A health problem in the UAE and the world today, is obesity. We find it in large proportions. The UK and other countries also suffer from this disease. There are many causes of obesity and it affects people locally in the UAE , the UK and the rest of the world. The incidence of obesity is a major problem with many serious effects for the individual and the countries of the UAE , the UK and the world. This study will highlight the problem in the UAE and the UK just to show that the UAE is not the only one afflicted by obesity.

Obesity -what is it?

The problem of obesity is a major one in today’s society, and it is estimated that more than 1 billion people are being classified as obese worldwide .Obesity is an increase in fatty tissue of the body and around organs, and it can cause a variety of bad health problems. Health problems include emotional as well as physical problems, for example, feelings of inferiority, and low self esteem due to an obese look. For children, name-calling, such as “tubby”, “fatty”, “elephant”, or others, as well as bullying from friends can occur. Physical problems are many, and include ones such as high blood pressure, heart disease, and some cancers. Type 2 Diabetes Mellitus (T2DM), where the body can no longer respond to insulin, also happens. This influences the control of blood sugar levels which can rise and fall. In the UAE we have high numbers of diabetes sufferers (Global Arab Network 2010).Estimates show that by 2025, about 300 million people are expected to suffer from diabetes related to obesity. This number is to be double that of 1998 (University Edinburgh).

Obesity is more than just having more weight or being overweight. It is an accumulation of extra body fat which puts the obese (overweight) person’s health at risk, in the form of heart disease and diabetes (Sofsian). Body mass index (BMI) is used by doctors to find out if a person is obese. BMI correlates with height: A normal range is said to be 18.5-25; overweight is 25-30 and a BMI over 30 is considered to be obese (Henderson; Patient UK).

Obesity in the UAE:

There are three main causes of obesity in the UAE , namely diet, lifestyle and education. Firstly, diet is seen as one of the most important causes. The dietary (food) intake of most young Emiratis revolve around foods of a high carbohydrate and high fat content such as deep-fried chicken, French fries, burgers and pizzas. Many stores such as KFC, McDonalds, Pizza Hut and Burger King are well-known and visited on a daily basis. This type of food is eaten more now than in the past due to the UAE having become wealthy after the discovery of oil (ADMC). Stevens (2006), reports that “…a boom in economic development and financial growth for all families in a region did not always come with improved health for the people who lived there. Sometimes that opposite could occur with the new found wealth going into junk food and too much of it”.

Next, the lifestyle of the Emiratis is another reason for obesity. Emiratis of today are less active and doing easier jobs such as desk-work, than in the past when they had to perform physical tasks. Today there is a big number of expatriate workers who do most jobs. Also, there is a general lack of exercise among young and old, male and female . This is mostly due to the weather and a lack of interest in sport or exercise. The healthy few, are mostly those who play football or other sports. Children are mostly found playing computer games in the home and eating too much. More money also means more to spend on food, relaxation and eating out. In some cases, married life also cuts back on exercise and contributes to weight-gain (ADMC).

Thirdly, a lack of knowledge about healthy eating is another cause. There is an idea that the more money a country has, the more food they consume irrespective of the consequences of wrong-eating. Another factor is that there is a general lack of intervention from parents in terms of children’s eating habits and nutritional values. Parents do not stop children from eating wrongly and sometimes give children too many snacks and sweets. An awareness of healthy dietary requirements is also absent (ADMC; Sify 2010; Stevens 2006;Yaqoob 2009 ).

Statistics UAE:

These show that more than 60% of Emirati nationals are overweight and this figure is growing. The World Health Organization (WHO) released the following statistics for 2009:39.9% women are obese, 7th highest in the world and the men 25.6% at the 9th highest. Children in the UAE are also obese and this figure is growing (AMEinfo; Sify 2010; Yaqoob, 2009).

UK

Obesity in the UK is mainly caused by more or less the same factors as in the UAE- overeating; eating the wrong foods; little or no physical exercise/ activity and inheritance. It is shown that about 2 in 5 adults are overweight and a further 1 in 5 are obese (NeLM;Patient UK). According to government statistics 1 in 4 men and 1in 3 women are overweight- 24% for women and 23% for men; however, the rate of men being obese is increasing and at this rate it is estimated that by 2010 about 6.6 million men and about 6 million women will be obese. About 1 in 3 children between the ages of 2 and 15 are overweight (Henderson; IOTF; Lean; Sofsian).The UK is an old developed country and it is long since people moved away from hard physical work. The average UK life is a sedentary one with easier jobs and lots of TV viewing and little exercise. Also, children are less active and stay indoors mostly to play computer games.

Effects

Individuals and the country are affected in many different ways. The biggest effect of obesity on the individual is that of health risks. Heart disease, diabetes, high cholesterol, high blood pressure and osteoarthritis, to name a few, are prevalent among overweight people. Other problems due to obesity are breathing problems, bad knee joints and difficulty walking (Henderson; Sofsian, 2007).

Due to these health concerns the individual’s quality of life drops to a low. Obese people can lose confidence and suffer psychologically- this goes for grown-ups and children (Henderson). A result of this could be depression, mood swings, yo-yo dieting, eating disorders like bingeing and withdrawal symptoms (Patient UK;Yaqoob, 2009). The country as a whole can suffer in the form of big numbers of unhealthy citizens in need of medical care. This could put strain on the government health budget in the form of medical-care, heart- transplants and medication. Sick and unhealthy workers are less productive and this leads to a loss of income for companies and job losses for these workers(Henderson). These workers might influence their children badly with eating habits and lifestyle because they are bad role-models (Ameinfo,2009).

TREATMENT:

Gastric-banding in the UAE to counter Obesity:

What is Gastric-banding, gastric bypass and gastric sleeve?

Gastric banding is an operation performed under general anesthesia. In this procedure, the surgeon places an adjustable band around the top part of the stomach. It creates a small pouch to hold food. The procedure is done by means of key-hole surgery (laparoscope). Food coming into the pouch is held and let through slowly into the stomach, so the person feels fuller sooner and for a longer time and so does not overeat. This is a safe procedure for those who are drastically overweight and cannot seem to eat less (virtualmedicalcentre 2010).

In gastric bypass a step is taken to make the stomach smaller. The surgeon will use staples to divide the stomach into a small upper section and a larger bottom section. The top part of the stomach (called the pouch) is where the food consumed, will go. It holds only a small amount of food. The second step is the bypass. The surgeon will connect a part of the small intestine, called the jejunum, to a small hole in the pouch. The jejunum is farther down from where the stomach normally attaches to the small intestine. Food eaten will now move from the pouch into this new opening into the small intestine. Food now bypasses the lower part of the stomach and the first part of the small intestine, and so the body will absorb less calories (Lee 2009).

In a gastric sleeve operation, up to 80 % of the stomach is removed. The remaining portion of the stomach is pinned together, creating a substantially smaller digestive tract (Shaheen 2009).

Shaheen (2009) reports that doctors are citing increases of up to 500 % in the number of people turning making use of gastric surgery in trying to lose weight and are even operating on patients as young as 12.This operation is not normally performed on younger than 16 years old, but in this case there was no alternative to curb the obesity.

Other Programmes to counter Obesity

In the UAE and the UK the governments have started with programmes to lessen obesity and cut back on the numbers of people suffering from it and dying from the results of obesity (Lean, 2006; Yaqoob,2009). Doctors and health practitioners are trying and investigating numerous ways in which to combat obesity (Pittler & Ernst 2005).

According to Arnold (2009), there are ways and means to overcome the problems of obesity- permanent lifestyle changes in terms of what is eaten, how much is eaten, eating manners and exercise levels. The British Medical Association agrees with the International Obesity Taskforce (IOTF) that, ‘…interventions at the family and school level need to be matched by changes in the social and cultural context so that the benefits can be sustained and enhanced’ (BMA, 2005). This means that there should be good efforts and progress made by the medical workers, teachers, doctors, parents, food manufacturers, and media to help with this effort (Yaqoob,2009). An idea even arose to levy a tax on sweet drinks to discourage consumption (New Scientist, 2009). Also, governmental town planners, architects, politicians and legislators should all play a role to build a better and a healthier society (BMA 2005; Yaqoob, 2009).

Change 4 Life was started in the UK to highlight child obesity. Their slogan is: “Eat well, Move More, Live Longer”. It focuses on reducing TV, video games and indoor play and encourages more outdoor play, movement and sports activities (Callaghan, 2009).

In the UAE the focus is also on exercise and diet ( McMeans 2008 ; Zawya,2009).At a seminar in Dubai, titled “Fat Truth” organized by the Ministry of Health and UNICEF, Dr Mariam Mattar, general manager of Community Development Authority, said that “In our society, there is an exaggerated focus on feeding children, regardless of their nutritional requirements”. In order to control and change the growing number of obese children in the UAE, social attitudes had to change first, according to a senior community doctor and others (Ameinfo,2009; Sify 2010).Schools and families should be encouraged to get children to exercise more and eat better (Baxter 2009).

Conclusion:

Obesity is not confined to the UAE and the UK alone -it is a world-wide problem. Many of the causes and effects for the UAE and the UK , as well as other countries are mostly similar. People are suffering from obesity in both countries and this is causing extreme health problems, and this puts strain on governmental health services. The problem of obesity has been identified and both countries are addressing these in the form of health education, lifestyle changes and exercise initiatives.

Introduction

In the 1960’s the Advance Nurse Practitioner role was initiated as an action plan initiative to resolve the epidemic of having enough accessible primary care physicians in underserved and rural areas to meet the healthcare needs of the community of people (Woo, Lee & Tam, 2017). Advanced nursing practice’s establishment into primary care’s role has expanded into additional healthcare settings like acute care.

Providing acute healthcare needs to patients in a primary care setting from the newly established primary care nurse practitioners, these patients in underserved and rural areas with known acute and chronic health illnesses closed the gaps in care needed to stabilized their health and prevent the potential of decline and exacerbations of their chronic and acute illnesses.

If the healthcare needs of these patients weren’t addressed and provided in timely manner, there was a potential need for urgent, emergent and critical care management need that could have caused a global healthcare epidemic. The expansion of the Nurse Practitioner role has grown in the past decade to an autonomous practice on the same level of a primary care physician.

The scope of practice of a Nurse Practitioner varies from state to state in the U.S. However, the current Nurse Practitioners scope of practice currently is equal to the practice of a primary care physician. The only variation in a Nurse Practitioners scope of practice is whether they have the autonomy to practice on their own or under the delegation of a collaborating physician. Primary care and acute care facilities have grown in the past decade. Nurse Practitioners  It incorporates both emergency and critical care with emergency and primary care advanced nursing practice sharing similarities since they serve as first-contact access to healthcare (Woo, Lee & Tam, 2017).

The expanded Advance Nurse Practitioner’s autonomy to practice lead to the influx of advanced practice registered nurses (APRNS) in the Nurse Practitioner field in the past 10 years has increased the practice and presence of Advance Nurse Practitioners in acute, ambulatory, emergency, long-term and critically ill care settings. (Woo, Lee & Tam, 2017).

Advanced Practice Nurses now serve as first contact when receiving care in the emergency and primary care settings. Acuity of the patient delineates the emergency NP/APNs who are trained to manage patients with critical life- or limb-threatening conditions unlike the primary care NP/APNs (Woo, Lee & Tam, 2017). It’s predicated that in 2020 there will be a 22% shortfall of critical care physicians and another successive shortfall of 35% in 2030 (Woo, Lee & Tam, 2017).

“Efforts are underway for measures to enhance productivity through increasing the capacity of the workforce. One potential measure is a greater utilization of nurses in advance practice. The global annual growth of the nurse practitioner (NP) workforce has been estimated to be between three to nine times greater compared to physicians” (Woo, Lee & Tam, 2017, p. 2).

Background of Antimicrobial Resistance

The first commercialized antibiotic, penicillin, was discovered in 1928 by Alexander Fleming. Germs will always look for way to survive and resist new drugs so ever since the discovery of penicillin there has been an active effort to discover and acknowledge resistance along with the discovery of new antibiotics. (CDC, Antibiotic/Antimicrobial resistance, 2018). Antimicrobial resistance microorganisms are difficult and sometimes impossible to treat. (CDC, Antibiotic/Antimicrobial resistance, 2018). There are a growing number of infections like, pneumonia, gonorrhea, tuberculosis, and salmonella that are a list of infections that are becoming difficult to treat due to the resistance of the usual antibiotic drugs used to treat these infections are becoming resistant (Littmann, 2015).  Identified as one of the major threats in the 21

^st

century to the population’s health globally is antibiotic resistance (Littmann, 2015). AMR is antimicrobial resistance and contributing to the manufacture and spread of AMR are numerous biological, behavioral, economic, environment and social factors (Littmann, 2015). The CDC estimates that 23,000 people are killed a year out of 2 million Americans who develop serious infections involving bacteria that resist one or more antibiotics (Manning, 2016).

In the non-traditional practitioner outpatient ambulatory care setting, Nurse Practitioners account for the mass majority of providers (Sanchez et al., 2016). The appropriate selection of antibiotics is critical to an Advanced Practice Nurse Practitioner goal to provide the best quality care that will decrease length of hospital stays, quicker recovery rates, comorbidities and unforeseen outcomes such as death.  This growing global epidemic of antimicrobial resistant will impact the practice of an Advanced Nurse Practitioner.

Literature review

A comprehensive overview of the articles in the literature review provide the ethical challenges that are causing antimicrobial resistant antibiotics to be one of the greatest threats to human health worldwide (Llor & Berrum, 2014). Prescribing the appropriate medication for advanced practice nurse patient’s disease process is critical but antimicrobial resistance in antibiotics can play a role. In the medical practice antimicrobial agents play a huge role to reliably cure infected patients which has saved countless lives over the last century. (Parsonage et all, 2017). Approxiametly 269 million antibiotic prescriptions were dispensed from outpatient pharmacies in 2015 in the United States. That’s “enough for five out of every six people to receive one antibiotic prescription each year. At least 30 percent of these antibiotic prescriptions were unnecessary” (CDC, Antibiotic Use in the United States, 2017, p. 14). Yearly there are approximately 47 million unnecessary antibiotic prescriptions written by doctor offices and emergency departments in the United States. It was identified that most of the unnecessary prescriptions were written for respiratory conditions that are most often caused by viruses (common colds, viral sore throats and bronchitis) that do not respond to antibiotic therapy or for bacterial infections that don’t always require antibiotics (CDC, Antibiotic Use in the United States, 2017).

It’s a combined collaborative effort that includes compliance to not misuse antibiotics from healthcare providers, the agriculture industry and multiple Federal and Government Agencies. The shortcoming centers on the inconclusiveness of the reviews. One review suggested although NP services in the emergency setting did reduce waiting time and provide care comparable to that of a midgrade physician, the cost of NP services was higher than that of resident physicians. In contrast, another review concluded that the use of NPs reduced the cost of emergency and intensive care services.

Who has taken initiatives to act? The CDC has implemented a plan of action to aid in halting the continued epidemic of antimicrobial resistance. “The Targeted Assessment for prevention (TAP) Strategy is a framework for quality improvement developed by the Center for Disease Control and Prevention (CDC) to use dada for action to prevent healthcare-associated infection (HAIS). The Targeted Assessments comprised of three components: 1) running TAP reports in the National Healthcare Safety Network (NHSN) to identify healthcare facilities with an excess burden of HAIS’s 2) Assess infection prevention standards, guidelines and resources of  those facilities and Implement Guides to address any gaps identified 3) Administering TAP  facility assessments tools to identify gaps in infection prevention. The TAP reports will allow ranking for the facility and will to accessible to the public for review (CDC, TAP, 2019).

The U.S. Federal Government has implemented an Action plan: “The National Action Plan was developed by the Interagency Task Force for Combating Atibiotic0 Resistant Bacteria in response to Executive Order 13676. This National Action Plan addresses policy recommendations from the President’s Council of Advisors on Science and Technology. “By February 15, 2015, the Task Force shall submit a 5-year National Action Plan to the President that outlines specifics actions to be taken to implement a Strategy. The Action Plan shall include goals, milestones, and metrics for measuring progress, as well as associated timelines for implementation” (Exec. Order No. 13676, 2014, p. 56932)

The review of this literature expresses the significance of why all health care providers should be ethically and morally obligated to using antibiotics in the appropriate manner. Due to the restrictions of a growing list of antibiotics that have resistance to known microorganisms the Nurse practitioner and other practitioners are constrained to treating their patients. Inappropriate antibiotic prescribing could result in successful management and care contingent on the patient’s diagnosis and the severity of the illness. Due to the reported limitations in the literature delay in care could lead to unanticipated clinical outcomes such as an acute illness developing into a chronic illness or a life-threatening event.

Application of findings

According to (Sanchez et al., 2016) a major problem that’s contributing to antibiotic resistance were identified as Nurse Practitioners and Physician Assistants in outpatient ambulatory care settings.  The research study referenced in this article “Outpatient Antibiotic Prescribing Among United States Nurse Practitioners and Physician Assistants” reports that the most common condition that antibiotics are prescribed for in the ambulatory care settings are for acute respiratory tract infections.

In many circumstances respiratory tract infections do not warrant an antibiotic prescription, yet this remains common (Sanchez et al., 2014). The classification of data being captured limited the research data analysis. There was a smaller number of visits being captured for NP’s and PA’s in comparison to physicians for antibiotic prescribing by condition and provider type for adult ambulatory care visits. This data leaves room to question its validity. Erroneous data can lead to analysis of imprecise commonness, applicability and information that is common or contraindicatory

.

Healthcare Providers, patient and families, Health Systems, hospitals, clinics, nursing homes and Federal, State and local health agencies has a role to play in improving antibiotic use. (CDC. Antibiotic Use in the United States, 2017).

Implication for the Nurse Practitioner in Primary Care

There is a large volume of Nurse Practitioners presence in the Primary care settings and antimicrobial resistant antibiotics would significantly affect their practice. They perform a crucial function in regulating access to antibiotics, educating patients about antimicrobial resistance and prescribing antibiotics.  Nurse Practitioners need a general understanding of drug resistance when educating patients about antimicrobial resistant antibiotics. This includes how practitioners play a vital role in guaranteeing antibiotics are being used in a correct manner and an understanding of the causative factors that lead to drug resistance.

Conclusion

This global epidemic is best addressed by promotion of a national educational campaign of intervention that’s tailored to confront all areas of deficits that are contributing to this ethical issue. These educational interventions should be available in designated areas for ease of accessibility and include the publication of practice standards and guidelines for review and compliance, offering education to patients, healthcare professionals and targeted deficient areas. The implemented audits should be completed, and the results are reviewed with the public to guarantee compliance and attain measurable data to assess the outcomes of intervention. Continuous audits should be performed intermittently if warranted once completion of all action plans and baseline assessments are obtained. Warnings should be enforced followed by a consistent course of punitive actions if continued non-compliance is acknowledged.

Numerous cultural characteristics linked to country background, socieo-economic influences, cultural beliefs of the patient and the prescriber, patient demand, and clinical independence influence prescribing antibiotics (Llor & Bjerrum, 2014). Advanced Nurse practiotioners’ local standards and guidelines differ from state to state and country to country and they are held accountable to practice within their scope and remain in compliance. Advanced Nurse Practitioners in the United States are held to a higher practice standard since in other countries antibiotics are readily available for use without a prescription. One of the potentially major contributing factors leading to the significant rise in antimicrobial resistance could be this significant cultural and geographic variations in practice standards. Responsible with providing secure, competent and satisfactory care the Advanced Nurse Practitioners in the United States have numerous of barriers to overcome. Instead of accepting new practice guideline standards that may involve a watch and wait period prior to prescribing antibiotics patients expect to go to the doctor and leave with a prescription.

Nurse Practitioners and their collaborating physicians have to mindful not to adapt to prescribing habits and behaviors they may be comfortable to practicing and/or were trained. Even if they are knowledgeable of evidence-based practice standards most are unwilling to adjust. Nurse Practitioners should practice in a manner that is within the best interest of the patient, the practice standards guidelines and the most recent evidence-based practice standards. The belief that endorsed agents are more likely to cure an infection, fear for the patient or parent satisfaction, and fear of infectious complications are motives for non-adherence (Sanchez et al., 2016). Providers are not taking this wide spread epidemic of antibiotic resistance into consideration when prescribing the correct antibiotic therapy.

References

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Worldwide, populations are experiencing increasing life expectancies with more serious chronic illnesses towards the end of life (World Health Organisation (WHO), 2011). In

the UK, 457,000 people require palliative care services annually, however there are significant shortcomings in providing care to all those in need.

In a recent survey, by the Palliative Care Funding Review (2011), it was estimated that 92,000 people are not being reached by palliative care services. After decades of declining death rates, we now face the dual demographic challenges of increasing life expectancy and an incline in chronic illnesses towards the end stage of life. As a result a rise in patients with more complex healthcare requirements could be expected.

Palliative care advocates a holistic, problem-based approach for patients facing terminal disease in order to improve quality of life and symptom control (WHO, 2009).

Studies have shown that, in addition to receiving the best possible treatment, patients want to be approached as individuals and have autonomy regarding decisions affecting their care (Gomes and Higginson, 2008).

This essay aims to discuss how an ageing population will influence the delivery of physiotherapy to the older person in palliative care. It will address the current necessary factors required to meet the needs of the older person whilst also evaluate the barriers preventing access to physiotherapy services in palliative care. The role of the physiotherapist will be evaluated with reference to appropriate and current health care policies.

In order to discuss meeting the needs of the older person, it is essential to establish a definition of the ‘older person’. As defined by WHO (2012) (1) ‘most developed world countries have accepted the chronological age of 65 years as a definition of ‘elderly’ or ‘older person”. Whilst it has generally been agreed by the United Nations (UN) that 60+ years is thought of as the cut-off point when referring to an ‘older person’ (WHO, 2011).

Over the last 25 years, the number of people aged 65 and over in the UK has increased by 18%, from 8.4 million to 9.9 million, and it continues to steadily increase (Office for National Statistics, 2010). Changing demographics mean that on average, people worldwide are living 30 years longer than they did a hundred years ago with life expectancy continuing to increase by approximately 4 months every year (United Nations, 2008). WHO (2011) estimates indicate that by 2050, more than one quarter of the population will be aged 65 years and older.

Whilst changing demographics indicate an inevitable increase in population of the older person, patterns of disease are also changing, with more people dying from multiple debilitating conditions such as cardiovascular disease, neurological conditions, and diabetes. It could be argued that advances in medical knowledge and technology have allowed many patients to live longer, however a paradox of this success is that many will struggle in managing such a wide range of diseases, symptoms, and disabilities towards the end of live (Wu and Quill, 2011). Inevitably the combined pressures of increasing life expectancy and greater numbers of people living with multiple conditions at the end of life mean that pressure will be put on palliative health and social care capacity in order to adapt to these changing demographics (NCPC, 2010).

Palliative care is defined by The World Health Organisation (WHO) as:

‘…an approach that improves quality of life of patients and their families facing the problems associated with life-threatening illness, through prevention, assessment and treatment of pain and other physical, psychosocial and spiritual problems.’

(WHO, 2002)

Physiotherapists are vital members of specialist palliative care teams, with a critical role to play in the management of the older person in palliative care. Physiotherapists work to restore physical function, reduce pain and disability, increase mobility; ultimately improving the life of patients, regardless of life expectancy (Medscape, 2011).

The Association of Chartered Physiotherapists in Oncology and Palliative Care (ACPOPC), guidelines for Good Practice (1993) describes the role of the physiotherapist in palliative care as being:

“. . . To improve the patients’ quality of life by helping to achieve maximum potential of functional ability and independence.”

As recognised by Baldwin and Woodhouse (2011), rehabilitation and palliative care may appear to be at the opposite ends of the spectrum however the World Health Organisations’ definition of palliative care (WHO, 2002) advocates offering support to improve quality of life and maximize functional ability until death. The appropriate physiotherapeutic intervention can allow functional ability and mobility levels to be maximized, thus improving quality of life. This in return promotes independence for the older person facing end of life.

There is sufficient evidence demonstrating that exercise can improve reduced mobility which is so prevalent among the elderly. In a high intensity strength training program of 100 nursing home residents, William (1999) concluded that because of their low functional status and high incidence of chronic disease, there is no segment of the population that can benefit more from exercise than the elderly.

A fundamental core value of palliative care is to allow the older person to feel empowered facing the end of their life. Wikman and Faitholm (2006) describe an empowered patient as a patient who works with the multidisciplinary team to formulate goals and make treatment decisions. A fundamental component of physiotherapy is to establish achievable goals with patients and work in partnership with both the patient and relative to achieve these goals. Within the context of palliative care, realistic joint goal setting gives the patient a measure of control at a time when they are experiencing helplessness and loss of independence (Robinson, 2000).

However, regardless of the evidence demonstrating the benefits of physiotherapy intervention to the older person, the National Institute of Health and Clinical Excellence (NICE) guidelines (2004) found that some patients are still unable to receive access to rehabilitation services. It is suggested that this is due to the patients’ needs not being recognized by healthcare members and a lack of allied health professionals who are adequately trained in the care of patients under palliative care (NICE, 2004).

Despite the important role physiotherapists can contribute and provide to the older person in palliative care, there are current barriers preventing the ageing population from accessing such services. With the current ageing population estimated to increase it is essential these barriers are overcome with measures set in place so that the demands and needs of such changing demographics can be met.

To date, the needs of the older person in palliative care has not been a research priority. Current research predominantly focuses on recommendations on the needs of the older person facing end of life as opposed to formal evaluations of the effectiveness of palliative care (WHO, 2004; WHO, 2011).

Until recently palliative care has been largely focused towards patients with a cancer diagnosis, with a large majority of palliative care research focusing upon palliative care specifically for the cancer diagnosis (Baldwin and Woodhouse 2011). However it is estimated by the National Council for Palliative Care that 300,000 people die each year from progressive non-malignant disease (Royal College of Physicians, 2007). For example, the Coronary Heart Disease Collaborative (2004) concedes that ‘heart failure produces greater suffering and is associated with a worse prognosis than many cancers’ (Baldwin and Woodhouse 2011). Whilst a study by Byrne et al (2009) concludes that there is a scarcity of evidence identifying the palliative care needs of patients with neurological conditions.

Considering that the number of older peeople having prolonged deaths linked to a combination of long-term conditions has been forecasted to increase, the inclusion of non-cancer related diseases within palliative care is essential (Gott and Ingleton, 2011). In correlation with recommendations from WHO (2011) guidelines, in order to meet the care needs of the older person, the dimensions of palliative care need to be expanded to encompass a broader range of conditions. This will require understanding from healthcare staff at all levels.

Discussions of ageing and palliative care assume that ageism is an important factor limiting access to palliative care for the older person. The TLC model of Palliative Care, Jerant et al., (2004) argues that palliative care is viewed as a terminal event rather than a longitudinal process, which as a result causes unnecessary distress to the elderly patient suffering from chronic, slowly progressive illnesses. The TLC model goes on to recognise that palliative care of the older person requires to be viewed as in any care primarily is intended; to relieve physical and emotional complications that often accompany chronic long term end of life diseases and the illnesses associated with ageing (Jerant et al., 2004). Therefore, regardless of whether death is imminent, palliative care should be a major focus throughout the ageing process, with physiotherapy services being readily available to improve symptom control (Jerant et al., 2004).

It can be predicted that physiotherapy services will be required over a prolonged period as a result of the older person facing more long term, chronic debilitating diseases. This emphasizes the need for palliative care teams to draw upon more physiotherapists to ensure the needs of the older person are met during the end of life.

Although changing demographics may suggest that more physiotherapists will be required in order to meet the demands of the older person, the CSP (2004) highlights that in current clinical practice there is already a shortfall of physiotherapists working within palliative care. They further go on to emphasize that a predominant problem in accessing physiotherapy services as part of palliative care is a lack of experienced physiotherapists available CSP (2004). With an increase in ageing population and the changes in demographic trends of long term chronic conditions, a shortage of physiotherapists within palliative care teams will detract from the delivery of effective care packages to patients.

Worldwide, it is recognised that physiotherapy in palliative care is a specialist field of practice. Physiotherapists are required to have years of experience before they become involved in palliative care (WHO, 2011).

Specialist palliative care is defined by the NCPC as a multidisciplinary approach, providing a variety of specialist services to patients facing end of life, either as a result of the ageing process or terminal illness. There is compelling evidence to demonstrate that compared to conventional care, specialist teams improve satisfaction and identify dealing more with patient and family needs, whilst they can also reduce the overall cost of care by reducing the time patients spend in acute hospital settings (House of Commons Health Committee, 2004)

It is the ability to call upon a broad range of health professionals in specialist palliative care teams that provides care responsive to the older patient’s individual needs. However, physiotherapists are only infrequently incorporated into specialist palliative care teams (CSP, 2004). In order for physiotherapists to be able to meet the demands of changing demographics of the ageing population it is essential that the role of the physiotherapist within palliative care is defined. Although NICE Guidelines on Supportive and Palliative Care (NICE, 2004) set aims relevant to the physiotherapeutic profession, whilst NICE (2011) guidelines on Palliative Care also state that physiotherapists are able to provide specialist skills, there is a lack of specific mention of physiotherapists and the role contributed. Proposals, such as NICE guidelines on Palliative Care (2011) and recommendations by WHO (2011) emphasis the importance of a multidisciplinary approach to palliative care however mentions of specialist palliative care teams are restricted to doctors, nurses and careers. Although guidelines recommend rehabilitation to be available to all patients, the role and effectiveness of the physiotherapist is not highlighted.

The NHS Cancer Plan (2000) outlines palliative care guidelines to ensure patients receive the right healthcare services and support, as well as receiving the best, most holistic treatment. However in contradiction to this it has been found by Montagnini, Lodhi and Born (2003) that in the palliative care setting, rehabilitation interventions are often overlooked and underutilized, despite patients demonstrating high levels of functional disability.

The Chartered Society of Physiotherapy (2004) have raised concerns regarding this as by excluding the attributes of specialist physiotherapists from specialist palliative care teams will be detrimental to patient care. More research is therefore required to identify the value and effectiveness of physiotherapy intervention for the older person under palliative care. Furthermore, it is essential that palliative care core guidelines are not just limited to medical teams and that physiotherapists are also recognised and identified as core members of specialised palliative care teams. This will allow for the development and production of a recognised clinical career structure for physiotherapists working in palliative care and thus to keep up with the changing demographics of ageing populations.

Specialist palliative care teams encompasses hospice care, including services such as inpatient services, day care and community care as well as a range of advice, education, support and care (NICE, 2011). Given that a common problem presented by the older person is a functional decline in mobility, a major barrier preventing the older person from accessing palliative care services are difficulties leaving the home. Worryingly, physical inactivity has been demonstrated to correlate to an increase in premature deaths of patients under palliative care services, therefore it is essential that provisions are put in place for patients unable to access palliative care services (Pate et al, 1995 and Bryan et al,2007).

There is great advantage of the older person receiving physiotherapy in their home setting as not only does it provide familiarity but it grants patient centred holistic care. Whilst it has also been found that the older person, in specific those with dementia, have been shown to demonstrate greater progress and benefits when treated in a familiar setting such as the home setting rather than the clinical setting (REWORD AND REF REF 2).

However as stated by Kumar and Jim (2011), the scope of physiotherapy practice is influenced by the ratio of qualified physiotherapists to the population. Therefore in order to meet the needs of the older person under changing demographics, the scope of physiotherapy services within palliative care will be required to expand, with more physiotherapists being readily available to treat the older person in outpatient and home settings.

CONCLUSION