The population in the UK is now living longer, meaning the overall population is ageing. The aim of health services now is to ensure that people are able to maintain their health for longer. However, studies have shown that just 50% of those aged over 65 years reported their health to be ‘very good’ or ‘good’, compared with 88% in the rest of the population (Office for National Statistics, 2011). As people age, their systems gradually lose their in-built reserves, which, in turn, reduces the capacity to recover from illness or injury (Clegg et al, 2013). A stressor event, such as a fall, could reduce their overall resilience and impact on their recovery. This could mean a longer period of reduced function and be considered an indication of frailty.
According to the British Geriatrics Society (BGS) (2016), frailty is a health state related to the ageing process. Physical frailty can be caused by a loss of function and muscle mass (sarcopenia). Falls are an important cause of disability and the leading cause of mortality due to injury in those aged over 75 years, even if there is no significant injury. Falls can also lead to psychological problems, loss of mobility and increased dependence. Around 50% of people over 80 years will fall at least once a year (National Institute for Health and Care Excellence (NICE), 2013). Using preventative work and keeping people more active at home are at the centre of reducing falls. Physical activity helps to prevent cardiovascular disease, diabetes and obesity (Turner, 2014), but strength and balance training is a key component of falls prevention, as it can improve muscle strength, which is important for performing activities of daily living, such as standing from a chair (Gillespie et al, 2012).
Tai chi
Although a wide range of approaches have been employed, the optimal exercise regimen to improve muscle strength in older adults remains uncertain. Exercise groups are not new, but the specific qualities of tai chi spark people's interest, as it is more than just exercise for exercise's sake and invokes a culture and philosophy that people can get involved in and make a way of life (Wolf et al, 1997). People are more likely to attend out of interest rather than just because it is ‘good for you.’ It is a way of involving family, friends and carers in a joint activity, promoting engagement and helping reduce social isolation. The focus on core stability and breathing is achievable to the frailest, making it accessible to people of all abilities, and the wealth of literature (Hong et al, 2000; Greenspan et al, 2007; NHS, 2018) suggesting the positive effects of tai chi on numerous conditions makes it an exciting area to introduce in caring for the frail older person.
This study, funded by the Queen's Nursing Institute, looked at the benefits of tai chi in older people living with frailty. The aim of the study was to measure balance, gait and wellbeing using validated tools, and to assess the impact of weekly tai chi classes on this group of people.
Recruitment methods
The study aimed to include one group of people in the community and one of those in a care facility, with approximately 30 participants in total. Only bed-bound patients were to be excluded. However, due to time constraints and limitations to being able to identify people living with frailty in the community, the study focused on those already in care facilities. It was assumed that these individuals had some element of frailty, given that they were in a care facility. The first group comprised residents living in a care home, with varying degrees of dementia. The second group were from a care facility that was a combined nursing and residential home, and the participants had varying degrees of mobility.
Participants
The inclusion criteria for participants were age over 65 years and living with frailty. They had to be able to practise tai chi while seated or standing.
People who were bed-bound or already practising tai chi were excluded, as were those who would not be able to attend weekly classes.
Tests used to determine efficacy of the tai chi classes
The timed up and go test (TUG) is a commonly used screening tool to assist clinicians to identify patients at risk of falling. This test is performed by clearly marking an area 3 m from a chair. The person is timed as they go from a seating position to the 3 m point and back to a sitting position. A normal healthy older person should complete this task in 10 seconds or less, and TUG completion times of over 14 seconds are associated with a high falls risk (Podsiadlo and Richard, 1991).
The functional reach test is a simple test of balance that can be used to identify people who may be at risk for falling while reaching. The person is instructed to stand next to, but not touching, a wall with a measure, and position the arm that is closer to the wall at 90 degrees of shoulder flexion. The starting position is recorded at the 3rd metacarpal, after which they reach as far as they can without taking a step, and another measurement is taken. This is usually measured in inches. The difference between the start and end position is the score. A normal score is 15 inches; between 6 and 10 inches indicates a moderate risk of falls, and below 6 inches indicates a high risk of falls. This test can also be adapted for those who are unable to stand (Duncan et al, 1990).
Last, the timed unsupported steady stand (TUSS) test measures standing balance. The person stands unsupported for as long as they can for up to 60 seconds. The timing stops when they place their hand on the table or until they have stood steadily for 60 seconds (Simpson and Worsford, 1996).
Procedure
In each group of residents, the three tests of balance and gait were conducted prior to starting the classes and at the midway point (5 months of classes), and they are due to be repeated at the end of this year-long project (in February 2020). The tai chi classes were specific for each group, and they progressed according to the improvements noted in the group each week. The movements were simple to follow, and practice was encouraged during the week before the next class. The classes were conducted by a highly experienced and trained instructor, and both groups were led by the same instructor.
The time taken to complete the TUG test should range between 10.0 and 12.7 seconds for those aged 80–99 years (Podsiadlo and Richard, 1991). In both groups, all the participants are aged over 80 years, and one person in group 2 is aged 103 years. Two people in group 2 were unable to participate in the TUG test as they were unable to stand. The results for the 103-year-old person have been shown separately, as they would not be a true representation of the data. In group 1, the mean time to complete the TUG was 18.48 seconds and, in group 2, it was 18.55 seconds. Both groups showed an increased risk in the number of falls from the onset. The 103-year-old completed the TUG in 1 min and 6 seconds (her sheer determination and support from her peers were fantastic to observe). The TUSS was completed in 60 seconds for all participants but one in group 1, who only stood for 57.67 seconds, and the 103-year-old woman in group 2, who stood for 58.75 seconds. Both groups were quite competitive, as the test was completed as a group activity, which could have improved these results.
The mean distances recorded in the functional reach test were 4.91 inches in group 1, indicating a high risk of falls, and 6.23 inches in group 2, indicating a moderate risk of falls.
These tests were repeated at the midway point at 5 months, and the results for each group were quite mixed. The mean time recorded in the TUG test in group 1 improved from 18.48 seconds to 17.36 seconds, but in group 2, it increased from 18.55 to 21.09 seconds. The 103-year-old woman had been unwell with pneumonia after the initial tests and had not been at the class for the preceding 6 weeks. She was a lot slower at completing the TUG test, taking 2 minutes and 37 seconds, indicating the impact that illness can have on frail older people. That being said, it was the first class that she had attended since recovering, and she was unsure if she could complete the test and had a fear of falling. She was advised to rest, but she was determined to complete the test, and she felt a sense of achievement that she said would aid her subsequent recovery.
The findings in the TUSS test were improved in both groups, as all participants stood for the full 60 seconds.
Similarly, the findings of the functional reach mean improved in both groups. In group 1, the distance covered improved from 4.91 inches to 5.64 inches, and in group 2, it improved slightly from 6.23 inches to 6.6 inches.
Although there were only minimal improvements in the test scores at the half-way point, what was noteworthy was the sense of inclusion and wellbeing experienced by the participants. All of them reported that they looked forward to the weekly classes, and even if they had had a bad week, they would make the effort to attend, as they enjoyed the class. Further, although the times in the TUG test did not reduce significantly, the gait of the participants improved, their confidence increased and their fear of falling reduced.
Overall, the feedback received so far from the participants has been very positive. They are committed to the weekly classes as they find them interesting and enjoyable. They also have fed back that they like the instructor.
Discussion
This study was initially conceptualised after a discussion with a resident of the care facility who was a retired nurse. She felt that, since she had been diagnosed with dementia and moved to a care home, people did not see the ‘real’ her. She felt low in mood and that she had no purpose in life. She was a very proud woman and felt that the activities on offer were babyish and not suitable for someone like her. This woman's physical and mental health had deteriorated from when she was living at home, something which is seen frequently by the older people's team. The researcher intended to identify non-pharmacological interventions to improve the health and wellbeing of such individuals.
Previous studies have suggested that exercise can improve balance and muscle strength in older people (Wolf et al, 1997). Many of the older people involved in the present project agreed that exercise could positively impact on their health, but barriers such as chronic illness and joint pain made them fearful of further injury or illness. In the present project, the author found that the perceived benefits of the tai chi classes seem to be greater than the actual physical benefits. Changing attitudes towards physical exercise could be the key to successful ageing.
Due to funding limitations, the tai chi classes described in this study conclude at the end of January 2020, although the residents in the care homes are keen for them to continue. To demonstrate how the classes have impacted on this group of people, semi-structured interviews collecting qualitative data will be conducted, since how people feel is at the core of regular engagement in exercise. Continuing the classes over a longer period of time could provide a better understanding of how exercise affects older adults.
Some limitations of this project were the small population included and, consequently, the limited amount of data gathered. The number of participants that have completed the weekly tai chi from the beginning in group 1 is six and in group 2 is eight. Additionally, the mid-point findings of the midway TUG and TUSS tests may have been better had the participants stood for the exercises from the outset. When the exercises are performed seated, the increase in muscle strength would be less, as the participant is not fully using their muscles. Unfortunately, the care facilities were apprehensive at the beginning about the residents standing for the classes.
The final measurements are to take place at the end of January 2020. Although the data may be too limited to show any statistical difference, the participants are keen to find out their ‘score’.
Last, the older people's team do a frailty review annually for people over 65 years of age, and part of this is falls in the preceding year. Using these data, the effects of the tai chi exercise programme in falls prevention will be examined in a future study.
Conclusion
The findings of this study indicate that tai chi can improve balance and, perhaps, reduce falls in the older population. Additionally, regardless of the physical benefits, there were certainly mental health benefits produced in this project. Further research is recommended on the effects of tai chi for this group of the population.