Healthy Aging Policies in the UK

Introduction:

It has been observed as of late that there is a significant achievement with regard to increased expectancies of life and this should be vividly attributed because of the huge success in the field of public health and progressive development of medical facilities (Ward, Parikh, and Workman, 2011). However, it has also been evidenced that a significant proportion of those extra years in the later period of life are spent with poor health conditions (ONS, 2017). Today, men aged around 65 can expect to live another 19 years, but only 10% of those will be able to spend their last days in good health. Similarly women who are aged around 65 can expect to live another 21 years, but only 11% will be able to carry on their last days in good condition of health and well being (ONS, 2017). There are varied policies with regard to healthy or active ageing in the United Kingdom such as The National Service Framework for Older People, Better Health in Old Age, A New Ambition for Old Age, Choosing Health, 2004, Our Health, Our Care, Our Say, 2006 and the Prevention Package for Older People set by the PHE and NHS (Age, U. K., 2010). However, there are still significant inequalities with regard to healthy life expectancy, for people in lower socio-economic groups spending a larger proportion of their later life in poor health (Age, U. K., 2010). There is no doubt that good health is a fundamental factor to ensure a good quality of life (Mayhew, 2005). Good health allows us to remain independent, to work or get involved in our local community, to maintain our social connections and family life and to do many other things that give us meaning and purpose in life. There are huge opportunities to support active ageing such as the proper diet, abstinence of smoking and alcohol consumption, strict adherence to long term medications, performing required amount of physical activities and to remain occupied with an occupation in their leisure time to overcome any psychological impediments enable more people to live well, actively contribute to society and reduce the demand for health and social care facilities in turn diminishing the total expenditures for the health care by an individual (Mayhew, 2005). A key part of healthy ageing is enabling the matured adult individuals to maintain their functional ability, even if they are living with a long-term condition or disability or eventually experiencing reduced capacity. The impact of ageing may be significantly averted if the above mentioned preventative health strategies are implemented to decrease, delay, or prevent frailty (Stephens, Breheny, and Mansvelt, 2015).

Tai Chi physical activity or often referred as “meditation in motion” , comprising the body, brain and spirit is a form of intervention that was scarcely explored within the community settings and is the chosen occupational therapy for this assignment for the focus group population of dementia. The existing focus on care approach for people with dementia has been on provision of self-care and offering support to them that involves personal care, eating and drinking, washing, dressing, and grooming. Therefore, this assignment will seek to critically discuss the utilization of occupational therapy practice and service provision for the elderly dementia service users, along with recommendation for the promotion of active (successful) ageing (Lyu, Li, Rong, Wei, Huang, et al. 2018).

The World Alzheimer Report 2009, which used a meta-analysis of prevalence studies, estimated that globally 35.6 million people aged over 60 (4.7% of that age group) would be living with dementia by 2010, and will rise to 115.4 million people by 2050. In this regard, Mathews et al., (2016) exerts that with a yearly projection of 209,600 new cases of dementia in UK, it is considered to be a significant health care challenge for the UK government. Indeed, a decline in over dependency on public funded care for the elderly is economically and socially desirable and can be only achieved with creative adjustments and interventions for the care of the elderly adults.

Occupational therapists focuses on enabling an individual’s participation in chosen everyday activities (White, 2016), therefore they are well placed to provide assistance needed in this area (NICE, 2008). The type of the disorder experienced by people will determine the type interventions applied to mitigate the functional challenges faced. In addition to direct assistance to those living with dementia, occupational therapist also assists carers and families of a person with dementia to understand issues of dementia and help them to develop strategies and skills necessary for promotion and comfort. Several past confirmations had discussed that the different kinds of interventions used for supporting dementia patients, includes pharmacological (drugs for slowing down the manifestations of degenerative symptoms) and non-pharmacological (cognitive stimulation therapy (CST), reminiscence therapy, validation therapy, reality orientation, multisensory stimulation: snoezelen rooms, aromatherapy and physical exercise) interventions. The kind of intervention strategy depends on the types of disorder affecting an individual (Spector, Orrell, and Woods, 2010; Davies, Kehoe, Ben-Shlomo, and Martin, 2011). However, for the purpose of this essay my focus will be on the use of the form of physical exercise cum meditation Tai Chi, reported to have immense benefits (Lim, 2019; Lam, 2014; lyu et al., 2018), yet not frequently used for the patients of dementia. It is evident that physical exercises show varied benefits to people who do not have a cognitive impairment, but exercise is also beneficial for people with dementia, particularly for those who once led a very active life (O’ Connor et al, 2009). Therefore a critical analysis will be conducted to examine the occupational therapy practice and service provision for older people aged 60 years and above living with dementia and ultimately formulating recommendation to promote active (successful) ageing based on Tai Chi therapeutic practice within occupational therapy practice framework. The key terms used in this essay will be defined, along with the discussion on the challenges confronting by the current occupational therapies or service provision in the promotion of active (successful) ageing.

Definitions of Key Terms:

Active ageing:

The WHO 2002 policy framework defined active ageing as “the process of optimising opportunities for health, participation and security to enhance quality of life as people age”. Economy, behaviour, person, society, health and social services were considered to be the 6 key determinants of active ageing (WHO, 2011,p.5; WHO, 2010; Kalache, 1999; Amarya, Singh, and Sabharwal, 2018).

Dementia

It’s a syndrome which results in the deterioration of memory, thinking, behaviour and the ability to perform everyday activities by an individual (WHO, 2017). It encompasses many diseases that are usually chronic or progressive in nature (Cheng, 2016). It is caused by neuro degeneration or a loss of nerve cells within brain and the loss of important nerve connections (Psychological Association (2015). The deterioration that occurs among the patients of dementia is more rapid in comparison to the normal aging process among matured adults.

Health promotion:

It can be defined as a procedure of empowering individuals to expand authority over, and to improve, their wellbeing. It's similarly and basically takes into consideration about making the requirements essential for wellbeing at individual, organisational, social, and ecological levels through a comprehension of the determinants of wellbeing which includes harmony, shelter, training, nutrition, financial requirements, a steady biological system, feasible assets, social equity and values (Trentham and Cockburn, 2005).

Healthy Ageing:

The process of healthy ageing is characterized "as the way toward creating and keeping up the capacity of functioning that empowers health and prosperity in more established age. (WHO, 2015).

Challenges to Active Ageing in Current Occupational Therapy Practice:

A detailed examination of active ageing and myriad of challenges besetting occupational therapy in community practice and service provision shall be explored in this section. The process of maturing is joined by an expanded danger of varied maladies with loss of working on a few substantial physical parts and mental areas (Kusumastuti, et al., 2016). On the other way round it can be highlighted that safeguarding of wellbeing and working is basic for effective maturing (Anton et al., 2015), and fruitful maturing is farthest evolved in the space of proper working of physical parts. With the passage of time, successful and healthy ageing has transformed into active ageing. In this regard, Foster and Walker (2015) introduce a more holistic, life course-focused approach to manage ageing, as opposed to Rowe and Kahn, 1997 according to whom the concept of successful ageing is a combination of three components: prevention of any kind of disease and disabilities, high cognitive and physical function, and quality engagement with life. The aspect of staying dynamic in the later part of life is the fundamental part of healthy ageing. For maintaining the active functioning of body parts routine practice of physical activities, which essentially incorporates muscle strengthening and aerobic activity , however the uptake of and adherence to physical activity programmes by older people can be variable based on individual tolerance limit (Goodman et al. 2010). With the progress of age, several evidences had suggested earlier that there is decline within a broad range of cognitive functions such as memory, attention, and executive functions that significantly contributes to reduced functional ability and eventually development of physical disability (Salthouse 2012;Woods, Cohen, and Pahor 2013;Woods, Mark, Pitts, and Mennemeier 2011). Therefore, participation in meaningful occupations will promote occupational performance and in turn will contribute to good health and wellbeing (Baum and Christiansen, 2005) Unfortunately, the existing prevention occupational programmes that target older adults are inadequate and disorganized, and not implemented within the framework of programmes with significant measurable outcomes. Active ageing places greater emphasis on independence, partnership working and active participation, as well as prioritising quality of life (Fernandez-Mayoralas et al., 2015). However, Archer et al., (2013) added to the above statements that it encompasses the truly well-lived life, portrayed by a sense of vigour and independence, liberation from any bodily pain and continued involvement in meaningful activities. The most recent ten years of government strategy have included rehashed responsibilities to accomplishing the objective of ageing healthy. The space between strategy goal and field execution has not been resolved yet. The National Service Framework for Older People was developed with an objective to augment the healthy life among older adults and the action was co-ordinated by NHS along with the local support of councils. However, within 2010, it was classified as 3 tier priority that refers to it as an option for the local primary trust care to implement it or not. Again the Better Health in Old Age was considered to be as positive response against NSF but it also lost its importance within 2006. Along these lines A New Ambition for Old Age was updated as a part of NSF to stress upon the economic aspects of health promotion activities for the matured adults. The Prevention Package for Older People was published to make available all the resources for the independence, health and prosperity of old individuals. All the available resources to till date are upon the following context such as services with regard to care of foot, hearing impediments, falls and the urgent care service required after the release from the healthcare organisation (Age, U. K., 2010; Age, U. K., 2013). The role played by the occupational therapist for the patients of dementia are educating the carers and the family members of the patients about the condition those who are in the initial phase of dementia. However, for those patients who are under the prolonged care service within a health care setting, the therapists can assist them to restore or at least retain their functioning capacity that can be achievable. As per the guidelines of the American Occupational Therapists Association (AOTA) different strategies could be used by then with regard to the patients of dementia namely promotion of health, restoring of the physical functioning capacity, keeping up the skills as long as possible and augmentation of the secured and supportive environment through adjustment and chasing. Therefore, their role is multi dimensional as they assist the patients not only to improve their functions but also augments the development of personal relationships (Edwards, 2015).

The factors that were considered to be as obstacles to active ageing and shows significant impact upon NHS and social care services are discussed in Appendix 1.

Using Tai Chi Physical Exercise as Therapeutic intervention for Dementia:

The capacity to perform occupations on a daily basis (occupational performance) positively affects wellbeing and prosperity of elderly individuals (Bar and Jarus, 2015). With the progress of time, dementia has become a growing problem worldwide and requires urgent interventions that will effectively manage and enhance their function amongst this population (Collier, et al., 2010; McDonnall, 2011). Past evidences had revealed that physical exercises is widely considered as one of the effective approaches for the prevention and management of falls risks amongst people living with dementia. Based on the findings provided by a systematic audit it was confirmed that several other therapeutic approaches have been shown to be effective for fall prevention among older adults such as either exercise as a single intercession or a joint effect of physical activities, pharmacological approach, knowledge and safety assessments at home along with modifications (Age, U. K., 2013). Among the physical activities utilized in the current practice are the strength training, Fall Management Exercises (FaME), the well known exercise type known as Otago Exercises and graded physical activities programmes (Age, U. K., 2013). The further importance of activity programmes is discussed in Appendix 2: Interestingly, several evidences had suggested along these lines that programmes based on aerobic and resistance exercise such as Tai chi, can be used to restore or maintain functional independence among older adults, and may also potentially prevent, delay, or reverse frailty (de Vries et al., 2012; de Labra et al., 2015). Scientific proofs has additionally demonstrated that Tai Chi is a fitting activity for people with dementia in the beginning stages, which improves personal satisfaction, working of cerebrum to initiate the reproduction of neurons and Tai Chi therefore could turn into a developing elective treatment for individuals with dementia. The subject of discussion “Cognition Protecting Tai Chi” is uncommonly intended for matured adult individuals with gentle dementia by the examination group of multidisciplinary experts. Current pharmacological intercessions used to keep up intellectual capacity, for example, memantine and acetylcholinesterase inhibitors, have restricted viability, and there are generally associated with contradictions. Similarly the usual and atypical antipsychotics for the treatment of dementia have the equivalent or even extreme adverse reactions. The process of Tai Chi requires mind fixation and moving the parity of body as per delicate and smooth developments and consistent relaxation according to the hypothesis of conventional Chinese medication (Lyu, et al. 2018). As the idea of Tai Chi practice fortifies the muscles of lower appendages of the body, it improves soundness and limits the danger of falls. Tai Chi is a suggested practice for fall anticipation in more aged individuals by the American Geriatrics Society, since it improves strong quality, coordination and balance, and is a pleasant action with a potential as a drawn out exercise regime. Tai Chi preparing procedure rehearsed with an accomplice advances a soothing private communication between the two people which in turn improves exercise adherence and state of mind in more aged individuals with dementia (Rogers, 2016; Scott, 2008; Cavegn, 2011). Despite positive reviews for use of physical activity, to date, only one non-pharmacological intervention with a focus on cognitive symptoms, cognitive stimulation therapy, is routinely recommended (National Institute for Health and Clinical Excellence [NICE], 2012). As highlighted in the National Service Framework – for older people, the impact of falls goes far beyond the physical injury, it also has significant consequences for an individual such as psychological problems, for example a fear of falling and loss of confidence and social isolation from lack of mobility and depression.

There are many studies on measures to prevent falls (Chan et al., 2018). A recent review of 111 randomised trials involving over 55,000 subjects singled out tai chi as individually prescribed exercise programmes to be effective (Lam, Kircher and Miller, 2013). Tai chi is a form of physical activity, originally developed as a martial art, is typically taught as a series of slow, low-impact movements that integrate the breath, mind, and physical activity to achieve greater awareness and a sense of well-being. Tai chi intervention is considered to be superior to many other interventions used because it has severe impact on all domains of cognitive functions such as visuospatial skills, semantic memory, learning memory, and self-perception of memory. The dementia patients usually have impairment in one to two cognitive domains. Consequently, cognitive impairment, considered as one of the most crucial fall risk factors amongst dementia people, could considerably benefit from the use of tai chi therapy to mitigate this risk. Hence, unlike any other group of the patient, tai chi intervention is most suitable for the patients living with dementia to improve cognitive function of the patients (Yang, 2011; Lim, 2019; Tao, 2017; Wayne, 2014). .

The study of Zhong et al. (2019), also affirmed that practicing Tai Chi intervention can increase the way of balance through the practice of soft and gentle movements of the different parts of the body. The study also states that Tai Chi is very easy to practice, and it is not limited due to the availability of any particular space. In order to provide mental and physical peace, in this intervention process muscle relaxation exercise, relaxed breathing exercises are practiced by the individuals. This therapeutic intervention is guided by the Kawa model. Dementia is characterised with a decline of memory functioning and performance, however there is no heterogeneity in the ways of its symptomatic manifestations among different individuals. Kawa model, as the only occupational therapy model that dwells on valuing the needs of a group or a community over the individual, represents a departure from traditional ways of thinking about human occupation (Turpin and Iwama, 2011; Iwama, 2006). Kawa model recognises that client, is not limited to the individual, and but may consist of family members, carers and others who act in their best interest (Turpin and Iwama, 2011). Therefore, occupational therapists use Kawa, a model with an understanding that many cultural influences could promote or hinder the success of therapy especially amongst the elderly dementia client group. COPM outcome measure and Kawa model would jointly enable an open dialogue between client and therapist on issues of importance based on the self report of client in order to promote client-centeredness and occupation-focused goal-oriented intervention (Christiansen et al., 2005; Kielhofner, 2008).

Using Occupational Therapy to Support Active (Healthy) Ageing:

Occupational therapy is strategically positioned to play very important role in supporting active (successful) ageing because of dearth of medical facilities for ageing. Few therapies have been identified to improve functional performance among aged adults; however, there are currently no MHRA-approved medications for the treatment of functional decline in older adults. In line with the National Service framework – for older people, an occupational therapy works in partnership with the patients, their family and multidisciplinary team towards achieving the aim of reducing the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen in hospital and community settings. This is approached is further enhanced by the NICE (2018) guidelines for assessment of dementia patients, with a recommendation that management and support should take a person-centred client-focused approach for the care of the elderly with dementia. The guideline also recommends that range of activities offered should aim to promote wellbeing that are adapted based on individual preferences including the use of occupational therapies to promote the functional ability of the individuals. Therefore, this guideline recognises the very crucial role that occupational therapists play in the care of elderly and people living with dementia. A number of options by which occupational therapist can help to promote active (successful) ageing has been proposed based on evidences. As enunciated by Clemson and Laver (2014) thorough the use of evidence based practice (EBP) which focuses on self-management, relapse prevention, fall prevention, and employment which is rapidly developing and the clinical evidence with respect to the application of Tai Chi had been discussed

Active (successful) ageing in the UK:

Occupational therapists strive to see their clients through a holistic lens, looking at how personal factors interplay with the progression of the disease. However, taking a holistic view also means taking an even wider lens and accounting for how public health issues are impacting our patients and how the provision of health care is itself, part of the public health framework specifically related to the use of occupational therapy to support and promote the mental wellbeing and independence of older people (Edwards, 2015). NICE (2016) provides specific suggestion in this area, covering occupational therapy interventions, as well as developing training programmes by the healthcare professionals along with occupational therapist at the centre for the “cognitive rehabilitation” of patients with gentle to considerate forms of dementia.

Recommendations:

At this juncture, the future recommendation for the occupational therapist is to involve Tai chi interventions as part of multidimensional intervention so that patients can experience active and comfortable ageing to extend life expectancy as well as the quality of life (Lyu et al. 2018). The occupational therapist must involve family members of the dementia patient in the intervention so that patients feel empowered, compassionate and safe and experience reduced fear of fall (Buric et al. 2017). For promoting active ageing and supporting patients with dementia, the occupational therapist must acquire a range of skills such as sound knowledge of the tai chi intervention, excellent observation skills, attention to the details and excellent communication skills (Liao et al. 2018). To promote the active ageing, the occupational therapist must ensure that patients are receiving a high quality of care in accordance to the Mental Capacity Act 2005 for promoting active ageing (Donnelly 2016.). Moreover, the occupational therapist must ensure that patients are receiving a high quality of care complying with the 'active ageing' framework 2015 so that they can experience active ageing. Hence, to gather experience and perception of the patients, it is crucial that occupational therapist must use outcome measures such as, COPM so that they can apply this in the practice for empowering patients and improving their quality of life (Christiansen et al., 2005; Kielhofner, 2008). The health and social care system should provide a wider and renewed selection of health awareness and promotion. Health prevention and community-based services for older citizens must enable and empower them to make considered and individual choices. New services should focus on rehabilitation, improving and maintaining functioning in daily life skills and the implementation of new technologies to enable the older people to stay in their own homes with dignity and fulfil their roles by engaging in occupations of their choice in order to support their participation in society. Public health strategies should aim to reduce the incidence and the impact of falls, through actions that encourages appropriate strength enhancing physical activity such as Tai Chi which for the effective management of falls (Burton et al., 2015). In conclusion it can be perfectly summarised with the aid of statement by Christiansen (2010) “A functional life devoid of meaning is merely existence, not living. Robots perform tasks, people engage in life activities to create and derive meaning”

Conclusion:

This paper has critically examined and discussed the use Tai Chi, a developing form of physical activity as important occupational therapy intervention for helping older adults with dementia. Throughout the essay, the role of occupational therapy with regard to the management of care for elderly people with dementia was clearly demonstrated and it is very vital to keep the ageing populace of the UK active and healthy to encounter the current global socioeconomic challenges. The challenges faced by the existing therapy practices were discussed along with the rationale of choosing Tai Chi as an effective intervention based on evidence based practice for the focus group population of elderly dementia patients.

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