Malaysian Healthy Ageing Society Professo fessor r Keith Hill, - - PowerPoint PPT Presentation

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Professo fessor r Keith Hill, School of Physiot

• ther

erapy py Keith.Hill Hill@C @Curti rtin.edu edu.a .au

 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”

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Peterson et al, 2009 (Fried et al 2004; Ferrucci et al, 2004)

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Frailty syndrome (Fried et al, 2001) INDICATOR OR 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

• f 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

10 20 30 40 50 W a l k i n g A e r

• b

i c / f i t n e s s G

• l

f percentage



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

• f effectiveness
• f training in
• lder people to

improve specific risk factor

Exercise

SING NGLE LE FOR ORMS

 strengthening  flexibility  cardiovascular  balance  desensitising

(vestibular)

 weight-bearing  hydrotherapy  others...

MULTI-FACETED EXERCISE PROGRAMS any combination

• f these

 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

 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

 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

Physically fit, Healthy Group III Physically unfit frail, Unhealthy dependent Group II Physically unfit, Unhealthy independent World Health Organisation Health-Fitness gradient

 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)

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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

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Peterson et al, 2009

Ind ndepende pendent, nt, gene nera rally lly well ll

• Infor

form m general eral practit ctition ioner er / other er healt alth h profes

• fessional

sionals

• An

Any form m of exercise rcise likely ely to be benefici eficial al

• Ai

Aim m for at least st mo moderate erate inte tens nsity ity and >150 50 minutes utes / week

• Opti

timi mise se outcomes comes by including cluding va vari riety ety

• f exercise

rcise types s (resistanc istance, e, cardiov rdiovascu ascula lar, , balanc nce and flexi xibil bility ity)

• Interm

ermittent ittent revie view w of key indi dicators cators for feedback dback and to facil ilitate itate adhere erence nce (eg eg fitness tness test, , BP, balance, ance, etc)

http://www.medicinenet.com

Physically fit, Healthy Group III Physically unfit frail, Unhealthy dependent Group II Physically unfit, Unhealthy independent World Health Organisation Health-Fitness gradient

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.

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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

• f 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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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
• lder sample on
• Functional Reach (<26cm) OR
• Step Test (<13 steps/15s) OR
• Timed sit to stand (>17.9s)

OR

• > 3 (out of 46 measures)
• n 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
• n:
• 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 73.3% 3%) participants cipants were cl classifi ified ed as havi ving ng mild balance ce dys ysfunc function tion (95% CI: 67.6%-79.1%)

 This group’s balance

performance lies between healthy

• lder 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)

• 10

10

• 5

5 10 10 15 15

Intervention group

* * * * *

Control group

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

34

See your doctor

• r 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

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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

• 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

• 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

Physically fit, Healthy Group III Physically unfit frail, Unhealthy dependent Group II Physically unfit, Unhealthy independent World Health Organisation Health-Fitness gradient

 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 r people should ld do physical cal activity, y, no matter r what their r age, weight, ight, health th problems or a abilities Recommendation 2 (level II) Older r people should ld be active every ry day in as many ways as possible, , doing a range ge of physi sical al activiti ties es that incorpora rate te fitness, st strength ngth and balance ce Recommendation 3 (level I) Older r people should ld accumul ulate te at le least 30 minutes tes of m moderate te intens nsity ty physica cal l activity y on most, prefera rably bly all, da days Recommendation 4 (level IV) Older r people who have stopped involve vement ment in physical al activity ty for m more than n severa ral l weeks, ks, or w who are starting ng a new w physical al activity, ty, shoul uld start at a level that is e easily y manage geable ble and gradually lly build up the amount, t, type and frequency uency of activity Recommendation 5 (level IV) Older r people who have enjoye yed a li lifetime me of v vigorous us physica cal l activity y shoul uld maintain in vigorous us physical al activity ty into later life Sims et al 2010

 Exercise approaches can achieve improved

• utcomes 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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 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
• f 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.

 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

Referen erence: ce: Nelson

• n M et al 2007

07 Physi sical cal activity ity and public lic health th in

• lder

r adults ts: : Recommen mmendati dation

• n from the American

rican College ege of Sports Medicin icine e and the American rican Heart t Associatio ciation.

• n. Circul

ulat ation ion 116 (9): ): 1094 94-11 1105 http:/ ://circ.ah circ.ahajo jour urna nals ls.org/cg rg/cgi/ i/reprin reprint/ t/116 116/9/1 9/109 094

KE KEY EL ELEM EMEN ENTS TS

• 30 minutes

utes of moderat rate e intensi ensity ty aerobic

• bic exerci

cise se 5 days / week

• St

Strengt rengtheni hening ng and endurance urance exerci cises ses minimum nimum

• f 2

2 (n (non-con consecu secutiv tive) e) days / week – 8-10 10 exerci ercises, s, 10-15 5 reps

• 10 minutes

utes flexi xibil bility ity exerci cise se at least t 2 days / week

• Balance exercises for those with “substantial risk
• f 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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