Susan Kurrle

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 to Reduce Physical Restraints in Nursing Home Residents

OBJECTIVES: To evaluate the effectiveness of a multifactorial intervention to reduce the use of physical restraints in residents of nursing homes.

Temporal relationship between handgrip strength and cognitive performance in oldest old people

BACKGROUND cognitive decline and muscle weakness are prevalent health conditions in elderly people. We hypothesised that cognitive decline precedes muscle weakness. OBJECTIVE to analyse the temporal relationship between cognitive performance and handgrip strength in oldest old people. DESIGN prospective population-based 4-year follow-up study. SUBJECTS a total of 555 subjects, all aged 85 years at baseline, were included into the study. METHODS handgrip strength measured at age 85 and 89 years. Neuropsychological test battery to assess global cognitive performance, attention, processing speed and memory at baseline and repeated at age 89 years. Associations between handgrip strength and cognitive performance were analysed by repeated linear regression analysis adjusted for common confounders. RESULTS at age 85 and 89 years, better cognitive performance was associated with higher handgrip strength (all, P<0.03), except for attention. There was no longitudinal association between baseline handgrip strength and cognitive decline (all, P>0.10), except for global cognitive performance (P=0.007). Better cognitive performance at age 85 years was associated with slower decline in handgrip strength (all, P<0.01) after adjustment for common confounders. CONCLUSION baseline cognitive performance was associated with decline in handgrip strength, whereas baseline handgrip strength was not associated with cognitive decline. Our results suggest that cognitive decline precedes the onset of muscle weakness in oldest old people.

DEVELOPMENT OF A TOOL FOR PREDICTION OF FALLS IN REHABILITATION SETTINGS (PREDICT_FIRST): A PROSPECTIVE COHORT STUDY

OBJECTIVE To develop and internally validate a simple falls prediction tool for rehabilitation settings. DESIGN Prospective cohort study. PARTICIPANTS A total of 533 inpatients. METHODS Possible predictors of falls were collected from medical records, interview and physical assessment. Falls during inpatient stays were monitored. RESULTS Fourteen percent of participants fell. A multivariate model to predict falls included: male gender (odds ratio (OR) 2.70, 95% confidence interval (CI) 1.57-4.64), central nervous system medications (OR 2.50, 95% CI 1.47-4.25), a fall in the previous 12 months (OR 2.21, 95% CI 1.07-4.56), frequent toileting (OR 2.14, 95% CI 1.27-3.62) and tandem stance inability (OR 2.00, 95% CI 1.11-3.59). The area under the curve for this model was 0.74 (95% CI 0.68-0.80). The Predict_FIRST tool is a unit weighted adaptation of this model (i.e. 1 point allocated for each predictor) and its area under the curve was 0.73 (95% CI 0.68-0.79). Predicted and actual falls risks corresponded closely. CONCLUSION This tool provides a simple way to quantify the probability with which an individual patient will fall during a rehabilitation stay.

ICF participation restriction is common in frail, community-dwelling older people: an observational cross-sectional study

OBJECTIVES To determine the extent of participation restriction in a sample of frail older people, and to identify the domains of participation that are most restricted. A secondary aim was to determine which health and demographic factors were associated with participation restriction. DESIGN An observational cross-sectional study. SETTING Adults recently discharged from an aged care and rehabilitation service in Australia who were enrolled in a clinical trial. PARTICIPANTS One hundred and eighty-one community-dwelling adults aged over 70 years (mean age 84, standard deviation 5.7) who met the Cardiovascular Health Study criteria for frailty, had a Mini Mental State Examination score over 18 and a predicted life expectancy exceeding 12 months. MAIN OUTCOME MEASURES Participation restriction was evaluated using the Reintegration to Normal Living Index. RESULTS Eighty percent of subjects reported participation restriction in at least one aspect of their life. Restricted participation was most prevalent in the areas of work in the home or community (114/181, 63%) and community mobility (92/181, 51%), and least common with regard to interpersonal relationships (9/181, 5%). Multivariate regression analysis showed that grip strength, mood, number of medical conditions and mobility were independently and significantly (P<0.05) associated with participation restriction, and explained 29% of the variance in participation restriction. Cognition and living alone were not significantly associated with participation restriction. CONCLUSIONS Participation restriction was common in this sample of frail, community-dwelling older people. It was associated with factors from multiple levels of the International Classification of Functioning, Disability and Health. Further research is suggested to investigate the causes and treatment of participation restriction.