Frailty and Falls

This post will look at falls which is one of the most written about topics in relation to the care of older people and people living with frailty.

The reason for this are quite clear. With an ageing population and more people living longer with complex health needs falls present an important challenge. In Scotland in 2017–2018, over 37,000 people – 22,400 of whom were over the age of 65 – were admitted to hospital because of a fall.

The Scottish Government have stated that we all need to do more and offer opportunities earlier in the lifespan to help older people age healthily to avoid or postpone the time at which they may fall or sustain a fracture.

Frailty can contribute to falls and result in a person making a slower or poorer recovery following a fall. Conversely, a fall can trigger or accelerate the progression of frailty. Some actions and approaches to prevent falls will also help prevent or slow the progression of frailty. These include being physically active and less sedentary, improving muscle strength and balance, promoting continence, and ensuring good medicines management and adequate nutrition.

The following SWAY presentation looks at the issues involved in managing frailty and falls in the community we hope you find it useful

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It is worth noting that the Scottish Government was consulting on a new ‘National falls and fracture prevention strategy for 2019-2024.’ which has not been published yet. The consultation document is at https://www.gov.scot/publications/national-falls-fracture-prevention-strategy-scotland-2019-2024/pages/1/

Welcome Back!

We would never have believed in early April when we last posted a blog item that it would take until the 19th of October to resume our coaching and teaching programme. It’s been a very strange and unique year and one that we are never likely to forget. We hope that you have all stayed well throughout the pandemic and our hearts go out to any of you who have had your lives or the lives of your family members affected by COVID-19.

Last month you would all have been sent a copy of our new plans for the coaching and teaching programme and we look forward to seeing you all again on Microsoft Teams on Thursday the 22nd of October between 3-5pm. We hope we have picked a time when most of you can be available.

From the timetable you will be able to see that new materials on the Blog should appear every Friday for 6 consecutive weeks. Please be patient with us if they don’t appear early, the intention is to have them available and posted by the commencement of each new week. Alongside the Blog it is our intention to include a number of podcasts/videocasts in line with topics that we are covering that week or that we have previously covered. If possible they will appear within the Blog posts for that week but they may have to be posted as separate items.

In the meantime we hope you #staysafe

#wearamask

Coaching an Education Classroom Session on 11th March 2020

UWS Ayr Campus

Attached is the PowerPoint used for the Coaching & Education Session that took place on the 11th March 2020 at Ayr Campus.

To download the file click the link given below

At the session Scott said he would edit his slides and send them over to Janetta and Constantina. When we have received them we will pass them on to you from the blog.

Note that the next Coaching and Education Sessions are due to take place on the 13th May 2020 between 10am – 4pm and then on the 4th June 2020 again from 10am – 4pm.

Realistic Medicine

Realistic Medicine was a concept first proposed by Scotland’s Chief Medical Officer Cath Calderwood in her annual report for 2014-15 which was published in 2016. Realistic Medicine puts the person receiving care at the centre of decision-making and creates a supported, personalised approach. It aims to reduce harm, waste and unwarranted variation, whilst acknowledging and managing the inherent risks associated with all healthcare. It also champions innovation and improvement. To achieve this, people using healthcare services and their families must feel empowered to discuss their treatment fully with healthcare professionals, in language that they will understand. This should include any possibility that a suggested treatment might come with side effects – or even negative outcomes. Realistic Medicine is an attempt to move away from the “Doctor knows best” approach to shared decision making and the co-production of care.

Realistic Medicine has a particular ethos which involves;

  • Listening to understand patients problems and preferences;
  • Sharing decision making between healthcare professionals and their patients;
  • Ensuring that patients have all the understandable information they need to make an informed choice;
  • Supporting healthcare professionals to be innovative, to pursue continuous quality improvement and to manage risk better;
  • Reducing the harm and waste caused by both over-provision and under-provision of care;
  • Identifying and reducing unwarranted variation in clinical practices.

Realistic Medicine is not about rationing healthcare or saving money. It’s aim is to improve patient care; ensuring that people receive appropriate and beneficial care that is evidence-based and in tune with their personal preferences.

To deliver Realistic Medicine everyone should feel able to ask their healthcare professional why they’ve suggested a test, treatment or procedure, and all decisions about a person’s care should be made jointly between the individual and their healthcare team. One of the early initiatives from Realistic Medicine was to encourage everyone to ask 5 questions

  • Is this test, treatment or procedure really needed?
  • What are the potential benefits and risks?
  • What are the possible side effects?
  • Are there simpler, safer or alternative treatment options?
  • What would happen if I did nothing?

Every healthcare professional should be able to answer these questions for all treatments and procedures they suggest. When people ask these questions they are more likely to receive healthcare suited to their needs that they also be more likely to comply with.

Since its adoption in 2016 the CMO for Scotland has continued to write about Realsitic Medicine and what it involves. Her 2017 report was called Realising Realistic Medicine, the 2018 report was called Practising Realistic Medicine and the most recent 2019 report was called Personalising Realistic Medicine. Last year also saw the introduction of a new comprehensive Realistic Medicine website which you can explore HERE

This video made by Healthcare Improvement Scotland talks to members of the public about realistic medicine and asked them what mattered most to them.

With regards to Fraily

In relation to Realistic Medicine and Frailty, the Director of Public Health for NHS Highland in his Annual Report in 2017 highlighted the following key points:

  • To reduce frailty we need to promote interventions that improve physical functioning by increasing muscle mass and strength, particularly progressive resistance strength training, exercise involving gait, balance, co-ordination, and encourage walking on a daily basis.
  • The effectiveness of dietary interventions are subject to more uncertainty but a healthy diet is important in preventing and addressing frailty.
  • A life-course approach to optimising peak muscle mass and strength in early life, maintaining this in adulthood, and reducing the rate of loss in older adulthood would be a useful strategy for reducing the rate of frailty across our population.
  • For hospitalised patients, better outcomes are associated with care delivered by older people’s multi-disciplinary teams, particularly when these are delivered in designated units or wards.
  • Interventions that reduce hospitalisation include certain types of nurse-led units, tele-health care for long-term conditions, discharge planning from hospital to home, case management in heart failure and integration where more generic case management is utilised would help keep more people in their own homes, where they want to be .
  • We need to maximise the network of support around every frail person so that they have the right support to improve their health, manage their condition and maintain their independence.

Delirium in the Community

Delirium is a common and serious medical condition that results in a person experiencing a sudden change in their behaviour. The onset of delirium always indicates the presence of a physical disorder or acute illness.
Any person can get delirium but it is more common when a person is older, has a cognitive or sensory impairment, is very ill, or requires complex treatments.
Of those aged 80 and older living at home, one in 10 people could have delirium at any time. In care home residents, six in 10 could have delirium at any time.
Nurses and nursing assistants working in these settings are well placed to recognise delirium in the people they care for.
It is important to remember that delirium is particularly common in people with dementia – if you see sudden changes in the physical or mental health of a person living with dementia don’t discount delirium. The types of changes to look out for a listed HERE. Early recognition of delirium could help prevent the person falling over, becoming even more unwell and/or being admitted to hospital. In some cases, early recognition of delirium might even prevent their death.

Delirium can be difficult to recognise and sometimes the signs are subtle. That is why any change in a person should trigger the question “Could this person have delirium?” A useful tool to consider using here is called SQiD (the Single Question in Delirium). The single question: ‘Do you think [name of patient] has been more confused lately?’ is usually put to a member of the family or a friend but if you know the person well you may be able to answer the question yourself. Although this seems simple SQiD is almost as good at delirium detection as psychiatric interview and other more sophisticated identification tools. See Sands et al (2010) for example.

It is always better to rule out delirium than miss it completely. Remember, if you identify delirium, it is very likely that the patient has a medical condition that requires assessment and treatment urgently.

Nationally, Scotland has recently adopted its own set of Guidelines regarding the Risk Reduction and Management of Delirium called SIGN Guidleine 157.

Health Improvement Scotland published a patient information booklet to complement Scotland’s first clinical guideline for delirium. These can be used alongside resources produced by @ihubscot to improve delirium care across Scotland: http://bit.ly/37M5vcu

SIGN Guideline 157 asks that health professionals in Scotland adopt a standard assessment tool called the 4AT tool and this should be used for identifying patients with probable delirium in emergency department and acute hospital settings. They go on to suggest that the 4AT tool should also be used in community or other settings for identifying patients with probable delirium. If you are unfamiliar with the 4AT then now would be a good time to adopt it and get your team used to using it.

Identifying delirium is however only part of the issue. It is really important that you and your team create, develop and follow a local escalation plan which provides you and your team with instructions regarding what to do if delirium is suspected. It is worth checking if your organisation has an existing delirium escalation plan in place. If not, you might find the template and the information on this RCN site very useful. https://www.rcn.org.uk/clinical-topics/older-people/delirium/delirium-champion

Anticipatory Care Planning

Throughout this series of blogs, you will hear repeatedly that our population is ageing and that is really good news.  However, we are also aware that the likelihood of having long-term, multiple chronic or complex conditions increases with age.  So, as healthcare professionals need to have models of care that are designed to meet the many needs of individuals.

Anticipatory Care Planning (ACP) is part of that support. So, what is Anticipatory Care Planning?  It’s about ‘thinking ahead’ and planning action or taking action before something happens.

It involves having detailed collaborative conversations between the person, their family and their care team about future care and preferred options. The process can also be used to explore how individuals can participate in their own care as an extension of self-management.

Anticipatory care planning conversations can be uncomfortable to initiate however with practice it becomes easier and as your experience develops you will become more confident in your approach.  Some people may wish to start the conversation themselves which is great, however others may experience anxiety when considering their future and may wish to avoid having such discussions until they are ready.  This is when your coaching skills will be of great value.

There will be many opportunities to start the process during care interactions and these conversations should focus on the person’s health, well-being and their actual clinical conditions in an attempt to reduce possible crises.  ACP’s also identify where  the person wishes to be  cared for and though collaborative discussion,  it helps identify their own personal outcomes.

Anticipatory Care Planning conversations are completely voluntary and are in no way  legally binding. We know people often change their wishes as circumstances change, so it is vitally important that care preferences are recorded in an ACP with any changes highlighted, dated and communicated to the wider care team.   Example ACP’s can be found at  https://ihub.scot/project-toolkits/anticipatory-care-planning-toolkit/anticipatory-care-planning-toolkit/

Anticipatory Care Planning conversations should be:

  • Collaborative: Individuals and carers are at the centre of their ACP conversations
  • Ethical:  Respect for the person’s values, beliefs and preferences for care, by including what matters to them
  • Comprehensive: Clear communication of key information (e.g. individuals or care providers involved in care or support requirements)
  • Informative communication: Establishes a robust pathway of communication sharing (including e-sharing), which can be helpful to other colleagues, care providers or agencies involved in care. Improving individuals understanding of their health and well-being (health literacy) is essential to person-centred care models which incorporate effective communication, self-management and essentially patient safety
  • Self management approach:
    • Demonstrates the unique symptoms the person may experience and simple actions they can take to address them
    • Enables early identification of health change or health needs, and relevant interventions required to support recovery or reduce crisis
  • Personal:  Information that is important to the individual or carer
  • Relevant: Highly important matters e.g. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) status and  Power of Attorney
  • Realistic: Recovery goals that reflect the individual’s hopes, aspirations and preferences e.g. “Things that I must do to keep well” or “What is important to me and why?” Such measures may help to facilitate hope and encourage active participation in the ACP process.
  • Carer considerate: Enabling alternative arrangements or contingency plans in the event of the carer becoming unwell, thereby reducing the need for acute admission to hospital.

(Barrie, Steel & Loughlin 2019, in Essentials of Nursing Adults, Eds: Elcock, Wright, Newcombe & Everett, Sage, London)

Please take some time to watch some of the personal experiences of those who have undertaken developing an ACP before and hear how important this was to them. 

https://ihub.scot/project-toolkits/anticipatory-care-planning-toolkit/anticipatory-care-planning-toolkit/videos/

Promoting Independence and Self Management

Almost half the population of Scotland have at least one long term condition (Scottish Health Survey 2014) and we know that the older people become, the more long term conditions they will develop.

It has been suggested that on average, the length of time someone with a long term condition spends with a healthcare professional is roughly 4 hours per year (NHS England 2006). For the rest of the time, they or their families are managing the condition and their circumstances at home.

For a more detailed background and more information check out the IFIC Scotland Webinar Integrated Care Matters, Series 4: Self Management and Co production https://vimeo.com/368784654

There are a number of techniques nurses can use to help people to self manage. By embedding these skills in our practice we can support people at every interaction to engage in the behaviours necessary to facilitate self management to the point where it becomes second nature.

These include:

1. Health promoting behaviours

2. Signposting to easy to read information and educational materials

3. Facilitate the person to set small achievable goals and plan actions to achieve these.

4. Peer Support

5. Provide a coaching role

6. Support unpaid carers and recognise the very important role they have.

As nurses we have a vital role to play in ensuring people have the right knowledge, skills and support when they need it. This will enable people to develop the skills and confidence to live as independently as possible and to live well despite their long term conditions. During the development of Scotland’s Self Management Strategy, the Health and Social Care Alliance (THE ALLIANCE), together with people living with long term conditions identified key stages when people said they needed more support to continue to self manage. The key stages are:

1. On diagnosis of a long term condition

2. Living for today

3. Progression

4. Transitions

5. End of Life

Please go and take a look at the Scotland’s Self Management Strategy entitled ‘Gaun Yersel’ which can be found at www.alliance-scotland.org.uk/wp-content/uploads/2017/11/ALLIANCE-SM-Gaun-Yersel-Strategy-2008.pdf

Most people will say they self manage to varying degrees. For some this may be in the form of managing complex medication regimens, for others this may involve using highly technical skills and equipment. As a result people need different levels of support at different times to help them to self-manage their own conditions.

There are some excellent resources on Self Management and Co Production available at: https://www.alliance-scotland.org.uk/self-management-and-co-production-hub/ Take a look and watch some of the very helpful videos.

In 2011, The Health Foundation published “Helping People help themselves” which looks at the evidence around self management.

The Key Points from this document are:

Evidence suggests that supporting self-management works. Supporting people to look after themselves can improve their motivation, the extent to which they eat well and exercise, as well as improving their symptoms and clinical outcomes.

Although many initiatives and different types of support are available, some are more useful than others. To encourage people to engage in self management activities the provision of information alone is unlikely to be enough to motivate behaviour change – more self-management approaches are necessary.

So, how do we know that people understand the health related information or instruction of techniques we provide to facilitate self management? There is an approach called Teach-Back. Its very simple and quick. After providing information about their condition or demonstrating a technique, all you have to do is ask the person to explain back in their own words what they have just heard or seen in order to demonstrate their understanding. If the person is unable to explain or describe the technique or information, then we should re-educate the person using different words until the person can show they understand. This is not a test for the patient, so asking the person to explain back what they have just heard should be done in a relaxed and friendly manner, avoiding technical jargon. Teach-Back has been shown to be a very useful technique to promote understanding and facilitate self management. It is a technique related to health literacy – for more about health literacy, look at the previous post on this blog site on Sensory Changes and Frailty.

For more information about teach-back go to http://teachbacktraining.org/home

Sensory Changes and Frailty

As we age, our sensory systems gradually start to decline. For more information about the ways in which our senses are affected by age the following article from MedlinePlus Medical Encyclopaedia, called Ageing Changes in the Senses is a useful summary which you can access HERE

To understand the scale of the problem consider firstly the number of older people who wear glasses or contacts who are over 55. It’s also worth noting that it is estimated that 945,000 people in Scotland are deaf or have hearing loss and that more than 500,000 people in Scotland have a form of tinnitus.

Sensory impairment has been shown to have psychological, psychosocial,
and functional effects that may lead to social isolation, anxiety, depression, paranoia, and decreased self-esteem.

Dual sensory loss (DSL), the presence of both hearing loss and vision loss is particularly prevalent among ageing populations across the world with studies showing that more than 20% of adults older than 70 years are affected with that percentage increasing with advancing age. The interaction between the variety of visual losses and the variation in types of hearing loss means that there is a wide variation in each individuals needs. This makes it difficult for community staff who have very little cross disciplinary training to meet every need they encounter even though they are meeting older people with multiple sensory impairments every day.

However DSL also affects the ability of older people to perform Instrumental Activities of Daily Living (IADL’s). So although problems with dressing and bathing may occur using a ‘phone or grocery shopping, preparing meals, managing housework and money are far more likely problems and will limit the ability of frail older people to remain at home. The likelihood of identifying and intervening when such problems exist is not helped by older adults themselves, who tend to overestimate their capabilities. Not only are AIDL’s affected, frail older people with sensory impairments also experience poorer overall mobility and the more severe the loss the more likely functional and cognitive decline will occur.

What Can You Do?

The Importance of Hearing Aids. One of the most important things you can do is encourage the use of hearing aids. Kochkin and Rogin (2000) in a study conducted for the US National Council on Aging showed that individuals with hearing impairment who did not use hearing aids participated in statistically significantly fewer social activities and reported statistically significantly more anxiety, depression, emotional instability, and paranoia than individuals who used hearing aids.

However there is a huge stigma surrounding hearing impairment that generally manifests as a reluctance to acquire hearing aids or to participate in any other types of aural rehabilitation.

Consider the Persons Manual Dexterity? With advancing age comes diminished manual dexterity. This has direct effects on several aspects of
hearing aid use and aural rehabilitation, with the most obvious being hearing aid insertion, manipulation of the hearing aid controls, and handling of the battery. There is a strong association between poor manual dexterity and poorer hearing aid outcomes, like less daily use, and lower satisfaction with hearing aids. A study by Parving and Philip (1991) reported that 40% of hearing aid users by the time they were 90 could not use the
volume control wheel, 36% could not change the hearing aid battery, and 34% could not clean the hearing aid ear mould.

Consider the Person’s Health Literacy. DSL is also known to limit a person’s ability to understand and recall the information provided and to successfully integrate self-care into their daily life. It has
been shown that generally older people have the lowest health literacy and
related adverse health outcomes than younger people. Therefore, communication needs to be optimized to accommodate the sensory needs of older individuals to the extent possible.

  • To ensure this the environment needs to be optimized.
  • You need to speak clearly and make efforts to clearly enunciate and to increase the time between spoken words, decreasing your rate of speech.
  • Provide clear written materials. Remember literacy level and pitch to a reading age around 12. Written material should be 14 points and have wide spaces between the lines. A sans serif font should be used and multiple columns on a page should be avoided.

A more extensive guide with videos on how to communicate with someone with hearing loss can be found HERE

Provide/Use Assistive Devices. Like hearing loops, magnifiers with lights, video magnifiers, tactile devices (like vibrating alarm clocks, door bells etc). Whatever you think might help the person. See: https://www.hearinglink.org/living/loops-equipment/ and https://shop.rnib.org.uk/

Provide Redundancy. When delivering information use multiple perceptual channels (visual, auditory, and tactile). This increases the person’s opportunity to all information provided. Supplement anything you say with written materials which can be verbally repeated by carers, relatives etc. If you use low or high technology always buy/use technology with built in redundancy. The reason for doing this is that the circumstances of the person the assistive technology/device will change. As a result, you never know when you might need more functions/capabilities to be switched on.

Use Patient Teach-back. A useful method for verifying that the information you want the person to understand is understood to get the person to repeat back in his or her own words what was said or demonstrate the procedure you are trying to get them to learn/understand indicated by the provider. This way you can check the communication is understood and correct any misunderstandings. See http://scottishhealthcouncil.org/patient__public_participation/participation_toolkit/teach-back.aspx#.Xhu9_sj7TIU

Further Information

See: Royal National Institute for the Blind Services page https://www.rnib.org.uk/services-we-offer-advice-professionals-health-professionals/services-patients

and Action on Hearing Loss’s Guidance for Nurses. https://www.actiononhearingloss.org.uk/how-we-help/health-and-social-care-professionals/guidance-for-nurses/

Living Well with Frailty

On the first day of teaching we looked at defining frailty and how you would recognise and screen people for it. What we didn’t discuss was why this is important. To make the effort worthwhile we need to know if frailty is amenable to prevention and treatment. The answer is YES.

Reducing the Likelihood of Frailty

So what can we do to reduce people’s chances of becoming frail? We know that “healthy ageing” reduces the risk of developing frailty. Healthy ageing involves ensuring

  • Good nutrition
  • That you don’t take too much alcohol
  • That you stay physically active
  • That you prevent obesity
  • That you remain engaged in your local community/ avoiding loneliness.
  • That Influenza and pneumococcal pneumonia vaccination is taken up by those identified “at risk”.

NHS England, in partnership with Age UK, Public Health England, and the Chief Fire Officer’s Association and older people themselves, have published “A Practical Guide to Healthy Ageing“. The guide is designed to help people to stay physically and mentally well by providing hints and tips on how to keep fit and independent. It recognises that there is always something that can be done to improve our own health and wellbeing. You can access the guide by clicking HERE

On the same page you will also find “Practical Guide to Healthy Caring“. This guide provides information and advice to carers about staying healthy and identifies the support available to help carers maintain their health and well-being.

What About People With Established Frailty?

The adverse effects of frailty can be mitigated by for example by:

  • Vision and hearing assessment and referral
  • Reducing people’s falls risk
  • Timely medication review can reduce risk of adverse drug reactions, drug interactions and non-compliance.
  • Strength and balance training
  • Assessment of home hazards and then interventions to reduce these
  • Using assistive technology as part of a menu of options in place to help people to effectively self-manage their long-term condition

(NICE, 2019)

A more detailed list of interventions that can be used by both commissioning groups and providers can be found in the NHS England Document “Compassionate care for frail older people using an integrated care pathway” which you can download from

https://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf

The interventions list starts on page 17 of the booklet and finishes on page 21.

You could also look at the information available from NICE onImproving Care and Support for People with Frailty” Click on THIS LINK to view.

Frailty Focus is a test campaign commissioned by NHS North Hampshire Clinical Commissioning Group which has a website for tackling frailty in their local area. There are areas of the website for healthcare professionals, the general public and carers/volunteers all aimed at enabling more of the local population to age well while planning ahead, discussing what matters most and ensuring they get the right care and support now, and into the future.

The Frailty Focus introductory video is below

This is the link to the projects main web page which you should explore and use with your own team

http://www.frailtyfocus.nhs.uk/