Keri Lockwood

A multifactorial interdisciplinary intervention reduces frailty in older people: randomized trial

BackgroundFrailty is a well known and accepted term to clinicians working with older people. The study aim was to determine whether an intervention could reduce frailty and improve mobility.MethodsWe conducted a single center, randomized, controlled trial among older people who were frail in Sydney, Australia. One group received an intervention targeting the identified characteristics of frailty, whereas the comparison group received the usual health care and support services. Outcomes were assessed by raters masked to treatment allocation at 3 and 12 months after study entry. The primary outcomes were frailty as assessed by the Cardiovascular Health Study criteria, and mobility as assessed by the Short Physical Performance Battery. Secondary outcome measures included disability, depressive symptoms and health-related quality of life.ResultsA total of 216 participants (90%) completed the study. Overall, 68% of participants were women and the mean age was 83.3 years (standard deviation, 5.9). In the intention-to-treat analysis, the between-group difference in frailty was 14.7% at 12 months (95% confidence interval: 2.4%, 27.0%; P = 0.02). The score on the Short Physical Performance Battery, in which higher scores indicate better physical status, was stable in the intervention group and had declined in the control group; with the mean difference between groups being 1.44 (95% confidence interval, 0.80, 2.07; P <0.001) at 12 months. There were no major differences between the groups with respect to secondary outcomes. The few adverse events that occurred were exercise-associated musculoskeletal symptoms.ConclusionsFrailty and mobility disability can be successfully treated using an interdisciplinary multifaceted treatment program.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000250336

Frailty Intervention Trial (FIT)

BackgroundFrailty is a term commonly used to describe the condition of an older person who has chronic health problems, has lost functional abilities and is likely to deteriorate further. However, despite its common use, only a small number of studies have attempted to define the syndrome of frailty and measure its prevalence. The criteria Fried and colleagues used to define the frailty syndrome will be used in this study (i.e. weight loss, fatigue, decreased grip strength, slow gait speed, and low physical activity). Previous studies have shown that clinical outcomes for frail older people can be improved using multi-factorial interventions such as comprehensive geriatric assessment, and single interventions such as exercise programs or nutritional supplementation, but no interventions have been developed to specifically reverse the syndrome of frailty.We have developed a multidisciplinary intervention that specifically targets frailty as defined by Fried et al. We aim to establish the effects of this intervention on frailty, mobility, hospitalisation and institutionalisation in frail older people.Methods and DesignA single centre randomised controlled trial comparing a multidisciplinary intervention with usual care. The intervention will target identified characteristics of frailty, functional limitations, nutritional status, falls risk, psychological issues and management of chronic health conditions. Two hundred and thirty people aged 70 and over who meet the Fried definition of frailty will be recruited from clients of the aged care service of a metropolitan hospital. Participants will be followed for a 12-month period.DiscussionThis research is an important step in the examination of specifically targeted frailty interventions. This project will assess whether an intervention specifically targeting frailty can be implemented, and whether it is effective when compared to usual care. If successful, the study will establish a new approach to the treatment of older people at risk of further functional decline and institutionalisation. The strategies to be examined are readily transferable to routine clinical practice and are applicable broadly in the setting of aged care health services.Trial RegistrationAustralian New Zealand Clinical Trails Registry: ACTRN12608000250336.

Treating frailty-a practical guide

Frailty is a common syndrome that is associated with vulnerability to poor health outcomes. Frail older people have increased risk of morbidity, institutionalization and death, resulting in burden to individuals, their families, health care services and society. Assessment and treatment of the frail individual provide many challenges to clinicians working with older people. Despite frailty being increasingly recognized in the literature, there is a paucity of direct evidence to guide interventions to reduce frailty. In this paper we review methods for identification of frailty in the clinical setting, propose a model for assessment of the frail older person and summarize the current best evidence for treating the frail older person. We provide an evidence-based framework that can be used to guide the diagnosis, assessment and treatment of frail older people.

A randomised trial of hip protector use by frail older women living in their own homes

Objectives: To investigate the efficacy and effectiveness of hip protectors in frail community living older women. Design: Randomised controlled trial. Setting: Aged care health services in New South Wales, Australia. Patients: 600 women 74 years of age or more (mean age 83 years), who had two or more falls or one fall requiring hospital admission in the previous year, and who lived in their own homes. Intervention: Use of hip protectors. Main outcome measures: Adherence with use of hip protectors, falls, incidence of hip fracture, and adverse effects of use of hip protectors. Results: Adherence was approximately 53% over the duration of the study and hip protectors were worn at the time of 51% of falls in the intervention group. The risk of hip fracture when falling while wearing hip protectors, compared with a fall with no hip protectors in place, was significantly reduced (relative risk (RR) 0.23, 95% confidence interval (CI) 0.08 to 0.67). On an intention to treat analysis, 21 and 22 hip fractures occurred in the intervention and control groups respectively (adjusted RR 0.92, 95% CI 0.51 to 1.68). Three users of hip protectors sustained a hip fracture while wearing properly applied protectors, while 16 hip protector users (5%) developed minor local complications. Conclusions: Hip protectors prevent hip fractures in community dwelling older women if worn at the time of a fall. The overall effectiveness of hip protectors was not established in this study, because of incomplete adherence with use of the protectors, and limited statistical power.

Effect of a multifactorial interdisciplinary intervention on mobility-related disability in frail older people: randomised controlled trial

BackgroundInterventions that enhance mobility in frail older people are needed to maintain health and independence, yet definitive evidence of effective interventions is lacking. Our objective was to assess the impact of a multifactorial intervention on mobility-related disability in frail older people.MethodsWe conducted a randomised, controlled trial with 241 frail community-dwelling older people in Sydney, Australia. Participants were classified as frail using the Cardiovascular Health Study definition, did not have severe cognitive impairment and were recently discharged from an aged care and rehabilitation service. The experimental group received a 12 month multifactorial, interdisciplinary intervention targeting identified frailty components. Two physiotherapists delivered a home exercise program targeting mobility, and coordinated management of psychological and medical conditions with other health professionals. The control group received usual care. Disability in the mobility domain was measured at baseline and at 3 and 12 months using the International Classification of Functioning, Disability and Health framework. Participation (involvement in life situations) was assessed using the Life Space Assessment and the Goal Attainment Scale. Activity (execution of mobility tasks) was measured using the 4-metre walk and self-report measures.ResultsThe mean age of participants was 83.3 years (SD: 5.9 years). Of the participants recruited, 216 (90%) were followed-up at 12 months. At this time point, the intervention group had significantly better scores than the control group on the Goal Attainment Scale (odds ratio 2.1; 95% confidence interval (CI) 1.3 to 3.3, P = 0.004) and Life Space Assessment (4.68 points, 95% CI 1.4 to 9.9, P = 0.005). There was no difference between groups on the global measure of participation or satisfaction with ability to get out of the house. At the activity level, the intervention group walked 0.05 m/s faster over 4 m (95% CI 0.0004 to 0.1, P = 0.048) than the control group, and scored higher on the Activity Measure for Post Acute Care (P < 0.001).ConclusionsThe intervention reduced mobility-related disability in frail older people. The benefit was evident at both the participation and activity levels of mobility-related disability.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ANZCTRN12608000507381.

Effect of a multifactorial, interdisciplinary intervention on risk factors for falls and fall rate in frail older people: a randomised controlled trial

BACKGROUND frail older people have a high risk of falling. OBJECTIVE assess the effect of a frailty intervention on risk factors for falls and fall rates in frail older people. DESIGN randomised controlled trial. PARTICIPANTS 241 community-dwelling people aged 70+ without severe cognitive impairment who met the Cardiovascular Health Study frailty definition. INTERVENTION multifactorial, interdisciplinary intervention targeting frailty characteristics with an individualised home exercise programme prescribed in 10 home visits from a physiotherapist and interdisciplinary management of medical, psychological and social problems. MEASUREMENTS risk factors for falls were measured using the Physiological Profile Assessment (PPA) and mobility measures at 12 months by a blinded assessor. Falls were monitored with calendars. RESULTS participants had a mean (SD) age of 83.3 (5.9) years, 68% were women and 216 (90%) completed the study. After 12 months the intervention group had significantly better performance than the control group, after controlling for baseline values, in the PPA components of quadriceps strength (between-group difference 1.84 kg, 95% CI 0.17-3.51, P = 0.03) and body sway (-90.63 mm, 95% CI -168.6 to -12.6, P = 0.02), short physical performance battery (1.58, 95% CI 1.02-2.14, P ≤ 0.001) and 4 m walk (0.06 m/s 95% CI 0.01-0.10, P = 0.02) with a trend toward a better total PPA score (-0.40, 95% CI -0.83-0.04, P = 0.07) but no difference in fall rates (incidence rate ratio 1.12, 95% CI 0.78-1.63, P = 0.53). CONCLUSION the intervention improved performance on risk factors for falls but did not reduce the rate of falls. TRIAL REGISTRATION ACTRN12608000250336.

Effectiveness of a multifactorial intervention on preventing development of frailty in pre-frail older people: study protocol for a randomised controlled trial

Introduction Frailty is a major concern due to its costly and widespread consequences, yet evidence of effective interventions to delay or reduce frailty is lacking. Our previous study found that a multifactorial intervention was feasible and effective in reducing frailty in older people who were already frail. Identifying and treating people in the pre-frail state may be an effective means to prevent or delay frailty. This study describes a randomised controlled trial that aims to evaluate the effectiveness of a multifactorial intervention on development of frailty in older people who are pre-frail. Methods and analysis A single centre randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. Two hundred and thirty people aged above 70 who meet the Cardiovascular Health Study frailty criteria for pre-frailty, reside in the community and are without severe cognitive impairment will be recruited. Participants will be randomised to receive a multifactorial intervention or usual care. The intervention group will receive a 12-month interdisciplinary intervention targeting identified characteristics of frailty and problems identified during geriatric assessment. Participants will be followed for a 12-month period. Primary outcome measures will be degree of frailty measured by the number of Cardiovascular Health Study frailty criteria present, and mobility measured with the Short Physical Performance Battery. Secondary outcomes will include measures of mobility, mood and use of health and community services. Ethics and dissemination The study was approved by the Northern Sydney Local Health District Health Research Ethics Committee (1207-213M). The findings will be disseminated through scientific and professional conferences, and in peer-reviewed journals. Trial registration number Australian New Zealand Clinical Trials Registry: ACTRN12613000043730.

Improving adherence with the use of hip protectors among older people living in nursing care facilities: a cluster randomized trial

OBJECTIVES To test different adherent strategies aimed at improving hip protector use among nursing care facility residents. DESIGN, SETTING AND PARTICIPANTS A cluster randomized controlled trial with 234 residents older than 75 years from 9 units of 7 nursing care facilities in the Northern Sydney region, Australia. INTERVENTION Residents were cluster randomized in 3 groups. The first group received hard shell hip protectors without cost (no cost group). The second group received an educational session, a demonstration of the use of hip protectors, and free choice of type of hip protectors without cost (combined group). The third group was the control group who received a brochure about hip protectors. MEASUREMENTS Primary outcome was adherence with the use of hip protectors at 3 and 6 months after recruitment. Secondary outcomes were falls, injuries, and fractures. RESULTS No participants in the control group purchased hip protectors at any stage. At 3 months, 33% of participants in the no cost group and 27% in the combined group wore a hip protector at the time of visit. This declined to 25% and 24% respectively at 6 months. No significant difference was seen in any of the 3 adherence outcomes between the 2 intervention groups. The number of falls or hospitalizations did not differ between groups, with 5 hip fractures reported during the intervention period. Residents were more likely to be adherent if they were female and had greater restriction in daily activities. CONCLUSION Providing free hip protectors to older people living in nursing care facilities was necessary to increase initial acceptance and adherence. Nevertheless, after 6 months the achieved level of adherence was not high enough to be associated with a reduction of hip fractures. The provision of educational sessions and demonstrations to nursing staff and participants had no added value in this trial.

Factors that challenge health for people involved in the compensation process following a motor vehicle crash: a longitudinal study

BackgroundMotor vehicle crashes (MVC) are associated with diminished mental health, and furthermore, evidence suggests the process of claiming compensation following an MVC further increases distress and impedes recovery. However, further research is required on why the compensation process is stressful. The aim of the current study is twofold. The first is to investigate whether the interaction with the insurance agency is associated with anxiety. The second is to explore qualitatively aspects of dissatisfaction with the compensation process.MethodsParticipants (N = 417) were injured people involved in a compensation scheme after a motor vehicle crash (MVC) in New South Wales, Australia. Interviews were conducted by phone at 2, 12 and 24 months after the MVC. A suite of measures were used including compensation related measures, pain catastrophising and the anxiety/depressed mood subscale of the EuroQol. The association between predictors and anxiety/depressed mood as the dependent variable were analysed using forward logistic regression analyses. The comments about dissatisfaction with the insurance company were analysed qualitatively.ResultsThe strongest predictor of mood status found was pain-related catastrophising, followed by dissatisfaction with the insurance company. Dissatisfaction was attributed to (1) lack of communication and lack of information, (2) delayed or denied payments of compensation, (3) slow treatment approval and discussions about causality, (4) too much complicated paperwork, and (5) discussions about who was at-fault.ConclusionsFactors were found that contribute to anxiety in the compensation process. The association between catastrophising and anxiety/depressive mood suggests it is worthwhile further investigating the role of negative cognitions in compensation processes. People who score highly on catastrophising after the MVC may benefit from early psychological interventions aiming at addressing negative cognitions. Another important stressor is the interaction with the insurance company. Stress is associated with problems of communication, medical treatment, and claim settlement. This study additionally draws attention to some under recognised problems such as delayed payments. Pro-active claims management could address some of the identified issues, which could improve health of injured people after a MVC.

Developing Interventions for Frailty

Frailty is a well-recognised, complex syndrome, predominantly affecting older people. Currently, there are two main conceptualizations of frailty: the phenotypic and the accumulated deficit models, with the phenotypic model being more widely applied in clinical research. Based on these models, we contend that a number of the phenotypic frailty components (weakness, slowness, and low energy expenditure) are potentially reversible. This paper outlines the results of a frailty research program. It summarizes the initial frailty treatment model and reports its effectiveness. Briefly, the effect of a twelve-month individually tailored multifactorial, interdisciplinary intervention targeting frailty was compared with usual care. The intervention reduced phenotypically defined frailty and improved mobility. Further, it is contended that there is evidence of substantial unmet need due to treatment fragmentation and the absence of a comprehensive approach for this population. Our paper then outlines the current stage of our research in which the model is now being extended to prefrailty. Interventions aimed at reversing the frailty syndrome or its consequences are only in their early stages. There is significant scope for future research to identify optimal management programs for frail older people.