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Exercise for older people in the UK: Challenges, opportunities and pathways

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Title: Exercise for older people in the UK: Challenges, opportunities and pathways


1
Exercise for older people in the UK Challenges,
opportunities and pathways
  • Dr Dawn Skelton PhD
  • Reader in Ageing and Health
  • HealthQWest, Glasgow Caledonian University
  • and
  • Scientific Co-ordinator Prevention of Falls
    Network Europe (ProFaNE)
  • University of Manchester

2
  • The challenges we face in the UK (not
    insurmountable)
  • The strength of the evidence (overwhelming )
  • The opportunities we have in the UK ? (many)
  • Example of the pathway of exercise and physical
    activity for an older person with a history of
    falls

Overview of presentation
3
Challenges - An ageing population
  • In the UK
  • 12 million people aged gt 65 yrs
  • 1.5 million people aged gt 85 yrs
  • gt13,000 people aged gt100 yrs

British pensioner Peggy McAlpine marks her 100th
birthday by paragliding off a 760m (2,500ft) peak
in northern Cyprus.
Annual European Home and Leisure Accident
Surveillance Survey (EHLASS) Report UK 2000
4
More Older People Living Longer
2004 4 people working to support 1 retired 16
of people aged gt65 yrs 4 of people aged gt80
yrs 2050 2 people working to support 1
retired 30 of people aged gt65 yrs 11 of people
aged gt80 yrs
5
Healthy, active and successful ageing a
benefit for all
6
Challenges of sedentary behaviour
  • Ageing…..Disuse…..
  • 1-2 in functional ability p.a.
  • Strength
  • Power
  • Bone density
  • Flexibility
  • Endurance
  • Balance and co-ordination
  • Mobility and transfer skills

Sedentary behaviour accelerates the loss of
performance...
7
A Vicious cycle of inactivity
Physical deterioration - Heart disease - High
blood pressure - Aches and pains - Osteoporosis
Increasing age
Further decrease in physical activity
Less exercise
Social / psychological ageing - Feeling old -
Acting ones age - Increased stress - Anxiety,
depression - Low self-esteem
Decreased physical abilities - Increased body
fat - Sagging muscles - Decreased energy
8
  • 40 of people aged 50 or over in the UK are
    sedentary
  • 60-85 are sedentary in ethnic minority groups
  • Between the ages of 45 and 74 the amount of
    people taking enough activity to benefit health
    declines from 1 in 3 to 1 in 7.

Challenges - UK Sedentary Behaviour
9
Benefits of Exercise
  • Psychological
  • Anxiety, depression, sleep, fear of falling
  • Physiological
  • Maintain bone density, ability to perform
    everyday activities, reduce breathlessness,
    reduce stiffness and chance of injury
  • Psychosocial
  • Isolation, social contacts, peer support, playing
    with grandchildren, using the bath
  • Even the very frail
  • DVT, constipation, transfer skills

10
A message for all older people
  • Entering old age
  • (To promote and extend healthy and active life
    and to compress morbidity)
  • Transitional phase
  • (To identify emerging problems ahead of crisis
    and ensure effective responses which will prevent
    crisis and reduce long term dependency)
  • Frail older people
  • (Anticipate and respond to problems and
    recognise.. Interaction of physical, mental and
    social care factors)
  • (The National Service Framework for Older People
    (DOH 2001)

11
Healthy, active and successful ageing a
benefit for all
  • Its never too late

The lower the baseline level of physical
activity, the greater the health benefit
associated with an increase in physical
activity (Haskell 1994) A 12 week high Intensity
Strength Training programme in 90 year old
nursing home residents doubled their leg strength
and improved QoL (Fiatarone, 1990)
12
Evidence of effectiveness
From a critical review of 29 physical activity
interventions
  • Increased activity levels over a longer period of
    time
  • Group/class-based and home-based activity were
    effective
  • Tailored to individual needs
  • Cognitive-behavioural strategies and goal-setting
  • Telephone support and continued contact
  • (King et al, 1998)

13
Healthy, active and successful ageing a
benefit for all
14
Public Health Agenda in UK Supporting Documents
1998 - present
  • Support from Government
  • - Policies
  • - Strategies
  • - Guidelines
  • - Referral Systems
  • - Qualifications

15
  • Research and audit
  • Policy analysis and influencing
  • Networks
  • Based on, but not as well established as USAs
    Ageing Blueprint

National Coalition for Active Ageing
16
Population wide interventions
  • The physical activity enhancing environment
  • Creating a culture of activity as normal
  • Safe places, streets, parks and neighbourhoods
  • The built and natural environment
  • Communications - media images, public awareness
    campaigns and information

17
Promoting physical activity through primary
health care
Physical activity advice/counselling can increase
physical activity.
  • King et al, 1995
  • Riddoch et al, 1998
  • PAL Goldstein et al, 1999
  • Eakin, 2001
  • NICE (2006)

18
Exercise Referral Scheme
  • National Quality Assurance Framework for Exercise
    Referral, 2001
  • Competencies
  • Insurance and liability
  • Streamlining
  • Involving GPs minimally
  • Links to Register of Exercise
    Professionals (REPS)
  • Covers range of patients
  • Low / Medium / High risk

19
National Bodies supporting
  • Register of Exercise Professionals
  • (independent)
  • Skills Active
  • (Government led)
  • Skills for Health
  • (Government led)

20
Educational and Training Standards
Quality Assured Qualification Prerequisite
Criteria Theoretical Practical Vocational ?
Graduate Continuing Professional Development
  • Accredited
  • National
  • Recognised
  • Good Practice
  • Specialist
  • Fit For Purpose

21
THE EXERCISE REGISTER UK
Specialist Exercise Instructor Clinical Exercise
MSc
High Risk
Physically frail housebound/outpatient
Specialist Exercise Instructor Postural
Stability/ Cardiac Rehabilitation etc NVQ4
Patient Populations Medium Risk
Independent with assistance/aids/carer
Advanced Exercise Instructor Exercise
Referral NVQ3
Independent with assistance/aids
Advanced Exercise Instructor Exercise for the
Older Person NVQ3
Special Populations Low Risk
Independently mobile older people
OTAGO Exercise Leader Chair-based Exercise
Leader NVQ2
Exercise Instructor NVQ2
General Populations
Dinan, 1999
22
Best practice how do we do it ?
  • Use of a health educator and extended
    consultation time
  • Agreement of problem areas
  • Goals agreed by both older person and
    professional
  • Identification and recognition of social and
    environmental barriers
  • Tailored action plan
  • Choice and range of accessible local activities
  • Supplementary educational materials
  • Systematic follow-up and support over time
  • (BHF NC 2007)

23
Encouraging high quality services
  • Multi-level services
  • Sustainable
  • Supported by experienced and trained
    professionals
  • Engage and involve the older person
  • Ecological models that recognise multilevel
    components (Whitehead 1999, Sallis et al 1999,
    CDC 2000)

24
The opportunity to make activity choices
  • As we enter old age the baby boomers
  • Previous experiences may be very positive
  • We should make demands upon service providers
  • Exercise and fitness as a growth area
  • Opportunities that avoid stereotypes and offer
    learning, adventure and challenge
  • A large group of people

25
Increasing the Circle of Life
  • The Transitional Phase
  • Those coming into contact with a variety of
    services
  • A downward spiral of inactivity and physical and
    mental decline
  • Over caring ? Services
  • A captured but not captive audience
  • Skills of front line staff critical
  • A priority group - inactivity is life limiting

26
Moving More Often in the Later Years
  • Frailer Older People
  • Increasing frailty and disease e.g. dementia,
    stroke, Parkinsons
  • Intervention dependent upon professional and
    health/care staff
  • Purposeful choices, dignity and autonomy
  • More than therapy and rehab
  • An excluded group

27
Barriers to physical activity
  • Extrinsic barriers - are those that
    relate to the broader physical activity
    environment, the attitudes of others and the
    types of opportunities that are available
  • These barriers are more likely to be influenced
    by those responsible for policy and strategic
    developments.
  • Intrinsic barriers - are those
    that relate to the individuals beliefs, motives
    and experiences concerning physical activity
  • These are most likely to be addressed by those
    who provide counselling, advice, motivation eg.
    a peer mentor, health visitor or GP

(adapted from Finch 1997)
28
Extrinsic barriers
  • Skills and attitudes of others, e.g. exercise
    instructors, GPs, family friends
  • Appropriate programming
  • Accessible opportunities (transport)
  • Safe activity environments (parks, well-lit
    streets)
  • Positive images of older people

29
  • Wanting to play with grandchildren
  • Physiological signs of ageing
  • Retirement, children leaving home
  • Onset of ailment or illness
  • Moving home
  • Bereavement
  • Maintaining independence
  • Peer and Health Professional support
  • (Finch, 1997)

Triggers and life events
30
Active role models
  • Who are the Significant others?
  • Older people are 3 times more likely to change if
    their GP is active
  • They are 5 times more likely if the health
    professional is active
  • Family/peer support?
  • Someone Like Me - Peer mentoring is a successful
    strategy - If (s)he can do it, so can !
  • Others think that I should be doing this

31
  • Community Healthy Activities Model Programme for
    Seniors (CHAMPS)
  • (Stewart et al, 1997, 1999, 2002, 2003, 2005)
  • Those enrolled in CHAMPS twice as likely to take
    part in physical activity
  • Effectiveness based on
  • attention from CHAMPS staff (peer mentors)
  • Belonging to a group
  • Written materials
  • Goal setting / self monitoring
  • Range of activities accessible

Peer Mentoring opportunities
32
Evidence of varied outcomes
  • Sutton in Ashfield, North Nottingham - Activity
    Friends
  • 23 mentors made 4,600 contacts in 12 months
  • Village walking routes established
  • Annual flower planting around village

33
Examples of varied outcomes
  • Kirklees PALs referral programme
  • 70 mentors trained over 3 years
  • Work as buddies meeting, greeting and
    exercising
  • 96 adherence beyond 12 mths
  • Extended to home visiting programme.
  • 1 mentor attracted 240 participants in 12 months

34
Walk with me !
  • Walk from Home Scheme
  • Mary Moffat age 93
  • Referred by physiotherapist after a fall
  • Loss of confidence and fear of falling
  • Isolated and lonely and dependent upon others to
    get out

35
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Assisted walking
  • Walking ( what we were born to do !)
  • Restores function
  • Reduces isolation and re-connects with friends
    and the local community
  • Offers a sense of purpose in later life
  • Mary has returned to independent walking and
    increased her Circle of Life

40
Theory of planned behaviour
Do others (who are important to me) think I
should do this?
Social norms
Attitude to intervention
Perceived control
Could I do this? Should I do this?
Will it make me feel better?
Ajzen (1985)
Working on reducing barriers
41
Breaking down barriers
  • Will it help me feel better?
  • Explain the benefits of exercise are relevant to
    all ages (in fact many of the trials have found
    the older you are, the more likely you will
    benefit).
  • Emphasise the many benefits of exercise
  • A pre-exercise assessment will provide
    individualised recommendations

42
Perceived control
  • Could I or should I do this?
  • Find out the persons goals what would they
    like to improve (balance, mobility, function,
    confidence, independence)
  • Then discuss the benefits of exercise in these
    terms
  • Provide choice over where and how an intervention
    can be delivered
  • Identify those who may require greater levels of
    support to commence a programme

43
Social Norms
  • What do others think?
  • Involve family, friends and even other healthcare
    professionals to support the benefits of exercise
  • Think about training and involving peer activity
    motivator mentors?
  • Starting the programme is one thing continuing
    is another!!
  • If a programme is continued for 6 months, it is
    more likely to be taken up as a longer term
    behaviour (Dischman et al, 1985)
  • Adherence is strongly determined by self-efficacy
    (McAuley et al, 2003)

44
Educational opportunities and an individual
action plan
  • Advice and support
  • Not just about choosing activity, the what, when
    and where
  • How much and what sort
  • The how (lifestyle planning)
  • Planning to go out,
  • create space,
  • anticipate consequences

45
Home based exercise
  • Strength and balance exercises for
    healthy ageing Help The Aged (FREE)
  • Be Strong, Be Steady - Help The Aged
  • - English, Hindi, Urdu and Punjabi
  • Step to the future
  • - Help The Aged
  • - English and Hindi

46
  • Much attention has been given to the need for
    better education of older people ... but it is
    the professionals who are probably in greater
    need of education than the older people.

J. A. Muir Gray Public Health Physician
Ageism has a powerful negative impact on
performance in older people
47
Under-used Referral Pathways Challenges…
  • Physical Activity Specialist - Encourage and
    motivate
  • Local Government based (with evidence) to be
    more active in daily life - Discuss
    local opportunities for appropriate
    physical activity
  • Trained seniors instructor - Supervised exercise
    classes Extend, Chair, BACR, PSI, etc. to
    improve strength, mobility and
    independence - Targeted and tailored (eg.
    Falls prevention, cardiac
    rehabilitation, pulmonary
    rehabilitation, stroke rehabilitation
    )
  • Senior Peer Activity Motivator - Encourage and
    accompany

48
Senior Peer Activity Motivator Course
  • Ongoing development of training resources with
    BHF NCPAH Ageing Well
  • Update of Active for Later Life Resource

49
The exercise pathway of a person with a history
of falls or fractures
50
Fracture Prevention Triangle
Adapted from National Institute for Health, USA
1999
Exercise can increase BMD and alter bone
properties
FRAGILITY
Exercise can increase muscle strength (padding)
and improve reaction times
Exercise can reduce falls
FRACTURE
FORCE
FALLS
51
Exercise to Prevent Falls
  • Exercise could help fallers in a number of ways
  • Reducing Falls (or injurious falls)
  • Reducing known Risk Factors for Falls
  • Reducing Fractures (or changing the site of
    fracture)
  • Increasing Quality of Life Social Activities
  • Reducing Fear
  • Reducing Long Lies
  • Reducing Institutionalisation

52
Reviews of Falls Exercise Evidence
  • 1995 Province MA et al. - J Am Med Assoc.
    2731341-1347.
  • 1999 Skelton Dinan Physio Theory
    Practice 15105-120
  • 2000 - Gardner M et al. - Br J Sports Med. 34
    7-17
  • Not to fit and Not too frail
  • 2001 - Skelton D - Age Ageing 30S4 33-39
  • 2002 Skelton Beyer Scand J Med Sports Sci
    131-9
  • 2004 - Chang et al. Brit Med J 328 680-687
  • Multifactorial trials reduce risk (RR 0.82)
  • Exercise only trials reduce risk (RR 0.86)
  • 2006 Whitney Sherrington In Press

53
Population-based interventions for the prevention
of fall-related injuries in older people
  • McClure et al. 2005 Issue 1. Systematic Review
  • www.thecochranelibrary.com
  • 23 studies identified, 5 met criteria No RCTs
  • All included - promotion of physical activity,
    education, advice, medication use, footwear, home
    hazard reduction
  • Some included town planning, public lighting
    and maintenance
  • Relative reduction in fall-related injuries 6 to
    33

54
Physical Activity and Falls
55
Fear and avoiding activity
  • Present in gt50 of fallers up to 40
    non-fallers
  • Predicts
  • decreases in physical and social activity
  • deterioration in physical functioning
  • higher risk of falling
  • Improves with exercise, as does balance
    confidence and self efficacy

Avoidance of activity
56
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57
When do we become fallers instead of
trippers?
Fracture site changes with age, wrist fractures
more common in younger people, hip fractures more
common in older people
58
  • The NHS, working in partnership with councils,
    takes action to prevent falls and reduce
    resultant fractures or other injuries in their
    populations of older people.
  • Older people who have fallen receive effective
    treatment and rehabilitation and, with their
    carers, receive advice on prevention through a
    specialised falls service.
  • (1) Prevention. (2) Diagnosis management. (3)
    Rehabilitation and longer term care.
  • Key Milestone April 2005

National Service Framework for Older People,
Department of Health, 2001
59
  • Community Dwelling gt80 year old women
  • 1 Year duration - Physiotherapist support
    home-based tailored progressive strength, balance
    and gait training (3x p/w)
  • 20-30 reduction in risk
  • Campbell J et al., BMJ, 1997
  • Then - Physiotherapist led nurse training
  • For over 65s cost effective
  • For over 80s saves money
  • Robertson C et al., BMJ, 2001

Evidence based falls exercise-home
60
FaME Group Exercise managing frequent fallers
Women aged 65 with a history of 3 or more falls
in previous year Group Exercise programme once a
week 2 home exercise sessions 9 months
duration, exercise instructors Falls risk
decreased by half (IRR 0.53)
Skelton et al. Age Ageing, 2005 34 636-639
Evidence based falls exercise-group
61
Interventions that cannot be recommended
  • Brisk walking. There is no evidence that brisk
    walking reduces the risk of falling. One trial
    showed that an unsupervised brisk walking
    programme increased the risk of falling in
    postmenopausal women with an upper limb fracture
    in the previous year. However, there may be other
    benefits of brisk walking by older people.

NICE, 2004
62
No two fallers are the same……
63
Whitney et al. 2006
Not ALL Exercise works to Prevent Falls
64
Trained Provision
  • Physiotherapist

Postural Stability Instructor
Cardiac Rehab. Instructor
  • Seniors Exercise Instructor

Chair Based Exercise Leader
OEP Str. Balance Leader
Walk Leader
Physical Activity Leader
Senior Peer Activity Motivator
Self Led Activity / Exercise
65
REFERRAL
REHABILITATION EDUCATION EXERCISE GROUP
Peer Mentor Support
FaME STRENGTH BALANCE EXERCISE GROUP
CHAIR BASED EXERCISE GROUP
OTAGO HOME EXERCISE PROGRAMME
SENIORS EXERCISE GROUPS
TAI CHI
A Continuum of Falls Exercise Provision
66
Chair Based Leadership Course
  • On National Qualifications Framework (NQF)
    Leadership in Care and Exercise
  • 4 day course including practical assessments and
    theory worksheets on course
  • For social care workers, wardens of residential
    settings, nurses, rehabilitation assistants
  • Seated strength, mobility and endurance work

www.laterlifetraining.co.uk
67
Otago Exercise Programme Leadership Course
  • Leadership NVQ Level 2 unit in Health Care, Level
    3 in Maintaining Independence
  • 4 day course including practical assessments and
    theory worksheets on course
  • For social care workers, wardens of residential
    settings, nurses, rehabilitation assistants
  • Standing strength and balance work evidence
    based

68
Postural Stability Instructor Course
  • Postural Stability Instructor
  • Exercise for Prevention of Falls, Fractures and
    Injuries Course
  • Nationally Validated 6 day course for
    Physiotherapists, Occupational Therapists,
    Seniors Exercise Instructors
  • www.laterlifetraining.co.uk

69
Eg. The Postural Stability Instructor
  • ENTRY REQUIREMENTS
  • Advanced Instructor Qualification in Exercise for
    the Older Person
  • OR
  • Health Professional Qualification
  • PLUS
  • A minimum of 12 months professional contact with
    older adults

www.laterlifetraining.co.uk
Educational and Training Standards
70
EDUCATION AND TRAINING NEEDS
  • THEORETICAL
  • Overview of ageing, physical activity and falls
  • Interdisciplinary, interagency partnerships
  • Multi-factorial causes and nature of falls
  • Prevalences and consequences
  • Risk Factors for falls and fractures

71
EDUCATION AND TRAINING NEEDS
  • also
  • Anatomy physiology - falls and risk management
  • Assessment of health and function
  • Exercise adaptations for frailer older people
  • Further adaptations for people with a history of
    falls
  • Implementation
  • Evaluation

72
EDUCATION AND TRAINING NEEDS
  • PRACTICAL
  • Health and functional assessment workshop
  • Exercise technique workshop
  • Exercise teaching models of practice
  • Teaching technique workshop
  • Exercise adaptation workshop
  • Case study presentation and workshop

73
EVIDENCE BASED TRAINING
  • Dynamic Balance
  • Resistance
  • Functional Movement
  • Gait and Posture
  • Mobility and Flexibility
  • Endurance
  • Floor work - Backward Chaining
  • Tai Chi Cool Down

Skelton Dinan Physiotherapy Theory Practice
J. 1999
74
EDUCATION AND TRAINING NEEDS
  • ASSESSMENT
  • Theory Paper
  • Case Study and Viva
  • Exercise Session Plan
  • Practical Teaching of Falls Exercise Session
  • Self Evaluation of Teaching

75
EDUCATION AND TRAINING NEEDS
  • TUTORS
  • Professional qualifications
  • Teaching qualifications
  • Lecturing in health / exercise
  • Current practical teaching of falls exercise
    sessions
  • Qualified Postural Stability Instructors
  • ASSESSORS
  • Assessor qualifications

76
Encouraging the participation of older people in
falls prevention programmes
  • Individuals at risk of falling, and their carers,
    should be offered information orally and in
    writing about what measures they can take to
    prevent further falls.

NICE, 2004
77
Falls Exercise Service Evidence
  • Average age 82 years (n124)
  • Average attendance 79
  • Improved functional reach Timed up go
  • Improved quality of life
  • Improved confidence
  • Improved timed floor rise
  • Simey, Skelton, Dinan, Land Irwin (BMJ letter,
    2001)

I can walk upstairs now. I havent been able to
walk upstairs for four years. I do my exercises
every day at home. I know its doing me good
78
Man does not cease to play because he grows old.
Man grows old because he ceases to play
George Bernard Shaw
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