ActiveAgeing

Everybody’sInterest,nobody’sresponsibility(?)

BobLaventureChairHEPAEuropeActiveAgeing

WorkingGroupDirectorLaterLifeTraining

Theplan?

• ActiveAgeingasapolicyfocus• Exemplifythroughphysicalactivitypromotion,(generic)andfallsprevention – (specific)

• WithinEUandEngland• Whathelpsandhinderspolicyimplementation

Researchintopractice

Policyinthehandsofpoliticians

“Investtosave”?• Demographicchangewaspredicted• Advantagetoourpoliticalopponents?• Policychangeswithpoliticians- resultinginshort-termism

• Ageingisnowtopical….But

“wearewoefullyunderprepared”forourlongerlivesandourgrowingolderpopulation”.

LordGeoffreyFilkin,(2014)

Policy– whatcounts?Strategy?Guidelines?Frameworks?

Bitof(horrible)history?

• Internationalconsensusandevidence• WHO 1993 - “exercise and lifestyle modification before

drug treatment for mild hypertension” and……..• WHO 1996 “regular physical activity helps to preserve

independent living” and “postpone the age associated declines in balance and co-ordination that are major risk factors for falls”

• US Surgeon General 1996 - “regular physical activity in older adults with chronic illness can potentially reverse loss of mobility”

• American College of Sports Medicine (1998) “Sedentariness appears a far more dangerous condition than physical activity in the very old.”

Describingolderpopulations- (WHO1996)

PhysicallyFit PhysicallyUnfit

PhysicallyUnfitand

FrailHealthy Group1

Unhealthyindependent

Group2

Unhealthydependent

Group3

(WHO 1996 Heidelberg Guidelines on physical activity (60+)

WHOPolicyFocus– ActiveAgeing

Activeageingistheprocessofoptimizingopportunitiesforhealth,participationandsecurityinordertoenhancequalityoflifeaspeopleage.

(WHO2002)

ButActiveAgeing….allthingstoallpeople?

• ActiveAgeing(WHO)– Health– Participation– Security

• Physicalactivity(PHE)– Activity– Moving– Exercise– Sportandrecreation

• Health– Physical– Psychological– Cognitive

• HealthyAgeing– developingand

maintainingthefunctionalabilitythatenableswell-beinginolderage

• Successfulageing– Participating– Volunteering– Contributingtosociety

• Well-being– SCIE– 5waysto…NEF– ICAA….9Pillars

Commentary– supportingpolicy?Physicalactivityandolder

people(65+)• Multipleneeds,target

populations,outcomes• Multipleservices/players• Multipleactivitymodes• (Little)agreementon

effectiveinterventions• Governmentpolicy

flip/flopping?• Leadershipchallenging

Fallsprevention• Strongevidenceofneed

andtargetpopulations• Clarityofevidencebased

interventions• Authoritativeguidance

(NICE,AGSandBGS)• (Sustained?)service

pathways/models• NHSattheforefront

1.EUActiveAgeingPolicyframeworks• EuropeanCharteronCounteractingObesity(2006)

– TheEuropeanFoodandNutritionActionPlan2015-2020– Stepstohealth:aframeworkforactionintheWHOEuropeanRegion'.

(2007)• ContentAnalysisof27EUNationalPolicyDocuments -

Only5includedreferencetoolderpeople65+Daugbjerg etal( 2009),

• ParmaDeclarationonEnvironmentandHealth adoptedbyWHOEuropeanMemberStates- importanceofprovidingsafeenvironmentstoenablephysicalactivity(2010)

• ActiveAgeing(Europe)nowwithintheWHOGlobalactionplanforthepreventionandcontrolofnon-communicablediseases2013–2020

• WHO/EuropecollaborateswithHEPAEurope(EuropeannetworkforthepromotionofHealth-EnhancingPhysicalActivity?)

Priorityarea4– Promotingphysicalactivityamongolderpeople.

• PhysicalactivitystrategyfortheWHOEuropeanRegion2016–2025HEPAActiveAgeingWorkingGroup

• Guidingprinciplesandobjectives• Objective4.1– Improvethequality

ofadviceonphysicalactivitybyhealthprofessionalstoolderpeople

• Objective4.2– Provideinfrastructureandappropriateenvironmentsforphysicalactivityamongolderpeople

• Objective4.3– Involveolderpeopleinsocialphysicalactivity

© Health Promotion and Disease Prevention Directorate, Malta

Physical activity strategy for the WHO European Region

2016–2025

REGIONAL COMMITTEE FOR EUROPE 65TH SESSION

Vilnius, Lithuania, 14–17 September 2015

Working document

OtherEUActivityonActiveAgeing• Actionresearchthrough3yearmulti-siteprogrammes,multipletopics

• 20+differentplatforms• Significantlackofdisseminationofresultsandlessons

• Permanentfeatures– EGREPA,ECSS,EUGMS• Collaborativeactivity- RomeStatement(2016)submittedtoEU– seekingcoordination

2.Falls- policyandimplementationinEurope

• Evidence-WHOHealthEvidenceNetwork(SkeltonandTodd2004)

• NBNomedicalcharityhome/support

• Evidence- Profaneprogramme –2003– 2007

• Policy - WHOGlobalreport2007

Falls– policyandimplementationinEurope

• Disseminationandimplementationofbestpractice- 17EUCountries

• Communitiesofinterest,resourcesandcascadetraining

• Falls,independenceandtechnology

• Policystatement- “Fallspreventioniseveryone’sbusiness”EuropeanStakeholdersAllianceforActiveAgeingthroughFallsPrevention(ESA)JointDeclaration2015

Thematicnetworks

Physicalactivityandageing– beginnings

• EmergingPhysicalActivityandHealthPolicy• (previouslydomainofvoluntarysector,both

ageingandmovementanddance)• 1996ActiveforLifeOlderPeople(1year

campaignremoderate physicalactivitymessage)

• 1997ActiveforLaterLife(1st NationalConference)

• LaunchofADNFSfollowupdataonphysicalfunctionandolderpeople(HEA1999)

3.Fallspreventionpolicy-beginnings.

• DepartmentofHealth(1999)• ProfessionalGuidance- Physical

activityandthepreventionoffallsandaccidents

• Evidencebasedpractice• Professionalneedsanalysis

• DepartmentofTradeandIndustry• Publiceducationcampaign• SlipsTripsandBrokenHips”

Standard 6 Falls• The NHS, working in partnership with councils,

takes action to prevent falls and reduce resultant fractures/other injuries in their populations of older people.

• Older people who have fallen receive effective treatment

• (1) Prevention. • (2) Diagnosis & management. • (3) Rehabilitation and longer term care.

Standard 8 • the promotion of health and active life for

older people

Startingpoint- NationalServiceFramework

(DH2001)

Home based exercise programme

OTAGO

Chair Based Exercise Class

(Community based)

Exercise Referral Scheme

12 weeks

PSI/Rehab based exercise group

12 weeks

Community based classes for older people

OTAGO exercise classes

(Community based)

Falls AssessmentIdentification of a falls problem and screening to determine risk factors

Cambridgeshire Falls Prevention EXERCISE PATHWAY

Motivation Screening Pathway

Independently mobile older people

Independent with assistance/aids

Independent with assistance/aids/carer

Physically frail housebound/outpatient

Exercise Instructor NVQ2

OTAGO Exercise Leader Chair-based Exercise LeaderNVQ2/3

Dinan, 2004

Advanced Exercise InstructorExercise for the Older PersonNVQ3

Advanced Exercise InstructorExercise ReferralNVQ4

Specialist Exercise InstructorPostural StabilityNVQ4

Specialist Exercise InstructorClinical Exercise MSc

General Populations

Special Populations

Low Risk

Patient

Populations

Medium Risk

HighRisk

The UK Register of Exercise Professionals

Reaching the older public, education and information giving

Falls Awareness Week Action pack for event holders

Authoritativesupportfrom

• RoyalSocietyforthePreventionofAccidents• American/BritishGeriatricsSociety• CharteredSocietyofPhysiotherapy• NICEGuidance(2013/15)• RoyalColleges(incl.GPs,Nursing)• NationalOsteoporosisSociety• AmbulanceServicesandother1st responders• ResearchintoAgeing- AgeConcern,AgeUK

Falls– PHEconsensusstatement

• Movingforward- includes• Keyinterventions• Commissioningservices• Commitment- NationalFallsPreventionCoordinationGroup

• Supportedby16memberorganisations

• Tobereviewed2019

Falls and fracture consensus statement Supporting commissioning for prevention Produced by Public Health England with the National Falls Prevention Coordination

Group member organisations

January 2017 To be reviewed January 2019

(PHEJan2017)

Returnoninvestmentofpublichealthinterventions:asystematicreview

“Interventionsaimedatreducingratesoffallsareabletoshowoneoftheswiftestreturnsoninvestmentofanyofthepublichealth interventionsidentified

withinthisstudy”• CBRof20.6returnedwithin18 months.• Fallspreventioninterventions…….arerelativelylowcost(structuredexerciseprogrammes forthoseatriskoffalls),andyettheirpotentialimpactondemandmanagementforhospitalservicesisclearlydemonstrated.

• Shiftinginvestmentfromsecondarycareforthetreatmentoffallstoprimarypreventionwouldshowsignificantandswiftreturnsoninvestment.

MastersR,etalJournalofEpidemiologyandCommunityHealth(2017)

4.Strengtheningphysicalactivitypolicy

• 2000onwards- successionofpolicydocumentsrelatingtoageing

• Physicalactivityandageinglaggingbehind(determinedby PA/sportpolicypriority)

• Demandsforevidencebasedpractice

• AtLeast5aweek– chapter6,OlderAdults(DH2004)

• Enthusiastsandfrontrunners(AgeUK,FootballFoundation)

Leadership,interestandresponsibility?

Health

Localgovernment

Voluntarysector

Strengtheningthecaseforpolicy- ashift?

6Keyelements……butRecommendationson

StrengthBalance

SedentarybehaviourUKCMOPhysicalActivityGuidelinesforOlderAdults

(65+)(DH2011)

Whatisfunctionalfitness?

“FunctionalFitnessperformanceishavingthephysiologicalcapacitytoperformnormaleverydayactivitiessafelyandindependentlywithoutunduefatigue”.

(Rikli @Jones1999)

Greaterpriorityinlaterlife?

Howimportantisit?

“……itislogicalandpossiblysafertosuggestthatolderadultswhosemobilityiscompromisedstartby

increasingtheirstrengthandimprovingtheirbalancebeforeembarkingonaerobic

training”.

WHOWorldReportonAgeingandHealth(Oct2015)

Overall (I-squared = 61.5%, p = 0.000)

Ebrahim, 1997

Barnett, 2003

Woo, Tai Chi, 2007

Luukinen, 2007

Campbell, 2005

Schoenfelder, 2000

Sihvonen, 2004

Lord, 2003

Buchner, 1997

Author,

Nowalk, Tai Chi, 2001

Mulrow, 1994

Day, 2002

Reinsch, 1992

Skelton, 2005

Wolf, Balance, 1996

Woo, Resistance, 2007

Wolf, Tai Chi, 1996

year

McMurdo, 1997

Korpelainen, 2006

Morgan, 2004

Campbell, 1999

Hauer, 2001

Voukelatos, 2007

Faber, Functional walking, 2006

Li, 2005

Lord, 1995

Schnelle, 2003

Steinberg, 2000

Faber, Tai Chi, 2006

Liu-Ambrose, Resistance, 2004

Lin, 2007

Bunout, 2005

Liu-Ambrose, Agility, 2004

Resnick, 2002

Latham, 2003

Madureira, 2007

Carter, 2002

Green, 2002

Toulotte, 2003

Wolf, 2003

Cerny, 1998

Sakamoto, 2006Rubenstein, 2000

Means, 2005

Protas, 2006

Suzuki, 2004

Campbell, 1997

Nowalk, Resist./Endurance, 2001

Robertson, 2001

0.83 (0.75, 0.91)

1.29 (0.90, 1.83)

0.60 (0.36, 0.99)

0.49 (0.24, 0.99)

0.93 (0.80, 1.09)

1.15 (0.82, 1.61)

3.06 (1.61, 5.82)

0.38 (0.17, 0.87)

0.78 (0.62, 0.99)

0.61 (0.40, 0.94)

Effect

0.77 (0.46, 1.28)

1.26 (0.90, 1.76)

0.82 (0.70, 0.97)

1.24 (0.77, 1.98)

0.69 (0.50, 0.96)

0.98 (0.71, 1.34)

0.78 (0.41, 1.48)

0.51 (0.36, 0.72)

size (95% CI)

0.53 (0.28, 0.98)

0.79 (0.59, 1.05)

1.05 (0.66, 1.68)

0.87 (0.36, 2.10)

0.75 (0.46, 1.25)

0.67 (0.46, 0.97)

1.32 (1.03, 1.69)

0.45 (0.33, 0.62)

0.85 (0.57, 1.27)

0.62 (0.38, 1.00)

0.90 (0.79, 1.03)

0.96 (0.76, 1.22)

1.80 (0.67, 4.85)

0.67 (0.32, 1.41)

1.22 (0.70, 2.14)

1.03 (0.36, 2.98)

0.71 (0.04, 11.58)

1.08 (0.87, 1.35)

0.48 (0.25, 0.93)

0.88 (0.32, 2.41)

1.34 (0.87, 2.07)

0.08 (0.00, 1.37)

0.75 (0.52, 1.08)

0.87 (0.17, 4.29)

0.82 (0.64, 1.04)0.90 (0.42, 1.91)

0.41 (0.21, 0.77)

0.62 (0.26, 1.48)

0.35 (0.14, 0.90)

0.68 (0.52, 0.89)

0.96 (0.63, 1.46)

0.54 (0.32, 0.91)

100.00

2.64

1.88

1.22

3.85

2.74

1.40

0.98

3.38

2.21

%

1.88

2.75

3.80

2.04

2.81

2.86

1.41

2.67

Weight

1.48

3.05

2.04

0.88

1.89

2.56

3.31

2.87

2.38

1.98

3.97

3.34

0.72

1.13

1.67

0.65

0.11

3.46

1.34

0.70

2.21

0.10

2.58

0.31

3.341.11

1.40

0.88

0.80

3.13

2.27

1.84

0.83 (0.75, 0.91)

1.29 (0.90, 1.83)

0.60 (0.36, 0.99)

0.49 (0.24, 0.99)

0.93 (0.80, 1.09)

1.15 (0.82, 1.61)

3.06 (1.61, 5.82)

0.38 (0.17, 0.87)

0.78 (0.62, 0.99)

0.61 (0.40, 0.94)

Effect

0.77 (0.46, 1.28)

1.26 (0.90, 1.76)

0.82 (0.70, 0.97)

1.24 (0.77, 1.98)

0.69 (0.50, 0.96)

0.98 (0.71, 1.34)

0.78 (0.41, 1.48)

0.51 (0.36, 0.72)

size (95% CI)

0.53 (0.28, 0.98)

0.79 (0.59, 1.05)

1.05 (0.66, 1.68)

0.87 (0.36, 2.10)

0.75 (0.46, 1.25)

0.67 (0.46, 0.97)

1.32 (1.03, 1.69)

0.45 (0.33, 0.62)

0.85 (0.57, 1.27)

0.62 (0.38, 1.00)

0.90 (0.79, 1.03)

0.96 (0.76, 1.22)

1.80 (0.67, 4.85)

0.67 (0.32, 1.41)

1.22 (0.70, 2.14)

1.03 (0.36, 2.98)

0.71 (0.04, 11.58)

1.08 (0.87, 1.35)

0.48 (0.25, 0.93)

0.88 (0.32, 2.41)

1.34 (0.87, 2.07)

0.08 (0.00, 1.37)

0.75 (0.52, 1.08)

0.87 (0.17, 4.29)

0.82 (0.64, 1.04)0.90 (0.42, 1.91)

0.41 (0.21, 0.77)

0.62 (0.26, 1.48)

0.35 (0.14, 0.90)

0.68 (0.52, 0.89)

0.96 (0.63, 1.46)

0.54 (0.32, 0.91)

100.00

2.64

1.88

1.22

3.85

2.74

1.40

0.98

3.38

2.21

%

1.88

2.75

3.80

2.04

2.81

2.86

1.41

2.67

Weight

1.48

3.05

2.04

0.88

1.89

2.56

3.31

2.87

2.38

1.98

3.97

3.34

0.72

1.13

1.67

0.65

0.11

3.46

1.34

0.70

2.21

0.10

2.58

0.31

3.341.11

1.40

0.88

0.80

3.13

2.27

1.84

Favours exercise Favours control

1.25 .5 1 2 4

(Sherringtonetal2011)

Shiftinpolicy- independence

Independenceiscommonlyunderstoodastheabilitytoperformfunctionsrelatedto

dailyliving– i.e.thecapacityofliving

independentlyinthecommunitywithnoand/orlittlehelpfromothers.

What’simportanttopeopleastheyage?

PolicyfocusacrossthelaterlifecontinuumTargetpopulation Policy focusand

outcomesPotential partners

EnteringoldageActivesGoal– buildandmaintaincapacity

Healthimprovementmaintainingandincreasingphysicalactivitylevels

Primarycare,physicalactivity,sport,recreationproviders andservices

ThoseintransitionGoal- reverse,stoporslowthelossofcapacity

Initiatingandmaintainingphysicalactivitytoimprove/maintainhealth,functionandindependence

Primary careandincontactwithadult,health/social/careservices,voluntarysector,housingandsupportservices

Frailer,olderpeopleGoal – compensateforlossofcapacity

Qualityoflifeandperformanceofactivitiesofdailyliving

Somewithhighlevelsofsupportathome,manyinresidentialcare

(WHO1996/2015,DH2001/11)

Compliance– servicesandinterventions

• Evidencebasedpractice/interventionsinfallsprevention– 50hours,(9months)tailoredandprogressivestrengthandbalance(Sherrington2011)

– SupportandguidancefromNICE,AGS/BGSRCGP• But

– NHSservices10hours=then??????– Behavioural changestrategiesnotreplicated– More“userfriendly”activitiesdesireable?

Externalcircumstancesimposeconstraints

• Realageingpolicypriorities?– Employmentandpensions– Healthandsocialcare– Demographicchanges(eg,older,olderpopulations(85+)

– Lonelinessandisolationwww.cpa.org.uk - www.ilcuk.org.uk -

www.ageuk.org.uk• Evidencebasedpractice• Ecologicalmodelandenvironmentalchange

UpdatingtheEvidencePhysicalActivityandOlderAdults(65+)

BaumannetalGerontologist(2016)

Theevidence– whatworks?

• Systematicreviews• Lacksreferenceto“bestpractice”programs

• Increasingevidencefromtranslationalresearch

• Behavioural change• Youngerolderpeopleandoldest,oldandfrailpeople

(Baumannetal2016)

So?• Scalingupthrough• Replicationofmodelprogrammes (egREAIM)

Or?• Capacitytodesignfrombestpracticeprinciples?

And….• ReturnonInvestment

Tailored,personaladvice,supportedthroughbehaviour changeovertime

Scalingupthroughenvironmentalchange

“Supportedbytheirenvironment, mostpeopleaged80+livinginthecommunity,canexpecttocontinuetogooutdoors

daily,engageinarangeofactivitiesandmaintainqualityoflifeintooldest

age”.(IDGO20120

LivingStreets“StreetAudits- Damagedorunevenpavementsandpavement

parking,lackofbenches/restingplaces,publictoilets,safercrossings’.

www.livingstreets.org.uk

Ageing(still)anegativeagenda?

• MediaprofileofdemandsonNHSandAdultandSocialService(bedblocking/burden/drain)

• Care- repeatedlykickedintothelonggrass• Morepeopleover65thanunder16– physicalactivityremainsschoolsandyouthfocused.

• Stayingyoungorgrowingold(dis)gracefully• Nike(DesigntoMove)– “notgoodforourimage”

Conclusions?Activeageingoffers“onesizefitsall”foradiverse

population• Multiplepolicydimensions,players andactors• FindingclarityforActiveAgeingwithinphysicalactivitypolicy

• FindingclarityforphysicalactivitywithinActiveAgeing• Westilldon’thavetherightsortofevidence• Individualorsocietal(environmental)change• Independenceandconflictwithnon-communicablediseaseaspolicyfocus

Thankyouforlistening

Bob.laventure@laterlifetraining.co.uk