27 th April 2012 Jackie Riglin Falls Prevention Co-ordinator, Cambridgeshire Community Services Clinical Associate for Falls, Royal College of Physicians Older people’s experiences of therapeutic exercise as part of a falls prevention service

Overview  Background  Results of national questionnaires around therapeutic exercise:-  Learning from older people’s experiences  Implications for practice

Background  Part of national audit programme for falls and bone health  Builds on previous work  Patient focus groups, 2008  Patient experience questionnaire, 2010

Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the “Blue Book ” standards Hip fracture patients Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care Non-hip fragility fracture patients Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention Individuals at high risk of 1st fragility fracture or other injurious falls Older people Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards Stepwise implementation DH Prevention Package 2009

Results of national questionnaires around therapeutic exercise What did older people say?  96% found exercises beneficial  92% satisfied with exercise programme

 ‘I don’t know how to express my gratitude for all the help they have given. They have been wonderful. They have restored my confidence.’  ‘I have never done anything like this before and would not have tried it without the advice and encouragement I was given. I was nervous at first but I gained confidence and got to enjoy it. I slowly noticed the benefits and I looked forward to going each week.’

84% felt reason for referral explained  272 commented on explanations given by HCP and social workers  Role of friends and family also important  ‘family explained it was to help me get mobile again.’  ‘I had friends who went to the local class and they said it had helped and they walked more easily.’

 Health promotion initiatives also mentioned ‘Council open days have advice on many things for senior citizens and we were informed about the falls prevention programme’  Some pro-active in seeking help ‘My husband and I attended a programme several years back, finding it beneficial. Enquired if our GP would refer us again.’

70% had opportunity to raise concerns about an exercise programme  ‘I was concerned about my fragile bones. The physio assured me of the programme’s safety.’  I was assured that if I found the exercises too strenuous or uncomfortable I would be able to rest at any time until I felt I was ready to try again.’

79% felt programme appropriately timed  ‘ Perhaps if my exercise programme had been sooner I may have avoided some of the falls. Just a thought!’  ‘I’ve been falling over and not hurting myself for years I hadn’t realised that other people don’t fall over as much as me! I didn’t know until I was hospitalised recently after a fall that there was help available.’

86% are continuing to exercise  ‘I continue to exercise because my walking is stronger and my morale is higher – not only because of the exercises but my being with other people in the same boat.’  ‘I continue to exercise because it helps me remain functional and independent. I hope to be able to continue attending for years, having seen how the exercises help those older than me.’

1. Many NHS providers are not delivering evidence based interventions for ↓ falls  Only 26% participants used ankle weights  Less than 50% felt exercises were progressed  Only 35% attended a class for >12 weeks  Only 45% supervised at home for > 12 weeks

2. Patients need to be aware of benefits of exercise Most common reasons given by staff for patients declining an exercise programme:-  Don’t feel exercise will help or is necessary  Feel too old to exercise

3. Appropriate training needed for those delivering exercise programmes  Only 54% sites have staff with PSI training  Only 41% sites have staff with Otago training  38% respondents not aware of level of training of those leading classes in community

4. Funding priorities can be a barrier to delivering exercise to ↓ falls  Wide variation in waiting times  1-14 weeks for a home programme  1-26 weeks for a class  Transport difficulties  Cost and availability of equipment  Lack of follow up classes in community

Comments from participants  ‘I feel frustrated about the delay between being referred to the exercise programme and being able to attend. A shorter waiting time might have reduced the risk of me falling and breaking my hip’  ‘Since problem is one’s balance, then assuming one can get to the class by public transport is…shall I say…NOT SENSIBLE’

5. Lack of follow up classes for ↓ falls in community  9% sites had no follow on classes  38% sites had only 1 follow on class  22% had only 2 classes  7% had 5+ classes

Examples of types of exercise being continued with:-  ‘I continued to exercise at home on an ad hoc basis, was not stringent with the exercises but did what was easy.’  ‘I do some exercises from TV called chair aerobics.’  ‘I continue with my tennis elbow and pelvic floor exercises rather than my falls exercises.’

Key messages  Implementation of evidence based exercise interventions by healthcare providers is incomplete and varies widely across different sites  There is lack of long term follow up classes for ↓ falls in the community

Recommendations  Commissioning of an integrated exercise continuum across health and local authority/ voluntary sector  National and local monitoring of quality of training and delivery exercise programmes to ↓ falls