Frailty: Treatment options and care plans
As outlined in our last article, frailty remains one of the most prominent issues facing elderly individuals, and potentially an alarming prospect for a large majority of an age population. Being a multi-faceted syndrome, the aetiology is unclear at best, but the wide ranging symptoms and causes make it extremely difficult to treat using one method unanimously. Below, we will outline some of the key, common interventions and practices used to address frailty.
Physical therapy and exercise interventions
The primary interventions for frailty in elderly individuals who are absent of contraindications (heart conditions, co-morbidities) is normally physical therapy and exercise interventions. A wide range of applications has been seen in the past, with current NHS interventions like the ‘Otago’ program consisting of resistance exercise, balance and aerobic walking. Even throughout the life span, it is crucial to maintain physical activity levels to stem the decline of muscle loss and to improve longevity in the fight against disease and aging. Several meta-analyses have described the ineffectiveness of lower body exercise training in frail subjects, although initial thoughts would be that training the legs and gait musculature may improve walking patterns. However, upper body resistance training is a vital part of a rehabilitation scheme due to the improvements in arm strength and endurance which helps individuals when avoiding a fall (grabbing a table side or bannister).
Interventions for frailty that have proved unsuccessful in the past include high intensity interval training, which is normally discontinued due to the low tolerance of elderly individuals to strenuous exercise, alongside extreme resistance training. Due diligence must be expressed in these populations as the risk of musculoskeletal injury is high, and provoking current injuries and invoking falls due to exercise uptake may still give outcomes of hip fracture. Therefore, it is crucial to include balance and proprioception (cognitive balance) exercises along side light walking and aerobic training. A crucial factor for individuals alongside isolated exercise is the potential for use of group exercise therapy which is particularly efficacious at ameliorating the other more discrete causes of frailty such as social isolation, depression and low mood. Indeed, it is often a case-by-case basis that works best in the prescription of exercise therapy, and indeed adjunct therapies must be included alongside any intervention for a more efficacious, holistic approach.
Often, social isolation and withdrawal can lead to changes in nutrition in elderly individuals, as well as the side effects from polypharmacy which can provoke nausea and other symptoms which predispose the avoidance of food. Indeed, elderly individuals with a lack of physical activity also may typically experience changes in gut microbiome constitution, affecting the ability of individuals to uptake vital nutrients from their food such as vitamin B12 and vitamin C. Coupled with a reduction in time spent in daylight hours, a prominent deficiency seen in clients screened for frailty is a Vitamin D deficiency. Aside from fatigue, exhaustion and mood disorders, vitamin D deficiency is particularly problematic when considering weight loss, resilience and bone constituency which may aggravate osteoporosis and further predispose hip fractures.
In elderly individuals with nutritional deficiencies, time is much of the essence – if a delay occurs in the detection of malnutrition, progression to frailty is difficult or impossible to combat. Indeed, individuals who present as pre-frail can typically regain strength and return to a normality of functioning, yet advanced frailty may require years to become more stable in a model including multiple interventional therapies.
Hormonal and medical therapies
Medical and hormonal therapies are under investigation in the literature, yet the safety and side effects seen with this approach typically contraindicates their use. However, testosterone and oestrogen reductions seen in middle age is thought to be highly linked to the progression of sarcopenia and inflammatory-mediated diseases normally leading to disability and death in later life. Experimental uses of these hormones on a supplementary basis has been proposed in the literature, but a longitudinal approach with randomised controlled trials has yet to be launched. Indeed, this dimension of healthcare provision treats the symptoms but not the causes of frailty in the elderly populations.
It is difficult to encourage individuals of all ages of the importance of a good diet, exercise and physical activity, substance abuse habits and social wellness. However, the treatment of frailty may start long before the presentation to a fracture clinic. Indeed, it is the early prevention of frailty which can reduce large public expenditure on the treatment of frailty once serious illness, social care and hospitalisations are required. Indeed, it appears maintaining physical activity and a good diet are key to staving off the impending sentence of old age, yet a complex relationship exists between frailty and the contributors to the syndrome. Additionally, observations of worsening physical functioning after the loss of a spouse or loved one highlights the social and psychological implications of this condition, and the importance of viewing human health in a much more holistic sense. Indeed, certain individuals living in shared accommodation may keep a sense of morale and maintain good social relationships, improving the chances of activities such as dancing, walking and gardening which are common in these populations. A public call to action and campaigns to highlight the prevalence of frailty in the cohort are much needed, along with alerts to healthcare providers about the dangers of dementia and other psychological co-morbidities which predispose vulnerable individuals to healthcare challenges and worsening disability.
This article is intended to be advisory and contains a brief review of the literature. For recommendations and adequate medical advice, please consult your doctor before commencing physical activity or changing your diet.