Slowing Decline in the Frail Elderly

Summarized by Robert W. Griffith, MD
October 25, 2002 (Reviewed: October 19, 2004)

Introduction

People are living longer than ever, and often enter their later years without any specific cause for disability, but are nevertheless so physically frail that their activities are limited. While acute medical conditions such as a stroke or a fractured hip are usually followed by intense rehabilitation efforts, little physical therapy is normally supplied for these frail people. A study has shown, however, that participation in such a program can slow their normal functional decline to a significant degree. It's summarized here.

Method

Primary care practices in Connecticut, USA, identified potential participants who lived at home. They had to be 75 or older, and be physically frail, i.e. they needed more than 10 seconds to walk a 10-ft course there-and-back, or be unable to stand from a sitting position in a chair with their arms folded. One test failure meant they were moderately frail, failure on both tests indicated severe frailty.

Subjects were excluded if they couldn't walk, had a Mini-Mental State Examination (MMSE) score of <20, had a recent severe medical condition, or a life expectancy of less than 12 months. A baseline questionnaire was used to get information on 8 activities of daily living: walking, bathing, upper- and lower-body dressing, standing up from a chair, using the toilet, eating, and grooming. Each was scored, using 0 for 'no difficulty', 1 for 'difficulty, but no help needed', and 2 for 'help needed'. The summary disability scores therefore ranged from 0-16. The questionnaires were repeated at 3, 7, and 12 months.

Participants were assigned randomly to a physical intervention program, or to an educational program (controls). For the intervention program, a physical therapist visited the participant for an average of 16 visits over a 6-month period. At each visit, the therapist focused on exercises that were designed to specifically deal with the subject's actual major impaired activities; they were selected from appropriate balance, muscle strength, movement, and mobility exercises. Participants completed a daily exercise calendar, which was reviewed by the therapist at each visit. After the 6-month visit period, the therapist phoned the participant monthly for another 6 months, to answer questions and provide encouragement.

The control group received equivalent visits from a health educator, and reviewed together practices to promote good health, such as proper nutrition, management of medications, physical activity, and so on. After 6 months of visits, the educator phoned participants monthly for another 6 months.

The primary outcome measured was the change in the summary disability score from baseline at 3, 7, and 12 months. Secondary outcomes were admission to a nursing home and the number of days spent in a nursing home. Analyses were done for the entire collective, for those with moderate frailty and severe frailty, and according to whether the subject lived alone or not.

Results

There were 188 participants, equally divided between the intervention and control groups. Their average age was 83 years, and 80% of them were women. Their mean MMSE score was 26.5; 58% of them had moderate, and 36% severe frailty.

In the intervention group, 65% completed the program, while 21% withdrew prematurely; 14% received no interventions at all, for various reasons - deteriorating health, illness in a family member, etc. In the control group, 83% completed the program, and 17% dropped out, at some stage.

Participants in the intervention group had less functional decline over time, according to their summary disability scores, than those in the education group:

* p</= 0.02 for difference between intervention and control groups at each time point

	Intervention Group	Intervention Group	Intervention Group	Control (education) Group	Control (education) Group	Control (education) Group
	Baseline	7 mos.	12 mos.	Baseline	7 mos.	12 mos.
Full population	2.3	2.0*	2.7*	2.8	3.6	4.2
Moderate frailty	1.9	1.0*	1.4*	1.9	3.0	2.8
Severe frailty	3.1	3.9	5.0	4.0	4.4	6.3

As can be seen, the benefits of physical therapy intervention were significant for the moderately frail, at both 6 month and 12 months. Participants with cognitive impairment (MMSE score <24) seemed to benefit less from the intervention than those with higher scores. Those who lived alone showed benefit from the intervention, while those who lived with others did not. There were no significant differences in disability scores for the severely frail, and for nursing home admissions.

The total cost of physical intervention per patient was an average of $1,998. There were no differences between the intervention and control groups with respect to adverse events (falls, injuries, chest pains, angina, muscle sprains).

Comment

This study shows that a relatively cheap intervention is able to delay increasing disability in moderately frail, home-dwelling, elderly people. The authors of the study call this a 'prehabilitation' program. They point out that beneficial effects were seen at 7 months, but not at 3 months, suggesting a shorter intervention period would not be useful. However, the full 16-visit program, at ~$2,000, is most likely a cost-effective way of postponing greater costs for at least 12 months.

The chief benefit of this study, however, lies it its demonstration that physical therapy is most helpful for older people when it is used before deterioration has reached the "severe frailty" level, and while the subjects are in good mental condition. The absence of a significant effect on nursing home admissions (14% for the intervention group, 19% for the control group) may have been due to an inadequate population size and/or insufficient length of follow-up. Certainly, the reduction in disability scores would be expected to translate into additional practical benefits for the subjects.

Source

• A program to prevent functional decline in physically frail, elderly persons who live at home. TM. Gill, DI. Baker, M. Gottschalk,  et al., N Engl J Med, 2002, vol. 347, pp. 1068--1074

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