Exercise and Frailty

Something you might want to try: Assessing strength and balance.

We know that physical activity can help people to maintain their functionality, independence, and quality of life, preventing and delaying some of the diseases which affect people as they age. The illnesses affected range from osteoporosis to cardiovascular disease and cognitive decline, as well as the syndromes which together can be described as frailty. Kidd, Mold, Jones et al, (2019) go further stating that physical activity interventions are the key to maintaining independence in pre-frail and frail older adults.

Older people tend to become less active – with 47% of people aged 75-84 being inactive, and 70% of those over 85 years. Over half of all inactive people across the UK are aged 55 and over.

Increasing physical activity has the potential to improve strength, decrease the risk of reduced bone mass, improve balance and overall fitness. Activity can also be an important way of reducing isolation and increasing well-being for older people. Improving strength and balance is particularly important to reduce falls, which are a common injury for older people and may lead to people no longer living independently at home. For advice about Falls Prevention from NHS Education for Scotland (NES) CLICK HERE

Evidence from NIHR suggests that a range of approaches may be effective in promoting exercise in older people, including both supervised exercise, from walking groups to dance classes, and behavioural approaches such as motivational counselling and tailored activity plans. They suggest that older people are more likely to keep exercising with group classes in a centre than through home-based activity. NIHR also suggest that there is a need for interventions that combine supervised exercise opportunities with an understanding of behavioural change principles as these are the most effective in increasing activity over time.

Increasing inactivity is also more likely in certain groups including women, smokers and those with a longstanding illness, depressive symptoms, arthritis, those who were obese, those with lower starting fitness or have weaker social networks. This suggests a need for more tailored approaches to get those people active. More effort also needs to be directed at these groups as they are the most likely to benefit and least likely to take part.

What Can You do to Promote Increased Activity

Firstly, you have to an awareness of what is available so the first issue to consider is “Are physically active social and group-based opportunities available for older people in your locality? If they are where are they and how do you refer people to go?

Secondly, this is a link to the Age Concern site “Being active as you get older” On the site is a lot of advice and links to other Age Concern resources that are designed to encourage older people to find the best way to keep their bodies moving. You will also find a resource designed for older people with one or more long term conditions called “We are Undefeatable” which is a good place to start. Note that if you follow that link you will also find Age Concern’s Falls Prevention advice.

Finally make use of the following acronym when promoting activity and reducing inactivity. F.I.T.T. This stands for start gently and build up your Frequency (the number of times per week you exercise) or Intensity (how hard you exercise) or Time (go for longer) or Type of exercise (e.g. build up from slow walking to brisk walking). Remember that the target is to get the person to be more active so any increase in activity no matter how it is achieved will be beneficial.

To help, here is something to try. It might not be useful for many people that you would identify as frail but anyone in a Pre-frail group may benefit from using this App. Its called iPrescribe and it creates a 12-week exercise plan based on health information entered by the user. It then sets the duration and intensity of the exercise based on this information. See https://www.nhs.uk/apps-library/iprescribe-exercise/

Some additional reading:

Academy of the Royal Medical Colleges (2015) Exercise: The miracle cure and the role of the doctor in promoting it. Available at: http://www.aomrc.org.uk/wp-content/uploads/2016/05/Exercise_the_Miracle_Cure_0215.pdf

Kidd, T., Mold, F., Jones, C. et al. (2019) What are the most effective interventions to improve physical performance in pre-frail and frail adults? A systematic review of randomised control trials. BMC Geriatrics, 19, 184 doi:10.1186/s12877-019-1196-x

The Value of Social Support

In class yesterday we looked at the value of social support and the damaging effect of loneliness even without the addition of frailty. Social support is the perception and actuality that one is cared for and has assistance available from other people. It requires you to be part of a social network. These supportive resources include

Appraisal support: Information that is useful for self-evaluation; like what should I wear? Should I buy this?

Informational support:  Advice, suggestions, and information

Instrumental support: Tangible aid, for example lending or giving you money, help if you broke your leg, or a service like babysitting for you.

Emotional support: Expressions of empathy, love, trust and caring

Social support can be measured as the perception that one has assistance available, the actual received assistance, or the degree to which a person is integrated into a social network and/or their local community. Support can come from many sources, such as family, friends, pets, neighbours, co-workers or via external organisations.

Below is the Sway that we discussed in class which focuses on tackling loneliness

The BBC Scotland Documentary that was mentioned during the day was called the “Age of Loneliness” and was made in 2016. Its not currently available on the BBC iPlayer but there are many clips from it scattered across the internet. This is the director Sue Bourne discussing making it.

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/

More about the eFI

In session one we introduced the electronic Frailty Index (eFI) indicating that it could be more widely used as a means of alerting community staff to people who are already frail or maybe at risk of becoming frail. Not a lot of detail was given about the method used ‘behind the scene’ that make it valuable, this short blog aims to explain more about what it does.

The electronic frailty index (eFI) itself is a clinically validated tool that can identify people with frailty on a population basis using routinely collected primary care data. The eFI, which uses a cumulative deficit model for frailty. The Cumulative Deficit model assumes that an accumulation of deficits (ranging from symptoms e.g. loss of hearing or low mood, through clinical signs of illness as tremor, through to various diseases such as dementia) which primarily occur as you age combine to increase the likelihood of you becoming frail. Becoming frail increases the risk of an adverse outcome.

The team who proposed this model, led by Rockwood at Dalhousie University in Canada used it to develop a Clinical Frailty Scale which was used in a very large Canadian Study of Health and Aging (CSHA) as a way to summarise the overall level of fitness or frailty of an older adult after they had been evaluated by an experienced clinician.

Rockwood et al (2005) proposed that their clinical frailty scale (CFS) should be used after a comprehensive assessment of an older person had been carried out. They suggested this to validate that the scores given using the scale matched what was seen in clinical clinical practice. 

Although introduced as a means of summarising a multidimensional assessment the CFS quickly evolved for clinical use, and has been widely taken up as a judgement-based tool to screen for frailty and to broadly stratify degrees of fitness and frailty. It is not a questionnaire, but a way to summarise information from a clinical encounter with an older person, in a context in which it is useful to screen for. It roughly quantifies the person’s overall health status. To find out more about the tool CLICK HERE

The electronic frailty index (eFI) uses a similar method to the CFS to segment the population into 4 categories; fit, mild, moderate and severe frailty. You can find a table that shows the on pages 2 and 3 of this document https://ihub.scot/media/6106/frailty-and-the-electronic-frailty-index.pdf

Being able to access the eFI and the data it creates for a GP’s population though is not something many of you can do currently so please remember that the simple screens for frailty introduced on the first day, that is the PRISMA 7 questionnaire and TUG. Remember using both prevents many false positives for frailty arising. They are both simple and quick to do.

What might alert you to Frailty? This list from Southern Health NHS Foundation Trust in England might help. They recommend screening in the event of

  • Falls
  • Sudden change in mobility
  • Delirium (acute confusion or suddenly worsening confusion)
  • Sudden change in continence
  • Reported side effects from medication

Coaching and Education-Session 1

The day started with introductions and establishing the ground rules for each session. Working in groups is like one to one clinical work, establishing good relationships and trust are the fundamentals of working well and moving learning and action, so focus is placed on “checking in” and setting the ways of working together.

A short film from Age UK on frailty was shown and then a discussion took place about what the film had brought up, what was recognisable and what was new. The group then split into pairs to do an exercise exploring our own experience of frailty. This had a two fold purpose, one to help us to understand our own experience and how these relate to learning and the second aspect of the exercise was to continually listen and not speak whist the other person was telling their story. Listening is an essential skill in coaching development. Although we spend our lives listening, how much do we truly listen; do we listen to hear or listen to respond? The focus here was on really listening and not talking in response, just encouraging. Each person took 10 minutes doing this. The group then discussed how this exercise made them feel and why it was important to listen. What people shared was that it was harder than they imagined to just listen and not interject with their own story or give advice. They also noticed how good it was to be really listened to questioning how often does that happen? Audrey suggested that if all they took away was how to really listen this will have made a difference to everyone.

We then went on to do an exercise in pairs discussing what matters to you rather than asking what’s wrong with you. Audrey shared the video on Don Berwick discussing where the campaign came from and the important shift in care and support that happens when we approach a therapeutic relationship with “what matters to you”. The exercise helped people experience that for themselves and start to look at how that will be different for each individual.

At the end of lunch the group participated in a mindfulness session. Audrey explained that offering mindfulness was about helping people develop tools for resilience which help everyone involved in the care relationship. Also mindfulness is not a relaxation technique but rather an awareness skill which the group will build on over the sessions but the sessions will be entirely voluntary to take part in.

In the afternoon the Frailty Matters Blog was introduced and since you are on it to read this you should know its at: http://frailtymatters.uws.uk

All the information on frailty covered in the programme will posted on this Blog. A new post will be made every fortnight for the duration of this phase of this project. You are encouraged to revisit the Blog and comment on any aspect of it. Suggestions for improvements, more information etc. are welcome this resource is designed to help you with all aspects of the programme.

Each participant was given a notebook for reflection to be used in whatever way is comfortable to them. This is each participants reflective book and participants won’t be asked to share it.

Each person was given a have a postcard that you have completed about what you would like to get out of these sessions. People in the main want to learn about frailty and how to work with it. Participants gave feedback at the end of the session and were asked to reflect on  what they would like covered in these sessions. Prevention was mentioned as important and the group was asked to bring further suggestions to the next session.   

Introducing Frailty

The definition of Frailty that we will use in this programme was introduced to you all on the first day. For us frailty is not an illness but a syndrome that combines the effects of natural ageing with the outcomes of multiple long-term conditions, a loss of fitness and reserves (Lyndon, 2014).

Older people who are living with frailty often say they have fatigue unintended weight loss, diminished strength and their ability to recover from illness or injury, even minor ones is greatly reduced. This can have a marked impact on the quality and length of their lives (RCN, 2019)

We also took sometime to look at this video from Age UK

https://youtu.be/_pEMrqOANzA

In this video older people talk about their desire to remain independent and in control. For more information on Age UK’s research in this area visit http://bit.ly/2B7toAn

In the afternoon we looked in more detail at identifying and assessing frailty. The presentation that we used and all the information it contains is accessible to you below. The presentation was built using a Microsoft application called SWAY. There are different ways to view Sway presentations and a brief guide to viewing Sway is available HERE.

To view the content scroll down the bar at the side of the object or click the “open to full screen” symbol you will see in the right hand corner where other viewing options are also available. Note that anything that is underlined is an active internet link.

Anything that has a “play” arrow in the middle of the picture is a video.

If you would like to comment on any aspect of the first day or on the blog or resources on it leave a comment below. The comment box is similar to sending an e-mail but your comment may not be available to all the participants at first. They have to be approved by the site editor before they become publicly visible.

Welcome

Thank you for agreeing to take part in our research study. As you are aware the research is being carried out by the University of the West of Scotland,  The Health and Social Care ALLIANCE ( the ALLIANCE) and NHS Ayrshire and Arran. It is funded by the Burdett Trust for Nursing.

The study aims to increase your skills in managing frailty in the community. We plan to create, deliver and evaluate a person-centred intervention with two components: a coaching programme and an educational intervention on effective and personalised care and support for people living with frailty in the community. To find out more CLICK HERE

Throughout the programme you will be able to provide feedback based on your experience of this training and how it is helping you to support other members of your team in managing frail older people. Your views may help other people affected by frailty in the future by helping the research team to understand what are the key issues in the management of  frailty in the community so that we can help others to identify the best ways to address them.

This Blog is going to act as your teaching resource and will be here for you throughout the study. The plan is to place all the teaching resources used in the sessions on this site and also to post additional information and useful materials we find while the project is running. Note that anything that you see on this site that is BLUE is a link to a useful resource.