Noeline Monaghan

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.

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.

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.

Whither Transition Care

The Australian Government’s Transition Care legislation was included in the Aged Care Act 1997 (Commonwealth) (the Act), and the Aged Care Principles 1997 made under the Act s96.1, in March 2005. Section 15.28 of the Flexible Care Subsidy Principles 1997 defines Transition Care as a form of flexible goal-oriented, time-limited, therapy-focused care provided at the conclusion of an inpatient hospital episode which includes low intensity therapy and is targeted towards older people [1].

Fatal Incidents in Australia’s Older Farmers (2001–2015)

ABSTRACT Objectives: This study assesses nonintentional injury deaths of older farmers and the causal agents associated with these fatalities in Australia (2001–2015). It also explores approaches based on the hierarchy of risk controls to reduce fatalities and injuries in this cohort. Methods: Data on farm-related incidents were sourced from the National Coroners Information System (NCIS) for the study period and coded. Rates were calculated and regression analyses completed to assess trends over time. Results: Those in the 50+ years category (n = 610) accounted for 49.8% of all on-farm nonintentional injury deaths, with males (n = 566) dominating the cases. The annual mean was 40.66 cases (SD = 8.08) and the average rate 36/100,000. Trend analysis revealed a nonstatistically significant (P < 0.05) increase in cases over the period. Farm vehicles and machinery were responsible for almost two thirds of the fatal cases. Conclusion: Nonintentional fatality rates for older farmers have remained relatively unchanged for a significant period in Australia. There is a need to examine additional approaches that not only maintain the benefits of work activity for older farmers but also balance this against a safety perspective.