Oldham Exercise Falls Prevention Service

Aims

The aim of the Oldham Falls Prevention Exercise programme is to help reduce the reoccurrence of falls by providing safe methods of exercise and advice on how to reduce or prevent falls for people aged 65 years and over who have had 2 or more falls in the past 12 months, or demonstrate abnormalities of gait or balance.

Objectives of the programme relating to the NICE Guidance CG161.

• Ensure the earlier identification of people at high risk of falls and/or further falls (Recommendation 1.1.1 and 1.1.2).
• Increase the number of people at high risk of falling or those who have fallen who receive a multidisciplinary multi–factorial falls assessment and preventive steps (in line with evidence of good practice) taken to prevent further falls (Recommendation 1.1.2).
• Increase the number of people who have fallen, or are at high risk of falls, to remain confident and continue to live independently and without becoming socially isolated. (Recommendation 1.1.9.2).
• Increase the provision of osteoporosis prevention. (Recommendation 1.12.2).

Preventing falls is a priority within the ‘Ageing Well’ theme of the Oldham Health and Wellbeing Strategy. The Council has also published a Joint Strategic Needs Assessment (JSNA) strategy for falls and osteoporosis.

Falls is a significant public health concern for older people following a hip fracture. In Oldham approximately 8,700 people over 65 fall each year. Levels of physical inactivity increases with age. £3.5 million per year is currently spent on hospital admissions in the over 65s from falls and fractures in addition to the costs for ambulances and Accident and Emergency attendances after a fall.

Hip fractures are the most common cause of accidental death in the older population. 50% of hip fracture patients lose their ability to live independently. Participation in physical activity reduces the risk of hip fractures by 50%.

The Oldham Falls Prevention exercise classes has been in operation for over 14 years. Previous to this, service classes were delivered in a hospital setting by the physiotherapy falls prevention team. Classes operated for a 6 week period. Following on from the six week programme there was no opportunity for the exercise to continue in a community setting.  A tailored exercise programme can reduce falls by as much as 54 per cent.

Falls prevention exercise has been proven to be extremely effective in reducing falls. It plays an important role in the falls care pathway, both in terms of primary and secondary prevention and can significantly contribute to reducing the financial burden on the NHS and social care by preventing fractures and avoidable hospital admissions.

Falls destroy confidence, increase isolation and reduce independence, with around 1 in 10 older people who fall become afraid to leave their home in case they fall again. This lead to social isolation and increased inactivity.

Research into ageing and exercise has shown that exercise can increase the stamina of an older person and increase their capacity for independent living by 10-20 years (Aoyagi and Shephard).

In the Joint Strategic Needs Assessment and Strategy Falls and Osteoporosis report, Jon Hobday, Speciality Registrar in Public Health, Public Health Directorate, and NHS Oldham states:

"There is clear evidence that falls programmes can reduce falls and prevent the fear of falling, as well as improve quality of life following falls. In addition there is literature to suggest, and focus group results to confirm, that falls programmes have much wider benefits than this. They have a major impact on mental well-being by reducing isolation, improving independence and reducing depression. The increased independence and confidence gained reduces reliance on carers and families and the exercise sessions can act as carer breaks for several hours at a time".

Oldham Clinical Commissioning Group (CCG) commissioned an integrated falls prevention pathway. This is provided in partnership through a multidisciplinary/inter-agency way of working between Pennine Care NHS Foundation Trust, Oldham Community Leisure and Oldham Age UK.

Following treatment for a fall, older people are offered a multifactorial falls risk assessment to identify and address future risk and individualised intervention aimed at promoting independence and improving physical and psychological function. The pathway addresses the NICE guidance for falls prevention as set out in the aims and objectives above.

Balance impairment and muscle weakness caused by ageing and lack of use are the most prevalent modifiable risk factors for falls. Strength and balance training has been identified as an effective single intervention and as a component in successful multifactorial intervention programmes to reduce subsequent falls. It is important that strength and balance training is undertaken after a multifactorial falls risk assessment has been completed.

Eligible people are offered a supervised one hour group exercise session. This is weekly for a period up to 9 months and is free. The aim of the programme is to prevent falls by improving the gait, balance, co-ordination, muscular strength, flexibility and confidence of those who have had a recent fall or been identified as being at high risk of having a fall. The service is funded by Oldham CCG.

What happens at the classes?

Instructors use a variety of strength, balance, co-ordination, flexibility and chair exercises tailored to the individual’s abilities. There is an emphasis on the education and empowerment of all participants.

The progress of each individual attending the classes is monitored regularly against the initial tests completed by the Physiotherapists. The tests include the Timed Up and Go, fear of falling assessment and the Problem Orientated Assessment of Mobility (POAM). Tests are carried out every three months after starting and at the end of the scheme to monitor progress.

The classes are delivered by qualified postural stability instructors (PSI). This PSI qualification is the first and only, evidence based, accredited and endorsed Level 4 falls prevention qualification available in the UK. All classes are supported with volunteers who help facilitate the sessions.

The Falls Management Exercise (FaME) research exercise classes take place at 7 different venues throughout Oldham to provide:

• 10 classes weekly
• 120 places weekly

The class operates for 45 minutes of exercise and 15 minutes social time. Classes operate for 50 weeks of the year offering each client 39 weeks of exercise. Accessible transport is critical to the success of the project. Suitable transport is offered, arranged and provided free of charge to help facilitate the client’s attendance at the activity. The range of transport options utilised include:

-           Ring and Ride

-           Age UK Oldham adapted buses

-           Approved taxis and volunteer drivers.

Falls awareness events

Falls prevention awareness events take place each year by working with the public, the media, relevant health workers, health improvement, social care, housing and voluntary sector agencies in Oldham. The aim of this health promotion event is to raise awareness of steps that can be undertaken to prevent falls and osteoporosis.

The programme also links with relevant Greater Manchester and regional ageing well, re-ablement/rehabilitation partnerships and also provides training for primary care and other health/social care/housing/care home professionals.

Volunteering Opportunities:

The programme provides volunteering opportunities for 6 volunteers. Volunteers are given appropriate training, support and supervision. Roles for the volunteer include:

• Meet and greet clients.
• Complete registers and note any changes in health.
• Offer refreshments.
• Assist clients from and to the transport.
• Education and information giving.
• Some people, who are signposted to the classes by the falls physiotherapy team decline to take part. This is due to various reasons but it’s often due to anxiety and fear of the unknown. To try to address this we have produced DVD of the scheme which the physiotherapist can show on home visits to encourage new people to take up the service. A video has been developed showcasing the benefits of the scheme for potential participants of the scheme who may need encouragement to join the classes.

The service set out to achieve the following outcomes:

• Help to reduce the incidence of initial and secondary falls and associated fractures and thereby help older people and other groups at risk of falling, to maintain their independence and remain living in their own homes for as long as possible.
• Raise awareness in older people, and other at risk groups, about the steps they can take to prevent falls and osteoporosis including the benefit of increased physical activity.
• Raise awareness amongst a wide range of agencies/organisations in Oldham of actions they can take to help to prevent falls and osteoporosis and to support residents of Oldham who have fallen to maintain their confidence, social participation and ability to live independently.
• A reduced fear of falling and an increase in confidence of people who have experienced falls/are at high risk of falling to maintain their mobility, independent living and social participation.
• Improved: muscle and bone strength; endurance; flexibility; gait; co-ordination and balance (measured for improvement in Tinetti Test (TT) assessment score, POAM and Timed Get Up and Go Test score).
• Enhanced functional skills (Backward chaining and sit to stand).
• Enhanced knowledge of steps they can take to avoid falling.
• Increased confidence and reduced fear of falling (FES1).
• Increased uptake of physical activity following completion of the FaME classes.
• Improved social interaction and participation in social activities leading to a reduction in social isolation.
• Maximisation of independence and ability to remain in own home for as long as possible.

Service user feedback has included:

• “They are helping to keep me more relaxed, and I’m steadier on my feet. I don’t seem to trip over my own feet as often as I did. I have more confidence to walk”.
• “I feel I’m getting benefit from attending the class by the strengthening of muscles”.

Cost Benefit Analysis:

The fiscal benefit of the scheme say’s for every pound spent on the programme it will bring back £3.73 in investment. The cost benefit ratio relates to 12 months of delivery and 12 months of impact.  If it was assumed that clients of an Integrated Care service saw benefits for many months/years after that support ended.

What happens after the initial nine months?

After the programmes finished participants are encouraged to continue exercise and will be given the option to attend falls prevention maintenance classes.

Accessible transport is an integral part of the service which we offer free in the form of Age UK and Ring & Ride adapted buses, volunteer drivers and also taxis. Generally older people have health conditions including arthritis, hip and knee problems which affect mobility. Other health problems such as bowel conditions and incontinence cause concerns about travel. These are issues that cause barriers in accessing transport.

Once someone has had a fall there is a massive impact on their confidence. They are frequently anxious about travelling on public transport, they worry they may have to stand, that the bus ‘jerky’ movement’s may cause them to over balance. Adding to anxiety about falling is that bus drivers sometimes start the bus moving before they have a chance to get a seat which could cause further falls. Without this accessible transport being available many people would not be able to access the service.

The classes are held in seven different venues covering the majority of the Oldham borough. This is to ensure people journey on transport isn’t too long. This offers more flexibility for people to attend. It also assists in enabling some people to make their own way if the venue is local to them. The instructor’s complete additional training for sight impairment, dementia, cerebral vascular accident and Parkinson’s disease. The classes are based on strong partnership working with monthly meeting held with all 3 partners. This enables us to adapt and make changes to service.

Monitoring:

The three evaluation tests completed are in line with the physiotherapy assessments to enable us to monitor the progress of people from start on pathway until the end of programme.

• After the initial nine months, stopping exercise will mean all benefits of attending the scheme could be lost. It is important that a sustainable plan of exercise is in place after the programme is completed.
• Attendance of the scheme sometimes may seem low, but the age and health of the participants will have an effect on this. The oldest people on the scheme have been aged 100 + and many of the participants are aged in their 80’s and 90’s.