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Organised by:
Malaysian Healthy Ageing Society
Co-Sponsored:
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Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
Professor Keith Hill,
School of Physiotherapy
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Definitions of frailty
What exercise do older people do?
What types of exercise are there and what are their general benefits?
Review evidence for exercise in reducing frailty in different samples
Highlight issues in targeting exercise, with examples of research
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Many definitions in the literature
“Frailty, a primary pathway to disability, has been
defined as a pathological condition that results
in a constellation of signs and symptoms and is
characterized by high susceptibility to adverse
health outcomes, impending decline in physical
function, and high risk of death”
5/27/2012 Footer Text
Peterson et al, 2009 (Fried et al 2004; Ferrucci et al, 2004)
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30.07.2010 Footer text - slideshow title
Frailty syndrome (Fried et al, 2001)
INDICATOR
Weakness
Slow walking speed
Self reported exhaustion
Low levels of physical activity
Unintentional weight loss
Rockwood et al, 2005
(3 or more present)
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Very frail/ High falls risk
Healthy older people
Ideal range for for early risk assessment
CONTINUUM OF FRAILTY
Starting to feel a little unsteady, curtailing activity, minor falls or near falls
Residential care, or receiving considerable home supports
Range commonly seeking health professional assistance
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Incidental physical activity is unstructured activity undertaken at times that suit the individual, that often meet a functional need, eg, walking to the shop, performance of ADLs, taking steps instead of elevator
Organised physical activity is activity performed usually for the purpose of improving physical performance, eg gym, swimming, exercise classes.
Both are beneficial, and count towards your daily
physical activity
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Discussion paper: Physical activity recommendations for older Australia
http://www.health.gov.au/internet/main/publishing.nsf/content/phd-physical-rec-older
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0
10
20
30
40
50
Walking
Aerobic/fitness
Golf
pe
rce
nta
ge
Older people participated in fewer types of activity (ave=1.6)
Participation in organised physical activity lowest in older people (30.7%; vs 66.1% for 15-24 yo)
Exercise, recreation and sport (ERASS) survey, conducted by the Australian Sports Commission, 2006
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Physically fit, Healthy
Group III Physically unfit frail, Unhealthy
dependent
Group II Physically unfit,
Unhealthy independent
World Health Organisation Health-Fitness gradient
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various forms of exercise ◦ balance ◦ strength ◦ cardiovascular fitness ◦ flexibility
specificity of training other health benefits of exercise programs
strong evidence of effectiveness
of training in older people to improve specific
risk factor
Exercise
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SINGLE FORMS
strengthening
flexibility
cardiovascular
balance
desensitising (vestibular)
weight-bearing
hydrotherapy
others...
MULTI-FACETED
EXERCISE
PROGRAMS
any combination
of these
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Reduced mortality: ◦ All cause
◦ Cardiovascular
◦ Respiratory
(Dutch)
Australian recommendations for physical activity for older people:
Discussion document
http://www.health.gov.au/internet/main/publishing.nsf/content/phd-physical-rec-older
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Reduced risk of: ◦ coronary and cardiovascular disease ◦ diabetes ◦ obesity ◦ cancer (especially colo-rectal cancer) ◦ falls / falls related injury
Improved physical performance / function / independence ◦ Including in chronic disease (eg OA)
Improved mental health (eg reduced depression)
Australian recommendations for physical activity for older people:
Discussion document
http://www.health.gov.au/internet/main/publishing.nsf/content/phd-physical-rec-older
http://www.medicinenet.com
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Group exercise programs
Home exercise programs (often prescribed by a physiotherapist
Tai Chi- (note: different types of Tai Chi may have different effects)
Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011)
Key elements of successful exercise interventions:
Moderate balance component
Moderate intensity (Sherrington et al, 2008)
Cochrane review: Gillespie et al 2009
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Positive outcomes when applied appropriately:
Improved fitness, function, reduced risk of cardiovascular disease....
Negative outcomes when applied inappropriately:
Increased falls when at risk samples recommended to increase walking without individualisation …
Eg Walking program
(Ebrahim S et al, 1997)
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Very frail/ High falls risk
Healthy older people
CONTINUUM OF FRAILTY
Tai chi for arthritis – Sun style 24 form Beijing style – Yang style
Otago Exercise Program “Otago Plus” – incl VHI kit
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Physically fit, Healthy
Group III Physically unfit frail, Unhealthy
dependent
Group II Physically unfit,
Unhealthy independent
World Health Organisation Health-Fitness gradient
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Health ABC study (USA) – healthy cohort followed longitudinally (5 years), n=2964, mean age 73.6
Initial sampling: no difficulty doing mobility-related tasks, such as walking quarter mile or climbing one flight of stairs or performing activities of daily living
Identified those with incident frailty: ◦ Gait speed <0.6m/s and / or ◦ Inability to stand (arms across chest) from chair (one impairment= moderately frail, both = severely frail)
5/27/2012 Footer Text Peterson et al, 2009
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Results: 37% performing >150 minutes physical activity / week
(19% in regular vigorous physical activity) ◦ 40% walked regularly ◦ 5% regular strength training
Sedentary group had significantly increased odds for developing frailty relative to those with regular exercise participation (OR=1.45; 1.04-2.01)
Significant dose response association between activity types (sedentary, lifestyle active, and exercise active) and development of frailty
Significant independent predictors of onset of frailty included number of co-morbidities, increased age, male gender, African American race, and lower educational level
5/27/2012 Footer Text Peterson et al, 2009
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Independent, generally well
• Inform general practitioner / other health professionals
• Any form of exercise likely to be beneficial
• Aim for at least moderate intensity and >150 minutes / week
• Optimise outcomes by including variety of exercise types (resistance, cardiovascular, balance and flexibility)
• Intermittent review of key indicators for feedback and to facilitate adherence (eg fitness test, BP, balance, etc)
http://www.medicinenet.com
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Physically fit, Healthy
Group III Physically unfit frail, Unhealthy
dependent
Group II Physically unfit,
Unhealthy independent
World Health Organisation Health-Fitness gradient
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Keith Hill, Xiao Jing Yang, Kirsten Moore, Sue Williams, Karen
Borschmann, Leslie Dowson,
Shyamali Dharmage
Project funded by the Australian Government Department of Veterans’ Affairs 23
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Loss of confidence
Activity curtailment
Feeling of “balance
not as good as it used
to be”
Effect of age, or
something
else???
Increased falls risk
Balance screening
process
24
PhD candidate:
Xiao Jing Yang
Yang et al, Physical Ther 2012
Yang et al, J Clin Geriatr & Gerontol 2012
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To determine the proportion of older people expressing concerns about their balance who do have a measurable balance impairment
For those with identified mild balance dysfunction, to determine the effectiveness of a home based exercise program in improving balance and related measures
25
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Sample and recruitment
Participants were recruited from Melbourne.
Inclusion criteria were:
• aged 65 years or older
• living in the community
• being community ambulant
• used no walking aid or a single point stick;
• had no more than one fall in the past 12 months;
• reported concerns about balance, confidence or near falls.
26
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Static
balance
Dynamic balance Lower limb
muscle
strength
Gait Reaching
/ leaning
Stepping Turning
Clinical
measures
Functional
Reach
(FR)
Step
Test
(ST)
Hand-held
Dynamometer
Sit-to-Stand
STS (5 times)
six
metre
walk
Laboratory
Measures
(NeuroCom
Balance
Master)
Modified
Clinical
Test of
Sensory
Interaction
of Balance
(MCTSIB)
Limits of
Stability
(LOS)
Rhythmic
Weight
Shift
(RWS)
Step
Quick
Turn
(SQT)
Sit-to-Stand
(STS)
Walk
Across
(WA)
27
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28
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Control
6-month
re-assessment
Intervention
Balance within
normal limits
Comprehensive balance
assessment for mild balance
dysfunction (MBD)
Group with
MBD
6-month
re-assessment
randomisation
CLASSIFICATION OF MBD
- >1SD from mean for
older sample on
- Functional Reach (<26cm) OR
- Step Test (<13 steps/15s) OR
- Timed sit to stand (>17.9s)
OR
- > 3 (out of 46 measures)
on the Neurocom Balance
Master outside of normal
limits (normative data
provided by Neurocom
(age and gender matched)
29
Yang et al, Physical Ther 2012
Yang et al, J Clin Geriatr & Gerontol 2012
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Exercise program based on: Otago Exercise
Programme; and Visual Health Information
(VHI) Exercise Prescription Kits - Balance & Vestibular Rehabilitation Set
Prescribed by a physiotherapist
Customised to individual’s balance performance and fitness level.
Example: toe walking —
no support
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All Participants (n=225)
Age, mean (SD) 79.7 years (6.1)
Gender (%Male) 126 (56%)
Living at home, no carer 208 (92%)
Receiving home help 61 (27%)
Using single point stick 42 (19%)
Walking daily (>30min) 179 (80%)
Fall in last year 81 (36%)
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At baseline, 165 (73.3%) participants were classified as having mild balance dysfunction (95% CI: 67.6%-79.1%)
This group’s balance performance lies between healthy older people and a sample of falls clinic patients, and is much closer to the healthy sample.
1 2 3
8
10
12
14
16 ] 16
] 8
] 14
Group 1: Falls and balance clinical sample (N=163);
Group 2: Participants in current study classified as
having early balance problems (N=165);
Group 3: healthy older people sample (104).
Step test-worst leg (95%CI)
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Following the 6-month exercise program:
•14 out of 59 participants (23.7%) in the intervention group achieved balance performance within the normative range
Participants entered RCT (n=165)
Control group
(n=83)
Intervention group
(n=82)
Randomisation
6-month follow up
62 returned to re-
assessment, 3 (4.8%)
were considered within
normal limits
59 returned to re-
assessment, 14
(23.7%) improved to
within normal limits
33
20% intervention vs 29% control group fell (NS)
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-10
-5
0
5
10
15
Intervention group
*
* *
* *
Control group
Results: RCT – exercise for mild balance dysfunction (2)
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See your doctor or physiotherapist
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Perform a comprehensive
assessment &
Prescribe targeted exercise for
identified deficits
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Modified method from RCT Two clinical measures to determine mild
balance dysfunction
Physiotherapists in 6 community health centres trained re home based exercise prescriptions
Additional home visits to modify, monitor and motivate
Results ◦ Same magnitude of effect on balance
performance, and same proportion regaining normative range balance performance
Funded by Department of Veterans’ Affairs 37
http://www.medicinenet.com
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Retirement village and surrounding community dwelling older people (n=503)
Age >65 (35%>80 years, 67% female) Pre-clinically disabled group according to
Fried’s classification Report difficulty with or modified approach to
walking and / or climbing stairs
Intervention and control activity – 2 x / week x 24 weeks)
Intervention group – Tai Chi for Arthritis (Sun style)
Control group – flexibility program (mostly seated)
Primary outcome – Late Life Function Disability Index
Secondary outcomes – balance, strength, mobility, fitness
Day et al, under review
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Results: Adherence: significantly higher dropout rate in Tai Chi
group (31% vs 23%). Median of 30 classes attended for both groups (out of 48)
Small non significant improvements in both groups in sub-components and overall Late Life Function Disability Index
Minor, mostly non significant differences between groups on most secondary measures (balance, muscle strength, mobility, 6 minute walk test)
Day et al, under review
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Possible factors relating to lack of effect: Insufficient challenge to musculoskeletal and balance
systems for this sample (cf – other forms of Tai Chi, eg 24 form Beijing style)
Insufficient dosage (dropouts / frequency of attendance)
??attrition bias – those who withdrew from the study may be those most likely to benefit
Disability measure insensitive to change in this group (though minimal change in secondary measures as well)
Day et al, under review
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Physically fit, Healthy
Group III Physically unfit frail, Unhealthy
dependent
Group II Physically unfit,
Unhealthy independent
World Health Organisation Health-Fitness gradient
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10 papers met inclusion criteria (2 nutritional interventions, 8 exercise interventions)
Concluded: ◦ No evidence for nutritional interventions in
preventing disability (although improved energy intake and weight gain)
◦ Some support that relatively long lasting and high intensity multi-component exercise interventions can have a positive effect on ADL and IADL
5/27/2012 Footer Text
Daniels et al, 2008
Disability defined as experienced difficulty in performing
activities in any domain of life
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Theou et al, 2011
47 papers met inclusion criteria
Wide variability between studies in sample characteristics, exercise type, exercise duration and intensity
RESULTS
Exercise adherence generally high
Few adverse events in exercise programs
Multi-component exercise had greatest effect on functional outcomes
Longer term, multi-component exercise programs with shorter duration (30-45 minutes) appear most effective in this population
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Need to determine ◦ Suitability for exercise (clearance from medical
practitioner / other health professional) ◦ Appropriate form of exercise Desired outcomes
Personal / health factors influencing ability to perform
Personal preference
Access
Commence slowly / gently, with supervision
Reduce intensity / dosage if unwell / had a break from exercise
May progress to independent / group exercise
Regular review of performance and outcomes
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Recommendation 1 (level I)
Older people should do physical activity, no matter what their age, weight, health problems or abilities
Recommendation 2 (level II)
Older people should be active every day in as many ways as possible, doing a range of physical activities that incorporate fitness, strength and balance
Recommendation 3 (level I)
Older people should accumulate at least 30 minutes of moderate intensity physical activity on most, preferably all, days
Recommendation 4 (level IV)
Older people who have stopped involvement in physical activity for more than several weeks, or who are starting a new physical activity, should start at a level that is easily manageable and gradually build up the amount, type and frequency of activity
Recommendation 5 (level IV)
Older people who have enjoyed a lifetime of vigorous physical activity should maintain vigorous physical activity into later life
Sims et al 2010
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Exercise approaches can achieve improved outcomes for older people across the frailty spectrum
Need for approaches to improve physical activity and exercise participation for older people (and across the life-span)
Exercise options need to be appropriate for: ◦ Desired outcomes
◦ Frailty / functional capacity of individuals
IAGG
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30.07.2010 Footer text - slideshow title
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potential barriers: cost / access / transport
target group
compliance / motivation
individualised vs group
Incidental vs structured vs combination
dosage effects
comparative effectiveness
Physical activity: Implementation
issues for consideration
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Department of Health and Ageing In accord with:
◦ Healthy Ageing Strategy ◦ Be Active Australia: A Health Sector
Framework for Action 2005-2010 ◦ National Obesity Taskforce (Department
of Health and Ageing 2005)
Endorsed and launched 2009
http://www.health.gov.au/internet/main/publishing.nsf/Content/ECBF57CB49827C0BCA2575820004650C/
$File/pa-guidelines.pdf
Sims J, Hill K, Hunt S, Haralambous B. 2010 Physical activity recommendations for older Australians.
Australasian Journal on Ageing. 29(2): 81-87.
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Moderate level
◦ Physical activity at a level that causes your heart to beat faster and some shortness of breath, but that you can still talk comfortably while doing ….
Vigorous
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1999: Panel established
2004: Combined with Panel updating Adult
recommendations
2007: Guidelines produced and published in Circulation and
Medical Science Sports & Exercise journals
Reference: Nelson M et al 2007 Physical activity and public health in
older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation 116 (9): 1094-1105
http://circ.ahajournals.org/cgi/reprint/116/9/1094
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KEY ELEMENTS • 30 minutes of moderate intensity aerobic exercise
5 days / week
• Strengthening and endurance exercises minimum of 2 (non-consecutive) days / week – 8-10 exercises, 10-15 reps
• 10 minutes flexibility exercise at least 2 days / week
• Balance exercises for those with “substantial risk of falls”
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Standard exercises for all
◦ Advantage of being able to widely disseminate
◦ Disadvantage of not being able to tailor to maximise benefits
Exercises tailored to individual need:
Safety
Frailty
Preferred option for people with some health problems
Can be individual or circuit
http://www.medicinenet.com