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Frailty in the elderly - Evidence base interventions for targeting … · 2020-01-23 · Frailty...
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Evidence base interventions for targeting FRAIL older people Systematic reviews on interventions to prevent adverse outcomes in frail older people
Transcript of Frailty in the elderly - Evidence base interventions for targeting … · 2020-01-23 · Frailty...
Evidence base interventions
for targeting FRAIL older people
Systematic reviews on interventions to prevent
adverse outcomes in frail older people
Randomized Controlled Trials
Frailty interventions
Community dwelling older adults or volunteers
2012, 2013 & 2014
No mention of the RCTs in progress
Evidence base interventions
for targeting frail older people
• Transitions of frailty states
• RCT on frail elders – Physical exercises
– Nutrition
– Exercises + Nutrition
– Mutifactorial interventions
• RCT on frailty consequences – Falls
– Disability
• Take Home Messages
Evidence base interventions
for targeting frail older people
• Transitions of frailty states
• RCT on frail elders – Physical exercises
– Nutrition
– Exercises + Nutrition
– Mutifactorial interventions
• RCT on frailty consequences – Falls
– Disability
• Take Home Messages
Evidence base interventions
for targeting frail older people
SHARE: Dynamics of Frailty
Not Frail
Pre Frail
Frail
31.7%
2.6%
No change 63.4 % Wave 2: 2006 Wave 4: 2011
N = 15’776
BORRAT-BESSON C et al 2013 http://www.degruyter.com/view/supplement/9783110295467_Contents.pdf last access 02 .14
Death 2.2%
N = 8’609
NO intervention
SHARE: Dynamics of Frailty
Not Frail
Pre Frail
Frail 4.6%
No change = 51.4%
32.4%
11.6%
Death
Wave 2: 2006 Wave 4: 2011
N = 15’776
N = 6’201
BORRAT-BESSON C et al 2013 http://www.degruyter.com/view/supplement/9783110295467_Contents.pdf last access 02 .14
NO intervention
SHARE: Dynamics of Frailty
Not Frail
Pre Frail
Frail 17.6%
No change = 43.5%
7%
31.9%
Death
Protectiveor risk
factors?
Wave 2: 2006 Wave 4: 2011
N = 15’776
N = 966
BORRAT-BESSON C et al 2013
NO intervention
Factors associated with
transitions in Frailty status (1)
3’018 Chinese community-living adults 65 years or older Frailty status was classified according to the Fried criteria in 2 visits 2 years apart
LEE JSW et al JAMDA 2014; 15: 281e286
23. 4% 11.1% 26. 6% 6.6% Men Women
Older age Previous Cancer
ROBUST worsening Older age Hospitalisation
COPD Previous stroke
Older age Hospitalisation
PRE FRAIL worsening Hospitalisation Previous stroke Osteoarthritis
Lower age Higher MMSE
No stroke
PRE FRAIL improvement Lower age No DIABETES
No Hospitalisation Higher economic status
No stroke FRAIL improvement
Factors associated with
transitions in Frailty status (1)
3018 Chinese community-living adults 65 years or older Frailty status was classified according to the Fried criteria in 2 visits 2 years apart
LEE JSW et al JAMDA 2014; 15: 281e286
23. 4% 11.1% 26. 6% 6.6% Men Women
Older age Previous Cancer
ROBUST worsening Older age Hospitalisation
COPD Previous stroke
Older age Hospitalisation
PRE FRAIL worsening Hospitalisation Previous stroke Osteoarthritis
Lower age Higher MMSE
No stroke
PRE FRAIL improvement Lower age No DIABETES
No Hospitalisation Higher economic status
No stroke FRAIL improvement
San Antonio: Comparison of two cross sectional cohorts (1992-96 and 2000-1) of Mexican Americans and European Americans – n = 477 – m.a. (at the inclusion) = 69.6 y.o.
ESPINOZA SE et al J Am Geriatr Soc 2012; 60: 652–60
Factors associated with
transitions in Frailty status (2)
Significant predictors of progression in any frailty characteristic are:
• Diabetes with macrovascular complications (OR = 1.84, 95% CI[1.02 – 3.33])
• Fewer years of education (OR = 0.96, 95% CI [0.93 – 1.0])
• Follow-up interval (OR = 1.3, 95% CI [1.17–1.46])
In the San Antonio (SALSA and H-EPESE) frail individuals were more likely to die than remain frail
Death rates increased according to poorer baseline frailty state performance-based measures & low physical activity
• Transitions of frailty states
• RCT on frail elders – Physical exercises
– Nutrition
– Exercises + Nutrition
– Mutifactorial interventions
• RCT on frailty consequences – Falls
– Disability
• Take Home Messages
Evidence base interventions
for targeting frail older people
Physical Exercise Interventions in
Community-Dwelling, Frail Older Adults:
A Systematic Review and Meta-Analysis
12 RCT comparing exercise with an inactive control Most exercise programs were multicomponentt !!
GINE-GARRIGA M et al Arch Phys Med Rehab 2014; 95: 753-69
Physical exercise Normal gait speed (mean difference .07m/s; [95% CI: .04-09])
Fast gait speed (mean difference .08m/s; [95% CI, .02-14])
The SPPB (mean difference 2.18; [95% CI, 1.56-2.80])
Results are inconclusive for endurance outcomes, and no consistent effect was observed on . balance . ADL functional mobility
The evidence comparing different modalities of exercise is scarce and heterogeneous
Effect of Exercise on Physical Function,
ADL & QoL Frail Older Adults:
A Meta-Analysis (2001-2010)
8 RCT WERE SELECTED AMONG 146 TRIALS predetermined frailty criteria and randomly assigned to either an exercise (simple or comprehensive) or inactive control group
1’068 participants (75.3 to 86.8 y.o.)
CHOU C-H et al Arch Phys Med Rehabil 2012; 93: 237-43
Compared with the control group, the EXERCISE GROUP Gait speed by .0 7 m/s (95% CI .02–.11)
Berg Balance Scale score: Weight Mean Difference 1.69; 95% CI .56 –2.82)
ADLs performance: Weight Mean Difference 5.33; 95% CI 1.01-9.64)
The exercise intervention had NO SIGNIFICANT EFFECTS on the • Timed Up & Go test performance (4 studies)
• QOL between the groups (2 studies)
• Transitions of frailty states
• RCT on frail elders – Physical exercises
– Nutrition
– Exercises + Nutrition
– Mutifactorial interventions
• RCT on frailty consequences – Falls
– Disability
• Take home Messages
Evidence base interventions
for targeting frail older people
Protein-Energy Supplementation in Frail Older
Adults with Low Socioeconomic Status:
A Community-Based RCT
87 frail adults (m.a = 78 y., usual gait speed <0.6 m/second; MMSE <24)
• intervention group : commercial liquid formula (additional 400 kcal of energy, 25 g of protein, 9.4 g of essential AA, 400 mL of water) per day for 12 weeks
• control group
Intervention Control
5,9% Physical functioning
SPPB 12.5%
1.1% Gait speed 11.3%
7.2% TUG 3.4%
Hand grip
One leg standing
KIM CO et al J Gerontol A Biol Sci Med Sci 2013 ; 68 :309–16
Resistance-type exercise training
protein supplementation on
COGNITIVE FUNCTIONING in F. & PreF.
2nd analysis – Parallel RCT, placebo control, 127 volunteers 1) Resistance training (2/week) (N = 62) Control (N = 65)
2) Randomization in 2 groups with or without protein supplementation (2 x 15 g/d)
VAN DE REST O et al Mech Ageing Develop 2014; 136-137: 85–93
Resistance training alone Attention Working memory
Resistance training + protein supplement
Information processing
Resistance training protein supplement
No change . Episodic memory . Executive function
Pre frail and frail adults aged over 70 y. selected with Fried criteria and equivalent MMSE at baseline
• Transitions of frailty states
• RCT on frail elders – Physical exercises
– Nutrition
– Exercises + Nutrition
– Mutifactorial interventions
• RCT on frailty consequences – Falls
– Disability
• Take Home Messages
Evidence base interventions
for targeting frail older people
A multifactorial interdisciplinary
intervention in frailty in older people
Single center RCT on frail (Fried criteria)
• Intervention targeting the frailty components (N = 120, m.a = 83.4 y.)
• Comparison group usual health care & support (N =121, m.a. = 83.1 y.)
• Outcomes were assessed by blind raters to treatment allocation at 3 and 12 m.
CAMERON ID et al BMC Medicine 2013; 11: 65
At 12 months, the comparison between the 2 groups intervention vs. control
SPPB < .001
MMSE .07
Barthel Index NS
Depressive symptoms NS
Health-related quality of life NS
Multifactorial interdisciplinary
intervention on mobility-related
disability in frail older people: RCT
241 frail (Fried criteria) community-dwelling older people (m.a. = 83.3 y.) without severe cognitive impairment, recently discharged from an aged care and rehabilitation service
• Intervention targeting Frailty components (physio [2/w], psycho, HCWs)
• Control, usual care
FAIRHALL N et al BMC Medicine 2012; 10: 120
At 12 months, blind raters ‘evaluation:
Life Space Assessment (Mobility during the preceding month)
Goal Attainment Scale (see examples)
Gait speed
Activity measure for post acute care (Self-report measures of activity)
Goal Attainment Scale
KIRESUK T et al In: Hillsdale, NJ: Erlbaum Associates; 1994.
Multifactorial interdisciplinary
intervention on mobility-related
disability in frail older people: RCT
241 frail (Fried criteria) community-dwelling older people (m.a. = 83.3 y.) without severe cognitive impairment and were recently discharged from an aged care and rehabilitation service
• Intervention targeting Frailty components (physio [2/w], psycho, HCWs)
• Control, usual care
FAIRHALL N et al BMC Medicine 2012; 10: 120
At 12 months, blind raters ‘evaluation:
Life Space assessment (Mobility during the preceding month) < . 004
Goal Attainment Scale <. 005
Gait speed .048
Activity measure for post acute care ) (Self-report measures of activity)
<. 0001
Considering ALL the participants , the 12 month cost for
1 extra person to transition out of frailty was
US$ 14’114 (2011 prices)
Multifactorial interdisciplinary
intervention on mobility-related
disability in frail older people: RCT
90% (216/241) of the randomized participants completed the study 99% (238/241) were included in the economic evaluation
Incremental cost-effectiveness ratios (ICERs) = Total costs of intervention - total costs of control
Benefits of intervention - benefits of control
For the “frail” participants, the 12 month cost for
1 extra person to transition out of frailty was
US$ 36’525 (2011 prices)
FAIRHALL N et al JAMDA 2014 online access
Evaluation of an eHealth Intervention in
Chronic Care for Frail Older People
• 290 patients in the intervention group and 392 in the control group from the Eastern part of the Netherlands
• The intervention used was the health and welfare portal (ZWIP): an Online Health Communication for frail elderly patients, their informal caregivers and professionals
MAKAI P et al J Med Internet Res 2014; 16: e156
Only 26.2 % of the participants in the active
group participate in the 12 month protocol
The participants got a
non significant improvement in
bADL and iADL
• Transitions of frailty states
• RCT on frail elders – Physical exercises
– Nutrition
– Exercises + Nutrition
– Mutifactorial interventions
• RCT on frailty consequences – Falls
– Disability
• Take home Messages
Evidence base interventions
for targeting frail older people
Exercise Interventions on
Risk of Falls
Systematic review 1990-2012
20 studies including 4 parameters: Incidence of falls, gait, balance, and lower body strength
CADORE EL et al Rejuvenation Research 2013 , 2, 105-14
Target Nb of study Results Type of exercises
Fall incidence 10 7 + ( 22% - 58%)
Multi-component exercise 4+ Resistance exercise 2+ Tai Chi 1+
Gait ability 11 6 + ( 4% - 50%)
Multi-component exercise 3+ Resistance exercise 2+ Endurance exercise 1+
Balance 10 7 + ( 5% - 80%)
Multi-component exercise 7+ (1 of them included Tai Chi)
Muscle strength 13 9 + ( 6% - 60%)
Multi-component exercise 4+ Resistance exercise 5+
Physical function and fear of falling
2 y. after the health-promoting RCT
3-armed, single blind, RCT in 459 independent community-dwelling people > 80 y.
• A single preventive home visit including health-promoting information / advice
• 4 weekly senior group meetings focused on health strategies and peer learning, with a follow-up home visit
• Control
ZIDEN L et al The Gerontologist 2013 ; 54,: 387–97 et GUSTAFSSON S JAGS 2012; 60: 447–54
Senior meetings Preventive home visit Control
% Berg Balance scale > 48 % Improved indoor walking speed
NS decrease number of falls at 2 y.
Structured Physical Activity &
Prevention of Major Mobility Disability
in Older Adults
The Lifestyle Interventions and Independence for Elders (LIFE) study Multicenter, randomized trial (8 US Centers)
1’635 sedentary men and women (70 to 89 y.o.) who had physical limitations February 2010 and December 2011, who participated for an average of 2.6 y.
• Activity program (n = 818) conducted in a center (twice/wk) and at home (3-4 times/wk) that included aerobic, resistance, and flexibility training activities
• Control: health education program (n = 817)
PAHOR M et al JAMA 2014 ; 311: 2387-96
The physical activity group attended
63 % of the scheduled sessions
after excluding medical leave
The education group attended
82 % of the scheduled sessions
after excluding medical leave
INTERVENTION CONTROL
30.1 % (N = 246)
Incident major mobility disability
HR = 0.82 [95% CI: 0.69-0.98]
35.5 % (N = 290)
14.7 % (N = 120)
Persistent major mobility disability
HR = 0.72 [95% CI: 0.57-0.91]
19.8 % (N = 162)
49.4 % (N = 404)
Serious adverse outcomes
RR = 1.08 [95% CI: 0.98-1.20]
37.3 % (N = 373)
Structured Physical Activity &
Prevention of Major Mobility Disability
in Older Adults
PAHOR M et al JAMA 2014 ; 311: 2387-96
Structured Physical Activity &
Prevention of Major Mobility Disability
in Older Adults
PAHOR M et al JAMA 2014 ; 311: 2387-96
• A structured moderate-intensity physical activity program compared
with a health education program reduced MAJOR MOBILITY DISABILITY
over 2.6 years among older adults at risk of disability
• These findings suggest mobility benefit from such a program in vulnerable older adults
• Transitions of frailty states
• RCT on frail elders – Physical exercises
– Nutrition
– Exercises + Nutrition
– Mutifactorial interventions
• RCT on frailty consequences – Falls
– Disability
• Take Home Messages
Evidence base interventions
for targeting frail older people
Factors associated with
transitions in Frailty status (1)
3’018 Chinese community-living adults 65 years or older Frailty status was classified according to the Fried criteria in 2 visits 2 years apart
LEE JSW et al JAMDA 2014; 15: 281e286
23. 4% 11.1% 26. 6% 6.6% Men Women
Older age Previous Cancer
ROBUST worsening Older age Hospitalisation
COPD Previous stroke
Older age Hospitalisation
PRE FRAIL worsening Hospitalisation Previous stroke Osteoarthritis
Lower age Higher MMSE
No stroke
PRE FRAIL improvement Lower age No DIABETES
No Hospitalisation Higher economic status
No stroke FRAIL improvement
To be successful fighting
against frailty…
3’018 Chinese community-living adults 65 years or older Frailty status was classified according to the Fried criteria in 2 visits 2 years apart
Adapted from LEE JSW et al JAMDA 2014; 15: 281e286
23. 4% 11.1% 26. 6% 6.6% Men Women
Older age Previous cancer
ROBUST worsening Older age Hospitalisation
COPD Previous stroke
Older age Hospitalisation
PRE FRAIL worsening Hospitalisation Previous stroke Osteoarthritis
Lower age Higher MMSE
No stroke
PRE FRAIL improvement Lower age No DIABETES
No Hospitalisation Higher economic status
No stroke FRAIL improvement
Fighting against social inequities
Promoting healthy life styles & behaviours
Fighting against midlife risk factors
Favouring community care
Physical exercises Protein supplementation
I do thank you
for your attention
Jean-Pierre MICHEL
