Public Health Impact of Frailty: Role of Physical Therapists

Systematic development of an implementation strategy to promote high-intensity rehabilitation uptake in skilled nursing facilities

BACKGROUND

Effective implementation of rehabilitation research into clinical practice is imperative to optimize patient outcomes; however, limitations persist. A systematic approach to develop implementation strategies can address known limitations.

OBJECTIVE

To detail the systematic process for developing a strategy to implement high-intensity resistance rehabilitation (HIR) in skilled nursing facilities (SNFs), to be evaluated in future pragmatic trials.

DESIGN

Expert-informed, theory-driven development study.

SETTING

Academic research institute.

PARTICIPANTS

An expert panel of clinician-researchers (n = 5) and SNF clinicians (n = 4) with experience implementing HIR collaborated on strategy development.

INTERVENTIONS

Development followed steps of implementation mapping: (1) identifying barriers and facilitators, (2) defining performance objectives, (3) selecting theory and evidence to develop the strategy, (4) producing the implementation strategy, and (5) planning for evaluation. Panel consensus meetings were held throughout the process.

MAIN OUTCOME MEASURE(S)

Not applicable.

RESULTS

Barriers and facilitators were identified at patient, clinician, and facility levels. Performance objectives included: (1) screening all patients for suitability, (2) dosing rehabilitation interventions at a high intensity for appropriate patients, (3) monitoring and adjusting dosage per patient response, and (4) progressing patients each session. Adult learning theories, social cognitive theory, and a review of the literature on effective implementation strategies guided development of a multicomponent implementation strategy: (1) train and educate clinicians (e.g., online modules); (2) provide interactive assistance (e.g., external implementation facilitator, check-ins); (3) support clinicians (e.g., job aids); and (4) change infrastructure (e.g., equipment provision). An evaluation plan was constructed.

CONCLUSION

This work illustrates a systematic approach, guided by implementation, adult learning, and behavior change principles, for developing an implementation strategy to promote HIR implementation in diverse SNFs. Health care leaders, clinicians, and researchers can replicate this approach to enhance rehabilitation practices, improving patient care and outcomes. Future work will evaluate this strategy for HIR implementation in SNFs.

Toward a Self-Report Cumulative Deficits Frailty Scale (Sr-CDFS): Development and Clinimetric Properties of a Novel Frailty Scale

BACKGROUND AND PURPOSE

Frailty, a multidimensional syndrome, is linked with heightened risk of adverse outcomes. Targeted physical therapy interventions for individuals with frailty have proven beneficial, underscoring the value of routine frailty assessment in both clinical and research settings. This study aimed to: (1) describe development of a simple self-report cumulative deficits frailty scale (Sr-CDFS); (2) establish the criterion validity of Sr-CDFS against the commonly used Fried's frailty scale and Study of Osteoporotic Fracture criteria (SOF); and (3) assess other concurrent validity and internal consistency of the new Sr-CDFS.

METHODS

The study included 230 older adults (M age = 79.27 ± 7.42 years), with 76.5% being women. Outcome measures were: (1) validated frailty scales, including Fried's frailty phenotype, SOF, and Sr-CDFS; and (2) a battery of tests for impairment, activity limitations, and health status. Data analysis involved calculating frailty prevalence using the validated frailty scales. The clinimetric properties of the Sr-CDFS were assessed against validated frailty scales. Convergent and discriminative validity of the Sr-CDFS were examined. Internal consistency and structure were evaluated using Cronbach's alpha and exploratory factor analysis.

RESULTS AND DISCUSSION

No differences (P = .80) in frailty prevalence were found between Fried (26.1%) and SOF (25.2%) methods. The Sr-CDFS exhibited excellent internal consistency (Cronbach's alpha = .92), with reliability of questionnaire components (health, falls, physical, cognitive, socioemotional function) ranging from .73 (falls) to .90 (physical ability). Additionally, the Sr-CDFS demonstrated convergent and discriminative validity, with its total score and various parts correlating significantly with most outcomes (r = .25-.59, P < .05). Using K1-criterion and a scree plot, we identified a 5-factor solution that had a common variance of 63.9%.

CONCLUSION

The newly developed Sr-CDFS exhibits robust clinimetric properties with good-to-excellent reliability and validity. The newly developed Sr-CDFS has the potential to increase the feasibility of assessing frailty in clinical settings or large-scale epidemiological studies.

Allied health and the frail patient in hospital - a prospective cohort study

Objectives Frailty is associated with significant mortality and morbidity in hospitalised patients. We describe physiotherapy and occupational therapy practices in hospitalised frail patients and examine the role of early intervention. Methods We performed a prospective, observational cohort study in a medical assessment unit in a tertiary care hospital. Patients with COVID-19 infection were excluded. Frailty was measured by the Clinical Frailty Scale (CFS). Early allied health intervention was defined as involvement within 48h of admission. Demographic data, clinical diagnoses, time spent with physiotherapy and occupational therapy, CFS, hospital length of stay and outcomes were recorded and analysed. Results A total of 356 patients were categorised into non-frail (CFS score <5) and frail (CFS score ≥5) groups. The prevalence of frailty was 68% (n =241). Physiotherapy (77.2%) and occupational therapy (75.5%) reviews were more frequent in frail patients than in non-frail patients. Frail patients who had allied health involvement within 48h of admission had a significant reduction in their hospital length of stay (mean reduction of 7.3days, 95% CI: 0.53, 14, P =0.035) and a 2.44% reduction in the relative risk of developing pressure injuries (95% CI: 1.31, 4.53). There was no statistically significant differences in outcomes with allied health intervention for non-frail patients and patients who require residential aged care facility level care. Conclusions Allied health have a key role in the management of frailty. Early allied health intervention was associated with a reduced hospital length of stay as well as a reduced incidence of pressure injury in frail patients.

Development and validation of frailty risk prediction model for elderly patients with coronary heart disease

OBJECTIVE

To analyze the influential factors of frailty in elderly patients with coronary heart disease (CHD), develop a nomogram-based risk prediction model for this population, and validate its predictive performance.

METHODS

A total of 592 elderly patients with CHD were conveniently selected and enrolled from 3 tertiary hospitals, 5 secondary hospitals, and 3 community health service centers in China between October 2022 and January 2023. Data collection involved the use of the general information questionnaire, the Frail scale, and the instrumental ability of daily living assessment scale. And the patients were categorized into two groups based on frailty, and χ2 test as well as logistic regression analysis were used to identify and determine the influencing factors of frailty. The nomograph prediction model for elderly patients with CHD was developed using R software (version 4.2.2). The Hosmer-Lemeshow test and the area under the receiver operating characteristic (ROC) curve were employed to assess the predictive performance of the model. Additionally, the Bootstrap resampling method was utilized to validate the model and generate the calibration curve of the prediction model.

RESULTS

The prevalence of frailty in elderly patients with CHD was 30.07%. The multiple factor analysis revealed that poor health status (OR = 28.169)/general health status (OR = 18.120), age (OR = 1.046), social activities (OR = 0.673), impaired instrumental ability of daily living (OR = 2.384) were independent risk factors for frailty (all P < 0.05). The area under the ROC curve of the nomograph prediction model was 0.847 (95% CI: 0.809 ~ 0.878, P < 0.001), with a sensitivity of 0.801, and specificity of 0.793; the Hosmer- Lemeshow χ2 value was 12.646 (P = 0.125). The model validation results indicated that the C value of 0.839(95% CI: 0.802 ~ 0.879) and Brier score of 0.139, demonstrating good consistency between predicted and actual values.

CONCLUSION

The prevalence of frailty is high among elderly patients with CHD, and it is influenced by various factors such as health status, age, lack of social participation, and impaired ability of daily life. These factors have certain predictive value for identifying frailty early and intervention in elderly patients with CHD.

Prevalence and risk factors of frailty in older patients with chronic heart failure: a systematic review and meta-analysis

AIM

To provide a summary of the available evidence concerning prevalence and risk factors of frailty in elderly patients with CHF.

METHODS

PubMed, Embase, Web of Science, CINAHL, The Cochrane Library, China National Knowledge Infrastructure Database (CNKI), Chinese Biomedical Database (Sinomed), Weipu Database (VIP), and Wanfang database were searched from inception to July 2023. This study strictly followed the PRISMA guidelines. The quality of the included studies was rated by the Agency for Healthcare and Research and Quality and the Newcastle-Ottawa Scale.

RESULTS

A total of 21 original studies were included, involving 4,797 patients. Meta-analysis results showed that the prevalence of frailty in older patients with heart failure was 38% (95%CI: 0.32-0.44). Age, cardiac function grading, left atrial diameter, left ventricular ejection fraction, hemoglobin, polypharmacy, BNP, nutritional risk, and hospitalization day are the influential factors of frailty in older patients with CHF.

CONCLUSION

The prevalence of frailty in older patients with CHF is high, and clinical medical personnel should identify and intervene early to reduce or delay the frailty in older patients with CHF as much as possible.

Physical Activity Behavior During and After COVID-19 Stay-at-Home Orders-A Longitudinal Study in the Austrian, German, and Italian Alps

Background

In Alpine regions, which are very similar due to their topographical location and their wide-ranging sports offerings, the restrictions on sports activities during the COVID-19 pandemic differed in type and level: while in some regions (Tyrol, South Tyrol, Trentino), all sports activities were forbidden except for walking near the home, in other regions (Upper Bavaria, Vorarlberg), people were allowed to go hiking and running during the first lockdown.

Objective

The aim of this study was to investigate the change in physical activity (PA) behavior in different Alpine regions (Upper Bavaria, Vorarlberg, Tyrol, South Tyrol, Trentino) over four periods in 2020, to examine the effects of COVID-19 measures of varying severity on PA behavior and to identify factors associated with a change in PA over time.

Methods

A retrospective online survey was conducted (N = 2975) from December 2020, to January 2021. Using the questionnaire of the Eurobarometer 472 study, PA behavior was measured over four periods: before COVID-19 (March), during the first lockdown (March and April), during the relaxed period (May-October) and during the second lockdown (November and December) in 2020.

Results

During the first (M = 5.0h, SD = 4.5) and the second lockdowns (M = 4.9h, SD = 4.3), the participants (age: 42 years, overly active in sports) engaged less in sports than before (M = 5.9h, SD = 4.8) and during the relaxed period in summer (M = 6.4h, SD = 5.0) (average number of hours per week being physically active). A larger percentage of participants from Alpine regions with severe restrictions (Tyrol, South Tyrol, Trentino) decreased their PA during the first lockdown as compared to participants from Upper Bavaria and Vorarlberg with a less strict first lockdown. Those with psychological distress, male participants, and individuals with decreased physical health and less free time during COVID-19 were more likely to reduce their PA.

Conclusions

Despite a short-term negative effect of COVID-19 restrictions on exercise participation during lockdowns, the majority of respondents returned to their original levels of PA during the relaxed COVID-19 phases. As a comparison of Alpine regions shows, particularly severe COVID-19 measures seem to have reduced PA with potential negative health effects. For the future, policy makers and sports organizations should collaborate to support the population in their PA behavior during pandemics to outweigh restrictions.

The utilization of primary healthcare services among frail older adults - findings from the Helsinki Birth Cohort Study

BACKGROUND

The impact of frailty on primary healthcare service use, especially general practice office visits and remote contacts, is currently unknown. Further, little is known about the association of frailty with physiotherapy contacts.

METHODS

We examined the utilization of primary healthcare services among 1064 participants from the Helsinki Birth Cohort Study between the years 2013 and 2017. Frailty was assessed based on Fried's frailty criteria at mean age of 71.0 (2.7 SD) years in clinical examinations between the years 2011 and 2013. General practice office visits and remote contacts, the total number of general practice contacts, physiotherapy contacts, and the total number of primary healthcare contacts were extracted from a national Finnish register. We analyzed the data with negative binomial regression models.

RESULTS

Of the 1064 participants, 37 were frail (3.5%) and 427 pre-frail (40.1%); 600 non-frail (56.4%) served as a reference group. Frailty was associated with general practice office visits (IRR 1.31, 95% CI=1.01-1.69), physiotherapy contacts (IRR 2.97, 95% CI=1.49-5.91) and the total number of primary healthcare contacts (IRR 1.41, 95% CI=1.07-1.85). Pre-frailty predicted the use of general practice remote contacts (IRR 1.39, 95% CI=1.22-1.57) and the total number of general practice contacts (IRR 1.25, 95% CI=1.12-1.40).

CONCLUSIONS

Frailty increases the overall primary healthcare service use whereas pre-frailty is associated with the use of general practice services, especially remote contacts. Primary healthcare needs measures to adapt healthcare services based on the needs of rapidly increasing number of pre-frail and frail older adults and should consider preventative interventions against frailty.

Prevalence of frailty in older adults in outpatient physiotherapy in an urban region in the western part of Germany: a cross-sectional study

OBJECTIVE

To investigate the prevalence of frailty in older people in outpatient physiotherapy services in an urban region in the western part of Germany.

DESIGN

Cross-sectional study.

SETTING

Outpatient physiotherapy clinics were recruited in the municipal area of the city of Bochum, Germany, and selected randomly.

PARTICIPANTS

Older adults aged 65 years and older seeking outpatient physiotherapy.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of frailty was assessed based on the frailty phenotype model of physical frailty and the accumulation of deficit model, expressed as a Frailty Index. Prevalence was calculated for the whole sample and according to age-related, sex-related and diagnosis-related subgroups.

RESULTS

A total of 258 participants (74±6 years, 62% female) from 11 out of 130 (8%) different physiotherapy clinics were included. Participants' main indication for physiotherapy was an orthopaedic or surgical condition (75%). According to the model of a physical frailty phenotype, 17.8% (95% CI 13.2 to 22.5) participants were frail and 43.4% (95% CI 37.4 to 49.5) were prefrail. The Frailty Index identified 31.0% (95% CI 25.4 to 36.7) of individuals as frail. In both models, prevalence increased with age and was higher in women than in men. Slow gait speed (34%), reduced muscle strength (34%) and exhaustion (28%) were the most prevalent indicators of physical frailty.

CONCLUSIONS

Frailty is comparatively common in older patients attending physiotherapy care in Germany, with one out of three individuals being frail and every second individual being physically frail or prefrail.

TRIAL REGISTRATION NUMBER

DRKS00009384; Results.