FROM FRAILTY TO FUNCTIONALITY:

Evidence-based Rehab Strategies for our

Deconditioned Patients

By: Ernest Roy PT, DPT

Objectives: after viewing this

presentation, attendees will ---

1. Identify 5 clinical aspects of Frailty and Hospital Acquired

Deconditioning

2. Describe current “typical” treatment practices and

methods of treating deconditioned elderly patients.

3. Be able to correctly identify 3 evidenced based

parameters for safe strength training with frail patients,

such as intensity, volume, & frequency.

Objectives for this webinar

Describe five clinical aspects of frailty.

Review consequences of frailty and deconditioning in elderly patients, (rates

of disability, hospital admission, and nursing home admission)

Identify effects of reduced activity and prolonged bed rest on elderly subjects

(muscle atrophy, changes specific to muscle type, mitochondrial changes)

Define and describe sarcopenia

Review validated field tests to assess functional aspects related to frailty or

deconditioning

Identify 3 evidenced based parameters for safe strength training with frail

patients, such as intensity, volume, & frequency.

Describe the distinction between muscle strength and muscle power.

Problem#1: HAD

Hospital Associated Deconditioning (HAD) is starting to get recognition as a key component of a larger constellation of physical, mental, and emotional consequences known as PHS (Post Hospital Syndrome)

Ref: Krumholz HM, Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk. N Engl J Med 2013; 368:100-102January 10, 2013Mp1212324 DOI: 10.1056/NEJ

The Debilitated Patient

A review of outcomes for > 84,000 patients over 65 y/o revealed:

Rate of functional recovery and discharge home for patients admitted to

rehab centers due to overall debility is very comparable to those admitted for

hip fracture or myopathies.

The category “debility” is quite problematic in that it is very broad. We need

better criteria to define who will benefit from OT/PT/ST.

Ref: Kortebein P, Granger CV, Sullivan DH. A comparative evaluation of inpatient rehabilitation for older adults with

debility, hip fracture, and myopathy. Arch Phys Med Rehabil. 2009 Jun;90(6):934-8. doi: 10.1016/j.apmr.2008.12.010.

The Frail Patient

Estimates of frailty among the US elderly population vary widely, from 4 to

59%.

Older adults with higher indicators of frailty accrue costs 22-46% greater than

non frail elderly following hospitalization.

“Frail older adults are characterized as having a loss of physiologic reserve

that results in an inability to maintain homeostasis in the presence of

external stressors (e.g., surgery, falls, or illness)”

Ref: A.M. GUSTAVSONJ.R. FALVEY, C.M. JANKOWSKI, and J.E. STEVENS-LAPSLEY PUBLIC HEALTH IMPACT OF FRAILTY: ROLE OF

PHYSICAL THERAPISTS. J of Frailty Aging. 2017 ; 6(1): 2–5. doi:10.14283/jfa.2017.1.

,

HAD Vs. Frailty

Deficits from HAD “closely mirror those of older adults

with frailty.”

“Frailty often develops insidiously over a period of months

or years,”

HAD can develop rapidly over a period of just a few days

Indicators of Frailty

Frailty has been described as having at least 3 of the following 5 characteristics:

Muscle weakness

Slow movement speed

Self-reported exhaustion

Low physical activity

Unintentional weight loss.

Ref:Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56:M146–M156.

Things to Watch for and Consider

Significant muscular weakness

Decreased stamina

Diminished appetite

Fatigue

Decreased ability to carry out ADL’s

Atrophy-sarcopenia-reduced mitochondrial respiration

The Effects of Bedrest

14 to 17% atrophy of Type 1 and 2 muscle fiber respectively, seen

after 72 hours of immobilization.

Antigravity muscles such as quadriceps and lumbar extensors weaken

more rapidly than flexor muscles, such as hamstrings

Mitochondria show reduced oxidative capacity, leading to reduced

muscle blood flow and increased fatigue of muscle.

Muscle recovery from immobility may be slower than muscle injury

from direct trauma.

Ref: Nigam, Y. et al (2009) Effects of bedrest 3: musculoskeletal and immune systems, and skin. Nursing Times; 105; 23,

early online publication

Mitochondria Fun Facts.

Methods to Screen for Frailty : SHARE

The Survey of Health, Aging and Retirement in Europe.

Based on work by LP Fried, SHARE is a simple assessment technique using 5

indicators to classify patients frailty status.

The 5 indicators are decreased appetite, exhaustion, grip strength, slowness,

and low activity

Results of these factors are then plugged into an algorithm indicating patient

as non frail, pre frail, or frail.

Ref:Roman Romero-Ortuno, Cathal D Walsh, Brian A Lawlor, Rose Anne Kenny. A Frailty Instrument for primary

care: findings from the Survey of Health, Ageing and Retirement in Europe (SHARE). BMC Geriatrics 2010, 10:57

http://www.biomedcentral.com/1471-2318/10/57

Definitions of the SHARE frailty

indicators Decreased appetite: defined by a response of “Diminution of desire for food

or eating less than usual”

Exhaustion defined as a yes to question: “In the last month, have you had too little energy to do the things you wanted to do?”.

Weakness defined based on results of grip dynamometry. 2 consecutive trials for each hand were allowed.

Slowness was defined as a yes answer to either of the following two: “Because of a health problem, do you have difficulty [expected to last more than 3 months] walking 100 meters?” or “... climbing one flight of stairs without resting?

Low activity item was addressed by asking: “How often do you engage in activities that require low or moderate level of energy such as gardening, cleaning the car, or doing a walk?”.

Focus on Sarcopenia

An age-related loss of muscle mass (not always function) that generally begins in the 4th decade of life. It often accelerates between ages of 65-75 and is more pronounced among physically inactive people. It may also be related to:

Age related reduction in the number of motor nerve cells

Reduced levels of hormones such as testosterone, HGH, and IGF.

Reduced ability of the body to synthesize protein with age.

Ref: Web MD

Catabolic Crisis Model of Sarcopenia

Sarcopenia

What happens when older patients with

HAD are sent home?

3 times the rate of re admission within 30 days as medically complex patients

discharged with higher functional levels.

Increased rates of falling.

As many as 68% of patients are discharged to post acute care below their pre

hospitalization of function

Hospitalized older adults are 61% more likely to develop ADL disability than

non-hospitalized older adults.

Ref:Jason R. Falvey, Kathleen K. Mangione, Jennifer E. Stevens-Lapsley Rethinking Hospital-Associated

Deconditioning:Proposed Paradigm Shift, Phys Ther. 2015;95:1307–1315.]

Frailty as a Predictor of Disability

A systematic literature review of < 7000 studies distilled 20 of sufficient

methodological quality. The study found frail elderly had;

Odds Ratio of 2.76 to develop ADL disabilities

Odds Ration of 3.62 to develop IADL disabilities

Pre-frail elderly had increased risks for ADL/IADL disability as well, albeit to

lesser degrees.

Ref: Kojima G, Frailty as a predictor of disabilities among community-dwelling older people: a systematic review and

meta-analysis. DISABILITY AND REHABILITATION, 2017 VOL. 39, NO. 19, 1897–1908

Frailty and Nursing Home Admissions

Research suggests that 1.5 to 8% of adults > 65 y/o are living in nursing home

environments.

Frailty among nursing home populations may be as high as 50%

Odds Ratios ranged from 3.26 to 5.58 in studies of the risk of frail and pre

frail elderly being admitted to nursing homes.

Ref: Kojima G, Frailty as a Predictor of Nursing Home Placement Among Community-Dwelling OlderAdults: A Systematic

Review and Meta-analysis. Journal of GERIATRIC Physical Therapy. 2016 Jun 23; [Epub ahead of print]

Frailty as a Predictor of Hospitalization

Another systematic review, also by Kojima, found:

In the USA, the cost of hospitalization among Medicare beneficiaries accounts

for approximately half of all Medicare fee-for-service expenditure.

Of the 4620 studies identified by the systematic review, 13 studies with

average follow-up period of 3.1 years were selected.

“Frailty and prefrailty were significantly associated with higher

hospitalization risks among 10 studies with OR ( pooled OR=1.90)

Ref: Kojima G, Frailty as a predictor of hospitalisation among community-dwelling older people: a systematicreview and

meta-analysis. J Epidemiol Community Health 2016;70:722–729. doi:10.1136/jech-2015-206978

Why do hospitalized elderly often

become weaker?

Study of 45 elderly VA patients using wireless accelerometers revealed:

77% of these patients were willing and able to ambulate independently.

Despite this, the average patient in the study spent a total of 95% of their

time in a bed or chair.

The average patient spent a total of 43 minutes or 3% of the day, in some

form of standing or walking.

Ref: Brown CJ, Redden DT, Flood KL, Allman RM. The under recognized epidemic of

low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57:1660-1665.

Not Doing Much Better With Stroke

Patients…..

Not all Stroke Patients get the Same

Care

Norway vs. Australia-where to have your

stroke?

So What are we Doing With Older

Patients?

“low-intensity and generalized treatments that may not adequately maximize

physical function—thus, leaving older adults with HAD vulnerable to

re-hospitalization, further disability development, and higher mortality

rates.”

General Conditioning Activities

Traditional method used by PT/OT of exercising older adult with HAD. Typically

may include:

Ambulation in hallways or rooms

General non specific AROM exercises at sub therapeutic intensities (SLR’s)

Use of 2 lb. (1 kg) weights for LE muscle groups

Real World Example

75 y/o severely deconditioned male patient. Currently recovering from bout

of cancer treated with chemotherapy.

Patient is able to ambulate with a walker in his home with a stand by assist of

1 person, for a distance of approx. 100’.

Computerized hand held dynamometer test of peak force for quadriceps

showed values of only 10 lbs. right quad and 24.5 lbs. left.

Therefore, simple ambulation is not a sufficient stimulus to train

strength/power deficits of the LE’s

Thus, the real problem with only using

GCA’s

“These activities are often performed without application of

the principles that define skilled exercise therapy—intensity,

frequency, duration, or specificity.”

“When all else fails, examine the patient.”

—Conventional medical intern

wisdom

What about the Aerobic component?

Studies suggest that frail elderly subjects show a

more aggressive response to Resistance Training

(RT), particularly when Sarcopenia is involved, vs

aerobic- based training.

New recommendations suggest using aerobic

exercise only when done together with RT and

balance-specific training.

But Guess What?

The most important treatment is Resistance Training. RT has been found to:

Preserve lean muscle mass

Reduce deterioration of hormone levels

Start to improve protein synthesis in as little as 2 weeks.

Ref: Web MD

The Patient Assessment

Tools for Assessing Your Patient

Remember-examine the patient! There are many evidence-based field tests to

assess strength and muscle condition. These all have normative data:

30 second or 5 Times chair stand tests

Grip dynamometry

Hand held computerized dynamometry

Gait speed tests

How do Elderly Subjects Fare on

Standard Physical Performance tests?

A 2009 study from Univ of New South Wales in Australia compared 50 healthy

adults ages 20-39 and 684 older adults aged 75 to 98 years old.

Tests included the 5 times sit to stand test, 6 meter walk test, near tandem

balance, alternate step test, and stair ascent/descent tests.

sit to stand 6 meter walk near tandem balance in sec.

20-39 y/o 7.6 1.5 30

80-84 y/o 11.5 1.1 17.4

Ref: Butler A, Menant J, Tiedemann A, Lord S. Age and gender differences in seven tests of functional mobility. Journal of

NeuroEngineering and Rehabilitation 2009, 6:31 doi:10.1186/1743-0003-6-31

Example: The 5 Meter Walk test-a simple

assessment tool

Test asks patient to walk a straight 5 meter (16.4 foot) distance.

Mark 5 feet before and after the 5 meter timing course

Patient is instructed to cover the entire distance at self selected speed

Slow gait speed (>6 seconds to cover the 5 meter course) was associated with an odds ratio of 3.05 for elderly patient morbidity and mortality after cardiac surgery.

Ref: Afilalo J, et al, Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery J Am Coll Cardiol. 2010 Nov 9;56(20):1668-76. doi: 10.1016/j.jacc.2010.06.039.

.

A Handy Reference Chart

The 5 times sit to stand test

Uses a chair with seat height of between 43-45 cm from floor level.

Subject starts with arms folded and back against chair

Instruct subject "I want you to stand up and sit down 5 times as quickly as you

can when I say 'Go'.“

Time starts with “Go” and ends when buttocks contact chair on 5th rep.

5 TSTS:Mean Times for Community

Dwelling Healthy Older Adults

60-69 y/o: 8.1 seconds, S.D. 3.1 seconds

70-79 y/o: 10 seconds, S.D. 3.1 seconds

80-89 y/o: 10.6 seconds, S.D. 3.4 seconds

How many of our patients can do even 1 repetition without use of their hands??

Ref: Bohannon, R. W. (2006). Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders. Percept Mot Skills 103(1): 215-222

Grip Dynamometry

Can be tested with relatively inexpensive equipment, such as the Jamar Hand

Dynamometer

2010 study from Finland examined grip scores of 2900 people aged 55 and above

Males with peak grip power of < 37 kg, and females < 21 kg were found to be at risk

for mobility limitations.

Males with BMI of obese (> 30 points) were found to be at risk for mobility limitations

with mean peak grip of < 40 kg.

Ref: . Sallinen J, Stenholm S, Rantanen T, Heliövaara M, Sainio P, Koskinen S. Hand-grip strength cut points to screen older

persons at risk for mobility limitation. J Am Geriatr Soc. 2010 Sep;58(9):1721-6. doi: 10.1111/j.1532-5415.2010.03035.x.

Hand Held Computerized Dynamometry

Many devices commercially available

Allows far more objective results vs MMT

Example of knee extension force norms found by Andrews et al among healthy community dwelling males/females aged 70-79: 80 lbs. male, 50 lbs. female.

Ref: Andrews W, Thomas M, Bohannon R. Normative Values for Isometric Muscle Force Measurements Obtained With Hand-held Dynamometers. Physical Therapy . Volume 76 . Number 3 . March 1996

The 4 Stair Climb test for power

assessment

A useful field test to assess leg power in elderly subjects.

May be done with or without use of hand railings

Preference is without railings if it can be safely performed.

Peak quartile times without railings were:

males: 65-74 y/o 2.58 sec

75-84 y/o 2.96 sec

females: 65-74 y/o 3.15 sec

75-84 y/o 3.39 sec

Ref: Martins P, DETERMINING NORMATIVE VALUES OF THE 4-STEP STAIR CLIMB TASK AS A MEASURE OF MUSCULAR POWER IN OLDER ADULTS. Thesis Presented to the Faculty California State University, Stanislaus. Aug. 2015

How to set up the 4 stair climb test

Need 4 steps-measure total height of all 4 steps.

Allow practice trial

Subject is told to ascend steps as rapidly as they safely can. Handrail use is

allowed

Formula to determine resultant power value (in watts) is

(weight in kg) x (9.8) x (stair height in meters)/(time to complete in sec.)

Minimal detectable change for improvement is 44 watts

Example

Subject weighing 80 kg ascends 4 stairs with total height of the flight being 0.762

meters (30 inches). Subject required 3.2 seconds to perform the test:

(80kg x 9.8) x( 0.762/3.2) =

(784) X (0.238125) = 186.69 watts

Strength Training

Exercise intensity for basic

strengthening

Recommended method for skeletal muscle strengthening :

Loads between 70-80% of the individuals 1RM (rep maximum)

This loading will generally cause momentary muscular failure

after approx. 8-12 repetitions.

Subtle form changes are often noted with the final 2 repetitions

What about frequency/duration?

A majority of the studies indicate that effective results are

strongly dose dependent. Current evidence indicates:

Training may be effective if carried out 2-3 times per week.

It is recommended that patients perform 2-3 sets of 8-12 repetitions for key

muscle groups such as quadriceps, hip extensors, etc.

Duration in many studies was noted to be 8-12 weeks. How long are we

seeing patients for?

Ref: Mayer F, et al. The Intensity and Effects of Strength Training in the Elderly. Dtsch Arztebl Int. 2011 May; 108(21): 359–364.

More on variables in resistance training

program design

Time under tension (TUT)-6 seconds per rep

Training frequency of 2-3 times per week (why do we tell patients to do their HEP every day?)

7-9 Repetitions per set

Rest time between individual reps of approx 2.5 to 4 seconds, rest between sets of 2-3 minutes.

Ref:Borde R, Hortoba T, Granacher U. Dose Response Relationships of Resistance Training in Healthy Old Adults: A Systematic Review and Meta-Analysis. Sports Med (2015) 45:1693–1720

Tools you can use in the home

Theraband

Adjustable ankle weights-at least 10 lbs. per pair in 1 lb.

increments.

Homemade items using shopping bags, empty gallon-

sized water jugs, etc.

Resistance chart for Theraband

The Role of Muscle Power

Muscular power can be defined as:

Force x Velocity

Work divided by Time

The importance of power

“Muscle power is a more discriminant predictor of functional performance in older adults than muscle strength”

Research has found peak muscle power to be more relevant than aerobic capacity and muscular strength for identifying an older individuals functional status.

High velocity lower body exercise has been shown to increase walking velocity in frail elderly women.

Ref: Reid KF and Fielding RA Skeletal Muscle Power: A Critical Determinant of Physical Functioning In Older Adults. Exerc Sport Sci

Rev. 2012 January ; 40(1): 4–12. doi:10.1097/JES.0b013e31823b5f13.

To increase muscle power

Studies suggest optimal loads may be between 40-70% of 1 rep maximum

This closely mirrors requirements for younger subjects in terms of intensity of training.

2 sets of 8 reps done 3 times/week

Emphasis on explosive concentric movement.

Ref: Reid KF, Fielding RA Skeletal Muscle Power: A Critical Determinant of Physical

Functioning In Older Adults. Exerc Sport Sci Rev. 2012 January ; 40(1): 4–12.

Sample power-oriented training program

for elderly subjects

Training program is 3x per week for a 10 week time frame

Program used 4 exercises: seated knee flexion, seated knee extension,

supine leg press and supine ankle press.

Subjects perform 3 sets x 6-10 repetitions with loads of 40-60% of the most

recent 3 repetition max in each exercise

Emphasis is on explosive concentric action, controlled eccentric action, 10

second pause in between each repetition

Ref:Beijersbergen C, et al. Effects of Power Training on Mobility and Gait Biomechanics in Old Adults with Moderate Mobility

Disability: Protocol and Design of the Potsdam Gait Study (POGS). Gerontology DOI: 10.1159/000444752

Does it Work?

Study of elderly subjects s/p hip fracture (avg 79-82 y/o)

who completed a 10 week strengthening regimen found

statistically significant gains for:

Average gait speed

Fast gait speed

6 Minute Walk Duration

SF-36 Physical Function

Ref: Mangione K, et al, Home-Based Leg Strengthening Exercise Improves Function One Year After Hip Fracture: A

Randomized Controlled Study J Am Geriatr Soc. 2010 Oct; 58(10): 1911–1917. doi: 10.1111/j.1532-5415.2010.03076.x

How exercise complements appropriate

nutrient intake

“Resistance exercise stimulates increased myofibrillar muscle

synthesis in older adults”

The effect appears as early as 2-3 hours after intensive resistance

exercise

Effect can be observed for up to 2 days after a single training bout

Ref: Makanae Y, Fujuta S. Role of Exercise and Nutrition in Prevention of Sarcopenia. J Nutr Sci Vitaminol, 61,S125-S127.

2015.

Can older adults utilize dietary protein?

Studies at Univ of Texas found no differences in post exercise fractional synthesis rate (FSR) for cohort of young vs elderly subjects.

All subjects received 340 g serving of lean beef (90 grams protein content) after performing 6 x 8 reps of knee extensions at 80% of 1 rep max

Patients must be instructed to couple resistance exercise with well timed intake of protein rich foods.

Ref: Symons TB, Sheffield-Moore M, Wolfe RR, Paddon-Jones D. The anabolic response to resistance exercise and a protein-rich meal is not diminished by age. J Nutr Health Aging. 2011 May;15(5):376-81.

What about really elderly people?

An 8 week study using 90+ y/o institutionalized frail subjects who underwent a high intensity training program found:

Average strength gain of 174% for quadriceps

9% increase for mid thigh muscle mass

Mean gait speed improvement of 48%.

Ref: Fiatarone, M.A., Marks, E.C., Ryan, N.D., Meredith, C.N., Lipsitz, L.A. & Evans, W.J. High intensity strength training in nonagenerians. Effects on skeletal muscle. Journal of the American Medical Association, 263, 3029-3034, 1990

Is this Type of RT safe for older adults?

ACSM guidelines indicate that it is, when carried out under supervision of trained

personnel. (Think about the COP/criteria for determining if a service is skilled)

Falvey, et al, cite several other studies indicating that this training is safe, even for

patients with chronic conditions.

Post exercise muscle soreness with initial loading bouts are the primary concern

noted in the research. This can be managed with proper dosing of the exercise

prescription at the start of the program.

Ref:American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing

and Prescription. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.

Are We Leaving Frail Patients With

Unmet Needs?

Let’s Get out there and Pump em’ Up!

Questions? Comments?