Frailty: Thy Name is Human

Frailty can be a condition that someone just slips into without realizing it. As we watch our patients we realize this insidious problem can benefit from physical therapy and be reversed.

Our previous article (June 6, 2016 issue) discussed ways to assess frailty. Once you realize the person is frail, evidence-based efforts must be undertaken to combat the frailty. In the institutionalized older population, there is firm evidence that exercise improves functional performance, activities of daily living, and quality of life.¹ The components of the best exercises are as follows:

• Training should include progressive resistive exercise, balance and functional training;
• Intensity should be moderate-to-high for most populations, and once the person can perform a consistent program. Rating of exertion should be 4-6 on a 0-10 Borg Scale;
• The program should be performed at least three times per week for a minimum of 10 weeks.¹

Egerton in 2013 came up with some useful suggestions for older persons that complain of fatigue. These guidelines could be considered when designing a program to help patients adhere to their exercise programs:

•   Exercise at 50-60% intensity;
• Perform shorter bouts, approximately 10 minutes;
• Perform interval rather than continuous exercise;
• Exercise in the morning.

In designing programs for frail older persons, the setting may play an important role. The following evidence-based suggestions are from intensive care (ICU) to community settings.

Trees et al., also in 2013, provided mobility strategies for ICU-acquired weakness. Their graded mobilization program contained four progressive phases, from the patient being unable to follow commands to the patient being able to transfer and ambulate with no assistance.

In each phase, treatment suggestions were given. For example, in the first and lowest phase, suggestions are for passive range of motion and sitting in a chair. Phase 2, in which the patient can follow simple commands, includes bed mobility skills, balance activities and graded partial weight bearing.³

Nolan and Thomas (2008) developed a targeted individual exercise program for older medical patients.⁴ He found that exercise was feasible and may change hospital and patient outcomes. This program is a functional maintenance program designed by physical therapy and administered by an allied health assistant within 48 hours of admission.

Researchers found that the program decreased length of stay and readmissions as well as improved function. The program consists of in-bed, seated, and standing exercises for strength, flexibility and balance. The program was performed daily for 30 minutes and included 6-8 exercises repeated 8-12 times and progressed as needed.

Ouslander et al. (2005) developed a program for nursing home residents titled the Functional Incidental Training program, which requires six minutes more of nursing time and improves mobility and physical activity.⁵ The nurse encourages the resident to perform sit-to-stand (1-16 times) as well as perform progressive resistive exercise to all large joints, and then to walk or propel their wheelchair for 5-20 minutes. This program is completed while the nurse works on continence care.

Finally, a good source for recommendations on physical activity for older adults is the ACSM/AHA Overview.⁶These suggest stretching at least twice per week, strengthening 2-3 times per week, and aerobics at least five days per week, which can be achieved with a target heart rate 20 BPM above resting. All activities are done to at least mild fatigue.

The original references have more details on these programs, including charts of the exercises. Locate them and find the best program for your older patients who may be frail. Physical therapy can help, and we can make frailty’s name inhuman.

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References

1. Weening-Dijksterhuis E, de Greef MH, Scherder EJ et al. “Frail Institutionalized Older Persons: A Comprehensive Review of Exercise, Physical Fitness, Activities of Daily Living, and Quality of Life.” Am J Phys Med Rehabil, February 2011; 90(2): 156-68.
2. Egerton T. “Self-Reported Aging-Related Fatigue: A Concept Description and its Relevance to Physical Therapist Practice.” PT Journal, October 2013; 93(10): 1403-1413.
3. Trees DW, Smith JM, Hockert S. “Innovative Mobility Strategies for the Patient With Intensive Care Unit-Acquired Weakness: A Case Report.” PT Journal. 2013; 93(2): 237-247.
4. Nolan, J, Thomas, S. “Targeted individual exercise programmes for older medical patients are feasible, and may change hospital and patient outcomes: a service improvement project.” BMC Health Services Research, 10 December 2008.
5. Ouslander JG et al. “Functional Incidental Training: A Randomized, Controlled, Crossover Trial in Veterans Affairs Nursing Homes.” JAGS 53:1091-1100,2005.
6. Elsawy B, Higgins KE. “Physical Activity Guidelines for Older Adults.” American Family Physician, January 2010; 81: 55-59.