborationPhysiotherapy ManagementPhysiotherapy ManagementGait & Balance Assessment ToolsTechnology in Fall-Risk AssessmentOther Measures……Community Falls PreventionCommunity Exercise ProgrammesExercise for Community Falls PreventionExercise for Community Falls PreventionBalance Training: What Works?Consider Mrs H’s Muscle Strength and Bone HealthShould we Include Gait Training?Aerobic exercise and cognitionConsider: ImplementationConsider: Uptake & Adherence: ongoing exercise is necessary�Consider: Behaviour Change & Self-ManagementThank you�Dr Valerie Power, University of Limerick, Ireland�Dr Amanda Clifford EU Falls Festival�Case study Mrs.H.��Occupational Therapy PerspectiveDutch OT Guideline Fall prevention 2016�PEO model�(Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L., 1996)�Diagnostic choicesSocial environment: EcogramInvolving other professionalsCoordination of treatment / care�Main intervention priorities OT�Main intervention priorities multidisciplinary�Challenges of liaising with other professionalsSlide Number 74Slide Number 75The Role of the Exercise Instructor in Self Management – Mrs HThe Role of the Exercise Instructor in Self Management – Mrs HThe Role of the Exercise Instructor in Self Management – Mrs HThe Role of the Exercise Instructor in Self Management – Mrs HThe Role of the Exercise Instructor in Self Management – Mrs HAddress Fear of FallingThink about sitting lessThe Role of the Exercise Instructor in Self Management – Mrs HThe Role of the Exercise Instructor in Self Management – Mrs HSlide Number 85The Role of the Exercise Instructor in Self Management – Mrs HThe Role of the Exercise Instructor in Self Management – Mrs HConclusionSelf-Management: Inter-professional approaches and challenges�TechnologistsSlide Number 90Technologists?Specifications:Risk Factors?Specifications:Risk Factors?Risk ScreeningModifiable?Specifications: Context?Specifications: Context?Technological Solutions?Slide Number 99Slide Number 100Slide Number 101Slide Number 102Slide Number 103Slide Number 104Take Home MessageSlide Number 106Self-Management: �Inter-professional approaches and challenges ��EU Falls Festival, 8th May 2017Three psychological perspectives1. A better understanding of Mrs. H2. Psychological flexibility3. Health behavior change processIntervention prioritiesLiaising with other professionals (Germany)Thanks for your attention��[email protected] Management:�Inter-professional approaches and challengesSelf Management:�Inter-professional approaches and challenges

powerpoint presentation...gait and balance, functional assessment vision: acuity, contrast...

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