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Falls and Frailty

Open the conversation

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Would you be happy to spend a few minutes talking about something that can make a big difference to your future health and wellbeing?

Insight

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Spending a moment to set the scene and asking permission can open a constructive person-centred conversation around behaviour change. This keeps the individual actively engaged in the conversation and decision making.

Did you know?

Brisk walking can be easily incorporated into everyday life for many people and is an acceptable form of physical activity.

Download this great infographic showing the UK Chief Medical Officers’ recommendations (2019) for physical activity in adults and older adults

The least active individuals stand to gain the most from a small increase in physical activity.

Real impact

“Going for a walk enriches my whole life.”

“I feel good when I’ve finished an activity that feels almost impossible to manage before you start on it-and you’re always surprised when you see how well you cope with it.”

“Let’s say that I do my exercises and so on. It’s not because I want to live longer but that I want to keep well longer. So that the countdown will be as short as possible”

Assess impact of the condition

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How has your condition affected your physical activity levels and the things you enjoy?

Insight

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Living life with a long term condition commonly affects an individual’s physical activity beliefs and behaviours. Focusing on this can be a useful way to introduce the topic.
Most people are ambivalent about, rather than resistant to, increasing their physical activity levels. Your challenge is to help an individual to consider and share their own ‘pros’ for increasing their physical activity levels and help them to develop these ideas into a workable plan that fits into their life.
Try to understand their perspective, agenda and priorities and do not assume they:

  • ought to change
  • want to change
  • are primarily motivated by their health
  • either ARE or ARE NOT motivated to increase their activity levels
  • will respond well to a tough approach from you
  • must (or will) follow your advice

Learning skills like motivational interviewing can help you avoid common pitfalls that sometimes make conversations about behaviour change unrewarding and ineffective. Visit our education section to learn more.

Did you know?

Brisk walking can be easily incorporated into everyday life for many people and is an acceptable form of physical activity.

Download this great infographic showing the UK Chief Medical Officers’ recommendations (2019) for physical activity in adults and older adults

The least active individuals stand to gain the most from a small increase in physical activity.

Real impact

“Going for a walk enriches my whole life.”

“I feel good when I’ve finished an activity that feels almost impossible to manage before you start on it-and you’re always surprised when you see how well you cope with it.”

“Let’s say that I do my exercises and so on. It’s not because I want to live longer but that I want to keep well longer. So that the countdown will be as short as possible”

Explore current activity

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How much physical activity do you manage to get done in a regular day?

Consider calculating their physical activity vital sign

Q1 On average, how many days each week do you do moderate or greater physical activity (like a brisk walk) ?

Q2 On those days, on average how many minutes do you do this physical activity for?

Results

Inactive. Only small increases in physical activity across the week can have large health benefits. Explain that just 30 minutes physical activity in one week can make a huge difference to their health.

Insufficiently active. A good start, but there is still a lot to be gained by increasing physical activity levels.

Active. Well done. Maintaining this level of activity is really important.

Insight

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Evaluating how active a person is, as part of a conversation to help them move more in the future, is recognised as being an important aspect of assessment. The way in which this is done, however, remains a cause for debate.

Gathering data about physical activity levels on a system wide basis can be a powerful way of integrating physical activity contacts into patient pathways, for instance through electronic medical records systems. They can also provide important data for demonstrating change and therefore the impact of an intervention, which can in turn drive changes in patient care and support commissioning of physical activity services.

However, recent evidence shows that any activity is better than none, and that there is no simple cut off or ‘threshold’ for health which applies to everyone. Identifying a cut off point introduces a concept of success or failure and can be detrimental to having a person-centred conversation based on individual values. In practice this can be the difference between a judgemental / diagnostic approach such as ‘you’re not doing enough and need to do more’ to a values based one such as ‘why might you want to become more active, personally?’ which can make them more likely to change their own behaviour.

Assessment tools can be used for screening and are particularly useful in systems. Whilst this can support systems delivery, it’s important to recognise that whilst those who say they are inactive generally are, many people who report being sufficiently active are not when compared with objective measures. This lead to many people who would benefit from a physical activity intervention being excluded on the false assumption they are sufficiently active.

Therefore we recommend that if you are going to assess physical activity levels, it can be helpful to approach it in one of two ways:

  1. Include the physical activity vital sign in the assessment phase of a healthcare contact, for instance alongside height, weight and blood pressure measurements.
  2. As part of a more focussed physical activity conversation, it might be preferable to explore current levels of activity as part of their daily/ weekly routine as a more informal way of ‘assessing’ physical activity behaviours, and resist the temptation to get too hung up on the numbers. This will facilitate a more patient -centred conversation which can then be developed to explore how they feel about becoming more active in the future and how they might go about it. It then provides an opportunity to share information about physical activity guidelines if appropriate, but try to avoid any statements such as ‘you are/ are not doing enough’.

Did you know?

Brisk walking can be easily incorporated into everyday life for many people and is an acceptable form of physical activity.

Download this great infographic showing the UK Chief Medical Officers’ recommendations (2019) for physical activity in adults and older adults

The least active individuals stand to gain the most from a small increase in physical activity.

Real impact

“Going for a walk enriches my whole life.”

“I feel good when I’ve finished an activity that feels almost impossible to manage before you start on it-and you’re always surprised when you see how well you cope with it.”

“Let’s say that I do my exercises and so on. It’s not because I want to live longer but that I want to keep well longer. So that the countdown will be as short as possible”

Find out what they already know

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What do you know about the benefits of physical activity in people who are frail and/or susceptible to falls?

Insight

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As an individual is more likely to change if they can personally identify with the ‘pros’ for change, help them to identify how they might benefit from being more active. Find out what they know first so that you can add to their existing understanding by sharing some of the wide-ranging benefits of being more active.

Did you know?

The risk of death from physical activity is extremely low. For Men it is 1 death per 23 million hours and Women it is 1 death per 36.5 million hours.

In order to benefit health, research has shown that activities need to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity

Start small and build up gradually for a safe approach to starting activity

Real impact

“Why haven’t I received [physical activity on prescription] before? I have been in pain for many years.”

“Exercise helps me decrease my fatigue”

Share benefits

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Can I share some other things people find beneficial to see what you make of them.

Insight

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Based on your discussion so far, choose to share the benefits you judge will be most relevant and important to them. Some benefits are quite generic and others will be condition specific.

Remember the conversation won’t work if you take away their control. Ask permission and keep this a conversation not a lecture.

Did you know?

The risk of death from physical activity is extremely low. For Men it is 1 death per 23 million hours and Women it is 1 death per 36.5 million hours.

In order to benefit health, research has shown that activities need to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity

Start small and build up gradually for a safe approach to starting activity

Real impact

“Why haven’t I received [physical activity on prescription] before? I have been in pain for many years.”

“Exercise helps me decrease my fatigue”

Encourage reflection

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What do you make of what I have just said?

Insight

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Allow some space for people to talk and explore the information rather than asking ‘do you understand?’ which can shut things down. Ask if they need anything clarifying and what concerns they might have about how the information applies to them.

Listen and reflect their concerns: ‘you’re worried about X’. Help them to address these issues by sharing the experience of other people: ‘other people I’ve worked with have had those concerns, but what typically happens when they get started is…’ or ‘whilst there is a small risk of X when you get started, this is outweighed by the risk reduction you experience once you have started moving more’. Ask what they think about what you have said.

Did you know?

The risk of death from physical activity is extremely low. For Men it is 1 death per 23 million hours and Women it is 1 death per 36.5 million hours.

In order to benefit health, research has shown that activities need to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity

Start small and build up gradually for a safe approach to starting activity

Real impact

“Why haven’t I received [physical activity on prescription] before? I have been in pain for many years.”

“Exercise helps me decrease my fatigue”

Explore how they think activity may help

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What do you understand about how physical activity might help you?

Readiness Cycle

Using your judgement, offer to share the most relevant and important problem commonly reported by people with falls and frailty then ask what they make of it.

is

  • More physical activity
  • Aerobic activity improves muscle quality and resistance training creases muscle mass
  • Build muscle and it works more efficiently so uses less energy
  • Become stronger
  • More physical activity
  • Less physical activity with ageing
  • Lose muscle strength initally
  • Lose muscle mass
  • Become weaker
  • Less physical activity with ageing
  • More physical activity to combat slowing down
  • Prevent the loss of nerves supplying muscles
  • More muscle keeps its nerve supply
  • More muscle available to perform the task
  • Maintain ability to perform movements and they are less difficult
  • More physical activity to combat slowing down
  • Less physical activity
  • Lose some nerves supplying signals to muscles
  • Muscle areas without a nerve supply cannot work
  • Less muscle is available to perform an activity
  • Movements are slower and more challenging
  • Less physical activity
  • More physical activity to combat feeling so tired
  • Improvement to muscles, hormones, nerve supply and immune system
  • Feel less tired and activity is easier
  • Feel the benefits so more motivated and feel better
  • More physical activity to combat feeling so tired
  • Less physical activity with ageing
  • Changes occur in muscles, nerves, hormones and immune system
  • Feel more tired and activity is harder
  • Lose the motivation to be active and may also feel low
  • Less physical activity with ageing
  • More physical activity to build muscle and improve health
  • Reduce inflammatory chemicals in your body
  • Build more muscle
  • Muscle mass maintained
  • Lose less weight and may become stronger
  • More physical activity to build muscle and improve health
  • Less physical activity and may develop long term illnesses with ageing
  • Some chemicals increase which cause inflammation
  • This inflammation causes more breakdown of tissues than repair
  • One of the tissues that breaks down is muscle so you lose muscle bulk
  • Become weaker
  • Less physical activity and may develop long term illnesses with ageing
  • More physical activity
  • Muscles become stronger
  • Strength and balance improve and feel more steady
  • Feel better
  • Motivated to continue being active
  • More physical activity
  • Less physical activity
  • Muscles become weaker
  • Weak muscles lead to reduced strength and balance, feel unsteady
  • Fearful of falling
  • Avoid activities that may increase risk of falling
  • Less physical activity
  • More physical activity
  • Muscles become stronger
  • Muscles use oxygen more efficiently
  • More energy and everyday tasks become easier
  • Motivated to continue being active
  • More physical activity
  • Less physical activity
  • Muscles become weaker
  • Muscles use more oxygen and are less efficient
  • Everyday tasks require more effort, feel fatigued and weak
  • Avoid everyday tasks
  • Less physical activity
  • More physical activity
  • Muscles become stronger
  • Strength and balance improve and feel more steady
  • Feel better
  • Motivated to continue being active
  • More physical activity
  • Less physical activity
  • Muscles and bones become weaker
  • Feel unsteady
  • Weak bones are more likely to break in a fall
  • Avoid activities that may increase the risk of falling
  • Less physical activity

Insight

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The symptoms and challenges experienced by people with long term conditions are a real and frequently debilitating part of everyday life. Understanding how physical activity can make a difference to their day-to-day life can help strengthen their resolve and confidence to become more active.

Did you know?

All physical activity counts towards moving more

Build strength with exercises which help develop muscle strength – Pilates and light weights can help and physical activity in the home and garden can be good too

In order to benefit health, research has shown that activities needs to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity.

Real impact

Respond to concerns

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What concerns might you have about becoming more active, if you decided to?

Insight

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Many people with health problems – and those without – have reasonable concerns about becoming more active. When you ask them about this, saying “if you decided to” reminds them that they are the decision maker, not you, keeping the discussion open and active, focusing your supportive role.

Find a way to reflect that you understand – ‘Yes, that is a common concern’ or ‘you’re concerned that being more active may make your pain worse’ (said as a statement, not a question).

Allow some space for people to talk about and explore new information, asking ‘what do you think about what I’ve just said?’ rather than asking ‘do you understand?’ which can shut things down. Ask if they need anything clarifying and what concerns they might have about how the information applies to them.

Did you know?

All physical activity counts towards moving more

Build strength with exercises which help develop muscle strength – Pilates and light weights can help and physical activity in the home and garden can be good too

In order to benefit health, research has shown that activities needs to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity.

Real impact

Make it personal

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What would be the top 2-3 reasons for you personally becoming more active, if you decided to?

In addition to the personal benefits that being active can have, living an active life can reduce the risk of many common medical conditions by up to 50%

Offer to share some of this evidence if you feel they might be interested in finding out out more about the impact of physical activity on disease prevention.

Insight

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Help them to generate and articulate their own reasons, which may or may not be health-related and recognise they might not be interested in long term disease prevention.

Saying ‘if you decided to’ reminds them that they are the decision maker, not you. This helps keep the discussion open and active, focusing your role on providing support.

Did you know?

In order to benefit health, research has shown that activities needs to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity.

The least active individuals stand to gain the most from a small increase in physical activity

Everything that people do to prevent or delay the onset of frailty will also prevent or delay the onset of dementia

Real impact

Look forwards

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Let’s imagine that you did decide to live a more active lifestyle and were able to keep it up for six months or so, what differences do you think you might notice?

Insight

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Personal motivation may be strengthened by having people look further into the future – since the benefits of a more active lifestyle may be cumulative. Certain benefits may only materialise several weeks or months into the future. Getting people to talk about a potentially better future helps to ‘develop discrepancy’ – highlighting the gap between where a person is and where they want to be.

Did you know?

In order to benefit health, research has shown that activities needs to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity.

The least active individuals stand to gain the most from a small increase in physical activity

Everything that people do to prevent or delay the onset of frailty will also prevent or delay the onset of dementia

Real impact

Help them build confidence

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What are the reasons you feel you could become more active if you decided to?

Or consider an alternative approach using a confidence ruler

“On a scale of 0-10, how confident are you that, if you did decide to become more active, you would be able to keep up an active lifestyle for, say, 6 months, where 0 is not at all confident and 10 is extremely confident?”

Explore “What makes you say x and not a lower number?”what makes you feel you could do this if you tried?”

Ask “What would help you become more confident?”

Insight

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These questions aim to get people talking about why they could be more active, if they tried, as this can help to increase their confidence, or self-efficacy. It also helps people to think about the concrete steps that they would need to take, which can help the change seem more achievable. Listen to and explore what they say: ‘are there any other reasons why you think you might be able to keep up an active lifestyle, if you decided this was what you wanted to do?’

Your focus is on encouraging them to think through what would help them to become more confident. This helps to strengthen their ideas about what else they might need to do. These questions can sometimes prompt individuals to create a personalised behaviour change plan. Continue to explore their ideas (before you share yours). Ask ‘and what else might help you become and stay more active?’

Did you know?

In order to benefit health, research has shown that activities needs to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity.

The least active individuals stand to gain the most from a small increase in physical activity

Everything that people do to prevent or delay the onset of frailty will also prevent or delay the onset of dementia

Real impact

Summarise without adding anything

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Can I summarise what I think you have said?

Don’t be tempted to impose your own plan at this stage – they may agree with you just to end the conversation. Summarise the main points of the conversation and find out what they are thinking

This may sound something like: ‘so some of the benefits of physical activity for someone like you with X include A and B and C. The most important reasons for you personally would be P and W’.

Using a summary can be a good way to demonstrate and express empathy, that you can see the world from their perspective. Empathy contributes to outcomes in a range of settings.

Insight

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Don’t be tempted to impose your own plan at this stage – they may agree with you just to end the conversation. Summarise the main points of the conversation and find out what they are thinking

This may sound something like: ‘so some of the benefits of physical activity for someone like you with X include A and B and C. The most important reasons for you personally would be P and W’.

Using a summary can be a good way to demonstrate and express empathy, that you can see the world from their perspective. Empathy contributes to outcomes in a range of settings.

Did you know?

Muscle strengthening and balance activities should be done on at least two days per week

The least active individuals stand to gain the most from a small increase in physical activity

Older adults should aim to be active daily, in bouts of at least 10 minutes and total at least 150 minutes per week.

Real impact

Ask the key question

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So, what do you think you will do?

If they decide that they are NOT ready:

Thank them for taking the time to talk with you about physical activity and offer an opportunity to review the conversation. Reassure them that help is available when they feel ready to change.

If they decide to become more active:

THEN move on to planning. Continue to keep the focus on them generating their own ideas for change, rather than telling and instructing. People are much more likely to make successful changes if they develop their own plans.

Insight

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The individual has heard about the benefits of physical activity for someone like them and has had the chance to consider the benefits they would most like to experience. They have heard their ideas spoken back to them, which can help to reinforce them. Now it’s decision time. Asking an open question ‘what do you think you will do?’ rather than a closed question ‘so, are you going to do physical activity?’ helps remind them that they – not you – are the decision maker. If they are not ready to change now this can be challenging for you, but they might have good reasons to keep things the same for now. Encouraging further reflection can be an important part of the process of helping people to make successful changes over time. Offer an opportunity to follow up on this conversation to review their thoughts about making changes.

Did you know?

Muscle strengthening and balance activities should be done on at least two days per week

The least active individuals stand to gain the most from a small increase in physical activity

Older adults should aim to be active daily, in bouts of at least 10 minutes and total at least 150 minutes per week.

Real impact

Explore opportunities in daily routine

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How do you think you might get started?

Build activity into everyday life
Gardening
MM-Icons-Home Exercise Videos Stand during advert breaks
Housework – doing the hoovering
mm-icons-dhair based activites Avoid prolonged sitting
Bicycle
Walk
Public Transport
MM-Icons-Pool based activities Swimming
Join a group for social interaction and motivation
Walk
Cycle
Dancing
MM-Icons-Home Exercise Videos Online exercise videos

Signpost the activity finder to explore local opportunities

Insight

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Useful questions to ask may include:

  • What easy or enjoyable ways can you think of fitting opportunities to move more into your daily life?
  • What’s the easiest thing you might do?
  • What kind of help might you need?
  • How often do you see yourself doing that?
  • Who might you do that with?

You may need to give some information here – about starting slow and building up, stopping if they notice any particular symptoms, etc.

Reflect back and expand on relevant points from your earlier discussion.

Did you know?

Muscle strengthening and balance activities should be done on at least two days per week

Rather than focusing on frailty and falls risk it is better to start by stressing the benefits of improved strength, balance and aerobic fitness

Brisk walking can be easily incorporated into everyday life for many people and is an acceptable form of physical activity.

Real impact

“Exercises shouldn’t be framed as six weeks, but forever. It only reinforces it as a short term thing.”

Agree a plan

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Can I share with you some things people find helpful when making a plan?

If they agree, ask them which of these might suit them

Share the relevant resource from the list below with your patient

Increase walking

This simple and progressive 12 week walking programme, developed by the ‘PACE-UP’ trial team is proven to help increase walking and health in the long term

Set some goals

Use our active lifestyles workbook to help those who are interested in building resilience and setting structured goals to create a roadmap for behaviour change

Use a diary

Creating a personalised monthly schedule helps work out where, when and how someone can start to fit opportunities to become more active into their own life

Use an app

iPrescribe Exercise is a NHS approved app, which provides a personalised 12 week physical activity plan with tailored support for people with long term health conditions. It is free to use, just add the code ‘moving’ when logging on

Insight

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Aim to keep the focus on the individual generating their own ideas about change, rather than telling and instructing. People are much more likely to make successful changes if they develop their own plans.

Did you know?

Muscle strengthening and balance activities should be done on at least two days per week

Rather than focusing on frailty and falls risk it is better to start by stressing the benefits of improved strength, balance and aerobic fitness

Brisk walking can be easily incorporated into everyday life for many people and is an acceptable form of physical activity.

Real impact

“Exercises shouldn’t be framed as six weeks, but forever. It only reinforces it as a short term thing.”

Troubleshoot

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What might get in the way of your plan?

Get some detail

When people come up with some ideas it’s good to get some detail, so ask them how they might find a way round that and who might help them get there.

Insight

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The pathway to successful behaviour change is seldom straightforward and people have often tried before. It is important to recognise, anticipate and prepare for setbacks and identify the individuals in someone’s life who will be able to support them through difficult periods. There is always more than one path to each destination and it is important to get support along the journey.Encouraging people to think of possible obstacles to success and ways around them can be helpful during the planning phase.

Did you know?

Muscle strengthening and balance activities should be done on at least two days per week

Rather than focusing on frailty and falls risk it is better to start by stressing the benefits of improved strength, balance and aerobic fitness

Brisk walking can be easily incorporated into everyday life for many people and is an acceptable form of physical activity.

Real impact

“Exercises shouldn’t be framed as six weeks, but forever. It only reinforces it as a short term thing.”

Arrange follow up

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What would be helpful for me to arrange for you to follow up on this conversation?

Ongoing support is a key factor of successful behavioural change and clinical services exist to support people through their own journey with frailty and falling.

Useful things to organise for people with frailty and susceptibility to falls may include:

  • A follow up appointment with you or a colleague
  • Referral to a multidisciplinary pain programme
  • Referral to a walking for health or exercise referral programme

Signpost the patient information section, which contains links to physical activity opportunities.

Insight

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Asking this as an open question helps make it clear that what is important is their own personal agenda, not yours. It can be appropriate to follow up by asking permission to share follow up options they may not know about, such as:

  • Exercise on referral schemes are widely available throughout the UK, but their referral criteria and programmes vary. Check the local council’s website or contact the council’s physical activity lead to find out more information.
  • Referral to a multidisciplinary pain programme may be particularly important for people who are fearful of activity, have co-existing mental health problems and have been previously been unsuccessful in becoming more active.

The arrangement of a follow up appointment would also be appropriate for those people deciding not to become more active yet, but who want to ‘think about it some more’ The follow up appointment could be face to face but could also be via telephone or text.

Did you know?

In order to benefit health, research has shown that activities need to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity

Move more by breaking up sitting time – stand up during TV advertisement breaks or walk around the office.

Download this great infographic showing the UK Chief Medical Officers’ recommendations (2019) for physical activity in adults and older adults

Real impact

“I would like a group with people of a similar age and issues to me.”

“Why haven’t I received [physical activity on prescription] before? I have been in pain for many years.”

Signpost support organisations

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There are some great, free resources available here and on other websites by people who understand what it’s like living with your condition if you’d be interested to have a look

Support organisations
Age UK

Age UK are a source of information for classes and local events to help you get more active.

British Geriatric Society

The British Geriatric Society along with Age UK and the Royal College of General Pracitiioners have produced the document ‘Fit for Frailty’ which gives an overview of Frailty and treatment strategies including physical activity.

We Are Undefeatable

“We Are Undefeatable” is a national campaign by 15 leading health and social care charities to inspire and support people with long-term health conditions to build physical activity into their lives, in a way that suits them.

Insight

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People may or may not be interested in accessing information and support groups, but they can offer unique support for people contemplating physical activity behavioural change with their condition. Particularly given the range and reliability of information on the internet, trusted resources are important to highlight.

Did you know?

In order to benefit health, research has shown that activities need to be of at least moderate intensity. For most people, this will mean experiencing an increased heart rate and breathing rate during the activity

Move more by breaking up sitting time – stand up during TV advertisement breaks or walk around the office.

Download this great infographic showing the UK Chief Medical Officers’ recommendations (2019) for physical activity in adults and older adults

Real impact

“I would like a group with people of a similar age and issues to me.”

“Why haven’t I received [physical activity on prescription] before? I have been in pain for many years.”