Interview with Professor Martin Underwood, Health Sciences Research Institute
Published August 2010
Residential and nursing homes have a justifiable reputation for being depressing places. Around two in five of the residential and nursing home residents have symptoms of depression. Each year one in eight of the residents who were well develop depressive symptoms. Social isolation and lack of exercise are both thought to be key contributors, but when people are physically incapacitated these factors are difficult (and expensive) to overcome.
The Older People’s Exercise Intervention in Residential and Nursing Accommodation (OPERA) trial is currently testing one potential solution: a whole home intervention to embed a positive attitude to physical activity within the culture of participating homes; this includes a twice-weekly exercise class run by a physiotherapist. Martin Underwood, a Professor at University of Warwick’s Health Sciences Research Institute who is running OPERA, described how the sessions run.
“Each session runs to music and starts slowly, then builds. It can be quite intense,” he explained. “It lasts for an hour and combines aerobic exercise with strength building. I was out of puff when I took part.” They use specially designed equipment like flexible plastic balls filled with heavy beans, stretchy elastic bands and large inflatable balls. The risk of injury or over-exertion means that extra care is taken in teaching the class - there are only about eight participants at each session - but the class is very social and purposefully so. Increasing social interaction is a key pathway through which the intervention may be effective.
In the homes that have hosted the classes the response has been overwhelmingly positive...
In the homes that have hosted the classes the response has been overwhelmingly positive which is no great surprise: “As expected everyone loves it. It is a good idea in principle. In some homes the trial has come to an end; it proved emotional for both the therapists and the residents. Tears have been shed.” The question is not whether people have fun, however, but whether depression is reduced and the problem is getting someone to agree to pay for the therapists to run the programme. “We must not be fooled,” Professor Underwood warned, “Unless we can prove that the intervention is cost-effective it is not going to happen.” The aim of the trial is to provide evidence that this programme should be offered for free on the NHS.
The currency of the NHS is the cost per Quality Adjusted Life Year (QALY) - a quantity determined by the notional concept of one year of life in perfect health. This is calculated by dividing the overall cost to the NHS of a particular intervention by the amount and quality of life gained from the intervention. The scale used to measure quality of life ranges from zero, a state equivalent to death, to one, a state equivalent to perfect health. Grimly the measure can produce negative values of quality of life, acknowledging that some living circumstances are worse than death.
Typically The National Institute for Health and Clinical Excellence (NICE) accepts that an intervention with a QALY of £20-£30,000 is cost-effective i.e. it represents good value to the NHS. Any new drug or treatment is considered according to this standard - the hope in this instance is that the money saved by the NHS having a healthier elderly population will offset the cost of delivering the intervention. Interestingly the cost compares favourably with that of the drugs for dementia, useful if the activity is linked to slowing the progression of this disease.
Overall the intervention is seeking to challenge the culture of inactivity within homes...
Running the trial is a major exercise. Monitoring the progress of depression without a formal clinical diagnosis, in an environment where many of the people are cognitively impaired and there is a high mortality rate within the group, necessitates careful consideration. Funded by the NHS Health Technology Assessment Programme, the team decided to measure the levels of depression in the whole home. Seventy-eight homes are taking part in the study and over 1,000 residents are contributing data to the study. It is one of the largest studies ever done in residential and nursing homes.
Staff in the control homes receive additional training in depression awareness. In the intervention homes the classes are offered to everyone who is physically capable of taking part whether or not they are depressed. The team have now run the session over 1,400 times with over 14,000 individual attendances. Depressive symptoms are assessed by completing a questionnaire with a research nurse. Overall the intervention is seeking to challenge the culture of inactivity within homes and to nurture social bonds that strengthen outside class.
We strive to break new ground every day.
Keeping up this momentum is a challenge but, by maintaining our research excellence, we continue to go beyond boundaries. That’s why we’re proud of our strong performance in the Government’s Research Excellence Framework (REF) 2014, for both overall grade point average (GPA) and intensity.
We’ve strengthened our position amongst the UK’s ten best research universities. Warwick’s intensity also achieved a top ten ranking, signifying the strength-in-depth of our exceptional body of research staff.
Professor Underwood is Vice-Dean of Warwick Medical School. After GP training in Carlisle Prof Underwood worked for 10 years as a full time general practitioner. He joined Warwick Medical School in 2007. He works as general practitioner in central Coventry for the Sky Blue Medical Group. Professor Underwood has established a substantial track record of community-based research into the improved diagnosis and management of musculoskeletal disorders, particularly back pain and osteoarthritis. He has completed large trials of exercise and manipulation for low back pain, (UK BEAM) and of anti-inflammatory ointments for knee pain (TOIB). Professor Underwood is chief investigator on a current trial of exercise for the treatment of depression in older people living in residential accommodation (OPERA). He has worked on the development of NICE guidelines for both osteoarthritis and back pain.