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Context
Frailty is a common and costly problem. Recent research has enhanced our understanding of the aetiology, diagnosis and impact of frailty, yet the next step is to identify and evaluate interventions that target remediable aspects of frailty. Preventing frailty in people who are prefrail and ameliorating frailty in those already frail, has the potential to reduce poor health outcomes associated with frailty, such as disability, falling, hospitalisation and institutionalisation. To date, few studies have specifically recruited frail individuals or targeted frailty as an outcome. This study examined the effect of four intervention programmes versus usual care on degree of frailty in older people.
Methods
This was a randomised controlled trial conducted in community-dwelling prefrail and frail volunteers aged 65 years or over, in Singapore. Frailty was measured using the Cardiovascular Health Study (CHS) criteria1 at baseline, at the end of the 24-week intervention period and again 6 months after the intervention ended. In all, 246 participants were randomised to one of five groups: exercise, nutritional supplementation, cognitive training, a combination of these or usual care. The pragmatic study was robust in design, conforming to CONsolidated Standards of Reporting Trials (CONSORT) guidelines. The results are reported as OR estimates and CIs.
Findings
Eighty-nine per cent of participants completed the study. At baseline, 72% were prefrail and 28% were frail. Compared with usual care, the combination intervention was five times more likely to result in reduced frailty at 12 months (OR 5.0, 95% CI 1.88 to 13.3), and the physical intervention was four times more likely (OR 4.05, 95% CI 1.50 to 10.8). The nutritional and cognitive interventions caused smaller, yet statistically significant, reductions in frailty (OR 2.98 and 2.89, respectively). There was no treatment effect on the secondary outcomes of activities of daily living (ADL), falls or hospitalisation.
Commentary
By showing that single and combined interventions can cause lasting reductions in degree of frailty, this randomised trial adds solid foundations to the evidence base for optimising treatment approaches for older people at risk of frailty. The results of this study are believable, yet confirmation is required from larger trials and studies in populations with greater frailty, poorer functioning (97% were independent in ADLs) and worse cognition (the mean Mini Mental State Examination score was 29/30). This study is novel as it evaluates the effect of single and combined interventions on the primary outcome of frailty, and measures frailty outcomes 6 months beyond the intervention period. The beneficial effect of the interventions is consistent with the results of earlier trials that targeted frailty using multifactorial interventions. The single interventions used by Ng and colleagues are appealing, as delivery of a single physical, nutritional or cognitive intervention is realistic in many existing healthcare systems and is relatively inexpensive. Larger studies are needed to investigate which interventions are best for subgroups with different frailty profiles; while the majority of this sample were prefrail, frailer individuals may require a broader approach targeting the complex medical, physical and social problems present. Finally, there was no evidence of a treatment effect on the secondary outcomes of hospitalisation, falls or ADL. It would have been interesting to evaluate functional outcomes such as community participation, using a tool with a higher ceiling.
The observed treatment effect was largely due to improvement in the muscle strength frailty criterion and, to a lesser extent, gait speed. Improvement in these outcomes is consistent with the results of systematic reviews and randomised trials of the effect of well-designed exercise intervention on strength and mobility in older people. For example, the intervention included tailored exercise prescription and progression, resistance training embedded within functional movements and adequate challenge to balance.
Adherence to the study intervention was commendably high, ranging from 79% for cognitive training to 91% for nutritional supplementation. The likelihood of replicating this adherence must be considered before extrapolating the results of this study.
The effect of cognitive training on reducing frailty is noteworthy and should prompt further investigation. The CHS definition of frailty has been criticised for not including cognition, and increased understanding of the role of cognition in frailty is indicated.
Implications for practice
This study supports recent evidence that frailty can be reduced with intervention, and it adds evidence that single and combination interventions containing a well-developed exercise programme are effective in prefrail older people with minimal cognitive or functional impairment. To a lesser degree, nutritional and cognitive interventions also reduce degree of frailty and further investigation of the optimal intervention is warranted. Frail and prefrail older people should be identified in the clinical setting and aged care management should include interventions targeting reduction in frailty.
Reference
Footnotes
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.