malaysian healthy ageing society · report difficulty with or modified approach to walking and / or...

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Malaysian Healthy Ageing Society

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CRICOS Provider Code 00301J

Professor Keith Hill,

School of Physiotherapy

[email protected]

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

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)

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)

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

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

Discussion paper: Physical activity recommendations for older Australia

http://www.health.gov.au/internet/main/publishing.nsf/content/phd-physical-rec-older

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

Physically fit, Healthy

Group III Physically unfit frail, Unhealthy

dependent

Group II Physically unfit,

Unhealthy independent

World Health Organisation Health-Fitness gradient

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

SINGLE FORMS

strengthening

flexibility

cardiovascular

balance

desensitising (vestibular)

weight-bearing

hydrotherapy

others...

MULTI-FACETED

EXERCISE

PROGRAMS

any combination

of these

Reduced mortality: ◦ All cause

◦ Cardiovascular

◦ Respiratory

(Dutch)

Australian recommendations for physical activity for older people:

Discussion document


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.medicinenet.com

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

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)

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

http://www.farmagain.com/wsimages/olli_taichi.jpg



dependent




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

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

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)




dependent




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

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

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

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

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

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

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

30

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%)

31

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)

32

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)

-10

-5

0

5

10

15

Intervention group

*

* *

* *

Control group

Results: RCT – exercise for mild balance dysfunction (2)

34

See your doctor or physiotherapist

Perform a comprehensive

assessment &

Prescribe targeted exercise for

identified deficits

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


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

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)


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)




dependent




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

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

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

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

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

30.07.2010 Footer text - slideshow title

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

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.

http://www.health.gov.au/internet/main/publishing.nsf/Content/ECBF57CB49827C0BCA2575820004650C/

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

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

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”

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


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