1. The ‘Balance of Frailty’ Concept – Implications for Occupational Therapy Practice
Laura Evans
Head of Occupational Therapy, Sheffield Teaching Hospitals
Professional Doctorate
@Laura JaneEvans5
Welcome to this final session and I hope you have had an enjoyable and thought provoking conference, in this session I will present to you the culmination of my Professional Doctorate which explored the Occupational Therapy Role for Older People who have become frail.

2. I have spent the last 6 years thinking and learning about frailty so what does frailty mean to you? Is it this picture
Frailty means different things to different people and I have changed the way I even speak about frailty now as compared to the beginning of my study, I used to say ‘frail older people’ where I now say ‘older people who have become frail. I have learnt that frailty is a condition that varies in severity, the degree of frailty is not static, it varies over time and can be made better or worse.

3. Or this? - Alma 104 years
Or this? Can I introduce you to Alma who was 104 years old in this picture and lived in a care home in a fragile but relatively stable ‘condition’. Despite having dementia and several falls she was visited by her son on almost a daily basis, he provided social stimulation, took her out regularly and helped with eating and drinking. He did this for 9 years and Alma who was my Nanny died last year.

4. An emerging evidence base
‘Early’ literature based on bio-medical, diagnostic set of parameters
Lack of agreement on ‘definition’ and measuring tools
Gradual change to consider a more ‘holistic’ approach to diagnosis
A long term condition that is not curable, persists but can be managed
The evidence base of frailty has increased and changed over the last few years, there has been disagreement about the definition of ‘frailty’ and a change from bio-medical based definition with markers such as walking speed and grip strength to a more wide ranging and encompassing approach that describes frailty as a long term condition that is possible to ‘manage’ but may not be cured. This interesting to consider with a younger person who can become frail for instance after major surgery and we would ‘expect’ them to recover and’be cured’

5. Presentations of Frailty Young, J (2015)
Frailty is a late life adverse health condition that develops over many years
Frailty is characterised by high vulnerability to minor stressors
Frailty shares many characteristics of LTC but current management is dominated by urgent and emergency responses
Older people with frailty can be readily identified in the community with simple evidence based tools
John Young has provided a helpful synopsis of the presentation of frailty that includes a high vulnerability to stressors or as the OT’s in my study called triggers and observed that frailty can be identified in the community but often presents in an emergency or urgent care scenario with a crisis.

6. People Living with Frailty
‘Frailty isn’t a label it’s a long term condition which our patients live with every day’ (#NHSBNOP)
‘The Fail Elderly’
(i.e. a label)
‘an older person presenting with frailty’
(i.e. a long term condition)
Presentation acute & in crisis
e.g. delirium, falls, immobility
Timely identification for preventative, proactive care by personalised care and support planning
During my study I have changed in my language around frailty, I am no longer comfortable with describing an older person as ‘frail’ per say but prefer to say an older person who has become frail. This slide is from an NHS benchmarking conference for older people who had a similar aspiration that frailty was not a label but a presenting condition that could be identified in a proactive approach in the community rather than an episodic and acute picture.
Hospital based episodic disrupted and disjointed
Community bases personal centred co-ordinated care and support

7. Professional Doctorate “A Rocky Mountain”
So how does this fit with Occupational Therapy practice?
The last 6 years have been a rocky road with lots of chocolate but I am now nearing the top

8. The view from the top!
And hoping this will be my view! The clarity of how, where and when OT’s can have a role with Older People who have become frail has gradually been constructed though my research

9. The Impact of Occupational Therapy
Exploring how our knowledge and skills applies to the concept of frailty
Stakeholder views ‘set the scene’
3 Occupational Therapy Case Studies across primary, intermediate and secondary care
Instrumental Case Study methodology
Framework and thematic analysis of 21 Interview transcripts
Cross Case Analysis – a ‘constructed’ model with four themes.
I presented last year my study which explored the practice of OT’s in 3 instrumental case studies. The OT’s worked in acute, intermediate and primary care and in addition I interviewed members of their MDT to gain their perspective on the impact of their role.
From the interview transcripts I then coded and themed the information and constructed a model of practice of frailty for occupational therapists. This process is described as iterative but it is more prolonged and painful that that sounds. I had to learn to stand back from the data and think what does that mean and what could it mean for practice?

10. The concept of the ‘balance’ of frailty
The concept that I will describe is one of the ‘balance’ of frailty.

11. Characteristics Frailty is a dynamic and changing picture
Transitions can be sudden or gradual from stability to imbalance
Specific ‘weights’ can affect balance
Balance is aspirational but not always possible
Balance requires effort and has a link to risk
The characteristics of the model is that frailty is a dynamic and changing concept, transitions within a frail condition can be sudden or gradual, balance can be lost gradually or suddenly. Specific weights or triggers can affect the balance pf frailty.
Balance can be aspirational but not always achievable and balance also requires effort and can link to risk.

12. “Life is a balance between what we can control and what we cannot, I am learning to live between effort and surrender” Danielle Orner (2017)
This lady is a yoga teacher who became an amputee as a teenager so you can see how this quote relates to her but also resonated with the OT’s in my study in relation to the effort required to maintain balance for an older person.

13. 4 constructed themes in the ‘balance’ of frailty
A ‘precarious’ balance
The ‘tipping point’
Restoring the balance
Maintaining balance
The 4 broad themes that I constructed are these :

14. The ‘Balance of Frailty’ Occupational Therapy Themes
Beyond the crisis
Embracing risk
Achieving occupational balance
Prevention
Signposting
Education
Predicting the tipping point
Managing the tipping point
Resilience
The frailty trajectory
Imbalance
The spiral of vulnerability
A precarious balance
The tipping point
Restoring the balance
Maintaining the balance
These 4 main themes all link together in the balance of frailty and each in turn have sub themes which I will describe. As I am describing each theme perhaps reflect on some of the older people you have seen and where they could have been within this model.

15. “A precarious balance”
The Frailty trajectory
Imbalance
The spiral of vulnerability
The theme of ‘a precarious balance’ I think may speak for itself, the OT’s talked about someone being “literally on the cusp or the edge”. The frailty trajectory describes the 2 ways that older people may ‘present’ either with a sudden onset or crisis or a gradual deterioration, this deterioration may be unseen or is only uncovered when a crisis occurs or families describe how their relative seemed fine last week and is now very unwell.
Imbalance was the description by the OT’s of the triggers that could lead to a precarious state of imbalance. These could be thought of the sudden or series of weights. This included obvious triggers such as a health crisis, a fall but also a bereavement, change in accommodation, sensory deterioration and how an admission in itself is a trigger to further upset the balance through disorientation, deconditioning…
Vulnerability was a word that was frequently used by OT’s in connection with a frail condition, they described how an increase in frailty could lead to increased vulnerability and associated dependence on care and support. The management of risk in this spiral of vulnerability was an important area of practice described by the OT’s and their teams.

16. A “precarious” balance
In what context can we identify older people in the stage of “a precarious balance”?
What are the strategies for identification of this stage?
What interventions would be useful to consider for Occupational Therapists?
Knowledge of the different trajectories can help identification
Awareness of the stressors/triggers in frailty
The link between frailty, risk and independence
So in thinking about this stage of a precarious balance where are the contexts in which OT’s can identify this stage and what are the strategies we could utilise?
Our interventions at this stage can be described to potentially reduce this state of imbalance.
Knowledge of the stressors that John Young described and the triggers that the OT’s named are useful for all OT’s to be aware of along with the link between an increasing frail condition, vulnerability, the management of risk and independence.

17. “The tipping point” Predicting the tipping point
Managing the tipping point
Resilience
The second main theme in the balance of frailty was the ‘tipping point’
Predicting the tipping point is the awareness of those cumulative weights that may finally lead to a crisis. Is there more that we could do to predict this point and prevent an admission perhaps to acute care. There are tools for predicting levels of frailty but these were not referred to in my study however the OT in primary care did describe a monitoring scenario to prevent the tipping point being reached.
When the tipping point is reached what can OT’s do to ‘manage’ this crisis point. This occurred both in the acute and community settings in my study. Admission avoidance strategies and discharge planning were unsurprisingly descibed in detail.
How successful the tipping point was managed was described by the OT’s as being affected by the resilience of the older person. They described resilience being affected by factors such as family support, meaningful activities and previous health.

18. The “tipping point”
In what contexts can we identify a tipping point for an older person
An admission to acute care is a significant tipping point with a potential high impact
Consideration of D2A/Home First models
Thinking about this tipping point I am sure you can identify when this has been reached, the importance of D2A and home first models is useful to consider in managing this tipping point especially with older people who have become frail

19. The “tipping point”
How can OT skills have the most impact at this point? (PJ paralysis, last days)
What are interventions are useful to consider at this point?
Understanding of resilience ‘factors’ for an older person.
The impact of the acute environment can be dramatic and appears to further add to the frail condition, campaigns such as PJ paralysis and get up, get dressed , get moving align well with the tipping point and what can help an older person’s resilience at this vulnerable time.

20. “Restoring the balance”
Moving beyond the crisis
Embracing risk in recovery
Achieving occupational balance
The third main theme from my research is the OT role in restoring the balance, how do we help an older person move beyond the tipping point, the crisis?
An understanding of transition theory has been very useful to apply to the stages of the balance of frailty. During a stage of crisis a state of chaos can follow so thinking of an admission and discharge process and that first period at home is useful for OT’s to consider.
The management of risk in recovery was discussed extensively in the interviews, strategies to minimise risk, reduce effort and make activities more ‘smooth’ was a very interesting observation. The importance of habituation and risk was also discussed, how changing existing habits needed careful consideration so risk is not increased rather than decreased.
Achieving a balance in activities or occupations was a sub theme of the research. How this is possible for an older person who is frail is worthy of consideration, where is the balance between effort and surrender? What is the most important thing for them to achieve, what is possible? Working this out collaboratively with an older person and their family was described in this study.

21. Restoring the balance
Where is the best context to restore the balance for an older person?
Timing of intervention, time to recover
Chaos of transition from acute crisis to a more steady state
Managing and embracing risk
Consider habituation
Occupational balance for an older person
Effort, risk and smoothness of activities

22. “Maintaining balance”
Continuity
Prevention
Education
Maintaining the balance within a frail condition was at times aspirational for the OT’s in this study, they stressed the importance of a therapeutic relationship across services including acute and community contexts and being able to ‘follow the patient’ was discussed. Models such as D2A with trust between services helped continuity for the older person including avoiding repetition of assessment information.
The prevention role was discussed comparing the body being like an engine that needed maintenance to keep running smoothly. Often the role in prevention was desirable but not achievable due to service parameters and criteria. Post discharge one of the OT’s descibed her service as a medical ward in the community and people were not ready, their internal balance had not been restored.
A large part of the OT role in the balance of frailty was anticipating future needs and support including signposting and education of the person, their families and other MDT members for example junior medical staff or support workers.

23. Maintaining balance
Proactive model of enquiry and collaboration within a local population
GP/community team based.
Continuity and a value of the therapeutic relationship, following the patient
Education of families and carers/support agencies
Prevention, signposting and social Contact
Meaningful occupations to maintain balance
To maintain a balance for an older person a proactive model of enquiry that is population based and identifies people who may be in a precarious state would appear to be a model for OT’s who understand how to maintain occupational balance at the core of their practice.

24. I like this quote because there is a symmetry between an aspirational quest to find balance both for older people who has become frail but also an opportunity for OT’s to utilise a balance analogy to desrcibe clearly and succinctly their role both in their interventions and the contexts in which they work.

25. Findings
Occupational Therapists can contribute to the diagnosis/identification of an older person who is becoming frail
The complexity of a frail condition aligns with Occupational Therapy as a complex intervention (Creek, 2010)
The ‘balance’ analogy is useful to describe our interventions across a range of contexts
Transitional theory aligns with the instability of a frail condition (Meleis, 2010)
Occupational Therapists need to reflect and be critical of how and where they can have the most impact
To summarise my findings in the development of the understanding of the complexity of frailty OT’s have a role to contribute to the diagnosis of an older person is becoming frail or ‘at risk’. The complexity of a frail condition aligns well with OT as a complex intervention.
The balance of frailty model is a framwork to describe our role at different stages or levels of frailty and transitional theory is useful for OT’s to understand and apply to their practice.
Within this consideration OT’s perhaps need to reflect of when and where they can have most impact.

26. Challenge your own thinking around ‘frailty’
I think we need to continue to challenge our own thinking about frailty, one of my stakeholders said that frailty is defined only by the person themselves rather than a medical model to ‘explain things’
Challenge your own thinking around ‘frailty’

27. The ‘Balance of Frailty’ Occupational Therapy Themes
Beyond the crisis
Embracing risk
Achieving occupational balance
Prevention
Signposting
Education
Predicting the tipping point
Managing the tipping point
Resilience
The frailty trajectory
Imbalance
The spiral of vulnerability
A precarious balance
The tipping point
Restoring the balance
Maintaining the balance
So to look back at the balance of model for frailty and the four main themes I hope I have conveyed how these can all link together and the potential role for occupational therapists across acute and community contexts, to identify when an older person is an a state of precarious balance, how we can prdict an tipping point, how the tipping point is managed and how balance can be restored and maintained is a great opportunity to clarify and explain our role with older people

28. Use the concept and stages of the balance analogy to consider how and where you bring impact Consider the evaluation of effort and risk to achieve occupational balance
So finally some take home messages for you…

29. Acute care and management is needed but the window is small Consider where is our occupational balance for older people who present as frail

30. Thank you Any feedback/comments to
or even better @LauraJaneEvans5 !
@AcuteFrailty
@frailsafe
@GeriSoc
@PJparalysis
#last1000days

31. References Acute hospitals and integrated care (2015) The Kings Fund
Creek, J (2010) The Core Concepts of Occupational Therapy : a dynamic framework for practice
Fit for Frailty (2014) British Geriatrics Society, consensus best practice.
Making our health and care systems fit for an ageing population (2014) The Kings Fund
McIntyre, A and Atwal, A (2005) Occupational Therapy and Older People
Meleis, A (2010) transitions theory, middle range and situational specific themes in nursing research and practice
NHS England(2016) Quick Guide, Discharge to Assess
Young, J (2015) Living with Frailty : a guide for primary care
Stake, R (1995) The Art of Case Study Research
NHS Benchmarking for Older People 2017 Conference, #NHSBOP