Defeating frailty: The power of a Do-It-Yourself (DIY) program

Dr Chad Han

Caring Futures Institute, Flinders University

Pre-frailty and frailty are clinical syndromes that increase an older adult’s risk to higher dependency and are associated with lower survival rates. [1, 2] This is especially important as many older adults already live with multiple chronic conditions such as metabolic diseases and cancers, that make them vulnerable. Frailty (physical) can be described as a syndrome when three or more of the following conditions are present: low physical activity, slow walking speed, unintentional weight loss, weak grip strength, and self-reported exhaustion. [2] Frailty (inclusive of domains other than just physical) can also be defined as deficits in cognition, general health status, functional independence and performance, social support, medication use, nutrition, mood, continence etc. [3] Pre-frailty, as its name suggests, is a state prior to the spectrum of frailty, though a consensus of its definition is underway. [4]

There is a high prevalence of pre-frailty and frailty in Australia. In a cohort of 329 hospitalised older adults at Flinders Medical Centre in Adelaide, more than half (n=220) were either pre-frail or frail, according to the Edmonton Frail Scale. [5] The acute stress of hospitalisation makes it harder for older adults to ‘bounce back’ as they get discharged [1]. There are ways to alleviate that. Multifaceted interventions combining exercise and nutrition as part of management strategies are recommended by The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Expert Working Group for pre-frail and frail hospitalised older adults. [6] However, the sustainability of these treatments is questionable, and involving a more collaborative partnership approach with patients may be equivalent as existing models but better reduce burden on healthcare resources.

The INDividualized therapy for Elderly Patients using Exercise and Nutrition to reduce depenDENCE post discharge (INDEPENDENCE) pilot program was developed by a group of researchers at Flinders University involving dietitians (Professor Michelle Miller, Dr Alison Yaxley, Dr Chad Han – as part of his PhD with College of Nursing and Health Sciences, Flinders University), a physiotherapist (Dr Claire Baldwin) and a physician (A/Prof Yogesh Sharma). The novelty of this program was the adaptation for pre-frailty and frailty of a chronic condition self-management model developed by Professor Malcolm Battersby, initially for self-management of conditions such as diabetes. [7] The pilot randomised controlled trial, recently published in Clinical Interventions in Aging, showed promising results on the preliminary effectiveness and acceptability of such a self-management hospital-to-home program. [8]

The trial highlighted that this self-management model was well received by participants, having an average participation in activities/visits of above 90%. [8] There were significant improvements in the Edmonton Frail Scale at 3 months (after the active support ended) and a legacy effect at 6 months (3 months after active support was removed). To understand more about the barriers and facilitators to this program, participants of the intervention group were also interviewed. The barriers and enablers we identified highlight the unique and individualized needs of older adults which can aid or hinder adherence (manuscript under preparation).

Intentions, Social influences, Environmental context/resource, and Emotions served as primary barriers towards adherence to both exercise and nutrition components. For example, a participant shared how depressive mood could prevent her from eating better and moving: ‘Now I hate getting out. I just like staying in my bed. I think the earlier I get up, the longer the day is.’ Common enablers for both components included Knowledge, Social identity, Environmental context/resource, Social influences, and Emotions. For example, the acknowledgement of benefits of exercise encouraged a participant to keep doing her exercises: ‘And I knew it was going to build up stamina and give me strength again. So there was a big incentive.’

Want to know more about the INDEPENDENCE pilot program?

*The views and opinions expressed in Knowledge Blogs are those of the authors and do not necessarily reflect those of ARIIA, Flinders University and/or the Australian Government Department of Health and Aged Care.

  1. Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, et al. Frailty consensus: A call to action. J Am Med Dir Assoc. 2013;14(6):392–397.
  2. Crow RS, Lohman MC, Titus AJ, Bruce ML, Mackenzie TA, Bartels SJ, et al. Mortality risk along the frailty spectrum: Data from the National Health and Nutrition Examination Survey 1999 to 2004. J Am Geriatr Soc. 2018;66(3):496–502.
  3. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526–529.
  4. Sezgin D, O'Donovan M, Woo J, Bandeen-Roche K, Liotta G, Fairhall N. et al. Early identification of frailty: Developing an international delphi consensus on pre-frailty. Arch Gerontol Geriatr. 2022 Mar-Apr;99:104586.
  5. Han CY, Sharma Y, Yaxley A, Baldwin C, Miller M. Use of the Patient-Generated Subjective Global Assessment to Identify Pre-Frailty and Frailty in Hospitalized Older Adults. J Nutr Health Aging. 2021;25(10):1229-1234.
  6. Daly RM, Iuliano S, Fyfe JJ, Scott D, Kirk B, Thompson MQ, et al. Screening, diagnosis and management of sarcopenia and frailty in hospitalized older adults: Recommendations from the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Expert Working Group. J Nutr Health Aging. 2022;26:1–15.
  7. Battersby M, Harris M, Smith D, Reed R, Woodman R. A pragmatic randomized controlled trial of the Flinders Program of chronic condition management in community health care services. Patient Educ Couns. 2015 Nov;98(11):1367-75.
  8. Han CY, Sharma Y, Yaxley A, Baldwin C, Woodman R, Miller M. Individualized Hospital to Home, Exercise-Nutrition Self-Managed Intervention for Pre-Frail and Frail Hospitalized Older Adults: The INDEPENDENCE Randomized Controlled Pilot Trial. Clin Interv Aging. 2023 May 17;18:809-825.
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