LTP Priority: Frailty strength and balance
Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service
Type of Interventions: Frailty strength and balance
Major driver of health inequalities in your area of work
Inequalities in distribution of frailty, falls and non-communicable disease – There are clear associations between low socioeconomic status and risk of frailty. Older people who live in socially disadvantaged neighbourhoods and who have low wealth are significantly more likely to be frail than those who live in more advantaged neighbourhoods and have high wealth. Inequalities in frailty are mediated by co-morbidity, which are also strongly associated with deprivation. There are also inequalities by protected characteristics – women are significantly more likely than men to experience frailty and frailty fractures. There is a strong geographic component to risk of frailty fractures, with over 50s in the south-west and north-east of England displaying higher incidence of frailty fractures. The relationship between ethnicity, frailty, falls and fractures is complex. Evidence indicates frailty is associated with non-white ethnic origin. However, white women are most at risk of frailty fractures. Due to complexity in patterns of inequalities associated with frailty, it is recommended that programmes are tailored to the need demonstrated in their local populations and that efforts to engage population groups address these inequalities.
Deprivation and protected characteristics
Older people, and as highlighted above, there are inequalities in relation to gender and ethnicity as well as geography.
Strength and Balance Programme
The 4 strands of this proposed programme are: 1. Raising awareness of the importance of strength and balance exercises among both health and care professionals and older people – developing parity with aerobic exercise and physical activity; 2. Identifying frailty in primary care – the British Geriatrics Society has produced Fit for Frailty guidance to support assessment of older people for the presence of frailty, including assessment of strength and balance. NHS Rightcare Published extensive guidance and support tools for frailty identification and intervention in June 2019 NHS commissioners should use this guidance to promote identification of frailty by primary care practitioners. 3. Multidisciplinary Team (MDT) assessment – individuals identified as at risk of frailty should be referred for multi-disciplinary assessment. This team may also review and assess broader clinical needs, e.g. cognitive impairment, gait disorder, sensory loss, polypharmacy. Each patient would have an average of 2 MDT meetings per year. NHS commissioners should commission a service which supports MDT assessment of individuals identified as at risk of frailty in line with the National Ageing Well Programme. 4. Provision of an evidence based strength and balance interventions – NHS commissioners should commission an evidence based strength and balance interventions with MDT oversight. Specific interventions include Otago, FaME and Tai Chi. Interventions should be structured to meet differing strength and balance needs – e.g. individuals living in the community with a low to moderate risk of fracture, individuals at high risk of fracture, very frail older adults. Self-referral should be considered and may be linked to awareness raising. To address health inequalities it will be important to enagage those adults at highest risk in both awareness raising and in formal Strength and Balance programmes. Outcomes – the key outcome of a S&B programme is reducing the proportion of over-65s living with mild or moderate frailty by 1-% over the next 10 years. Additional outcomes include reductions in falls – this has been demonstrated with the Otago programmes, FaME programmes and Tai Chi programmes. Other outcomes include improvements in functional ability, wellbeing, objective measures of strength and management of long-term conditions. These programmes are also anticipated to impact positively on mental wellbeing and ‘fear of falling’. Cost-effectiveness – FaME, Otago and Tai Chi programmes have all found to be cost effective in improving strength and balance in frail older people.
The evidence listed below highlights return on investment for falls prevention, and strength and balance activities for older people. The ROI document outlines the evidence in relation to specific programmes including Otage, FaME and Tai Chi. The above intervention builds on this evidence by proposing a comprehensive strength and balance programme.
Guidance for Commissioners
- Interventions should be overseen and delivered through clinically led Multi-Disciplinary Teams (MDTs) at community level.
- The MDTs would link the programme to existing falls prevention programmes and MDTs delivering broader ambitions in relation to integrated care for older people, as part of primary care networks.
- In relation to this programme, MDTs could comprise:
- Occupational therapists,
- Fracture liaison nurses
- Specialist exercise instructors
- Other professionals as appropriate from existing local falls prevention services (including local Home Assessment and Modification programmes)
- The composition of these MDTs would depend on the risk group they were working with. Those reaching moderately frail older adults would likely require greater clinical oversight by the nurse / primary care lead.
NHS RightCare guidance and support tools for frailty identification and intervention, June 2019
Additional commissioning support is available in the PHE Falls and Fracture consensus statement documentation