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


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The COTSS - Older people Conference keynote presentation by Dr Dawn Skelton PhD Reader in Ageing and Health, HealthQWest, Glasgow Caledonian University coordinator of Prevention of Falls Network Europe Chair, Organising Committee, and World Congress on Active Ageing 2012. COT Annual Conference 2010 (22-25 June 2010)

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  • Ratio of rate ratios
  • Ratio of rate ratios
  • Implementing programmes to encourage active healthy lifestyles in older people - the role of the OT

    1. 1. Dr Dawn Skelton PhD Reader in Ageing and Health, HealthQWest, Glasgow Caledonian University Co-ordinator of Prevention of Falls Network Europe Chair, Organising Committee, World Congress on Active Ageing 2012 Implementing programmes to encourage active healthy lifestyles in older people - the role of the OT
    2. 2. Why active ageing? <ul><li>Many older people are dissatisfied, depressed and socially isolated </li></ul><ul><li>40% of older people attending GP surgeries, and 60% of those living in residential institutions have ‘poor mental health’. </li></ul><ul><li>Five key factors: </li></ul><ul><ul><li>discrimination (for example, by age or culture) </li></ul></ul><ul><ul><li>participation in meaningful activity </li></ul></ul><ul><ul><li>relationships </li></ul></ul><ul><ul><li>physical health (including physical capability to undertake everyday tasks) and </li></ul></ul><ul><ul><li>poverty </li></ul></ul>Nice 16: 2008; Allen 2008; UK Inquiry into Mental Health and Well-being in Later Life 2006
    3. 3. 3 Dimensions of Human Frailty TIME DISEASE DISUSE HUMAN FRAILTY Spirduso, 1995
    4. 4. <ul><li>1-2% in functional ability p.a. </li></ul><ul><ul><li>Strength </li></ul></ul><ul><ul><li>Power </li></ul></ul><ul><ul><li>Bone density </li></ul></ul><ul><ul><li>Flexibility </li></ul></ul><ul><ul><li>Endurance </li></ul></ul><ul><ul><li>Balance and co-ordination </li></ul></ul><ul><ul><li>Mobility and transfer skills </li></ul></ul>Ageing affects us all, and earlier than you think! Sedentary behaviour accelerates the loss of performance...
    5. 5. A Vicious cycle of Inactivity Physical deterioration - Heart disease - High blood pressure - Aches and pains - Osteoporosis Further decrease in physical activity <ul><li>Social / psychological </li></ul><ul><li>ageing </li></ul><ul><li>- Feeling ‘old’ </li></ul><ul><li>- ‘Acting’ one’s age </li></ul><ul><li>- Increased stress </li></ul><ul><li>- Anxiety, depression </li></ul><ul><li>Low self-esteem </li></ul><ul><li>Fear of falling </li></ul>Increasing age Less exercise Decreased physical abilities - Increased body fat - Sagging muscles - Decreased energy
    6. 6. Sedentary Behaviour = Active bone and strength loss <ul><li>No standing activity leads to active loss of bone and muscle </li></ul><ul><ul><li>1 wk bed rest  leg strength by ~ 20% </li></ul></ul><ul><ul><li>1 wk bed rest  spine BMD by ~1% </li></ul></ul><ul><li>Sedentary behaviour = worse balance </li></ul><ul><li>Nursing home residents spend 80-90% of their time seated or lying down </li></ul>(Krolner 1983; Tinetti 1988; Skelton 2001; Beyer 2002)
    7. 7. 70 yr old woman, active, strength-trained 70 yr old woman, sedentary (Adapted from Sipilä & Suominen Muscle Nerve 1993;16:294 ) Size difference is equivalent to a 30 year old (L) and an 70 year old (R)
    8. 8. Ageing and Energy
    9. 9. Ageing and Posture/Falls
    10. 10. National Service Framework For Older People 2001 <ul><li>Role of Exercise explicit in 5/8 Standards </li></ul><ul><li>3 Intermediate Care </li></ul><ul><li>5 Stroke </li></ul><ul><li>6 Falls </li></ul><ul><li>7 Mental Health </li></ul><ul><li>8 Promotion of Health and active life in old age </li></ul>
    11. 11. Active Lifestyles <ul><li>>3 hrs per week targeted exercise </li></ul><ul><ul><li>Heart Attack - 3 x less likely </li></ul></ul><ul><ul><li>Osteoporosis - 2 x less likely </li></ul></ul><ul><ul><li>Fall-related injuries - 2 x less likely </li></ul></ul><ul><ul><li>Hip fracture - 2 x less likely </li></ul></ul><ul><li>regular moderate physical activity </li></ul><ul><ul><li>reduces the risk of cardiac death by 20 - 25% among people with established heart disease. </li></ul></ul><ul><ul><li>Reduces risk of high blood pressure, obesity, stroke and diabetes </li></ul></ul><ul><ul><li>Maintains function even in the presence of disease </li></ul></ul>ACSM 2007; CDC 1996,2002; Sesso et al 2000; Nicholl 1994, WHO 1997, NIA 1998.
    12. 12. Benefits of Exercise <ul><li>Psychological </li></ul><ul><ul><li>Anxiety, depression, sleep, fear of falling </li></ul></ul><ul><li>Physiological </li></ul><ul><ul><li>Maintain bone density, ability to perform everyday activities, reduce breathlessness, reduce stiffness and chance of injury </li></ul></ul><ul><li>Psychosocial </li></ul><ul><ul><li>Isolation, social contacts, peer support, playing with grandchildren, using the bath </li></ul></ul><ul><li>Even the very frail </li></ul><ul><ul><li>DVT, constipation, transfer skills </li></ul></ul>
    13. 13. It’s never too late <ul><li>The lower the baseline level of physical activity, the greater the health benefit associated with an increase in physical activity </li></ul><ul><li>(Haskell 1994) </li></ul><ul><li>A 12 week high Intensity Strength Training programme in 90+ year old nursing home residents doubled their leg strength (Fiatarone, 1990) </li></ul>
    14. 14. What’s the difference? <ul><li>Physical Activity </li></ul><ul><ul><li>any bodily movement produced by skeletal muscles that results in energy expenditure . </li></ul></ul><ul><li>Exercise </li></ul><ul><ul><li>planned, structured and repetitive bodily movement undertaken to improve or maintain one or more components of physical fitness. </li></ul></ul><ul><li>Bouchard 1990 </li></ul>Gardening DIY Housework Bowling Walking Cycling Exercise class Sports
    15. 15. How much is enough? <ul><li>Adult population - physical activity of a moderate intensity for half an hour , on at least five days of the week. </li></ul><ul><li>(Department of Health 1999) </li></ul><ul><li>New guidelines for older people….2010 </li></ul><ul><ul><li>Addition of strength and balance guidelines </li></ul></ul><ul><li>(BHF NC PAH 2010) </li></ul><ul><li>Maintenance of Independence – twice/three a week minimum – specific, progressive exercise </li></ul><ul><li>(Consensus) </li></ul><ul><li>But for falls prevention….Don’t forget STRENGTH AND BALANCE… </li></ul>
    16. 16. Wide range of abilities and needs
    17. 17. Training Standards in provision Physiotherapist Postural Stability Instructor Seniors Exercise Instructor Chair Based Exercise Leader Physical Activity Leader Senior Peer Activity Motivator Self Led Activity / Exercise Otago Exercise Instructor
    18. 18. Chair Based Exercise <ul><li>Improvements </li></ul><ul><ul><li>Strength and Power (Fiatarone 1990, 1994; Skelton 1995, 1996) </li></ul></ul><ul><ul><li>Flexibility and Functional Ability (McMurdo 1993; Skelton 1995, 1996) </li></ul></ul><ul><ul><li>Arthritic Pain (Hochberg, 1995) </li></ul></ul><ul><ul><li>Postural Hypotension (Millar, 1999) </li></ul></ul><ul><ul><li>Depression (McMurdo, 1993) </li></ul></ul><ul><ul><li>Rehabilitation following hip fracture (Nicholson, 1997) </li></ul></ul>
    19. 19. <ul><li>Reducing Falls (or injurious falls) </li></ul><ul><li>Reducing known Risk Factors for Falls </li></ul><ul><li>Reducing Fractures ? (or changing the site of fracture) </li></ul><ul><li>Increasing Quality of Life & Social Activities </li></ul><ul><li>Improving bone density </li></ul><ul><li>Reducing Fear </li></ul><ul><li>Reducing Institutionalisation </li></ul>Gardner 2000; Skelton & Dinan 1999; Skelton & Todd, 2005; NICE 2004 Exercise could help fallers in a number of ways
    20. 20. Sherrington et al., JAGS 2008 <ul><li>Effective Exercise </li></ul><ul><ul><li>Community Dwellers (11) </li></ul></ul><ul><ul><li>Sheltered Housing (1) </li></ul></ul><ul><ul><li>Group Based (8) </li></ul></ul><ul><ul><li>Home Based + walking (3) </li></ul></ul><ul><li>Ineffective Exercise </li></ul><ul><ul><li>Community Dwellers (6) </li></ul></ul><ul><ul><li>Sheltered Housing (2) </li></ul></ul><ul><ul><li>Nursing Care (1) </li></ul></ul><ul><ul><li>Visually impaired (1) </li></ul></ul><ul><ul><li>Group Based (7) </li></ul></ul><ul><ul><li>Home Based (5) </li></ul></ul><ul><ul><li>Walking Programmes (2) </li></ul></ul>But not all exercise helps reduce falls
    21. 21. Lessons that last a lifetime
    22. 22. Highly challenging Balance Training <ul><li>Exercise in standing involving: </li></ul><ul><ul><li>movement of the centre of mass </li></ul></ul><ul><ul><li>narrowing of the base of support </li></ul></ul><ul><ul><li>minimising upper limb support </li></ul></ul>24% RR 0.76 (95%CI =0.62 to 0.93) Sherrington et al., JAGS 2008
    23. 23. High Dose <ul><li>50+ hours </li></ul><ul><ul><li>At least 2 hours a week of exercise for at least 6 months </li></ul></ul><ul><ul><li>Home or group-based or a combination of both </li></ul></ul>20% RR 0.80 (95%CI =0.65 to 0.99) Sherrington et al., JAGS 2008
    24. 24. No reduction: RR 0.95 (0.78 to 1.16) No reduction: RR 0.96 (0.80 to 1.16) No reduction: RR 0.91 (0.79 to 1.05) Increased risk: RR 1.20 (1.00 to 1.44) High balance Low dose Walking Low balance Low dose Walking Low balance Low dose No walking Low balance High dose Walking Sherrington et al., JAGS 2008
    25. 25. <ul><li>Greatest effects of exercise on fall rates from interventions including: </li></ul><ul><ul><li>Highly challenging balance training </li></ul></ul><ul><ul><li>High dose </li></ul></ul><ul><ul><li>No walking program </li></ul></ul><ul><li>These 3 factors explained 68% of variance </li></ul>Sherrington et al., JAGS 2008 So what do we need to know?
    26. 26. Commonly found in the UK <ul><li>Otago Home Exercise Programme (OEP) </li></ul><ul><ul><li>1 yr; 3 x p/w; standing strength and balance; graded walking programme; 6 home visits (physiotherapist, nurse) to progress and tailor exercise but otherwise unsupervised </li></ul></ul><ul><ul><li>6 mths; 3 x p/w (1 p/w group, 2 p/w home) exercise instructor </li></ul></ul><ul><li>Falls Management Exercise Programme (FaME) </li></ul><ul><ul><li>9 mths; 3 x p/w (one group, two home); standing strength and balance plus floorwork; specialist exercise instructor to progress and tailor exercise </li></ul></ul>(Campbell 1997; Robertson 2001; Campbell 2005; Liu_Ambrose 2008; Skelton 2005, 2008;) Falls Injuries Cost effective >80s Cost neutral >65s Cognitive Function Falls Quality of Life Bone Mineral Density Change of residence Coping strategies Long lies
    27. 27. OEP Strengthening Exercises <ul><li>5 exercises </li></ul>
    28. 28. OEP Balance Exercises <ul><li>12 exercises </li></ul>
    29. 29. Teaching transfer skills Regaining Floor Coping Skills FaME – Postural Stability Instructor: Avoid long-lies - Crawling, rolling, getting to help, keep moving to avoid complications…. Get back up again….play with grandchildren 
    30. 30. Motivators Barriers <ul><li>Social activities Cost </li></ul><ul><li>Playing with grandchildren Access </li></ul><ul><li>Getting out and about Overprotective carers </li></ul><ul><li>Keeping healthy Health </li></ul><ul><li>Family contact Attitudes/beliefs </li></ul><ul><li>Approval from others Caring committments </li></ul><ul><li>Self confidence Pain / discomfort </li></ul><ul><li>Remaining independent Discrimination </li></ul><ul><li>Weather Weather </li></ul><ul><li>Extrovert Introvert </li></ul><ul><li>Ability to adapt Safety Concerns / Vision </li></ul>
    31. 31. Reducing barriers <ul><li>Walk from Home </li></ul><ul><ul><li>Mary Moffat - 93 </li></ul></ul><ul><ul><li>Referred to a class but unable to travel to the class and unwilling to leave the home </li></ul></ul><ul><ul><li>Loss of confidence and fear of falling </li></ul></ul><ul><ul><li>Isolated and lonely and dependent upon others to get out </li></ul></ul><ul><ul><li>Mentoring with peers / volunteers / rehabilitation assistants </li></ul></ul>
    32. 32. Recommendations for Promoting the Engagement of Older People in Falls Prevention Exercise Yardley L, 2007 <ul><li>Raise awareness in the general population that undertaking specific physical activities has the potential to improve balance and prevent falls </li></ul><ul><li>When offering or publicising interventions, promote benefits which fit with a positive self-identity </li></ul><ul><li>Utilise a variety of forms of social encouragement to engage older people in interventions </li></ul><ul><li>Ensure the intervention is designed to meet the needs, preferences and capabilities of the individual </li></ul><ul><li>Encourage self-management rather than dependence on professionals by giving older people an active role </li></ul><ul><li>Draw on validated methods for promoting and assessing the processes that maintain adherence, especially in the longer-term </li></ul>
    33. 33. What can the OT do? ….with thanks to…. <ul><li>Gayle Kinniburgh 2010: MSc OT student, GCU dissertation </li></ul><ul><ul><li>Systematic review of the role of the OT in engaging older people in leisure activities (community and nursing home) </li></ul></ul><ul><li>NICE 16 Guideline: Oct 2008 </li></ul><ul><li>COT & NAPA 2008: Activity Provision: benchmarking good practice in care homes </li></ul><ul><li>Hurtley et al 2005: The successful activity co-ordinator. Age Concern </li></ul><ul><li>BHF Active – </li></ul>
    34. 34. NICE 16: OT & PA interventions to promote mental wellbeing <ul><li>Guidance for OT’s working with older people in primary care and residential care </li></ul><ul><li>Mental Wellbeing </li></ul><ul><ul><li>life satisfaction, optimism, self-esteem, mastery and feeling in control, having a purpose in life, and a sense of belonging and support </li></ul></ul><ul><li>Recommendations </li></ul><ul><ul><li>Occupational Therapy Interventions </li></ul></ul><ul><ul><li>Physical Activity Interventions </li></ul></ul><ul><ul><li>Walking Schemes </li></ul></ul><ul><ul><li>Training </li></ul></ul>
    35. 35. What actions should OT’s take? <ul><li>Offer regular group and/or individual sessions to encourage older people to identify, construct, rehearse and carry out daily routines and activities to improve their health and wellbeing </li></ul><ul><ul><li>involve older people as experts and partners </li></ul></ul><ul><ul><li>pay particular attention to communication, physical access (and provision of aids), length of session and informality to encourage the exchange of ideas and foster peer support </li></ul></ul><ul><ul><li>take place in a setting and style that best meet the needs of the older person or group </li></ul></ul><ul><ul><li>provide practical solutions to problem areas </li></ul></ul><ul><ul><li>Work particularly with those from ethnic minorities, those in rural areas and those aged over 75 who may be widowed or living alone </li></ul></ul>Nice 16: 2008
    36. 36. OT interventions <ul><li>Well elderly intervention (Clarke et al. 1997) </li></ul><ul><ul><li>RCT (USA) evaluated the efficacy of preventative occupational therapy to reduce health-related decline among urban, multi-ethnic independent-living older adults. </li></ul></ul><ul><ul><li>Health through occupation (regularly performed activities such as grooming, exercising and shopping) </li></ul></ul><ul><ul><li>Cost effective </li></ul></ul><ul><li>Lifestyle matters intervention (Mountain et al. 2006) </li></ul><ul><ul><li>Adapted version of the ‘Well elderly’ intervention to determine its feasibility in a UK setting. </li></ul></ul><ul><ul><li>8 month intervention delivered through a combination of group sessions, individual sessions and visits or outings, giving participants the opportunity to put their ideas into practice. </li></ul></ul>
    37. 37. <ul><li>Increase older people’s knowledge and awareness of where to get reliable information and advice on a broad range of topics & arranging trips and social activities. Topics covered should include: </li></ul><ul><ul><li>meeting or maintaining healthcare needs (for example, eye, hearing and foot care) </li></ul></ul><ul><ul><li>nutrition (for example, healthy eating on a budget) </li></ul></ul><ul><ul><li>personal care (for example, shopping, laundry, keeping warm) </li></ul></ul><ul><ul><li>staying active and increasing daily mobility </li></ul></ul><ul><ul><li>getting information on accessing services and benefits </li></ul></ul><ul><ul><li>home and community safety </li></ul></ul><ul><ul><li>using local transport schemes. </li></ul></ul>What actions should OT’s take? Nice 16: 2008
    38. 38. <ul><li>… Physiotherapists, registered exercise professionals….other health, social care…staff who have the qualifications, skills and experience to deliver exercise programmes appropriate for older people. </li></ul><ul><ul><li>Focus on a range of mixed exercise programmes of moderate intensity </li></ul></ul><ul><ul><li>Strength and resistance exercise </li></ul></ul><ul><ul><li>Toning and stretching exercise </li></ul></ul><ul><ul><li>Reflect preferences of older people </li></ul></ul><ul><li>Encourage attendance at sessions at least once or twice a week </li></ul><ul><li>Unfortunately, did not take into account evidence for balance activities  </li></ul>Physical Activity Recommendations Nice 16: 2008
    39. 39. Walking Schemes <ul><li>… anyone working with older people </li></ul><ul><li>Offer a range of walking schemes of low to moderate intensity with a choice of local routes to suit different abilities </li></ul><ul><li>Promote walking as a way to improve mental wellbeing (but beware fallers!) </li></ul><ul><li>Encourage and support older people to participate fully according to health and mobility needs and personal preference </li></ul>Nice 16: 2008
    40. 40. Training <ul><li>Professional bodies, Skills Councils, NHS training providers… </li></ul><ul><ul><li>Involve OT in the design and development of locally relevant training schemes for those working with older people </li></ul></ul><ul><ul><li>Essential knowledge (and application) of principles and methods of OT and health and wellbeing promotion </li></ul></ul><ul><ul><li>Effective communication (including group facilitation and person-centred approach) </li></ul></ul><ul><ul><li>Foster peer support </li></ul></ul><ul><ul><li>Promotion of activity within daily routines </li></ul></ul>Nice 16: 2008
    41. 41. Confounding factors? <ul><li>Fear of falling, over-exertion or “doing harm” e.g. (Finch et al 1997) </li></ul><ul><li>Ageism amongst health professionals </li></ul><ul><li>Roles / Professional boundaries?? </li></ul><ul><li>Concerns re workforce, liability and safety </li></ul><ul><li>Concept of “gentle exercise” !! </li></ul><ul><li>Transport for the frailest who need “specialist instruction”…. why ignore if no transport? </li></ul><ul><li>A little support goes a long way </li></ul>
    42. 42. Active Ageing Weeks… <ul><li>To provide a national and local profile to celebrate and promote the concept of Active Ageing. </li></ul><ul><li>To provide support for local Active Ageing programmes. </li></ul><ul><li>To stimulate debate and policy on Active Ageing. </li></ul><ul><li>To provide a national and local programme of Active Ageing events and promotions . </li></ul><ul><li>To ensure that older people are included in activities designed to leave a health and physical activity legacy . </li></ul><ul><li>WANT TO GET INVOLVED?: email </li></ul>
    43. 43. Ideas for AA Weeks <ul><li>Mass participation events </li></ul><ul><ul><li>How many people all together or at the same time ? </li></ul></ul><ul><li>Walking your local area, be a guide or share your knowledge </li></ul><ul><li>Open days to gyms, community centres with sessions etc….. </li></ul><ul><li>Mobile library buses bringing people into libraries </li></ul>
    44. 44. Issues in activity provision in Nursing homes… <ul><li>Family tend to try previous favoured activities (problem if unable) </li></ul><ul><li>Access to opportunities (rare) </li></ul><ul><li>Involving spouses and family important </li></ul><ul><li>Staff time to support (rare) </li></ul><ul><li>Staff interest and knowledge (poor) </li></ul><ul><li>Appropriate space and environment </li></ul><ul><li>Structured inflexible routines </li></ul>
    45. 45. Olympage Games – Sheffield 2009 <ul><li>20 Teams competing </li></ul><ul><li>6 events </li></ul><ul><li>Teams of 6 – 8 (participants + carers) </li></ul><ul><li>Unruly supporters in team kit ! </li></ul><ul><li>Medals, certificates and prizes </li></ul><ul><li>Lots of cheating as well ! </li></ul><ul><li>Average age 87! </li></ul>
    46. 47. Key Messages <ul><li>Active Ageing is important and vital for quality of life, physical and mental health </li></ul><ul><li>OT’s can help support and encourage maintenance in an active lifestyle </li></ul><ul><li>OT’s can deliver exercise – if appropriately trained </li></ul>
    47. 48. “ Man does not cease to play because he grows old. Man grows old because he ceases to play” George Bernard Shaw [email_address] Any Questions? Come and join the fun – Glasgow SECC Aug 13-17 th 2012
    48. 49. Other useful sites <ul><li>www. bhfactive .org. uk /older-adults/index.html for useful resources to download including Active Ageing weeks </li></ul><ul><li> for Activity Provision: benchmarking good practice in care homes </li></ul><ul><li>Training Organisations: </li></ul><ul><ul><li> for trained exercise professionals directory and training providers </li></ul></ul><ul><ul><li>www. laterlifetraining .co. uk - Otago, FaME and Chair based exercise training </li></ul></ul><ul><ul><li> - Chair Based exercise training </li></ul></ul><ul><ul><li> - exercise to music </li></ul></ul><ul><ul><li> - one day motivation courses on chair exercise in nursing homes </li></ul></ul>