Analysis: researchers have found that a combination of simple strength exercises and dietary changes could be effective to tackle the onset of frailty
By John Travers, UCD
Frailty has long been in the lexicon of everyday language. "How easily the wind overturns a frail tree," the philosopher and spiritual teacher Buddha reflected some 2,500 years ago. Many feel that becoming frail as we age is an unavoidable one-way street. However, recent research by a team of doctors in Dublin highlights how frailty can be delayed and even reversed. It is a message worth sharing to dispel a myth that frailty is inevitable and improve the health of ourselves and our loved ones.
Most people have an inherent instinct for recognising frailty, but it is only in recent years that frailty has been defined in a medical sense. This reflects a shift of emphasis on medicine for a single system, such as the heart or the lungs, to care for the whole-person.
Frailty is a state of physiological vulnerability to external stressors that increases the risks of illness, falls, dependency, disability and death. It is becoming a more common challenge as populations age and life expectancy lengthens. The prevalence of frailty is estimated at 11% in adults aged over 65 years and increases to some 50% in those over 80 years of age. The United Nations estimates that the world population of individuals over 60 years will more than double from 962 million in 2017 to 2.1 billion in 2050. The population of individuals aged over 80 years will triple from 137 million to 425 million in the same period. In Ireland, the population of over 65s is growing four times faster than the total population.
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From RTÉ Radio One's Ray D'Arcy Show, Sarah Harper, Prof of Gerontology at Oxford University, on healthy ageing and how we have to reform our thinking around old age
Frailty has been described as the most problematic expression of ageing in the context of this fast growth. It has forced fundamental changes in national health policies. For example, general practitioners in England since 2017 are contractually obliged to use an appropriate tool to identify patients who are living with moderate or severe frailty. A commonly used tool for frailty screening, developed by Linda Fried, is to assess for three or more criteria (exhaustion, unexplained weight loss, slowness, weakness and low physical activity), with the presence of one or two criteria defining pre-frailty.
Despite the contractual requirement in England and growing recommendations for screening internationally, there is a lack of clear guidance on the most effective and practical interventions for frailty once identified. In this context, a team of doctors at Trinity College Dublin and St Vincent's University Hospital College Dublin set out to map the comparative effectiveness and ease of implementation of primary care interventions for frailty and help inform practitioners and patients on the most appropriate choices.
They searched scientific databases for every trial and study published on primary care frailty interventions. Effectiveness was scored in terms of change of frailty status or frailty indicators and ease of implementation in terms of human resources, marginal costs, and time requirements.
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From RTÉ Radio 1's Drivetime, Rose Anne Kenny, Professor of Medical Gerontology at Trinity College Dublin, on healthy ageing
A total of 925 studies were assessed and 46 were analysed in detail. There were 15,690 participants (median study size was 160 participants). Studies reflected a broad diversity. For instance, there were 17 different frailty screening methods. Of the frailty interventions, 23 involved physical activity and others involved health education, nutrition supplementation, home visits, hormone supplementation and counselling.
A significant improvement of frailty status was demonstrated in 71% of studies and of frailty indicators in 69% of studies where measured. A combination of muscle strength training and protein supplementation was the most effective intervention to delay or reverse frailty and the easiest to implement in primary care. The team created a map of interventions that can be used to inform choices for managing frailty.
The team were surprised and hopeful on finding that readily accessible plans such as strength exercises and dietary protein had such a profound impact on delaying and reversing frailty. Walking, which has clearly demonstrated benefits for cardiovascular health, had relatively less impact on frailty, underlining the need for varied exercise. The good news is that the exercises are straightforward, can be done at home and studies showed high compliance rates. Sufficient protein can be consumed in the diet without use of supplements necessarily.
Readily accessible plans such as strength exercises and dietary protein have a profound impact on delaying and reversing frailty
A typical exercise regime should consist of 20 to 25 minutes of activity, four days per week at home, comprising 15 exercises: three for strengthening arms, seven for strengthening legs, and five for balance and coordination. Each exercise is repeated 10 times per minute, progressively reaching 15 times after two to three months, with a rest of half a minute between each set. Only 4% of participants who undertook this regime progressed to frailty after a year, while over 15% of participants in a control group became frail. Nutrition or protein supplementation regimes described in studies included appropriate dietary emphasis on daily milk, eggs, tuna, chicken or plant based protein; or where preferred, 2 x 200 mL of formula per day (containing 25g protein, 400 kcal energy, 9.4 g essential amino acids, and 400 mL water).
While some strength exercises can simply involve using water bottles or elastic bands, engaging in exercises may not be possible for patients with debilitating conditions. Other options, such as health education, score in the mid-zone for relative effectiveness and may be easy to implement. The map of programmes can be used as a tool by GPs and patients discussing the best personal approach to delaying and reversing frailty.
John Travers is a medical doctor practising in Dublin and a PhD student at UCD
The views expressed here are those of the author and do not represent or reflect the views of RTÉ
