Frail Elderly: The Physiotherapist's Role in Preventing Hospital Admission

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Introduction[edit | edit source]

A frail older person is in a condition that is associated with an increased risk of falls, harm events, institutionalisation, care needs and disability/death[1] Introduction to Frailty. Today, with life expectancy continuing to rise globally, there is an increasing number of frail elderly. The physiotherapist is well placed to screen for frailty and should be aware of the risk factors for frailty. If frailty is suspected referral to other professionals may be required. Frailty can be identified using the Clinical Frailty Scale. Identifying interventions that improve physical outcomes in pre-frail and frail older adults is of vital importance. [2][3]

Introduction to the Physiotherapist's Role[edit | edit source]

Physiotherapists working with frail older people could play a role in promoting healthy ageing. Evidence shows that interventions to promote healthy ageing can be used to the delay the onset of frailty and reduce its adverse outcomes among older people[4]. 

  • It has been suggested that physiotherapists could be stationed within hospital A&E departments to undertake frailty and falls risk screening and make rapid decisions on whether the patient can safely return to their pre-admission destination. Frailty can be identified using the Clinical Frailty Scale.[5][6].
  • The comprehensive geriatric assessment also is a valuable tool for risk of frailty screening.
  • Falls prevention: Critical injuries leading to hospitalisation are more common in people over 65 and often preventable, with falls representing the most frequent and serious type of accident[7] [8]. Falls risk increases with age and physiotherapists need to identify those at risk and provide timely intervention to prevent falls and subsequent injury[9][10].
  • Falls Reduction, in the frail: exercise strength and balance has been shown to have the most effective outcomes in reduction of falls rates. As the majority of people who attend balance programmes relapse into old ways by six months, the physiotherapist should attempt to reinforce and encourage adherence to their home exercise program.

Examples of Physiotherapy Interventions below:

  • Resistance training : A significant component of age-related weakness and frailty is sarcopenia. Sarcopenia increases the risk of frailty and falls and in turn, hospitalization in the older adult population[11]. Resistance training has been suggested as a potential treatment for sarcopenia and its prevention. Resistance training is designed to improve muscular fitness by exercising a muscle or a muscle group against resistance[12]. This could lead to improved function, increased quality of life and reduced likelihood for falls[13]. Resistance training programmes have consistently shown to improve muscle strength and mass in older adults[14][15], however, it is questionable whether this transfers to reducing the risk of falling.
  • Balance Re-education: Balance disorders are very common in frail older adults and are a key cause of falls in this population. They are associated with reduced level of function, as well as an increased risk of disease and death. Most balance disorders comprise of several contributing factors including long-term conditions and medication side effects[16]. See Balance Training, Otago Exercise Programme ,Inoculation Against Falls: Balance Intervention Strategies , Reactive Balance Training.
  • Tai Chi: Tai chi is a newly emerging exercise incorporating breathing, relaxation and slow and gentle movements with strengthening and balance exercises.[17]. See Tai Chi and the Older Person
  • Backward-chaining (see link): Declining muscle function in older adults reduces their ability to rise from the floor following a fall and up to a half of all non-injured fallers are unable to get up[18]. When someone is unable to get up off the floor unassisted, the associated risks are far greater due to the complications that can occur from lying on the floor for an extended period of time – for example, dehydration, hypothermia, pneumonia, pressure sores, unavoidable incontinence and even death[19]. This inability to get up has a poor prognosis in terms of hospitalisation and mortality[19], thus, a long lie is one of the most serious consequences of a fall. It was found that the backward-chaining method significantly enhances ability in rising after an incidental fall (20-40%)[20]. This training falls within the physiotherapists domain.
  • Fear of falling (FOF): The prevalence of FOF in community-dwelling older adults ranges between 12% and 65%[21]. The physiotherapist is in an ideal position to steer the individual towards the route of confrontation and recovery as opposed to activity avoidance and disability[9]. There is high quality evidence from two systematic reviews highlighting the benefits of treatment to improve confidence and reduce fear of falling[22][23]. Recommended interventions include: exercise, including tai chi, and multi-component falls prevention programmes.
  • Multi-Component Falls Prevention Programmes: As most falls are multifactorial in origin, they usually require several interventions[24]. Such interventions typically involve a combination of medication review and optimisation and education, environmental modification and exercise. This type of programme would be delivered by a multidisciplinary team in which the physiotherapist would be a key member.Physiotherapy treatments should combine strengthening, balance, backward chaining, tai chi and confidence building with education, tailored to each individual. Clinic-based group exercise or individual exercise in the home setting is suitable. [25]. For the greatest effect, exercise programmes should include a high level challenge to balance, alongside strength and walking training. Programmes should be performed for at least two hours per week on an ongoing basis.[26]

Benefits of Physical Activity in Frail Older Adults[edit | edit source]

Strength, endurance, balance and bone density is lost at a rate of 10% per decade, while muscle power reduces at around 30% per decade[27]. Sarcopenia is highly prevalent among older adults and has been identified as a risk factor for frailty[28]. Being physically active slows down these physiological changes associated with ageing. Physical activity can also reduce the risk of falls, promote cognitive health and self-management of chronic diseases. It can also slow down the deterioration in ability to perform ADLs and maintain quality of life in older adults[29][30]. A meta-analysis[29] found that exercise is beneficial to improve balance, gait speed and abilities to carry out ADLs in the frail older adult population ,Physical Activity in Older Adults.[31]

Physiotherapists Role in Promoting Physical Activity in Frail Older Adults[edit | edit source]

Due to their training and experience, physiotherapists are in a good position to promote health and well-being of individuals and the community through education on physical activity and exercise prescription[32]. Recently there has been a shift in the general public's health agenda towards the prevention of chronic conditions and enabling the ageing population to stay active and manage conditions in the community. This has required a change in the role of the physiotherapist towards addressing these issues through promotion of physical activity and other lifestyle changes[33]. When encouraging physical activity, physiotherapists should also aim to[34]:

  • Identify fears and barriers to being physically active and provide solutions to overcome these
  • Provide ongoing support and encouragement

Exercises for Frail Older Adults[edit | edit source]

These are the recommended activities and intensity for frail older adults to increase physical activity. These aim to improve general health and well being, as well as reduce the risk of falls and manage chronic lifestyle conditions[27]. Frail older adults should aim to accumulate numerous 5 - 10 minute exercise sessions to achieve the recommended activity guides[35]

Suggested activities:

  • Walking[36]
  • Group exercise classes[27]
  • Adhering to a physiotherapist recommended home exercise program
  • Breaking up time spent sitting with short regular periods of standing or walking[35]

Conclusion[edit | edit source]

With the ageing of the global population the prevalence of frailty will multiply[37]. Subsequently, we need a shift of care from reactive to preventative strategies, focusing on providing early interventions to reduce costly unplanned admissions to hospital[38]. Several guidelines are available, but none specifically detail the physiotherapist's role.

References[edit | edit source]

  1. ↑ GAjOS M, PERkOwSki R, KUjAwSkA A, ANdROSiUk JO, WydRA JO, FiliPSkA K. Physiotherapy methods in prevention of falls in elderly people. Journal of Education Culture and Society. 2016 Jun 28;7(1):92-102.
  2. ↑ Kidd T, Mold F, Jones C, Ream E, Grosvenor W, Sund-Levander M, Tingström P, Carey N. 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. 2019 Dec;19(1):1-1.Available:https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1196-x (accessed 13.11.2022)
  3. ↑ British Geriatrics Society. Fit For Frailty: Part 1: Recognition and management of frailty in individuals in community and outpatient settings. http://www.bgs.org.uk/index.php/fit-for-frailty (accessed 12 Oct 2015)
  4. ↑ Cramm JM, Twisk J, Nieboer AP. Self-management abilities and frailty are important for healthy aging among community-dwelling older people; a cross-sectional study. BMC Geriatrics 2014;14:28. http://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-14-28 (accessed 11 Jan 2016)
  5. ↑ Anaf S, Sheppard LA. Describing physiotherapy interventions in an emergency department setting: an observational pilot study. Accident and emergency nursing 2007; 15:1:34-9
  6. ↑ Arendts G, Fitzhardinge S, Pronk K, Donaldson M, Hutton M, Nagree Y. The impact of early emergency department allied health intervention on admission rates in older people: a non-randomized clinical study. BMC Geriatrics 2012; 12:8
  7. ↑ Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Archives of Internal Medicine 2000; 160; 2717-28
  8. ↑ Age UK. Stop Falling: Start Saving Lives and Money. London: Age UK, 2010.
  9. ↑ 9.0 9.1 CSP. Physiotherapy works: Falls and frailty. http://www.csp.org.uk/professional-union/practice/evidence-base/physiotherapy-works/falls-and-frailty (accessed 8 Jan 2016)
  10. ↑ Perracini MR, Kristensen MT, Cunningham C, Sherrington C. Physiotherapy following fragility fractures. Injury. 2018 Aug 1;49(8):1413-7.
  11. ↑ Sousa AS, Guerra RS, Fonseca I, et al. Sarcopenia and length of hospital stay. Eur J Clin Nutr 2015.
  12. ↑ Azeem K, Al Almeer A. Effect of weight training programme on body composition, muscular endurance, and muscular strength of males. Annals of Biological Research 2013; 4; 154-6
  13. ↑ Burton LA, Sumakadas D. Optimal management of sarcopenia. Clin Interv Aging 2010; 5; 217-28
  14. ↑ Liu CJ, Latham NK. Progressive resistance training for improving physical function in older adults (Cochrane review). Cochrane Database Syst Rev 2009; (3); CD002759
  15. ↑ Seynnes O, Fiatarone Singh MA, Hue O. Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. J Gerontol Ser A-Biol Sci Med Sci 2004; 59A; 503-9
  16. ↑ Rubenstein, LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age and Ageing 2006; 35.
  17. ↑ NHS Choices. A guide to tai chi. http://www.nhs.uk/Livewell/fitness/Pages/taichi.aspx (accessed 8 Jan 2016)
  18. ↑ Skelton D, Dinan SM, Campbell M, et al. Tailored group exercise (Falls Management Exercise – FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34; 636-639
  19. ↑ 19.0 19.1 Tinetti ME, Liu WL, Claus EB, et al. Predictors and prognosis of inability to get up after falls among elderly persons. JAMA 1993; 269; 65-70
  20. ↑ Zak M, Skalska A, Szczerbinska K. Instructional programmes on how to rise unassisted effectively after sustaining an incidental fall, designed specifically for the elderly: a randomized, controlled trial. Ortop Traumatol Rehabil 2008; 10; 496-507
  21. ↑ Legters K. Fear of falling. Phys Ther 2002; 82; 264-272
  22. ↑ Zijlstra GAR, van Haastregt JCM, van Rossum E. Interventions to reduce fear of falling in community-living older people: a systematic review. J Am Geriatr Soc 2007; 55; 603-15
  23. ↑ Rand D, Miller WC, Yiu J, et al. Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis. Age Ageing 2011; 40; 297-206
  24. ↑ Hausdorff JM, Nelson ME, Kaliton D, et al. Etiology and modification of gait instability in older adults: a randomised controlled trial of exercise. J Appl Phys 2001; 90; 2117-29
  25. ↑ Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community (Cochrane review). Cochrane Database Syst Rev 2012; (2): CD007146
  26. ↑ Sherrington C, Tiedemann A, Fairhall N, et al. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. New South Wales Public Health Bulletin 2011; 22; 78-83
  27. ↑ 27.0 27.1 27.2 The British Heart Foundation National Centre for Physical Activity and Health. Interpreting the UK physical activity guidelines for older adults in transition. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/39/429/index.html (accessed 17 Oct 2015)
  28. ↑ Jansen FM, Prins RG, Etman A, van der Ploeg HP, de Vries SI, van Lenthe FJ, Pierik, FH. Physical Activity in Non-Frail and Frail Older Adults. PLoS One 2015;10:1-15. http://www.ncbi.nlm.nih.gov/pubmed/25910249 (accessed 27 Oct 2015)
  29. ↑ 29.0 29.1 Chou CH, Hwang CL, Wu YT. Effect of Exercise on Physical Function, Daily Living Activities and Quality of Life in the Frail Older Adults: A Meta Analysis. Arch Phys Med Rehabil 2012;93:237-44.http://www.sciencedirect.com/science/article/pii/S0003999311008173 (accessed 16 Oct 2015)
  30. ↑ Weeks LE, Profit S, Campbell B, Graham H, Chircop A, Sheppard-LeMoine D. Participation in Physical Activity: Influences Reported by Seniors in the Community and in Long-Term Care Facilities. Journal of Gerontological Nursing 2008;34:36–43. http://www.healio.com/nursing/journals/jgn/2008-7-34-7/%7Bf65345f8-58ac-4381-a607-f663b5d57d53%7D/participation-in-physical-activity-influences-reported-by-seniors-in-the-community-and-in-long-term-care-facilities (accessed 7 Jan 2016)
  31. ↑ Yau L, Soutter K, Ekegren C, Hill KD, Ashe M, Soh SE. Adherence to Exercise Programs in Community-Dwelling Older Adults Postdischarge for Hip Fracture: A Systematic Review and Meta-analysis. Archives of Physical Medicine and Rehabilitation. 2022 Sep 1;103(9):1827-38.
  32. ↑ Verhagen E, Engbers L. The physical therapist’s role in physical activity promotion. Br J Sports Med 2009;43:99–101. http://bjsm.bmj.com/content/43/2/99.abstract (accessed 28 Oct 2015)
  33. ↑ Spijker J, MacInnes J. Population ageing: the timebomb that isn’t? BMJ 2013;347:1-5. http://www.bmj.com/content/347/bmj.f6598.full.pdf+html (accessed 11 Jan 2016)
  34. ↑ The British Heart Foundation National Centre for Physical Activity and Health. Physical activity interventions for older adults. http://www.bhfactive.org.uk/older-adults-resources-and-publications-item/18/405/index.html (accessed 13 Jan 2016)
  35. ↑ 35.0 35.1 The British Heart Foundation National Centre for Physical Activity and Health. Interpreting the UK physical activity guidelines for frailer older adults. http://www.bhfactive.org.uk/resources-and-publications-item/39/430/index.html (accessed 17 Oct 2015)
  36. ↑ Department of Health. Start active, stay active: report on physical activity in the UK. https://www.gov.uk/government/publications/start-active-stay-active-a-report-on-physical-activity-from-the-four-home-countries-chief-medical-officers (accessed 28 Oct 2015)
  37. ↑ Karunananthan S, Wolfson C, Bergman H, Beland F, Hogan DB. A multidisciplinary systematic literature review on frailty: overview of the methodology used by the Canadian Initiative on Frailty and Aging. BMC Med Res Methodol 2009;9:68.
  38. ↑ Edwards N. Community services - how they can transform care. London: The King's Fund, 2014.








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