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PHYSICAL ACTIVITY INTERVENTIONS FOR OLDER ADULTS LIVING WITH FRAILTY: A SYSTEMATIC REVIEW AND META-ANALYSIS

PREPARED AND PRESENTED FOR: NUTRITION AND PHYSICAL ACTIVITY CLINICAL PRACTICE GUIDELINES FOR OLDER ADULTS WITH FRAILTY STAKEHOLDER PANEL MEETING JUNE 29TH, 2020

On behalf of the McMaster Evidence Review and Synthesis T eam: Megan Racey, PhD Mohammad Usman Ali, MD Donna Fitzpatrick-Lewis, MSW Diana Sherifali, PhD

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SCOPE OF THE PROBLEM

 Frailty is a leading contributor to functional decline

and early mortality in older adults.

 One of the major components of frailty is loss of

muscle mass, strength, and/or performance.

 By addressing these physical deficits and reducing

dependence, frailty progression can be slowed and is potentially reversible through physical activity interventions.

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2.0M Canadians

in 10 years

1.5M Canadians

Falls Mobility decline Hospitalization Death

RESEARCH QUESTION

What is the effectiveness of physical activity interventions in older adults (age 65+ years) living with frailty or pre-frailty on clinical, patient important, or health utilization

• utcomes?

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PICO

P – Older adults ≥ 65 years of age with frailty Must have formal definition of frailty using a tool, assessment of frailty, or established criteria 80% of study population is pre-frail or frail I – Any physical activity interventions in all settings from RCTs/CCTs or observational cohorts with a comparison group C – True comparison group, treatment as usual, standard care, minimal contact O – Frailty, Mobility, Psychological (cognitive function

• nly), Health Services Use, Physical, Quality of Life

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Screening and extraction Data analysis Screening

• f articles

Data extraction PICO Inclusion / Exclusion criteria Search strategy Meta analysis of data Defining strategy

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DEFINITIONS

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Intervention Category Aerobic Move large muscles in a rhythmic manner for a sustained period. This type of activity is also called endurance activity. Aerobic activity makes a person's heart beat more rapidly to meet the demands of the body's movement. Examples: Brisk walking, jogging, biking, dancing, swimming, water aerobics, aerobic exercise class, bicycle riding, tennis, golf Muscle-Strengthening Activities that increase skeletal muscle strength, power, endurance and mass using the principles of strength training, resistance training, or muscular strength and endurance exercises. Examples: Exercises using exercise bands, weight machines, hand-held weights, Calisthenic exercises (body weight provides resistance to movement), some yoga and tai chi exercises Mixed (multi-component) Combination of aerobic and muscle-strengthening. Mobilization/Rehabilitation Purpose of intervention was to increase mobilization of the participants.

DEFINITIONS

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Intervention Intensity Resistance/strength training Muscle-strengthening exercises. Light intensity Activities during which one can easily carry a conversation. Moderate intensity Activities that require a medium level of effort. On a scale of 0 to 10, where sitting is 0 and the greatest effort possible is 10, moderate-intensity activity is a 5 or 6 and produces noticeable increases in breathing rate and heart rate. Can also be measured using 70% VO2 max or 80% of peak heart rate. High/strenuous intensity Using the same scale as above, activities that are a 7 or 8 on this scale and produces large increases in a person's breathing and heart rate. Holding a conversation during these activities are difficult.

METHODS: CERTAINTY OF EVIDENCE (GRADE APPROACH)

 Common, systemic and transparent approach to grading certainty of evidence and strength of

recommendations

 Assess based on 5 categories:

• 1. Risk of bias
• 2. Inconsistency
• 3. Indirectness
• 4. Imprecision
• 5. Other consideration

 RCTs start as high certainty and can be downgraded; Observational studies start as low certainty and

can be upgraded Results in Certainty of Evidence:

 High, Moderate, Low, or

Very Low

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METHODS: STATISTICAL ANALYSIS

 Continuous outcome data using standardized mean difference (SMD)

 SMDs 0.2-0.5 = small effect  SMDs 0.5-0.8 = medium effect  SMDs >0.8 = large effect

 Dichotomous outcome data using risk ratio (RR)  Studies assessed for Heterogeneity  Multi-level meta-analytic approach

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RESULTS

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PRISMA FLOWCHART

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Records identified through database searchings N = 11261 Additional records identified through other sources N = 0 Records after duplicates removed N = 4668 Records screened N = 4668 Records excluded N = 4450 Full-text articles assessed for eligibility N = 218 Full-text articles excluded, with reasons N = 192

• Study population (younger than 65, frailty not defined, clinical) (N = 113)

Not physical activity intervention (N = 34) Study Design (N = 38) Full-text unavailable (N = 7) Studies included in qualitative synthesis N = 26 (34 articles; 24 RCTS; 2 observational) Studies included in quantitative synthesis (meta-analysis) N = 23

CHARACTERISTICS OF INCLUDED STUDIES

Majority of studies were;

 Location: Asia (n=11), Europe (n=8), North America (n=7)  Setting*: Community-based (n=12), Research centre (n=7), Primary care & hospital (n=6), Long-term

care home (n=3)

 Frailty tool:

Very diverse including Fried's frailty phenotype, ADL indices, other scales/assessments and mobility measures

 Duration: 1 to 3 months (n=10), 4 to 8 months (n=12), ≥9 months (n=4)

*intervention can be conducted in more than one setting; any and all settings were captured

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DESCRIPTION OF INTERVENTIONS

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Category

• Aerobic: 1
• Mixed: 12
• Mobilization/

rehabilitation: 4

• Muscle

strengthening: 9

Intensity

• High/strenuous: 1
• Moderate: 7
• Light: 4
• Resistance/strength

training: 9

• Can't tell: 5

Frequency

• 1-2x/week: 12
• 3-4x/week: 11
• ≥4x/week: 2
• N/R: 1

Session Duration

• < 15 minutes: 2
• 30-60 minutes: 13
• >60 minutes: 5
• N/R: 6

Delivery

• Physiotherapist: 9
• Fitness instructor

/trainer: 7

• Researcher: 3
• Other: 2
• N/R: 5

N/R = Not Reported

RESULTS OVERVIEW | EFFECTIVENESS OF INTERVENTIONS

There was data for all outcomes but not for all PA intervention categories. *Physical outcomes was further broken down into ADLs, Falls, Fatigue level.

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Physical Activity

(and by PA intervention category/type)

Frailty Mobility Cognitive Function Health Services Use Physical* Quality of Life

OVERALL PHYSICAL ACTIVITY

Outcome # studies | N SMD (95% CI) p value GRADE rating Mobility 19 | 1724

Medium; 0.60 (0.37, 0.83) <0.0001 MODERATE

downgraded for risk of bias

ADLs 9 | 910

Medium; 0.50 (0.15, 0.84) 0.005 MODERATE

downgraded for risk of bias

Cognitive Function 5 | 377

Small; 0.35 (0.09, 0.61) 0.008 MODERATE

downgraded for risk of bias

Quality of Life 6 | 500

Medium; 0.60 (0.13, 1.07) 0.0115 MODERATE

downgraded for risk of bias

Frailty 4 | 244 4 | 1538

Large; -1.29 (-2.22, -0.36) 0.0067 MODERATE

downgraded for risk of bias

RR 0.58 (0.36, 0.93) 0.02 MODERATE

downgraded for risk of bias

Falls 7 | 724

RR 0.80 (0.51, 1.26) 0.34 VERY LOW

downgraded for risk of bias, inconsistency, and imprecision

Fatigue Level 3 | 184

No effect; -0.27 (-0.65, 0.12) 0.18 LOW

downgraded for risk of bias and imprecision

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Bold denotes significance p<0.05; Italics for binary outcome; N = total number of participants; SMD = standardized mean difference; CI = confidence interval; RR = risk ratio

AEROBIC PHYSICAL ACTIVITY

Outcome # studies | N SMD (95% CI) p value GRADE rating Mobility 1 | 36

Medium; 0.71 (0.23, 1.20) 0.004 LOW

downgraded for risk of bias and imprecision

ADLs 1 | 36

No effect; 0.46 (-0.03, 0.94) 0.06 VERY LOW

downgraded for risk of bias and imprecision

Cognitive Function 1 | 36

No effect; 0.15 (-0.50, 0.80) 0.65 VERY LOW

downgraded for risk of bias and imprecision

Quality of Life

No data

• Frailty

No data

• Falls

No data

• Fatigue Level

1 | 36

No effect; -0.39 (-0.87, 0.09) 0.11 VERY LOW

downgraded for risk of bias and imprecision

Hospital Services Use

No data

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Bold denotes significance p<0.05; N = total number of participants; SMD = standardized mean difference; CI = confidence interval

MOBILIZATION/REHAB PHYSICAL ACTIVITY

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Outcome # studies | N SMD (95% CI) p value GRADE rating Mobility 3 | 330

Small; 0.29 (0.17, 0.42) <0.0001 MODERATE

downgraded for risk of bias

ADLs 1 | 182

Small; 0.48 (0.28, 0.67) <0.0001 MODERATE

downgraded for risk of bias

Cognitive Function 1 | 116

No effect; 0.12 (-0.10, 0.34) 0.28 LOW

downgraded for risk of bias and imprecision

Quality of Life

No data

• Frailty

No data

• Falls

1 | 184

RR 0.88 (0.69, 1.12) 0.30 LOW

downgraded for risk of bias and imprecision

Fatigue Level

No data

• Hospital Services Use

No data

• Bold denotes significance p<0.05; Italics for binary outcome; N = total number of participants; SMD = standardized mean difference;

CI = confidence interval; RR = risk ratio

MUSCLE-STRENGTHENING PHYSICAL ACTIVITY

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Outcome # studies | N SMD (95% CI) p value GRADE rating Mobility 6 | 722

Medium; 0.57 (0.08, 1.06) 0.02 MODERATE

downgraded for risk of bias

ADLs 2 | 278

No effect; 0.16 (-0.05, 0.37) 0.14 LOW

downgraded for risk of bias and imprecision

Cognitive Function 1 | 45

Small; 0.45 (0.19, 0.72) 0.0008 VERY LOW

downgraded for risk of bias and imprecision

Quality of Life 1 | 70

No effect; 0.15 (-0.33, 0.63) 0.54 VERY LOW

downgraded for risk of bias and imprecision

Frailty 1 | 45 1 | 66

No effect; -0.20 (-0.79, 0.39) 0.5 VERY LOW

downgraded for risk of bias and imprecision

RR 0.21 (0.10, 0.43) <0.0001 MODERATE

downgraded for imprecision

Falls 2 | 442

RR 0.78 (0.37, 1.65) 0.51 VERY LOW

downgraded for risk of bias, inconsistency, and imprecision

Fatigue Level

No data

• Hospital Services Use

No data

• Bold denotes significance p<0.05; Italics for binary outcome; N = total number of participants; SMD = standardized mean difference;

CI = confidence interval; RR = risk ratio

MIXED PHYSICAL ACTIVITY

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Outcome # studies | N SMD (95% CI) p value GRADE rating Mobility

9 | 636 Medium; 0.75 (0.40, 1.10) <0.0001

MODERATE downgraded for risk of bias

ADLs

5 | 414 Medium; 0.64 (0.004, 1.27) <0.05

LOW downgraded for risk of bias and inconsistency

Cognitive Function

2 | 180 Medium; 0.62 (0.12, 1.11) 0.016

MODERATE downgraded for risk of bias

Quality of Life

5 | 430 Medium; 0.68 (0.16, 1.21) 0.01

MODERATE downgraded for risk of bias

Frailty

3 | 199 3 | 1472 Large; -1.57 (-2.57, -0.57) 0.0021

MODERATE downgraded for risk of bias

RR 0.72 (0.63, 0.83) <0.0001

MODERATE downgraded for risk of bias

Falls

1 | 82 1 | 98 No effect; -0.37 (-0.81, 0.07) 0.10

LOW downgraded for risk of bias and imprecision

RR 0.62 (0.16, 2.47) 0.50

LOW downgraded for imprecision

Fatigue Level

2 No effect; -0.23 (-0.85, 0.39) 0.47

VERY LOW downgraded for risk of bias, inconsistency, and imprecision

Health Services Use

1 | 82 1 | 98 No effect; -0.21 (-0.65, 0.23) 0.35

LOW downgraded for risk of bias and imprecision

RR 0.52 (0.05, 5.56) 0.59

LOW downgraded for imprecision

Bold denotes significance p<0.05; Italics for binary outcome; N = total number of participants; SMD = standardized mean difference; CI = confidence interval; RR = risk ratio

HARMS OR ADVERSE EVENTS OF THE INTERVENTION

 Harms directly related to the intervention were reported in 7 of 26 studies

 Falls  Fractures  Sprains, strains, or other injuries  Muscle ache and fatigue (mostly managed by adjusting intervention)  Other health problems (ie. angina)

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KEY FINDINGS & CONCLUSIONS

 There appears to be a small to large benefit for physical activity interventions of

various types on certain outcomes including; mobility, ADLs, cognitive function, quality

• f life (QoL), and frailty

 Overall, there was a large effect on frailty, a medium effect on QoL, ADLs, and

mobility, and a small effect on cognitive function

 There appears to be no evidence of an effect on falls or fatigue level regardless of

intervention category/type

 The evidence supported the development of five recommendations for practice.

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CREATING RECOMMENDATIONS FROM THE EVIDENCE: EVIDENCE TO DECISION MAKING TABLES

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https://www.youtube.com/watch?v=iGVEdNa1xFY

CLINICAL PRACTICE GUIDELINES FOR OLDER ADULTS WITH FRAILTY

Five recommendations are supported by evidence from this review

• 1. We recommend that older adults living with frailty or pre-frailty perform physical activity

[strong recommendation; moderate certainty of evidence].

• 2. We suggest that older adults living with frailty or pre-frailty perform aerobic physical activity

[weak recommendation; low certainty of evidence].

• 3. We recommend that older adults living with frailty or pre-frailty perform muscle strengthening

activities [strong recommendation; moderate certainty of evidence].

• 4. We recommend that older adults living with frailty or pre-frailty perform mobilization or

rehabilitation exercises [strong recommendation; moderate certainty of evidence].

• 5. We recommend that older adults living with frailty or pre-frailty perform multi-component physical

activity (i.e. incorporating combinations of aerobic, resistance, balance, and flexibility training) [strong recommendation; moderate certainty of evidence].

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ACKNOWLEDGEMENTS

This work would not have been possible without our partners. We acknowledge indirect and direct support from the following organizations and institutions:

 Canadian Frailty Network  McMaster Institute for Research and Aging (MIRA)  McMaster Evidence Review and Synthesis T

eam (MERST)

 Heather M. Arthur Population Health Research Institute/Hamilton Health Sciences

Chair in Inter-Professional Health Research

 School of Nursing, McMaster University

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thank you

For more information or to hear more about our work, please contact MERST: raceym@mcmaster.ca fitzd@mcmaster.ca

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